In the last few years there has been more research around sexual function during the menopause transition in areas such as low libido or pain during intercourse, but very little specifically focused on how important sex is to women during this time, says Holly N. Thomas, MD, assistant professor of medicine at the University of Pittsburgh in Pennsylvania. Dr. Thomas is the lead author of research presented on the topic of the importance of sex in women as they age at the 2020 Virtual Annual Meeting of The North American Menopause Society (NAMS), which opened on September 28, 2020.

We were interested in looking at how womens ratings of how important sex was to them changes or stays the same as they move through the menopausal transition, says Thomas.

To find out the answer, investigators studied a total of 3,257 women from The Study of Womens Health Across the Nation (SWAN), all of whom completed 14 evaluations over 15 years. Visits included interviews, questionnaires, blood draws, and biometric measures such as body mass index (BMI), blood pressure levels, hormone levels, and depression symptoms.

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Women were asked to rate how important sex was to them with the choices of not at all, not very, moderately, quite, or extremely.

Rather than look at averages of the women over time, investigators looked at trajectories within the cohort. This analysis technique allowed us to see if there are unique pathways that women can follow, explains Thomas.

If you just looked at averages of the group as a whole, it would look like how important sex is to women would go down for everyone, but what we actually found three distinct pathways women commonly follow when it comes to how much they value sex as they get older, she says.

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For the largest group, about 45 percent of the women, sex did become less important to them as they went through their forties and fifties and early sixties, says Thomas. For 27 percent of the women, sex remained highly important to them throughout midlife, and for 28 percent of the women sex was not very important to them throughout the whole duration of midlife, from forties to sixties.

Its important to recognize not all women are going to follow the same pathway when it comes to sex at midlife, each woman has her own unique experience, says Thomas.

There were a few trends that Thomas and her team noticed.

These results show that its not necessarily true that sex becomes less important to all women at midlife and that its just an inevitable fact of aging, says Thomas.

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My takeaway was that we need to be more routinely asking women in midlife about their sexual function and whether there are barriers such as having pain during intercourse or if theyre having problems with low sexual desire thats bothering them, says Stephanie Faubion, MD, director of the Mayo Clinic Center for Womens Health in Rochester, Minnesota, and medical director of NAMS.

Sexual function is usually under addressed in women in general but certainly in women beyond menopause, adds Dr. Faubion.

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In general, women who have a good sex life before menopause have a good sex life after menopause, she says. This research indicates that if sex is important to a woman before menopause, its important after.

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Keep in mind that sex doesnt look the same with aging, says Faubion. We have to modify our expectations about sexual functioning as we get older. Sex may not be always be penis and vagina sex; I have that conversation often with my patients, she says.

As peoples bodies and health changes, including medical illnesses that can be experienced by both men and women, we may need to modify what we are doing, but nonetheless, sexual intimacy remains important to all people for as long as they live, says Faubion.

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About 30 percent or so of women in the United States report low libido or sex drive, and about 10 percent report being bothered or distressed by it, Brooke Faught, doctor of nursing practice and board-certified women's healthcare nurse practitioner, who is clinical director of the Womens Institute for Sexual Health in Nashville, Tennessee. Dr. Faught presented on sexual health, libido, and testosterone at the NAMS 2020 conference.

Having a low sex drive isnt automatically a reason for treatment; hypoactive sexual desire disorder (HSDD) is when women have a low libido and are bothered or distressed by it. If the patient isnt directly impacted or bothered by it and its not impacting their daily function, its not a true diagnosable condition, says Faught.

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Even when they are bothered by a lack of desire, many women put up with it rather than seek treatment; they think its a normal part of aging or something they should just deal with, she says.

One barrier that stands in the way of treating HSDD is the lack of an U.S. Food and Drug Administration (FDA)approved testosterone for women with HSDD, even though there is quite a bit of published research on how and when to use it, says Faught.

Faubion agrees, saying Testosterone is fairly well studied for sexual health in women and is effective in almost all areas of sexual function.

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The barrier that exists isnt lack of science or lack of interest, its the FDA, says Faught. The FDA has asked for more long-term data for using testosterone in hypoactive sexual desire disorder (HSDD) in women, potentially up to five years [worth], she says.

A study that would fulfill the FDAs request seems to be cost prohibitive for pharmaceutical companies, says Faught. I dont know of any specific product that is on the cusp of getting approval or seeking approval, which is unfortunate and frustrating, she adds.

There are options and guidance for how to use testosterone products for HSDD, says Faught. In 2018, the International Society for the Study of Womens Sexual Health (ISSWSH) published a process of care (POC) for the diagnosis and management of hypoactive sexual desire disorder (HSDD) in pre- and postmenopausal women, including guidelines for prescribing testosterone in postmenopausal women with HSDD.

A global consensus statement that was endorsed by several international medical societies including The International Menopause Society, The Endocrine Society, and the NAMS was published in The Journal of Clinical Endocrinology & Metabolism in October 2019. The statements purpose is to provide clear guidance on which women may benefit from testosterone therapy, as well as any potential risks.

The issue is that treating off-label can carry additional risk and expense for patients, says Faught. If I prescribe a testosterone product thats intended for men, I can prescribe it at a lower dose as is necessary, but because it isnt FDA approved for this use, usually insurance wont cover it. That could mean a cost of anywhere from $300 to $500, she says.

Compounding testosterone, a process where a pharmacist specifically makes the product from scratch may be cheaper, but then there is increased potential for human error as well as a lack of regulations, says Faught.

Probably the main reason there is no FDA-approved testosterone product for HSDD is that theres a lack of long-term safety data, says Faubion. For example, we dont know breast cancer risk, we dont know cardiovascular risk, she says.

The cardiovascular risk appears to be less of concern for women than it is for men taking testosterone, but the bigger question is breast cancer risk over time, says Faubion. This is because testosterone converts to estrogen inside the body, and so there is a question on whether that increases breast cancer risk, she says.

Ive used it in my practice and its effective for women, says Faubion. Yes, we still have questions about long-term safety and long-term efficacy, but for short-term efficacy and short-term safety, we have pretty convincing data; I think ultimately it probably will be approved for use in women.

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