Female sexuality and changes with age

Sexuality is an integral part of the human psyche and is present from birth to death in everyone. Sexuality is expressed throughout life in all people both consciously and unconsciously in body movements and body language, speech, appearance and in every imaginable way people interact with each other. The way people demonstrate their innate sexuality varies according to their stage of life. It is expressed in family intimacy and as part of play in childhood, more overtly in adolescence and in physical sexual activity throughout adult life. The importance of sexual health to overall health is often overlooked by health care professionals and society in general to the detriment of all. One cannot dismiss the impact that sexual health has on a woman’s general wellbeing. It’s as important as nutrition and physical activity.

According to the World Health Organization:

“Sexual health is a state of physical, emotional, mental and social well-being related to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed.”

Individual expression of sexuality is influenced by cultural and social environment, personal knowledge, past experiences and current expectations; physical and psychological well being. We are all sexual beings whether or not we have a partner.

Sexual function and ageing

Although ageing in itself interferes with the level of sexual performance, the improved health of older people and possibly altered expectations appear to have impacted on the sexual lives of older people over the last few decades. A Swedish study reported an increase in sexual activity of 70-year-old women between 1971 and 2000 from 38% to 56% and in married men from 52% to 68%. These data confirm that sexual activity remains an important part of life for many older women.

Older women experience fewer sexual thoughts and fantasies, lessened vaginal lubrication with intercourse and less sexual satisfaction. For many women these changes are subtle and do not interfere with their overall sexual relationships. One of the greatest predictors of a woman having a satisfying sexual relationship or experiences after menopause is the quality of the sexual aspects of her life before menopause, with those most satisfied with this aspect of their life in the late premenopausal years least likely to report problems. The availability of an interested partner appears to be a critical factor for older women, who often attribute lessened sexual activity to impotence or illness in their partner.

The physical changes resulting from both ageing and declining oestrogen levels affect female sexuality. In addition to circulating oestrogen levels falling at menopause, the nervous system and vascular system also decline with age. Loss of fat and glandular tissue combined with lessened muscle tone and tissue elasticity makes the breasts and other body regions more drooping and flabby. The cervix, uterus and ovaries shrink, the vagina becomes dry and the lining tissue thinner, and the clitoris, which retains its sensitivity, decreases in size. Oestrogen loss causes much of the discomfort of intercourse that may occur with ageing, and oestrogen therapy as vaginal oestrogen creams or pessaries will successfully reverse symptoms such as vaginal dryness and
contact bleeding with intercourse.

Sexual arousal is achieved through touching, kissing, clitoral stimulation and erotic fantasies. In older women, touch sensation is diminished as is vascular responsiveness, therefore nipple erection and genital response and congestion is lessened. Vaginal secretions are reduced and a longer time is required for adequate lubrication to occur. Although the clitoris becomes smaller with age, the response to stimulation remains intact, but it usually takes longer to achieve a sexual plateau.

The duration of orgasm is reduced in women over 50 years of age. In some women, uterine contractions during orgasm may become spasmodic and painful instead of being rhythmic and pleasurable. Alternatively, the contractions may become so mild in older women that they are not sure whether they have achieved orgasm. Resolution – the phase where breathing, heart rate and blood pressure return to normal - is more rapid in older women. Many women generally feel relaxed and satisfied after one orgasm however some women of all ages are able to experience multiple orgasms.

The personal health of a woman as she ages impacts on sexual activity.

Physically coitus is about as strenuous as a vigorous walk. For a woman with heart disease sexual activity is usually safe if she is able to climb a flight of stairs or walk briskly for 10–15 minutes without any distress.

Diabetes is a common cause of loss of ability to sustain an erection in men, but does not appear to affect either sexual desire or performance in women. Urinary tract and vaginal infections such as thrush are more common in diabetics so practices such as emptying the bladder before and soon after intercourse are worthwhile.

Medications prescribed for various diseases can potentially affect female sexual function, but unfortunately have been little studied in women, as opposed to the vast literature on drug induced impotence in men.

Anti-depressants are the most likely medications to suppress sexual function. Female sexual dysfunction is an established side-effect of antidepressant therapy, and is most frequently reported by women using selective serotonin reuptake inhibitor (SSRI) therapy. (see pdf on “Antidepressant Therapy and Sexual Functioning”).

Sexual health after gynaecological and other cancers is an increasingly common issue which fortunately is being more openly discussed. The Cancer Council of Victoria has produced an excellent book for patients and their partners that comprehensively addresses this issue. Other cancer resource groups are also having patient support information available.

Partner health is an important factor in a sexual relationship. Many older women do not have a partner or are in a relationship with a person who suffers ill health or sexual dysfunction. Masturbation is less well accepted by women than men, but is an important sexual outlet for many women. Early research suggests that up to 25% of women over the age of 70 masturbate. Mutual masturbation is a common healthy sexual practice for many couples that have ill health preventing vaginal intercourse.

Fundamentally age is no deterrent to good sex. The changes of ageing may require some adjustments, but these can always be made to permit ongoing sexual activity.

The low level of sexual desire unfortunately expressed by so many older women often strongly reflects negative societal feedback on aging in general and sexual repression of older women specifically. Improving our attitudes towards ageing, increasing respect for older women in the community and liberalizing our views regarding sexual expression in older people will hopefully enable older women to experience better sexual wellbeing.

Women with concerns about their sexual life should find a doctor or counsellor with whom they feel comfortable discussing this very personal but important aspect of their life.