The biological changes associated with menopause do not occur in isolation but against a background of age-related changes in all the body systems of a woman. These age-related effects often interact with the menopausal changes and may exacerbate their impact. However, there is compelling evidence that menopausal changes, rather than age-related changes, are a primary precipitating factor of changes in sexual function. This is certainly more evident in premature menopause.
The natural decrease in oestrogen levels during perimenopause and post-menopause has profound structural and functional impact on the genital and urinary tracts. The typical changes in the external and internal genitalia include a reduction in size, thinning of the skin and mucous membrane, reduction in overall blood flow and loss of subcutaneous fat.
The vulva and vagina becomes thin, dry and less elastic. Over time, the pubic hair will decrease and the vagina will become shorter and narrower. Sometimes, the vaginal skin is more prone to infection or injury during sexual intercourse or even a gynaecological examination. There is increased risk of vaginal atrophy in premature menopause or when there is lack of regular sexual stimulation of the vagina.
It should not be assumed that all vulval and vaginal problems are due to decreasing oestrogen levels. If there are vulval and/ or vaginal complaints, it would be prudent to consult a doctor.
Water-soluble lubricants and moisturisers may be helpful in mild vaginal atrophy. Regular sexual intercourse has also been shown to maintain vaginal health. If these measures are ineffective, topical application of oestrogen will restore vaginal thickness and elasticity as well as relieve dryness.
The decreasing oestrogen levels also cause the lining of the urinary tract to thin, the bladder size to be reduced and it also weakens the supporting pelvic muscles. As a result, the following urinary symptoms may occur :
It should not be assumed that all urinary symptoms are due to decreasing oestrogen.
Many women with incontinence do not seek medical attention because of embarrassment or misconception that the condition is due to ageing and cannot be treated. The fact is that with diagnosis and treatment, most women are completely cured of incontinence. The treatment depends on the cause. The treatment options include:
The significant reduction in pelvic muscle tone and the resilience of the supporting tissue of the urogenital structure is associated with an increased risk of prolapse of the uterus and vagina.
Menopausal women may also have other health conditions e.g. diabetes, high blood pressure, stroke which can affect the functioning of the urogenital tract and sexuality.
Sexuality is an important part of life from youth to old age.
Many women in their 40s and 50s notice a decrease in libido, but how the menopause and hormones contribute to this change is totally known. There is no correlation between a decline in libido and falling oestrogen levels. Androgen does play a role in a woman’s libido and the ageing ovaries produce less androgen. In contrast to the sharp fall in circulating oestrogen during the natural menopause, androgen levels tend to peak in women in their 20s and then decline gradually with age.
Sexual arousal may take a longer time with ageing. More stimulation may be required to achieve adequate lubrication or orgasm.
Several factors influence a woman’s sexual activity during the perimenopause and beyond. They include:
It is important to remember there are also sexual changes in ageing men. Sexual arousal may take a longer time and erections may be less rigid.
Some men cannot maintain an erection long enough for sexual intercourse. This condition is called erectile dysfunction or impotence. It is due to conditions like diabetes, stress, anxiety, depression, operations and medicines.
It is important to discuss with one’s partner about what one feels and what excites oneself. More time may need to be spent on foreplay or new positions may be tried.
Other activities like caressing, massage, sensual baths and manual stimulation may be as satisfying. Single women may explore masturbation, which is a normal and healthy expression of sexuality.
An understanding of the various factors, which influence sexual activity, making adjustments and seeking medical advice and treatment can enable a person to cope with any anxiety and improve sexual functioning.
If vaginal dryness or discomfort is a problem, water-soluble lubricants or moisturisers sold over the counter can help. The dryness can also be relieved by local oestrogen therapy prescribed by the doctor. Having regular sexual intercourse is also helpful. An active sex life increases the blood flow to the genital organs and may help avoid some of the vaginal changes as one ages.
If either partner has any sexual difficulties, consultation with the doctor would helpful.
There is increasing understanding about sexual function and sexual dysfunction, which involves the interaction of multiple historical, developmental, endocrinological and psycho-social factors in ways that differ considerably between patients.
Dr Milton Lum is Chairperson of the Commonwealth Medical Trust. This article provides general information only and is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation that the writer is associated with.
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