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target="_blank" rel="nofollow" href="#ulink_2e865b5a-dc80-525e-b85c-6433d917402f">Table 5.1 Therapies for women with vaginal dryness and vulvovaginal atrophy.

Therapy	Formulations	Indication	Comments
Vaginal moisturizers	Topical creams, gels	First‐line for vaginal dryness	For routine use, usually two to three days per week.
Vaginal lubricants	Topical (water‐based, silicone‐based, or oil‐based)	First‐line supplementation for sexual intercourse	For use during sexual intercourse.
Vaginal oestrogen	Vaginal creams, tablets, capsules, or ring	For symptoms that do not respond to moisturizers and lubricants.	Effective for dryness and discomfort, tissue fragility, and dyspareunia. Not indicated in women with oestrogen‐dependent tumours.
Prasterone (vaginal DHEA)	Vaginal suppository	For dyspareunia	Routine daily use. Creates small elevations of estrone, leading to possible concern for use in women with or at risk for oestrogen‐sensitive cancers.
Ospemifene (SERM)	Oral tablet	For moderate to severe dyspareunia and vaginal dryness	For daily use. A reasonable option for women who prefer not to use a vaginal product. Most common side effect is hot flashes.

      DHEA = dehydroepiandrosterone; SERM = selective oestrogen receptor modulator.

Hypoactive sexual desire disorder (HSDD) is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised (DSM‐IV‐TR) as ‘persistent or recurrent deficient (or absent) sexual fantasies and desire for sexual activity that causes marked distress or interpersonal difficulty, and is not better accounted for by other psychiatric disorder, problems in the relationship, or due exclusively to the direct effect of a substance, medication, or general medical condition’.¹¹ In DSM‐V, HSDD was split into male hypoactive sexual desire disorder and female sexual interest/arousal disorder (FSIAD). The change in nomenclature is considered controversial, and the specifics of diagnosis and semantics are not covered in this chapter; instead, we focus on the body of knowledge about HSDD and the underlying issue for patients with complaints of low sexual desire that causes them distress. HSDD is present in 7.4% of women over the age of 65 and is associated with lower health‐related quality of life, less satisfaction with partners, and negative emotional states like unhappiness and disappointment.¹² Risk factors include postmenopausal status, medical illness, and past sexual trauma. Barriers to diagnosis and management include feelings of shame and embarrassment on the part of older women to disclose symptoms, fear that they would not be taken seriously, physicians’ lack of time to assess and manage, and physicians’ low confidence in their ability to treat. Experts recommend that physicians simply ask if their patients have problems or concerns related to sex, using a ubiquity statement such as ‘Many women have concerns about sexual functioning’ followed by a closed‐ended question like, ‘How about you?’¹¹ There are several screening questionnaires, including the Decreased Sexual Desire Screener and Female Sexual Function Index, that can be used to further elicit symptoms. Treatment of HSDD should include evaluating an underlying trigger such as depression, vulvovaginal atrophy, or dyspareunia. A referral to a sexual health counsellor may also help patients.

      Menopause

      Many women associate menstruation with femininity, fertility, and youth, which is in sharp contrast to the symbolism of menopause, which signals biological ageing triggering a new dynamic in self‐identity and sexuality. In the medical literature, the view that menopause is a deficient state is prolific. Some would argue this negative portrayal is a social construct based on the medicalization of menopause and failure to recognize it as a natural life transition.¹³ These debates aside, menopause is an individual experience derived from the interplay of physiological, psychological, and other factors. Natural menopause occurs in women at an average age of 52 years.

      Numerous studies of ageing and menopausal transition demonstrate multiple health‐related changes, alterations to sexual response, and impacts on intimate relationships that lead women to seek support through either traditional or alternative medicine.¹⁴ The major symptoms of menopause are hot flashes and night sweats, also known as vasomotor symptoms (VMS), which occur in approximately 80% of women. The occurrence of VMS coincides with a decrease in endogenous oestrogen and an increase in follicle‐stimulating hormone. Although VMS lasts 7–9 years for most women, some women experience symptoms upwards of 10 years.¹⁵ In an older woman with persistent nocturnal VMS leading to disrupted sleep, it is important to investigate other potential causes for sleep disturbance, such as untreated obstructive sleep apnea.¹⁶

      For many women, behavioural adaptations such as using fans, lowering the room temperature, wearing layered clothing, and avoiding triggers such as spicy food can help alleviate VMS. Hormone therapy, including oestrogen‐only and combined oestrogen‐progesterone therapies, has been shown to be highly effective in reducing hot flashes and night sweats. However, these are associated with increased risks of coronary events, venous thromboembolism, and stroke. There is also a well‐documented increased risk of endometrial cancer among those who take oestrogen‐only hormone therapy.^17,18 Selective serotonin reuptake inhibitors have been associated with some improvement in the severity and frequency of hot flashes, and cognitive behavioural therapy has also been shown to affect menopausal symptoms.^19,20 Reviews of the evidence on exercise, Chinese herbal medicines, and black cohosh have demonstrated insufficient evidence to support their use.^21‐23

Sexuality and the older man

      The most common sexual problems among men are difficulty in achieving or maintaining an erection, lack of interest in sex, climaxing too quickly, anxiety about performance, and inability to climax.⁵

      Erectile dysfunction (ED) is defined as the inability to attain or maintain a penile erection sufficient for sexual performance on at least two‐thirds of occasions. Physiologically, older males take an amount of increased time to develop erection and experience less full erections with a decreased pre‐ejaculatory secretion. During orgasm, there is a decline in expulsive force and urethral contractions. Following ejaculation, there is a rapid tumescence with rapid testicular descent. The refractory period is markedly prolonged compared to younger men.²⁴

      An international study demonstrated the prevalence of ED in men aged 70–75 to be 37%.²⁵ Risk factors include heart disease, hypertension, hyperlipidaemia, tobacco use, obesity, and diabetes. Other contributors to ED include medication side effects (antihypertensives, antidepressants, and antipsychotics), neurological disorders, and benign prostatic hypertrophy.²⁶ Physicians can screen for ED using a validated questionnaire such as the Erection Hardness Score, Sexual Health Inventory for Men, and International Index of Erectile Function. Testosterone evaluation may be considered and is discussed in more detail later in the chapter.

      First‐line treatments for erectile dysfunction are phosphodiesterase‐5 (PDE‐5) inhibitors such as sildenafil, tadalafil, vardenafil, and avanafil, which increase erection hardness and duration. The major side effects of PDE‐5 inhibitors are headache, flushing, dyspepsia, rhinitis, visual disturbances, hypotension, and death. People on nitrates should avoid using PDE‐5 inhibitors and nitrates within 24 hours of each other due to the risk of severe hypotension, and men who are on PDE‐5 inhibitors for pulmonary

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