Let’s Talk about Sex and the Older Woman

1. Let’s Talk about Sex and the Older Woman Gerti E. Heider, PhD, APRN, GNP-BC

2. Objectives Differentiate the normal age associated changes from the pathological ones in the older woman. Examine commonly prescribed medications and their effect on sexual function in older women. Identify strategies to facilitate dialogue between the practitioner and the older female patient as it relates to sexual function.

3. Introduction • Our understanding of sexual function and dysfunction in older men has increased significantly • We know much less about sexual function and dysfunction in older women • The difference is due in part to: • Difficulty of measuring female sexual response • Exclusion of older adults from research

4. SIGNIFICANCE • Sexuality adds to quality of life. • Women who have sexual dysfunction often do not to report to their healthcare providers. • Few practitioners ask their patients about sexual health. • Treatment of any contributing factors can lead to improvement in this area.

5. Sexuality of the older woman Level of sexual activity, interest, and enjoyment in younger years determines sexual behavior with aging

6. Sexuality of the older woman • Decreased sexual activity is associated with: • Poor health • Social issues • Partner availability • Decreased libido • Menopause

7. Stages of sexual response:Age-related changes in women • Excitement: • clitoris requires longer direct stimulation; genital engorgement is decreased • Plateau: • less expansion and vasocongestion of the vagina

8. Stages of sexual response:Age-related changes in women • Orgasm: • fewer and weaker contractions; still can achieve multiple orgasms • Resolution: • vasocongestion is lost more rapidly

9. Normal Age-Related Changes • Menopause is associated with decreased sexual function • Decreased sexual interest • Decreased responsiveness • Decreased coital frequency • Increased urogenital symptoms, often not discussed with the physician

10. Normal Age-Related Changes • Decreased estrogen levels • Decreased thickness, elasticity, and lubrication of vaginal tissues • Decreased glandular tissue in breasts • Increased time needed for arousal

11. DYSPAREUNIA IN OLDER WOMEN(pain with intercourse) • Due to organic or psychological factors, or a combination of the two • Most common organic cause: atrophic vaginitis due to estrogen deficiency • Other causes: • Localized vaginitis • Cystitis • Bartholin's cyst • Retroverted uterus • Improper angle of penile entry • Pelvic tumors • Excessive penile thrusting • DeLamater, J., & Karraker, A. (2009). Sexual Functioning in Older Adults. Current Psychiatry Reports 2009, 11:6-11

12. LIBIDO • Thought to depend on testosterone, even in women, rather than estrogen • Estrogen replacement: • Can improve vaginal lubrication and sense of well-being • Has little effect on libido • Ovaries and adrenals are the main sources of androgens in women

13. Pathophysiologic Changes that Affect Female Sexuality Diabetes Cardiovascular disease Stroke Arthritis Surgeries that affect body image and diminish self-esteem (e.g.mastectomy, ostomies)

14. Pathophysiologic Changes (cont’d) Neurological disorders (e.g., Spinal cord injuries, or diseases of the central or peripheral nervous system) Effects of alcohol or recreational drugs Female urinary incontinence

15. MEDICAL ILLNESS AND THE OLDER WOMAN’S SEXUALITY • Studies on the effect of chronic illnesses and medications on women’s sexuality are limited. Women with diabetes mellitus report decreasedlibido and lubrication, and longer time to reach orgasm. In a study of eight women aged 24 – 83, older women with diabetes reported lower sexual function, desire and enjoyment than their younger counterparts. (RockliffeFidler, C., & Kiemle, G. (2003) • Rheumatic diseases decrease functional ability

16. MEDICAL ILLNESS AND THE OLDER WOMAN’S SEXUALITY Coronary artery disease affects women’s sexual function. In a study of 2,763 postmenopausal women, the presence of coronary heart disease was significantly associated with: • Lack of sexual interest. • Inability to relax during sexual activity. • Arousal and orgasmic disorders. • General discomfort with sex . (Addis et al 2005)

