The foremost change in discussing the medical effects of aging in women with regards to sexuality is perhaps that of the menopause as DeLamater (2012) [8
] indicates. This period of transition as Avis et al [10
] discuss, rather than being a singular event, lasts on average 3.8 years and is preceded by the climacteric or peri-menopause which begins at the mean age of 47.5 years. It is during this climacteric period, when there is a gradual decline in the functioning of the ovaries, that symptoms begin to appear, consisting mainly of vaginal dryness and vaginal atrophy as Howard et al [11
] discovered in their research of women aged 40 to 79. However, in their study of middle aged and older women in Australia, vaginal dryness was reported as completely absent in 35.8% of women and always present in only 11.5%. Furthermore, only 14.6% of women experience dyspareunia 50% or more of the time. Interestingly, they also found that the overall incidence of both dyspareunia and of dryness did not vary significantly in their age group of 40 to 79. However Leiblum et al [12
] in their international study of 6,725 women from 11 countries including the UK, Germany, Japan, Canada, Spain, and Brazil found that the incidence of vaginal dryness varied significantly between different countries. In Italy vaginal dryness was reported by 5.8% of women, by contrast in Brazil 19.7% of women complained of the same problem. A similar picture emerged with reports of dyspareunia, which was experienced by 3.6% of women in Australia but 18.6% of women in Brazil; this contrast also casts some doubt over the value of extrapolating the results of Howard et al’s [10
] study internationally. In addition, this detailed research found that there was significantly more vaginal dryness in the UK, Australia, Canada, Italy, Spain, Argentina, and Thailand in the 50–65 year old age group compared with the 18–43 year age group. Lastly, the researchers highlighted an important contrast in health beliefs in these two age groups; internationally, the majority of women under 50 attributed vaginal dryness to inadequate sexual arousal whereas the over 50 age group blamed this on their age or the menopause.
Crucially, this also illustrates the importance of how the individual woman perceives biological aging and may explain, to a certain extent, the varied views of attitudes towards sex post-menopausally as discussed by DeLamater (2012) [8
]. Also there is little evidence that sexual desire declines directly as a result of the menopause as Hinchliff et al [1
] discovered in their qualitative study of the sexual experiences of women over the age 50. It is also worth noting that there is little consistent evidence to show that the menopause causes depression as Eden et al [13
] discuss in their review article; furthermore Avis et al’s [10
] study of 2565 women aged 45–55 years in Massachusetts highlighted that previous depression is the most likely factor to predict depression at menopause, supported also by Guthrie et al’s [14
] study of 438 Melbourne women. Clearly a complex biopsychosocial model is necessary to explain how the menopause effects female sexual functioning.
Although obviously not universal like the menopause, diabetes mellitus type II in the older woman is increasingly common internationally and the incidence increases with age as Whitehouse [15
] indicates. In her literature review she highlighted two main consequences of diabetes; firstly, the direct effect of the disease on the physiology of the body and secondly, the psychological effects of diabetes. Firstly, hyperglycaemia which can commonly occur in poorly controlled diabetes and indeed before it is diagnosed is thought to reduce the hydration of the mucus membranes which include vaginal tissues therefore resulting in vaginal dryness and associated dyspareunia. In addition the increased incidence of urinary tract infections in women with diabetes can cause further vaginal discomfort. Additionally, diabetes causes significant pathological changes to vascular structures leading to potential damage to the blood supply to the vagina. This can result in reduced lubrication and diminished circulation to the clitoris, inhibiting engorgement during sexual arousal.
Secondly, the psychological effects of diabetes such as increased perceived tiredness, embarrassment about the disease as well as reported loss of desire all serve to indirectly reduce sexual function. There is a disagreement in the literature about whether type I or type II diabetes effects sexual functioning the most, with no conclusive answer. This lack of clarity could be accounted for by the lack of research. Enzlin et al [16
] are scathing both about the scarcity and quality of research about diabetes and its effect on the diabetic women, whilst they corroborate Whitehouse [15
] citing the combination of decreased or slow vaginal lubrication with reduced sexual arousal. However they suggest that problems with achieving orgasm are not more common in diabetic women.
Urinary incontinence and pelvic organ prolapse are also more common in the older woman. Unsurprisingly urinary incontinence results in significant psychological distress in many women, with the fear of urine leakage during intercourse uppermost in their minds, accompanied with increased feelings of guilt and disgust about sex as Melin et al [17
] explored. They also found that the fear of incontinence led to women avoiding sexual contact. Interestingly in Tannebaum et al’s [18
] study 2361 women with a mean age of 71 in Canada found that the women with urinary incontinence weren’t less likely to be sexually active, however the severe incontinence did correlate with less intercourse. Here, overall, they found age (younger) and marital (married) status to be better predictors of regular sexual activity. Closely related to urinary incontinence in effect is pelvic organ prolapse on women’s perception of their sexuality; a subject which Sublett [19
] highlights is often unvisited by health care professionals and yet despite the scarcity of research on this subject, there may be a considerable impact on sexual function.
A common risk factor for diabetes mellitus type II, urinary incontinence and pelvic organ prolapse is obesity, a commonly known growing epidemic. Beyond the direct pathological links between these conditions and obesity it is important to consider the relationship between obesity and sexual function directly, on which there is little research as Zabelina et al [20
] discuss. In their study of 9991 overweight and obese men and women they used the Impact of Weight on Quality of Life-Lite (IWQOL-Lite), a measure of weight-related quality of life tool, to explore sexual function. Interestingly the results showed that at all age groups, the overweight and obese women had less self-esteem, encountered more public distress at their perceived image and had a less active sex life than the men. They found that the frequency of sexual activity in the women took a sharp dive after the age of 25 and then levelled out, in contrast to the more gradual decline for the men. However, self-esteem increased every decade in women peaking aged 70 along with a consistent decline in public distress as they got older. This research did not compare obese or overweight individuals with those of a more healthy weight but the aforementioned study by Melin et al [17
] usefully contrasts obese and non-obese women, finding the former group experiencing less sexual excitement, lower sexual activity and less satisfaction with their sexual lives. Yet dyspareunia and ability to achieve orgasm were not significantly different when obese women were compared with non-obese women. Obesity therefore clearly impacts on sexual function in women of all ages. There has, thus far, been very little research into the impact of obesity on the sexual functioning specifically of older women.
Although certain chronic illnesses have been discussed, the older woman may encounter a variety of debilitating conditions. Encouragingly however, Howard et al’s [11
] Australian study which compared women with breast cancer, osteoarthritis and hypertension to healthy women of the same age, found little difference in their sexual function and satisfaction. Despite these findings the authors suggest that advances in medical care for the older women, would very probably lead to increases in sexual functioning in the future. Their findings were supported by Lindau et al’s [21
] study of 6037 US American women where they found that men tended to have their sexual functioning impaired much more by chronic illness than their female counterparts at all ages. Good health was associated strongly with a good quality frequent sex in their study, however the exact causality and nature of this relationship is unknown.