Journal of Women's Health Care
Open Access

"Aging, Illness, or Menopause?": Exploring Perceptions, Needs and Sexual Behaviors during Menopause

Chithramali Hasanthika Rodrigo^1*, Ruwan Ferdinando² and Rohini Seneviratne^{3 *}Correspondence: Chithramali Hasanthika Rodrigo, University of Aberdeen, Scotland, Email:

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Background

Menopause introduces women to the post-reproductive phase of life. Natural menopause is defined as “permanent cessation of menstruation resulting from the loss of ovarian follicular activity” [1] National Institute for Healthcare Excellence (NICE) advises to diagnose menopause in otherwise healthy women above 45 years based on menopausal symptoms and lack of menstruation for at least 12 months [2].

Oestrogen hormone level is reduced during menopause manifesting as menopausal symptoms. Sexual symptoms of menopause include decreased libido, vaginal dryness/itching and dyspareunia [3]. While most symptoms of menopause resolve within a few years, sexual symptoms related to vulvovaginal atrophy could persist and may worsen with time [3] leading to a decrease in sexual activities among post-menopausal women. Although vaginal estrogen preparations could help with these discomforts only a minority of Asian women have been shown to seek treatment, probably due to poor awareness and safety concerns on HRT [4]. In addition, reduced libido and sexual responsiveness could significantly affect sexual functioning during menopause contributed by other changes of aging, co-morbidities and partner’s sexual problems [5].

Although, sexual symptoms of menopause could negatively affect intimate relationships, due to cultural norms and embarrassment women might not seek treatment. Asian women from some ethnic backgrounds have been reported to tolerate the sexual discomforts during menopause silently by prioritizing to their spouse’s needs rather than their own [6]. Despite this silence, information and treatment needs for sexual problems of menopause has been shown to be high among Asian women [4]. It is important for healthcare providers to inquire about these problems during routine care since most women might not readily discuss such issues or seek help [7].

There was no literature available on how Sri Lankan menopausal women with sexual symptoms respond to their symptoms and what needs are perceived by them. Perceptions of menopausal women may have implications for their quality of life, as well as for help seeking [7]. The objective of this study was to explore sexual symptoms as experienced during menopause using the research questions: how menopausal women with sexual symptoms perceive the changes in sex life, their understanding of sexual changes associated with menopause, and what are the implications of these for help seeking and any unmet sexual health needs.

Methods

Study Design

A qualitative research approach using semi-structured interviews was chosen for this study. We recruited post-menopausal women having sexual symptoms of menopause. We used open ended questions to elicit responses and facilitate information collection since we wanted to explore lived experiences and needs of participants. The post-menopausal women were invited for individual interviews since we were exploring a personal and sensitive topic in depth.

Participants and Recruitment

Post-menopausal women aged 45-55 years were recruited purposively out of participants of a larger survey on menopausal symptoms from Kalutara district. Those who had responded as positive for any of the three sexual symptoms in Menopause Specific Quality of Life Questionnaire (MENQOL) namely, ‘changes in sexual desire’, ‘vaginal dryness during intercourse’ and ‘avoiding intimacy’ were considered eligible [8] Post-menopausal status was determined with absence of menstruation for at least 12 months [1]. Those who had undergone hysterectomy or ovariectomy, stopped menstrual cycles due to radiotherapy or chemotherapy, reached menopause before 40 years and on hormonal contraceptives or hormone replacement therapy during past three months were excluded since we intended to explore the experience of those who had undergone natural menopause. Participants were purposively selected among those who had reported the highest degree of distress during the survey and were living in the Kalutara Medical Officer of Health area at the time of the study. Eligible women were provided information over the telephone and those who consented were invited to participate an in-person interview. Participants were recruited until theoretical saturation point was reached and no new themes emerged from the interviews [9]. All participants were provided with detailed information on personal encounter, and written consent to participate the study was obtained. Ethical approval was obtained for the study.

