Dr. Taylor is assistant professor in the Department of Psychiatry and Behavioral Neuroscience at McMaster University in Hamilton, Ontario, Canada. Dr. Soares is academic head of the Mood Disorders Division and associate professor in the Department of Psychiatry and Behavioural Neurosciences at McMaster University, as well as director of the Women’s Health Concerns Clinic at St. Joseph’s Healthcare Hamilton.

Disclosure: Dr. Taylor is a consultant to sanofi-aventis; is on the speaker’s bureaus of Allergan, AstraZeneca, and sanofi-aventis; has received grant support from the Canadian Institute of Health Research, the Center for Minimally Invasive Surgery, the Community Health, Education, and Research Fund, the National Alliance for Research on Schizophrenia and Depression, the Ontario Mental Health Foundation, and the Society of American Gastrointestinal and Endoscopic Surgeons; and has received funding from Novartis and sanofi-aventis. Dr. Soares is a consultant to Bayer, Concert, Sepracor, and Wyeth; is on the speaker’s bureaus of AstraZeneca, Lundbeck, and Wyeth; and receives research support from Allergen, NCE, AstraZeneca, the Canadian Institute of Health Research, Eli Lilly, the Hamilton Community Foundation, the National Alliance for Research on Schizophrenia and Depression, and Physicians Service Incorporated.

Please direct all correspondence to: Valerie H. Taylor, MD, PhD, FRCPC, Assistant Professor, Department of Psychiatry and Behavioral Neuroscience, McMaster University, 1280 Main St West, Hamilton, Ontario L8S4L8, Canada; Tel: 905-522-1155, ext. 35410; Fax: 905-575-6029; E-mail: taylorv@mcmaster.ca.


 

Focus Points

• Women are more likely to suffer from major depressive disorder (MDD) than men; cardiovascular disease (CVD) is the largest single cause of death among women, accounting for 33% of all deaths.
• The heightened prevalence of MDD and CVD result in a compounded burden of illness among women; nonetheless, few studies have explored the potential role of gender differences for the development and management of CVD among depressed patients.
• The prevalence of CVD in MDD female patients appears to be modulated by hormone changes and different inflammatory response across the reproductive life cycle.
 

Abstract

Worldwide, cardiovascular disease (CVD) is the largest single cause of death among women, accounting for 33% of all deaths. In many countries, more women than men die every year of CVD, highlighting the unique aspects of risk factor management of CVD in women. Major depressive disorder is also an illness that affects women more often than men; thus, cardiovascular conditions among patients with chronic mental illness such as depression represent an additional vulnerability and a compounded burden of illness for women. Clinical and hormonal changes that occur during pregnancy and the postmenopausal period also represent life events that require specific attention and represent a time of heightened vulnerability for both mood disorders and CVD risk. This article addresses the role of gender in risk stratification and in the responsiveness to preventive interventions for CVD in women with depression. Moreover, it reviews existing evidence on sex hormones as modulators of biomarkers and clinical measures of CVD in depressed patients.

Introduction

Coronary heart disease (CHD), stroke, and peripheral vascular disease all contribute to overall mortality rates attributed to cardiovascular disease (CVD); despite significant efforts in disease prevention, CVD remains a major health concern in the developed world. It kills one in every five individuals1 and remains the leading cause of death in the United States and most developed western countries. CVD is also the largest single cause of death among women.2 In many countries, including the US, more women than men die every year of CVD.2,3 While most of the attention remains focused on more “traditional” female diseases such as breast cancer, many more women die from CVD than from breast cancer (1 in 2.6 versus 1 in 30, respectively).

Major depressive disorder (MDD) is more commonly diagnosed in women.4 The occurrence of cardiovascular events in patients with chronic mental illness such as depression may, therefore, represent a compounded burden for women both in terms of disease prevalence and access to treatment. Gender seems not only to predispose women with depression to the development of CVD, but also to influence the occurrence of MDD in women with heart disease. For example, recent data suggest that young women may be at particularly high risk for depression after an acute myocardial infarction.5

Overall, patients with MDD die earlier than those without mood disorders from a variety of physical illnesses, and mortality data among patients with mood disorders from as early as 1916 has documented this increase.6,7 A 4-decade study found excess mortality for manic and depressed patients of both genders, with the increase in mortality being most prominent in the first 10 years post admission due to a mood episode. A population-based study of the specific mortality ratios (SMRs) for patients with MDD or bipolar disorder from 1973–1995 found that SMRs for all natural causes of death were 1.9 for males and 2.1 for females with bipolar disorder, and 1.5 and 1.6 for MDD, respectively.8 A meta-analysis that examined excess mortality in MDD found an increased relative risk for depressed subjects to die compared to non-depressed subjects (1.81, 95% CI: 1.58–2.07).9 A large component of this increased mortality risk is attributed to CVD.8 Among women with MDD, CVD is responsible for more deaths than suicide.8 Existing data suggest that the pathophysiology of the mood disorders and its contribution to the relative risk of cardiovascular events and heart failure may be affected by gender, which might be of potential relevance for the prevention, diagnosis, and therapy of these conditions.

Metabolic Syndrome in Women with MDD

A partial explanation for increased CVD in women in general and in particular among women with mood disorders is the heightened vulnerability in this population for the development of metabolic syndrome (MeS). MeS is defined by a cluster of risk factors that ultimately contribute to CHD.10 By definition, MeS requires the presence of any three of the following five criteria: central obesity (waist circumference >102 cm [>40 in] in men, >88 cm [>35 in] in women); elevated triglycerides (>150 mg/dL [>1.7 mmol/L] or specific treatment for this lipid abnormality); raised blood pressure (BP; systolic BP >130 or diastolic BP >85 mm Hg, or treatment of previously diagnosed hypertension); raised fasting glucose (>100 mg/dL [>5.6 mmol/L] or treatment for type 2 diabetes); and reduced high density lipoprotein (HDL) cholesterol (<40 mg/dL [<1.03 mmol/L] in males, <50 mg/dL [<1.3 mmol/L] in females or specific treatment for this lipid abnormality).11 People with MeS are twice as likely to die from, and three times as likely to suffer, a heart attack or stroke. They have up to a nine-fold greater risk of developing type 2 diabetes, compared with people without the syndrome.12-14 Given that up to 80% of the 200 million people with diabetes globally will possibly die of CHD, MeS and diabetes now rank ahead of HIV/AIDS in worldwide morbidity and mortality.15

Approximately 40% of the adult population in the US meets diagnostic criteria for MeS.16 A closer look at the National Health and Nutrition Examination (NHANES) III data that was obtained between 1984–1998, compared to the NHANES 1999–2000 results, reveals a greater increase in MeS prevalence in women. Young women (20–39 years of age) seem especially vulnerable, with a 78% increase in prevalence, compared to a non-significant 5% increase in men in this age group.17 Data on 728 women from the Women’s Ischemic Syndrome Evaluation study18 showed that MeS was strongly associated with angiographic coronary artery disease and conferred an approximate two-fold adjusted risk of death and major adverse cardiac events.

In the Atherosclerosis Risk in Communities study,19 a total of 12,809 individuals who did not have diabetes or CVD at baseline were followed for an average of 11 years. Men and women with MeS were 1.5–2.0 times more likely to develop CHD than individuals who did not have MeS after adjustment for age, smoking status, low-density lipoprotein cholesterol, and race. In addition, the risk of CHD associated with the MeS was significantly higher in women (crude hazard ratios [HRs]=2.55) than in men (HRs=1.51).

In the San Antonio Heart Study,20 the cardiovascular mortality risk in subjects who had MeS was also shown to be significantly higher in women than in men, although the gender differences seen in cardiovascular mortality were only significant in individuals who had both MeS and type 2 diabetes. This association between type 2 diabetes and fatal CHD was also examined in a recent meta-analysis21 that showed a relative higher risk in women compared to men. The subgroup analysis of two recently published meta-analyses22,23 also indicate that the MeS might be a stronger risk factor for CVD in women than in men (relative risk=2.10 vs. 1.57,22 and 2.63 vs. 1.98,23 respectively).

Many of the physical illnesses linked to MeS occur at high rates in patients with mood disorders and may represent the expression of overlapping pathophysiologies linking these illnesses. The association between MeS and mood disorders, however, remains controversial due to conflicting data.24,25 These discrepancies might be due to differences in methodology (longitudinal vs. cross-sectional), or type of population studied (age, presence or absence of associated cardiovascular risk factors, history of MDD). A potential confounder appears to be the role of gender differences. While the majority of studies addressing the association between mood disorders and MeS indicated a relationship between the two conditions, those that were unable to find a correlation between the two conditions did find a relationship between women with mood disorders and MeS when populations were divided by gender.24,25

This highlights the need to explore the potential role of gender differences for the development and management of CVD among depressed patients and to target female sub-populations during periods of heightened vulnerability for both CVD and MDD (eg, the menopausal transition).26,27

The Contribution of Obesity to CVD in Women with MDD

A key variable linking mood disorders with CVD is obesity. Obesity is associated with increased risk of all-cause mortality and, in the general population, obesity and its associated metabolic and cardiovascular complications represent a significant contribution to premature death.28,29 This relationship is especially relevant to the field of mental health. People with mood disorders are at higher risk for obesity in part due to a complex interplay of factors that include unhealthy lifestyle choices, reduced energy expenditure and increase in consumption of palatable energy-dense foods, unwanted effects of pharmacotherapy, and, ultimately, poorly understood biologic factors.

