The “Academic Article” that you will read below is a part of the book “Klimakterik Kadın Sağlığında Güncel Gelişmeler” (in English: Recent Developments in Climacteric Women Health), which was written by Prof. Dr. Süleyman Engin Akhan. (Prof.Dr.Süleyman Engin Akhan. Chapter 23. Menopause and Sexuality. Ed:Prof.Dr.Tamer Erel, Klimakterik Kadın Sağlığında Güncel Gelişmeler. Nobel Medical Books. 2013: (23) 181-186)
Menopause and Sexuality
Prof.Dr.Süleyman Engin Akhan
Istanbul University, Faculty of Medicine, Department of Gynecology and Obstetrics
At 1978, “Alma-Ata Declaration”, which was published after the conference World Health Organization conducted at Alma-Ata, begins with these sentences: “An healthy sexual life is not a luxury, it is a fundamental right” (1) and this right is valid for any individual in a lifetime
1. Outlines of Sexuality and Psychosexual Developments
Sexuality is a multi-variable process including psychology, biology, morality, and cultural. This process is a motion that continues throughout life and it is formed and developed as a result of one’s lifetime experience, self-identity, relations and privacy.
Sexuality and sexual attitude includes learning of sexual development, reproduction health, interpersonal relationships, affection, physical appearance, and sexual roles. Hence, the most important thing is that sexuality is a part of a person’s character in terms of human relations; it reflects and shapes some part of the person’s character (2,3).
Nowadays, psychosexual development of a person is defined as a complex model in which prenatal and postnatal factors affect sexual identity and sexual tendency (2,4).
Hence, our sexual identity, which does not start developing inside uterus, is one of the factors that makes us how we are and shapes our lives, that is shaped after birth, in childhood and adolescent periods, in which outline is drawn affected by many different factors, and keeps being shaped for both men and women until the end of life.
The most important organ that shapes one’s sexual response and forms behavior patterns, for both men and women, is brain. Psychosexual development of brain is formed by genetics, pre and post natal hormonal environment, sexual experiences and learning processes (4).
The process defined as “learning” is the process in which humankind builds an attitude towards life, and character, in other words, “learns” the life. To illustrate, in childhood period, behaviors of parents towards each other (do they kiss and hug?) in front of their kids, or in the environment in which the child is growing, roles of men and women is effective to this period.
For this reason, sexual perception differs from one individual to another. Moreover, this difference makes every individual unique. In addition, every individual has a different perspective of sexuality and self-positioned place in one’s life. This is why, there is such thing called “privacy”
2. Menopausal Period and Quality of Life
Turkish data showed an increase in human life similar to the entire world. Approximate female life rates are 73.4 in 2003, 73.8 in 2005, 74.2 in 2007, 75.8 in 2008 and 76.1 in 2009.
Therefore, women’s menopausal life period is extended and will keep on extending. Today, life expectation of northern Scandinavian countries is around 90. There is a similar case in Turkey.
One of the basic numbers that do not change in woman’s life cycle is the age of menopause. While the age of first menopause is reducing (we should discuss that some other time), the age of menopause does not change and it is around 50. With another point of view, the duration spent in menopause is approximately 26 years for our country according to 2009 data!
These data increasingly emphasize a fact, which is a focal point in our life, and changes the construct of health system in the whole world, in which we doctors play the role of gears; Increase in human life expectancy also increases the expectancy of quality of life.
There are four foundation of the concept of quality of life for women in menopausal period, and this four vital system increasingly come into prominence with increasing age. It affects and shapes our quality expectance of life deeply: 1. Cardiovascular system; 2. Skeletal system; 3. Sexual life, libido; 4. Mental health (Dementia and Alzheimer’s disease)
Perimenapausal and postmenapausal periods are necesarry periods for a woman to adapt the life again in terms of both physiologically and psychologically. The job of the menopause clinics and we doctors who serve in the system is to help this adaptation process; to show a path to a life of good quality, to do protective medicine, and if necesarry, present other treatment options. Nowadays, one of the reasons of application to menapause clinics is woman’s sexual function disorder.
