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Try out PMC Labs and tell us what you think. Learn More. Sexuality is an important component in the lives of menopausal women.

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The addition of phosphodiesterase type 5 inhibitors for the treatment of male erectile dysfunction in combination with longer life expectancy has impacted attitudes and expectations to maintain sexual functioning. Despite the importance of sexual function in menopausal women, sexual dysfunction increases with age. Age-related decline in sexual function may ificantly reduce quality of life, making recognition of sexual dysfunction by physicians important for getting menopausal women effective care. Sexual dysfunction can result from multiple etiologies including psychosocial factors, medication side effects, vulvovaginal atrophy, chronic illness, or hypoactive sexual desire disorder HSDD.

Discovering the etiology and identifying modifiable factors of the sexual function will help define appropriate treatment. Sexuality may impact quality of life through effects on the emotional and psychological health of a woman. Consequently, clinicians who take care of women appreciate when they may be vulnerable to sexual dysfunction.

The menopausal transition, a time characterized by hormonal, physiological and social changes, is often associated with sexual dysfunction. The physiological mechanism by which the menopausal transition affect sexual health involves declining and fluctuating gonadal steroid hormone levels which adversely affect elasticity of the vaginal mucosa, vaginal secretions and result in vaginal atrophy and pain with sexual intercourse [ 1 ]. Additionally, social conditions or life stressors such as divorce, lack of a partner, job loss, or declining health may affect desire for sexual intercourse.

Improved access to medical care and nutrition Woman want real sex Carr Colorado increased the average life expectancy. Therefore, the average woman making the transition into menopause can expect to live for at least 25 years [ 2 ]. With increased expectations for a longer and healthier life, women are thinking more about quality of life issues, which include maintaining sexual function [ 3 ]. Additionally, attitudes and expectations regarding sexual function were further impacted when the FDA approved phosphodiesterase type 5 inhibitors for male erectile dysfunction, which Woman want real sex Carr Colorado in more menopausal women with male partners who have renewed sexual interest and improved function [ 45 ].

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Regardless of age and menopausal status, sexual interest continues for many women. Even though sex is important to reproductively senescing women, sexual activity and function decline with age. The etiology of this decline in sexual function and activity may vary and is often multifactorial.

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Thus, a careful evaluation is required to determine the cause and recommend the best intervention. In the regularly menstruating woman, each month follicular phase follicle stimulating hormone FSH stimulates follicular growth and estradiol synthesis. Increasing estradiol production from the dominant follicle Woman want real sex Carr Colorado a negative feedback and suppressive effect on FSH and luteinizing hormone LH.

Estradiol synthesis from the dominant follicle continues until a critical level is reached and estradiol positive feedback induces positive feedback, an LH surge and ovulation [ 9 ]. Estradiol synthesis during the menstrual cycle affects vaginal secretions and the vaginal mucosa. Multiple physiologic changes that occur during the menopausal transition result from reduced ovarian reserve and reduced s of gonadotropin responsive follicles. Menstrual cycles in late perimenopausal women are characterized by increased FSH, decreased inhibin B, and irregularly short and long cycle lengths[ 10 ].

Until the time of the last menstrual period LMPestradiol levels are equally variable in perimenopausal women. After estradiol falls, estrone, primarily generated by the aromatization of androgens, becomes the main circulating estrogen. Compared to estradiol, serum androgen levels demonstrate a steady but less dramatic decline Figure 1 [ 813 ]. The less dramatic fall in serum androgens is related to the decrease in sex hormone binding globulin associated with hypoestrogenism[ 14 ].

Compared to premenopausal women, menopausal women experience ificant shifts in serum levels of gonadal steroids and gonadotropin. Reduced ovarian estradiol synthesis in a 4. Menopausal women synthesize 0. However, the fold change is not nearly as great as that observed in estradiol.

Data from Rothman, M. Woman want real sex Carr Colorado, Hormonal changes during menopause may impact sexual functioning. A prospective, population-based study of Australian born women, observed for eight years as they passed through natural menopause, reported that low estrogen levels adversely affected sexual interest and responsiveness, but did not affect the frequency of sexual activity [ 15 ].