The amount of weight gain in patients with a mood disorder may not be the only factor linked to an increase in morbidity from obesity-related diseases; another factor may be the increased amount of centrally deposited adipose tissue. Abdominal fat distribution consists of two discrete depots, subcutaneous adipose tissue (SAT) and visceral (intra-abdominal) adipose tissue (VAT). These patterns of body fat distribution predict CVD better than total body fat volume.30,31 A measure of VAT, the waist to hip ratio, is positively associated with increased blood pressure, increased triglycerides, and decreased HDL cholesterol.32 This association is of particular relevance for women with mood disorders as a recent study that investigated this relationship in premenopausal women showed that the depression was associated with VAT, not SAT.33 It has been speculated that these findings may, in part, explain the association between depression and CVD in this population as the reduced tendency to accumulate fat within the intra-abdominal sites may be one of the primary metabolic differences underlying the reduced risk of cardiovascular disease, metabolic syndrome, and diabetes in women.34 Normally, premenopausal women more frequently develop peripheral obesity with SAT, whereas men and postmenopausal women are more prone to VAT. After menopause, concentrations of lipoproteins as well as body fat distribution shifts to a more male pattern. Postmenopausal women have an increased tendency of visceral fat deposition, which by virtue of its proinflammatory and prothrombotic properties, contribute to their risk of developing MeS and CVD.35

The Role of Inflammation

Women are more susceptible than men to obesity in general; presently, 2 million more women than men have a body mass index >30.36 Obesity predisposes individuals to an increased risk of developing many diseases, including atherosclerosis, diabetes, non-alcoholic fatty liver disease, certain cancers, and immune-mediated disorders such as asthma.37-39 Part of this increased vulnerability is related to the ability of adipose tissue to function as an endocrine organ and secrete a wide range of hormones. Among the soluble mediators derived from adipocytes (fat cells) are leptin, adiponectin, and resistin, all of which are considered to play a role in the regulation of energy metabolism.40-42 Obesity is also associated with a chronic inflammatory response characterized by abnormal cytokine and adipokine production, increased synthesis of acute-phase reactants, and the activation of pro-inflammatory signaling pathways. Inflammation plays an essential role in the development of insulin resistance and type 2 diabetes, the initiation and progression of atherosclerotic lesions, and plaque disruption.43

Mood disorders are also associated with the production of pro-inflammatory cytokines that influence CVD, and some studies suggest that depression promotes an inflammatory process. The most compelling evidence of this derives from studies that have ameliorated depressive symptoms through psychotherapy and found corresponding declines in the magnitude of inflammation markers.44 Conversely, inflammatory processes contribute to depression and exposure to inflammatory mediators produces a constellation of behaviors (eg, hyposomnia, anhedonia, anorexia) that resemble depressive symptoms.45,46 Existing literature links mood disorders and inflammatory markers; several cytokines that are elevated in individuals with MDD and bipolar disorder, including IL-6 and C-reactive protein (CRP), predict cardiac morbidity and mortality,47,48 while an association between adiposity and elevated Il-6 and CRP levels has been suggested in clinically depressed individuals.49 Woman seem especially vulnerable to the risks posed by inflammation. In an analysis of women participating in the Nurses’ Health Study, high levels of Il-6, tumor necrosis factor-a, and CRP were significantly related to an increased risk of CHD.50 These findings supported the results from the Women’s Health Initiative study, demonstrating white cell count and CRP as the strongest predictors for cardiovascular morbidity and mortality in postmenopausal women.51 The combination of increased central obesity and chronic low-grade inflammation appears to be a mechanism for the pathogenesis of CVD.52

Variables other than weight also play a role in inflammation in women. Sex steroids may influence inflammatory processes and hence modify cardiovascular risk. Raised levels of CRP, homocysteine, lipoprotein(a) (Lp-a), and IL-6 are each independently associated with increased risk for cardiovascular events in women. While changes in these parameters across the menopausal transition cannot clearly be attributed solely to hormonal changes, endogenous sex steroid levels and exogenous hormone therapy seem to exert a modulatory effect. Elevations of the amino acid homocysteine, which is associated with arterial and venous thromboembolic disease, and Lp-a, a known independent risk factor for the development of atherosclerosis, occur with age and/or menopause,53,54 while CRP and IL-6 appear to be influenced by endogenous sex steroid levels and exogenous hormone therapy.55,56

Prevention

It was noted with the recently updated guidelines on prevention of CHD in women that healthcare professionals should focus on women’s lifetime heart disease risk and not just on short-term risk.2 The guidelines emphasized that prevalence of CHD in women is such that nearly all women should be considered at risk for atherosclerosis. Prevention of CVD is paramount to the health of women and even modest control can have significant impact. Fortunately, most CVD in women is preventable, if recognized. Even the presence of a single risk factor at 50 years of age is associated with a substantially increased lifetime absolute risk for CVD and shorter duration of survival.57 With few exceptions, such as the use of aspirin for primary prevention of heart disease in women >65 years of age,58 recommendations to prevent CVD in women do not differ from men.2 However, there are certain circumstances in which prevention strategies or interventions should be individualized.

Hormone replacement therapy (HRT) is not recommended for either primary or secondary prevention of CVD, particularly in women in their late postmenopausal years.59 Estrogen deficiency leads to an unfavorable lipid profile,60 which until recently had been considered the main pathologic phenomenon responsible for development of atherosclerosis and CHD. However, improvement in lipid profile with HRT does not reduce cardiac disease events in clinical studies.61,62 It remains controversial whether different estrogen therapies would offer a better risks/benefit ratio when administered via different pathways or to younger versus older sub-populations of menopausal women.62

The efficacy of non-pharmacologically based treatments in women also needs further evaluation. Data suggest that women with CVD respond differently than men to psychological treatments. Subgroup analyses of the Enhancing Recovery in Coronary Heart Disease Patients trial showed a significant treatment by sex interaction on cardiovascular outcomes, suggesting a protective effect of cognitive-behavioral therapy in men, but a tendency for harm in women.63 These results mirrored those of an earlier study, the Montreal Heart Attack Readjustment Trial (M-HART), which tested the effect of a nurse-based psychosocial support intervention at home for distressed patients after myocardial infarction.64 The M-HART program had no overall impact on cardiac or all-cause mortality over the year. However, separate preplanned comparisons in men and women revealed two times the odds of cardiac and all-cause mortality in treated women compared with control women, while there was no impact in men. Altogether, these data suggest that women and men respond differently to psychological interventions and highlight the importance of performing gender-specific analyses. At the very least, gender-based stratification should be better planned in future studies to allow sufficient power to examine gender-related differences. A more targeted emphasis could also be placed on prevention programs based on gender. In a US study65 designed to examine the extent to which modifiable lifestyle behaviors are associated with the risk of having MeS, MeS was associated with physical inactivity in overweight men and in normal weight and overweight women, suggesting a high protective value of physical exercise in women.

Gender biases in the diagnosis and management of women with CVD also plays a role in the outcome of this illness,66 and this is compounded by the stigma associated with mental illness. During the past several decades, CVD mortality has markedly declined in the US, from >50% to approximately 36% as the underlying cause of death.1 Recent data suggest that the decline is largely due to improved diagnosis and treatment rather than to major successes in primary prevention. In contrast, patients with severe mental illnesses,67 lose ≥25 years of life expectancy, with the majority of the excess premature deaths due to CVD.68 There is now a sufficient consensus that depression is a risk factor for CHD as well as an important prognostic factor in cardiac patients. Nonetheless, <50% of depressed medical patients are recognized by their physicians, and recognition has only mildly increased in the last 10 years.69 During an admission for acute myocardial infarction, <15% of patients with depression are identified,70 and evaluation and treatment of depression continue to be mostly ignored during routine cardiac care.71

Conclusion

Knowledge of the unique aspects associated with the management and occurrence of CVD in women has improved significantly in the last few years, and there is now acknowledgement that gender is a confounder that needs to be addressed appropriately (Figure).

 

 

 

 

The additional risk conferred by MDD both to CVD risk and its impact on long-term outcome also needs to play a role in risk stratification and management. This way, we may hope to decrease the mortality attributed to this illness in women. PP

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Dr. Wilkins is assistant professor and Dr. Warnock is professor of psychiatry in the Department of Psychiatry at the University of Oklahoma in Tulsa.

Disclosure: Dr. Wilkins reports no affiliation with or financial interest in any organization that may pose a conflict of interest. Dr. Warnock has received research support from Boehringer Ingelheim, Forest, and Wyeth.

Acknowledgments: The authors would like to acknowledge the assistance of Ms. Faye Biggs in the preparation of this manuscript.