3. Postmenopausal Period and Women Sexuality
Some changes emerge for a woman who is in menopause, which I don’t want to mention thoroughly but are very important. These alterations can be specified under three categories:
1. Physical Alterations: Symptoms such as central/male type adiposity (this is the reason why a woman in her menopause period should do sports and take care of her diet); reducing levels of collagens and looking “aged” especially over facial areas (and this is why you have to quit smoking); hot flashes, excess sweating; “draught” which effect sexual activity in woman directly, losing control of bladder.
2. Psychological Alterations: Emotional condition changes where specifically, depression can be observed; “Empty home syndrome” which can intensify with the moving out of the children because of education or marriage. Woman feels alone and unhappy.
3. Cognitive Alterations: Loss of attention, or problem caused by short-term memory loss; problems that come with having a hard time learning things, “not understanding and not comprehending” complaints are often. My patients who are mathematics teachers complain about “not being able to solve pool problems.” My suggestion is that you should do plenty of crosswords or Sudoku. They are good for your cognitive functions.
The alterations listed under these 3 main topics which occur to women during menopausal period can cause loss of self-confidence and will directly affect sexuality negatively. But the most important point is that the damage which is done to the woman’s body image during these changes.
Body image is an intellectual and/or spiritual “structure” which continuously and dynamically shapes itself throughout the life with the effect of psychological and neurologic processes.
Throughout the life, every neurobiological, psychological process can change the perception of the body image of oneself. Body image is one of the key aspects of sexual identity. Physical, emotional relation and its quality and importance one experiences during sexual activity, having a direct effect on their body image, also body image can effect and change sexual functioning and response. Physical and mental alterations taking part in menopausal period negatively effects this perception (3).
When it comes to menopause and woman’s sexual identity, another point on sexuality that should be made is sociocultural environment. Sexuality in postmenopausal period is considered a taboo in many cultures.
Because, “passion is an obstacle on path to wisdom while aging”. It is considered “shameful” for a woman who is mother and/or a grandmother to talk about sexuality, especially in a man dominated world. Whereas in literature, “negotiating sexuality” which can be described as “sharing and talking about sex”, is vital for a woman who is in her menopause period (7).
While woman is afraid of controlling these physical and psychosexual excitations due to sexuality in this period, the ambition for sexual experience she wants to have brings the risk of social rejection with it.
By the way, primarily the visual media always imposes the myth; “Only the young and beautiful woman deserves sexual activity!”
Helen Kaplan makes a clear definition about the relation between sexuality and age in her compilation written in 1990: “As long as Men and Women are healthy and have adequate partners, they stay sexually active until the end of their lives.”
4. An Approach towards Women’s Sexuality Dysfunction in Menopausal Period
Reasons lying underneath the women’s sexual dysfunction are pieces of a complicated structure. The base of these involute reasons that we generalize as hormonal and psychosocial factors can be listed as; age, menopausal condition caused by hormonal environment, previous sexual experience and woman’s perception of sexuality (her attitude), her relationship with her partner, and as a dominating factor, whether her partner has an erection and/or premature ejaculation problem for this relationship.
It has been shown that exposure to the hormonal environment in the menopausal period and the age are effective on the sexual functions of women independently (8, 9). On the other hand, triggering factors of female sexuality are multi-directional and it is not clearly known which part and in which amount they affect female sexual functional disorders such as age or estrogen level.
“The Melbourne Women’s Midlife Health Project” is a population based prospective study published in 2002 by Dennerstein et al. A total of 438 female in perimenopausal period who did not use hormone drugs (oral contraceptives and/or hormone replacement therapy) in any period of their lives were followed for 8 years prospectively (8).
At the end of the study, woman’s libido in menopausal transition period and age, estradiol level, “free estradiol index” were found to have significant relations. Researchers showed that basic hormonal parameter that affects women’s sexual functions in this transmission period was the estrogen levels.
Similarly, SWAN study which is a wide epidemiologic study, showed that age and menopausal status had negative effects on woman’s libido separately (9).
