Sexual function among married menopausal women in Amol (Iran).

BACKGROUND: Sexual activity is an important part of the human being's life but this instinct could be influenced by some factors such as diseases, drug using, aging, and menopause. But information about that is limited. AIM: The aim of this study is to determine the status of sexual activity among married menopausal women in Amol, Iran.
MATERIALS AND METHODS: This descriptive analytical study was conducted to describe the sexual activity and sexual dysfunction of women after menopause. Data were collected from health centers in Amol from 280 married women using a questionnaire (self-completed or by interview). FINDING: Mean age of subjects were 55.9 ± 6.02 years. 23.4% of subjects reported that their sexual intercourse had been low. 70% of subjects reported a decrease in their sexual activities after menopause. Sexual dysfunctions includes sexual desire disorder 80% arousal dysfunction 80%, orgasmic dysfunction 25%, dyspareunia 55.6%, and lack of sexual satisfaction 43.2%.
CONCLUSION: Findings revealed high percentage of sexual desire disorder and sexual arousal disorder in menopausal women. Therefore, we should have emphasis on counseling and education about sexual activities during the menopause period.

INTRODUCTION

Increasing life expectancy has been accompanied by improvements in the health and quality of life of the middle-aged and elderly and knowing that women live one third of their lives during menopause.[1]

Apart from age, decreased well being, increased symptomatology, and natural menopause contribute to significant reduction in sexual activity.[2] Physical changes, such as urogenital ageing and musculoskeletal changes which occur just before or after menopause, affect sexual functioning.[34] On the other hand, some studies have shown that having sexual activity may have positive effect on health improvement and protection of the natural physique of postmenopausal women.

In a global study, Nicolosi et al., found that 39% of women were affected by at least one sexual dysfunction,[1] while in a survey, only 14% of Americans aged 40–80 said that they’d been asked by their physicians about sexual difficulties during the past 3 year.[5]

Beliefs and practices that influence a woman's perception of menopause can also influence her sexual function in many societies. There is a belief that older women become “sexually retired” after menopause and are, therefore, expected to be less sexually active.[367] On the other hand, some women may feel freedom because of the end of the reproductive age and also less responsibility about children.

In our society, lots of women are embarrassed to ask questions about their sexual function because of some cultural taboos. No information exists on sexual functioning of postmenopausal women who are living in Amol, a city in Iran. Therefore, we have conducted a research to determine the frequency of sexual activity, satisfaction and sexual dysfunction among postmenopausal women.

MATERIALS AND METHODS

This is a cross-sectional study that has been done on 280 postmenopausal women. These women were randomly chosen from those attending the Health Centers in Amol.

Exclusion criteria include known disease that have effect on sexual function, such as thyroid disease, heart-pulmonary diseases, supra renal disorders, diabetes, infectious diseases, genitalia injury, use of some medications such as antidepressants, antiblood pressure, opioids, HRT (hormonal replacement therapy), surgery resulting in menopause, stress experience or living without spouse, sexual dysfunction in spouse, etc.

A semi structured questionnaire in the Persian language was designed to obtain information on the sexual functioning of postmenopausal women. The development and design of the questionnaire was done following extensive literature review of related studies and FSFI (female sexual function index) to ascertain face validity of the questionnaire. The content of the questionnaire was reviewed by 5 academic faculty members (psychologist, nursing, and midwifery department faculty members). Reliability co-efficient (Cronbach's alpha) was 0.82, which indicated that the instrument has a good reliability.

The questionnaire had two parts, demographic characters and sexual function.

To assess the desire, arousal, orgasm, sexual pain, lubrication of vagina, their satisfaction, and spouse's satisfaction about these women's sexual function, two questions were considered and each question was scored from 0 (no problem) to 4 (worst problem). Total score was from 0–48 and based on total score, subjects were classified into three groups:

0–24 normal, 25–36 borderline, and 37–48 severe.

All statistical analyses were conducted using SPSS version 10.

FINDINGS

The mean age of the subjects and their spouses in this study was (55.9 ± 6.02, 61.1 ± 7.83) years and average time from their last date of menstruation was 7.5 ± 5.43 years.

Most of them were house wives. 90% of the subjects had primary school education, and majority of them mentioned their economic status as good [Table 1].

Table 1

Mean of some socio demographic factors among selected subjects

In our study 56.4% of subjects had sexual dysfunction in different phases. More than half of them had severe dysfunction based on our scoring system, one third were facing borderline dysfunction. Prevalence of sexual dysfunction in different sexual phases has been shown in Figure 1. It can be seen from the Figure that desire and arousal dysfunction are predominant in females. Based on these observations it is obvious that that menopause women are high risk for sexual dysfunction. Sexual dysfunction is a broad collection of concerns that occur in menopausal women and can be effective in their quality of life. 23.4% of women reported that they rarely have sexual activity. 70% reported decrease in frequency of intercourse after menopause.

Figure 1

Percentage of sexual dysfunction in menopausal women

41.8% of women revealed that their spouses’ sexual interest decreased,

While frequency of sexual desire decrease among women was twice more than their spouse; more than half of the subjects reported that spouses’ sexual interest was more than their interest.