Please direct all correspondence to: Kirsten M. Wilkins, MD, Assistant Professor, Department of Psychiatry, University of Oklahoma–Tulsa; 4502 E 41st St, Tulsa, OK 74136; Tel: 918-660-3514; Fax: 918-660-3517; E-mail: Kirsten-Wilkins@ouhsc.edu.


 

Focus Points

• Sexual dysfunction in older women is a common yet neglected area of medicine.
• Older women with sexual dysfunction require careful assessment of biologic and psychosocial contributing factors.
• Treatment options for female sexual dysfunction in later life are available but under-utilized.
 

Abstract

The geriatric patient population is anticipated to grow significantly in the coming decades. As individuals are living longer, healthier lives, there is interest in maintaining sexual health throughout the latter decades. The aging female faces many biologic and psychosocial factors which impact sexual functioning and satisfaction. Given this, it is not surprising that ~33% of older women will experience sexual dysfunction. As sexual dysfunction has been strongly associated with quality of life, physicians should be familiar with the assessment and treatment of sexual disorders in older women. This article reviews the effects of aging on the normal female sexual response cycle, as well as the various biologic and psychosocial factors affecting female sexuality in late life. The article then provides an overview of common female sexual disorders of desire, arousal, orgasm, and sexual pain. Finally, the authors discuss assessment and treatment of sexual dysfunction in the older woman.

Introduction

As individuals are living longer, healthier lives, there is a growing interest in maintaining one’s sexual health throughout the latter decades. Previous studies have reported that 70% of healthy 70-year-olds enjoy sex on a regular basis and that 80% of men and women 60–91 years of age are sexually active at least once per month.1,2 A recent study3 concluded that the majority of older adults are engaged in sexual activity and regard sex as an important part of life. However, many biologic and psychosocial factors related to aging impact the quality and quantity of sexual activity an older person experiences. The physical and mental health of the individual as well as their partner, the availability of a willing partner, and the previous level of sexual activity all play an important role in sexuality in aging.

Given the many factors related to aging which can impact sexual functioning, it comes as no surprise that the prevalence of sexual dysfunction increases with age.4 While the advertising market and popular media have paid much attention to sexual disorders among older men, these disorders are also common among older women. A recent national sample3 of sexual behaviors and problems in older community-dwelling individuals reported that women 57–64 years of age had the following sexual complaints: lack of interest in sex (44.2%), difficulty with lubrication (35.9%), inability to climax (34%), pain during intercourse (17.8%), and lack of pleasure during sex (24%). Despite the prevalence of sexual complaints, the same study found that women are less likely than men to discuss these matters with their physician. Physicians themselves may fail to assess a patient’s sexual functioning due to personal discomfort, time constraints, placing sexuality low on the priority list, or out of fear of embarrassing the patient or being perceived as too intrusive.5

Given the anticipated increase in the geriatric population and the prevalence of sexual dysfunction with aging, physicians in both primary care and psychiatry should be familiar with common sexual disorders among older women. The purpose of this article is to review the diagnosis, evaluation, and treatment of sexual disorders among older women. The authors begin with a review of the normal sexual response and aging, followed by a discussion of biologic and psychosocial factors associated with changes in sexual functioning in aging. Finally, the article reviews common sexual disorders and their treatments.

Normal Sexual Response and Aging

Before one can accurately diagnose and effectively treat sexual disorders in the older woman, one must understand the effects of aging on the normal sexual response cycle. The normal adult sexual response cycle, as originally described by Masters and Johnson,6 is comprised of four stages: arousal, plateau, orgasm, and resolution. A fifth stage, desire, has been added to include the psychological and physiologic part of sexual functioning which underlies response.7 Any of these stages may be impacted by age-related changes in sexual functioning.

Due to the significant changes in sex steroids that occur during reproductive life events, women are particularly vulnerable to sexual dysfunction during these times.8 Menopause, cessation of menses for >12 months, constitutes the major reproductive life event of the older woman. Perimenopause is defined as the transitional period from the reproductive years to reproductive quiescence.9 Perimenopause and menopause are associated with a decline in ovarian function, resulting in reduction and eventual cessation of estrogen production. Estrogen decline impacts sexual functioning in several ways. The urogenital tissue atrophies and vaginal size is reduced. Vaginal lubrication decreases, which can result in uncomfortable intercourse. The sensitivity of the nipples, clitoris, and vulvar tissue is reduced, and the strength and amount of vaginal contractions during orgasm decrease. In addition, the majority of women undergoing menopause experience other symptoms such as mood lability, fatigue, body aches, and hot flashes.7

In addition to changes in estrogen, the menopausal woman also undergoes a decrease in testosterone production. Androgen deficiency in women is associated with a global loss of sexual desire or libido, decreased production of body oils, thinning of pubic hair, reduced vital energy, and decreased sensitivity of the nipples and clitoris.10

Biological Factors and Sexuality in Aging

In addition to the hormonal changes that occur via menopause, the older woman faces other biologic factors which impact sexual functioning. Many medical and psychiatric illnesses are more prevalent in older adults and are known to impact the quality of sexual activity. These illnesses are often the primary cause of sexual dysfunction in this population.7 Illnesses such as urogenital cancers, cardiovascular disease, arthritis, and chronic obstructive pulmonary disease, as well as many neurologic diseases (stroke, Parkinson’s disease, multiple sclerosis, and others), are associated with sexual dysfunction.

The medical condition itself may directly affect sexual functioning. Diabetes, in particular type II, has been associated with sexual complaints among women, including lack of libido, reduced orgasmic capacity, decreased vaginal lubrication, and reduced sexual satisfaction.11,12 Similarly, studies on the sexual functioning of stroke patients have shown that sexual dysfunction and dissatisfaction are common among women.13 Some illnesses such as arthritis may cause pain or limit flexion and range of motion, leading to uncomfortable intercourse.14 Psychiatric conditions including depression, dementia, and substance abuse can also lead to reduced sexual interest and impaired functioning. Medical illnesses may have an indirect effect on sexual functioning as well. Fear of pain or of exacerbating a medical condition such as angina may lead to an inability to relax and enjoy sexual activity.15 Some illnesses, such as breast cancer or gynecologic malignancies, may result in altered self-image and reduced feelings of sexual attractiveness.14

Various symptoms of sexual dysfunction may arise iatrogenically, as a result of prescription medications. A recent review on medications and sexual function reported that >100 drugs or drug classes have been associated with sexual dysfunction, and that the impact of medications on sexuality increases with age.16 Sexual side effects in women secondary to medications may include loss of libido, reduced capacity for arousal, and difficulty achieving orgasm. Psychiatric medications, including selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, mood stabilizers, and antipsychotics are known to carry a risk of sexual side effects. Antihypertensive medications, such as beta-blockers, diuretics, and clonidine, among others, have also been associated with sexual side effects. Other medications associated with sexual dysfunction include digoxin, corticosteroids, antihistamines, histamine subtype 2 receptor blockers, opioids, and cancer chemotherapeutic agents.7,16

Psychosocial Factors and Sexuality in Aging

Psychosocial factors also significantly impact sexual activity among older women. The life expectancy of women is greater than that of men; hence, many older women have lost their spouse or partner. As women outnumber men in the latter decades of life, the availability of a willing and functional sexual partner becomes a legitimate issue for heterosexual women. Lesbian women in this age group remain understudied. For those older adults who are able to enter into new sexual relationships, concern about sexually transmitted diseases has been reported as a reason for lack of sexual activity.3

One’s social environment can also play a role in the expression of sexuality. Some older women will find themselves living with their adult children and their families or in assisted living or long-term care facilities, where opportunity and/or privacy for sexual activity is lacking. On the other hand, many older women will continue to live independently. Some couples may even enjoy increased time for intimacy due to retirement or “the empty nest.” Among postmenopausal women, the elimination of concern about the possibility of pregnancy may result in decreased anxiety and increased ability to enjoy sex.7

Psychological and cultural factors are also important. Our culture is notoriously geared toward the notion that sex is for the young and, therefore, older adults are often not seen as sexually desirable or capable.17 This view is not always bestowed equally upon the genders. Movies and television frequently pair younger, attractive women with older men. Such ageist stereotypes about sexuality are unfortunately accepted by many older individuals, who may see sexual activity as inappropriate or dangerous.7

Sexual Disorders in Older Women

Hypoactive Sexual Desire Disorder

Sexual desire comprises a critical portion of the human sexual response cycle, and includes sexual fantasies and thoughts as well as motivation and receptivity to sexual activity. This phase has been postulated to include biologic, motivational-affective, and cognitive components.18 Basson19 suggested that a woman’s sexual response arises not from a biologic neediness or urge, but rather from intimacy. Motivation to participate in sexual activity is theorized to derive not only from sexual pleasure, but also from closeness and tenderness. Therefore, a woman may choose to experience sexual activity in order to have intimate relationship needs met.

Female hypoactive sexual desire disorder (HSDD) may occur in up to 33% of adult women in the United States. The complaint of low sexual desire alone does not meet criteria for the diagnosis of HSDD. However, such a complaint is not uncommon among older women. The prevalence of lack of interest in sex for women in the US 50–59 years of age has been reported as 27%, slightly lower than rates in younger women.20 A more recent study,3 however, reported prevalence rates of 38% to 49% for women 57–85 years of age. It is important to note that not all women are distressed by a decrease in sexual desire. In 2007, Hayes and colleagues21 reported that while the proportion of women with low sexual desire increases with age, the proportion of women distressed about their low desire actually decreases with age.

