madman
Super Moderator
Abstract
Purpose of Review Among the growing elderly population, sexual health remains an important concern for individuals and couples. An understanding of the expected changes with aging and taking care of aging men and women is important for treating sexual dysfunction. Sexual health issues related to aging can be both linked between men and women and independent. The aim of this study is to determine the most important considerations that contribute to sexual satisfaction in men and women in this population.
Recent Findings Many factors contribute to the overall sexual health of men and women. Hypogonadism and erectile dysfunction both warrant thorough evaluation and consideration of treatment to improve sexual satisfaction. Underlying cardiovascular issues may be present in men presenting with these concerns. In addition to hormone replacement and traditional therapy for erectile dysfunction, therapeutic stem cell injection has shown some promise. Menopause, vaginal dryness, and dyspareunia play important roles in sexual satisfaction in women. Vaginal moisturizers, topical estrogen, and MonaLisa Touch laser therapy all may aid in improving these symptoms and ultimately sex lives. Studies have also demonstrated some benefit in populations with arousal disorders, which can be present in the elderly.
Summary Male patients often describe issues related to erectile dysfunction and hypogonadism, and issues with sexual drive. The pathophysiology is linked between these conditions and treatment of one component can provide symptom relief on a larger scale. A combination of testosterone therapy, lifestyle modifications, and therapy for erectile dysfunction relates to sexual satisfaction in men. In women, an understanding of the physiological process of menopause and offering therapy when indicated can improve the quality of sexual health and provide satisfaction to both patient and partner. While aging can diminish drive and desire, proper counseling and treatment may significantly benefit some patients. A multimodal approach involving the physician, patient, and partner will optimize care and may improve the quality of life in the elderly. This review outlines some normal changes due to aging and identifies some current treatment options for a population in which sexual health can be often ignored or dismissed. By understanding the available tools, a more comprehensive approach can be taken to achieve satisfaction in couples and individuals alike.
Introduction
Increased life expectancy in a growing elderly population makes sexual health an important part of patient care. Men and women experience many physiological changes that impact their sexual health as they age. In a survey of 355 individuals, ages 50–90 years, 81.5% were currently involved in one or more sexual relationships [1••]. Despite 90.9% of patients reporting they wanted their physicians to ask them questions regarding sexual history, only 40.5% report ever having a discussion regarding their sexual life with their doctor [2]. By understanding the mechanisms of aging, men and women can be optimized for sexual performance with the assistance of lifestyle changes, medications, and even in some cases surgical intervention. Modifiable components of aging include improvement in cardiovascular health, treatment of hormonal deficiency, psychosocial counseling, therapy for erectile dysfunction, and reversal of vulvovaginal atrophy. We will review the pathophysiology of conditions affecting sexual health in the elderly population and outline the treatments available for each condition as it applies to the aging population. It is important for healthcare professionals to address this often-overlooked topic due to the stigmatization that comes with sex in the aging population.
Sexual Health and Aging in Men
*Erectile Dysfunction
Introduction
ED is defined as the inability to achieve or maintain an erection rigid enough for penetration. ED increases in prevalence as men age. Seventy percent of men over the age of 70 struggle with some degree of ED, compared to 45% in their 60s and 15% in their 40s [3]. The Massachusetts Male Aging Study reported a 52% prevalence in men ages 40–70 years old [4]. While age alone is a risk factor for ED, additional risk factors among the elderly include hypertension, diabetes, hypogonadism, medication side effects, metabolic syndrome, increased body mass index (BMI), cholesterol, and decreased high-density lipoprotein (HDL) [5]. Medications are known to cause ED includes beta-blockers, thiazide diuretics, and antidepressant medications [6].
Given the prevalence of cardiovascular disease among the elderly, it is important to understand how cardiovascular disease impacts sexual performance. In fact, it is thought that ED may serve as a harbinger of concomitant cardiovascular disease and even mortality in some cases. Min et al. studied men undergoing cardiac stress testing and found severe coronary artery disease in 43% of men with ED compared to 17% in those without [7••]. The pathogenesis of ED in the elderly is believed to be via systemic atherosclerosis with symptoms manifesting in smaller vessels including the arterial supply to the penis. Hypertension and other peripheral artery diseases damage these small vessels over time, allowing fewer nutrients and less oxygen to reach the sex organs. In a study by Rogers et al., stenosis of the internal pudendal artery was similar in comparison to stenosis of coronary arteries (52% vs. 65%) with comparable vessel diameter [8]. Endothelial dysfunction secondary to conditions of metabolic syndrome also contributes to the pathophysiology by damaging the source of nitric oxide production in penile tissue [9].
