academic essay Gender, Sexuality, Race, Ethnicity, and Age influence individuals’ experiences of the social world and the social problems

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exuality

orraine Dennerstein, PhD,a Philippe Lehert, PhD,a,b Henry Burger, MD,c

anet Guthrie, PhDa

Office for Gender and Health, Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia; the Faculty of Economics, University of Mons, Mons, Belgium; and

Prince Henry’s Institute of Medical Research, Monash Medical Centre, Clayton, Victoria, Australia

This article reviews changes in sexual function in middle-aged women and discusses how these changes relate to aging, hormone alterations, and psychosocial and physical factors. A Medline search of population-based studies that measured sexual function, menopausal status and/or hormone levels was conducted. Longitudinal findings are from the Melbourne Women’s Midlife Health Project, a popula- tion-based sample of 438 Australian-born white women, aged 45 to 55 years, who were menstruating at baseline. Annual assessments included hormone levels and the Short Personal Experiences Ques- tionnaire. Few of the population-based studies of the menopausal transition measured sexual function or hormones. Aging and the length of the woman’s relationship with her partner are associated with decline in sexual function. An additional decrement in sexual function occurs in midlife associated with menopause. Findings from the Melbourne Women’s Midlife Health Project using structural equation modeling, found the most important factors influencing a woman’s sexual function are prior level of sexual function; losing or gaining a sexual partner; feelings toward a partner; and estradiol level. When psychosocial and lifestyle status were added to the model, mood was the only additional variable affecting sexual function. There is a decline in all aspects of female sexual function with age. A further incremental decline in most aspects of sexual function occurs as women pass through the menopausal transition and is related to decreasing estradiol levels. Other factors such as prior sexual function and partner issues have larger effects on women’s sexual function than do hormonal factors. © 2005 Elsevier Inc. All rights reserved.

KEYWORDS: Aging; Estrogen; Hormones; Menopause; Sexuality; Testosterone

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The opinions offered at the National Institutes of Health (NIH) State- f-the-Science Conference on Management of Menopause-Related Symp- oms and published herein are not necessarily those of the National Insti- ute on Aging (NIA) and the Office of Medical Applications of Research OMAR) or any of the cosponsoring institutes, offices, or centers of the IH. Although the NIA and OMAR organized this meeting, this article is ot intended as a statement of Federal guidelines or policy.

Publication of the online supplement was made possible by funding rom the NIA and the National Center for Complementary and Alternative

edicine of the NIH, US Department of Health & Human Services. Requests for reprints should be addressed to Lorraine Dennerstein,

hD, Department of Psychiatry, The University of Melbourne, Victoria 010, Australia.

hE-mail address: [email protected].

002-9343/$ -see front matter © 2005 Elsevier Inc. All rights reserved. oi:10.1016/j.amjmed.2005.09.034

The 3 critical physiologic requirements for female sexual unction are as follows: intact sex steroids, autonomic/so- atic nerves, and arterial inflow/perfusion pressure to the

enital organs.1 Sex steroids are known to play a crucial role n maintaining the anatomical and functional integrity of all tructures involved in female sexual function.1 Epidemio- ogic and double-blind clinical trials have focused on the ole of estrogens (alone or in combination with progestins) nd the androgen testosterone.1–3 Recent expert review1

oncludes that further studies are needed to clarify the elevance of sex steroids to women’s sexual function.

This article reviews the changes that occur in the differ- nt domains of women’s sexual function in middle age, and valuates how these relate to the overall aging process, to

ormonal changes of the menopausal transition, and to other

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sychosocial and physical factors. Clinicians have long een concerned about effects of menopause on female sex- al function as sexual complaints are among the most fre- uently reported health concerns of women attending meno- ause clinics.4 Yet clinical experience is based on a small roportion of self-selecting women and may not be repre- entative of most women’s experience of the menopausal ransition.5

There are a number of other possible explanations for eteriorating sexual function in this phase of life. Major onfounders include the length of the woman’s relationship ith her partner, chronologic aging, other physical health roblems, loss of her partner, the partner’s health and med- cation usage, and the many psychosocial stressors associ- ted with midlife.