The diagnosis of HSDD is made when the patient has persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity, which cause marked distress or interpersonal difficulty and are not better accounted for by another Axis I disorder, general medical condition, or substance.22 Frequently, in women, HSDD and the physiologic effects of a general medical condition are both present. Thus, HSDD due to combined factors is diagnosed. HSDD may be lifelong (eg, patients with history of sexual trauma or abuse) or acquired (as in the case of a general medical condition). It may be generalized or situational and is frequently associated with dysfunction in sexual arousal and orgasm.23 An extreme version of HSDD, sexual aversion disorder, consists of persistent or recurrent extreme aversion to, and avoidance of, all genital sexual contact, which causes marked distress or interpersonal difficulty.22

Female sexual desire in later life may be impacted by numerous factors. As reviewed above, these factors may include medical or psychiatric illnesses, medications, and psychosocial factors such as availability of a partner or marital harmony. Hormonal fluctuations associated with surgical or natural menopause and endocrine disorders such as diabetes mellitus may affect desire. Psychiatric conditions such as major depressive disorder or panic disorder may also contribute to lack of desire or even aversion to and avoidance of sexual activity.24 Medications, including psychotropics, antihypertensives, tamoxifen, and antiepileptics, may result in decreased libido.

Female Sexual Arousal Disorder

Female sexual arousal disorder (FSAD), as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition–Text Revision,22 includes a persistent or recurrent inability to attain, or maintain until completion of sexual activity, an adequate lubrication-swelling response of sexual excitement. As in HSDD, the symptoms cause marked distress or difficulty with interpersonal functioning and may not be better accounted for by another Axis I diagnosis, general medical condition, or substance.22 Approximately 36% to 43% of women 57–85 years of age report difficulty with vaginal lubrication during sexual activity.3 The clinician should make the distinction between difficult lubrication due to physiologic changes during menopause versus a symptom of FSAD. In the older woman, this distinction may be challenging as estradiol deficiency prevents an adequate lubrication response. Gathering an adequate medical and sexual history, including the timing of onset of the arousal difficulties, may help the clinician make this distinction.

FSAD is commonly associated with other sexual disorders. For example, a woman who is not able to maintain her arousal response may complain of low desire. The clinician should assess the onset of her decreased sexual interest as it may correlate to her delayed arousal response. If so, her primary difficulty is FSAD, with a secondary HSDD. That is, since her arousal response is significantly diminished, she may “report” low sexual desire. This is an important distinction for the clinician to make as the diagnosis and treatment may vary.

Arousal difficulties may have underlying psychological, vascular, neurologic, or endocrinologic etiologies.25 The most notable endocrinologic etiology for the older woman is, of course, menopause. Estrogen decline results in vaginal dryness and difficulty attaining adequate lubrication for sexual activity. With regard to vascular etiologies, atherosclerosis may result in decreased vaginal and clitoral blood flow. Traumatic injury to the pelvic arterial bed from fractures, trauma, surgical disruption, or chronic perineal pressure from activities such as bicycle riding can result in diminished vaginal and clitoral blood flow.26 Spinal cord injuries and peripheral and central nervous system disorders may inhibit sexual arousal as well. As in HSDD, psychological factors (eg, self-esteem issues, presence of a mood or anxiety disorder) and relationship problems may also contribute to difficulties in female arousal. Medications with antihistaminic and anticholinergic properties may prevent adequate lubrication and arousal.

Female Orgasmic Disorder

Among women, there is significant variability in the type and intensity of sexual stimulation that results in orgasm. In addition, orgasm may vary within an individual over her life cycle. Female orgasmic disorder (FOD) is defined by the DSM-IV-TR as a persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. Given the variability of sexual response among women, the DSM-IV-TR dictates that the diagnosis of FOD should be based on the clinician’s judgment that the patient’s orgasmic capacity is less than would be expected for her age, sexual experience, and adequacy of sexual stimulation.22 As in the other sexual disorders, inability to achieve orgasm may be a problem she has had all of her life or one that has developed due a wide variety of biopsychosocial issues including relationship issues, the normal process of aging, general medical conditions, or any of a variety of possible medications.

Up to 38% of women >57 years of age report an inability to climax.3 Some women have never experienced orgasm, possibly the result of inexperience, religious inhibitions, or emotional or sexual trauma. Others acquire FOD after previously enjoying a satisfying sex life. As with the other female sexual disorders, if a women “had it, lost it, and wants it back” for herself, treatment will generally have a more favorable outcome.27 FOD is more common among unmarried women and those without a college degree.20 Psychosocial factors including relationship quality, self-esteem, and attitudes toward sex may also contribute to FOD. Medical etiologies of anorgasmia include medications, substance abuse, hormonal deficiency, surgery, or trauma.

Sexual Pain Disorders

Eleven percent to 18% of women 57–85 years of age report pain during intercourse.3 Sexual pain disorders include dyspareunia and vaginismus. The two disorders are characterized by difficulty with vaginal penetration. The DSM-IV-TR defines dyspareunia as recurrent or persistent genital pain associated with sexual intercourse. Vaginismus is defined by the DSM-IV-TR as recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse, though some authors have proposed reconceptualizing this disorder as either an aversion/phobia of genital penetration or a genital pain disorder.28 In order to make either diagnosis, the symptoms must cause marked distress and interpersonal difficulty and are not better accounted for by another Axis I disorder (eg, somatization disorder) or a general medical condition or substance.22

Dyspareunia may be due to psychological factors or a combination of psychological factors plus a general medical condition. DeUgarte and colleagues25 suggested dividing dyspareunia into three categories for ease of diagnosis: pain with intromission (often secondary to vestibulitis, vaginismus, or superficial vaginal lesions), mid-vaginal pain (often secondary to vaginal dryness, surgical scars, etc), and deep-thrust dyspareunia (secondary to endometriosis, pelvic adhesions, neoplasm, or interstitial cystitis).

Vaginismus may be so severe that penetration of the vagina by any means (tampon, speculum, or penis) may be impossible. Vaginismus may be primary, wherein no penetration has ever been achieved, or secondary, wherein penetration has been achieved in the past. There is often a negative feedback cycle, wherein the discomfort and humiliation of attempted penetration leads to a phobic avoidance of any sexual contact at all.29 Proposed psychological factors contributing to vaginismus may include psychosexual conflicts, strict religious upbringing which associates sex with sin, a history of sexual abuse or rape, or emotional disconnect between sexual partners.30

Assessment and Treatment of Sexual Disorders in the Older Woman

Assessment

The evaluation of the older women who presents with a sexual complaint requires careful consideration of the patient and the multitude of factors that impact on the various components of the sexual response cycle (Table 1).23 A comprehensive medical and psychiatric history must be obtained, with special attention paid to any psychiatric or medical condition which may impact sexual functioning (eg, depression, anxiety, substance abuse, menopause, diabetes). A complete sexual history is imperative and includes attitudes toward sexuality, level of sexual knowledge of the patient and partner, relationship with the current partner, past sexual behaviors, and current and past sexual levels of functioning (ie, desire, arousal, and orgasm).

 

Equally as important as assessing the patient’s current level of sexual functioning is assessing her level of distress due to her symptoms. Shifren and colleagues31 recently reported that while sexual problems are greatest in elderly women, sexual problems causing distress are least prevalent in this age group. They noted that the reasons for this are unclear, but may include changes in partner status or partner’s health, significance of other medical conditions, or other factors important to relationships of long duration. Clinicians should be able to identify relevant age-appropriate issues with older couples; it may be helpful to interview partners alone and together.17 Accurate assessment of sexual dysfunction in late life is contingent upon a trusting, secure doctor-patient relationship in which both parties feel comfortable discussing these sensitive topics.7

The use of a simple intra-individual assessment tool such as the Sexual Energy Scale (SES) may be helpful in providing an objective means of measuring the patient’s report of their subjective experience of vitality/sexual energy.32 The patient is educated that sexual energy is not comprised merely of the frequency of intercourse or masturbation, but also includes sexual dreams, fantasies, genital sensations, and sexual appetite. The patient rates her current sexual energy on a scale of 1–10, with 1 being the lowest sexual energy she has experienced in her adult life, and 10 being the highest (Figure). The SES may be repeated at subsequent visits. The busy primary care physician can use this simple, one-item scale to track symptomatic improvement over time as the patient is being treated. The scale may help both patient and physician evaluate response to treatment.

 

A thorough medication inventory, including over-the-counter medications, is essential. As discussed above, many medications carry risk of sexual side effects and may impact all components of the sexual response cycle. Physical examination, including gynecologic examination, may help identify medical factors impacting sexual functioning (eg, vaginal atrophy, cystocoele, leakage). Laboratory testing may include complete blood count, electrolyte levels, lipid panel, and thyroid function tests as well as levels of prolactin, follicle-stimulating hormone, estrogen, and free and total testosterone.

