MEDICC Review

Sexual functioning is the ultimate expression of functional and organic integrity of the neuro-endocrine and reproductive systems-the apparatus that permits the body’s response during sexual activity. Sexual response is also influenced by several psychological, socio-cultural and biological factors, favored by some of these, and inhibited by others.^{1, 2}

The study of sexual function was taboo in the past. It was only after 1966, when Master and Johnson³ published a fully scientific study--Human Sexual Response--that we begin to see significant contributions in this field. Scientific studies have revealed six major sexual dysfunction categories: sexual desire disorders, orgasmic disorders, genital pain disorders, non-specified sexual disorders (anesthesia with orgasm, and genital pain during non-coital activities), lack of pleasure during intercourse, and loss of sexual satisfaction.⁴ Moreover, researchers have gone into greater depth on the physical and pathological aspects of sexual functioning. Special interest has been given to the study of sexual function during postmenopause, mainly to its link with sex hormones.

The production of ovarian hormones declines during postmenopause. A prolonged deprivation of estrogens has been associated with cervical atrophy, reduced production of mucus, atrophic changes, and reduced vaginal lubrication, which can bring about dyspareunia, vaginitis, or vaginismus. These changes can reduce sexual satisfaction and lead to secondary sexual dysfunctions.

Changes in sensory perception, systemic blood flow and muscular contractility, are among the extragenital manifestations of postmenopause. The decline in the production of androgens often negatively affects sexual desire, sexual fantasies, excitation, and sexual satisfaction.^5-12 However, not all menopausal women undergo these changes, and their intensity can vary from one woman to another. What’s more, many women do not develop any sexual dysfunction during this phase of their life.^13,14

The factors that contribute to the sexual changes that take place during climacterium, and the suspected role of hormones in these changes, have not yet been elucidated.^15,16 Age could be part of the answer. As women advance in age, they experience a slow progressive decline in the intensity of their sexual response, thus requiring more direct and prolonged stimulation than when they were younger. Furthermore, circulatory and organic functions in general are better in younger women. Psychological factors also change with age.¹⁵

Although ongoing, the study of sexual function has largely been carried out in women with normal menopause. However, specialized literature worldwide does not include specific studies on the sexual function of women with premature menopause, also termed post-pubertal premature ovarian failure-the cessation of the menstrual cycles before age 40.^17-19 Sexual behavior and response, mental status, and organic function and structure change with age. Aware of the fact that normal postmenopausal women experience changes in their sexual life, which may vary in intensity and form from one woman to another, and that a number of them do not develop sexual dysfunctions despite the decline in ovarian hormone production, we consider it important to investigate the characteristics of sexual functioning in premature menopausal women as well as the role of sex hormones in this phase of a woman’s life.

Methods

Our study included all women under 40 years of age who were being seen at the Cuban Institute of Endocrinology for one year due to secondary amenorrhea and elevated serum levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) ¥ 40 UI/L, at least on two occasions, and who voluntarily agreed to participate in our study. We excluded those who had received hormonal treatment in the previous three months, those with mild or severe psychiatric disorders, and those with chronic systemic disorders or secreting pituitary tumors. Patients who were eligible for our study (31) were given two questionnaires.

Questionnaire No. 1: This included five sections: (A) General Data, (B) Lifestyle, (C) OB-GYN History, (D) Past Medical History, and (E) Comprehensive Physical Examination.

Questionnaire No. 2: This questionnaire was designed at the Cuban Institute of Endocrinology to evaluate sexual response, and modified for use in our study. It consists of 11 questions-each having several items-aimed at obtaining subjective information regarding degree of sexual satisfaction, as well as objective difficulties in engaging in an appropriate sexual relationship. Answers to these questions reveal the existence or non-existence of sexual dysfunctions in women and their sexual partners. This questionnaire also explores sexual desire and sexual fantasies, the existence of vaginal dryness, frequency of sexual relations, and onset of any existing disorder.

The description of sexual functioning was based on whether the cause of premature menopause was iatrogenic or non-iatrogenic, although we did not intend to establish comparisons between these two groups given the limited number of cases with iatrogenic premature menopause. However, we did establish differences between them based on our awareness of the particular characteristics of sexual function and hormones in women with iatrogenic premature menopause.⁴

An exploratory analysis was conducted of two sets of variables: sexual function variables (sexual intercourse, lack of or decreased sexual desire, dyspareunia, vaginal dryness, erotic fantasies, frequency of sexual relations, and sexual satisfaction) and sex hormone variables (FSH, prolactin-PRL, estradiol-E₂, T, androstenedione-A’dione, dehydroepiandrosterone-DHEA, and dehydroepiandosterone sulfate-DHEAs).

