Sexuality in menopausal women
Salvatore Caruso, Agnese M.C. Rapisarda, and Stefano Cianci
Purpose of review
Sexuality is an essential part of a healthy life. It can contribute significantly to the physical, psychological
and social wellbeing of menopausal women, therefore, to their quality of life. This study is an overview of
the most recent findings in the literature retrieved from searches of computerized databases. We extracted
all notable information concerning definition, epidemiology, symptoms, diagnostic evaluation and
The experience of sexuality in menopause is fundamentally shaped by the biological and psychological
changes that occur on a substrate of modifications linked to the ageing process. Moreover, several
additional factors, including effects of illness, medications and psychosocial stressors can contribute to
sexual dysfunction. Patients should be educated about the causes of sexual dysfunction and available
In recent years, the field of research in sexual dysfunctions has made great progress in many areas of
investigation, from epidemiology to pathophysiology providing a better understanding of causes and
promoting better care. However, the multifactorial nature of human sexuality still makes our ability to
comprehensively treat sexual dysfunction quite difficult. An integrated approach is needed to recognize
different aspects involved and to identify the proper intervention strategies for early prevention and
promotion of a healthy sexuality in menopause.
climateric, menopause, sexual dysfunctions, sexuality
The gradual extension of life span over the last 100
years continues: recent statistics suggest that life
expectancy for United States women is now 81 years
. Therefore, a woman may spend on average one-
third of her life in the postmenopausal stage. Sexu-
ality is a central aspect of being human. Though
essentially it is meant for procreation, it is a source of
pleasure, a natural relaxant, it bolsters one’s self-
esteem, intimacy and a couple’s relationship .
Sexual health is defined as ‘a state of physical,
emotional, mental and social wellbeing related to
sexuality; not merely the absence of dysfunction or
The pattern of menopausal changes, symptoms
and their natural history have become increasingly
clear thanks to several longitudinal long-term
studies that have examined many aspects of
women’s biology through this time of life [4
Oestrogen deficiency is known to be the principal
pathophysiological mechanism that underlies men-
opausal symptoms and sexual dysfunctions. It has a
multitude of effects on several organs and tissues
including urogenital tissues, brain, skin, breasts,
muscles and skeleton [5
]. Female sexual dysfunc-
tions (FSDs), however, are complex and distinguish-
ing the effects of menopause from those related to
the ageing process is a major challenge for the
physician [6,7]. Moreover, age and type of meno-
pause, premenopausal sexuality, physical and men-
tal health, life-events, as well as relationship status
and partner availability are important confounding
In the setting of recent studies a new conceptu-
alization and definition of FSDs that mirrors the
complexity of human sexuality is needed [11
Soliciting open discussions about sexual problems,
Department of General Surgery and Medical Surgical Specialties, Clinic
of Gynecology, Research Group of Sexology, University of Catania, Italy
Correspondence to Prof Salvatore Caruso, MD, Gynecological Clinic of
the Policlinico Universitario, Via S. Sofia 78, 95124 Catania, Italy.
Tel: +39 095 3781101; fax: +39 095 3781326;
Curr Opin Psychiatry 2016, 29:323– 330
0951-7367 Copyright ß2016 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com
providing an accurate and comprehensive evalu-
ation considering different cultural and social
beliefs seem to be the most critical steps for a early
recognition and an effective therapeutic manage-
ATTITUDES ABOUT SEX IN MENOPAUSE
There is a tendency to assume that women lose
interest in sex after menopause . Instead, many
midlife women declare that sex is a moderately or
extremely important element in their life . How-
ever, many studies report a decline in all phases of
the sexual response, as well as higher levels of sexual
distress as a consequence of ageing and/or meno-
A decrease in sexual desire and an increase in
painful intercourse were found during perimeno-
pause ; these changes were found to be inde-
pendent of chronological ageing and likely related
to menopausal changes. Moreover, women main-
taining sexual activity showed stability in sexual
functioning, whereas inactive women reported an
overall decline .
The overall prevalence of dysfunction in men-
opausal women is estimated between 68 and 86.5%
depending on cultural, religious, ethnic and indi-
vidual differences . The most common com-
plaints are reduced sexual desire, vaginal dryness
and dyspareunia, poor arousal and orgasm as well as
impaired sexual satisfaction .