Treatment

Treatment for the older woman with sexual dysfunction depends in part on whether the problem is considered a sexual disorder that she has had all of her life or one that has developed more recently (Table 2).23 If the problem has developed more recently, assuming that there is no significant change in her health, then the clinical prognosis is likely to be more optimistic. In either case, the patient should be encouraged to cultivate a positive attitude toward sexuality in late life and avoid unrealistic expectations, such as that sex must be the same as when she was younger.7 Education may be required as to what constitutes normal and dysfunctional sexuality as well as how to modify sexual activity in the face of fatigue and pain. Maintaining open and honest communication between partners is essential. Lifestyle adjustments are likely to be beneficial. Patients should be instructed to cease smoking and avoid alcohol or illicit drugs. Regular exercise, as tolerated, including pelvic floor exercises, proper nutrition, and sleep hygiene techniques should be encouraged, in addition to stress management techniques and social and partnership skills training.23

 

 
If the disorder is due to a substance such as a prescription or over-the-counter medication, one could wait to see if tolerance will develop and the sexual side effect will attenuate, though this does not commonly occur.33 Attempts to reduce or eliminate that medication may be undertaken, if feasible. If the patient is felt to require the medication, consideration may be given to switching to another class which may have lower likelihood of sexual side effects (eg, switching from fluoxetine to bupropion for treatment of depression). An alternative strategy is to utilize antidotes to reverse sexual side effects (eg, bupropion or sildenafil for SSRI-induced sexual dysfunction). Of note, no medication is Food and Drug Administration-approved for the treatment of sexual disorders in women.

If the sexual dysfunction is due to a medical or psychiatric condition, treatment for that condition (eg, hypothyroidism, depression, vulvitis) should be optimized first. Postmenopausal women should be assessed for signs and symptoms of estrogen deficiency (ie, hot flashes, vaginal dryness) and androgen deficiency (ie, global loss of sexual desire, decreased genital sensitivity). Hormone replacement therapy (estrogen and/or testosterone) may be considered and is available in a variety of routes of administration (oral, transdermal, injection or topical). The use of estrogen replacement has been controversial in the US because of its reported association with breast cancer, stroke, and ovarian cancer. In selecting patients for estrogen replacement, the clinician should carefully consider the individual’s medical history, including history of smoking, migraine headaches, breast cancer, or stroke.

The testosterone patch is currently available for women with HSDD in Australia, Canada, and Europe. While it is known that testosterone can improve sexual desire in postmenopausal women on estrogen therapy, the question has been raised as to whether or not the testosterone patch is effective for HSDD in postmenopausal women who are not on estrogen. To answer this question, Davis and colleagues34 conducted a randomized, double-blind, placebo-controlled multisite trial. They found that for postmenopausal women with HSDD not on estrogen, 300 mcg/day of testosterone had a significantly greater improvement in the 4-week frequency of satisfying sexual episodes than those using placebo. In the US, physicians may prescribe physiologic replacement levels of testosterone for women using low doses of products that are approved for men or by referring patients to compounding pharmacies. Prior to beginning testosterone replacement, clinicians should engage patients in a thorough discussion of the risks and benefits. Potential long-term risks may include hyperlipidemia, hirsutism, clitoromegaly, voice changes, liver tumors, and transaminase dysfunction, although these side effects are generally considered dose dependent. Physiologic replacement levels of testosterone in women do not appear to have significant adverse events. A clinician may want to order a baseline fasting lipid profile before initiating testosterone, with a repeat panel in several months. Women in this age group are at increased risk of hyperlipidemia, and if these studies have not been done within the last year, then it is prudent to obtain these studies.

While many medications have been tried in the treatment of female sexual disorders, randomized controlled trials are limited, particularly in older women. Agents such as sildenafil, bupropion, prostaglandin E1, phentolamine, and others have been reported as possible treatments for female sexual disorders, in addition to medical devices such as vacuum therapy and electronic stimulation.25 Currently, there are non-hormonal medications for the treatment of low sexual desire in ongoing phase III clinical trials in the US (ie, flibanserin).

For the older woman whose sexual disorder is felt to be related to psychological issues, sex and/or marital therapy should be considered. Cognitive-behavioral techniques are replacing previously used psychodynamic models of therapy.35 Therapy often begins with psychoeducation and support, to help cultivate more positive attitudes toward sexuality in late life. The therapist may help correct “all or nothing” cognitive distortions, wherein the patient feels that if orgasm is not achieved, sex is worthless. Patients may be educated on techniques such as self-stimulation, sensate focus, and foreplay, so that the focus of sexual activity is not exclusively intercourse. For the older woman with vaginismus, psychoeducation and cognitive-behavioral therapy may be accompanied by the use of vaginal dilators of graduated sizes, allowing the woman to be in control while extinguishing the involuntary muscle contraction.29

Conclusion

As women are living longer, healthier lives, they seek to maintain sexual health and satisfaction throughout the latter decades. Many biologic and psychosocial factors uniquely affect the older woman and place her at risk for sexual dysfunction. She must overcome hormonal fluctuations, medical conditions, necessary medications, changes in intimate relationships, and a culture which equates sexiness and vitality with youth. Physicians who treat older women should be familiar with the effects of aging on the normal female sexual response cycle, as well as the biologic and psychosocial factors which impact female sexual functioning in late life. Physicians should routinely inquire about patients’ sexual functioning and satisfaction and provide an open, supportive environment in which to discuss such concerns.

Older women may experience disorders of sexual desire, arousal, orgasm, and pain. Identifying the biologic and psychosocial contributors is essential in the treatment of these disorders. Treatment in all cases should include psychoeducation and lifestyle adjustments, such as exercise, proper nutrition, sleep hygiene, elimination of alcohol and drugs, and improving communication skills among partners. Treatment should also include optimizing treatment of underlying medical and psychiatric conditions, reduction or elimination of problematic medications, and referral for sex therapy, as clinically indicated. Medications for the treatment of various sexual disorders in women are currently under investigation. Given the strong association between sexual dysfunction and quality of life,20 further research is needed in this area. Sexual dysfunction is a common, but neglected area in medicine, in particular for the older woman. PP

References

1.    Kaplan HS. Sex, intimacy, and the aging process. J Am Acad Psychoanal. 1990;18(2):185-205.
2.    Starr BD, Weiner MB. The Starr-Weiner Report on Sex and Sexuality in the Mature Years. New York, NY: McGraw-Hill; 1981.
3.    Lindau ST, Schumm LP, Laumann EO, Levinson W, O’Muircheartaigh CA, Waite LJ. A study of sexuality and health among older adults in the United States. N Engl J Med. 2007;357(8):762-774.
4.    Spector IP, Rosen RC, Leiblum SR. Sexuality. In: Reichman WE, Katz PR, eds. Psychiatric Care in the Nursing Home. New York, NY: Oxford University Press; 1996:133-150.
5.    Clayton AH. Sexual function and dysfunction in women. Psychiatr Clinics of N Am. 2003;26(3):673-682.
6.    Masters WH, Johnson VE. Human Sexual Response. Boston, MA: Little, Brown; 1966.
7.    Agronin ME. Sexual disorders. In: Blazer DG, Steffens DC, Busse EW, eds. Textbook of Geriatric Psychiatry. Washington, DC: American Psychiatric Publishing, Inc; 2004:303-317.
8.    Warnock JK. Impact of medical illness and reproductive transitions on sexual functioning in women. Mental Fitness. 2004;3(4):34-39.
9.    Altshuler LL, Cohen LS, Moline ML, et al. The Expert Consensus Guidelines. Treatment of depression in women. Postgrad Med. 2001;(Spec No):1-107.
10.    Sarrel PM. Sexuality and menopause. Obstet Gynecol. 1990;75(suppl):26S-30S.
11.    Schreiner-Engel P, Schiavi RC, Vietorisz D, Smith H. The differential impact of diabetes type on female sexuality. J Psychosom Res. 1987;31(1):22-33.
12.    Erol B, Tefekli A, Ozbey I, et al. Sexual dysfunction in type II diabetic females: a comparative study. J Sex Marital Ther. 2002;28(s):55-62.
13.    Korpelainen JT, Nieminen P, Myllyla VV. Sexual functioning among stroke patients and their spouses. Stroke. 1999;30(4):715-719.
14.    Kaiser FE. Sexual function in the older woman. Clin Geriatr Med. 2003;19(3):463-472.
15.    Addis IB, Ireland CC, Vittinghoff E, Lin F, Stuenkel CA, Hulley S. Sexual activity and function in postmenopausal women with heart disease. Obstet Gynecol. 2005;106(1):121-127.
16.    Thomas DR. Medications and sexual function. Clin Geriatr Med. 2003;19(3):553-562.
17. Sbrocco T, Weisberg RB, Barlow DH. Sexual dysfunction in the older adult: assessment of psychosocial factors. Sex Disabil. 1995;13(3):201-218.
18.    Graziottin A. The biological basis of female sexuality. Int Clin Psychopharmacol. 1998;13(suppl 6):S15-S22.
19.    Basson R. The female sexual response: a different model. J Sex Marital Ther. 2000;26(1):51-65.
20.    Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;281(6):537-544.
21.    Hayes RD, Dennerstein L, Bennett CM, Koochaki PE, Leiblum SR, Graziottin A. Relationship between hypoactive sexual desire disorder and aging. Fertil Steril. 2007;87(1):107-112.
22.    Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.
23.    Warnock JK. Female hypoactive sexual desire disorder: epidemiology, diagnosis, and treatment. CNS Drugs. 2002;16(11):745-753.
24.    Figueira I, Possidente E, Marques C, Hayes K. Sexual dysfunction: a neglected complication of panic disorder and social phobia. Arch Sex Behav. 2001;30(4):369-377.
25.    DeUgarte CM, Berman L, Berman J. Female sexual dysfunction: from diagnosis to treatment. Sexuality, Reproduction, and Menopause. 2004;2(3):139-145.
26.    Berman JR, Goldstein I. Female sexual dysfunction. Urol Clin North Am. 2001;28(2):405-416.
27.    Warnock JK. Acquired, generalized, female hypoactive sexual desire disorder: I had it, I lost it, I want it back. Psychiatric Times. 2005;22(9):45-52.
28.    Reissing ED, Binik YM, Khalifé S. Does vaginismus exist? A critical review of the literature. J Nerv Ment Dis. 1999;187(5):261-274.
29.    Butcher J. ABC of sexual health: female sexual problems II: sexual pain and sexual fears. BMJ. 1999;318(7176):110-12.
30.    Sadock VA. Normal human sexuality. In: Sadock BJ, Sadock VA, eds. Comprehensive Textbook of Psychiatry. 7th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2000:1577-1631.
31.    Shifren JL, Monz BU, Russo PA, Segreti A, Johannes CB. Sexual problems and distress in United States women: prevalence and correlates. Obstet Gynecol. 2008;112(5):970-978.
32.    Warnock JK, Bundren C, Morris DW. Female hypoactive sexual desire disorder due to androgen deficiency: clinical and psychometric issues. Psychopharm Bull. 1997;33(4):761-66.
33.    Rothschild AJ. Sexual side effects of antidepressants. J Clin Psych. 2000;61(suppl 11):28-36.
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35.    Rosen RC, Leiblum SR. Principles and Practice of Sex Therapy: Update for the 1990s. New York, NY: Guilford Press; 1988.

