Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles, and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or shown [1-3].

Physiological aging in older adult females it is not necessarily the cause of a change in their sexual attitudes. The organic changes, during concomitant illness, is often known to be the causal factor of sexual dysfunction, when present. Psychosocial factors are also very important in determining sexual dysfunction [4].

Sexual intercourse is a complex interaction between two souls that can be realized solely within the overall context of their kinship. It is a union between two masses of different sex acting in a social context in accordance with their physiological and psychological needs [5].

Until recently, sexuality of elderly people was not paid adequate attention in many lands, including Egypt. Although up to 8% of the total population will be elders by 2030, even so most people consider even the idea of sexuality of elderly people as absurd [6].

Hypoactive sexual desire is shaped as a haunting lack of desire for sexual activity and sexual fantasies. Female arousal disorder is a continuing inability to obtain and maintain sexual excitement and genital lubrication. Orgasm disorder is a persistent delay or absence of, orgasm following a normal sexual excitement and stimulation [7].

Finally, sexual pain disorders include dyspareunia, which is defined as recurrent complaints of genital pain associated with sexual intercourse. Vaginismus, a subset of pain disorder, is an involuntary contraction of the perineal muscles when vaginal penetration is attempted [8].

Sexual pain disorders include dyspareunia, which is defined as recurrent complaints of genital pain associated with sexual intercourse. Vaginismus, a subset of pain disorder, is an involuntary contraction of the perineal muscles when vaginal penetration is attempted [9].

There is a widespread tendency to assume that old people are too old for sex. It is difficult for women to conceive later in life (especially of their parents and grandparents) as having sexual feelings, sexual relationships. This attitude is ill-founded and grossly unfair and stems largely from the society's current emphasis on youth and youthful attractiveness [8].

It is a well-established fact that sexual functioning does not depend only on physical factors. The soul or mind plays an equal part in sexual performance. Moreover, sexual behavior is not purely instinctual, but mostly learnt. Hence, it is really important to see that, besides body organs, several others, (including socio-cultural) factors are affected during the sexual act [8].

More women are immediately awaiting to their doctors for advice and guidance about improving their sexual experiences. However, many physicians are reluctant to engage in such treatments due to lack of knowledge, embarrassment, and/or time limitations. Thus, it is important for physicians to acquire the tools to diagnose and care for such problems, and to discern when referral to a sex therapist is indicated [10].

The multitudes, which have enjoyed sex before in life, can and continue to behave so in their old age. Although the ageing process may make it necessary to adapt their love-making to some extent, older people remain capable of intercourse for as long as their general health permits.

The multitudes, who choose to be sexually active in their later years, must understand the bodily changes that are coming about with them, due to the ageing procedure. It should come as no surprise to them to see that sexual anatomy and physiology are also subject to change with age [11].

Human Sex Response Cycle

The traditional model for the human sex response cycle can be represented as desire, arousal, orgasm and resolution [12,13] as illustrated in Figures 1 and 2; any deviation from this is referred to as sexual dysfunction.

Figure 1: The four phases of human sex response cycle.

Figure 2: Kaplan's 3 phase’s human female sex response cycle.

Desire

• Includes fantasies, interest in sex, etc.

• No physical attributes noted during this phase.

Excitement

• Psychological stimulation or physical stimulation or a combination will start out this phase.

• Males erections, testicular enlargement and elevation; Females= breast size increases, nipple erection, vaginal lubrication, the outer third of vaginal constricts, forming orgasmic platform

• In both males and females= respiratory rate increases, heart rate increases, blood pressure elevates.

• This stage can last several minutes to several hours

Orgasm

• Peaking of sexual delight

• Males ejaculation of semen, associated with 4-5 contractions of the prostate, seminal vesicles, vas deferens, and urethra

• Females=3-15 contractions of outer third of the vagina, sustained contractions of the womb

• Both elevated blood pressure, heart rate, respiratory rate, contraction of rectum

• Can last a few seconds to approximately 30 minutes

Resolution

• Disgorgement of genitalia

• If orgasm occurs, the result is rapid; if not, can last 2-6 hours

• Male erection will resolve, in men leads to a fractious period of minutes to hours when cannot reach climax

• Females= resolution of orgasm physiologic changes, no refractory period.

After menopause, a loss of estrogen in women results in significant sexual changes, including [14]:

• Thinning of the vaginal walls

• Decreased or delayed vaginal lubrication, which may contribute to pain during coitus

• Labia atrophy

• The vagina shortens

• The cervix may descend downward into the vagina

• Loss of fat pad over the pubic symphysis may lead to pain from direct pressure over the ivory.

