Normal Changes in Sexual Function
posted in Sexuality |Sexual change in old age is a process of gradual slowing; more time is needed to become sexually aroused and to reach sexual climax. This should not be considered an impairment, since it may permit a better response synchronization between the sexes, compared to that in earlier years when men responded more quickly than women. Men and women often converge in other ways as they grow older: women typically become more assertive and men become more nurturant.
Special Concerns of Men
In addition to gradual slowing, older men may notice less preejacu-latory fluid and less forcefulness at ejaculation. In general, testosterone levels decline only gradually, and some very ofd men still have levels identical to those in younger men. However, chronic illness or alcoholism reduces testosterone levels markedly. Men do not undergo a physiologic climacteric, and they remain fertile until the end of life.
A common concern of men of all ages including older men is their ability to maintain sexual potency and performance. Impotence is distressing and is usually (although inaccurately) attributed to aging (see IMPOTENCE in Ch, 69). However, impotence may occur from time to time at any age for a variety of reasons (eg, stress, fatigue, tension, guilt, depression, illness, excessive drinking, and anxiety over performance). A comprehensive evaluation is needed to separate psychologic from organic causes. Recent studies suggest that organic causes are a major factor in > 80% of persistent male sexual dysfunction, and psychologic factors alone probably account for only 10% of cases of erectile dysfunction. However, psychologic and organic factors are often intermixed: anxiety over an organic cause of impotence often aggravates the problem.
The diagnostic process begins with a history and physical examination. Depression, anxiety, and stress must also be evaluated. Sleep studies that measure nocturnal penile tumescence help distinguish psychogenic from organic impotence. Such studies can be conducted al home with a portable monitoring unit or in sleep clinics.
Impotence can be treated successfully in most cases, often without surgery. In the case of psychogenic impotence, sexual capacity may return spontaneously; reassurance reduces anxiety and speeds recovery, but psychotherapy or professional sex therapy may be required. Involving the partner in the diagnosis and treatment program is important. Much of the expense of professional sex therapy (including that for couples) may be covered by Medicare or private health insurance, -but the cost may be a problem for many older people. Medicare now pays 50% of the allowable charges for psychotherapy whether performed by a physician, psychologist, or social worker. Increasingly, insurance companies are paying for diagnosis and treatment of scxua! dysfunction.
Special Concerns of Women
Older women usually can continue their earlier patterns of sexual functioning until the end of life or until serious illness intervenes. Women tend to be less concerned about sexual performance than men but are more worried about loss of youthful appearance. Some women enjoy sex more without the possibility of pregnancy. The frequency of intercourse for heterosexual women is often related more to the age. health, and sexual function of their partners for the availability of a partner) than to their own sexual capacity or interest.
For women, most sexual changes are associated with menopause, when estrogen production slows. The effects of menopause on sexuality may include vaginal dryness leading to irritation or pain, a change in vaginal shape (shortening and narrowing), less acidic vaginal secretions with greater possibility of vaginal infections, cystitis due to thinning of vaginal walls with less protection for bladder and urethra, reduction in clitorai size, stress incontinence, and increase in facial hair.
Estrogen replacement therapy has long been used for menopausal symptoms and is effective in treating all of these changes as well as in controlling hot flushes; the specific therapy is discussed in Ch. 83. However, given the risks associated with estrogen replacement therapy, many women are skeptical about its benefits and often experience “estrogen anxiety,” a fairly new psychologic issue of midlife sexuality. Other measures, such as using water-based vaginal lubricants (eg, K-Y Jelly), can help prevent or control vaginal dryness and irritation during intercourse.