Data Collection

We conducted in-depth interviews with sixteen post-menopausal women from January 2019 to February 2019. Interviews were conducted at a private room in the area midwife’s office and privacy of the participants was ensured. Interviews were conducted by the principal investigator who had been trained in qualitative data collection. An open-ended flexible interviewer guide was used to guide the interviews. The interviewer guide contained questions about any genitourinary symptoms participants have been experiencing after their menstrual cycles stopped, changes related to sexual desire/response, impact by these changes on their intimate relationships, how they and their partners have been responding to the changes, help seeking behaviors and perceived unmet needs. An interview lasted approximately 40 minutes. All interviews were audio recorded and responses and non-verbal cues were noted with participants’ consent.

Data Analysis

Data collection and analysis were conducted manually using the steps of thematic analysis outlined by Braun and Clerk [10]. The transcripts were read and re –read noting important verbal and non-verbal responses. Audio recordings were listened to several times and additional notes were entered to transcripts. Chunks of data were identified and labeled with flexible codes to mark the salient points. Next similar codes were combined to make categories and preliminary themes were identified. Preliminary themes were reviewed and modified, and sub-themes were looked for. Final themes and their relationship with each other were established and a narrative description was prepared.

Results

Mean age of the participants was 52 years (range 47 to 55 years). Seven participants had their last menstruation > 5 years ago (44%), while five (31%) had their last menstruation between 1-5 years. The women represented multiple ethnic and religious backgrounds and included women from varying educational and occupational backgrounds. Table 1 outlines the socio-demographic and other characteristics of informants for the in–depth interviews.

Table 1: Socio-demographic and other characteristics of informants for the in–depth interviews (N=16).

Four major themes were identified: ‘passive acceptance’ (acceptance that symptoms were due to aging or illness); ‘information needs’ (lack of awareness on sexual problems of menopause and treatment), ‘avoidance or tolerance’, and ‘painful intimacy and unmet treatment needs’. Figure 1 illustrates the concepts map of sexual problems of menopause among Sri Lankan women.

Figure 1:Concept map: Sexual changes among Sri Lankan post-menopausal women.

Passive Acceptance; Its Aging and Illnesses

Most women (n=9, 56%) did not find anything unusual about the sexual changes they were experiencing. Women noted that they were having sexual intercourse less often and several women spoke of experiencing a low sexual drive.

“Oh. We rarely get together now” {laughs} no...I don’t feel like it anymore. It’s not like when I was young. When we used to be very active. If we ever do. It’s purely because my husband wants it …you know”.

According to them, their partners seemed to understand and comply with the changes in sexual relationships. They had silently adjusted to the changes and were in harmony despite less sexual intimacy than before.

“Both of us are not concerned about those things anymore. We have simply lost the habit of sex, but we are totally ok about it”.

“I don’t feel like having relationships with my husband anymore. It’s not an issue since my husband also feels the same. We are a couple who lived with good understanding from the beginning”.

The changes were attributed to natural aging, major life changes or other social and family circumstances and they did not feel any special need to proactively find a solution to lack of intimacy. For some women the priorities in their life, focus and source of enjoyment had changed. The women welcomed the lack of interest in sexual intimacy as sign of maturity and were satisfied with their status in life. Having grown up children was considered an esteemed position in life. They were focusing more on their children and grandchildren than on having an intimate relationship with their spouse.

“I live at my daughter’s place to help her look after the kids and my husband lives at our place…so living at two places…but we don’t miss not being able to have sex…I love looking after my grandchildren …but I’m too tired after running about with my grandchildren…..to think about being with my husband”.

“My kids are big now {looking pleased}… I don’t feel like being intimate with my husband at this old age. Husband also does not force me because he knows that I don’t like it anymore”.

For some women identified lack of enthusiasm towards sexual activities their spouses and linked this to the presence of comorbidities:

“We didn’t have sexual relationships since many months. I don’t feel any desire anymore and he is also not very enthusiastic about it. I have diabetes since two years. {Looking concerned}… He has both diabetes and hypertension. We both agree we are too old to have sex now. It’s probably these illnesses {laughs}.

Information Needs: Is There Help?

While women were aware that they were in menopause they did not consider that their sexual problems could be related to the menopause. Women had not sought any information nor tried any treatment, and this was linked with the belief that the symptoms were due to aging.

