A quotation by the Australian author Kathy Lette says: ‘Age to women is like Kryptonite to Superman’. Does aging have a similar deleterious effect on women’s sexuality?
In 2010, the percentage of Egyptians aged 60 and older was 8.5%, a percentage that is expected to double to around 17.9% by the year 2050. Considering aging characteristics, as in all countries, Egyptian women are more likely to outlive men. Hence, in 2050, women are expected to constitute almost 54% of the population aged above 60 years 1.
Cross-sectional studies provide evidence that sexual activities and sexual function generally decline with age. Such a decline has been found to begin sometime between the late 20s and the late 30s. This assessment, however, is based on limited data 2. Many women describe a decline specifically with menopause 3, whereas only a small percentage of women (5–15%) report an improvement in sexual activities and function with age 2.
A woman’s sexual function changes over the course of her lifetime. There is a multitude of reasons for this change, including physical changes, relationship changes, acquiring diseases that accompany aging, behavioral changes, and the sexual capacity of the partner. Perimenopause presents a unique time period during which a woman goes through a number of life changes and often has a shift in concerns about her sexual health. Whereas younger women tend to report concerns about family planning, sexuality, and body image, middle-aged women tend to be preoccupied with their lack of sexual interest, sexual aversion, and difficulty with orgasm 4. However, even with these concerns, 50–60% of postmenopausal women remain interested in sex 5.
One of the most obvious changes that occur during perimenopause is a drastic decrease in the serum estrogen level. Estrogen is vital for maintaining the tissues related to sexual health. Women with prolonged estrogen deficiency have difficulty with vaginal and genital atrophy, clitoral shrinkage, and decreased sensation 6.
Female sexual dysfunction affects about 50% of postmenopausal women. Unfortunately, it often goes undiagnosed because both patients and healthcare providers may be reluctant to bring it up during regular office visits 7.
Despite the increase in senior citizens’ percentage, little is known about the sexuality of Egyptian women past the age of 40. The present study was conducted on a sample of Egyptian women in a trial to explore the effect of advance in age on their sexuality.
Participants and methods
The current study is a cross-sectional observational cohort study. Approval of the Dermatology and Andrology department and the Ethics Committee of Benha University was obtained on 22 December 2013.
The study was carried out in the Outpatient clinic of Benha Faculty of Medicine for a 6-month period after the approval of the Ethics Committee.
The study primarily included 350 married women. Of these, only 332 participants gave usable questionnaires. The 332 participating women were divided into three groups according to their ages:
- The first group included 113 women aged 40–49 years.
- The second group included 104 women aged 50–59 years.
- The third group included 115 women aged at least 60 years.
- Women aged 40 years and above.
- Engaged in regular sexual intercourse.
- Have an educational level that allows them to at least read and write.
- The presence of medical conditions affecting female sexuality, for example neuropsychiatric diseases.
- Individuals refusing to cooperate.
A self-report questionnaire designed by the authors was used in the study. It was written in English, and then translated into Arabic. The aim of the study and details of the questionnaire were explained to the women before taking their informed consent.
To ensure that all gathered information was kept confidential and that the individual’s identity was kept anonymous, each questionnaire was handed in an open envelope and after filling it out in private, the participant sealed the envelope and put it in a basket containing the other sealed envelopes.
The questionnaire included the following items:
- Epidemiological data: age and the educational level (read and write, secondary school, university degree).
- Assessment of female sexual functions including the frequency of intercourse, unprovoked desire to have sex, lubrication, orgasm, and the overall sexual satisfaction.
- Assessment of realizing the effects aging has on their sexual activity.
- Assessment of experiencing pain during sexual intercourse and the presence of a sexual dysfunction in the husband.
The clinical data were tabulated and analyzed using the computer program statistical package for social science, version 16 (SPSS Inc., Chicago, Illinois, USA).
Descriptive statistics were calculated for the data in the form of the frequency, and the distribution was used for qualitative data.
In the statistical comparison between the different groups, the significance of difference was tested using one of the following tests:
- Intergroup comparison of categorical data was performed using the χ2-test (x2-value).
