Sex and the Perimenopause

Sex and the Perimenopause

Sexual difficulties are common across the female lifespan, increasing at midlife. Although changing hormone levels at this time may contribute to the development of female sexual dysfunction, other factors, including relationship issues, psychological well-being, physical well-being and medication use, such as antidepressants, may also play a part.

Surveys conducted across a variety of cultures demonstrate that the vast majority of women believe sexual activity to be important and it has been shown higher levels of physical pleasure in sex are significantly associated with higher levels of emotional satisfaction.

The most common sexual difficulties experienced by women at midlife include
·    loss of interest in sex
·    inability to relax
·    painful sex (dyspareunia )
·    arousal difficulties
·    inability to orgasm(anorgasmia)

Women with vaginal dryness are more likely to experience painful sex, arousal difficulties, more frequent masturbation and less physical and emotional sexual satisfaction. An important observation is that despite the reduction in desire and increase in pain seen in the perimenopause, the frequency of sexual activity does not seem to change.

Non-hormonal factors that contribute to sexual function problems in perimenopausal women

The sexual difficulties at midlife are more common amongst women who are more highly educated, in a significant relationship, experiencing poor personal health, have urinary incontinence, have depression, or who have a past history of sexual abuse. Home, work or relationship stress may be a factor for some women. Bereavements, economic problems, retirement, children leaving home, divorce and personal illness, or illness of their partner or close relative can be related with sexual impairment during the perimenopause.  Poor body image and loss of self-esteem due to weight often contributes to a woman's reluctance to engage in sexual activity.

Impaired sexual function is a common feature of depression. It may also be due to incomplete treatment of the depression or to antidepressant medication. Female sexual dysfunction is most frequently reported by women using selective serotonin reuptake inhibitor (SSRI) therapy, the most commonly used antidepressants by Australian women. Loss of libido, arousal difficulties or delayed orgasm/anorgasmia due to antidepressant medication may not be a pressing issue for women initially commencing treatment but with long-term treatment, women are generally well and anything that interferes with sexual functioning may be a problem.

Women who have their ovaries removed (called  “surgical menopause”) are more likely to have sexual problems than naturally menopausal women.  However women who have undergone hysterectomy with the ovaries left in place are not more likely to experience sexual difficulties.

Hormonal factors that influence sexual function at the perimenopause

The perimenopause is characterized by irregular periods and fluctuating oestrogen levels, often with a random mixture of high oestrogen and low oestrogen symptoms. One week a woman might be experiencing painful breasts and heavy bleeding and the next, experiencing hot flushes night sweats, sleep disturbances and anxiety as a consequence of low oestrogen. These hormonal changes will have substantial impact on the woman's sexual interest and capacity to become aroused and/or achieve orgasm.

During the perimenopause, women often complain of vaginal dryness in relation to sexual activity. At this time it may be a sign of failure to be aroused and lubricate and treatment with vaginal oestrogen does not address the problem.

Testosterone levels do not change abruptly through the perimenopause, but fall progressively with age from the mid reproductive years. Studies of testosterone therapy have not been conducted in perimenopausal women. However, treatment of women in their late reproductive years and postmenopausal women with testosterone, has been associated with increased arousal and vaginal lubrication, and reduced dyspareunia.

The use of the oral contraceptive pill may not have caused a woman to experience diminished desire and arousal earlier in life, but it may do so during the late reproductive years and the perimenopause, as perimenopausal women are more susceptible to symptoms of testosterone depletion with the oral contraceptive pill use.

The need to treat Female Sexual Dysfunction

Female sexual dysfunction impacts adversely on self-esteem, quality of life, mood and relationships with sexual partners. Female sexual dysfunction is associated with significantly lower health-related quality of life. As well, sexual desire within a relationship is a key determinant of the quality of the nonsexual aspects of the relationship. Both men and women reporting a difference between their own and their partner’s sexual desire have lower relationship satisfaction, and individuals in sexually inactive marriages report less marital happiness.

It is not uncommon for loss of sexual desire to cause affected women profound distress, regardless of whether she has withdrawn from sexual interactions or has chosen to continue to engage to maintain a level of intimacy despite her loss of desire.

Treatment for sexual dysfunction in perimenopausal women

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.

Many women link their loss of desire to specific lifestyle circumstances, such as lack of privacy due to adult children still at home. Discussing these issues and developing possible strategies to overcome them can provide substantial improvement for the affected woman

• Current circumstances and psychological factors impacting on sexual function need to be addressed and counselling may be appropriate
• Physical conditions/illness, such as urinary incontinence, need to be identified and managed
• Perimenopausal women are more vulnerable to depression. Treatment and the side-effects of antidepressant medication need to be managed
• Women may need to look at their alcohol intake
• A trial off the OCP is worthwhile in affected women.  The levonorgestrel impregnated intrauterine device (Mirena IUD) provides an excellent contraceptive alternative for perimenopausal women, and can help regulate troublesome menstrual bleeding in the perimenopause
• Some women will benefit from testosterone therapy.  Large trials have shown that testosterone therapy will improve desire, arousal, frequency of orgasm and sexual satisfaction in both pre-and postmenopausal women. This should be administered by a GP experienced with testosterone therapy or specialist referral is indicated. Importantly, the use of compounded testosterone products can result in unpredictable and sometimes very high testosterone levels, and testosterone products approved for men should not be prescribed to women.