Sexual Dysfunction in Some Women Can Occur Years Before Menopause, Study Says

 Vaginal dryness and painful intercourse are common in women between 40 and 55 years of age.

Sexual health changes may begin during perimenopause, the lead up to menopause, which can last up to 10 years.

New research suggests that women’s sexual function and desire can decrease significantly after age 40 — several years before they reach menopause. The study, published on October 31, 2019, in the journal Menopause, found that sexual satisfaction scores decreased while sexual dysfunction increased by about 30 percent during the perimenopause years, in large part due to vaginal dryness.

Although previous studies have documented the impact of vaginal atrophy and vaginal dryness on menopausal women, this new study is one of only a few to assess impact during perimenopause, the transitional time prior to menopause when the ovaries gradually begin to make less estrogen, according to Stephanie Faubion, MD, internal medicine doctor at the Mayo Clinic in Rochester, Minnesota, and medical director for the North American Menopause Society. Dr. Faubion was not involved in this research.

Symptoms Start During Perimenopause, the Long Lead-Up to Menopause

“These results show that certain symptoms of menopause, such as vaginal dryness, are much more prevalent during the menopause transition,” adds Faubion.

Painful Intercourse, Sexual Dysfunction Are Common for Midlife Women

The study looked at 518 women ages 40 to 55 in 30 healthcare centers throughout Italy in order to evaluate how women’s experience of sex changed before and during menopause, as well as the impact of vaginal atrophy (VA). Vaginal atrophy is the thinning, drying, and inflammation of the vaginal walls that can occur during age-related hormone flux, when the body produces less estrogen.

According to the authors, Italian women tend to reach menopause between ages 49 and 50. Based on this average, women were placed into one of four groups: women in the late fertile period, (40 to 45 years), women in the years preceding menopause (46 to 48 years), women in menopausal years (49 to 51 years of age), and women in early postmenopausal years (52 to 55 years of age).

Investigators identified vaginal atrophy by the coexistence of a vaginal pH of greater than 5, a sensation of dryness experienced by the woman, and objective signs of VA, such as color, dryness, and thinning.

Personal Sexual Function Was Measured via Questionnaire

Sexual function was measured by the Female Sexual Function Index (FSFI), a self-administered questionnaire. The FSFI is made up of 19 questions that fall into six domains: desire, arousal, lubrication, orgasm, satisfaction, and dyspareunia, also known as painful intercourse. Each question was scored on a Likert scale from 0 to 6, with 0 meaning lack of sexual function in that domain, and 6 corresponding to full sexual function for that domain. The scores could range from 0 to 36, and based on previous research on women of reproductive age, authors considered scores under 26.55 as indicating sexual dysfunction.

Researchers observed the following trends:

70 percent of the women had sexual dysfunction according to their FSFI results, increasing from 55 percent of women in the youngest group to 82.2 percent in the women ages 52 to 55.

Sexual dysfunction increases by roughly 30 percent during perimenopause; vaginal dryness is most often the problem and has the greatest impact on desire, arousal, lubrication, and overall satisfaction.

These results indicate that vaginal atrophy is not a late event of menopause, but rather something that many women can start to experience in their forties, significantly prior to menopause, according to Angelo Cagnacci, MD, PhD, professor of obstetrics and gynecology at the University of Udine in Italy and coauthor of the study.

“We also found that vaginal dryness and painful intercourse is prevalent in women between 40 and 55 years old," Dr. Cagnacci wrote in an email message, adding that these symptoms were present in as many as 60 percent of the women in the study.

Authors found the number of women in the study who self-reported sexual dysfunction to their doctor was only 25 percent — much lower than the 70.6 percent indicated by the questionnaire results. “This may be the consequence of the embarrassment produced in women discussing sexuality issues,” noted the authors.

The authors acknowledged that the 26.55 cutoff score on the FSFI was “probably excessive for menopausal and postmenopausal women, whose sexuality is likely diminished with respect to that of younger women.” The study is also limited because it included only white women who visited the outpatient centers in Italy.

Treatments for Vaginal Dryness, Atrophy Critical for Healthy Sex Life 

These results highlight the importance of treating vaginal dryness says Cagnacci. “Vaginal atrophy is a progressive disease that if left untreated can progressively evolve into a situation in which there is no coming back,” he says. “Early and prolonged treatment is critical to keep a healthy vagina and a healthy sexual life.”

“Symptoms such as vaginal dryness and hot flashes that are typically associated with menopause can begin well before the last menstrual cycle and should be addressed early,” agrees Faubion. These findings underscore the importance of addressing sexual health concerns during the menopause transition, she adds.

“Women should tell their providers if they have symptoms such as vaginal dryness, itching, burning, irritation, pain with sex, urinary frequency or urgency, or urinary tract infections, which women don’t always associate with the menopause transition but can have a significant impact on quality of life and relationships with their partners,” says Faubion. Talking about this topic shouldn’t be taboo, but rather should be a routine part of a health assessment, she adds.

“For treatment of genitourinary syndrome of menopause, over-the-counter solutions include use of lubricants for sexual activity and moisturizers used every one to three days for maintenance of moisture,” she suggests.

If that doesn’t address the symptoms completely, low dose vaginal hormonal preparations are very helpful and are not linked to any adverse long-term risks, according to Faubion. “These include vaginal estrogen in the form of cream, rings, tablet or inserts as well as vaginal DHEA inserts, which are all easy to use and very effective,” she says.

Use It or Lose It

Faubion also suggests regular, painless sexual activity to help maintain sexual function. “Sometimes working with a pelvic floor physical therapist to treat tight, tender pelvic floor muscles can also help,” she says.

Another potential option is vaginal laser therapies for treatment of vaginal dryness, says Faubion. “Preliminary evidence is promising, but longer-term studies looking at safety and effectiveness are needed before these treatments can be widely recommended.”

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