“I don’t think changes in my sex life have anything to do with my cycles stopping.... actually I’m more comfortable now that there is no hassle every month with bleeding and all”….there are no treatments for these kinds of things…are there? No. Really I never talked with anyone about this before…no didn’t try any treatment …actually I did not think of it at all…isn’t it just our age?”. Are there medicines? It’s good if it can be like old times again {laughs} if so, from where can I get treatment?”

Cultural inhibitions and embarrassment were major barriers not to seek information or treatment. Women found it embarrassing to talk about sexual relationships and felt the need of a competent female healthcare provider to discuss their problems.

“I am embarrassed to talk about these things with anyone. I haven’t even told our village midwife about this. Now I am telling you because you are a lady and because you asked…I can tell you, because you can understand these things, I think”.

Avoidance or Tolerance

According to three participants (19%) their spouses were unhappy about the decline in sexual activities and this had resulted in disharmony and arguments. They constructed that the male partner was being unreasonable because of in-adequate awareness on sexual changes during menopause.

“I don’t get feelings anymore. But my husband does. When I don’t be with him he fights with me. He asks me if he should find someone else. I feel very sad when he says so. Then we fight and sleep separately. {sighs} …Now we don’t have much peace at home because of this problem”.

“It’s good if some doctor can explain things and aware my husband because he listens to doctors...I can’t really tell him that I don’t feel like it anymore...anyway he would not accept what I say”

Women sought religion as a source for help because they attributed the sexual problems to unavoidable circumstances in life, such as aging or illness.

“I don’t feel like being with my husband at all. Not even a little bit. It all started after I got diabetes and hypertension last year. I fight with my husband saying I am not well due to my illnesses and ask him to let me be {Sighs}. He is unhappy and cold towards me. I know but I can’t help it. I go to temple to find some peace when it’s all too much for me. You know, it’s the age we should find peace not be behaving like young days”.

Some women felt it was worth being tolerant of partner’s sexual advances since it helped maintain harmony. They constructed sexual intimacy as an essential component in intimate relationships irrespective of their lack of desire to engage in sexual activities.

“I don’t want it but I just tolerate you know for his sake that must happen in a marriage. You know, I don’t want him to be displeased with me”.

Unmet Treatment Needs

Six women (38%) avoided sexual relationships because of vaginal dryness and the associated pain.

“Having relationships with husband is very painful. I feel very dry. It hurts and feels like burning when you know. So, I am not very keen to be with him anymore”.

Women preferred a lower frequency of sexual relationships because of pain.

“Oh. It’s so painful {grimaces}. I wish I didn’t have to do it anymore. I am just enduring it {with gritted teeth} you know. Luckily my husband is a fisherman and he comes home only once a month {looks happy}. So I just let him thinking it’s just once a month.

These women expressed a desire for managing their distressing symptoms and being sexually active.

“I would really love to do something to get rid of the pain. But I don’t know what to do really. Are there actually any treatments? If so I would love to get them. Where should I go? Will you be able to direct me?”

Discussion

To the authors’ knowledge this is the first qualitative study from Sri Lanka that has explored how post-menopausal women with sexual symptoms perceive the changes in sex life, implications of these for help seeking and their unmet needs. During our study, women’s responses to changes in sexual relationships showed a wide variation and ranged from passive acceptance of lack of intimacy to painful struggles to maintain intimacy and relationship harmony. We identified four major themes among the participant women: ‘passive acceptance’ (acceptance that symptoms were due to aging or illness); ‘information needs’ (lack of awareness on sexual problems of menopause and treatment), ‘avoidance or tolerate’, painful intimacy and treatment needs.

Some women’s understanding of sexual problems during menopause during the current study was limited by their lack of awareness on menopause. Most women constructed poor libido and decreased sexual responsiveness during the menopause as results of the natural aging process. Beliefs that they are mature women with grown up children and grandchildren were observed as social reasons for not being intimate with their partners. Presence of co-morbidities changed life circumstances and their partner’s acceptance of the changes in sex life also affected their attitude towards intimacy and all these culminated in the women’s acceptance that they are too old to be sexually active. While this silent acceptance could be regarded as highly culture-specific, similar sentiments have been reported among post-menopausal women from other Asian countries [4]. Interestingly, a survey on European women’s perception of sexuality during menopause has reported that although a significant proportion of women experienced reduced sexual desire, the majority perceived being sexually active as an important component of general wellbeing. In contrast to the Asian context, European women have reported negative impacts on their sense of self-worth because of decreased libido [11].

