Increasing our understanding of women's sexuality at midlife and beyond.

A lthough the sex life of Samantha Jones as she enters her fifth decade in BSex in the City[ may not be typical of midlife sexuality in the United States, sex remains an important part of women’s lives beyond menopause. Findings of the National Social Life, Health, and Aging Project have greatly increased our understanding of the sex lives of older Americans. In a national probability sample of 1,500 women, aged 57 to 85 years, a decline in sexual activity with age was observed. Partnered activity in the past year was reported in 62% of women aged 57 to 64 years, 39% of women aged 65 to 74 years, and 17% of women aged 75 to 85 years. The impact of age on the availability of a spouse or other intimate partner was significant. Among sexually active women in all age groups, greater than 50% reported activity at least two to three times per month, and among active women in the oldest age group, 23% reported sex once a week or more. Most women regarded sexuality as an important part of life. This study also confirmed that sexual problems are common in older Americans, with about half of both men and women reporting at least one bothersome sexual problem. Among women, the most prevalent problems were low desire (43%), difficulty with vaginal lubrication (39%), and inability to climax (34%). Women who rated their health as being fair or poor had a higher prevalence of sexual problems, and physical health was more strongly associated with sexual problems than was age alone. Despite the high prevalence of sexual problems, only 22% of women reported having had a discussion with a physician about sex since the women turned 50 years of age. A greater understanding of the impact of age on the prevalence and predictors of sexual problems in women resulted from a representative survey of 50,000 US households, including approximately 31,000 women 18 years or older. Sexual problems were common (43%), but sexual problems associated with distress were much less prevalent, occurring in 12% of all women. Although sexual problems were greatest in older women, distressing sexual problems were least prevalent in this age group. Distressing sexual problems were more common in midlife women, aged 45 to 64 years, than in younger or older women. Correlates of distressing sexual problems included poor self-assessed health, low education level, depression, anxiety, and urinary incontinence. Interestingly, only about a third of women with a distressing sexual problem sought formal care; about 80% of the time, the woman, rather than the physician, initiated the conversation. Factors related to help seeking were having a current partner and interacting with the healthcare system. Barriers were poor self-perceived health and embarrassment about discussing sexual topics with a physician. Independent of aging, the impact of the menopausal transition on female sexuality is of great interest. This was assessed in the Study of Women’s Health Across the Nation (SWAN), a longitudinal cohort study including approximately 3,000 ethnically diverse women aged 42 to 52 years who were premenopausal or early perimenopausal at baseline. In the baseline cohort, variables having the greatest association across all sexual function outcomes were relationship factors, the perceived importance of sex, attitudes toward aging, and vaginal dryness. In an analysis of longitudinal sexual function data from SWAN, 78% of women were sexually active at baseline and 71% were active at the annual follow-up study visit 6 years later. Lack of a partner was the primary reason stated by women for not being sexually active. The menopausal transition was related to increased pain with intercourse and decreased sexual desire, frequency, and arousal. Worse sexual functioning was associated with vaginal dryness, depression, anxiety, poor health, and loss of a relationship. Hot flashes were not related to any sexual function outcome. In cross-sectional data from the study, Do Stage Transitions Result in Detectable Effects (STRIDE), which examined the impact of menopause on health-related quality of life, 68% of women aged 41 to 68 years reported partnered sexual activity during the past 6 months. Sexually active women were more likely to be younger, married, and more educated and to have more social support. They had fewer comorbid medical illnesses, lower body mass index, and a higher prevalence of vaginal dryness. The principal reason for sexual inactivity was lack of a partner. Enhanced sexual engagement and enjoyment were associated with being physically active, having more social support, and lacking sleeping difficulties and vaginal dryness. A relationship between vaginal dryness and sexual problems is seen in most studies of midlife sexuality. In the Menopause Epidemiology Study, a population-based study of US women aged 40 to 65 years, among approximately 1,500 sexually active postmenopausal women, those with sexual dysfunction as defined by a validated questionnaire were 3.8 times more likely to have symptoms of vulvovaginal atrophy than were