CHANGES IN SEXUAL FUNCTION IN OLDER COUPLES, MEN AND WOMEN, PROBLEMS AND MANAGEMENT

1. Aging And Sexual Function
Dr. Mamdouh Sabry
MD. Ain Shams, Ph.D Paris V Un. France
Consultant Ob. & Gyn.
EL Mataria Teaching Hospital, Nasser Institute
Cairo, Egypt

2. Introduction
• As More individuals are living into late life, a
significant proportion of which remain sexually
active. So clinicians are more likely to treat older (65
or more) patients with sexual dysfunction
• Evidence and acceptance about the role of
sexuality in late life has expanded. Medication and
other treatments have been developed that enable
individuals to maintain successful sexual functioning
regardless of age.
• Highly specialized and understanding clinicians are
needed to treat such problems

3. Sexual Function In Late Life
• The current model of normal sexual function across
the lifespan is fixed into five stages of psychological
and physiological changes:
●Desire (or libido); Centered in the hypothalamus and
limbic system, stimulated by testosterone in men and
women.
●Arousal; Triggered by strong desire, hormonal factor
and intimate contact, either social or physical.
●Plateau; Euphoric sexual release or orgasm.
●Orgasm; Physical and emotional peak of satisfaction.
●Resolution; Psychological and physical state of
relaxation following orgasm.

4. Age Related Changes
– Normal aging is associated
with a general and gradual
decline in physiological sexual
response, and more variable
declines in sexual activity in
men and women.

5. Women
1-menopausal physiologic changes;
●Atrophy of urogenital tissue .
●Decrease vaginal lubrication and vascularity.
●Decline erotic sensitivity of sexual organs.
2-Accompanying changes in sexual function ;
●Decline in libido ●Sexual responsiveness
●Comfort level (dyspareunia) ●Sexual frequency
3-Declines in testosterone production;
●Loss of libido
●Decreased clitoral, vulvar, and nipple sensitivity
●Fatigability

6. Men
• Andropause is not common, but gradual decrease
in testosterone production in as men age, leads to:
- Gradual decrease in sexual function and activity.
- Sexual desire remains relatively stable in most men
- Erections are less reliable and durable, and require
more stimulation to achieve and sustain.
- Ejaculation involves decreased amounts of seminal
fluid, with increase period between orgasms.
- With age, the total testosterone level in men drops
by an average of 1.6 percent per year.

7. Men cont.
- With age, the total testosterone level in men
drops by an average of 1.6 percent per year.
- Levels below 8 nmol/L are typically associated
with loss of libido, erectile dysfunction, loss of
bone and muscle mass, loss of strength, fatigue,
and even poor concentration and depression.
- Levels between 8 and 12 nmol/L are often
symptomatic
- By age 60, 20 percent of men have low
testosterone levels, and this rises to 50 percent
of men over age 80.

8. Men & Women
• The impact of age-related changes in sexual
function has a variable effect on sexual attitudes
and behaviors.
• There is a general decline in the frequency of
sexual activity in both sexes after the age of 65, but
not as much as might be expected. Fifty to 80
percent of men and women over 60 surveyed
continue to be sexually active, usually having
sexual intercourse at least once a month .
• Older men tend to be more sexually active than
older women, although sexual satisfaction among
those active with a partner remains relatively high
in both sexes.

9. Men & Women cont.
• The major predictors of both sexual interest and
activity in late life include:
●The previous level of sexual activity
●The individual’s physical and psychological
health
●The availability, interest level, and health of a
partner
- Physical health appears to be the most influential
factor for older men while the quality of the
relationship is most important for older women

10. Reactions to age related changes
- Aging can bring increased emotional maturity and
intimacy that can enhance sexual relationships.
-Older couples may have greater privacy and more
time for intimacy.
- Couples who understand these changes in sexual
function as normal are less better able to adapt. So, a
woman may welcome the freedom from worry about
contraception and unwanted pregnancy.
-Instead of focusing solely on sexual intercourse, men
may be able to shift to other pleasurable sensations.
- Couples communicating well can adjust sexual
practices in order to maintain or even improve upon
previous levels of enjoyment. ( Positive impact )

11. Reactions… cont.
- Some individuals will react negatively to age-
related changes, viewing them as a period of
physical decline or sexual dysfunction.
- Some men view declines in erectile function as
threatening to their sense of masculinity, and lead to
excessive worry, anger, or even depression.
- Some women grieve menopause and its changes,
having negative impact on their life.
- These reactions may reinforce negative views
about late-life sexuality being inappropriate or
dangerous, and may lead to less frequent and less
enjoyable sexual relations

12. Late Life Sexual Dysfunction
It is common. Causes are typically multifactorial ;
-Medical illness, e.g diabetic neuropathy, peripheral vascular
disease…..
-Secondary sexual dysfunction may result from fatigue, pain,
physical disability, or some other effect of a medical illness.
-Medications, Medications often play a role, and can affect both
sexes at any point in the sexual response cycle. Some of the
most common culprits include antihypertensives (eg, beta-
blockers, diuretics), antiandrogens, and many psychotropic
medications, particularly antidepressants, men more affected.
-Comorbid psychiatric illness or stress — as delusions….,
-Some people may feel less sexual because they are
embarrassed over changes in their personal appearance (eg,
due to a surgical scar or others),

13. • Menopausal female sexual problems are common,
with underestimated prevalence . 50% worldwide ??
• Female sexual dysfunction (FSD) was recently
redefined, now includes Female Sexual Interest/
Arousal Disorder (FSIAD), Female Orgasmic
Disorder and Genitopelvic Pain/ Penetration
Disorder. Mostly secondary.
• These symptoms must cause distress and must
occur at least 75% of the time over a 6-month
period.

