Female Sexuality and Vaginal Health Across the Menopausal Age

Angelo Cagnacci, MD, PhD; Martina Venier, MD; Anjeza Xholli, MD; Chiara Paglietti, MD; Salvatore Caruso, MD


Menopause. 2020;27(1):14-19. 

In This Article

Abstract and Introduction


Objective: The primary aim was to evaluate changes in female sexuality across the menopausal period, and the secondary objective was to test the associations of female sexuality domains with vaginal atrophy and its symptoms.

Methods: A cross-sectional multicenter study was performed involving 518 women, 40 to 55 years of age, consulting outpatient gynecological services at 30 centers across Italy. Vaginal atrophy was identified by the contemporaneous presence of a pH >5, subjective vaginal dryness, and an objective sign. The relationships between vaginal atrophy and its main symptoms (vaginal dryness and dyspareunia), and Female Sexual Function Index (FSFI) score and its domains (desire, arousal, orgasm, dyspareunia, lubrication, and sexual satisfaction) were analyzed.

Results: The prevalence of sexual dysfunction, as defined by a FSFI score <26.55, was 70.6%, increasing from 55% in the years 40 to 45, to 82.8% (P < 0.01) in the years 52 to 55 of age. Mean FSFI score decreased from 40 to 45, to 46 to 48 years of age (23.13 ± 9.76 vs 19.49 ± 9.88; P < 0.05), and from 48 to 51, to 52 to 55 years of age (21.3 ± 8.06 to 17.59 ± 9.11; P < 0.01). Independent determinants of FSFI were age, vaginal atrophy, and the presence of vaginal dryness and dyspareunia (R2 0.208; P = 0.011). FSFI score was independently correlated (R2 0.116) with weight (CR −0.067; 95% confidence interval [CI] −0.126, −0.006; P < 0.032), menopausal status (CR −2.406; 95% CI −4.180, −0.63; P < 0.008), and vaginal dryness (CR −5.647; 95% CI −7.677, −3.618; P < 0.0001). Vaginal dryness was the only variable correlated independently with each FSFI domain, including desire (also correlated with menopausal status), arousal (with age and menopausal status), lubrication (with age), orgasm (with age), satisfaction (with vaginal atrophy and being an ex-smoker), and dyspareunia (with age and spontaneously referred dyspareunia).

Conclusions: In the perimenopausal years, FSFI score decreases and sexual dysfunction increases by about 30%. Vaginal dryness is the symptom of vaginal atrophy most closely related to all domains of female sexuality.


There are various factors involved in female sexual health, including desire, arousal, satisfaction, lubrication, orgasm, and dyspareunia. Conditions that affect one or more of these domains may induce female sexual dysfunction (FSD). However, as the definition and diagnostic criteria of FSD are still being debated, its prevalence in postmenopausal women is still unclear, and figures between 35.9% and 86.5% have been reported in different countries.[1–6]

Factors negatively impacting sexual function are mental and emotional status, aging, chronic medical problems, metabolic syndrome and its components, and menopausal status.[3,7–12] Endocrinological changes during the menopause induce climacteric symptoms and biological modifications leading to vaginal atrophy (VA). The intensity of menopausal symptoms[13,14] and VA are associated with sexual dysfunction.[15,16]

Although only limited data are available for perimenopausal women, evidence indicates that sexual dysfunction increases during this period of life.[12,17,18] Indeed, risk factors for sexual dysfunction such as climacteric symptoms[19] and VA[20] are known to increase in this period. Interestingly, the rise in isolated but bothersome symptoms of VA such as vaginal dryness or dyspareunia is much more prevalent than VA in women undergoing the menopause transition.[20] However, whether it is these symptoms or VA itself that has a greater effect on sexual function and its different aspects[21] is still unclear, and we set out to investigate this issue in women undergoing the menopause transition. The primary aim was to evaluate changes in female sexuality across the menopausal period, and the secondary objective was to test the association of female sexuality with vaginal atrophy and its symptoms.