Changes in womens sexual behavior at menopause

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The preceding brief review of research on variations in sexual behaviors during the menstrual cycle did not offer much support for the hypothesis that ovarian hormones are closely involved in the control of sexual behaviors in women. The consequences of menopause, surgical or natural, for these behaviors do not seem to be more impressive than those of the menstrual cycle. The lack of effect of ovariectomy on sexual behavior in women was described many years ago (Filler and Drezner, 1944; Werner, 1946; Kinsey et al., 1953) and has later been confirmed in a number of studies. Likewise, menopause does not seem to be associated with any particular decline in sexual activity. As always, questionnaire and self-report studies have given conflicting results and conclusions of such studies range from no effect (e.g. Kinsey et al., 1953) to a substantial decline (Dennerstein et al., 2002). Sexual activity is known to diminish with increasing age and this fact may explain the notion held by some that menopause is causally related to a reduced sexual activity. There is inevitably an age difference between pre- and menopausal women, and the effects attributed to menopause may just as well be attributed to the passage of time. Socially created expectations of a reduced sexual activity in menopausal women may be self-fulfilling. For the more cultivated reader I suggest a superb article written by two German psychoanalysts, published in German, where the rationale for our prejudices regarding appropriate climacteric female sexual behavior is given (Sies and Nestler, 1992). It is also useful to remember that social desirability is one of the main determinants of answers to questionnaire items (Hebert et al., 1997; Plaud et al., 1998). This important fact may account for the menopause-associated decline in sexual activities sometimes found. Furthermore, there are data suggesting that such a decline may be related to health and marital condition more than to menopause itself (Avis et al., 2000). Rather than wasting time discussing the impressive amounts of paper employed in questionnaire studies, I will turn to some solid experimental data that will convince us that menopause has marginal effects on sex behavior functions. Obviously, I do not consider fertility as part of sexual behavior.

Vaginal blood flow in pre- and menopausal women was determined at baseline and during exposure to a pornographic movie. The premenopausal women had significantly higher baseline vaginal pulse amplitudes as determined by the photo-plethysmographic procedure than the menopausal women. The authors explained this difference as a consequence of less estrogen actions on the vaginal epithelium in these women. I can see no reason to disagree. What is far more interesting, though, is that the response to the pornographic movie was similar in both groups, meaning that the menopausal women enhanced vaginal blood flow as much as the premenopausal women did (Laan and van Lunsen, 1997). A completely different procedure for evaluating genital blood flow responses to sexual incentives has been employed in several studies. Comparisons of MRI images of the female genitals obtained before, during and after viewing a pornographic movie show that exposure to sexual incentives enhanced the vestibular bulb, the labia minora and the clitoris to an equal extent in pre- and menopausal women (Suh et al., 2004). Similar data had been published previously from the same group (Maravilla et al., 2003b). Interestingly, clitoral size in the unaroused state does not differ between pre- and menopausal women (Maravilla et al., 2003a). All these objective data point in the same direction, suggesting that menopause does not affect the genital response to sexual incentives. This being the case, it is possible to suggest that the effects of menopause on sexual functions observed in some questionnaire studies are indirect consequences of factors unrelated to sexual functions per se. Some of these factors have been mentioned above, and I will not repeat them here. Nevertheless, I conclude by stating that the considerable reduction in circulating estrogens typical of the climacteric and lasting for the rest of women's life has slight impact on sexual functions. This fact, in addition to the marginal or non-existent variations in sexual behaviors during the menstrual cycle despite the large variations in estrogen concentrations, inevitably suggests that neither short- nor long-term changes in estrogen availability is an important determinant of sexual behavior in the human female.

Before leaving the discussion of the effects of menopause, I need to make another comment on word usage. Menopause is, according to the online version of the Oxford Dictionary of the English Language, defined as 'permanent cessation of menstruation' (retrieved from query_type=word&queryword=menopause&first = 1&max_to_show = 10&single= 1&sort_type=alpha on July 5, 2006). In any woman, this period begins at the end of the climacteric and continues until the end of life. The word 'postmeno-pausal', then, acquires a peculiar meaning: after the menopause. Considering that menopause ends with the end of life, a postmenopausal woman must indeed have a low sexual activity, if any at all. Despite this quite obvious fact, some scientists report data on behavior in postmenopausal women. I wonder how these data were collected.

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