After sexual intercourse is completed, women return to the prearoused stage faster than they would at an earlier age.

• Women with hypoactive sexual desire disorder,

• Female sexual arousal disorder

• Female orgasmic disorder

• Sexual pain disorders

Thither are a number of medical conditions that induce sexual dysfunction among older people, including: Heart Disease, Diabetes, Depression, Breast cancer, HIV/AIDS, the presence of urinary incontinence and Dementia [15].

How important is sex in the overall life?

Many older adults are sexually active. Women are less likely than men to be sexually active. The prevalence of sexual activity declined with age (73% among respondents who were 57 to 64 years of age, 53% among respondents who were 65 to 74 years of age, and 26% among respondents who were 75 to 85 years of age); adult females were significantly less likely than humans of all ages to describe sexual activity. Among respondents who were sexually active, more or less half of both human beings and women reported at least one bothersome sexual problem. The most prevalent sexual problems among women were low desire (43%), difficulty with vaginal lubrication (39%), and inability to climax (34%). A sum of 22% of women reported having talked about sex with a physician since the age of 50 years [16].

The best sex positions for older women

Spooning

Spooning is best-known as the cuddle position and for many, it’s more of a go-to position post-coitally — during which both parties fall asleep. For maximum effect, the male cuddles up to the female are back. She put up either just press back against him and he can penetrate her from the rear or move up a leg and he can enter from an angle. Its doggie style, but with no pressure on knees.

Doggy position

In this very popular spot among other partners, the woman kneels and the man gets across her from the back. This position allows stimulating the G spot and is a very enjoyable one. While this sex position can place considerable pressure on your lower spinal column, it can be great fun to try out. Before the start, one should be certain that both partners don’t have any back issues.

Chair position

In the chair position, the male sits down and the woman faces him, sitting on his circuit. One significant note: The chairman needs to be low enough to the footing that the woman can touch the earth with her feet to steady herself.

Woman-on-top position

These are preferred by older people as the human being does not have to exert himself too much and the woman can assume command. The most common is when the woman TEMPhas to crouch on or lie atop the man while straddling his hips allowing him to penetrate her. This post affords the woman to control and enjoy this position as it helps stimulate the G-spot allowing for greater joy.

Diagnosis of Sexual Dysfunction

Sexual dysfunction in women is a problem that is not well considered. The prevalence of sexual dysfunction among all women is estimated to be between 25% and 63%; the prevalence in postmenopausal women has been yet higher [17,18].

A detailed sexual history (preferably from partners and performs a thorough physical exam. After this, the necessary laboratory investigations are depended upon the contingency. Ask about medications that can cause, interfere with, or worsen sexual dysfunction as: antipsychotics, antiepileptics, antihypertensives, hormonal contraceptives, antidepressants, neurolepic medications, water pills, alcohol, and illicit drug use: marijuana, cocaine, heroin, methadone, antiparkinsonians, anticholinergics, antihistamines, cimetidine and steroids [19].

State-of-the-art diagnostic tools are available today to identify the causative agents. Some of these are:

• Biochemical Tests

• Hormone Assays

• Nerve Conduction Studies

• Ultrasound Scans

• Doppler Studies

• Psychological Assessment Tests

Treatment: The Treatment Strategies Include

• Sex counseling and sex therapy [20].

• Hormone replacement therapy. A figure of choices is available for treating vaginal dryness, including the prescription of topical estrogen cream, to be put on several times a workweek [21]. Testosterone administration in early studies included oral, intramuscular injection, and subcutaneous implants, all of which resulted in increases in sexual desire in postmenopausal women [22].

• Medication: The use of non-hormonal moisturizing gel for treating vaginal dryness.

• Psychosocial factors also significantly impact sexual activity among senior adult females. A comprehensive psychiatric history must be obtained, with extra attention paid to any psychiatric or medical term which may touch on sexual performance (eg, depression, anxiety, substance abuse, menopause, diabetes) [23].

• Surgical (Corrective) therapy. Often painful sex is due to narrowing and shortening of the vagina after surgery or menopause or involuntary tightening of the muscles of the vaginal wall, called “pelvic floor hypertonus.” This is best treated by vaginal dilators and gently stretching the vagina over several months. A well-lubricated dilator of the appropriate size is graded in the vagina several times from 5 to 10 minutes nightly. The size of the dilator is gradually increased until intercourse is once again prosperous. These drills are best conducted by a gynecologist or pelvic floor physical therapist [24].