On the other hand, although androgens are main physiological factors in reproductive ages that trigger desire and excitement in female sexual cycle, researchers expressed that there is a reduction in sexual functions in menopausal transition period but this reduction cannot be explained with endogen androgen levels in the study of Dennerstein et al (8, 10).
No significant link was found between any part of female sexuality (desire, excitement, orgasm etc.) and endogen androgens studied in this research (total testosterone, free androgen index, DHEAS) (8).
One of the important parameters that affect female sexuality in menopausal period is education. As the educational level increases, woman’s attitude towards sexuality, pleasure she gets and the results acquired from various tests in which female sexual functions are evaluated are increasing in positive direction. Especially in tests applied in high school and university graduates are clearly higher when compared with other women (9, 10).
Also in menopausal period one of the most important factors that cause female sexual function disorder is the status of the husband. Impaired communication regarding sexuality with husband affects female sexual functions negatively while concurrent sexual function disorder in husband (i.e. erection problems and/or premature ejaculation) affects the woman directly (10).
However, at this point, the results of multi-central CLOSER study published by Nappi et al must be mentioned of. The study which was published this year (2013) is a prospective study evaluating the effects of vaginal atrophy and dryness which occur in menopause on the woman and husband. One of the emphasized results of the study is that it shows that dryness affects the relations in sexuality very negatively if there is a concurrent erection problem in the husband (11).
Also, MARIA study including 179 sexually active women aged 40-65 which was published in 2012 in Spain shows positive correlation between sexuality scores and educational levels while showing negative correlation with concurrent erection problems (10).
5. Basic Principles in Treatment of FSFD in Menopausal Period
In presence of the factors affecting female sexuality as we told above, a woman presenting with sexual problems in menopausal period must be evaluated with a totalitary approach, her experiences, relations with her husband in sexuality must be questioned in the anamnesis.
In the last two decades, understanding the basics of neurovascular mechanism of sexual response and use of vasoactive agents in men parallel to these advancements in both men and women made an important breakthrough in treatment of male sexual dysfunctions.
The same advancement could not be achieved in treatment of sexual functional problems in women. Still, postmenopausal hormone treatment (PHT) is considered to be a serious alternative to treatment of female sexual functional disorders which occur as a result of menopausal process along with aging (12, 13).
Although prospective randomized researches showed that there is a positive effect of PHT on FSFD, the question how effective PHT is and in which part of FSFD it is effective is still up-to-date.
The subject that hasn’t been argued yet is the positive effet of PHT on female sexuality. Estrogen replacement has a positive effect on body image of woman while it also removes vaginal atrophy.
Another important subject of discussion is treatment of androgen replacement. Especially in women who entered in menopause surgically, sudden depletion of androgen and estrogen due to castration brings forth severe vasomotor symptoms and loss of libido.
Although it has been claimed that women’s mood and sexuality will be affected negatively with surgical menopause as a result of acute falling in androgen levels after surgery, Dennerstein et al. showed that the basic factor is estrogens in this tranmission period (8). Also, in series of surgical menopause cases of Aziz et al, it was found that mood and sexuality are not affected negatively (12).
It has been showed that androgen replacement affects female sexuality positively after surgical menopause in prospective randomized trials. One of the important criticizes is that androgen doses are high and case volumes are limited in some of these studies (13).
Androgen replacement treatment should only be used in well estrogenized women and after evaluation of sexual functions objectively under certain scales by experienced doctors and after profit/loss balance is discussed.
The duration a woman spends in postmenopausal period is increasing. Menopausal period is a period in which woman must take precautions to protect life quality, thus reconsider her priorities in order to adapt to many changes in this period without losing the facts.
In this process, sexuality is an inseparable part of a qualified life. It is possible to provide different solutions to women who consult for sexuality problems.
However, due to excessiveness of factors that affect sexuality and personal nature, in postmenopausal patients who consult with sexual function disorders, all these factors should be considered, other disciplines should be consulted when necessary, and a totalitarian approach should be taken.
(Image: Danny O’Connor; from facebook open art page)
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