Biological and Psychosocial Pathophysiology of Female Sexual Dysfunction During the Menopausal Transition

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Abstract
Introduction: Although increasing age is a primary determinant of reduced sexual function in older women, hormonal changes may be significant contributors to female (and couples’) sexual dysfunction.Aim: To analyze the most relevant biological, psychosexual, and/or contextual factors that influence changes in women's sexuality during and after menopause.Methods: A Postmenopausal FSD Roundtable consisting of multidicsiplinary international experts was convened to review specific issues related to postmenopausal women and sexual dysfunction.Main Outcome Measure: Expert opinion was based on a review of evidence-based medical literature, presentation, and internal discussion.Results: Menopause is associated with physiological and psychological changes that influence sexuality: the primary biological change is a decrease in circulating estrogen levels. Estrogen deficiency initially accounts for irregular menstruation and diminished vaginal lubrication. Continual estrogen loss is associated with changes in the vascular, muscular, and urogenital systems, and also alterations in mood, sleep, and cognitive functioning, influencing sexual function both directly and indirectly. The age-dependent decline in testosterone and androgen function, starting in the early 20s, may precipitate or exacerbate aspects of female sexual dysfunction; these effects are most pronounced following bilateral ovariectomy and consequent loss of 50% or more total testosterone. The contribution of progestogens to sexual health and variability in the effects of specific progestogens are being increasingly appreciated. Comorbidities, influenced by loss of sexual hormones, between mood and desire disorders and urogenital and sexual pain disorders are common and remain frequently overlooked in clinical practice. Physical and psychosexual changes may contribute to lower self-esteem, and diminished sexual responsiveness and sexual desire. Nonhormonal factors that affect sexuality are health status and current medication use, changes in or dissatisfaction with partner, partner's health and/or sexual problems, and socioeconomic status.Conclusion: Determination of the best way to provide optimal management of sexual dysfunction associated with menopause requires additional controlled studies.