Population-based studies provide information on the revalence and type of changes in sexual function and their elation to menopausal hormonal changes and other possible eterminants. These studies complement clinical trials that rovide evidence on hormonal effects on specific parame- ers of sexual function in the groups studied.

exual function versus sexual dysfunction

urrent definitions of female sexual dysfunction include oth low sexual function and personal distress components or each of the domains of desire, arousal, orgasm, and ain.6 Studies published before the development of these efinitions usually do not include measures of personal istress. Only a proportion of those who have low sexual unction will be distressed about it7 and, hence, will be ysfunctional.

A number of studies concur in finding that women more requently report low sexual desire or interest than do men nd that there is poor correlation of women’s subjective exual arousal with observable increases in genital conges- ion in response to sexual stimulation.8 To address these ndings, an expert panel convened by Basson and col-

eagues8 has reconceptualized women’s sexual response. hey found a circular model of overlapping phases of vari- ble order influenced by psychological, societal, and bio- ogic factors.

ethodologic limitations

opulation-based studies enable the study of women in their wn naturalistic setting. These investigations also assess the ffects of factors other than hormonal changes. The results re then generalizable to the ethnic group and location tudied. Most population-based studies of female sexual unction have failed to include validated measures of female exual function.2 Measures used have mostly been single uestions that addressed particular domains of function or hat asked respondents to report their sexual problems or

ifficulties. Studies of large sample sizes often ask fewer s

uestions with less assurance of a reliable answer than do maller studies, which may be able to collect more detailed ata. Based on our own experience of longitudinal studies of hanges in health outcomes with the menopausal transition,9

minimum baseline study population of 400 subjects is eeded to provide enough power to detect change.

The age of subjects at baseline should be young enough o that measures are obtained before major change occurs in he hypothalamic-pituitary-ovarian axis. Documentation is eeded of any use of hormone therapy (HT) and of surgery hat may compromise ovarian function, such as hysterec- omy. Also crucial to the inferences that can be drawn are he type of study (cross-sectional versus longitudinal), and tatistical techniques that can unravel the complex interre- ationships between outcomes and determinants.

Relatively few of the population studies of the meno- ausal transition in middle-aged women have inquired bout sexual function. Even fewer have used a validated uestionnaire to assess the different aspects of sexual func- ion. A major problem has been to disentangle the effects of ging from that of menopause. The hormonal changes of the enopause take place over a variable period of time known

s the menopausal transition, so that aging and menopause re inevitably confounded. Most epidemiologic studies have ot directly measured hormonal status of the women sur- eyed, instead using menstrual status as a proxy for hor- onal status. Cross-sectional studies allow us to identify differences

cross age ranges, reproductive status groups, and ethnic roups. A major advantage of longitudinal studies is that of ess reliance on retrospective data, providing that the recall eriod inquired about is kept short. Longitudinal studies of amples derived from the general population are in the best osition to sort out whether there is a change in sexual unction associated with the menopausal transition and, if o, whether this reflects aging, health status, or hormonal or sychosocial factors. A major advantage of longitudinal tudies is the ability to control for the effect of prior level of exual function.

For longitudinal studies, the length of prospective fol- ow-up is crucial. For example, after 9 years of follow-up of ur population-based Melbourne Women’s Midlife Health roject cohort of women aged 45 to 55 years (mean age, 48 ears) at baseline, 8% were still menstruating and 51% of he women had reached documented final menstrual period FMP) without medical intervention. A total of 21% had egun HT before reaching their FMP, and 8% of the cohort ad undergone surgical menopause.10

ffects of aging

ging and length of the relationship with a partner are nown to affect sexual function of both men and wom- n,11,12 and these variables are often confounded. The lon- itudinal Melbourne Women’s Midlife Health Project found highly significant negative effect of aging on frequency of