Despite the potentially impairing effects, a
recent study shows that overall sexual functioning
is moderately stable across 4 years from menopause,
suggesting that there is considerable variation and
hence, room for improvement [21
]. The main pre-
dictors of changes were desire and arousal, high-
lighting their role as possible key players in women’s
sexual health. These findings somewhat question
the role of menopausal transition as a ‘total’ and
‘enduring’ risk factor for sexual problems and focus
attention on considering FSDs in a broader context
taking into account the different aspects that may
affect sexual behaviour.
UNDERSTANDING FEMALE SEXUAL
DYSFUNCTIONS IN MENOPAUSE
FSDs are rooted in a wide range of predisposing,
precipitating and maintaining factors that can be
of different origins.
Predisposing factors comprise constitutional
and developmental influences that render a person
susceptible to dysfunction. They include preexisting
medical conditions such as congenital, hormonal,
and/or metabolic disorders and underlying psycho-
social considerations, such as body/sexual self-ima-
ge and relationship issues. Contextual predisposing
factors are centred on cultural, and religious beliefs
about sexuality, as well as the meanings attached to
menopause itself and basic socioeconomic and
Precipitating factors include events, situations
and/or comorbidities that are more directly and
causally linked to the development of dysfunction.
Menopause itself may represent a biological
Maintaining factors act to prolong or intensify
the dysfunctional state. One critical maintaining
factor is ‘diagnostic omission’: the failure to recog-
nize FSDs, consequently lack or inappropriate treat-
ment. Others are loss of intimacy and changes in
feelings towards the partner [22,23].
MENOPAUSE AND BIOLOGICAL CHANGES
The hormonal environment is the major driver of
women’s sexual functioning. Sex steroids –
estrogens, progestogens and androgens – exert
both organizational and trophic effects within
the genitals influencing brain responsivity and
modulating the threshold of tissue response to
]. The characteristic trigger of
natural menopause is a decline in ovarian func-
tion, leading to a reduction in circulating levels of
]. The small amount of circulating
estrogens in postmenopausal women depends on
two factors: the intensity and rate of ovarian
exhaustion and the amount of adipose tissue,
which functions as an endocrine gland. A higher
body mass index is associated with increased
production of estrone, via conversion of adrenal
and residual ovarian androgens by aromatases in
Sexuality is an integral part of healthy life; it should not
abruptly come to an end with the onset of menopause.
Satisfaction with different aspects of sex is strongly
associated with general health and quality of life.
FSDs in menopause are rooted in a wide range of
predisposing, precipitating and maintaining factors of
different origins and menopause itself represents a
biological precipitating event.
Soliciting open discussions, providing an accurate
evaluation considering different cultural and social
beliefs seem to be the most critical steps for an early
and effective therapeutic management of FSDs.
324 www.co-psychiatry.com Volume 29 Number 6 November 2016
The precipitous drop in estrogen levels is the
most important underlying biological precipitating
factor for FSDs during menopausal transition. It
initially accounts for irregular menstruation, and
vasomotor instability, then with changes in the
vascular, muscular and urogenital systems, in mood,
sleep and cognitive functioning, influencing sexual
function both directly and indirectly [4
Typical changes in external-labia minora, labia
majora, clitoris and internal-vagina, uterus-repro-
ductive components include reduction in size, thin-
ning of skin and mucous membranes, involution of
the corpus cavernosa and loss of subcutaneous fat.
The clitoris becomes fibrous, resulting in decreased
blood flow and attenuated vasocongestion during
sexual activity. The vaginal vault becomes pale in
appearance with loss of rogation and more friability,
vaginal pH shifts from acidic to alkaline, with
changes in the vaginal flora and more vulnerability
to infections. When coital exchange is attempted
after years of estrogen loss and abstinence, the
marked shortening and narrowing of the vagina
may make sexual intercourse extremely painful or
impossible to achieve [26,27
These changes are accompanied by significant
alterations in the urinary tract, including reductions
in intraurethral pressure, bladder size and thickness
of the mucous membranes lining the bladder and
urethra. Complaints of urinary frequency, urgency,
nocturia, dysuria, incontinence and postcoital
infection are common [28,29]. In addition, there is
significant reduction in pelvic muscle tone and resili-
ence of connective tissue support for urogenital struc-
tures, such as the uterosacral ligament, which is
associated with increased risk for pelvic prolapse .
