Declining sexuality at midlife

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Many sexual medicine experts and psychological professionals agree that with time and age come sexual changes and most often reported decline in function. Many biological, psychological, and sociocultural variables have been implicated in this decline. Retirement, financial hardships, and child rearing challenges all may be implicated in the decline of sexual function as both men and women age. Stress, fatigue, and time constraints, in addition to our extensive digital connections with work and/or social media, may also hinder our connectedness, leading to changes in sexual intimacy and relationship dynamics. The menopausal period is no exception, and sexual functioning has been known to decline as women transition to complete amenorrhea. In this month's issue of Menopause, Avis et al1 use new data from The Study of Women's Health Across the Nation (SWAN) to reexamine the menopausal transition and its direct and indirect implications on sexual function.
The SWAN was an observational study that examined the physiological and psychological changes that occurred from the perimenopause into the menopause transition. Women of diverse ethnic backgrounds (White, African American, Hispanic, Japanese, and Chinese) were included in this unique research. In the cohort of 1,390 women who were aged 42 to 52 years, sexual function remained stable until approximately a year and a half before the final menstrual period. The authors noted a gradual decline from this time point, and also an annual decline after cessation of menses. The longitudinal duration of the decline was noted to be up to 5 years after the last menstrual period. In addition, there was a racial disparity, whereas the decline was lower in White women when compared with Japanese women, and the largest decline was noted in African American women. The study's results are indicative and suggestive that women who undergo natural menopause may indeed experience a decline in sexual function approximately 20 months before their menstrual cycles cease.1 Women who underwent a hysterectomy, were stable until surgery, after which the decline in sexual function began and persisted in the postoperative period.
It has long been recognized that there are other medical and psychological confounders of sexual function at the menopause, including but not limited to decline in estrogen/testosterone and induced genitourinary syndrome of menopause (with their vulvovaginal atrophy component) changes in marital status, medication use due to recent diagnosis of chronic illness, and psychosocial/relationship considerations that all may influence sexuality. These variables may contribute to dyspareunia or painful intercourse, emerging depression, and/or anxiety. In this study, however, the crucial and principal focus was on the decline in sexuality after the final menstrual period. It can henceforth be assumed that even when these other psychosocial variables of sexuality on the menopause were examined and controlled for, it would not explain the decline in sexual function. The authors did select several facets (age at final menstrual period, partner status, hormone therapy, and overall health) as a collection of contributing factors impacting menopause.
Some of the many strengths of the study included the detailed longitudinal study design (observational cohort study of the menopause transition at seven sites across the United States) and the diverse multiracial patient population of sexually active women in the menopause transition. Prospective measurement of sexual function with standardized measures was also demonstrated; however, validated questionnaires like the Female Sexual Function Index (FSFI) or the Short Personal Experience Questionnaire (SPEQ) were not used in this study. Many facets of menopause sexuality that have an impact have not been included, but have been reviewed elsewhere.

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