Total testosterone was not ificantly affected in this cohort. Moreover, free testosterone levels did not ificantly affect any sexual domains. Similarly, no ificant difference in testosterone levels was observed in women undergoing natural menopause with SPEQ scores suggesting sexual dysfunction compared to women with SPEQ scores showing no dysfunction [ 8 ]. It is worth noting that it is possible that there are differences in serum testosterone, however, it may be difficult to observe ificant differences in very low levels of testosterone because of the sensitivity limitations of non-mass spectrometry-based testosterone assays [ 8 ].

Pelvic organ prolapse POP is the descent of one or more of the following: anterior vaginal wall, posterior vaginal wall, uterus or apex of the vagina. The incidence of pelvic floor weakening increases with aging and is thought to result from a combination of connective tissue degradation, pelvic denervation, and devascularization, all of which predispose to prolapse [ 16 ]. Dyspareunia, chronic pelvic pain, and modified self-image are associated with POP. Any one of these adverse symptoms can devastate sexual function. Hypoactive sexual desire disorder HSDD occurs when Woman want real sex Carr Colorado is a persistent or recurrent absence of sexual fantasies or desire for sexual activity that in personal distress.

For the diagnosis of HSDD to be made, iatrogenic or organic causes for sexual dysfunction must be ruled out and the patient must report marked distress or interpersonal difficulty [ 17 ]. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months. The prevalence of HSDD has been difficult to determine and has varied among studies. Disparate estimates of prevalence may reflect differences in the age of the study group and different criteria for diagnosis and study inclusion.

These s represent all women reporting occasional, periodic, or frequent problems with desire. If the population were restricted to women reporting frequent problems the prevalence of low desire would vary between 5.

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The risk for HSDD is greatest in women who have undergone surgical menopause. It is hypothesized that abrupt reductions in circulating B-estradiol and testosterone levels ificantly contribute to HSDD because testosterone replacement can increase sexual desire and arousal in this group of women [ 22 ] [ 23 ]. These data suggest that healthcare providers should routinely assess women with Woman want real sex Carr Colorado menopause for s of sexual dysfunction. Androgen therapy may be considered in this population of women.

HSDD correlates with low feelings of physical and emotional satisfaction, poor self-image, and unhappiness [ 25 ]. Research suggests multiple psychological reasons why women choose to engage in sexual activity, including wanting to feel close Woman want real sex Carr Colorado a partner, expression of love, and wanting to feel feminine[ 26 ]. Decreased levels of estrogen are associated with symptomatic vulvovaginal atrophy, a condition characterized by thin, pale, and dry vaginal and vulvar surfaces.

During menopause, the decline in estrogen le to a decrease in lactobacilli, acid producing bacteria that play a key role in keeping the vaginal epithelial pH in the range of 3. As lactobacilli decrease, the vaginal epithelium becomes more basic, leading to a change in vaginal flora. It has been noted that increased bacterial diversity is correlated with increased symptoms of vaginal dryness [ 28 ].

Symptomatic vulvovaginal atrophy is often accompanied by diminished secretions from sebaceous glands and reduced vaginal lubrication during sexual stimulation [ 1 ]. Women with vulvovaginal atrophy experience pain with intercourse that le to decreased interest and frank avoidance of sexual activity [ 30 ].

Twelve percent of women without a partner reported that they were not seeking a sexual partner due to symptoms related to vulvovaginal atrophy. Despite the high prevalence of symptomatic vulvovaginal atrophy in midlife and postmenopausal women, almost half of women report that they never discuss the impact of the symptoms on their quality of life with a health care provider.

Health care providers should be vigilant about asking patients about satisfaction with their sex life and they should query patients about s and symptoms of vulvovaginal atrophy. When a diagnosis of sexual dysfunction is suspected, a complete and detailed medical history should be obtained to evaluate women for chronic diseases that can adversely affect sexual health. This is especially true in menopause, because as women age they are at an increased risk for acquiring chronic diseases that impact sexual function [ 22 ].

Chronic diseases such as hypertension, diabetes, depression, neurological diseases, urinary incontinence, and osteoarthritis commonly impact sexual function [ 222734 ].

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The mechanisms by which cardiovascular disease affects sexual arousal is hypothesized to be related to the fact that female genital arousal is achieved when the vascular system increases blood flow and engorges the labia via vasodilation. Vascular disease may reduce vulvovaginal vasodilation and reduce sexual arousal [ 35 ].