Contrasting with the sharp decline in estradiol
during menopausal transition, circulating andro-
gens seem to remain stable. They tend to peak when
women are in their 20s, then gradually decline with
ageing. After menopause, peripheral conversion of
androstenedione becomes the major source of cir-
culating testosterone . Serum levels of andro-
gens exceed those of estradiol, even during peak
reproductive years, suggesting that androgenic hor-
mones play important roles in maintaining sexual
integrity as well as libido and orgasm and their
importance in overall health is the subject of much
current research . We are still missing, however,
a cut-off plasma level for androgens or androgen
precursors to diagnose a deficiency in clinical prac-
Natural menopause represents a good model to
understand the role of estradiol deprivation. On the
other hand, surgical menopause (following oopho-
rectomy) represents a suitable model to explore the
effects of acute estrogen and androgen deprivation
. As an effect of natural menopause, a reduction
in circulating androgen levels is not seen, contrast-
ing with the sharp decline in estradiol . Instead,
after iatrogenic menopause only the adrenal glands
continue to produce low levels of androgens .
Bilateral oophorectomy is associated with 25%
lower testosterone levels versus natural menopause
. Oophorectomized women are more likely to
report high prevalence of FSD .
FEMALE SEXUAL DYSFUNCTIONS IN
FSDs comprise a wide range of disorders, including
hypoactive sexual desire, reduced genital arousal,
sexual pain and inability to achieve orgasm, these
can be multidimensional in nature and often coex-
isting. Over the past decades, the classification of
FSDs has undergone intense revisions that mirror
the new understanding of their complex aetiology
]. The International Classification of Diseases,
10th Edition (ICD-10)  and the Diagnostic and
Statistical Manual of Mental Disorders fourth edi-
tion with text revision or fifth edition (DSM-IV-TR
and DSM-V) [39,40] have been the most widely used
systems. There is still no consensus on the contri-
buting role of discrete factors because of a high
overlap between desire and arousal in women has
been reported. Recently, in the DSM-V, female
sexual interest/arousal disorders were merged into
a single category .
Hypoactive sexual desire disorder (HSDD) was
found to be the most prevalent recent and lifelong
sexual complaint , affecting up to one in 10 US
women . It is defined as ‘persistently or recur-
rently deficient or absent sexual fantasies and desire
for sexual activity’ accompanied by ‘marked distress
and interpersonal difficulty’ . Major representa-
tive studies in the literature over the past few years
are reported in Table 1 [42–47]. The vast majority of
which, such as the Women’s International Study of
Health and Sexuality (WISHeS)  and Prevalence
of Female Sexual Problems Associated With Distress
and Determinants of Treatment Seeking (PRESIDE)
 are cross-sectional surveys and do not strictly
include the requirement for the diagnosis of HSDD.
The prevalence rates obtained are thus more repre-
sentative of low desire with distress rather than
HSDD. In the PRESIDE study, the prevalence of
distressing sexual problems peaked in middle-aged
women and was considerably lower than the preva-
lence of sexual problems. This underlines the
importance of assessing related personal distress
in accurately estimating FSDs. Greater impairment
of sexual function was observed to be associated
with surgical versus natural menopause [45 – 47].
Sexuality in menopausal women Caruso et al.
0951-7367 Copyright ß2016 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com 325
In many years of research, vasoactive agents,
hormone therapy and psychoactive drugs have been
investigated, and randomized placebo-controlled
trials have shown their efficacy and safety; however,
the FDA did not approve a transdermal testosterone
patch for HSDD in postmenopausal women [48
Flibanserin, a multifunctional serotonin 1A receptor
agonist and 2A antagonist, hypothetically targeting
brain circuits that mediate motivation, interest in
and desire for sex. It soon became the candidate to
change the history of sexual medicine for women,
similar to sildenafil for men. In deed, it is the first
medication approved to treat HSDD in women, after
three large phase III trials demonstrated significant
improvements of satisfactory sexual events, level of
sexual desire and distress in comparison with
Genitourinary syndrome of menopause (GSM) is
found to be the most important cause of genito-
pelvic pain disorders among menopausal women
[50–52]. GSM can be defined as an aggregate of
signs and symptoms associated with any morbid
process, only some of which need to be present
for the diagnosis. They include genital symptoms
(dryness, burning and irritation), sexual symptoms
(lack of lubrication, discomfort or pain) and urinary
symptoms (urgency, dysuria and recurrent urinary
tract infections). The term GSM improves on
previous more restrictive terms like vulvovaginal
atrophy and atrophic vaginitis, which are not
adequate for referring to the complexity of the
condition. Most prevalent urogenital symptoms
are vaginal dryness, dyspareunia, irritation, burn-
ing, itching and dysuria [27
,53]. Between 50
and 70% of postmenopausal women state that
vulvovaginal symptoms have a negative impact
on sexual life and relationship with partner. Vaginal
discomfort is considered the major cause for avoid-
ance of intimacy and loss of libido [50–53,54
(Table 2). The principal treatment options in GSM
include local and systemic hormonal treatment .
