Elders' Sexual Activities and Health: Out of the Closet

Do seniors have sexual needs? Fueled by stereotypes, health care professionals often consider sexual activity late in life abnormal.¹ Elders, however, are sexual beings (Table 1). A survey of seniors aged 65 to 97 found that 40% were sexually active, averaging ^2.5 sexual encounters monthly.² Many people stop having sex, not because desire wanes, but because they lack partners, are physically challenged, or are embarrassed. Understanding seniors? sexual issues helps clinicians identify diagnosis and treatment opportunities.^3,4

Sexual Health Defined

Once clinicians accept late-life sexual activity, they see that elders may suffer sexual health conditions, including consequences of earlier experiences. AIDS prevention efforts can be tailored, because people over age 50 comprise 10% of new cases. In people over 65 years, 11,555 AIDS cases were reported in 2001.⁵

Some sexually transmitted diseases lie dormant for years. Early infection with human papillomavirus increases the risk of cervical cancer 12-fold in women who test positive.⁶

Sexual health also involves hormonal changes, reproductive system disorders, and medications affecting sexual performance (Tables 2 and 3).^7-15

Medications and Sexual Performance

The likelihood that an older patient is taking one of many medications that might affect sexual performance is high. Antidepressants, for example, induce adverse sexual effects in 20% of all patients and 23.4% of men.16 Other drug classes implicated include diuretics, central-acting agents, adrenergic blockers, nonadrenergic vasodilators, sympathetic nerve blockers, angiotensin-converting enzyme inhibitors, antipsychotics, antidepressants, mood stabilizers, and ulcer medications.¹⁵

Treatment Issues in Women

Hormone Replacement Therapy

Clinicians are rethinking hormone replacement therapy (HRT) recommendations. HRT always has been contraindicated in women who have vaginal bleeding of unknown causes; a history of breast, uterine, or endometrial cancer; and a history of chronic liver disease and thrombosis.¹ Women concerned about systemic effects of HRT may use topical estrogen creams to relieve local urogenital symptoms. They also may opt for the diaphragm-like estradiol vaginal ring (Estring), which remains in place for 90 days. Potential side effects of this ring, however, include increased vaginal secretions, abdominal pain, and vaginal itching and discomfort.^17,18

Pelvic Organ Prolapse

Any of the 3 types of prolapse?uterine, cystocele, or rectocele?can be corrected surgically, but 33% of patients require additional surgical corrections.¹⁹ Several kinds of vaginal pessaries can correct prolapse severity. Patients selecting pessaries over surgery must be able to provide significant self-care.

Cancer

Because 57% of cancers and 71% of cancer-related deaths occur in people considered elderly, screening continues to be important. After age 65, women who have had 3 normal consecutive annual Pap smears may have these tests less frequently, but the rate of false positives may be higher.⁶ Since the tissues at the summit of the vagina are identical to cervical cells, Pap smears should continue to be taken even after a total hysterectomy.¹

The importance of mammography increases with age. The American Geriatrics Society recommends biennial mammograms for women younger than 75 years, and every 2 to 3 years for older women.¹

Sexual Response

Researchers are focusing on agents that may increase a woman?s sexual response. Several are being tested, including sildenafil citrate, and some hold promise.

Treatment Issues in Men

Benign Prostatic Hyperplasia

Symptoms of benign prostatic hyperplasia (BPH) fluctuate, causing lack of consensus about treatment. Generally, when symptoms are mild, physicians recommend watchful waiting. For severe cases, surgical interventions are required (eg, transurethral resection of the prostate). Most cases fall in the middle, requiring medication.

Selective alpha-1 blockers improve urinary flow but do not reduce prostate size.²⁰ They reduce smooth muscle tone at the bladder neck and facilitate urinary flow, alleviating symptoms.20 The alpha-1 blockers terazosin, doxazosin mesylate, and tamsulosin also are used. Terazosin and doxazosin are indicated for both BPH and hypertension, which are frequent comorbidities.²⁰ Both agents can cause hypotension, however, and titration and close monitoring are necessary.

Finasteride and dutasteride are 5-alpha reductase inhibitors.²⁰ A 7-year follow-up of men with BPH taking finasteride found reduced prostate volume (28% from baseline) as well as increased urinary flow.²¹ Approximately 5% of treated men, however, experienced erectile dysfunction (ED), decreased ejaculatory volumes, or decreased libido, compared with 1.5% in placebo-treated men.¹²

Cancer

Annual prostate-specific antigen (PSA) screening is generally recommended for men age 50 and older. Consensus is lacking; some experts recommend against annual screening unless patients present additional risk factors (eg, family history of prostate cancer). PSA readings higher than 4 ng/mL and a positive digital rectal examination are significant. Some specialists advocate age-adjusted PSA threshold levels where a PSA level of 6.5 ng/mL would be considered normal for a 70-year-old man.²² PSA tests alone fail to detect 10% to 20% of cancers.¹³ The majority of PSA-detected cancers (70%) are organ-confined. Most men undergoing prostatectomy, however, suffer from postsurgical ED (80%) and urinary leakage (49%).¹³

Erectile Dysfunction

Sildenafil citrate treats ED effectively, but it is contraindicated in men receiving any form of nitric oxide donor drugs, isosorbide mononitrate, or glyceryl trinitrate. Vardenafil has been approved by the FDA, and Eli Lilly?s yet-unapproved ED drug, tadalafil, also holds promise.

Related to ED is loss of sexual vitality, which some attribute to normal testosterone decline. Males with laboratory-confirmed testosterone may benefit from testosterone replacement therapy; patients report improved mood and less depression. Testosterone therapy may increase red blood cells dangerously, however, and it is contraindicated in men who have prostate cancer.²³

Editor?s Note: The views expressed are those of the authors and not those of the National Cancer Institute.