Return

 

Dr. Wilkins is assistant professor and Dr. Warnock is professor of psychiatry in the Department of Psychiatry at the University of Oklahoma in Tulsa.

Disclosure: Dr. Wilkins reports no affiliation with or financial interest in any organization that may pose a conflict of interest. Dr. Warnock has received research support from Boehringer Ingelheim, Forest, and Wyeth.

Acknowledgments: The authors would like to acknowledge the assistance of Ms. Faye Biggs in the preparation of this manuscript.

Please direct all correspondence to: Kirsten M. Wilkins, MD, Assistant Professor, Department of Psychiatry, University of Oklahoma–Tulsa; 4502 E 41st St, Tulsa, OK 74136; Tel: 918-660-3514; Fax: 918-660-3517; E-mail: Kirsten-Wilkins@ouhsc.edu.


 

Focus Points

• Sexual dysfunction in older women is a common yet neglected area of medicine.
• Older women with sexual dysfunction require careful assessment of biologic and psychosocial contributing factors.
• Treatment options for female sexual dysfunction in later life are available but under-utilized.
 

Abstract

The geriatric patient population is anticipated to grow significantly in the coming decades. As individuals are living longer, healthier lives, there is interest in maintaining sexual health throughout the latter decades. The aging female faces many biologic and psychosocial factors which impact sexual functioning and satisfaction. Given this, it is not surprising that ~33% of older women will experience sexual dysfunction. As sexual dysfunction has been strongly associated with quality of life, physicians should be familiar with the assessment and treatment of sexual disorders in older women. This article reviews the effects of aging on the normal female sexual response cycle, as well as the various biologic and psychosocial factors affecting female sexuality in late life. The article then provides an overview of common female sexual disorders of desire, arousal, orgasm, and sexual pain. Finally, the authors discuss assessment and treatment of sexual dysfunction in the older woman.

Introduction

As individuals are living longer, healthier lives, there is a growing interest in maintaining one’s sexual health throughout the latter decades. Previous studies have reported that 70% of healthy 70-year-olds enjoy sex on a regular basis and that 80% of men and women 60–91 years of age are sexually active at least once per month.1,2 A recent study3 concluded that the majority of older adults are engaged in sexual activity and regard sex as an important part of life. However, many biologic and psychosocial factors related to aging impact the quality and quantity of sexual activity an older person experiences. The physical and mental health of the individual as well as their partner, the availability of a willing partner, and the previous level of sexual activity all play an important role in sexuality in aging.

Given the many factors related to aging which can impact sexual functioning, it comes as no surprise that the prevalence of sexual dysfunction increases with age.4 While the advertising market and popular media have paid much attention to sexual disorders among older men, these disorders are also common among older women. A recent national sample3 of sexual behaviors and problems in older community-dwelling individuals reported that women 57–64 years of age had the following sexual complaints: lack of interest in sex (44.2%), difficulty with lubrication (35.9%), inability to climax (34%), pain during intercourse (17.8%), and lack of pleasure during sex (24%). Despite the prevalence of sexual complaints, the same study found that women are less likely than men to discuss these matters with their physician. Physicians themselves may fail to assess a patient’s sexual functioning due to personal discomfort, time constraints, placing sexuality low on the priority list, or out of fear of embarrassing the patient or being perceived as too intrusive.5

Given the anticipated increase in the geriatric population and the prevalence of sexual dysfunction with aging, physicians in both primary care and psychiatry should be familiar with common sexual disorders among older women. The purpose of this article is to review the diagnosis, evaluation, and treatment of sexual disorders among older women. The authors begin with a review of the normal sexual response and aging, followed by a discussion of biologic and psychosocial factors associated with changes in sexual functioning in aging. Finally, the article reviews common sexual disorders and their treatments.

Normal Sexual Response and Aging

Before one can accurately diagnose and effectively treat sexual disorders in the older woman, one must understand the effects of aging on the normal sexual response cycle. The normal adult sexual response cycle, as originally described by Masters and Johnson,6 is comprised of four stages: arousal, plateau, orgasm, and resolution. A fifth stage, desire, has been added to include the psychological and physiologic part of sexual functioning which underlies response.7 Any of these stages may be impacted by age-related changes in sexual functioning.

Due to the significant changes in sex steroids that occur during reproductive life events, women are particularly vulnerable to sexual dysfunction during these times.8 Menopause, cessation of menses for >12 months, constitutes the major reproductive life event of the older woman. Perimenopause is defined as the transitional period from the reproductive years to reproductive quiescence.9 Perimenopause and menopause are associated with a decline in ovarian function, resulting in reduction and eventual cessation of estrogen production. Estrogen decline impacts sexual functioning in several ways. The urogenital tissue atrophies and vaginal size is reduced. Vaginal lubrication decreases, which can result in uncomfortable intercourse. The sensitivity of the nipples, clitoris, and vulvar tissue is reduced, and the strength and amount of vaginal contractions during orgasm decrease. In addition, the majority of women undergoing menopause experience other symptoms such as mood lability, fatigue, body aches, and hot flashes.7

In addition to changes in estrogen, the menopausal woman also undergoes a decrease in testosterone production. Androgen deficiency in women is associated with a global loss of sexual desire or libido, decreased production of body oils, thinning of pubic hair, reduced vital energy, and decreased sensitivity of the nipples and clitoris.10

Biological Factors and Sexuality in Aging

In addition to the hormonal changes that occur via menopause, the older woman faces other biologic factors which impact sexual functioning. Many medical and psychiatric illnesses are more prevalent in older adults and are known to impact the quality of sexual activity. These illnesses are often the primary cause of sexual dysfunction in this population.7 Illnesses such as urogenital cancers, cardiovascular disease, arthritis, and chronic obstructive pulmonary disease, as well as many neurologic diseases (stroke, Parkinson’s disease, multiple sclerosis, and others), are associated with sexual dysfunction.