exual activity; sexual interest (libido); and aspects of sex-

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al responsiveness, sexual arousal, enjoyment, and or- asm.13 In the Women’s International Study of Health and exuality (WISHeS), a multinational cross-sectional study arried out concurrently in Europe and the United States sing validated measures of sexual function and sexual istress, a decline in all aspects of sexual function was vident with age.14 Sexually related distress, however, de- reased with age so that there was no increase in sexual ysfunction with age.14

ging versus menopausal status

number of studies have found an additional decrement in spects of sexual function in midlife,15,16 coinciding with ean age of menopause17 or menopausal status where mea-

ured.18,19 Studies that failed to find effects of menopausal tatus have been limited by small sample sizes,12 wide age anges, and lack of validated measures.20

Very few studies have followed the same cohort prospec- ively across the menopausal transition. Longitudinal stud- es allow us to disentangle the effects of aging from those of enopausal hormonal changes (which are inevitably con-

ounded) as well as to measure the powerful effects of sychosocial factors, including the individual’s own prior evel of sexual function and changes occurring in sexual artnerships.21 The Melbourne Women’s Midlife Health roject is a population-based sample of 438 Australian-born omen who were aged 45 to 55 years at baseline and were

till menstruating. The women have been followed with nnual assessments and hormone measures for 13 years. he Personal Experiences Questionnaire short form

SPEQ), a validated measure of sexual function based on the

Figure 1 Total score of sexual fun

cCoy Female Sexuality Questionnaire,22–25 was used. The f

PEQ scale provides domain scores for frequency of sexual houghts (libido), arousal, enjoyment and orgasm (sexual esponsivity), frequency of sexual activities, and dyspareu- ia. Feelings about partner and partner problems are also easured. A total score of sexual function is calculated

rom the domains of libido, sexual responsivity, and fre- uency of sexual activities. Scores �7 indicate low sexual unction, similar to women with sexual dysfunction.25 From arly to late menopausal transition, the percentage of omen with SPEQ scores of low sexual function increased

rom 42% to 88%.13 By the postmenopausal phase, there ere significant declines in sexual responsivity, frequency f sexual activities, libido, and the total score of sexual unction, combined with significant increases in dyspareu- ia and partner’s problems in sexual performance.26 In- reasing dyspareunia and decreasing libido and responsivity orrelated with decreasing estradiol but not with andro- ens.13 Figure 1 shows the decline in the total score of exual function in relation to time to FMP.

elative importance of hormonal and sychosocial factors

hese results assist us in understanding the impact of the enopausal transition on women’s sexuality. However, an-

lytic techniques that can include psychosocial factors and he effects of increasing age are necessary to understand the elative importance of hormonal factors. Using techniques f autocorrelation and cross-correlation together with struc- ural equation modeling, the Melbourne Women’s Midlife ealth Project found that for the 336 women for whom data ere available for 8 years of follow-up, the most important

n relation to final menstrual period.

actors (in decreasing order of importance) influencing do-

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ains of libido and sexual responsiveness (together termed exual response) are prior level of sexual function, losing or aining a sexual partner, feelings toward the partner, and stradiol level27 (coefficient of determination for multivar- ate analysis [R2] � 0.65). Relationship factors were less mportant for dyspareunia, which was predicted by prior evel of dyspareunia and estradiol level (R2 � 0.53). Fre- uency of sexual activities was not influenced by estradiol evel but was predicted by prior level of sexual function, hange in partner status, feelings for partner and level of exual response (R2 � 0.52). The minimum effective dose eeded to increase sexual response by 10% (700 pmol/L stradiol) is twice that needed to decrease dyspareunia.27

ndogenous testosterone (determined as the free testoster- ne index) and dehydroepiandrosterone sulfate were not elated to sexual function domains.13,27 When a validated easure of distress (the Female Sexual Distress Scale) was

ncluded in the 11th year of follow-up, we found that only 7% of the women (then aged 57 to 67 years) were signif- cantly distressed.7

