Many women over the age of 75 are reported to have received little or no formal health education, particularly sex education (Langer, 2009). They grew up at a time when sexual behaviour was not discussed and sexual feelings and inquiry were suppressed. It was not until the 1960s that formal sex education for young people was widespread as Langer (2009) explained that:
‘Even the most liberated knew little of the facts of life and most held to strong superstitions.’
Women over the age of 75 have experienced huge changes in gendered activities and technological and medical innovations in their lives, including contraception. These developments have resulted in the increasing independence of women and changes in the role of marriage and sexual activity, and have had a particular impact on sexual expression in older age. Divorce in later life, remarriage rates and sexual relationships outside of marriage are also steadily increasing (Brown and Wright, 2017). Previously, older women may have felt compelled to remain in unsatisfactory relationships due to social mores. Gott (2006) explained that later-life divorces and remarriage rates have been steadily increasing.
As a consequence, older women can often hold beliefs about their own bodies that have been formed without sound biological or psychological understanding. These beliefs can impact on both health-seeking behaviours and quality of life. In order for nurses to support older women and address their genital health needs, it is helpful to establish some of the normal processes of sexual ageing before any discussion about pathological changes and recommendations for practice.
Normal sexual ageing process
Discussion of sexual activity and genital health in older age is frequently avoided by health professionals (Watters and Boyd, 2009). Failure to discuss the effects of normal ageing on sexual activity and genital health can lead to myths and misunderstanding being perpetuated by older women and the wider community. The extent and timing of genital ageing varies widely, but there is some commonality of changes that occur during the life course.
Weeks (2002) explained that testosterone supports the libido in both men and women and is produced by both the testes and ovaries. It is important to note that for several years after the menopause the ovaries also supply small amounts of testosterone as well as oestrogen and androstenedione (Mueller, 1997), which can support libido. The physical changes most frequently commented on in relation to the female body is the menopause and the resultant decline in oestrogen production and its implications for urogenital ageing (Naumova and Castelo-Branco, 2018). Urogenital ageing is particularly associated with vaginal dryness and atrophy, with the consequences for individuals ranging from none to severe. Naumova and Castelo-Branco (2018) state that 50-60% of postmenopausal women will develop urogenital atrophy. Symptoms can include vulval pain, dyspareunia (painful sexual intercourse) and itching (Zeiss and Kasl-Godley, 2001). In addition, there may be reduced lubrication (Skultety, 2007) associated with sexual arousal and a reduction in vaginal blood flow and engorgement. Lack of oestrogen is also associated with alterations to the vaginal pH, which becomes more alkaline, and the increased risk of urinary tract and vaginal infections. In addition, certain vulva conditions are more prevalent in peri- and postmenopausal women—atrophied genital tissue may be more vulnerable to pH changes and enzymatic action, and skin healing may be impaired (Pinelli et al, 2013).
In summary, physiological sexual changes occur in women in older age and these may impact on their previous choice of sexual activity; however, such changes do not necessarily result in an inability to maintain sexual activity or even coitus. However, Gott (2003) emphasised that older people are not a homogenous group and they do not necessarily hold similar views and experiences. DeLamater (2012) explained that, although it is clear that normal ageing does cause physical changes, those changes do not necessarily result in a decline in sexual functioning. Being physical healthy is shown to result in older women remaining sexually active (DeLamater, 2012).
Discussion
Health professionals are often reluctant to discuss sexual activity with older women (Gott and Hinchliff, 2003); however, the health implications of not doing so are becoming more apparent. Both older heterosexual and homosexual couples have increasing opportunities to maintain and develop their partnered sexual activity with the advent of drugs such as sildenafil (Viagra) to treat male sexual dysfunction. Access to internet dating sites also provides the opportunity to meet other partners. As a result the rates of sexually transmitted infections (STIs) in older adults is rising and older women may not recognise that they are or have been at risk of an STI (Benjamin Rose Institute on Aging, 2019). They are less likely to be consistent or confident condom users as sexual health messages and safer sex campaigns are frequently targeted at younger women, often with concerns about unplanned pregnancy. However, older women may have concerns related to normal genital ageing and, indeed, some may misinterpret the signs of age progression, such as vaginal soreness and irregular bleeding or a vulval skin condition, as the signs and symptoms of STIs.