17. MEDICAL ILLNESS AND THE OLDER WOMAN’S SEXUALITY There are not many studies on urinary incontinence and its effect on sexual function. However, it is thought to interfere with sexual function among older women due to: • Shame and embarrassment. • Avoidance of sexual activity for fear of incontinence. In a study of 2, 361 Community-dwelling women aged 55 to 95, UI was significantly associated with alterations in sexual activity. (Tannenbaum et al, 2006)

18. BREAST CANCER AND SEXUALITY • Possible causes of sexual dysfunction after mastectomy: • Disruption of body image • Family or marital problems • Spousal reaction • Adjuvant therapy • Psychological impact of cancer diagnosis • 20% to 40% of women experience sexual dysfunction after mastectomy

19. PSYCHOLOGICAL FACTORS IN THE OLDER WOMAN’S SEXUALITY • Important role in sexual dysfunction • Many women marry older men, outlive their spouses, and spend later years alone • ED common among older men • Lack of privacy (e.g., when couple lives with children or in a nursing home)

20. TREATING DECREASED DESIREIN OLDER WOMEN

21. TESTOSTERONE FOR DECREASED LIBIDO IN WOMEN • Approved by FDA for moderate to severe vasomotor symptoms not improved with estrogens alone, not for sexual dysfunction • Only available orally in combination with estrogen • Contraindicated in hepatic disease • Masculinizing side effects

22. TESTOSTERONE FOR DECREASED LIBIDO IN WOMEN Check liver function and lipid profile at baseline and every 6 months as it may decrease HDL More studies are needed Schwenkhagen, A., & Studd, J. (2009). Role of testosterone in treatment of hypoactive sexual desire disorder. Maturitas, 63, 152-159.

23. SILDENAFIL CITRATE FOR WOMEN • Not FDA-approved for women • Studies have shown that it: • Is well tolerated • May not produce better outcomes than placebo • Needs further study

24. DECREASED LUBRICATION: TREATMENTS BY CAUSE • Postmenopausal atrophic vaginitis: • Longer foreplay • Regular intercourse • Water-soluble lubricants • Estrogens • Allow 2 years to restore vaginal tissue function • Lower systemic absorption with low-dose vaginal estradiol ring (7.5 μg/24 hr) • Anticholinergic drugs: Review medications, including OTC medicines, and adjust drug choices, dosing

25. DELAYED OR ABSENT ORGASM: TREATMENTS BY CAUSE • Postmenopausal: Estrogen ± testosterone (not FDA-approved for this) • Psychological: • Sex therapy • Antidepressant

26. DYSPAREUNIA:TREATMENTS BY CAUSE • Organic cause: Treat underlying physical condition • Vaginal dryness, atrophy: • Longer foreplay • Regular intercourse • Lubricants • Estrogen • Vaginismus (involuntary vaginal contractions): • Sex therapy

27. Medications that May Impair Sexual Function Benzodiazepines β-Blockers Calcium-channel blockers Cimetidine Digoxin Lipid-lowering agents Lithium Monoamine oxidase inhibitors Neurotoxic cancer chemotherapies Estrogens Opiates, including synthetic opiates Phenytoin Progesterones Thiazide diuretics Tricyclic antidepressants Selective serotonin reuptake inhibitors

28. Medications associated with sexual dysfunction ANTIDEPRESSANTS • One of the most common iatrogenic causes of sexual dysfunction is the use of SSRIs (Fluoxetine, Sertraline, Paroxetine), creating such side effects as anorgasmia, delayed orgasm, or diminished libido • Tricyclics (Imipramine, Nortriptyline) cause decreased desire

29. Medications associated with sexual dysfunction ANTIHYPERTENSIVES Alpha2-adrenergic agonists (Clonidine)=> decreased desire, inhibition of orgasm (alpha2-adrenergic stimulation in the hypothalamus) Diuretics (Amiloride, Hydrochlorothiazide, Chlorthalidone, Indapamide, Spironolactone)=>decreased desire, decreased lubrication

30. Medications associated with sexual dysfunctionANTIHYPERTENSIVES Beta-adrenergic antagonists (Propranolol, Atenolol, Labetol): • decreased desire

31. Medications associated with sexual dysfunction • Alpha-adrenergic antagonists (Doxazosin, Terazosin): • urinary incontinence in some women from decreased bladder outlet sympathetic tone • H2antagonists (Cimetidine, Famotidine, Ranitidine): • decreased desire

