July 12, 2019
Free-text survey responses from thousands of postmenopausal women in the United Kingdom as to why they do or do not have sex highlight familiar patterns, according to results published July 10 in Menopause. The findings raise serious concerns about why so few women seek help for sexual dysfunction, experts said.
Just 6% of older women sought medical help for sexual dysfunction, report Helena Harder, PhD, Sussex Health Outcomes Research and Education in Cancer, University of Sussex, Brighton, United Kingdom, and colleagues.
That low proportion points out the need for more questions by healthcare providers, particularly primary care providers, who were the go-to providers when women did seek help.
The data come from a subset of women who participated in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS). At baseline, 24,305 women completed the Fallowfield Sexual Activity Questionnaire; of those, 4418 (19%) provided free-text comments on sexual activity, which were the basis of this analysis.
About One Fourth Sexually Active
In the study group (median age, 64 years), 65% of respondents had a partner, and 22.5% were sexually active.
Among those who reported being sexually inactive, the most common reason was not having an intimate partner (44.8%). Nearly a third of the women were widows (28.2%) "and mentioned that they found it difficult to meet other men, had lost interest in sex after their partner's death, or did not want to engage in other sexual relationships," the authors write.
A smaller proportion of women reported not having a partner as a result of divorce or separation (4.2%), and a few said they were celibate, primarily for religious reasons (2.4%).
"Only 5% of unpartnered women in this study engaged in physical tenderness (fondling, kissing) and just over 1% reported having sexual intercourse," the authors write.
The other reasons participants gave for being sexually inactive were that they were not interested in sex (30%); their partner had a physical problem (23%); their partner was not interested (21%); the respondent herself had a physical problem (11.2%); the respondent was too tired (9%); the partner was too tired (7.6%); and other (26.1%).
'If We Don't Ask, They Don't Tell'
That only 6% sought medical help for sexual dysfunction may suggest the kinds of questions that healthcare providers should be asking their postmenopausal patients.
"If we don't ask, they don't tell," Jennifer Berman, MD, a urologist with Berman Women's Wellness Center in Los Angeles, California, who is a renowned sexual health expert, told Medscape Medical News. "It's hard enough to talk about it to our partners, much less in the doctor's office when that door hasn't been opened."
Validated questionnaires about arousal, libido, and menopause should be used routinely, she said. In the past, physicians may have avoided the subject because there were no medical treatments, but that has changed, she noted.
"There's no excuse for doctors not to be prescribing them," she said.
Berman added that women may not seek treatments because they don't know about them. Those who do know something about such treatments may be misinformed about potential side effects if they had not heard about the treatments from their physician, she noted.
Berman and the authors say the study's conclusions are not new.
"Overall the current findings support previous research on the role of physical and mental health in understanding sexual problems experienced by older women," Harder and colleagues write.
Harder told Medscape Medical News in an email that although it makes sense that widowhood may lead to a decrease in sexual activity, the researchers found some of the findings surprising.
"In some of the comments, it was clear that women were widowed for a long time and still relatively young [some were in their 50s]," she noted, "and unable or not interested in finding a new partner."
Harder added, "I was struck by the finding that menopause-related symptoms have an impact on sex life in 1 in 8 women. These problems were quite diverse (mainly dryness and pain during intercourse) but could be resolved with often simple (and safe!) solutions."
Berman said that in some cases, the findings are misleading.
For instance, the authors write, "Levels of sexual activity in partnered women in our study were lower than published data." A little more than a third of the women (34.5%) said they had been sexually active in the past month.
Being "sexually active in the past month" doesn't give much information, according to Berman. It is possible that a partner lost a job or that the woman had a urinary tract infection, she said.
In addition, the article refers too broadly to sexual activity, Berman said, and does not indicate whether the sexual activity was intercourse or masturbation.
She also questioned the generalizability of the data, because in the United Kingdom, cultural norms regarding sex are different from those in the United States.
Harder, however, disagrees. "I would like to think that these days, there shouldn't be any cultural differences ... between women in the UK and the US. I think that if a physician discusses potential sexual problems in the context of other health problems, this shouldn't make a difference."
Kate Thomas, PhD, RN, director of clinical services for the Sex and Gender Clinic and instructor of psychiatry and behavioral sciences at Johns Hopkins Medicine in Baltimore, Maryland, said the fact that it was a large study adds some weight to its conclusions.
She said the main message for her was that, as providers, "there's work to be done here.
"Obviously, medicine can't do anything about your partner surviving or not surviving, your partner's physical health, but we can do something about sexuality, even with health concerns, and do something about sexual dysfunction and menopause-related symptoms," she said.
These results are more proof that providers may need to ask questions beyond whether someone is sexually active, Thomas said.
There is evidence that maintaining sexual activity can help promote physical and mental health, she noted.
Thomas also pointed out that only 3% of the comments referred to positive sexual experiences, which raises questions about why some women don't enjoy sex.
"These are things we really need to look at as a society," she said.
Harder has disclosed no relevant financial relationships. Other authors' disclosures are listed in the original article. Berman is a paid consultant for Plan B One-Step. Thomas has disclosed no relevant financial relationships.