Published on 8 May 2022

    Hormone-related changes during menopause can cause female sexual dysfunction – but awareness remains low. A new study aims to shed light on this elusive topic, including its symptoms and therapies.

    At 54 years old, menopause was on the horizon for Miss A. 

    For the past three or four years, she’d been getting hot flushes and mood swings: symptoms indicative of perimenopause (when the body starts to transition to menopause). It’d been uncomfortable, but still bearable.

    But then her symptoms began to worsen. She experienced increasing vaginal dryness, which made sex with her partner painful and difficult. Urinary tract infections became commonplace. 

    “And then I realised that the people around me of the same age…not many were open or candid about it. Not many of them wanted to talk about what they were going through,” she said. “I think most people were embarrassed to talk about it, obviously, it’s a private matter…so I couldn't get much input or help from them.”

    Finally, she decided to ask her doctor about her symptoms. That’s when she realised they were connected with her perimenopause.

    “So I started reading the literature on it,” she shared. However, she found that information was scarce, although plenty of women were – like herself – looking for answers on the internet.

    Miss A isn’t the only one who shares such sentiments. “Female sexual function [of menopausal women] is underreported, under-treated, and under-studied,” said Dr Susan Logan, Senior Consultant at the National University Hospital’s (NUH) Department of Obstetrics and Gynaecology

    Globally, studies on sexual function tend to be broad and Caucasian-centric. There is a major American study, called the Study of Women’s Health Across the Nation (SWAN), that focuses on the sexual function of multi-ethnic middle-aged women – but while fairly comprehensive, the study still had very little in the way of Asian representation, said Dr Logan. 

    And in Singapore itself, most studies are review articles, and very few actually focus on the local population, she added. 

    “So we don’t know a lot about [the topic], due to sensitivities, and Asian values…and issues may be rarely raised by women,” she said. 

    Opening discourse about sex

    It was in 2012 when Dr Logan left her successful career in Aberdeen, Scotland, to work as a gynaecologist at NUH. 

    Before long, she realised that information regarding ‘normal’ sex was scarce here, particularly during the menopause years. This, she thought, was a problem. 

    “Sex is important,” she summarised. “Menopause…can leave couples at a loss when they perhaps wish to continue physical closeness. This can lead to relationship issues and can affect self-esteem.”

    Her passion for this topic eventually led her to join the NUHS Integrated Women’s Health Programme (IWHP), led by Professor Yong Eu Leong, Emeritus Consultant at NUH’s Department of Obstetrics and Gynaecology

    The IWHP was conceptualised as a study on midlife health issues in Singapore women, with a focus on menopausal health issues. That was all very well and good, but Dr Logan wanted more. “I just said to [Prof Yong], can we ask the ladies about sex?” she quipped. “And he was open enough, and brave enough, to say yes.”

    Altogether, the study recruited over 1200 women aged between 45 and 69. All participants were well (that is to say, without cancer or severe health conditions). 

    The women underwent a thorough assessment: they took questionnaires, had their measurements taken, and underwent a body composition scan. They were also asked questions about their sexual function.

    Due to the sensitivity of the subject, all participants were given the option to refuse to complete the study or to complete just part of it. 

    “Unexpected” findings

    Despite having free rein to opt-out, around 90% of the participants elected to attempt the FSFI. The mean age of the cohort was 56.3 years, and most were post-menopausal.

    The study found that while the majority of women were sexually active in the past four weeks, an even higher majority were scored as likely to be experiencing female sexual dysfunction. “So the recently sexually active form the majority, but with high levels of female sexual dysfunction,” said Dr Logan.