Reduced physical function in obese women and women with osteoarthritis may also adversely affect sexual activity. Additionally, sexual dysfunction observed in women with diabetes is attributed to reduced energy, altered body image, and suboptimal vaginal engorgement during orgasm [ 22 ]. Medications must be considered Woman want real sex Carr Colorado a possible source of sexual dysfunction in menopausal women.

Organ systems have limited homeostatic reserve with aging, resulting in decreased clearance and enhanced toxicity of many drugs [ 36 ]. For these reasons, undesired effects of medications are more prevalent in the elderly. Medications commonly associated with sexual dysfunction include serotonin reuptake inhibitors SSRIs neuroleptics, and cardiovascular medications [ 2234 ].

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A detailed list is shown in Box 2. The menopausal transition and early postmenopausal years are considered windows of vulnerability for depression; therefore antidepressants may be a common medication amongst menopausal women [ 37 ]. When possible, the medication suspected of causing sexual side effects should be stopped or switched. Menopausal symptoms and sexual dysfunction can negatively impact quality of life for women.

A higher sense of purpose in life is Woman want real sex Carr Colorado by midlife women who report higher levels of enjoyment with sexual activity [ 38 ]. Women more likely to engage in partnered, intimate sexual activities tend to be of younger age, lower body mass index, married, and have better emotional well-being [ 38 ]. This raises the possibility that aging women affected by obesity or Woman want real sex Carr Colorado status may be at high risk for experiencing an overall decrease in quality of life.

By counseling patients about the benefits of healthy diet and exercise for weight control and screening for medications and illnesses that impact sexual function, health care providers may improve overall quality of life. Educational level and economic status impact sexual functioning and quality of life for women. Baseline data from the SWAN study suggested that women reporting financial strain were more likely to report decreased frequency of sexual desire and arousal as well as lower levels of emotional and physical satisfaction with intercourse when compared to their more financially secure counterparts [ 6 ].

Despite their decrease in desire and arousal, the majority of these women still reported that sex was moderately to extremely important to them. Menopausal women with some college or graduate school education have better physical and mental parameters of health that are related to quality of life compared to those with a high school education or less [ 3 ]. This demonstrates that multiple socioeconomic factors impact sexual functioning and quality of life for menopausal women.

Women affected by socioeconomic stressors may benefit from increased social support. Menopausal symptoms such as vasomotor symptoms and vaginal dryness negatively impact health related quality of life [ 39 ]. Women with vaginal dryness, even if they do not identify the symptom as bothersome, have worse mental health composite scores as well as worse emotional well-being and social functioning [ 3 ]. These data suggest that there is a need for physician vigilance and early detection so that interventions can be employed to prevent potentially debilitating effects on quality of life.

Psychological counseling, solely or in combination with medical treatment, can be helpful to women and couples suffering from sexual dysfunction.

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Couples therapy can help identify relationship issues contributing to sexual problems and allow opportunities for couples to improve communication[ 40 ]. Issues such as relationship distress, extended periods of sexual abstinence, sexual abuse history, lack of sleep, and taking care of an elderly parent can all impact sexual function [ 41 ].

Behavioral exercises may help individuals reduce anxiety associated with sexual dysfunction [ 42 ]. The role of hormone therapy in consistently increasing sexual desire or activity has not been established [ 25 ]. Current evidence does not support the use of estrogen or combined estrogen and progesterone therapy to treat sexual interest or arousal disorders in menopausal women [ 43 — 45 ].

Prior sexual functioning and relationship factors, such as having an attractive and available partner, a safe environment, and self-esteem, have been shown to be more important than hormonal determinants of sexual function in midlife women [ 15 ]. However, hormone therapy with estrogen may improve sexual function by increasing vaginal lubrication and reducing dyspareunia in women affected by vulvovaginal atrophy [ 25 ].

Local vaginal estrogen therapy is recommended as the treatment of choice for symptomatic Woman want real sex Carr Colorado atrophy [ 47 ]. Low dose vaginal estrogen formulations come in vaginal creams, tablets, and rings see Table 1.

Systemic absorption is low for these preparations and they are not effective for the relief of vasomotor symptoms [ 1 ]. A progestin is generally not needed when low dose vaginal estrogen formulations are used, although clinical trial data supporting endometrial safety beyond 1 year are lacking [ 48 ]. Thorough evaluation of any uterine bleeding should be done in women using low dose local estrogen therapy.

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