What activates desire? What role do hormones play in sexual arousal? How is sexual appetite - and the ability to experience pleasure - affected by the aging process?
To answer these questions, we turned to Alessandra Graziottin, an internationally known expert in women's health. Dr. Graziottin is trained in four fields: medical sexology, gynecology, oncology and psychotherapy for sexual issues, and is currently director of the Menopause Center and the Center for Gynecology and Medical Sexology at the Hospital San Raffaele Resnati in Milan, Italy.
A well-known educator, she has written nine books, over 250 journal articles and contributes to many Italian health and women's magazines. Dr. Graziottin is past president of the International Society for the Study of Women's Sexual Health and a member of the board of the Italian Menopause Project (IMP) and the European Menopause and Andropause Society (EMAS).
She recently talked with our managing editor, Valerie Andrews, about ways women can stay sexually active as they grow older, and the special challenges they may encounter from simple tension to certain types of vaginal pain.
Andrews: How long does our sexuality last? Until what age can women expect to feel aroused?
Dr. Graziottin: Theoretically, women can go on feeling sexual until they are 80 or 100. However, maintaining an active sex life is dependent on a number of variables. First is the quality of your sex life and frequency with which you have it. The old expression "use it or lose it" really is true, as the work of noted Australian researcher Lorraine Dennerstein shows.
There are two ways of keeping active: one is with a partner and the other is masturbation, but a woman's culture or religion may not favor the second option. Often, single women don't pursue this alternative because they feel guilty. Yet this form of stimulation can be effective in helping to maintain sexual response. It's a natural function and also relieves tension.
If a woman has a partner, we have to ask, "What are your feelings for your mate? Have they changed in any way?" Dr. Dennerstein has found that sexual experience corresponds to the quality of the relationship.
Another significant factor is hormonal status. Loss of estrogen accounts for some decline in sexual arousal but androgens also play a role. Signs of androgen insufficiency are: loss of libido and arousal difficulties, problems with clitoral orgasm, a loss of pubic hair and reduced muscle mass. Some believe a loss of assertiveness and a decline in vital energy occurs as well when a woman suffers from so called "Androgen Insufficiency Syndrome". [Androgen is a hormone with testosterone-like effects.]
We also need to know if a woman is having a natural menopause or one induced by surgery. Women who have their ovaries removed have an early menopause. They also report more dramatic changes in their sexuality and may experience more dramatic hot flashes than those who stop menstruating on their own time clock.
In addition, we have to consider lifestyle choices. Regular daily exercise helps a woman to maintain a positive body image, self-confidence and favorable mood. It's important to eat healthy food, get an adequate night's sleep - in duration and quality - and stay in good mental shape, reading and doing stimulating activities instead of watching too much television. It also helps to have supportive friends and affectionate relationships. Mental and emotional well-being are prerequisites for long-lasting sexuality. This is true for women and for men.
Andrews: Is a woman's overall health also a factor?
Dr. Graziottin: Absolutely.
Certain illnesses or their treatments can lead to an early menopause. Consider women who have chemotherapy and still have their ovaries. Here we see an exhaustion of the follicles that produce estrogen and the destruction of the cells that produce androgens. As a result, these women don't produce enough of the hormones they need to become aroused.
We also see Androgen Insufficiency Syndrome in the wake of leukemia or problems with pituitary or adrenal function.
Finally, you have to take into account the sexual health of the woman's partner. Is the man having problems with erection or ejaculation, a sexually transmitted disease or his general health? Is he suffering from depression or undue stress?
Andrews: What if a man starts to take Viagra, and his partner isn't able to respond with the same enthusiasm?
Dr. Graziottin: A doctor should ask the man if his partner is menopausal, if she's on hormone replacement or a supplemental vaginal estrogen.
As men and women both age, it's important to explain to them that a well-lubricated vagina can allow intercourse even when there's less of an erection, and this, in turn, can improve the man's response.
Before prescribing Viagra, it's also important to find out if the woman is still willing to have intercourse, if she's still arousable, and if she is having any problems with lubrication or pain related to menopausal changes in the vagina or vulva.
There are psychological issues to address, as well. After 20 years of marriage, the woman may no longer be that interested in sex. Many men stop taking Viagra in two years' time because there is no marital agreement on the goals of intimacy.
When a woman complains about her sexual functioning, I recommend that she come in with her partner, so we can address all sides of the issue.
Andrews: You have written a book, published in Italy, which shows that our senses also become less acute as we age. How does this affect our sexuality?
Dr. Graziottin: The skin and all our sensory organs are affected by hormones. Research shows that women have increased sensitivity to smell during ovulation. We are attracted to a mate because we like the way he smells, but as we age, our sensory response declines.
Salivary secretion also diminishes with age and loss of estrogen. After menopause about 46 percent of women complain of dry mouth. This goes up to 62 percent if the women are on other medications.
