Sexual function represents an important component of health and life quality. The objective of this study was to assess female sexual function in postmenopausal women and to identify factors associated with sexual dysfunction among this population. From August to December 2013 a cross-sectional study was carried out with 111 postmenopausal, sexually active women aged 45–65 years. A semi-structured questionnaire made up of itemized questions was applied to identify demographic variables, socio-economic and clinical issues. Participants were requested to fill out the Female Sexual Function Index (FSFI) and the Menopause Rating Scale. Among the studied group, 70.3% of the women presented sexual dysfunction (FSFI⩽26.6). The affected domains were desire and arousal (P<0.01). Multiple regression analysis revealed that the main risk factors associated with postmenopausal sexual dysfunction were: marital status (prevalence ratio (PR) 1.67; 95% confidence interval (CI) 1.17–2.39; P<0.01), urogenital dysfunction (PR 1.08; 95% CI 1.03–1.12; P<0.00), bladder surgery (PR 1.35; 95% CI 1.09–1.66; P<0.01) and sexual abuse (PR 1.45; 95% CI 1.21–1.72; P<0.00). Our results show a high female sexual dysfunction among postmenopausal women. Sexual dysfunction was associated with multiple factors such as: socio-demographic factors, biological factors (urogenital dysfunctions, bladder surgery), psychological matters and sexual abuse.
Life expectancy among the female population has presented a significant rise around the world and constitutes a significant process in developing countries.1 Population aging is a Brazilian reality: life expectancy in the country exceeds 70 years of age with a tendency for female population increase.2 The increase of life expectancy means that women live a greater part of their lives in menopause.3
Female sexual function represents an important component of health and life quality. According to the World Health Organization, sexuality is influenced by a conjunction of factors: biological, psychological, socio-economic, political, cultural, ethical, historical, religious and spiritual.4 Sexual dysfunction can have a negative impact on the well-being of men and women.5
In contrast to the male sexual dysfunction that most of the times have biological causes,6 female sexual dysfunction (FSD) is often associated to psychogenic factors that include stress, depression, sexual abuse and relationship problems with the sexual partner.7
FSD is characterized by trouble and difficulty during a sexual response phase or when pain occurs during the sexual intercourse which could prevent an individual from performing the intercourse and even create a situation where there is no pleasure.8
Menopause is a period of great life changes when hormone levels fluctuate and decrease. When this factor is associated to the aging process it impacts on the interest and frequency of sexual intercourse.9, 10 Other factors that may be associated to FSD are: individual’s general health, social and physical environment, educational level, previous life experiences, cultural practices, and the relationship with the sexual partner.11
During the perimenopausal and postmenopausal periods there seem to be an increase of sexual problems, but in fact, it is during the postmenopausal period that women are more inclined to present poorer sexual function compared with other stages of life.12
An important multicentric study that involved men and women over 40 years of age was carried out in the USA. It showed that the rise of women ages was associated to the loss of vaginal lubrication, low desire (libido) and inability to reach orgasm.13
Corroborating the findings of this study, a Brazilian study held with 1219 women identified that 49.0% of them reported sexual function complains. This study also found out that women over 40 years of age showed greater risk of libido loss and orgasm dysfunction compared with younger women.14
The prevalence of FSD is estimated to be between 25.0% and 63.0%.11 Among mid-aged Latin American women, the prevalence of FSD is 56.8%.15 Studies held with postmenopausal women demonstrated that this rate may be higher and vary from 45.3 to 67.9%.16, 17 These values vary according to the instruments used to assess sexual dysfunction, the different populations studied, menopause status and the trial design used in the research.18
The objective of this study was to evaluate sexual function in postmenopausal women and identify other factors associated to sexual dysfunction among this population.
Materials and methods
A secondary analysis from a cross-sectional observational study was performed among a postmenopausal group of women aged 45–65 years, in a Rio de Janeiro’s center of reference gynecology clinic (endocrinology, gynecology and urogynecology as subspecialty) from August to December 2013.
Inclusion criteria for the research were as follows: 45–65 years of age, >12 months of amenorrhea, follicle-stimulating hormone ⩾40 IU l−1 and being sexually active during the previous period of 4 weeks (counting from the interview date).