The correlation among variables in each set (sexual function variables and sex hormones variables) was calculated using the Spearman and Pearson lineal correlation coefficients, respectively (significant correlation was considered at significance level < 0.05). We also calculated the correlation among all variables together, ²⁰ using the multiple correlation technique-a very useful technique in the assessment of lineal and non-lineal associations among sets of variables. This technique is based on the calculation of the main overall dispersion components of all variables according to their profiles and frequencies.

For statistical calculations and elaboration of graphs, the SPSS (version 8.0) and the SPAD (version 3.0) computer systems were utilized.

To obtain the participants’ informed consent, we explained the objectives and general procedures of our research to them as well as their right to drop out at any given moment with no ensuing change in the quality of the medical care they would continue to receive. Our study did not endanger the participants’ life nor worsened their health condition; therefore, we did not violate ethical norms or individual human rights. The questionnaires and clinical and laboratory exams used in our study contributed to a better understanding of the patients’ clinical record and situation, thus improving their treatment and health.

Results

The description of sexual function was carried out based on whether the cause of premature menopause was iatrogenic or non-iatrogenic. The analysis of specific problems affecting sexual relations showed that the number of women with iatrogenic premature menopause who had never reached orgasm was equal to the number of these women who had always reached orgasm (25% respectively). The majority of women with non-iatrogenic premature menopause referred to have always or almost always reach orgasm during sexual intercourse (51.8%). Only a small percentage of them (11.1%) reported never experiencing orgasm. Three fourths of women with iatrogenic premature menopause reported a decrease in or lack of sexual desire. However, approximately the same amount of those with non-iatrogenic premature menopause (77.8%) reported no alteration in this respect. A similar pattern was found for dyspareunia. Most women with iatrogenic premature menopause reported to suffer from this disorder (75%); in contrast, the majority of women with non-iatrogenic premature menopause did not report important alterations (85.2%). The majority of women with iatrogenic premature menopause (75%), and approximately half of those with non-iatrogenic premature menopause (48.1%), reported to have erotic dreams. Moreover, the majority of women in both groups did not report vaginal dryness (75% and 59.3%, respectively) (Table 1).

Table 1. - Distribution of Women with Iatrogenic and Non-iatrogenic PM* According to Characteristics of Sexual Function Variables

The analysis of the frequency of sexual relations showed that 50% of women with iatrogenic premature menopause had sexual relations with an average frequency while the other 50% reported a frequency of 2-4 times a month. The majority of women with non-iatrogenic premature menopause (59.3%) reported an average frequency in their sexual relations, while 40.7% of them reported a frequency of 4 times a month (Table 2).

Table 2. - Distribution of Women with Iatrogenic and Non-iatrogenic PM* According to the Frequency of Sexual Intercourse

As to the degree of satisfaction during sexual intercourse, 25% of women with iatrogenic premature menopause reported satisfaction, while over half of those with non-iatrogenic premature menopause evaluated their satisfaction as adequate; 25.9% considered it as very satisfying, 37.1% as satisfying and only 7.4% as unsatisfying. None evaluated their relations as very unsatisfying. In relation with our participants’ general assessment of their relation with their partner, only 25% of those with iatrogenic premature menopause considered them as satisfying, and 75% as average or unsatisfying (50% and 25% respectively). The majority of non-iatrogenic menopausal women considered their relation with their partner as very satisfying (25.9%) or satisfying (48.1%), while only 3.85% considered them as unsatisfying (Table 3). None of our participants considered their relation with their partner as very unsatisfying.

Table 3. - Distribution of Women with Iatrogenic and Non-iatrogenic PM* According to their Assessment of their Sexual and Partner Relationships

We also found that sexual life disorders in these women are frequently caused not only by them but by their partners as well. Of those who reported difficulties with their partner, 9.6% considered that the cause was their partner’s fault and 33.3% considered that it was caused by both.

The correlation analysis among sexual function variables showed that erotic fantasies were not correlated with any other variable. We also found that the degree of sexual satisfaction was lineally correlated with the rest of the sexual function variables; i.e., the higher the incidence of declined sexual desire, dyspareunia and vaginal dryness, and the lower the frequency of orgasms and sexual intercourse, the lower the degree of satisfaction, and vice versa. Declined sexual drive, dyspareunia, vaginal dryness, and low frequency of orgasm are inter-correlated: the first three in a positive way among them, while their correlation with the frequency of orgasms was negative. No lineal correlation found between the frequency of sexual intercourse and dyspareunia, orgasm or vaginal dryness (Table 4).

Table 4. - Spearman Correlation Coefficients Among Sexual Function Variables

Table 5 shows the correlation among sex hormones studied in the total group of patients.. We found a positive correlation between T and A’diona (p=0.039), T and DHEAs (p=0.028), A’diona and DHEA (p=0.049), as well as between DHEA and DHEAs (p=0.001).

