Introduction

Women experience many changes as they pass through middle age. These changes, many the result of menopause, help set the stage for transition into older adulthood. Menopause is a natural process that typically begins a few years before a woman's last menstrual period. As women age, the ovaries produce smaller and smaller amounts of estrogen, progesterone, and testosterone—the sex hormones. Eventually, menstrual periods end and pregnancy is no longer possible. These changes certainly do not bring an end to sexual activity and pleasure.

Menopause has its price: It puts women at greater risk of developing heart disease, osteoporosis, and genital and sexual disorders. However, not all genital and sexual disorders experienced by older women are caused exclusively by the changes of menopause.

Female Reproductive System

The female reproductive system consists of both external and internal genitals.

The external genitals consist of the labia majora, labia minora, Bartholin's glands, clitoris, and vestibule. The area containing these organs is called the vulva. The external genitals have three main functions: enabling sperm to enter the body, protecting the internal genitals from infectious organisms, and providing sexual pleasure.

See the figure External Female Genitals.

The labia majora are folds of tissue that enclose and protect the other external genitals. The labia majora contain sweat and sebaceous glands, which produce lubricating secretions. The labia minora lie just inside the labia majora. During sexual stimulation, increased blood flow causes the labia minora to swell and become more sensitive to stimulation. The surface of the labia minora is kept moist by fluid secreted by specialized cells.

The two Bartholin's glands, located just inside the vaginal opening, secrete lubricating fluid during sexual intercourse.

The clitoris, located between the labia minora, is a small protrusion that is very sensitive to sexual stimulation. Stimulating the clitoris can result in an orgasm.

The vestibule is the tissue between the labia minora, including the openings to the vagina and the urethra (which carries urine from the bladder to the outside of the body). The vestibule is highly sensitive and is prone to inflammation.

The internal genitals consist of the vagina, uterus, cervix, fallopian tubes, and ovaries.

See the figure Internal Female Genitals.

The vagina connects the external genitals with the uterus. The lower third of the vagina is surrounded by muscles that provide support to the vagina, bladder, and rectum and sometimes contract rhythmically during orgasm.

The lining of the vagina is highly sensitive to estrogen, which allows the vagina to be kept moist by fluids secreted from cells on its surface and by secretions from glands in the cervix (the lower part of the uterus). These fluids may pass to the outside of the body as a vaginal discharge, which is normal.

The uterus is situated behind the bladder and in front of the rectum. The main function of the uterus is to sustain a fetus. The opening to the uterus is called the cervix.

The ovaries produce the female sex hormones (estrogen and progesterone) as well as male sex hormones (testosterone). In women of reproductive age, the ovaries produce and release eggs into the fallopian tubes.

With aging, the ovaries produce smaller and smaller amounts of estrogen, progesterone, and testosterone. The changes in a woman's reproductive organs that occur with aging are due mostly to the effect of lower levels of estrogen and progesterone after menopause. The uterus and the ovaries both become smaller and firmer (atrophy). The labia lose fat, connective tissue, and elasticity. The skin of the labia thins, as do the walls of the vagina. In addition, blood flow to the vagina decreases dramatically, causing the vagina to become shorter, narrower, and drier. All of these changes may make sexual intercourse uncomfortable.

The acidity of the vagina decreases with aging, making the genitals more susceptible to irritation and infection. The muscular support structures in the pelvis weaken, which can lead to collapse of any of the pelvic organs (the bladder, intestines, uterus, and rectum) into the vagina. The level of testosterone becomes proportionately higher because lower levels of female sex hormones are being produced. As a result, women may begin to develop very mild characteristics usually associated with men, such as hair loss and growth of facial hair. Within 5 to 10 years of menopause, testosterone levels drop as well, resulting in a decrease in sex drive.