- The Fisher exact test was used when one of the cells of a table was 5 or less.
P value less than 0.05 was considered statistically significant (S), whereas a value greater than 0.05 statistically insignificant. P value less than 0.01 was considered highly significant (HS) in all analyses.
Table 1 shows the demographic data of the women participating in the study.
Sexual activities and functions
Results show a decrease in the coital frequency with aging. For example, the number of individuals who had a coital frequency of two to three times/week decreased from 50.4% in the youngest group to 3.5% in the oldest group (Table 2).
Frequency of unprovoked sexual desire
Also, the frequency of unprovoked sexual desire decreased sharply with advance in age, for example 11.5% of the women aged 40–49 years felt an unprovoked desire daily, but this percentage deceased sharply to only 1.7% in women aged at least 60 years.
The percentage of women who were always able to obtain lubrication during intercourse decreased from 45.1% in group I to almost one-tenth (4.3%) in group III. Likewise, the ability to always maintain lubrication decreased from 34.5% in group I to 2.6% in group II.
Ability to reach orgasm
Women who were always able to reach orgasm constituted 29.2% of group I, but they accounted for only 0.9% of group III. This may have influenced the overall satisfaction with their sexual life negatively. In the youngest age group, 11.5% of the women were dissatisfied with their sexual life, a percentage that increased to more than three-fold to reach 38.3% in the older women’s group.
The aforementioned differences between groups were statistically highly significant.
How participants compare some aspects of their present sexuality with what they had 10 years ago
There was a significant impact of aging among the three groups and the decrease in the three aspects of sexuality was evident. There was a highly statistically significant difference between the three groups (P<0.001) (Table 3).
Frequency of dyspareunia in participants and sexual dysfunctions in their husbands
A majority of women in group I (44.2%) never experienced dyspareunia in their lives, whereas it was encountered more than half the time during intercourse among group II and group III (35.6 and 45.2%, respectively).
Husband’ sexual dysfunction
Husbands’ sexual dysfunction increased progressively among the three studied groups as it was 20.4% in the first group, 30.7% in the second group, and 57.4% in the third group. There was a highly statistically significant difference between the three groups (P<0.001).
Sexuality in older people is a multifaceted field of study. Aging may offer opportunities for and restrictions on sexuality. Aging individuals may have increased time for sex and may wish to explore their sexuality. However, they may also lack a partner or autonomy. They may develop or have increased symptoms from chronic diseases. Consequent medication may affect their sexual functioning. Their attitudes toward sex often change, and their capacity for sexual activity may diminish unless they seek help. However, they may lack the confidence to do so, and the health professionals consulted may be disinclined or ill-equipped to assist them. While the challenge for researchers is to clarify accurately the impact of individual factors on sexuality and identify helpful potential interventions, increased academic and educational focus in this area will enhance the prospects for a sexually enjoyable old age 8.
In the present study, most of the participants (81.7%) finished secondary school or had a university degree, which adds up to the accuracy and the credibility of the information they supplied. However, this is not a fully representative sample as illiteracy among Egyptian women is still high (34.2% according to 2012 estimates) 9.
The mean age at natural menopause in Egypt is 46.7 years 10. Menopause is associated with anatomical, physiological, and psychological changes that often influence sexuality in aging women. Decreased estrogen levels have a multitude of effects on the sexual function, including decreased support of female pelvic muscles, loss of the ability to lubricate the urogenital tissue adequately, and changes in body configuration. This situation is aggravated by alterations in the skin, breasts, muscles, and the skeleton caused by estrogen loss. For many women, these changes translate into a poorer self-image, diminution of self-esteem, and, eventually, a loss of sexual desire. Societal expectations also have a negative impact on sexuality, as most cultures still believe that older women become sexually retired 11.
The decrease in sexual activity observed in the current study as evidenced by decreasing coital frequency with aging was also noted in another study 12, where 73% of the women aged 55 to 85+ were sexually inactive. Also, a study about the sexuality in old persons in the USA by Lindau et al.13 found that the prevalence of sexual activity decreased with age (73% among respondents who were 57–64 years of age, 53% among respondents who were 65–74 years of age, and 26% among respondents who were 75–85 years of age). Compared with men, women at all ages were significantly less likely to report sexual activity.
