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Intimacy and sexuality after the menopause

Research consistently reports that older people tend not to seek medical help for sexual concerns or difficulties. Many people assume that sexual changes are 'normal' with ageing. This is true, but if changes are causing distress within a relationship, a couple should be able to seek help.

A review of studies examining sexual problems in middle and later life reveal that people were more likely to seek help if their doctor had asked about sexual function during a routine visit within the past three years. However doctors tend not to take a proactive approach to sexual health management and may have limited knowledge of sexual wellbeing in later life. There is an assumption from healthcare professionals that sex is less important to older patients than it is to their younger ones.1

Many older people do remain sexually active; one study reported sexual activity in 73% of adults aged 57-64 years, 53% of adults aged 65-74 years, and 26% of adults aged 75-84 years.2 Sexuality is an integral part of humans. Sexual contact not only helps to fulfill physical needs but also social, emotional, and psychological needs. Although sexuality in older people is often ignored in today's youth-loving society, the need for intimacy does not disappear with increasing age and indeed sexual activity can contribute to happiness and well-being of older people.

Sexual wellbeing is dependent on many factors and there are changes in sexuality throughout life, linked to events such as childbirth or new relationships, changes linked to psychological and medical problems, the quality of a relationship and hormonal changes.
Hormones, menopause and sexuality
At menopause, with a decline in circulating oestrogen, changes occur that may affect sexual function. Many women following menopause experience a loss of sexual desire. However a woman's motivation for sexual activity is complex, combining the need for emotional intimacy with the partner as well as for sexual satisfaction. A negative experience during sexual activity, such as pain or embarrassment, will contribute to this loss of desire. The recent CLOSER (CLarifying vaginal atrophy's impact On SEx and Relationships) survey showed that menopause has an ongoing negative effect on sexual relationships in about 70% of British post-menopausal women.3

Most commonly, about 45% of women experience vulval and vaginal atrophy resulting in vaginal dryness, itching, irritation, reduced lubrication, dyspareunia, and even vaginal bleeding associated with sexual activity. Pain experienced during intercourse due to vaginal atrophy may then be made worse by vaginismus making penetrative intercourse even more difficult. Low levels of oestrogen following menopause may also result in reduced clitoral sensitivity, arousal, orgasm and sexual satisfaction.  

Other changes associated with menopause and ageing, such as weight increase and changing body shape, can lead to a loss in confidence about feeling sexually attractive. Menopausal flushes and sweating can further add to these feelings of unattractiveness, further compounded by disruption to sleep resulting in tiredness and low mood.

As oestrogen loss is a significant cause of sexual dysfunction in menopausal women, oestrogen replacement therapy is a logical and effective treatment option. Both systemic and local oestrogen therapy improve vaginal health and sexual functioning. A low dose vaginal oestradiol or oestriol preparation, given as a cream, ring, pessary or tablet, is appropriate for women with menopausal vaginal symptoms alone. Women experiencing other distressing menopause symptoms, a systemic oestrogen therapy, alone or in addition to a vaginal product, should be considered. It is important to note that there is a relationship between intensity of menopause symptoms in women and sexual problems, particularly after a surgical menopause.4

Systemic absorption is very limited from vaginal oestrogen products. Vaginal oestradiol tablets have a licence for indefinite use and this sets precedence for continuous use of vaginal oestrogen, certainly for as long as a woman remains sexually active (longer if treatment helps urinary problems).

There is no need for a progestogen for endometrial protection. However because of the low dose of vaginal oestrogen products, it may take several months before treatment is totally effective.

Couple and partner issues
Studies indicate that sexuality and intimacy remain an important part of long-term relationships, although expressions of intimacy may change with ageing and may no longer include penetrative intercourse.5 If a woman is presenting with sexual problems, any additional sexual problems of a partner should also be understood, such as erectile dysfunction and loss of libido, as these will impact on a woman's level of interest in sexual activity. If there are relationship stresses, then referral to an agency such as Relate may be appropriate.

