Referral to a therapist also may be necessary so that other barriers to intimacy and sexuality can be determined.
Sexual dysfunction tends to increase with age
As menopause approaches, so do a number of interrelated issues that may affect a woman’s sexual function. Here are five of them:
Body image may deteriorate, leading to feelings of unattractiveness that can lower interest in sexual activity.
Testosterone levels decline throughout a woman’s reproductive life, as does estrogen—but the decline in testosterone is much more gradual without any abrupt reduction at menopause. In addition, some common medications, such as oral contraceptives and oral estrogen formulations, increase sex hormone binding globulin, which can reduce dramatically the free testosterone level. Some women are especially sensitive to the effects of these drugs and may report a rapid loss of sexual desire when these agents are given. To sidestep the problem, give transdermal or transvaginal estrogen, when possible.
Comorbidities take a toll on sexual function in many cases. Arthritis, diabetes, cardiovascular disease, and other impairments may hamper sexual satisfaction. In addition, fatigue, insomnia, and depression are common with age.
Partner issues also play a role in diagnosis and treatment of female sexual dysfunction. For example, poor health in the partner can cause or exacerbate sexual problems.
Pain during sex can trigger desire and arousal disorders
Pain during sexual activity can lead to disorders of desire as well as arousal. When a patient reports pain during sex, pay careful attention to her medical history and perform a detailed physical examination. Patience is vital. Successful treatment of pain disorders requires commitment from the patient and her partner as well as the medical team.
Consider asking the following questions:
- Over the past 4 weeks, how often have you experienced discomfort or pain during vaginal penetration?
- How often have you experienced discomfort or pain following vaginal penetration?
- How would you rate your degree of discomfort or pain during or following vaginal penetration?6
Consider pain as a cause when any patient reports low libido, as pain is a potent suppressor of desire. A meticulous clinical history is required to determine the cause. For example, it is important to uncover whether the pain is of recent onset or of long duration, or whether it is related to childbirth, lactation, or menopausal changes.
Pain upon penetration could be caused by chemical, infectious, or atrophic vulvovaginitis. Dryness and pain upon penetration are often caused by:
- contact dermatitis
- irritation from soaps or scrubbing
- daily use of panty liners
- use of so-called feminine hygiene products
- regular use of swimming pools or hot tubs that contain chemicals.
Another cause of pain to consider is vulvar dystrophy. When lichen sclerosis or hypertrophic dystrophy goes untreated, the result may be fibrosis, lack of elasticity, painful fissures, and loss of normal architecture. These changes usually occur in postmenopausal women, so it is important that treatment address both the fibrosis and the hypoestrogenic atrophy.
If treated early, vulvar vestibulitis may not require surgery
Vulvar vestibulitis is poorly understood. It tends to occur most often in premenopausal women, frequently as a result of vulvar infection or during the postpartum period.
Vulvar vestibulitis involves point tenderness—sometimes experienced as a burning, searing sensation—around the introitus, specifically, the vestibular glands. When this condition is suspected, examine the vulva and vestibule with a moistened cotton swab to assess whether the classic distribution of pain is present. The necks of the vestibular glands may appear inflamed and erythematous.
If the condition is treated early enough with topical steroids and, in some cases, hydroxyzine, surgery may be avoided, provided the patient also avoids topical irritants. In many women, however, vestibulectomy is required to eliminate symptoms.
Vulvodynia may be associated with other pain syndromes
This disorder is a more generalized pain syndrome that involves the entire vulvar region. Like vulvar vestibulitis, it can cause painful penetration. It is also associated with other pain syndromes, including interstitial cystitis and endometriosis. Sensitization to pain at a central level may lead to hyperesthesia and allodynia. Also consider pudendal neuropathy, especially if the patient is a regular bicycle rider.
Treatment usually consists of off-label use of neuromodulators, such as gabapentin, tricyclic antidepressants, or duloxetine. The use of topical local anesthetic creams or gels may also permit pain-free sexual activity.
Vaginismus may indicate a history of sexual abuse
When the perineal muscles surrounding the outer third of the vagina contract involuntarily upon contact with a penis, speculum, or other item, vaginismus may be present. This disorder can be primary or secondary. In primary vaginismus, the patient may be unable to tolerate any vaginal penetration at all, not even a single digit or tampon. When this is the case, the patient may have a history of childhood sexual abuse. Explore her history, including any medical examinations that may have been painful or generated fear and anxiety. Also be aware that women with sexual aversion disorder may present with primary vaginismus.