Sexuality among Postmenopausal Women and its

ORIGINAL ARTICLE Sexuality among Postmenopausal Women and its 10.5005/jp-journals-10032-1069 Relation to Menopause Rating Scale Sexuality among Postmenopausal Women and its Relation to Menopause Rating Scale 1 Syeda Batool Mazhar, 2 Yasmeen Mansha Kayani, 3 Shagufta Yasmin ABSTRACT Background: There has been a misperception that menopausal women automatically lose interest in sexual life. At menopause, women have low estrogen levels; the vagina becomes thinner with less lubrication resulting in discomfort and lack of sensation with dyspareunia. There was a lack of standardized scales to measure the severity of menopausal symptoms and their effect on the healthrelated quality of life (HRQoL). So, in the 1990s menopausal rating scale (MRS) was developed to measure the severity of these problems. The MRS scores will be correlated with sexuality among postmenopausal women in this study. Objective: To study psychosexual health issues and attitudes toward sexuality among postmenopausal women and correlate it with MRS. Materials and methods: A cross-sectional study was conducted among 100 postmenopausal women who presented in maternal and child healthcare (MCH) centre as a patient or accompanying person. Divorced, widow or women sepa rated from their husbands were not included in the study. It was ques tionnaire-based convenience sampling conducted from 1st March to 31st August 2012 in MCH centre, Pakistan Institute of Medical Sciences (PIMS). The results were analyzed on Statistical Package for the Social Sciences (SPSS) version 17. Results: The mean age of participants was 53 years and the mean age at menopause was 47 years. All the women had engaged in sexual intercourse in the past 6 months. A total of 93% women reported sexual activity, two to three times in a month while 2% were active more than four times. Only five having sex to make their partner happy. Seventy-four percent had reduced libido and 72% had diminished sexual response. The mean MRS was 11.2% with a range from 5 to 26. On analyzing MRS, the most frequent reported symptoms were anxiety, physical and mental exhaustion (90%), hot flushes (89%), night sweats (87%), anxiety (85%), irritability (83%) and depressive mood (82%). Vaginal dryness and sleep problems (74%), heart discomfort (71%), sexual problems (70%) and 41% had bladder problems were less frequent. On correlation of sexual functioning with MRS, women with higher MRS score (16 26) had significantly reduced sexual response (p = 0.046) compared to women with scores lower than or equal to 15 while there was no relation of MRS with importance of sexual relations in marital life. 1 Professor, 2 Trainee Resident (FCPS), 3 Senior Registrar 1-3 Maternal and Child Healthcare Centre, Pakistan Institute of Medical Sciences, Islamabad, Pakistan Corresponding Author: Syeda Batool Mazhar, Professor, Maternal and Child Healthcare Centre, Pakistan Institute of Medical Sciences Islamabad, Pakistan, e-mail: batoolmazhar@yahoo.com Conclusion: Sexual dysfunction in postmenopausal women was found to be quite high, but despite of these problems most of the women were satisfied with their sexual life. The MRS is a valuable for the assessment of menopausal complaints and had some correlation with sexuality. Keywords: Climacteric, Dyspareunia, Libido, Menopause, Orgasm, Sexuality. How to cite this article: Mazhar SB, Kayani YM, Yasmin S. Sexuality among Postmenopausal Women and its Relation to Menopause Rating Scale. J South Asian Feder Menopause Soc 2015;3(2):39-43. Source of support: Nil Conflict of interest: None Date of submission: 20 May 2015 Date of acceptance: 14 August 2015 Date of publication: December 2015 INTRODUCTION According to World Health Organization (WHO), menopause is defined as permanent cessation of menstruation that results from failure of ovarian follicular activity. Natural menopause is recognized to have occurred after 12 consecutive months of amenorrhea for which no other physiological or obvious pathological cause is present. 1 The symptoms of menopause vary in different cultures. 2 Vasomotor symptoms (VMS) are more common in the West (30 75%) and in Europe (20 30%). In Asian countries, prevalence is 5 to 20%. Studies found lower level of estrogens in Asians compared to whites. 3 The prevalence of VMS is increased in those living in regions with greater seasonality. 4 Vasomotor symptoms are more common in blacks as compared to whites. 5 The women with higher education level seem to have fewer symptoms. The effect of exercise is conflicting. 6 The psychological symptoms include depressed mood, anxiety, irritability, mood swings and lethargy. Previous psychological problems and current life stresses appear to increase the risk. 7 Sexual problems are common in postmenopausal women, it has been estimated that these affect approximately one in two women. How a woman perceives and responds to menopause is determined by her culture and her view on ageing and sexuality. These are related to genetics interacting with lifestyle, culture and other Journal of South Asian Federation of Menopause Societies, July-December 2015;3(2):39-43 39