During the present study ‘avoidance or tolerance’ emerged as a major theme during in depth interviews. Some women reported to tolerate intimacy with partners, describing it as an obligation in a relationship. Avoidance or tolerance occurred due to either lack of sexual desire or pain during intimacy or both. While most studies report heterogeneous sexual activity levels among post-menopausal women ‘sexual disharmony’ is a common theme that has been reported during previous studies on sexuality in menopause as well [12]. The disharmony occurs when there is a difference between sexual relationship expectations of menopausal women and their partners. During the current study women used social reasons to avoid sexual intimacy by spending time away from the partner due to reasons such as occupation, looking after grandchildren, religious commitments etc. Similarly, a study on sexual needs of Iranian menopausal women, has reported women cope with menopause-associated decline in libido by ‘self-sacrifice’ [6].

Despite the above findings, some women do not report any decrease in their desire for sexual intimacy during menopause [13, 14]. Some women who desire sexual intimacy during menopause have attributed poor sexual relationships to their male partner’s health conditions [15]. While illness emerged as a subtheme contributing to poor intimacy, women in our study were not dissatisfied with male partners with regards to lack of sexual intimacy. It is possible that women who participated in our study attributed changes in sexual relationships to their own problems than to their partner’s problems given the paternalistic cultural context. Comorbidities have been reported as a reason for reduced sexual capacity during menopause [16, 17] and we observed that optimal control of co-morbidities and provision of relevant information is an unmet need related to sexual problems of menopause in Sri Lanka at present.

Women who participated in our study had not sought information or treatment for their problems due to poor awareness, embarrassment, or cultural inhibitions. The majority of women expect healthcare professionals themselves to inquire about menopause related problems and they prefer a female healthcare provider [18]. Observations from our study show that sexual health has not been adequately addressed in the Sri Lankan health system through the reproductive health package implemented at present. There is an urgent need for an improved discussion among post-menopausal women and their healthcare practitioners on menopause related sexual changes. While a female healthcare provider such as a field midwife is likely to be more acceptable to Sri Lankan women to discuss their sexual problems in the community, more research is needed to explore how to fill the gap of healthcare seeking and unmet need observed in our study.

Limitation

This study reflects the views of symptomatic post-menopausal women in natural menopause. In the future it would be worthwhile to explore the experiences and views of peri-menopausal women, women who had reached menopause prematurely or due to iatrogenic reasons, partners of menopausal women and their healthcare providers to obtain a more comprehensive understanding of sexual problems during the menopause in Sri Lanka.

Conclusions and Recommendations

Through this study we explored the lived experiences of postmenopausal women reporting sexual problems of menopause in a Medical Officer of Health area in Sri Lanka. We observed that sexual behaviors and help seeking during menopause are influenced by the cultural background that women live in and their level of awareness of availability of reproductive health services. Most postmenopausal women in Sri Lanka seem to passively accept or silently suffer due to differences in sexual desire between male and female partners. Decreased libido and painful intercourse seem to impose a significant negative impact on sexual harmony and satisfaction among some couples. Health-care professionals could help address the unmet needs related to sexual problems of menopause through awareness creation and by delivering a comprehensive reproductive healthcare package, thereby improving sexual wellbeing among women in menopause.

Ethical Approval

This study was approved by The Ethics Review Committee National Institute of Health Sciences, Kalutara, Sri Lanka (approval no. NIHS/ERC/18/75). All participants provided written informed consent prior to enrollment in the study.

Conflicts of Interest

The authors declare no conflicts of interest.

Contribution List

CHR and RF were responsible for design of the study. CHR undertook the data collection, analysis, interpretation and writing of the article. RF and RS critically reviewed and revised the article. We confirm this manuscript has been read and approved by all the authors, the requirements for authorship as stated have been met, and the manuscript represents honest work.

Acknowledgement

We would like to acknowledge the support extended by the Director, National Institute of Health Sciences, Kalutara, and the Medical Officer of Health and Public Health Midwives of Kalutara Medical Officer of Health area, Sri Lanka.

Funding Statement

No external funding was received for this study.

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