The medical condition itself may directly affect sexual functioning. Diabetes, in particular type II, has been associated with sexual complaints among women, including lack of libido, reduced orgasmic capacity, decreased vaginal lubrication, and reduced sexual satisfaction.11,12 Similarly, studies on the sexual functioning of stroke patients have shown that sexual dysfunction and dissatisfaction are common among women.13 Some illnesses such as arthritis may cause pain or limit flexion and range of motion, leading to uncomfortable intercourse.14 Psychiatric conditions including depression, dementia, and substance abuse can also lead to reduced sexual interest and impaired functioning. Medical illnesses may have an indirect effect on sexual functioning as well. Fear of pain or of exacerbating a medical condition such as angina may lead to an inability to relax and enjoy sexual activity.15 Some illnesses, such as breast cancer or gynecologic malignancies, may result in altered self-image and reduced feelings of sexual attractiveness.14

Various symptoms of sexual dysfunction may arise iatrogenically, as a result of prescription medications. A recent review on medications and sexual function reported that >100 drugs or drug classes have been associated with sexual dysfunction, and that the impact of medications on sexuality increases with age.16 Sexual side effects in women secondary to medications may include loss of libido, reduced capacity for arousal, and difficulty achieving orgasm. Psychiatric medications, including selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, mood stabilizers, and antipsychotics are known to carry a risk of sexual side effects. Antihypertensive medications, such as beta-blockers, diuretics, and clonidine, among others, have also been associated with sexual side effects. Other medications associated with sexual dysfunction include digoxin, corticosteroids, antihistamines, histamine subtype 2 receptor blockers, opioids, and cancer chemotherapeutic agents.7,16

Psychosocial Factors and Sexuality in Aging

Psychosocial factors also significantly impact sexual activity among older women. The life expectancy of women is greater than that of men; hence, many older women have lost their spouse or partner. As women outnumber men in the latter decades of life, the availability of a willing and functional sexual partner becomes a legitimate issue for heterosexual women. Lesbian women in this age group remain understudied. For those older adults who are able to enter into new sexual relationships, concern about sexually transmitted diseases has been reported as a reason for lack of sexual activity.3

One’s social environment can also play a role in the expression of sexuality. Some older women will find themselves living with their adult children and their families or in assisted living or long-term care facilities, where opportunity and/or privacy for sexual activity is lacking. On the other hand, many older women will continue to live independently. Some couples may even enjoy increased time for intimacy due to retirement or “the empty nest.” Among postmenopausal women, the elimination of concern about the possibility of pregnancy may result in decreased anxiety and increased ability to enjoy sex.7

Psychological and cultural factors are also important. Our culture is notoriously geared toward the notion that sex is for the young and, therefore, older adults are often not seen as sexually desirable or capable.17 This view is not always bestowed equally upon the genders. Movies and television frequently pair younger, attractive women with older men. Such ageist stereotypes about sexuality are unfortunately accepted by many older individuals, who may see sexual activity as inappropriate or dangerous.7

Sexual Disorders in Older Women

Hypoactive Sexual Desire Disorder

Sexual desire comprises a critical portion of the human sexual response cycle, and includes sexual fantasies and thoughts as well as motivation and receptivity to sexual activity. This phase has been postulated to include biologic, motivational-affective, and cognitive components.18 Basson19 suggested that a woman’s sexual response arises not from a biologic neediness or urge, but rather from intimacy. Motivation to participate in sexual activity is theorized to derive not only from sexual pleasure, but also from closeness and tenderness. Therefore, a woman may choose to experience sexual activity in order to have intimate relationship needs met.

Female hypoactive sexual desire disorder (HSDD) may occur in up to 33% of adult women in the United States. The complaint of low sexual desire alone does not meet criteria for the diagnosis of HSDD. However, such a complaint is not uncommon among older women. The prevalence of lack of interest in sex for women in the US 50–59 years of age has been reported as 27%, slightly lower than rates in younger women.20 A more recent study,3 however, reported prevalence rates of 38% to 49% for women 57–85 years of age. It is important to note that not all women are distressed by a decrease in sexual desire. In 2007, Hayes and colleagues21 reported that while the proportion of women with low sexual desire increases with age, the proportion of women distressed about their low desire actually decreases with age.

The diagnosis of HSDD is made when the patient has persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity, which cause marked distress or interpersonal difficulty and are not better accounted for by another Axis I disorder, general medical condition, or substance.22 Frequently, in women, HSDD and the physiologic effects of a general medical condition are both present. Thus, HSDD due to combined factors is diagnosed. HSDD may be lifelong (eg, patients with history of sexual trauma or abuse) or acquired (as in the case of a general medical condition). It may be generalized or situational and is frequently associated with dysfunction in sexual arousal and orgasm.23 An extreme version of HSDD, sexual aversion disorder, consists of persistent or recurrent extreme aversion to, and avoidance of, all genital sexual contact, which causes marked distress or interpersonal difficulty.22

Female sexual desire in later life may be impacted by numerous factors. As reviewed above, these factors may include medical or psychiatric illnesses, medications, and psychosocial factors such as availability of a partner or marital harmony. Hormonal fluctuations associated with surgical or natural menopause and endocrine disorders such as diabetes mellitus may affect desire. Psychiatric conditions such as major depressive disorder or panic disorder may also contribute to lack of desire or even aversion to and avoidance of sexual activity.24 Medications, including psychotropics, antihypertensives, tamoxifen, and antiepileptics, may result in decreased libido.

Female Sexual Arousal Disorder

Female sexual arousal disorder (FSAD), as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition–Text Revision,22 includes a persistent or recurrent inability to attain, or maintain until completion of sexual activity, an adequate lubrication-swelling response of sexual excitement. As in HSDD, the symptoms cause marked distress or difficulty with interpersonal functioning and may not be better accounted for by another Axis I diagnosis, general medical condition, or substance.22 Approximately 36% to 43% of women 57–85 years of age report difficulty with vaginal lubrication during sexual activity.3 The clinician should make the distinction between difficult lubrication due to physiologic changes during menopause versus a symptom of FSAD. In the older woman, this distinction may be challenging as estradiol deficiency prevents an adequate lubrication response. Gathering an adequate medical and sexual history, including the timing of onset of the arousal difficulties, may help the clinician make this distinction.

FSAD is commonly associated with other sexual disorders. For example, a woman who is not able to maintain her arousal response may complain of low desire. The clinician should assess the onset of her decreased sexual interest as it may correlate to her delayed arousal response. If so, her primary difficulty is FSAD, with a secondary HSDD. That is, since her arousal response is significantly diminished, she may “report” low sexual desire. This is an important distinction for the clinician to make as the diagnosis and treatment may vary.

Arousal difficulties may have underlying psychological, vascular, neurologic, or endocrinologic etiologies.25 The most notable endocrinologic etiology for the older woman is, of course, menopause. Estrogen decline results in vaginal dryness and difficulty attaining adequate lubrication for sexual activity. With regard to vascular etiologies, atherosclerosis may result in decreased vaginal and clitoral blood flow. Traumatic injury to the pelvic arterial bed from fractures, trauma, surgical disruption, or chronic perineal pressure from activities such as bicycle riding can result in diminished vaginal and clitoral blood flow.26 Spinal cord injuries and peripheral and central nervous system disorders may inhibit sexual arousal as well. As in HSDD, psychological factors (eg, self-esteem issues, presence of a mood or anxiety disorder) and relationship problems may also contribute to difficulties in female arousal. Medications with antihistaminic and anticholinergic properties may prevent adequate lubrication and arousal.

Female Orgasmic Disorder

Among women, there is significant variability in the type and intensity of sexual stimulation that results in orgasm. In addition, orgasm may vary within an individual over her life cycle. Female orgasmic disorder (FOD) is defined by the DSM-IV-TR as a persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. Given the variability of sexual response among women, the DSM-IV-TR dictates that the diagnosis of FOD should be based on the clinician’s judgment that the patient’s orgasmic capacity is less than would be expected for her age, sexual experience, and adequacy of sexual stimulation.22 As in the other sexual disorders, inability to achieve orgasm may be a problem she has had all of her life or one that has developed due a wide variety of biopsychosocial issues including relationship issues, the normal process of aging, general medical conditions, or any of a variety of possible medications.

Up to 38% of women >57 years of age report an inability to climax.3 Some women have never experienced orgasm, possibly the result of inexperience, religious inhibitions, or emotional or sexual trauma. Others acquire FOD after previously enjoying a satisfying sex life. As with the other female sexual disorders, if a women “had it, lost it, and wants it back” for herself, treatment will generally have a more favorable outcome.27 FOD is more common among unmarried women and those without a college degree.20 Psychosocial factors including relationship quality, self-esteem, and attitudes toward sex may also contribute to FOD. Medical etiologies of anorgasmia include medications, substance abuse, hormonal deficiency, surgery, or trauma.

Sexual Pain Disorders

Eleven percent to 18% of women 57–85 years of age report pain during intercourse.3 Sexual pain disorders include dyspareunia and vaginismus. The two disorders are characterized by difficulty with vaginal penetration. The DSM-IV-TR defines dyspareunia as recurrent or persistent genital pain associated with sexual intercourse. Vaginismus is defined by the DSM-IV-TR as recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse, though some authors have proposed reconceptualizing this disorder as either an aversion/phobia of genital penetration or a genital pain disorder.28 In order to make either diagnosis, the symptoms must cause marked distress and interpersonal difficulty and are not better accounted for by another Axis I disorder (eg, somatization disorder) or a general medical condition or substance.22

Dyspareunia may be due to psychological factors or a combination of psychological factors plus a general medical condition. DeUgarte and colleagues25 suggested dividing dyspareunia into three categories for ease of diagnosis: pain with intromission (often secondary to vestibulitis, vaginismus, or superficial vaginal lesions), mid-vaginal pain (often secondary to vaginal dryness, surgical scars, etc), and deep-thrust dyspareunia (secondary to endometriosis, pelvic adhesions, neoplasm, or interstitial cystitis).