    Female Sexual Dysfunction IN CONSULTATION WITH DR SUSAN LOGAN, SENIOR CONSULTANT, DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY, NATIONAL UNIVERSITY HOSPITAL (NUH) AND PROFESSOR YONG EU LEONG, EMERITUS CONSULTANT, DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY, NATIONAL UNIVERSITY HOSPITAL (NUH) Who were the participants? Factors linked with sexual inactivity Unmarried Underweight (BMI <18.5) Older age Mean age: 56.3 yearsMean menopausal age:49.7 years 90.4 % 57 % of participants attempted the FSFI sexually active in past 4 weeks 70 % likely to experienceFemale Sexual Dysfunction (FSD) ••••••••••••••••••••••••••••• •••••••••••••••••••••••••••• ••••••••••••••••••••••• 6 % Malay 10 % Indian 84 % Chinese Interestingly, being underweight (defined as having a Body Mass Index value of less than 18.5) was also linked with sexual inactivity – “a novel finding [which] hadn’t been reported before”. This could be because being underweight tends to be associated with poorer health and a lower quality of life, both of which influence sexual function, explained Dr Logan. Underweight women also produce less estrogen. But by far most significant finding was that women who reported moderate or severe vaginal dryness were 14 times more likely to have female sexual dysfunction – “a huge, huge association,” said Dr Logan.On the other side of the spectrum, the use of menopausal hormone therapy was associated with a 70% reduced likelihood of female sexual dysfunction. Women of the Malay ethnicity also had better sexual function, the study found. Factors linked with FSD *MHT was the only factor found to be significantly protective against FSD Moderate/severe vaginal dryness Nulliparity(not having given birth to a child) Use of menopausal hormone therapy(MHT)*

    “Overall, more support is needed for midlife women to navigate changes in sexual function related to menopause,” Dr Logan concluded. 

    “And with regards to the strong association [of vaginal dryness], there’s a need to publicise and make aware of treatments that can reduce this, including vaginal moisturisers, lubricants, vaginal estrogen in cream and tablet form (a localised form of hormone therapy), or whole-body menopausal hormone therapy.”

    In Singapore and beyond

    For Miss A, hormone therapy was a last-ditch effort at regaining the normalcy of her sexual life.

    “I tried traditional Chinese medicine, I tried cutting back on alcohol, I turned vegan for a year,” she said. “And none of that actually helped with my menopausal symptoms.”

    Finally, one of her friends suggested hormone therapy. After seeking help, “it took all of three months for me to get my life back,” she shared.

    Today, she no longer suffers from hot flushes or hormone-related mood swings. An estrogen insert helped with local vaginal dryness, and so far, her days have been smooth sailing. 

    While Miss A’s story has a happy ending, many others suffering from undiagnosed female sexual dysfunction may not have been so lucky. 

    As such, the team hopes that the insights from this study will enable more women facing similar predicaments to receive help as well. 

    “The…data shows us that Singaporean women are keen, they want to have satisfaction, they want a good sexual life,” explained Prof Yong. “But [there is] this lack of awareness, and we call this a modifiable factor because we’ve got good medication [that can help].”

    And while existing interventions have helped many with their adverse symptoms, Dr Logan also hopes to discover and learn more about other measures that can help women facing such issues, both locally and beyond.

    “We all know that Singapore is ageing, and so by 2050…[women facing perimenopause and menopause] will form the majority of the population,” she said. 

    With public discourse on the topic still relatively muted, more research has to be done on the area. Already, the IWHP team is setting out on a follow-up study, with all participants having been invited back for a re-assessment. 

    “We’re very thankful for them, that they're willing to give up their time to come back and be assessed,” said Dr Logan, “and we hope that this study will be even more successful than SWAN in terms of giving information on changes related to ageing within Singapore.”

    She also highlighted that given Singapore’s unique ethnic profile – with three Asian ethnic groups that comprise more than 40% of the world’s population – results gleaned from a study here would be applicable to a vast group of women, and not just the nation’s tiny populace.

    “So we can provide some very important information on menopausal ageing, not only here in Singapore, but globally,” she added.

    “Ultimately, we hope to open conversations to help women help themselves to sail through menopause gracefully.”

    In consultation with Dr Susan Logan, Senior Consultant, Department of Obstetrics and Gynaecology, NUH and Professor Yong Eu Leong, Emeritus Consultant, Department of Obstetrics and Gynaecology, NUH.

    Download the full infographics here.

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