Syeda Batool Mazhar et al undefined factors. Stereotypically, the western women dread menopause while Asian women welcome because of end of menses, childbearing, more respect. Women of higher society believe it as a medical condition, while less educated consider it a natural event. Asian women had more conservative attitude toward sexuality than their western counterparts. Asian women are less disturbed with vaginal dryness and loss of libido. There are various scales used for measuring meno pausal problems, e.g. Green climacteric scale (UK), Women s health questionnaire (SE England), MRS (Germany), Utian QoL score (USA). The MRS is a relevant, simple, easily applicable tool for assessing menopausal symptoms in our society. It consists of three dimensions somatovegetative, psychological and urogenital symp toms. It consists of 11 symptoms, each rated on five point scale of severity. The sexuality includes the knowledge, beliefs, attitudes, values and behavior of individual about sex. 8 The abrupt fall in estrogen level due to menopause has adverse effects on sexual function. Menopause can directly and indirectly affect sexuality. The direct effects include genital atrophy which may cause dyspareunia, vaginismus, inadequate lubrication and loss of libido. While the indirect effects result from changes in body contour. Menopause is associated with increased in intraabdominal fat. This results in a perceived loss of sexual attractive ness and self-image. This results in a perceived loss of sexual attractiveness and self-image. This causes sagging, wrinkling and drying of skin. 8 The term female sexual dysfunction is used now. An international classification system was developed by an International Consensus Conference on female sexual dysfunction. According to this sexual dysfunction is classified into, sexual desire disorder, sex arousal disorder, orgasmic disorder and sex pain disorder. MATERIALS AND METHODS Objective of our study was to study the psychosocial health issues and attitude towards sexuality among postmenopausal women and correlate it with MRS. This study was conducted at MCH center, PIMS, Islamabad. The duration of this study was from 1st March to 31st August 2012. It was a descriptive cross-sectional study. Total 100 women were included in the study by convenient sampling technique. All postmenopausal women living with their husbands, coming to MCH or postmenopausal women accompanying patients were included in the study. Women separated from husband, divorced and widows were excluded from the study. This was a questionnaire based study. The main outcome measures were frequency of sexual activity, satisfaction and understanding importance of sexual relationship, perceived problems and relationship of sexual problems to MRS. Statistical Package for the Social Sciences (SPSS) version 17 was used to analyze the results. Descriptive summary statistics, such as means, frequencies and percentages were computed for continuous variables. The inferential analysis was also carried out using Chi-square test along with cross tabulation to assess the level of association of categorical and nominal variables. The results were presented in graphical and tabular form. RESULTS Mean age of the study respondents was 53 years and the mean age of menopause was 47 years (Table 1). All the women had sexual activity in the past 6 months. A total of 93% women had sexual activity 2 to 3 times a month while 2% had more than 4 times. Only 5% considered sexual activity after menopause as a natural part of life while 95% women had sexual activity to please their husbands (Graph 1). The most common symptoms were anxiety, physical and mental exhaustion (90%), hot flashes (89%), night sweats (87%), irritability (83%), depressive mood (82%), sleep problems (74%) (Graph 2). Sexual problems were seen in 70% women. Vaginal dryness was a problem in 75% (Graph 2) and 74% had decreased libido, while 72% had decreased sexual response (Graph 3). The mean menopausal rating scale was 11.2 with a range of 5 to 26. On correlation of sexual function with MRS, women with higher MRS score Table 1: Demographic characteristics (n = 100) Variable Mean Range SD Age at presentation (years) 53 44 70 4 Age of husband (years) 59 40 80 7 Age at menopause (years) 47 38 55 3 Graph 1: Importance of sexual relations 40

Sexuality among Postmenopausal Women and its Relation to Menopause Rating Scale Graph 2: Frequency of menopausal symptoms Graph 3: Sexual problems at menopause Table 2: Relation of menopause rating scale and sexual desire among women Loss of sexual desire Yes No p-value MRS 5 15 59 (70%) 25 (30%) 0.04 16 26 15 (93%) 1 (7%) (16 26) had significantly reduced sexual response (p = 0.046) (Table 2). There was no relationship of MRS to the perceived importance of sexual relationship in marital life. Bladder symptoms were less common (41%). DISCUSSION There has been a misconception that postmenopausal women automatically loose interest in sexual life. Sexuality is a healthy and natural part of living. It includes sexual knowledge, beliefs, values and behavior. 8 In an interview survey in Hong Kong, it was seen that the women did not take the menopause negatively but they consider it a natural phenomenon. In our study, the women accepted menopause positively. The menopause was welcomed and majority of women felt themselves free to practice religion without any problem. 9 In our study, the mean age of menopause was 47 years, similar to studies carried out in Karachi and Hyderabad. 