14. Female Sexual Response Cycle
• Desire (libido)- including thoughts, wishes…
• Arousal (excitement)- sexual sense, genital
vasocongestion, heart and respiratory rate…
• Orgasm- peaking sexual pleasure……
• Resolution-relaxation and sense of well-being.
- The phases may vary in sequence, overlap,
repeat, or even be absent totally or partially.
- Females are motivated by emotional, psych.,
or other reasons, and sexual act may not lead
to orgasm or other response phases.

15. Pathophysiology
• Causes of menopausal FSD are diverse and
overlapping.. Etiologies include hormonal,
neurological and vascular issues, as well as
psychosocial factors as relationship issues, social
stress, mood,
• Neurotransmitters play an important role, female
sexual function requires a delicate balance of
dopamine for desire, and epinephrine,
norepinephrine, and serotonin for arousal and
orgasm. Disorders and medications that disrupt
these elements may lead to FSD. Hormonal deficits
is a main factor in pathophysiology..

16. Estrogen And Androgens
• Decrease estrogen results in reduction of vulvo-
vaginal lubrication and vasocongestion during
arousal as well as vaginal atrophy and sexual pain.
• Decrease levels of estrogen were associated with
decrease libido and sexual responsiveness.
• Androgens are the same in women as men and
differ only in concentration.
• Conflicting data support its value in female sexual
act, but it is valuable…

17. Presentation
• Female Sexual Desire / Arousal Disorder:
-Decrease sexual desire ( hypoactive )
-Sexual aversion disorder.
• Female Sexual Pain/ Penetrative Disorder:
-Insertional, external or vaginal structures, or
deep, which would suggest intra-peritoneal
structures as a source.
• Female Orgasmic Disorder:
-Mostly secondary.

18. Diagnostic Consideration
• Sexual problems often overlap, with one problem
contributing to another. A woman with inadequate
arousal may experience insertional pain due to a
lack of lubrication. While patients may have multiple
sexual complaints, it is helpful to take a good history
that identifies which problem came first.
• Most FSD diagnoses are made based mainly on
history , and laboratory evaluation is rarely
helpful. Hypothyroidism affects desire.
• It is important to differentiate between a true disorder
and the normal changes over time.
• Orgasmic Disorder requires careful evaluation.

19. TREATMENT

20. Female Sexual Interest/ A. D.
• Many drugs have been implicated in impacting sexual
desire and arousal (as antihistamines, beta blockers,
diuretics and hormonal contraceptives), the
commonest are SSRI antidepressants
56%. Bupropion or mirtazapine are preferred.
• Flibanserin is a 5HT1A/2B agonist/ antagonist, FDA
approved, indicated for premenopausal women with
low sexual desire. It is taken nightly and requires
daily use.
• Androgens not approved in the US for sexual
dysfunction. However, multiple trials demonstrated a
positive effect of testosterone in postmenopausal
patients complaining of decreased libido,.

21. Orgasmic Disorder
• Lifelong or acquired, generalized or
situational !!!.
• Sildenafil 50 mg one hour before coitus.
• Stop SSRI.
• Exercise.
• Surgery.

22. Sexual Pain
• It is vulvo-vaginal or pelvic pain that is provoked by
or exacerbated during sexual contact.
• Pain can be mild to severe, generalized or
localized, lifelong or acquired, deep or superficial
and idiopathic or secondary.
• Genitourinary syndrome of menopause, dermatoses
as well as dyspareunia, vulvodynia (persistent
vulvar pain of without an identifiable etiology), and
vaginismus (difficulty in allowing vaginal penetration
despite willingness to do so) .

23. Sexual Pain cont.
• Treatment of the cause, deep or
superficial, hormonal or symptomatic,
Androgen or Estrogen.
• Vaginismus; local, surgical or Botox.
• Vulvodynia; Botox, PRP and local
anesthesia.
- Dilators are helpful, Reinjection is needed.

24. CONCLUSION

25. ●The diagnosis of female sexual dysfunction
is based upon the presence of diagnostic
criteria obtained through the medical and
sexual history.
● Estrogens and androgens are involved in ttt
but the magnitude of their roles needs further
clarification.
●Sexual function is strongly affected by
relationship and sociocultural factors.
●Menopause is associated with dyspareunia.
Otherwise, the effects of age and menopause
on female sexual dysfunction vary
considerably among women.

26. Thank you