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Prior Function and Relationship, More Than Hormones, Affect Sexual Function for Midlife Women CME
News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd

Disclosures

To earn CME credit, read the news brief along with the CME information that follows and answer the test questions.

Release Date: July 22, 2005; Reviewed and Renewed: July 20, 2006; Valid for credit through July 21, 2007


Credits Available


Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™ for physicians


July 22, 2005 — Prior function and relationship factors are more important than hormonal determinants of sexual function for women in midlife, according to the results of a population-based, prospective study reported in the July issue of Fertility and Sterility.

"Longitudinal analysis of the relative effects of age and hormonal factors on aspects of female sexual function found that age impacts negatively on all domains of sexual function and that lower E2 [estradiol] levels significantly adversely affect women's sexual interest and responsiveness (arousal, enjoyment, orgasm) but not the frequency of sexual activity," write Lorraine Dennerstein, PhD, from the University of Melbourne in Parkville, Victoria, Australia, and colleagues. "The midlife years, when most women pass through the menopausal transition, coincide with other social transitions as children leave home and parents may experience ill health associated with older age. In addition, some women may lose (or gain) sexual partners, some of whom have their own problems with sexual performance."

In this questionnaire study, 438 Australian-born women age 45 to 55 years who were still menstruating at baseline were interviewed at their homes. Eight years of longitudinal data were available for 336 of these women, none of whom had had a hysterectomy.

On the basis of longitudinal structural equation modeling, sexual response was predicted by prior level of sexual function, change in partner status, feelings for partner, and E2 level (r2 = .65). Prior level of dyspareunia and E2 level predicted dyspareunia (r2 = .53), and frequency of sexual activity was predicted by prior level of sexual function, change in partner status, feelings for partner, and level of sexual response (r2 = .52).

The minimum effective dose needed to increase sexual response by 10% was 700 pmol/L E2, or twice the dose needed to decrease dyspareunia.

"Prior function and relationship factors are more important than hormonal determinants of sexual function of women in midlife," the authors write.

Study limitations include the yearly measurements of hormones, the lack of sensitivity of certain assays, and study dropout over time.

"The level of E2 needed to produce a minimal clinically relevant difference on sexual response is twice that needed to improve dyspareunia," the authors conclude. "E2 replacement thus needs to be equivalent to mid– to late–follicular phase levels of regularly cycling women. This suggests that the low doses of estrogen currently advocated in hormone therapy will not be effective in sustaining women's sexual function."

Fertil Steril. 2005;84:174-180

Learning Objectives for This Educational Activity

Upon completion of this activity, participants will be able to:
Identify important predictors of sexual function in women during the menopause transition.
Describe the relationship between E2 and T levels and female sexual function during the menopause transition.
Clinical Context

Population-based studies have shown that women have more sexual dysfunction than men and that sexual function declines with age and length of relationship, according to the authors. Women's sexual function is hypothesized to be more dependent on psychosocial factors such as relationship, family, and partner issues than on hormonal factors. This is an analysis of the Melbourne Women's Midlife Health Project, an eight-year prospective, longitudinal study using annual questionnaires and hormone blood assays with the aim of deriving a correlation between domains of female sexual function, hormonal status, and relationship factors during the menopause transition.

Study Highlights

Participants were Australian-born women age 45 to 55 years recruited by telephone interview. Inclusion criteria at baseline were menses within 3 months and not taking oral contraceptive pills or hormone therapy (HT). Exclusion criteria were menopause induced by hysterectomy or endometrial ablation, use of oral contraceptives, and inability to participate in annual blood hormonal assays.
336 of 438 eligible women comprised the analysis sample.
Sexual function was assessed by the modified Personal Experiences Questionnaire (PEQ) and its short form (SPEQ), and the domains assessed included frequency of sexual activities, sexual response (arousal, interest, enjoyment, and orgasm), feelings for partner, dyspareunia, and change in partner status. Women completed the questionnaires themselves at home during an annual interview and handed sealed envelopes containing the completed forms back to the field worker.
Hormonal assays were performed on the day of annual interview. Fasting morning samples were obtained between days 4 and 8 of the menstrual cycle or after 3 months of amenorrhea. Assays were obtained for follicle-stimulating hormone (FSH), E2, T, sex hormone-binding globulin (SHBG), dehydroepiandrosterone sulfate (DHEAS), and immunoreactive inhibin (Inh).
Because previous analysis had demonstrated that libido was not separable from sexual responsiveness, these domains were combined in the analysis of sexual response.
Analysis was by year of study, with a total of 8 time periods for the 8 years of follow-up, using the year before and the year after the final menstrual period (FMP) as the menopause transition.
There were 4 menopause status groups: those menstruating within the prior 3 months, those with 3 to 11 months of amenorrhea, postmenopausal women with at least 12 months of amenorrhea, and those receiving HT. The latter group was analyzed as a subgroup.
Women's sexual response was correlated with domains of the PEQ and hormonal levels.
Significant change in hormone level was seen for FSH, E2, and Inh, occurring in the year before the FMP. The largest change was for FSH and E2.
As women passed through the menopause transition in the year before and after the FMP, there was a significant decrease in sexual response and frequency of sexual activities and an increase in dyspareunia.
All the variables examined highly correlated with the values of each variable in the prior year.
The androgens were constantly poorly correlated across time periods. The rate of age decline of T was slow and not specifically related to menopause. DHEAS levels did not significantly decline with the menopause transition and showed only a slow decline with age.
The key predictor of sexual response was prior function. The second predictor was whether the woman had lost, remained with, or gained a new partner. The third predictor was feeling for partner.
Changes in E2 levels significantly affected sexual behavior, and the effect of the menopausal transition on sexual function was overwhelmingly caused by the marked decline in E2 level. E2 level had an effect on only 2 domains of sexual function: sexual responsiveness and dyspareunia. The effect of E2 level was of less importance than that of prior level of function, change in partner, and frequency of sexual activities, demonstrating a powerful effect of psychosocial factors on sexual functioning.
Treatment with HT increased the level of E2.
Analysis of the HT subgroup showed that the dose of E2 needed to improve the subjective aspects of sexual function was twice that needed to improve local symptoms of vaginal dryness. The minimum dose of E2 to teach a minimal important difference was between 650 and 758 pmol/L.
Pearls for Practice

Predictors of sexual function in women experiencing the menopause transition include prior functioning, frequency of sexual activities, feelings for partner, change of partner and E2 level.
The dose of E2 needed to minimally improve sexual response at the menopause transition is twice that needed to improve vaginal dryness. T level does not predict change in sexual response.