13,16 In Singapore, the incidence of menopausal symptoms was found to be very low as compared to those seen in European studies and had less effect on women s life. 10 In a study of woman s health across the nation (SWAN) of USA, it was seen that most menopausal symptoms are affected by ethnicity. In this study, the frequency of hot flashes was 89 and 74% of women had sleep disturbance. Incidence of VMS was more in African and Hispanic women. 11 In our study, these symptoms were seen in 87 to 89% of women. In another study carried out in Bangladesh, the incidence of hot flashes was 35.8%. 12 In other studies carried out in Karachi and Hyderabad, the incidence of hot flashes was 55 to 86%. 13-15 In another study, the incidence of VMS was found to be affected by culture. These symptoms were more commonly seen in the West (30 75%) and in Europe (20 30%) as compared to Asian countries (5 20%). In these studies, lower levels of estrogen were seen in Asians compared to that seen in Western countries. 3 In an other interesting study, it was seen although that Mayan women had similar level of estrogen as American women but the VMS were less in them. 17 In another study, the incidence of VMS was found to be increased in the areas with increased seasonal variations. 4 Gold et al found that VMS were more common in blacks compared to whites, may be due to increased heat and cold intolerance. 5 In our study, anxiety and irritability was seen in 83 to 85% of women and physical and mental exhaustion in 90% of women compared to another study carried out in Karachi which show these symptoms in 81.7% of women. 14 In our study, depression was seen in 82% and sleep disturbances in 74%. In a survey carried out in America, the incidence of anxiety and other psychological symptoms was less (38%) as compared to US. 20 In our study, all women were engaged in sexual activity in the past 6 months, 93% had sexual activity 2 to 3 times in a month while 2% were active more than 4 times but only 5% considered the sexual activity as a normal part of postmenopausal life while 95% had sexual activity only to please their husband. While in a European survey, 71% of women considered sexual activity important and 50% women had sexual activity more than 4 times a month. 21 In our study, sexual problems were seen in 70% of women. The most common sexual problem was vaginal dryness and painful intercourse (75%). Loss of sexual desire was seen in 74% of women compared to a Journal of South Asian Federation of Menopause Societies, July-December 2015;3(2):39-43 41

Syeda Batool Mazhar et al study of Bangladesh in which 31.2% women had sexual problems. 12 In a survey of Europe lack of orgasm and sexual pleasure was seen in 16% of women, vaginal dryness and painful intercourse in 13.6% of women. 18 In another study of Europe decrease in vaginal lubrication was seen in 34% and decrease in sexual desire in 53% of women. 19 In an Australian study, it was seen that different aspects of sexual functioning are affected directly by feelings of women for their partners and other social variables, such as job, interpersonal clashes, daily problems, education level of education indirectly affect the sexual functioning. 20 In another study carried out in Australia, a significant decrease in sexual arousal, decreased infrequency of sexual activity, increase in vaginal dryness and dyspareunia was found. 21 In another study, it was seen that the decrease in sexual function is associated with decrease in estrogen level than androgen level. 22 It was seen that sexual responsiveness is adversely affected by both aging and menopause, while other aspects of sexual function were adversely affected only by the menopausal status. 23 In another study, it was seen that postmenopausal women had difficulty with intercourse even without the effect of aging and other psychosomatic factors. 24 History of prior sexual functions and partners sexual problems could adversely affect women s sexual function than the hormonal factors. 25 In a study from USA, it was seen that general health, psychological health and understanding the importance of sexual activity were important for sexual function outcomes. 26 In 1990 due to deficiency of standard scales to measure the severity of menopausal symptoms and their impact on HRQoL, the MRS was developed. in our study, we correlated menopausal symptoms with MRS. Women with higher MRS (16 26) had significant decrease in sexual response (p = 0.046) while there was no relationship of MRS to understand importance of sexual relations in life. In our study, mean MRS was 11 with a range of 4 to 24. Menopause rating scale of 16 to 26 is associated with 93% loss of sexual desire. In another study carried out in MCH, PIMS, Islamabad, Pakistan MRS was 12. 27 CONCLUSION Sexual dysfunction in postmenopausal women is quite high. However, women were still satisfied with their sexual relationship. The MRS is a valuable tool for assessing menopausal complaints. It has some correlation with sexuality. REFERENCES 1. Utian WH. The International Menopause Society: menopauserelated terminology definitions. Climacteric 1999 Dec;2(4):284-286. 2. Melby MK, Lock M, Kaufert P. Culture and symptoms reporting at menopause. Hum Reprod Update 2005 Sep-Oct;11(5):495-512. 3. Randolph JF, et al. 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