The Melbourne Women’s Midlife Health Project in- luded measures of many variables found to influence do- ains of sexual function in cross-sectional studies. These

nclude availability of a partner, well-being, educational evel, parity, stress, mood, health status.28 The study used ongitudinal structural equation modeling to determine the ost important influences on sexual response and frequency

f sexual activity. Included in the modeling were potential eterminants measured at baseline (education; parity; atti- udes; premenstrual complaints) or annually over the course f 8 years of follow-up (hormone levels; partner’s problems ith sexual performance; change in partner status; feelings

oward partner; stress; daily hassles; lifestyle factors; well- eing; and self-rated health and bothersome symptoms,

Figure 2 Longitudinal structural equatio

hich were grouped into vasomotor, insomnia, other, vag- m

nal dryness). The only additional factor found to affect the exual function domains was well-being, as measured by the ffectometer 2 scale.29 Well-being was itself affected by

ifestyle factors, stress, daily hassles, vasomotor symptoms, leep, and self-rated health (Figure 2).

thnicity

he Melbourne sample included only white Australian omen. It is not clear whether there will be any ethnic varia-

ion in response to declining estradiol at menopause. Using ross-sectional data from baseline (when women had not be- un the menopause or were early in the menopausal transition), he US-based Study of Women’s Health Across the Nation SWAN)28 reported substantial ethnic differences in sexual omains. After controlling for a wide range of variables, Af- ican American women reported a higher frequency of sexual ntercourse than white women; Hispanic women reported ower physical pleasure and arousal; Chinese and Japanese omen reported more pain and less desire and arousal than the hite women, although the only significant difference was for

rousal.28 Other studies carried out in Europe also have re- orted substantial differences between countries in domains of exual function, such as frequency of sexual intercourse; but evertheless they found a similar pattern of decline in the ffects of menopause on desire, arousal, and orgasm across all ountries.30

urgical menopause

his article has focused on changes related to the natural

eling of factors affecting sexual response.

enopausal transition. Surgical menopause, in which both

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varies are removed, was predicted to have more deleterious ffects on sexual function because all ovarian estrogen and ndrogen is removed.

ummary

here is a decline in all aspects of female sexual function ith age. A further incremental decline in most aspects of

exual function occurs as women pass through the meno- ausal transition. This further decline is related to decreas- ng estradiol levels. Other factors such as prior sexual func- ion and partner-related factors have larger effects on omen’s sexual function than do hormonal factors. How-

ver, when relationship factors are stable, declining estra- iol has noticeable effects. Not all women with low sexual unction are distressed about it.7

eferences

1. Nappi R, Salonia A, Traish A, et al. Clinical biologic pathophysiolo- gies of women’s sexual dysfunction. J Sex Med. 2005;2:4 –25.

2. Dennerstein L, Alexander J, Kotz K. The menopause and sexual function: a review of population-based studies. Annu Rev Sex Res. 2003;14:64 – 82.

3. Alexander JL, Kotz K, Dennerstein L, Kutner SJ, Wallen K, Notelo- vitz M. The effects of postmenopausal hormone therapies on female sexual functioning: a review of double-blind, randomized controlled trials. Menopause. 2004;11:749 –765.

4. Sarrel P, Whitehead M. Sex and menopause: defining the issues. Maturitas. 1985;7:217–224.

5. Morse CA, Smith A, Dennerstein L, Green A, Hopper J, Burger H. The treatment-seeking woman at menopause. Maturitas. 1994;18:161–173.

6. Basson R, Berman J, Burnett A, et al. Report of the international consensus development conference on female sexual dysfunction: def- initions and classifications. J Urol. 2000;163:888 – 893.

7. Dennerstein L, Burger H, Randolph J, Taffe J, Clark M. Sexual function, dysfunction and the natural menopausal transition. In: Schneider HPG, ed. Menopause: The State of the Art in Research and Management. London, UK: Parthenon; 2003:402– 407.

8. Basson R, Brotto L, Laan E, et al. Assessment and management of women’s sexual dysfunctions: problematic desire and arousal. J Sex Med. 2005;2:291–300.