52.6% of them had noticed changes in vaginal stretching for full penetration and half of them reported some problems with their sexual function. Menopausal changes suggest that most mid-life women report a range of somatic, emotional, and vasomotor conditions including irritability and vaginal dryness. The research on whether these conditions are caused by hormonal fluctuations due to menopause, aging, or life stressors of midlife is inconclusive.

31.9% of respondents revealed that their spouses were unsatisfactory with their sexual function, and 52.5% mentioned that sexual problems had an effect on their relationship to their husbands.

55.6% of subjects had painful intercourse after menopause. 43.2% mentioned lack of sexual satisfaction.

DISCUSSION

In this study, 70.3% of subjects reported a decrease in sexual activity after menopause. This incidence is somewhat similar to Park's study in Korea and Dhillon's study in Malaysia.[89] It is, however, different from Dennerstein's study in Australia where 31% of respondents reported a decrease in sexual activity with nearly two-third reporting no change.[10] The reason for the differences between the two studies may be related to the age range of the study population and it seems that in our study subject's mean age are higher than Dennerstein's study.

In this study, 56.4% of subjects had sexual dysfunction but according to Arman, et al., the frequency of sexual dysfunction in Isfahan was 72.4%,[11] while the frequency of sexual dysfunction among middle-aged and elder women in Addis's study was 45%[12] and in Bonnie's study was 20%.[13] Possible explanations for the higher frequencies in our study include sociocultural differences, genetic (racial) differences and religions differences. A study in Australia revealed all types of sexual dysfunction increased significantly with age and apart from age, sexual dysfunction significantly increased with advancing menopausal years.[4] Also other studies showed that natural sexual activity will be reduced on becoming older.[4814] On the other hand, menopausal conditions may increase this situation that it needs more controlled studies.

Women reported either an absent or decreased sexual desire that is the same as Kaboody's study which was done in 2002 in Kermanshah (70%).[15] Hayes et al., found the proportion of European women with low desire increased from 11% amongst women aged 20–29 years to 53% amongst women aged 60–70 years.[14] Also Ponholzer et al., found women aged 61–70 years had a 2.8-fold higher risk for sexual desire disorder as compared to those aged 12–30 years.[16]

Although we did not find any association between dyspareunia and number of sexual intercourses, frequencies showed women with dyspareunia had a lower intercourse frequency. In a study in Malaysia relationship between number of intercourse and dyspareunia was significant.[9]

In our study, frequency of dyspareunia was 55.6% and it is higher than studies that have been done in other parts of the world, such as Australia 12%, Taiwan32%, Pakistan 16.9%, and Turkey 16%.[217-19] Reason for this high difference is unknown. Decrease in vaginal lubrication during sexual activity or menopausal atrophic changes can be reasons for pain during sexual intercourse.

80% of women stated vaginal dryness after menopause. Prevalence of vaginal dryness in Singapore was 20.7%, Thailand 20.7%, and 23.6% among Taiwanese women.[172021] One of the reasons for high incidence in our study could be due to the age range of our study population. Recent evidence suggests that the declining vaginal secretion might also be due to the effect of age and hypoandrogenism.[22] A negative correlation between age and the density of androgen receptor expression has been reported, suggesting that androgen might also be involved in the regulation of vaginal blood flow and secretions.[23]

In this study, we found significant relationship between sexual desire loss and number of sexual intercourses during the last year (P=0.000). A similar prevalence was reported in Australian, Turkish and Dutch studies.[4192425]

We found association between the number of sexual intercourse with some variables, such as subject's education level and their spouse's education level (P=0.000, P=0.006) and these findings were similar to Addis et al., findings.[12]

A negative correlation was noticed between the age of spouse and the number of sexual intercourse (P=0.000) and also between age of the spouse and the sexual desire of the women (P<0.01) similar to the Kelantanese women in Malaysia.[9] Addis also found more frequent sexual activity was associated with the younger aged.[12] Study among American and Australian women showed similar association.[72426]

There were no association between sexual dysfunction and occupation, income, number of children.

Arousal problems were 80% and it was similar to another study in Iran that was done by Arman et al., in their study arousal problems was 75.3%.[11]

Orgasmic problems were 25% and Nicolosi et al., reported 16% of women suffered from inability to reach orgasm.[1]

52.5% of the subjects mentioned that sexual problems had an effect on their relationship with their husbands, also Nicolosi et al., Study found that 76% of the women agreed that satisfactory sex is essential to maintain relationships.[1]

This data show poor sexual function and high sexual dysfunction among postmenopausal women. Iranian traditional sexual beliefs persist and moreover the meaning of sexuality in Iranian society is based on religious minds, which makes them feel themselves passive in sexual activities. These women avoid showing their sexual emotion because of lack of knowledge and traditional beliefs. Nowadays promotion of quality of life in elder women is one of the most important issues. So it seems to need more investigations because sexual activity and satisfaction is one of the important aspect of human life which is largely ignored, especially in developing countries.