“I think women are foolish to pretend they are equal to men, they are far superior and always have been.”
                                                            ― William Golding, Lord of the Flies

Changes in Women

While women lose the capacity to reproduce well before they reach the average lifespan, some men maintain reproductive capability in extreme old age. In women, the rapid decline in eggs produced by the ovary is precisely and quantitatively regulated.  After menopause very few, if any, eggs can be seen in the ovary, which become scarred and withered

At menopause, the production of ovarian estrogen is markedly reduced. This reduction is responsible (through complex hormonal mechanisms) for “hot flashes” felt by about two-thirds of menopausal women. Estrogen decline also produces changes in the uterus and the vagina: the lining of the uterus, the endometrium, thins and the connective tissue increases. This thinning of the vaginal lining (with reduced secretions) can predispose to dryness and pain with sexual intercourse. Changes in the urethra can contribute to urinary incontinence, and may increase susceptibility to urinary infections. Changes in breast tissue are attributed to hormonal changes, and cysts may appear. The stretching of ligaments and loss of muscular tone alter the contours of the breast.

Changes in Men

In men, the decline in reproductive ability is a gradual process since sperm cells continue to be formed. Very recent studies suggest a marked reduction in sperm counts of Western men of all ages over the past forty years (1). The prostate tissue is replaced by scar tissue. The prostate gland enlarges, particularly around the urethra. Changes in the concentration of testosterone, particularly its conversion to dihydrotestosterone, appear to cause this enlargement. Changes of the penis include progressive decline in blood flow and the formation of scar tissue in the inner compartments.

Older men usually notice a distinct difference between their current level of sexual interest and that experienced during early adulthood. Not only is there less interest in the frequency of sexual contact but also the focus of sexual interaction may change from primarily physical to increasingly emotional. Nevertheless, even men over the age of 85 still have sexual interest, and intercourse remains the preferred form of physical sexual contact.

Social Considerations

In both genders, the frequency of sexual activity generally declines with age, but how much this is due to aging and how much do to circumstances not known. The most important factor may be the presence of a willing and able partner. Social and cultural circumstances tend to reinforce the decline in sexual activity, especially for older women. The normal changes in sexual behavior in older people are not well known, although surveys of sexual activity in older age groups suggests mild decreases in sexual interest in frequency of sexual intercourse in both men and women. Across all age ranges, these findings must be interpreted cautiously because surveys cannot distinguish between affects that are due to aging, social customs and values, and gender differences and marital status. There are more elderly widows and widowers, and husbands tend to be several years older than their wives.

Social and cultural influences all this sexual behavior in elderly people include age-related assumptions about appropriate gender specific behaviors and acceptable sexual practices. For example one assumption might be that men should be the initiators of sexual activity. Another belief might be that there is only one correct position for intercourse with intercourse is the only way of expressing intimacy. These assumptions may persist even in the face of physical or emotional changes that occur with aging. Clearly a broader definition of acceptable activities, responses or expressions should be considered to accommodate the older self and the older body. Ethnic and cultural differences require increasing tolerance and diversity in our thoughts about expressing sexuality.

Sexuality in relationship to coexisting illnesses

Diseases common in older people such as arthritis can have an important impact on sexuality. And any medical illness, especially if it engenders anxiety about sex or physical discomfort during sex, can be a barrier to healthy sexual enjoyment. Depression is another common condition that can affect sexual function. Because any sexual problem can be a symptom of a problem within a relationship the quality of the partnership might also be an issue.

Heart Disease

 Various forms of heart disease including congestive heart failure, recent heart attacks, and angina pectoris, can interfere with sexual function. For example, ordinarily anxiety after a heart attack can cause a decrease in sexual desire. However, elderly people who can tolerate mild physical exertion, such as walking up two flights of stairs, are usually capable of sexual activity. Even people who have had a recent heart attack can safely engage in routine sexual activity if they can tolerate mild or moderate activities. Clearly it is important of these fears be addressed with an informed health advisor and normal sexual activity encouraged when appropriate.

Arthritis

Sexual activity can also be reduced in people who have arthritis and suffer from pain, limited joint movement, or impaired mobility. About half of people who have osteoarthritis of the hip report that there were some interference with sexual activity.  In addition to interventions that include adequate management of the underlying arthritis and counseling, specific advice on the selection of positions for sexual intercourse that reduce the stress on the affected joints is available.     

Prostate Surgery

Very few men who undergo surgical removal of all or products are part of the prostate gland at operation known as transurethral resection of the prostate or TURP experience difficulties with potency. Therefore other causes may need to be considered if impotence does occur. Before surgery, however, the Counselor should discuss with the patient a common complication called retrograde ejaculation into the bladder. This complication, where in the seminal fluid goes into the bladder rather than out the urethra with orgasm, occurs in as many as 90 percent of men who undergo TURP. Erectile capability and the potential for orgasm however are not impaired. Men who must have a very extensive prostate surgery are often concerned that the surgery will result in incontinence or impotence. When a nerve sparing procedure is used the likelihood of this complication is generally less than 10 percent.

Breast Cancer

Although men can have breast cancer, by far the greatest incidence is among women. In relation to sexuality, women who have had newly diagnosed breast cancer commonly have concerns of mutilation, changes of body image and anxiety about rejection by their sexual partners. Fortunately procedures are generally less invasive and more individualized now than in the past. In addition to adjusting psychologically to the diagnosis, problems may arise from various treatment complications such as profound fatigue that may place physical limitations on other forms of sexual activity.

The emotional responses to cancer cannot be easily summarized. Terminally ill people may also have sexual needs or sexual concerns. Some people may want to push others away but more typically people who were affected by malignancy closeness and reassurance from their sexual partner.                                                                                                                                                                               

References

Levine H, Jorgensen N, Martino-Andrade A et al.  Temporal trends in sperm count: a systematic review and meta-regression analysis

Hum Reprod Update July 25, 2017: 1-14.

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