9. Dennerstein L, Lehert P, Dudley E, Guthrie J. Factors contributing to positive mood during the menopausal transition. J Nerv Ment Dis. 2001;189:84 – 89.

0. Guthrie JR, Dennerstein L, Taffe JR, Donnelly V. Health care–seeking

for menopausal problems. Climacteric. 2003;6:112–117.

1. James WH. Decline in coital rates with spouses’ ages and duration of marriage. J Biosoc Sci. 1983;15:83– 87.

2. Hawton K, Gath D, Day A. Sexual function in a community sample of middle aged women with partners: effects of age, marital, socioeco- nomic, psychiatric, gynecological, and menopausal factors. Arch Sex Behav. 1994;23:375–395.

3. Dennerstein L, Randolph J, Taffe J, Dudley E, Burger H. Hormones, mood, sexuality, and the menopausal transition. Fertil Steril. 2002; 77(suppl 4):S42–S48.

4. Hayes RD, Dennerstein L, Bennett C, Koochaki PE, Leiblum SR, Graziottin A. Low sexual desire, distress due to low sexual desire, and aging (abstract). In: International Society for the Study of Women’s Sexual Health (ISSWSH). 2004 International Society for Women’s Sexual Health. Annual Meeting Program Book, Atlanta, Georgia, October 28 –31, 2004. Schaumberg, IL: ISSWSH; 2004:36.

5. Pfeiffer E, Davis G. Determinants of sexual behavior in middle and old age. J Am Geriatr Soc. 1972;20:151–158.

6. Hallstrom T, Samuelsson S. Changes in women’s sexual desire in middle life: the longitudinal study of women in Gothenburg. Arch Sex Behav. 1990;19:259 –268.

7. Pfeiffer E, Verwoerdt A, Davis GC. Sexual behavior in middle life. Am J Psychiatry. 1972;128:1262–1267.

8. Hallstrom T. Sexuality in the climacteric. Clin Obstet Gynaecol. 1977; 4:227–239.

9. Dennerstein L, Smith AM, Morse CA, Burger HG. Sexuality and the menopause. J Psychosom Obstet Gynaecol. 1994;15:59 – 66.

0. Osborne M, Hawton K, Gath D. Sexual dysfunction among middle- aged women in the community. BMJ. 1988;296:959 –962.

1. Dennerstein L, Lehert P. Modelling mid-aged women’s sexual func- tion: a prospective, population-based study. J Sex Marital Ther. 2004; 30:173–183.

2. McCoy NL, Matyas JR. Oral contraceptives and sexuality in university women. Arch Sex Behav. 1996;25:73–90.

3. Dennerstein L, Dudley EC, Hopper JL, Burger H. Sexuality, hormones and the menopausal transition. Maturitas. 1997;26:83–93.

4. Dennerstein L, Lehert P, Dudley E. Short scale to measure female sexuality: adapted from McCoy Female Sexuality Questionnaire. J Sex Marital Ther. 2001;27:339 –351.

5. Dennerstein L, Anderson-Hunt M, Dudley E. Evaluation of a short scale to assess female sexual function. J Sex Marital Ther. 2002;28: 389 –397.

6. Dennerstein L, Dudley E, Burger H. Are changes in sexual function during midlife due to aging or menopause? Fertil Steril. 2001;6:456 – 460.

7. Dennerstein L, Lehert P, Burger H. The relative effects of hormones and relationship factors on sexual function of women through the natural menopausal transition. Fertil Steril. 2005;84:174 –180.

8. Avis N, Zhao MS, Johannes CB, Ory M, Brockwell S, Greendale GA. Correlates of sexual function among multi-ethnic middle-aged women: results from the Study of Women’s Health Across the Nation (SWAN). Menopause. 2005;12:385–398.

9. Kammann R, Flett R. Affectometer 2: A scale to measure current level of general happiness. Aust J Psychol. 1983;35:259 –265.

0. Dennerstein L, Lehert P. Women’s sexual function, lifestyle, mid-age, and

menopause in 12 European countries. Menopause. 2004;11:778 –785.