*Management
Sexual Health and Aging in Women
*Menopause
Introduction
Menopause is defined as the cessation of hormone production by women’s ovaries with a lack of menstrual periods for 12 months [29]. There is a transition from cyclical high levels of estrogen to varying levels of estrogen during menopause to a consistently low level of estrogen production observed in post-menopausal women [30]. The resulting changes in estrogen levels drive many of the potential pathologies of aging such as osteoporosis, dyspareunia, and decreased libido. The loss of estrogen results in unhindered osteoclast activity and bone reabsorption, leading to structurally weaker bones. Estrogen levels also mediate some of the dissatisfying qualities of sexual health noted by elderly women. Decreased estrogen sensitivity in vaginal epithelial cells results in vaginal dryness and decreased lubrication with sexual activity. Pain with intercourse, or dyspareunia, is another often reported finding associated with physiological aging in sexually active women [31]. Despite these drawbacks, older women remain sexually active and consider this to be an important part of their life.
*Management
*Vulvovaginal Atrophy/Orgasmic Changes
Introduction
Vulvovaginal atrophy (VVA) is a common cause of significant physical and emotional distress among aging women. The manifestations of VVA are primarily seen in perimenopausal women with a 4% incidence in women experiencing early menopause and 47% in women experiencing late menopause [38]. The pathophysiology of VVA is well established and believed to occur as a direct effect of decreased estrogen activity on the vaginal epithelium [39]. The vaginal epithelium thins and, as a result, there are fewer cells exfoliated into the vagina, which raises pH and disturbs the natural lactobacillus flora of the vagina [40]. Some of the reported symptoms associated with this condition include vaginal dryness, irritation, postcoital bleeding, and soreness. In addition to these symptoms, women with VVA have an increased incidence of recurrent urinary tract infections as well as urge and stress incontinence [41].
*Management
Conclusions
Healthcare providers carry an important responsibility in the general care of patients’ overall health, and sexual health comprises only a small part of this goal. Dedicated men’s and women’s clinics may thus offer an opportunity to address multiple issues as they affect the general well-being of patients. Understanding the physical and social changes that occur with aging has proven critical to addressing issues related to sexual health in these patients. Advances in medicine have increased longevity, and sexual health remains an important part of life for both elderly men and women. As we gain more insight, our ability to counsel our patients may be able to better address their issues related to sexual health and improve overall patient quality of life.
Purpose of Review Among the growing elderly population, sexual health remains an important concern for individuals and couples. An understanding of the expected changes with aging and taking care of aging men and women is important for treating sexual dysfunction. Sexual health issues related to aging can be both linked between men and women and independent. The aim of this study is to determine the most important considerations that contribute to sexual satisfaction in men and women in this population.
Recent Findings Many factors contribute to the overall sexual health of men and women. Hypogonadism and erectile dysfunction both warrant thorough evaluation and consideration of treatment to improve sexual satisfaction. Underlying cardiovascular issues may be present in men presenting with these concerns. In addition to hormone replacement and traditional therapy for erectile dysfunction, therapeutic stem cell injection has shown some promise. Menopause, vaginal dryness, and dyspareunia play important roles in sexual satisfaction in women. Vaginal moisturizers, topical estrogen, and MonaLisa Touch laser therapy all may aid in improving these symptoms and ultimately sex lives. Studies have also demonstrated some benefit in populations with arousal disorders, which can be present in the elderly.
Summary Male patients often describe issues related to erectile dysfunction and hypogonadism, and issues with sexual drive. The pathophysiology is linked between these conditions and treatment of one component can provide symptom relief on a larger scale. A combination of testosterone therapy, lifestyle modifications, and therapy for erectile dysfunction relates to sexual satisfaction in men. In women, an understanding of the physiological process of menopause and offering therapy when indicated can improve the quality of sexual health and provide satisfaction to both patient and partner. While aging can diminish drive and desire, proper counseling and treatment may significantly benefit some patients. A multimodal approach involving the physician, patient, and partner will optimize care and may improve the quality of life in the elderly. This review outlines some normal changes due to aging and identifies some current treatment options for a population in which sexual health can be often ignored or dismissed. By understanding the available tools, a more comprehensive approach can be taken to achieve satisfaction in couples and individuals alike.