Taste is modulated by hormones, so when we grow older, even our experience of kissing or the taste of our partner's skin may change. Studies show that increased salivary secretion during arousal is a strong predictor of sexual enjoyment.
Andrews: What about antidepressants, which are often prescribed for women in mid-life?
Dr. Graziottin: Overall, only 30 percent of women seem to have arousal and libido problems. However, antidepressants may be a contributing factor. They have a frequent and underestimated effect on desire, and we need more research in this area.
I believe these medications play an important role, provided we use the minimal effective dose. I prescribe them for patients who complain of depression, of being easily moved to tears, of general lack of energy or weakness (anergia). But I give them the lowest possible therapeutic dose. It's important to acknowledge that depression causes not only psychological symptoms but also impairs somatic function.
Andrews: We've talked about women who are having trouble getting sexually aroused. What about those who find sex painful?
Dr. Graziottin: Clinicians should examine a woman very carefully, asking when and where it hurts. A woman is often unable to articulate her problem, and when she does bring it up, it may be viewed as a symptom of anxiety and depression. And yet this pain is very real.
We call this condition dyspareunia, and the first thing we need to determine is, where does the pain start? And where is it most intense? Pain can arise from inflammation, muscle spasms or neurological problems.
Pain at the entrance to the vagina, or tiny tears, may result from dryness or lack of lubrication. This can often be addressed with vaginally applied estrogen.
This problem may occur gradually, as in normal onset of menopause, or abruptly when, for example, a woman has her ovaries surgically removed.
Chemotherapy and pelvic radiotherapy for different tumors can also cause a premature menopause and lead to this kind of discomfort. And androgen insufficiency can be a contributing factor.
Andrews: How does the normal aging process affect the vagina?
Dr. Graziottin: Many otherwise healthy women complain of irritation and infection as the vaginal ecosystem changes. The PH [acid-base level] of the vagina with normal estrogen levels is usually around 4. But as estrogen levels drop, the vagina becomes less acidic, and this leads to the proliferation of bacteria and increased vulnerability to sexually transmitted diseases.
Over time, the tissues of the labia or external genitalia can grow thinner, and the skin and mucosa become more fragile.
A woman may also have pain in the mid-vagina when her muscles are tightened. We call this vaginismus. A small percentage of women may develop "defensive contractions" if they've been experiencing pain with intercourse. If the initial pain is properly treated, this problem may be avoided.
The good news is that women who do suffer from this problem can be helped by a massage of the pelvic muscles with oil made from St. John's Wort. There is no clinical study on this, but the oil itself appears to have some anti-inflammatory properties. And I've found the massage is useful to women and their partners.
First, I teach the woman how to perform the massage on her own vagina. At the beginning she may feel reluctant. But soon she feels empowered in understanding the cause of her pain and what she can do to reduce it. This gives her hope and improves her self-confidence and self-esteem as well. If she agrees, I teach her mate how to do this gentle massage and include it in the foreplay.
It costs nothing, takes three minutes to teach, and once a man is told where the pain is and how to relieve it, his face changes dramatically. He understands there's a reason for his partner's discomfort, and there's something he can do to help. (Editor's note: Before attempting pelvic massage, you will need instruction. Talk with your clinician or ask for a referral to a medical sexologist.)
Andrews: What about pain deep within the pelvis?
Dr. Graziottin: Among the causes are endometriosis, pelvic inflammatory disease, adhesions from previous surgeries or an occult problem such as an ovarian cyst. And the women may be more likely to feel this with deep thrusting during intercourse. This is an important symptom which patients should bring to their gynecologist's attention.
If the pain is radiating outward and occurs independent of intercourse, it may be caused by a compression of the pudendal nerve. For this reason, we ask if a woman has had a bad fall sometime within the last 10 years. This problem can also result from radical surgery for gynecological or anal cancer.
Andrews: What is the best way for a woman to get help if she has any of these difficulties ranging from problems with arousal and minor discomfort to pain during sex?
Dr. Graziottin: Many gynecologists are not trained to deal with the diagnosis and treatment of pelvic pain, which can have a variety of causes. And women are often unable to articulate the problem, so it goes unaddressed.
My advice would be this: First find out if your physician is trained in medical sexology. If not, get a referral to someone who is by contacting the American Association of Sex Educators, Counselors, and Therapists or the International Society for the Study of Women's Sexual Health.
If your discomfort is related to natural aging and menopause, this can usually be addressed by a gynecological practitioner. The more complex pain and sexuality problems often require a knowledge of sexology.
A clinician with this background will take a multi-modal approach to pain and sexuality, can prescribe a variety of treatments and deal with both the emotional and physical aspects of the problem. This can empower you and your partner and strengthen your relationship.
This article is for educational purposes only and is not intended as a substitute for medical advice. Please consult with a clinician to review any current symptoms and address your medical concerns.