Lindau et al. 13 listed the reasons reported by women for the decrease in their sexual activity with aging. In descending order, they included partner’s physical health problems or limitations, a lack of interest in sex, physical health problems or limitations, and partner not interested in sex.
The present study provided further evidence that the proportion of women who experience a low desire increases with age as shown by the decrease in the frequency of unprovoked desire by aging (33.9% of the women aged ≥60 years had almost no desire). A study conducted by Hayes et al. 14 assessed the effect of aging on the prevalence of a low sexual desire. The study included 1547 women from the USA and 1879 women from Europe, who were having regular sexual relationships at the time of the study. In Europe, it turned out that the proportion of women with a low desire increased significantly with age as 11% of the European women aged 20–29 years had a low sexual desire compared with 53% of women aged 60–70 years. The decrease in sexual desire with aging was evident among American women also although it was not as obvious as in European women. In the age group of 60–70 years, only 32% of the American women had a lower sexual desire compared with 22% of the women aged 20–29 years. These results are in agreement with earlier studies 2,15.
The ability to obtain and maintain lubrication during intercourse decreased with advance in age in our sample. This is expected as our sample consisted of perimenopausal or menopausal women. Lo and Kok 16 studied the sexuality of Chinese women around menopause and concluded that ‘no lubrication’ was the most common sexual dysfunction, affecting 42.9% of their participants. A similar result was found in an American study 13 of 1550 women aged 55–85 years, where 39% of them complained of difficulty with vaginal lubrication.
A drastic increase in the percentage of anorgasmic women related to aging was noticed in our study. Lindau et al.13 found that the inability to climax ranged from 34% in the youngest group to 59% in the oldest group of the women they studied. Similarly, a study conducted on married Iranian women 17 revealed that the prevalence of anorgasmia in the age group of 40–50 years was nearly double that of women aged 20–30 years.
In the present study, the frequency of dyspareunia increased with advance in age, with a highly statistically significant difference (P<0.001) between the three studied groups. Our findings conform with the findings of Avis 18 and Dennerstein et al.19.
Repetitive dyspareunia caused by vaginal dryness represents a sexual problem for women and can lead to a lack of arousal, an inability to achieve orgasm, and a loss of sexual desire. This situation may end up with women avoiding all sexual activities 20.
When participants were asked to compare their sexuality at the time of the study to what they had a decade ago, most of them thought that they were better 10 years ago. The highest percentage of those admitting a deterioration of sexual functioning belonged to the oldest group. This does not necessarily mean that older women are sexually inactive, as 81.7% of the women in the older age group reported having coitus once or less per month, and only 38.3% of them were unable to reach orgasm. In discussing their results, Lindau et al.13 stated that ‘The prevalence of sexual activity declines with age, yet a substantial number of men and women engage in vaginal intercourse, oral sex, and masturbation even in the eighth and ninth decades of life’.
A survey of 27 500 men and women aged 40–80 years in 29 countries 21 also showed that women were more likely than men to rate sex as an unimportant part of life and to report a lack of pleasure with sex.
We cannot deny the role played by sociocultural negative attitudes towards women’s sexuality and sexuality at older age. Nevertheless, a logical reason for the decreasing sexual activity in women in the present sample is the occurrence of sexual dysfunctions in the husbands. The frequency of sexual dysfunctions in the husbands in group I was 20.4%, which increased to 30.7% in group II, and then nearly doubled (57.4%) in the third group. Kaiser 22 indicated that partner-related issues seemed to be most closely related to the decreasing sexual function in women. Lack of a partner, partner’s health problems, or performance issues, such as erectile dysfunction, are causally linked to women’s sexual dysfunction.
Longitudinal studies also show that partner factors play an important role in determining the frequency of sexual activities and desire over time 23–25.
Aging affected female sexuality negatively in our sample of Egyptian women. There was a decrease in the frequency of intercourse, the frequency of unprovoked desire, and the ability to obtain vaginal lubrication. It was found that the frequency of dyspareunia increases, whereas the overall satisfaction with the sexual life decreases with age.