32. Medications associated with sexual dysfunction Typical and Atypical Antipsychotics: (Chlorpromazine, Thioridazine, Risperidone)=> decreased desire Antianxiety: (Lorazepam, Oxazepam, Alprazolam)=> decreased desire, inhibition of orgasm (especially alprazolam) Narcotics: (Morphine)=> decreased desire

33. Medications associated with sexual dysfunction Anticonvulsants (Phenobarbitol, Phenytoin, Primidone, Carbamazepine)=> decreased desire Lipid-lowering medications (Niacin, Statins)=> decreased desire Alcohol => interferes with ability to climax

34. Discussing Sexuality Women have difficulties: ~ Often raised not to openly discuss sex ~ Generally taught in negative terms ~ Fear of embarrassing the practitioner

35. Discussing Sexuality Practitioners have difficulties: ~ Feel they lack the training ~ Uncomfortable with the topic ~ Fear of offending the patient ~ Time constraints

36. Discussing Sexuality(cont’d) • Research suggests that open dialogue can improve sexual health. • However, a 2005 survey showed that only 14% of people aged 40 or older have been asked about sexual difficulties, within the past 3 years by their healthcare providers. (Pfizer Global Study of Sexual Attitudes and Behaviors, 2005).

37. Best Clinical Practice Strategies • Promote sexual health in practice environments (e.g. advertisements, medications). • Attend continuing education activities focused on sexual health. • Provide patients with up to date information on treatment options.

38. Best Clinical Practice Strategies Be respectful of patients’ values and norms as it relates to their lifestyles. Understand how practitioner’s values or clinical environment may influence practice and prevent comprehensive care.

39. Best Clinical Practice Strategies • Practitioners should understand their own feelings about sexuality. • Be able to communicate openly and honestly at the expense of increasing their own exposure.

40. Best Clinical Practice Strategies Have the ability to listen to patients’ concerns regarding sexual health. Establish trust in order for the patient to talk freely about sexual health.

41. Breaking the Barrier: Taking a Sexual History Provide comfortable atmosphere Frame careful questions Ask about any previous negative sexual experience (e.g., rape, child abuse, domestic violence) Ask about current dyspareunia

42. Breaking the Barrier: Taking a Sexual History • Are you currently in a relationship? • Are you sexually active? • Do you have sex with a man, woman or both? • Are you or your partner currently experiencing any sexual difficulties? • Are you satisfied with your sexual relations?

43. Additional Questions to Ask • Do you have any sexual difficulties that you would like to talk about? • Tell me about your sexual history - first sexual encounter, number of partners, any sexual abuse. • Do you have difficulty with desire, arousal or orgasm?

44. Additional Questions to Ask Inform the peri-menopausal or menopausal women that many women experience vaginal dryness and changes in libido around this time in their life.

45. Sexual Health Assessment • Perform pelvic examination, esp. with dyspareunia • Check for lack of vaginal lubrication • Identify and treat underlying conditions. • Discontinue medications that effect sexual function and replace with appropriate ones.

46. Management of Sexual Problems • Discuss with patient different positions. • Use of pillows for support. • Various methods of sexual expression. (masturbatory, orogenital techniques, etc). • Treating UI with lifestyle changes.

47. Management of Sexual Problems • Teach pelvic floor exercises • The use of topical estrogens, and anticholinergic or antimuscarinic agents to improve sexual function as well as general well-being.

48. Case Study- Sexual Assessment in an Older Woman “Frances" is a 67-year-old woman, widowed for the past 9 years. She has recently met “Tom", a 69-year-old widower who would like to “date” her. Frances comes to see her primary practitioner about resuming an "intimate relationship". She mentions that her 3 children do not like Tom and it really upsets her.

49. Taking the History • Take a general medical history • Include medications • Gyn history (age at menopause, any urogenital problems, or past sexual history). • Being empathic can help with psychosocial issues. • France’s feelings- apprehensive, guilt, self-image, lack of support of her children.

50. Examination • Inspect the vulva and vagina to assess vaginal atrophy. • If appropriate recommend a Pap smear. • Assess any urogenital problems.