Many studies of sexuality and aging show that older women report less distress about lack of desire when compared with younger women (17,18,43). In a nonclinical study of 102 women, the determinants of sexual satisfaction in those younger than 45 years of age were compared with those of women older than 45 years of age (18). There was no difference in sexual satisfaction achieved either by intercourse or noncoital sexual activities. Older women reported lower frequency of orgasm and different ratings on certain dimensions of sexual satisfaction. For the older women, the dominant qualities important to their satisfaction were those related to an emotional sense of calm and to factors such as feeling secure with their partner, whereas for younger women the subjective physical experience was more important.
Despite reports of reduced sexual interest and desire by some older women, most retain some interest and maintain the potential for sexual pleasure for their entire lives. In older women, a strong predictor of continued sexual interest is sexual behavior and enjoyment at an earlier age. A discrepancy between sexual interest and actual sexual activity occurs in many cases because an adequate partner is no longer available. In other instances, the cessation of sexual activity with age is more an expression of emotional problems resulting from lack of tenderness, communication, and attraction.
In addition to partner availability, an older woman’s sexuality is inﬂuenced by her partner’s general and sexual health and the relationship itself, which will determine how well the couple can adapt to changes in their sexual function as they age (17,44,45). Although some older women may retain negative societal attitudes toward sex that it is not “natural” (i.e., not focused intercourse), studies show a shift from intercourse to nonpenetrative sex and to a variety of activities that involve affection, romance, affectionate physical intimacy, and companionship (46). For some older women, it is clear that the setting, whether a nursing home or a grown-up child’s home, strongly inﬂuences the opportunity for sexual expression.
If intercourse is perceived as a necessary component of sexual activity with a partner, some older women will lose motivation and interest as a result of discomfort and dyspareunia associated with lack of estrogen. Although the increase in vaginal congestion in response to visual sexual stimulation is similar in women with and without estrogen, baseline vaginal blood ﬂow is lower in estrogen-deficient women (23). Thus, the increase in lubrication may be insufficient. There may be loss of elasticity and thinning of the vaginal epithelium, which becomes vulnerable to damage from intercourse. Estrogen depletion predisposes women to vulvar vaginitis and urinary tract infections, both of which contribute to dyspareunia and reduce sexual self-image. Women who remain sexually active, alone or with a partner, may have less vulvar and vaginal atrophy than sexually inactive women but may still be symptomatic (47).