Reduction in sexual activity with age may not be a problem for many couples, if it is mutual. It is important to find out the views and concerns of both partners before treating one member of a partnership, as this might lead to incompatibility.

Communication between a couple is always priority to prevent misunderstandings. The CLOSER survey highlighted that British men were most uncomfortable in talking about vaginal atrophy, more than in any other country, and one in five men reported that it aggravated their own sexual health issues such as erectile dysfunction.3

Medical issues and sexual problems
Sexual activity, quality of sexual life, and interest in sex are linked with general health in middle age and later life. Ill-health can lead to a loss of libido in both men and women, often secondary to the lack of well-being and discomfort. Generally men remain sexually active for longer than women but they are more likely to become sexually inactive due to poor health. Health issues affecting sexuality include diabetes, multiple sclerosis, hypertension, arthritis, or other pain and mood problems. Medications too cause further difficulty in loss of libido, arousal and orgasm.

Disfiguring surgery may not only have a severe detrimental effect on a woman's body image and subsequent sexual function but it may also affect her partner's desire. Healthcare professionals must get used to talking about resumption of sexual activity after traumatic illness and life events, offering 'permission' to patients to be able to discuss their sexual problems and feelings.

Gynaecological disorders increase dramatically with age such as  pelvic floor disorders that may result in urinary incontinence, pelvic organ prolapse, and faecal incontinence. These have a significant impact on sexual function due to fear of embarassment.6 Fear and other psychological issues can have a major impact on sexual quality of life and feelings of self-worth.

Now what?
The RCN (2000) state that 'nurses vary in skill levels, but all have a duty to work at their level of competence using evidence-based practice' and 'to work on the issue of sexuality and sexual health without feeling embarrassed, ill-equipped or ill-informed'.7

Practice and specialist nurses should be proficient in taking a sexual history and to provide a comfortable environment where patients feel secure to discuss their sexual health. Using cue questions, nurses can provide an opportunity to raise any concerns.

For the non-expert nurse, it may be appropriate to give limited information. However to give specific suggestions and intensive therapy requires specialist training.8 It is essential that the local care pathway is identified for individuals and couples who need further support and treatment for complex issues.

In conclusion, older women are interested in continuing sexual activities. It is a component of life satisfaction and it remains an important area for patient education and treatment. Health providers should include sexual health issues in their discussions with patients irrespective of age.

1.     Hinchliff S, Gott M. Seeking medical help for sexual concerns in mid- and later life: A review of the literature. Journal of Sex Research 2011;48(2):106-17.
2.     Kazer MW. Issues regarding sexuality. Evidence-based geriatric nursing protocols for best practice (4th ed.), 2012;500-515.
3.     Domoney C, Currie H, Panay N, Maamari R, Nappi RE. The CLOSER Survey: Implications of vaginal discomfort in postmenopsual women and their partners. British Menopause Society (BMS), 22nd Annual Conference July 2012.
 4.     Topatan S, Yildiz H. Symptoms experienced by women who enter into natural and surgical menopause and their relation to sexual functions. Health Care for Women International 2012;33(6):525-39.
5.     Barker J. Couples' perception of sexual intimacy through the ageing process in long-term heterosexual marriages: Faith-based population. Dissertation Abstracts International: Section B: The Sciences and Engineering 2011;71/7-B4493.
6.     Ratner ES, Erekson EA, Minkin MJ, Foran-Tuller KA. Sexual satisfaction in the elderly female population: A special focus on women with gynecologic pathology. Maturitas 2011:70(3);210-5.
7.     Royal College of Nursing. Sexuality and sexual health in Nursing Practice. RCN; 2000. Publication code 000 965. Available at:
8.     Armitage K. How to take a sexual history in primary care. Primary Care Women's Health Journal 2011:3(2)63-65. Available at: