Gerontol Geriatr Res. 2017; 3(1): 1027.
School of Nursing, California State University, USA
*Corresponding author: Paola Castillo Gomez, School of Nursing, California State University, 5151 State University Drive, Los Angeles, USA
Received: March 02, 2017; Accepted: March 30, 2017; Published: April 05, 2017
Hispanic geriatric woman sexuality and libido are affected by hormonal imbalances; for example, low estrogen level causes physiological concerns such as, vaginal atrophy and vaginal dryness, among other symptoms. Also, comorbidities, such as diabetes, vascular diseases, hypertension, and hyperlipidemia are common diseases in the Hispanic menopausal woman. Another important aspect affecting libido is the psychological issue the Hispanic geriatric women population suffers, including depression, anxiety, or partner’s pressure for intercourse. In addition to physiological and psychological issues, medications’ side effects can also decrease the woman’s libido. Healthy lifestyles as well as controversial treatments have been shown to improve geriatric women sexual dysfunction and decreased libido.
Keywords: Depression; Geriatric women sexual dysfunction; Low libido; Menopause; Vaginal dryness; Hormonal imbalance
HTN: Hypertension; HRT: Hormone Replacement Therapy; MHT: Menopausal Hormone Therapy; BMI: Body Mass Index; DM: Diabetes Mellitus; PHQ9: Patient Health Questionnaire; GDS: Geriatric Depression Scale
Commonly, in all races the number of ageing woman is increasing. This is directly associated with life expectancy due to innovative treatments and the modern lifestyle. Ageing women usually out number older men; however, their sexuality and libido at menopause is still a taboo in the 21st century society. According to Bauer et al., it is clear that sexuality is an important component of quality of life for many older people and can be just as fulfilling as it is for younger people . Geriatric women sexual dysfunction is a symptom that a majority of geriatric women 65 years old or older complains about it in the outpatient setting. According to Abernethy et al., the prevalence of sexual dysfunction in postmenopausal women is even higher, with rates between 68% and 86.5% . Some women express their menopausal symptoms as vaginal dryness, low or not sexual desire, depression, anger, and/or anxiety due to partner pressure for intercourse.
This case study is based in a geriatric Hispanic woman suffering menopausal symptoms. It would cover physical factors such as, vaginal dryness and psychological factors corresponding to depression affecting women geriatric population. According to Watters et al., being able to remain sexually active often indicates greater self-worth, prevents social disengagement and avoids depression . Vaginal dryness and depression cause geriatric women sexual dysfunction. In addition to the mentioned causes, there are many other factors that can affect the changes in sexual desires in this population. For instance, socio-cultural factors, stress, traumas, and medications adverse effects are some reasons of women decrease libido. Attitudes toward sex are a cause of social and sexual experiences .
A 66 years old woman is experiencing signs and symptoms of post menopause, such as, feeling sad, vaginal dryness, and decreased libido. She finds literature about her symptoms. She stated that her primary physician has tried to adjust medication doses for her sadness. Her healthcare provider had try either Prozac or Paxil multiple times, but failing to help with her sadness and decreasing her libido even more. As a clinician, what should you tell this patient?
Geriatric woman, 65 years old and older go through a roller coaster of hormones and emotions, especially when reaching menopause. A lot of times, they are unable to express their feelings due to cultural and psychosocial limitations.
Menopause is one whole year without menses. As the women ages the sexuality change. According to Maciel et al., aging is a physiological, psychological, and social transition that typically affects sexuality . Moreover, other factors like genetics, alcohol intake, tobacco use, physical inactivity, and a diet rich in high fat, cholesterol, and sodium can affect women’s immune system. The declining ovarian function may cause women to experience a wide spectrum of menopausal symptoms that vary in severity and duration . Menopause generally includes symptoms related to estrogen deficiency that is associated with hot flashes, sweating, insomnia, vaginal dryness and discomfort in up to 85% of menopausal women .
The menopause indicators can vary from woman to woman, some experiencing physical symptoms and others psychological symptoms or both. According to Hunter et al., the experience of the menopause and menopausal symptoms differs widely around the world .
Low libido also known as hypoactive sexual disorder is a decrease sex drive  that can be related to hormonal levels. Hormones can affect the physical and the psychological aspects of the woman’s life and her interaction with medications. According to Thase et al., a growing body of research indicates that a woman’s hormonal status may influence response to different forms of antidepressant medication .
Healthcare practitioner initial evaluation may aid to diagnose and treat decrease libido in the menopausal women’s population with a holistic approach. A comprehensive history and physical, cognitive evaluation, and depression screening should be performed to obtain a baseline for the menopausal symptoms.
In the history and physical the healthcare provider should carefully assess complications of menopause related to obesity, coronary artery diseases, renal, endocrine, vascular, and chemicaldrugs induced Hypertension (HTN). Also, a cardiovascular risk assessment using the Framingham Risk Score should be completed every 3 to 5 years. Documentation of patients’ blood pressure, weight, height, Body Mass Index (BMI), as well as waist circumference has to be written in the patient’s chart and needs to be controlled as women goes through menopause.
Menopausal women libido varies due to hormonal imbalances in addition to concomitant physical diseases, such as, HTN, thyroid dysfunction, Diabetes Mellitus (DM), kidney disease, heart disease , and peripheral vascular diseases. Concomitant diseases can alter menopausal symptoms. The Women’s Health Questionnaire (WHQ) is widely used to measure perceptions of physical and emotional symptoms in the evaluation of interventions for menopausal .
Furthermore, psychological issues, such as, depression, anxiety, cognitive decline or isolation affects the libido of the geriatric women. According to Berent-Spillson et al., cognitive decline is prevalent in aging populations, and cognitive complaints are common during menopause .
The healthcare provider needs to assess the woman using a cultural approach. Usually, Hispanics geriatric women do not disclose what challenges are affecting their libido, they just say, “I feel sad”. The healthcare practitioner should perform a depression screening using tools such as, the Patient Health Questionnaire (PHQ9), or the Geriatric Depression Scale (GDS). According to Aakhus et al., clinical practice guidelines for the management of depression are available for primary and specialist healthcare in many countries .
In the absence of the appropriate assessment of the woman’s inside, it is almost impossible to determine the actual woman’s issues, the physiological and psychological changes they are suffering in solitude. Sadness in the Hispanic geriatric women is a growing issue that in multiple occasions is labeled and treated by healthcare practitioners as depression without the appropriate saliva or blood test for hormonal levels. According to Jensen et al., depression is often cited as the most frequent cause of decreased sexual desire .
Additionally, include a medication list in the comprehensive history taking into consideration adverse effects that could cause sexual dysfunction. Medications for blood pressure can delay or prevent orgasm, as well as, antidepressants, particularly SSRIs . For the healthcare provider taking care of the menopausal woman, the North American Menopause society has developed educational materials, which address each of the specific competencies required (www.menopause.org) .
Healthcare providers should take into consideration modifiable risk factors such as medications, stress, and a sedentary lifestyle for the menopausal woman that can directly affect libido. Predisposing risk factors for menopausal symptoms should be assessed and manage, in order to prevent further complications, such as sexual dysfunction.
Treatment should be started slowly, providing the patient with information about the side effects of the medications and what to do if symptoms do not get better.
Cyclic or continuous progesterone therapy in conjunction with estrogen if the woman has an intact uterus can be recommended. Given the limited discussion about risks more information is needed for healthcare consumers regarding both the benefits and risks of these pharmaceutical products for the treatment of menopause .
Osteoporosis screening is significant important in the Hispanic menopausal woman. Various medications have proven efficacy in treating postmenopausal osteoporosis; however, potential adverse effects such as hypocalcaemia, worsening of renal impairment, and osteonecrosis of the jaw must be considered . For the dyspaneuria provide lubricants due to vaginal dryness and vaginal atrophy.
- Healthcare providers should assess the benefit-versusrisk of Menopausal Hormone Therapy (MHT) profile, including a multiple organ approach.
- Limiting the duration of HRT, prescribing a low-dose regimen, and using a patch rather than oral therapy can help to minimize the risk.
- The dose of MHT may be reduced with advancing age.
- Venlafaxine, desvenlafaxine, and paroxetine have been shown to provide the best vasomotor symptom relief, with symptom reduction of 67% vs. 15% with placebo.
- The use of the transdermal route of estrogen administration should be considered in order to avoid the hepatic first-pass effect.
Through an active lifestyle and incorporating a nonpharmacologic approach, menopausal symptoms can diminish their severity. According to Sathyanarayana et al., in elderly females, arousal disorder is the most prevalent female sexual dysfunction .
According to the menopause management resource guide recommendations :
- Educate the overweight patient about the importance of losing weight, eating low salt and low carbohydrates diet, and the use of sugar substitutes.
- Exercise at least 40 minutes minimum three times per week.
- Herbal remedies for menopause symptoms not only lack clear evidence that they actually work, but may hold health risks .
- Increased vegetable, fiber, and fruit consumption during the day.
- Decrease stress by practicing meditation, guided image or respiratory techniques.
- Stop smoking.
- Limit or quit alcohol intake to no more than one drink a day for women.
- Teach the patient that interruption of prescribed treatment can lead to the symptoms return.
- Patient is encouraged to bring the symptoms’ journal to follow up visit with the healthcare provider.
- Give patient information regarding treatment, diagnosis, and when to follow up. According to Toglia et al., as our society ages, demands for gynecologic surgery in elderly women will increase .
- Provide the patient with educational material taking in to consideration patient’s culture.
Healthcare providers need to encourage the Hispanic geriatric woman to make lifestyle management in the hope of diminishing menopausal symptoms.
Unfortunately, not much literature has been written to c o v e r the issue of geriatric women sexuality physiological and psychological challenges affecting libido that keeps affecting thousands of women in our communities. An informal therapy for patients’ sadness is to treat women’s patients with antidepressants. Without performing a detail history and physical, hormone’s labs, decodification of the woman’s feelings, or referring the patient to a psychologist or sexualtherapist, the healthcare practitioner has not enough information to correctly diagnose and treat the patient. Before proceeding to add antidepressant medications, a healthy lifestyle needs to be implemented in the hope of controlling the geriatric women sexuality challenges affecting libido.
- Bauer M, McAuliffe L, Nay R, Chenco C. Sexuality in Older Adults: Effect of an Education Intervention on Attitudes and Beliefs of Residential Aged Care Staff. Educational Gerontology. 2013; 39: 82-91.
- Abernethy, K. Making sense of hormone replacement therapy. Nurse Prescribing. 2015; 13: 452-456.
- Watters Y, Boyd T. Sexuality in later life: opportunity for reflections for healthcare providers. Sexual & -Relationship Therapy. 2009; 24: 307-315.
- Waite L, Laumann E, Das A, Schumm L. Sexuality: measures of partnerships, practices, attitudes, and problems in the National Social Life, Health, and Aging Study. Journals of Gerontology Series B: Psychological Sciences & Social Sciences. 2009; 64: i56-66.
- Maciel M, Laganà L. Older women's sexual desire problems: biopsychosocial factors impacting them and barriers to their clinical assessment. Biomed Research International. 2014.
- Carroll N. A review of transdermal nonpatch estrogen therapy for the management of menopausal symptoms. Journal of Women's Health. 2010; 19: 47-55.
- Slavin MN, Farmer S, Earleywine M. Expectancy mediated effects of marijuana on menopause symptoms. Addiction Research & Theory. 2016; 24: 322-329.
- Hunter M, Gupta P, Chedraui P, Blümel J, Tserotas K, Sturdee D, et al. The International Menopause Study of Climate, Altitude, Temperature (IMS-CAT) and vasomotor symptoms. Climacteric. 2013; 16: 8-16.
- Kalra G, Subramanyam A, Pinto C. Sexuality: Desire, activity and intimacy in the elderly. Indian Journal of Psychiatry. 2011; 53: 300-306.
- Thase M, Entsuah R, Cantillon M, Kornstein S. Relative antidepressant efficacy of venlafaxine and SSRIs: sex-age interactions. Journal of Women's Health. 2005; 14: 609-616.
- Morris M Gelfand. Journal of Women's Health & Gender-Based Medicine. 2004; 9: 15-20.
- Locklear T, Huang Y, Frasor J, Doyle B, Perez A, Gomez-Laurito J, et al. Estrogenic and progestagenic effects of extracts of Justicia pectoralis Jacq., an herbal medicine from Costa Rica used for the treatment of menopause and PMS. Maturitas. 2010; 66: 315-322.
- Berent-Spillson A, Persad C, Love T, Sowers M, Randolph J, Smith Y, et al. Hormonal environment affects cognition independent of age during the menopause transition. Journal of Clinical Endocrinology & Metabolism. 2012; 97: E1686-1694.
- Aakhus E, Granlund I, Odgaard-Jensen J, Oxman A, Flottorp S. A tailored intervention to implement guideline recommendations for elderly patients with depression in primary care: a pragmatic cluster randomised trial. Implementation Science. 2016; 111-115.
- Jensen K. Revive your sex drive: low libido: causes and cures. Alive: Canada's Natural Health & Wellness Magazine. 2005; 273: 36-37.
- Yes, you can have better sex in midlife and in the years beyond. Harvard Women's Health Watch. 2017; 24: 4-5.
- Santen R, Stuenkel C, Burger H, Manson J. Competency in Menopause Management: Whither Goest the Internist?. Journal of Women's Health. 2014; 23: 281-285.
- Charbonneau DH. An analysis of benefits and risk information on pharmaceutical web sites for the treatment of menopause. Health Information & Libraries Journal. 2013; 30: 212-219.
- Sanders S, Geraci S. Osteoporosis in postmenopausal women: considerations in prevention and treatment: (women's health series). Southern Medical Journal. 2013; 106: 698-706.
- Dickson G. Menopause management: how you can do better. Journal of Family Practice. 2012; 61: 138-145.
- Sathyanarayana Rao TS, Ismail S, Darshan MS, Tandon A. Sexual disorders among elderly: An epidemiological study in south Indian rural population. Indian Journal of Psychiatry. 2015; 57: 236-241.
- Menopause management resource guide. Practice Nurse. 2007; 34: 26-27.
- Scant Evidence, Some Risk for Herbal Menopause Treatments. Tufts University Health & Nutrition Letter. 2009; 27: 3.
- Toglia M, Nolan T. Morbidity and mortality rates of elective gynecologic surgery in the elderly woman...includes discussion by Toglia MR. American Journal Of Obstetrics & Gynecology. 2003; 189: 1584-1589.