The exclusion criteria were: hormone replacement therapy in the last year, cancer, women that have been through or were at the moment under chemotherapy, radiotherapy, pelvic surgery for bilateral oophorectomy, premature menopause, neurological disorders, type 1 diabetes, thyroid disease, hiperprolactinemia and homosexual partnership.
Postmenopausal status was defined using the Stages of Reproductive Aging Workshop+10 (STRAW+10). According to STRAW+10 early menopause is represented by the stages +1a and +1b (2 first years since the last period) and by the stage +1c, (follicle-stimulating hormone stabilization at high level lasts from 3 to 6 years). The postmenopausal is identified as +2 stage and encompasses the women in +1c stage.19
Participants first answered a semi-structured questionnaire on individual socio-demographic, clinical and behavioral characteristics. Minimum wage in Brazil at the time of the collection of the data for this study (from August to December 2013) was BRL 678.00. Following the medium exchange rate from Brazilian Reais to American Dollars - according to information from the Central Bank of Brazil - the minimum wage was equivalent to USD 296.46. The main instrument to evaluate female sexual function was the Female Sexual Function Index (FSFI)—previously validated, adapted and translated into Portuguese.20
The FSFI is a questionnaire created in English and was developed as a brief self-reported instrument to assess the main dimensions of female sexual function. This instrument can be easily administered among women in a broad age group, including postmenopausal women. The questionnaire was designed to evaluate female sexual response and quality of life in clinical or epidemiological studies21 and is in line with new models of female sexual response.8, 22
The FSFI questionnaire is a 19-item self-reported instrument used for assessing key dimensions of female sexual response: desire, arousal, lubrication, orgasm, satisfaction and pain. Each of the six specific domains analyzed in the FSFI is scored on a scale ranging from either 1 to 6 or 0 to 6 (depending on the domain), with higher scores indicating better performance. The total score, falling in a possible range from 2 to 36, is obtained by adding the six domain scores together. A cutoff total score of 26.55 on the FSFI is the current standard for diagnosing sexual dysfunction. Therefore women presenting scores ⩽26.55 must be considered with sexual dysfunction.21, 23
Climacteric symptoms were evaluated through the Menopause Rating Scale (MRS) a validated and recognized instrument in Brazil. The MRS is composed of 11 items and divided into three subscales: somatic, psychological and the urogenital. Each item can be graded by the subject from 0 (not present) to 4 (1=mild, 2=moderate, 3=severe and 4=very severe). Graded items within each subscale are summed to provide a total subscale score. Higher MRS scores are indicative of more intense symptoms and quality of life impairment.24
Abdominal obesity was measured by abdominal circumference with a threshold at 88 cm, according to the Brazilian Association for the Study of Obesity and Metabolic Syndrome (ABESO).25 The weight was verified in kilograms and the height in meters (kg m−2). The body mass index was categorized as follows: eutrophia (18.5–24.9), overweight (25.0–29.9) and obesity (⩾30.0).26
The present analysis is part of a database from a cross-sectional study that assessed sexual function and metabolic syndrome across premenopausal women. The study project was submitted and approved by the Research Ethics Committee of Fernandes Figueira Institute, under the protocol CAAE 03498812 7 0000 5269 and approval number 359174. All participants signed an Informed Consent Form.
Exploratory analysis was performed to ensure the consistency of the data set. For continuous variables with normal distribution, results were recorded as the mean±s.d. When normality was not observed, results were expressed in median, minimum and maximum values. The Kolmogorov–Smirnov test was used to check the assumption of normality. Bivariate analyses were performed to identify factors associated to FSD. Categorical variables are presented as frequencies (percentages) and were analyzed using Pearson’s χ2 test or Fisher’s exact test.
The Student’s t-test and the Mann–Whitney U-test were used to compare continuous normal and non-normal variables between two groups, respectively. Finally, Poisson regression models with robust error variance were applied. Variance inflation factor was used to detect multicollinearity. All independent variables that had a P-value below 0.20 in the bivariate analysis were selected for the multiple regression model P-values lower than 0.05 were considered statistically significant. Prevalence ratio and 95% confidence intervals were estimated. Data analysis was performed with SPSS 20 (Armonk, NY, EUA) and R 3.0.2 (Vienna, Austria, AU).