Vaginal estriol has proven to be effective in treating
vaginal dryness, in improving vaginal maturation
index (VMI), vaginal pH and dysuria . Recent
data indicate the benefits of local intravaginal dehy-
droepiandrosterone on vaginal atrophy symptoms
and sexual dysfunction . New treatments have
recently appeared such as ospemifene [58
], a selec-
tive hormone receptor modulator as well as the use
of vaginal laser .
MEDICAL CONDITIONS AND USE OF
When a diagnosis of FSD is suspected, a complete
and detailed medical history should be obtained to
evaluate the presence of chronic diseases and use of
drugs. This is especially true in menopause because
of a cumulative impact on interest and ability to
have sexual activity [7,60]. Sexual dysfunction in
later life is often comorbid with psychiatric illness,
particularly mood and anxiety disorders, neurologic
diseases, diabetes, thyroid diseases and osteoarticu-
lar problems [61–66]. Diabetes can causes vascular
and nerve dysfunction with structural and func-
tional changes in female genitalia. Disorders of
arousal, orgasm and sexual pain are the main con-
sequences of the diabetic neuropathy . Thyroid
Table 1. Prevalence of HSDD/low desire disorders: review of the literature
Original articles Study population Prevalence of HSDD/low desire disorders
Burri et al.  1.489 UK women; age: 18– 85 years Low desire: 21.4% of women; sexual distress: 26.6% of
Leiblum et al.  4.517 US women; age: 20– 70 years HSDD women aged 50–70 years: 9% naturally
postmenopausal; HSDD women aged 20– 49 years: 26%
for surgically postmenopausal women
Shifren et al.  31.581 US women; age: 18–102 years Low desire: 38.7 (overall prevalence), 38.9% in women
aged 45– 64, 74.8% among 65 or older; personal
distress: 22.8% (overall prevalence), 25.5% in women
aged 45– 64, 12.5% among 65 or older
West et al.  2.207 US women; age: 30–70 years Low desire: 26.7% premenopausal women, 52.4% naturally
menopausal women, 39.7% surgically menopausal
women; HSDD: 7.7% premenopausal women, 6.6%
naturally menopausal women, 12.5% surgically
Dennerstein et al.  2.467 European women; age: 20–70
HSDD (women 20– 49 years): 7% for premenopausal
women, 16% surgically menopausal women; HSDD
(women 50– 70 years): 9% naturally postmenopausal
women, 12% surgically menopausal women
HSDD, hypoactive sexual desire disorder.
326 www.co-psychiatry.com Volume 29 Number 6 November 2016
diseases are considered risk factors for women’s
sexual health. Some data suggest a possible role of
thyroid-stimulating hormone in impaired sexual
Several studies have revealed an effect of cardi-
ovascular diseases on women’s sexual desire; arousal
and pain disorders [68–70] but contrary to men
wherein the association is widely recognized, in
women it is less clear .
Medications often play a role in precipitating
FSDs. They can interfere through effects on the
central and peripheral nervous system or hormonal
effects . Some of the most common culprits
include antihypertensives (beta-blockers and diu-
retics)  and many psychotropic medications,
particularly antidepressants such as serotonin
reuptake inhibitors (SSRIs) and serotonin/norepi-
nephrine reuptake inhibitors (SNRIs) .
Though certain physiologic and pathologic changes
are responsible for the aforementioned compli-
cations, there are a number of other possible factors
for deteriorating sexual function. Decreased sexual
activity may be interpreted as a biological phenom-
enon or as sexual dysfunction, or it may be the result
of adapting to changed circumstances . Ageing
and menopause may bring on significant changes in
body shape and facial appearance, weight gain and
self-consciousness about other health issues. These
may lead to an extended period of grief over lost
youth and beauty, poorer self-esteem and a loss of
sexual desire. Changes related to ageing in both
women and their partners frequently exacerbate
pre-existing relationship problems that may be
marked by poor communication and mismatch of
sexual ‘scripts’ or interest. Low levels of relationship
satisfaction and increased distress have been
strongly associated with attenuated sexual desire
and low frequency of sexual activity. Partner avail-
ability can be a significant problem for ageing
women, because of divorce, partner death, chronic
illness or sexual dysfunction [76,77]. The import-
ance of sex and level of distress may also differ as a
consequence of values and attitudes towards sexu-
ality and personal experiences .