Conflicts of interest
There are no conflicts of interest.
2. Hayes R, Dennerstein L. The impact of aging on sexual function and sexual dysfunction in women: a review of population-based studies. J Sex Med 2005; 2:317–330.
3. Potter JE. A 60-year-old woman with sexual difficulties. JAMA 2007; 297:620–633.
4. Nusbaum MR, Helton MR, Ray N. The changing nature of women’s sexual health concerns through the midlife years. Maturitas 2004; 49:283–291.
5. Greendale GA, Hogan P, Shumaker S. Sexual functioning in postmenopausal women: the postmenopausal estrogen/progestin interventions (PEPI) trial. J Women’s Health 1996; 5:445–448.
6. Masters WH, Johnson VE. Human sexual response: the ageing female Boston, MA: Little, Brown and Company; 1966.
7. Chervenak JL. Reproductive aging, sexuality and symptoms. Semin Reprod Med 2010; 28:380–387.
8. Wylie KR, Wood A, McManus R. Sexuality and old age. Bundesgesundheitsblatt Health research 2013; 56:223–230.
10. Hidayet NM, Sharaf SA, Aref SR, Tawfik TA, Moubarak II. Correlates of age at natural menopause: a community-based study in Alexandria. East Mediterr Health J 1999; 5:307–319.
11. Bachmann GA. Influence of menopause on sexuality. Int J Fertil Menopausal Stud 1995; 401Suppl 116–22.
12. Barlow DH, Cardozo LD, Francis RM, Griffin M, Hart DM, Stephens E, Sturdee DW. Urogenital ageing and its effect on sexual health in older British women. Br J Obstet Gynaecol 1997; 104:87–91.
13. Lindau ST, Schumm LP, Laumann EO, Levinson W, O’Muircheartaigh CA, Waite LJ. A study of sexuality and health among older adults in the United States. N Engl J Med 2007; 357:762–774.
14. Hayes RD, Dennerstein L, Bennett CM, Koochaki PE, Leiblum SR, Graziottin A. Relationship between hypoactive sexual desire disorder and aging. Fertil Steril 2007; 87:107–112.
15. Bancroft J, Loftus J, Long JS. Distress about sex: a national survey of women in heterosexual relationships. Arch Sex Behav 2003; 32:193–208.
16. Lo SS, Kok WM. Sexuality of Chinese women around menopause. Maturitas 2013; 74:190–195.
17. Jaafarpour M, Khani A, Khajavikhan J, Suhrabi Z. Female sexual dysfunction: prevalence and risk factors. J Clin Diagn Res 2013; 7:2877–2880.
18. Avis NE. Sexual function and aging in men and women: community and population-based studies. J Gend Specif Med 2000; 3:37–41.
19. Dennerstein L, Alexander JL, Kotz K. The menopause and sexual functioning: a review of the population-based studies. Annu Rev Sex Res 2003; 14:64–82.
20. Seyisoglu HAtasu T. Menopause and sexual life. Menopause-treatment and cancer Istanbul, Turkey: Nobel Medical Publishing; 2001; 385–396.
21. Laumann EO, Paik A, Glasser DB, Kang JH, Wang T, Levinson B, et al.. A cross-national study of subjective sexual well-being among older women and men: findings from the Global Study of Sexual Attitudes and Behaviors. Arch Sex Behav 2006; 35:145–161.
22. Kaiser FE. Sexual function and the older woman. Clin Geriatr Med 2003; 19:463–472.
23. Hallstrom T, Samuelsson S. Changes in women’s sexual desire in middle life: the longitudinal study of women in Gothenburg. Arch Sex Behav 1990; 19:259–268.
24. Koster A, Garde K. Sexual desire and menopausal development. A prospective study of Danish women born in 1936. Maturitas 1993; 16:49–60.
25. Dennerstein L, Randolph J, Taffe J, Dudley E, Burger H. Hormones, mood, sexuality, and the menopausal transition. Fertil Steril 2002; 77:S42–S48.