The study analyzed 111 women divided in two groups: women with sexual dysfunction and women without sexual dysfunction. The majority of women were aged 56–60 years, and the median age was 55.91 (±4.84), they were married, had completed a full course of primary schooling and had a monthly per capita income of a minimum wage salary or less.
The average menopausal age was 48.31 (±4.54). Regarding the climacteric symptoms, we can verify that the average score was 17.25 (±9.47) and was more elevated among the group of sexual dysfunctional women. Socio-demographical, clinical and behavioral characteristics can be verified on Table 1. During bilateral analysis, marital status, per capita income, MRS total score, somatic and urogenital MRS domains and history of sexual abuse showed statistical differences among women with and without sexual dysfunction.
Across the studied group, 70.3% of the women showed sexual dysfunction (FSFI⩽26.6). The median FSFI score levels of women at sexual dysfunction was significantly lower (21.55) than the women at no sexual dysfunction (29.70). When individually analyzing the domains that constitute the FSFI, it was found that the domains that most contributed to the low scores presented by women with sexual dysfunction were desire (2.40) and arousal (3.00) as it can be observed on Table 2.
Multiple linear regression analysis was performed to determine the main factors associated with FSD during the postmenopausal period. It was concluded that the factors were: marital status (married women), urogenital domain in the MRS questionnaire, bladder surgery and sexual abuse (Table 3).
The aim of this current study was to evaluate the sexual function of postmenopausal women and to identify factors associated with sexual dysfunction among this population.
Postmenopausal women sexual function is often influenced by vasomotor, neurogenic, endocrine, muscular, psychological, sleepiness, metabolic and psychosomatic disorders symptoms. In thus way we can verify that its etiology is multifactorial.27
The prevalence of FSD has shown to be high and appears to increase with age. As a result we can observe a decrease on both sexual interest and sexual relations, a decrease of vaginal lubrication and low estrogen levels.7
In the present study it was verified that most women were likely to be sexually dysfunctional. Corroborating the present results, other studies with postmenopausal women that used the same assessment tool showed similar results, such as the recent study with Lithuanian women, in which the sexual dysfunction rate was 67.9%.17 Another cross-sectional study in Malaysia also identified a high prevalence of FSD, showing a prevalence of 85.2%.28
In a multicentric study with mid-aged Latin American women, Blumel et al.15 identified a sexual dysfunction average across women of 56.8% with a prevalence that varied from 21.0 to 98.5%, depending on the country and the population studied. This variation can be explained due to cultural and economic factors specific of each population. In that study, the risk factor more often associated with FSD was the loss of vaginal lubrication.15
When studying Brazilian women Valadares et al.16 recognized that sexual dysfunction was associated with more advanced age groups, confirming that sexual dysfunction is a problem that occurs more frequently among elder women. Women’s maturity is accompanied by climacteric symptoms that can influence the development of sexual dysfunction or accentuate pre-existent disorders.29
In this study, bivariate analysis showed that climacteric symptoms identified by MRS showed more elevated scores among sexual dysfunction women when compared with the women with no sexual dysfunction.29 This shows a higher intensity of climacteric symptoms among sexual dysfunction women.
These findings were also present in Cabral et al. studies, indicating that sexual response are affected by age and menopausal status. It is known that climacteric symptoms influence life quality and that sexual satisfaction is an important wellness score. Therefore when menopause affects sexual function it compromises women’s life quality.29
In this study, logistic regression analysis showed that married women presented a higher sexual dysfunction risk. Abdo et al.14 claims that FSD is strongly associated with psychosocial problems and conjugal relationship difficulties.
According to Lara et al. women in long-term relationships may have more complains about libido decrease because of conflicts generated along many years of marriage. Over time, even in non-conflicting loving relationships, a decrease in interest in sex and the loss of sexual interaction may occur motivated by the sexual routine.30
MRS urogenital score that contemplates bladder and sexual problems and vaginal dryness was associated to a higher FSD. Corroborating the findings of our study, Chedraui et al.10 study with sexually active mid-aged women also found association among MRS urogenital domain and FSD.