A HEALTHY SEXUALITY IN MENOPAUSE:
THE ROLE OF HEALTHCARE
A menopause consultation provides an excellent
opportunity to make a sexual health assessment as
Table 2. Prevalence of VVA symptoms/signs and effects on sexuality: review of literature
Original articles Study population
Prevalence of VVA symptoms/signs and effects
Kingsberg et al.  10.486 US women; age: 45–75 years 3046 (38%) experiencing VVA symptoms: vaginal dryness
(55%), pain during intercourse/dyspareunia (44%), vaginal
irritation (37%); VVA symptoms had the greatest impact on
enjoyment of sex (59%)
Simon et al.  1.000 American women; 1.000
American male partners; age:
55– 65 years
Effect of vaginal discomfort: avoidance of intimacy (women:
58%, men: 78%), loss of libido (women: 64%, men: 52%),
pain during sex (women: 64%, men: 59%), cessation of
sex (women and men: 30%)
Nappi et al.  4.100 females; 4.100 males (from the
United Kingdom, Finland, Norway,
Sweden, Denmark, Italy, France,
Canada and the United States)
Effects of VVA: having sex less often (women: 58%, men:
61%), less satisfying sex (women: 49%, men: 28%),
putting off having sex (women: 35%, men: 14%); major
causes for intimacy avoidance: painful sex (women: 55%,
men: 61%), women’s reduced desire (women: 46%, men:
Nappi et al.  3.768 women (from Italy, Germany,
Spain and the UK); age: 45– 75 years
VVA-associated symptoms: vaginal dryness (70.0%), vaginal
irritation (32.7%), pain during intercourse (29.0%), vaginal
tenderness (14.3%); VVA has a significant impact on: the
ability to be intimate (62%), enjoyment of sexual
intercourse (72%), feeling of sexual spontaneity (66%)
Palma et al. [54
] 913 Italian women; age: 59.3 7.4
Diagnosis of GSM 722 (79.1%). Symptoms: vaginal dryness
(100%), dyspareunia (77.6%), burning (56.9%), itching
(56.6%), dysuria (36.1%); signs detected by gynecologists:
mucosal dryness (99%), thinning of vaginal rugae (92.1%),
pallor of the mucosa (90.7%), mucosal fragility (71.9%),
GSM, genitourinary syndrome of menopause; VVA, vulvar and vaginal atrophy.
Sexuality in menopausal women Caruso et al.
0951-7367 Copyright ß2016 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com 327
part of a general assessment. A wide number of issues
can hinder the proper management of FSDs [12
Several themes relating to healthcare professionals’
experience of discussing sexuality have emerged,
they include fear about ‘opening up a can of worms’,
lack of time, concerns about knowledge and abil-
ities, worry about causing offense, personal discom-
fort, lack of confidence, embarrassment combined
with stereotypes about the lack of sexual needs and
age-appropriate behaviours [12
barriers exist for older women to access information
and professional help, making it even less likely that
adequate treatment is sought and/or received. The
importance of health professionals’ strong and
effective communication skills has been high-
lighted, as well as the need to appear interested,
empathetic and be more prepared to initiate such
conversations . Management of FSDs can
include reassurance, education, sex therapy, and/
or medication as part of an optimal multidiscipli-
nary management following an accurate diagnostic
workup and taking into account the biopsychoso-
cial model [11
Great progress has been made over the past years,
clarifying the effects following natural and iatro-
genic menopause and demonstrating that meno-
pause itself and not simply increased age is the
primary driver for FSDs. A comprehensive collection
of medical and sexual history can address whether
the sexual problems began before or after the onset
of menopause. Proper knowledge of different
cultural and social beliefs helps to understand what
role menopause plays in the woman’s overall sexual
health. Giving the opportunity to talk about sexu-
ality is a fundamental part of healthcare, and early
recognition of distressed FSDs is a critical step in
effective therapeutic management. New discoveries
have led to improve the approach to FSDs but
human sexuality still remains complex by its very
nature. The multifactorial etiology, clinical con-
sequence and the indication for treatment need to
be evaluated in a multidisciplinary setting.
The authors wish to thank The Scientific Bureau of the
University of Catania for language support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Papers of particular interest, published within the annual period of review, have
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