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The major sexual problems reported by older women include lack of interest in sex, difficulty with lubrication, inability to climax, finding sex not pleasurable, and pain (most frequently at the vagina during entry).^4,5,8 While some women have reported sexual problems, other older women view sex in older age as more fulfilling, partially due to having better communication skills and being able to focus on their own pleasure instead of feeling the pressure of ‘keeping a partner present or interested’.^7,8 Some women view intercourse without the possibility of conception as liberating, while others express disinterest in sexual activity in older age.

First‐line therapies for women with vaginal dryness and dyspareunia include vaginal moisturizers and lubricants, which can be effective when used on a regular basis. Oral, transdermal, or vaginal oestrogen therapy (available in the form of creams, tablets, or rings) can alleviate sexual dysfunction due to vulvovaginal atrophy.⁹ Prasterone, or vaginal dehydroepiandrosterone (DHEA), is a daily vaginal suppository approved to treat dyspareunia. Its efficacy has not been directly compared with vaginal oestrogen, and its use leads to a slight increase in circulating DHEA, testosterone, and estrone levels, leading to some concern about its use in women with oestrogen‐sensitive malignancies. Ospemifene is an oral selective oestrogen receptor modulator (SERM) with oestrogen‐agonist effects in the vagina but without effects in the breast or endometrium. It is also approved to treat dyspareunia and vaginal dryness due to vulvovaginal atrophy and is an oral alternative to nonpharmacological or intravaginal treatments.¹⁰ Table 5.1 describes therapeutic options for women with vaginal dryness due to vulvovaginal atrophy.

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.