Vaginismus may be so severe that penetration of the vagina by any means (tampon, speculum, or penis) may be impossible. Vaginismus may be primary, wherein no penetration has ever been achieved, or secondary, wherein penetration has been achieved in the past. There is often a negative feedback cycle, wherein the discomfort and humiliation of attempted penetration leads to a phobic avoidance of any sexual contact at all.29 Proposed psychological factors contributing to vaginismus may include psychosexual conflicts, strict religious upbringing which associates sex with sin, a history of sexual abuse or rape, or emotional disconnect between sexual partners.30

Assessment and Treatment of Sexual Disorders in the Older Woman

Assessment

The evaluation of the older women who presents with a sexual complaint requires careful consideration of the patient and the multitude of factors that impact on the various components of the sexual response cycle (Table 1).23 A comprehensive medical and psychiatric history must be obtained, with special attention paid to any psychiatric or medical condition which may impact sexual functioning (eg, depression, anxiety, substance abuse, menopause, diabetes). A complete sexual history is imperative and includes attitudes toward sexuality, level of sexual knowledge of the patient and partner, relationship with the current partner, past sexual behaviors, and current and past sexual levels of functioning (ie, desire, arousal, and orgasm).

 

Equally as important as assessing the patient’s current level of sexual functioning is assessing her level of distress due to her symptoms. Shifren and colleagues31 recently reported that while sexual problems are greatest in elderly women, sexual problems causing distress are least prevalent in this age group. They noted that the reasons for this are unclear, but may include changes in partner status or partner’s health, significance of other medical conditions, or other factors important to relationships of long duration. Clinicians should be able to identify relevant age-appropriate issues with older couples; it may be helpful to interview partners alone and together.17 Accurate assessment of sexual dysfunction in late life is contingent upon a trusting, secure doctor-patient relationship in which both parties feel comfortable discussing these sensitive topics.7

The use of a simple intra-individual assessment tool such as the Sexual Energy Scale (SES) may be helpful in providing an objective means of measuring the patient’s report of their subjective experience of vitality/sexual energy.32 The patient is educated that sexual energy is not comprised merely of the frequency of intercourse or masturbation, but also includes sexual dreams, fantasies, genital sensations, and sexual appetite. The patient rates her current sexual energy on a scale of 1–10, with 1 being the lowest sexual energy she has experienced in her adult life, and 10 being the highest (Figure). The SES may be repeated at subsequent visits. The busy primary care physician can use this simple, one-item scale to track symptomatic improvement over time as the patient is being treated. The scale may help both patient and physician evaluate response to treatment.

 

A thorough medication inventory, including over-the-counter medications, is essential. As discussed above, many medications carry risk of sexual side effects and may impact all components of the sexual response cycle. Physical examination, including gynecologic examination, may help identify medical factors impacting sexual functioning (eg, vaginal atrophy, cystocoele, leakage). Laboratory testing may include complete blood count, electrolyte levels, lipid panel, and thyroid function tests as well as levels of prolactin, follicle-stimulating hormone, estrogen, and free and total testosterone.

Treatment

Treatment for the older woman with sexual dysfunction depends in part on whether the problem is considered a sexual disorder that she has had all of her life or one that has developed more recently (Table 2).23 If the problem has developed more recently, assuming that there is no significant change in her health, then the clinical prognosis is likely to be more optimistic. In either case, the patient should be encouraged to cultivate a positive attitude toward sexuality in late life and avoid unrealistic expectations, such as that sex must be the same as when she was younger.7 Education may be required as to what constitutes normal and dysfunctional sexuality as well as how to modify sexual activity in the face of fatigue and pain. Maintaining open and honest communication between partners is essential. Lifestyle adjustments are likely to be beneficial. Patients should be instructed to cease smoking and avoid alcohol or illicit drugs. Regular exercise, as tolerated, including pelvic floor exercises, proper nutrition, and sleep hygiene techniques should be encouraged, in addition to stress management techniques and social and partnership skills training.23

 

 
If the disorder is due to a substance such as a prescription or over-the-counter medication, one could wait to see if tolerance will develop and the sexual side effect will attenuate, though this does not commonly occur.33 Attempts to reduce or eliminate that medication may be undertaken, if feasible. If the patient is felt to require the medication, consideration may be given to switching to another class which may have lower likelihood of sexual side effects (eg, switching from fluoxetine to bupropion for treatment of depression). An alternative strategy is to utilize antidotes to reverse sexual side effects (eg, bupropion or sildenafil for SSRI-induced sexual dysfunction). Of note, no medication is Food and Drug Administration-approved for the treatment of sexual disorders in women.

If the sexual dysfunction is due to a medical or psychiatric condition, treatment for that condition (eg, hypothyroidism, depression, vulvitis) should be optimized first. Postmenopausal women should be assessed for signs and symptoms of estrogen deficiency (ie, hot flashes, vaginal dryness) and androgen deficiency (ie, global loss of sexual desire, decreased genital sensitivity). Hormone replacement therapy (estrogen and/or testosterone) may be considered and is available in a variety of routes of administration (oral, transdermal, injection or topical). The use of estrogen replacement has been controversial in the US because of its reported association with breast cancer, stroke, and ovarian cancer. In selecting patients for estrogen replacement, the clinician should carefully consider the individual’s medical history, including history of smoking, migraine headaches, breast cancer, or stroke.

The testosterone patch is currently available for women with HSDD in Australia, Canada, and Europe. While it is known that testosterone can improve sexual desire in postmenopausal women on estrogen therapy, the question has been raised as to whether or not the testosterone patch is effective for HSDD in postmenopausal women who are not on estrogen. To answer this question, Davis and colleagues34 conducted a randomized, double-blind, placebo-controlled multisite trial. They found that for postmenopausal women with HSDD not on estrogen, 300 mcg/day of testosterone had a significantly greater improvement in the 4-week frequency of satisfying sexual episodes than those using placebo. In the US, physicians may prescribe physiologic replacement levels of testosterone for women using low doses of products that are approved for men or by referring patients to compounding pharmacies. Prior to beginning testosterone replacement, clinicians should engage patients in a thorough discussion of the risks and benefits. Potential long-term risks may include hyperlipidemia, hirsutism, clitoromegaly, voice changes, liver tumors, and transaminase dysfunction, although these side effects are generally considered dose dependent. Physiologic replacement levels of testosterone in women do not appear to have significant adverse events. A clinician may want to order a baseline fasting lipid profile before initiating testosterone, with a repeat panel in several months. Women in this age group are at increased risk of hyperlipidemia, and if these studies have not been done within the last year, then it is prudent to obtain these studies.

While many medications have been tried in the treatment of female sexual disorders, randomized controlled trials are limited, particularly in older women. Agents such as sildenafil, bupropion, prostaglandin E1, phentolamine, and others have been reported as possible treatments for female sexual disorders, in addition to medical devices such as vacuum therapy and electronic stimulation.25 Currently, there are non-hormonal medications for the treatment of low sexual desire in ongoing phase III clinical trials in the US (ie, flibanserin).

For the older woman whose sexual disorder is felt to be related to psychological issues, sex and/or marital therapy should be considered. Cognitive-behavioral techniques are replacing previously used psychodynamic models of therapy.35 Therapy often begins with psychoeducation and support, to help cultivate more positive attitudes toward sexuality in late life. The therapist may help correct “all or nothing” cognitive distortions, wherein the patient feels that if orgasm is not achieved, sex is worthless. Patients may be educated on techniques such as self-stimulation, sensate focus, and foreplay, so that the focus of sexual activity is not exclusively intercourse. For the older woman with vaginismus, psychoeducation and cognitive-behavioral therapy may be accompanied by the use of vaginal dilators of graduated sizes, allowing the woman to be in control while extinguishing the involuntary muscle contraction.29

Conclusion

As women are living longer, healthier lives, they seek to maintain sexual health and satisfaction throughout the latter decades. Many biologic and psychosocial factors uniquely affect the older woman and place her at risk for sexual dysfunction. She must overcome hormonal fluctuations, medical conditions, necessary medications, changes in intimate relationships, and a culture which equates sexiness and vitality with youth. Physicians who treat older women should be familiar with the effects of aging on the normal female sexual response cycle, as well as the biologic and psychosocial factors which impact female sexual functioning in late life. Physicians should routinely inquire about patients’ sexual functioning and satisfaction and provide an open, supportive environment in which to discuss such concerns.

Older women may experience disorders of sexual desire, arousal, orgasm, and pain. Identifying the biologic and psychosocial contributors is essential in the treatment of these disorders. Treatment in all cases should include psychoeducation and lifestyle adjustments, such as exercise, proper nutrition, sleep hygiene, elimination of alcohol and drugs, and improving communication skills among partners. Treatment should also include optimizing treatment of underlying medical and psychiatric conditions, reduction or elimination of problematic medications, and referral for sex therapy, as clinically indicated. Medications for the treatment of various sexual disorders in women are currently under investigation. Given the strong association between sexual dysfunction and quality of life,20 further research is needed in this area. Sexual dysfunction is a common, but neglected area in medicine, in particular for the older woman. PP

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