Table 5. - Pearson Correlation Coefficients Among Sex Hormones in Women with PM*

Figure 1 shows the interrelation among sexual function variables, which were categorized using the multiple correspondence technique. We found correlation among vaginal dryness, dyspareunia, reduction or loss of sexual desire, sexual satisfaction and general satisfaction with couple relations; i.e., the lower the incidence of vaginal dryness (2), the lower the incidence of dyspareunia (5) and the lower the incidence of reduced or loss of sexual desire (5); while the higher the incidence of sexual satisfaction (1), the higher the degree of general satisfaction with couple relations (1). However, orgasm and frequency of sexual intercourse did not show a complete lineal association, as did the other variables. The existence of erotic fantasies was not associated with the rest of the variables.

Figure 1.-Correlation Among Categorized Sexual Function Variables and Sex Hormones (Multiple Correlation Technique)

We can easily distinguish two well-defined groups. To the right side of the figure are those women with no sexual dysfunction; i.e., those with no reduction or loss of sexual desire (5), the ones that had always reached orgasms (1), the ones who reported no dyspareunia (5), the ones that did not have vaginal dryness (2), the ones with the highest frequency of sexual intercourse (5), and those who felt very satisfied during sexual intercourse (1) and with their couple in general (1). To the left side of the figure are the women who reported just the opposite (the ones who felt unsatisfied).

The correlation analysis between sex hormone and sexual function variables showed a strong positive association between sexual satisfaction and serum levels of androgens (mainly T and DHEAs). The degree of association is marked in the figure by the length of the arrows. The rest of the hormones did not show any association with the sexual function variables (Figure 1).

Discussion

Sexual function in young women with premature menopause resembles, to some extent, that of women with normal postmenopause. Most of them have a certain degree of difficulty in their sexual relations with their couple; but the frequency, intensity, and repercussion of these difficulties differ greatly from the ones described in women with normal postmenopause.

To analyze the characteristics of sexual function in these patients, we took into consideration whether the cause of their premature menopause was iatrogenic or non-iatrogenic, although the number of cases with iatrogenic premature menopause was too limited to reach a conclusion. The majority of the women with iatrogenic premature menopause reported difficulties in their sexual relations, specifically in reaching orgasm; they had reduced or loss of sexual desire, and dyspareunia. This coincides with what has been described by Heiman and Meston⁴, who say that sexual dysfunction symptoms and signs in women with iatrogenic premature menopause are more acute and intense than the ones found in women with normal menopause, and that this has been associated with an abrupt decline in the production of ovarian hormones. However, the majority our participants reported erotic fantasies and did not complain about vaginal dryness. Moreover, the majority of those with non-iatrogenic premature menopause showed no sexual dysfunction.

These outcomes are explained by the fact that in this study, sexual desire, dyspareunia, orgasm and vaginal dryness were found to be lineally correlated, while erotic fantasies were expressed as an independent variable. Nevertheless, despite the existing correlation, a variable can sometimes show unexpected behavior, as is the case of vaginal dryness in patients with iatrogenic premature menopause. This demonstrates that under certain circumstances a given factor can predominantly influence and modify one aspect of sexual function. Continual sexual activity is known todiminish vaginal dryness.^13,21 In our study, a strong lineal correlation between these variables did not exist; however, a correlation, although not lineal, was found when we used the multiple correlation technique. Most patients maintained a regular and continual sexual activity, which explains the low incidence of vaginal dryness in both groups. It has been stated that the mechanic activity of sexual relations and the absorption of prostaglandins from prostatic secretions during coitus causes vasodilatation, which favors local vaginal circulation and propitiates transudation in local blood vessels. This fluids ensure vaginal lubrication.^13,21

The great majority of participants with non-iatrogenic premature menopause considered that their relation with their partner was, in general, satisfying, which was strongly correlated with their degree of sexual satisfaction. This suggests that understanding, communication, affection, and respect between menopausal women and their partner have a positive impact on their sexual functioning. A correlation between the degree of satisfaction regarding couple relations and the degree of sexual satisfaction was also observed in women with iatrogenic premature menopause, most of whom evaluated their couple relations as fair or unsatisfying, which greatly coincided with their evaluation of their sexual relations.

We must emphasize that in spite of the fact that 67.7% of our participants (21 cases) admitted the existence of specific difficulties in their sexual relations, the majority of them evaluated them and, in general, the relationship with their partner, as satisfying. Some of them considered that difficulties such as the absence of orgasm and, sometimes, vaginal dryness, did not have had an impact on their degree of satisfaction.

