Key Points

• Although the likelihood of being sexually active declines with age, many older adults remain sexually active.

• Approximately half of sexually active older adults report at least one sexual problem, and two-thirds have at least two.

• The likelihood of being sexually active correlates with good health.

• Although testosterone levels decline with age, androgen supplementation is recommended only in hypogonadal men.

Although the likelihood of being sexually active declines steadily with age, many older adults remain sexually active; 84% of men and 62% of women age 57 to 64 and 67% of men and 40% of women age 65 to 74 report being sexually active in the previous 12 months, with two thirds of both genders in each cohort sexually active more than two to three times a month. For those age 75 to -85, only 39% of men and 17% of women reported sexual activity within 12 months (those sexually active still had >2-3/mo) (Lindau et al., 2007). Several factors impact the decline in sexual activity. As men and women age, physiologic changes in sexual functioning occur. During arousal, older men experience less scrotal vasoconstriction and testicular elevation, erection may be delayed or insufficient, and orgasm may be of shorter duration with less ejaculatory fluid. Women may have decreased labial engorgement and less vaginal lubrication during arousal and fewer and weaker uterine contractions during orgasm. Regardless of these physical changes, many older adults continue to have active sexual lives.

In one large U.S. study, approximately half of sexually active older adults reported at least one sexual problem, with almost two-thirds having at least two bothersome sexual problems. Sexual problems most often reported by women were lack of interest (43%), difficulty with lubrication (39%), inability to climax (34%), finding sex not pleasurable (23%), and pain (17%). Among men, the most common sexual problems were difficulty in achieving or maintaining an erection (37%), lack of interest in sex (28%), climaxing too quickly (28%), anxiety about performance (27%), and inability to climax (20%). The likelihood of being sexually active is associated with good health. Men and women who reported good to excellent health were 80% and 70%, respectively, more likely to be sexually active than men and women with "poor" or "fair" health status (Lindau et al., 2007). Many common health conditions, such as arthritis or back pain, can inhibit sexual activity. Vascular disease and its risk factors, including coronary artery disease, stroke, diabetes, hypertension, hyperlipidemia, and smoking, correlated with ED in the Global Study of Sexual Attitudes and Behaviors (GSSAB). Women with diabetes are also less likely to be sexually active than women without diabetes (Laumann et al., 2005). Pudendal nerve disruption following hysterectomy and bladder, rectal, or prostate surgery may cause sexual dysfunction. Since they take more medications, older adults may be particularly susceptible to iatrogenic sexual dysfunction, because many common medications affect sexual functioning, especially antihypertensives and antidepressants (see Table 43-1).

At all ages, women are less likely to be sexually active than men. For example, 50% of women age 60 to 69 reported that a healthy sexual life was at least "moderately important" to them; however, only 30% reported continued regular participation in sexual intercourse (Ponholzer et al., 2005). Women may be more likely not to have a spouse or intimate partner because of their greater longevity. In those age 75 to 85, men are almost twice as likely as women to have an intimate partner (78% vs. 40%). In addition, women are frequently younger than their male partners. Partner health may be an issue; 64% of women reported the male partner's physical health as the reason for sexual inactivity longer than 3 months (Lindau et al., 2007). Data from the 2005 Vermont Civil Unions suggest a similar age discrepancy among samesex partners; for women and men age 40 to 44, more than 25% and about 50%, respectively, had a partner more than

5 years older (see Web Resources). Lack of privacy may be problematic for elderly adults, who may live with family members or in long-term care settings.

Decline in sex steroid production is a factor in sexual dysfunction for both women and men. Postmenopausal estrogen deficiency is responsible for loss of vaginal lubrication and elasticity. The Women's Health Initiative (WHI) raised concerns regarding deleterious effects of systemic estrogen replacement (Rossouw et al., 2002). Clinicians should counsel women desiring long-term oral estrogen supplementation to diminish vaginal atrophy symptoms regarding the increased risk of coronary artery disease, thrombotic disease, and breast cancer. Vaginal estrogen supplementation may be helpful to decrease vaginal mucosal atrophy with much less systemic absorption. Using creams, pessaries, or a vaginal ring to apply estrogen vaginally relieves the symptoms of vaginal atrophy, although some creams may cause adverse effects such as uterine bleeding, breast pain, and perineal pain (Suckling et al., 2006). Women who remain sexually active may avoid significant vaginal atrophy through continued stimulation of the epithelium and vascular supply.

Androgen deficiency in adult males (ADAM), often called "male menopause" or "andropause," is controversial. Testosterone levels do decline with age, eventually by 50% from midlife to old age, and predictable physiologic changes occur. One large, double-blind RCT demonstrated that supplementing older men with low-normal circulating testosterone levels with 80 mg of oral testosterone undecenoate twice daily for

6 months increased lean body mass and decreased fat mass, but it did not improve functional mobility or muscle strength. There also was no demonstrable beneficial effect on cognition or quality-of-life measures (Emmelot-Vonk et al., 2008). Androgen supplementation does have risks, such as altering cholesterol metabolism; thus it currently is not recommended unless the man has hypogonadism (Bhasin et al., 2006).

In one global study in men 40 to 80 years old who visited a primary care physician, almost half (49%) had ED (Mulhall et al., 2008). Despite the increasing prevalence of sexual difficulties in aging persons, the GSSAB reported only 9% of both men and women had been asked about sexual health by their physician during the preceding 3 years. Only 18% of the men and women in that study population sought medical assistance for their sexual problems (Moreira et al., 2005). The increased acceptance and availability of PDE-5 inhibitors may have improved physician-patient discussions over the last few years. In a recent study, 38% of men and 22% of women reported having discussed sex with a physician since age 50 (Lindau et al., 2007). Clinicians can improve their older-adult care by inquiring about sexual health and illness during the course of routine geriatric health care. Normal physical changes can be explained. ED and other sexual problems can often be treated effectively, thus assisting elderly patients in maintaining healthy sexual lives.

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