Introduction
Increased life expectancy in a growing elderly population makes sexual health an important part of patient care. Men and women experience many physiological changes that impact their sexual health as they age. In a survey of 355 individuals, ages 50–90 years, 81.5% were currently involved in one or more sexual relationships [1••]. Despite 90.9% of patients reporting they wanted their physicians to ask them questions regarding sexual history, only 40.5% report ever having a discussion regarding their sexual life with their doctor [2]. By understanding the mechanisms of aging, men and women can be optimized for sexual performance with the assistance of lifestyle changes, medications, and even in some cases surgical intervention. Modifiable components of aging include improvement in cardiovascular health, treatment of hormonal deficiency, psychosocial counseling, therapy for erectile dysfunction, and reversal of vulvovaginal atrophy. We will review the pathophysiology of conditions affecting sexual health in the elderly population and outline the treatments available for each condition as it applies to the aging population. It is important for healthcare professionals to address this often-overlooked topic due to the stigmatization that comes with sex in the aging population.
Sexual Health and Aging in Men
*Erectile Dysfunction
Introduction
ED is defined as the inability to achieve or maintain an erection rigid enough for penetration. ED increases in prevalence as men age. Seventy percent of men over the age of 70 struggle with some degree of ED, compared to 45% in their 60s and 15% in their 40s [3]. The Massachusetts Male Aging Study reported a 52% prevalence in men ages 40–70 years old [4]. While age alone is a risk factor for ED, additional risk factors among the elderly include hypertension, diabetes, hypogonadism, medication side effects, metabolic syndrome, increased body mass index (BMI), cholesterol, and decreased high-density lipoprotein (HDL) [5]. Medications are known to cause ED includes beta-blockers, thiazide diuretics, and antidepressant medications [6].
Given the prevalence of cardiovascular disease among the elderly, it is important to understand how cardiovascular disease impacts sexual performance. In fact, it is thought that ED may serve as a harbinger of concomitant cardiovascular disease and even mortality in some cases. Min et al. studied men undergoing cardiac stress testing and found severe coronary artery disease in 43% of men with ED compared to 17% in those without [7••]. The pathogenesis of ED in the elderly is believed to be via systemic atherosclerosis with symptoms manifesting in smaller vessels including the arterial supply to the penis. Hypertension and other peripheral artery diseases damage these small vessels over time, allowing fewer nutrients and less oxygen to reach the sex organs. In a study by Rogers et al., stenosis of the internal pudendal artery was similar in comparison to stenosis of coronary arteries (52% vs. 65%) with comparable vessel diameter [8]. Endothelial dysfunction secondary to conditions of metabolic syndrome also contributes to the pathophysiology by damaging the source of nitric oxide production in penile tissue [9].
*Management
Sexual Health and Aging in Women
*Menopause
Introduction
Menopause is defined as the cessation of hormone production by women’s ovaries with a lack of menstrual periods for 12 months [29]. There is a transition from cyclical high levels of estrogen to varying levels of estrogen during menopause to a consistently low level of estrogen production observed in post-menopausal women [30]. The resulting changes in estrogen levels drive many of the potential pathologies of aging such as osteoporosis, dyspareunia, and decreased libido. The loss of estrogen results in unhindered osteoclast activity and bone reabsorption, leading to structurally weaker bones. Estrogen levels also mediate some of the dissatisfying qualities of sexual health noted by elderly women. Decreased estrogen sensitivity in vaginal epithelial cells results in vaginal dryness and decreased lubrication with sexual activity. Pain with intercourse, or dyspareunia, is another often reported finding associated with physiological aging in sexually active women [31]. Despite these drawbacks, older women remain sexually active and consider this to be an important part of their life.
*Management
*Vulvovaginal Atrophy/Orgasmic Changes
Introduction
Vulvovaginal atrophy (VVA) is a common cause of significant physical and emotional distress among aging women. The manifestations of VVA are primarily seen in perimenopausal women with a 4% incidence in women experiencing early menopause and 47% in women experiencing late menopause [38]. The pathophysiology of VVA is well established and believed to occur as a direct effect of decreased estrogen activity on the vaginal epithelium [39]. The vaginal epithelium thins and, as a result, there are fewer cells exfoliated into the vagina, which raises pH and disturbs the natural lactobacillus flora of the vagina [40]. Some of the reported symptoms associated with this condition include vaginal dryness, irritation, postcoital bleeding, and soreness. In addition to these symptoms, women with VVA have an increased incidence of recurrent urinary tract infections as well as urge and stress incontinence [41].
*Management
Conclusions
Healthcare providers carry an important responsibility in the general care of patients’ overall health, and sexual health comprises only a small part of this goal. Dedicated men’s and women’s clinics may thus offer an opportunity to address multiple issues as they affect the general well-being of patients. Understanding the physical and social changes that occur with aging has proven critical to addressing issues related to sexual health in these patients. Advances in medicine have increased longevity, and sexual health remains an important part of life for both elderly men and women. As we gain more insight, our ability to counsel our patients may be able to better address their issues related to sexual health and improve overall patient quality of life.
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