We also found that sexual life disorders were often caused by both members of the couple, although occasionally it was exclusively caused by the man. This is a situation commonly reported by premenopausal women.^10,13

Age is another important factor in sexual function and activity. As we know, sexuality changes with age, each phase of life being marked by specific characteristics. Therefore, it is impossible to speak of sexuality irrespective of age without making serious generalization mistakes.²²

It is a fact that the intensity of sexual response lowers with age, and older women need a more direct and longer stimulation to reach an appropriate degree of excitation and satisfaction.¹⁵ In older women, blood circulation declines ²¹, as well as sexual desire, frequency of sexual activity and orgasm.^1,23 Some authors have associated this with normal menopause^24,25, while others have associated them with age.²⁶ Indications exist that the production of adrenal androgens declines with age, regardless of the onset of menopause.^27,28 DHEA and DHEAs show a negative correlation with age,²⁹ and like the rest of androgens, they have shown a correlation with desire, orgasm, sexual satisfaction, and other sexual function variables.^6,9,10,12 Nevertheless, this is not absolute. Some of these women struggle for self-assertion and voluntarily increase the frequency of their sexual relations, and succeed in reaching satisfaction.^4,7,15Whatever the impact of the variables initially considered, our study has revealed that, in women with premature menopause this impact is less significant than the one found in women of advanced age-a finding not previously reported in medical literature.

The correlation between sexual function variables has already been analyzed to some extent. It is important to add, however, that the lack of correlation between erotic fantasies and the rest of the variables can be easily explained by the fact that erotic fantasies are strongly influenced and shaped by attitudes and principles that result from the patient’s social environment, by their individual way of perceiving, conceiving and projecting sex, as well as by their previous experience. Furthermore, the fact that the degree of sexual satisfaction is correlated with the other sexual function variables makes us consider it a sensitive indicator to characterize the overall state of sexual function in these women.

A lineal correlation among androgens was to be expected since these substances share a common synthesis path: ovarian and adrenal estrogenesis. The negative correlation between PRL and A’diona is also easy to explain if we consider that PRL inhibits the activity of the enzymes 3b-ol-dehydrogenase and 17,20 desmolase, which convert DHEA into A'diona, and 17-OH-Progesterone into A'diona, respectively.

The correlation analysis between sex hormones and sexual function is remarkable. PRL has not been correlated with sexual dysfunctions²⁸, which coincides with the outcomes in our study. Hypoestrinism has been associated with the decrease in vaginal lubrication, the increase of dyspareunia, and the decrease in sexual satisfaction.^4-9 Some authors^5,30 have found that this correlation occurs when the serum levels of E2 is lower than 35 pmol/L. Our study did not show such a correlation. What’s more, of eight patients with serum levels of E2 at 30 pmol/L, only three had vaginal dryness, which means that 62.5% of patients did not report this symptom. Furthermore, two of them reported dyspareunia, and none of them was dissatisfied with their sexual relations. This demonstrated that sexual function variables were not influenced by the serum levels of 17-b-estradiol.

Serum levels of androgens have been associated with the degree of sexual desire, and with the frequency of sexual fantasies, orgasm, sexual intercourse, as well as with the degree of sexual satisfaction.^7,8,12,31 A similar association was found in our study. Androgens were also associated with the lower incidence of vaginal dryness and dyspareunia, as well as with the higher degree of general satisfaction with couple relations. T and DHEAs were the sex hormones more highly associated with sexual function. This association may be explained by the fact that T is known to be the most potent of androgenic hormones, and that DHEAs is the one which reaches the highest serum levels, although it is not a potent androgen.

In conclusion, our results indicate that the majority of young women with premature menopause do not have major sexual dysfunctions, which is corroborated by a high frequency of orgasm and sexual relations as well as a low frequency of dyspareunia and reduction of sexual desire. These women seldom evaluate their sexual relations and the relation with their partner as unsatisfying. The degree of sexual satisfaction can be considered as a sexual function indicator in these patients. Sexual dysfunctions are frequent in women with iatrogenic premature menopause, although not in all of them. We also found that sexual life disorders are often caused not only by the menopausal women but by their partner. The social environment also influences sexual functioning. Patients with a bigger work load have orgasms more frequently. The low prevalence of sexual dysfunction in these patients indicates that biological and hormonal factors are important but not determinant. Psychosocial factors, age, and general physical condition also seem to have an influence.

References

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24. Hunter MS. Emotional well-being, sexual behaviour and hormone replacement therapy. Maturitas 1990;12:299-314.

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27. Padrón RS, Lozano EE, Seuc A. Estudio clínico epidemiológico de los esteroides sexuales y gonadotropinas en mujeres postmenopáusicas. Endocrinología 1996;43:43-46.

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Cuban Medical Research

SEXUAL FUNCTION AND SEX HORMONES IN WOMEN WITH PREMATURE MENOPAUSE

Introduction

Methods

Results

Discussion

References

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