Vulval skin conditions
The prevalence of vulval skin conditions is likely to be underestimated, as many women delay seeking medical advice and self-treat because of embarrassment or concerns about a possible infectious or malignant cause for their condition (Lawton, 2016). As a result, many women of all ages live with their symptoms and the impact these have on their lives for a number of years, with time frames ranging from 2 months to 40 years (Bellman, 1998), 5 to 10 years (Wojnarowska et al, 1997) and 18 months to 11 years (Lawton and Littlewood, 2013) before they receive a definitive diagnosis and treatment plan. Symptoms include intractable itching, soreness, burning, discomfort, dysuria, dyspareunia), and pain on defaecation, which affect a woman's physical functioning, and affect everyday activities such as walking, sitting, relaxing, and sleeping, as well as causing pain during a range of sexual and nonsexual contact that impacts on their social, psychosexual and psychological wellbeing (Lawton and Littlewood, 2013).
In 2015, in a survey of 325 women (the age range was not specified), 89% reported that their vulval condition had negatively affected their emotional and mental wellbeing and 22% said their condition had led to thoughts of self-harm or suicide (British Association of Dermatologists (BAD), 2015). A further 70% reported a change in the way in which they viewed themselves: embarrassment, feeling ‘less feminine’ and feeling ‘abnormal’ were frequently mentioned. A large proportion of the women surveyed found that their vulval condition affected their sexual life, with 86% reporting that their condition had affected their libido, and 84% that engaging in sexual activity was difficult, unpleasant or impossible (BAD, 2015).
Specific issues associated with vulval skin conditions
For women of all ages, there are many conditions affecting the genital area and some can change the normal architecture and appearance of the vulva (Table 1). However, as alluded to earlier, older people may not have received appropriate sex education or even discussed the function and anatomy of the vulva, so when things start to change or feel different many women either ignore or self-treat rather than seeking a diagnosis and advice to manage their symptoms appropriately. Self-treatment often involves buying over-the-counter treatments or products marketed for women's health, such as wipes, washes, antifungal products, barrier and continence products, which have the potential to cause more irritation to an undiagnosed vulval skin condition. For women with lichen sclerosus and other skin conditions, sexual difficulties and dyspareunia may be attributed to the sensitive and delicate skin, which easily tears and splits (often described as feeling similar to paper cuts), the fear of pain lowers arousal, decreases lubrication and causes the pelvic muscles to contract (Lawton and Littlewood, 2013). In lichen sclerosus the anatomical changes and introital stenosis may make intercourse painful or give rise to problems with achieving orgasms (Van de Nieuwenhof et al, 2010). Vulvodynia (vulval pain or burning) may be the main presenting symptom and women presenting with vulval pain and/or a vulval skin condition should be referred appropriately for assessment, diagnosis and a management plan. Bornstein et al (2016) suggested the following classifications for vulval pain:
| Condition | Symptoms | Signs |
|---|---|---|
| Vulval lichen sclerosus | Vulval Itch, soreness |
Pale, white atrophic areas affecting the vulva |
| Vulval lichen planus | Vulval Itch/irritation, soreness |
Erosive vulval lichen planus is the most common subtype to cause vulval symptoms. The mucosal surfaces are eroded. It is important to recognise the vaginal lesions in erosive lichen planus early and start treatment as they can lead to scarring and complete stenosis. There are other types less commonly seen |
| Vulval eczema | Vulval itch, soreness |
Erythema, lichenification, excoriations and fissuring |
| Vulval psoriasis | Vulval itch, soreness |
Well demarcated brightly erythematous plaques, often symmetrical |
Vulvar pain caused by a specific disorder
Vulvodynia: vulvar pain of at least 3 months' duration, without clear identifiable cause
Such vulvar pain may have some potential associated factors. The following are the descriptors:
Today there are many online sources of information for patients and health professionals (see Box 1).
Conclusions
Older women are less likely to seek clinical help and may be experiencing genital symptoms which should be discussed and assessed in more depth to identify if this is normal or if there is an underlying vulval issue such as vulva pain or a vulval skin condition. All too frequently their symptoms are dismissed by health professionals and the women themselves, blaming normal ageing. As a result, this can have a huge impact on their quality of life and emotional, mental and physical wellbeing. Nurses are well placed to make a difference for older women and the following recommendations should be considered