The effects of urogenital aging are frequently detected during postmenopausal, period that represents approximately one third of women’s lives and during which a hypoestrogenism condition persists.18 Estrogen deprivation may lead to the loss of vaginal lubrication, genital atrophy and pain during sexual intercourse.31 A cross-sectional study conducted with 98 705 postmenopausal women, identified that the main complains related to urogenital symptoms are: vaginal dryness, irritation and pain during the intercourse.32
Some studies have suggested that hormone replacement therapy may improve postmenopausal women life quality and may affect psychological matters related to vasomotor symptoms and sleeping problems. Therefore, hormone replacement therapy has been considered an alternative to protect women from FSD.33, 34, 35
Our study also found out that women who have carried out any type of bladder surgery, such as urinary incontinence correction and prolapses are more opened to sexual dysfunction.
A systematic review analyzed 21 articles on FSD and urinary incontinence postoperative. Results suggested that sexual function improves after surgery, but 13.0% of the women mentioned their sexuality was worse after surgery. Therefore, future investigations and controlled studies need to be performed in order to better understand the problem.36
Sexual function improvement was reported in relation to the surgical approach of the prolapse. However, a significant number of women reported the decline of the sexual function and the most common complaint was dyspareunia. The motives for the worsening of sexual function can be related to the materials used in the surgical correction or the repair of tissues.37 It can also be associated to inappropriate surgical results or other postoperative symptoms.38
Kammerer-Doak39 reports that urinary incontinence and prolapse surgeries results are conflicting. Whereas some studies suggest that surgery may be prejudicial to sexual function, other studies point out that improvements might occur. In this sense, the researcher concludes that there is a lack of valid data to evaluate sexual function after gynecological surgeries and that more studies on the subject are necessary.39
Other important aspects that interfere negatively on sexual response capacity are psychological factors such as low self-esteem, anxiety, traumatic past experiences, sexual violence, childhood sexual abuse and rape.40
In our study a history of sexual abuse was associated to sexual dysfunction. A dysfunctional situation may occur because of organic causes but most of the times it is aggravated by emotional and psychosocial impacts.41 When evaluating sexual function among mid-aged Ecuadorian women, Chedraui et al.42 also encountered associations between FSD and sexual abuse history. Burri et al.43 study revealed that emotional matters associated to childhood sexual abuse and to high levels of psychological distress are associated to higher sexual difficulties.
This research was based on a secondary analysis from a cross-sectional observational study; therefore some limitations must be taken into consideration. Women that did not have stable sexual relationships and women on anti-depressive drugs were not excluded from this study, which may have influenced the results. It is known, based on other publications, that FSD is influenced by a conjunction of factors.
There are many factors associated to sexuality such as aging, diabetes, hypertension, cardiovascular diseases and pelvic surgery, among others. Although all these factors are related to FSD, this study's main goal was to understand which factors are more often associated to postmenopausal women. The design of a study as well as the application of questionnaires and data evaluation may influence the results of a study. We suggest further longitudinal studies to be done to evaluate other predisposing factors as well as the first signs of FSD. We also suggest variables to be controlled to diminish confounding factors.
We verified that the women that participated in our research presented high rates of sexual dysfunction and that the risk factors associated to FSD were related to marital status—specifically for married women, urogenital dysfunction—shown through the MRS questionnaire, bladder surgery and history of sexual abuse.
Few studies evaluate sexual function among postmenopausal women. Given the evidence of high prevalence of sexual dysfunction, as well as the rise of comorbidities during postmenopausal period, it is important to recognize the major complains and worries related to sexuality during this stage of life. As a result women may access proper treatment and have a better aging process.
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The authors declare no conflict of interest.
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Dombek, K., Capistrano, E., Costa, A. et al. Risk factors associated with sexual dysfunction in Brazilian postmenopausal women. Int J Impot Res 28, 62–67 (2016). https://doi.org/10.1038/ijir.2016.4
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