Exploring sexual life enrichment: a journey into strengthening well-being for women post- menopause through qualitative study

Abstract

Background

women post-menopause, are faced with various physical, emotional, and relational challenges. One such aspect that tends to be overlooked is the impact of menopause on sexual well-being. This study aimed to elucidate the concept of enriching the sexual life of women post-menopause.

Methods

A qualitative research strategy was adopted using a conventional content analysis approach. Data collection was conducted through semi-structured interviews with 24 participants (17 women post-menopause and 7 experts), using purposive sampling.

Results

The data analysis resulted in the extraction of 341 codes, 24 subcategories, and 8 categories. Ultimately, the following three themes emerged: “maintaining and enhancing the position of sexual relationships,” “deepening sexual relationships and expanding intimacy,” and “improving communication skills with the spouse “.

Conclusion

Enriching the sexual life of women post-menopause, as suggested by the themes, involves nurturing their relationships, keeping these connections strong and valued, deepening intimacy, and promoting effective communication to ensure a fulfilling and enjoyable experience during this phase of life. This leads to a sense of security, health, and tranquility, ultimately manifesting positive repercussions on the couple’s and family’s health.

Background

The sexual aspect of life constitutes one of the important physiological needs of humans, providing a framework for the attainment of individual and social well-being [1]. Dissatisfaction in sexual life stands as a primary contributor to relational conflicts, capable of instigating doubt regarding love and affection, and increasing concerns among couples regarding the stability of their relationships [2]. Numerous factors exert an influential impact on sexual life, with menopause being one of the foremost among them [3].

The term postmenopause refers to the period of time after the final menstrual period and includes early stage (first 5 years) and late stage (after five years until death) based on the Stages of Reproductive Aging Workshop (STRAW) guidelines [4]. Continuation of sexual activities in women post-menopause enhances the quality of life and leads to increased satisfaction with life [5, 6]. Women post menopause, due to the complex interplay of individual, interpersonal, and societal factors influencing health, are more susceptible to sexual disorders compared to women in the reproductive phase [5]. Additionally, the postmenopausal period is typically accompanied by physiological and psychological changes that impact sexual issues [7]. The reduction in estrogen levels, coupled with alterations in vascular, muscular, and urinary systems, as well as changes in mood, sleep pattern, and cognitive function, gives rise to sexual problems directly and indirectly affecting sexual performance [5, 6]. Sexual dysfunction prevents the experience of satisfying sexual activity and results in decreased overall life satisfaction [8, 9]. The prevalence of this disorder in women post-menopause is reported to be 85.2% globally [10] and more than 80% in Iran [11]. The significant prevalence and adverse consequences of sexual problems in women post-menopause have prompted an increasing focus on providing scientifically sound solutions, particularly in preventive care, with a specific emphasis on sexual health [1, 12].

Enrichment programs are proposed as one of the solutions to improve the quality of life. These programs are comprehensive counseling or education designed to enhance the lives of individuals, by providing them with new knowledge, skills, or experiences [13, 14]. Various studies indicate the positive effects of enrichment interventions in some fields, including enhancing marital relationships [15]. Aspects such as improving the sexual knowledge of couples, strengthening relationship skills, and applying conflict resolution strategies, have been highlighted in enrichment programs [13, 14, 16]. These aspects involve a movement toward the growth of the marital relationship, aiming to enhance the relationship by establishing goals and direction for achieving the desired objectives [17]. Based on our knowledge, existing studies in the field of the sexual life of menopausal women have primarily focused on variables such as sexual function and interventions like education, symptom recognition, health promotion, attention to the sexual partner, and individualized therapeutic approaches [7, 18,19,20,21]. None of these studies have comprehensively evaluated the sexual life of women in the context of enrichment, and it appears that the lack of a well-defined concept of sexual life enrichment in the existing literature may contribute to this limitation. Given the absence of documentation to clarify this issue, it seems necessary to first define this concept for planning effective and comprehensive interventions based on it. Therefore, the present study was conducted to explore the concept of sexual life enrichment among women post-menopause.

Materials & methods

Study design and participants

This was a qualitative study employing the conventional content analysis approach. The study setting comprised comprehensive health centers in Qazvin, Iran. The purposive sampling was the sampling strategy. Participants included women post-menopause and experts (sexologists, sex-therapists, and psychologists) who expressed willingness to participate in the study. The inclusion criteria for women post-menopause were as follows: being Iranian, having at least basic literacy skills, being married (having a male spouse), being sexually active, not experiencing a stressful event (such as accidents, serious illness, or death of close relatives) in the past six months, women and their spouses not suffering from recognized mental illnesses, women and their spouses not having a severe physical illness that impedes sexual relationships (such as uncontrolled diabetes or mobility restrictions), being in the first ten years of postmenopause, and not experiencing severe marital conflicts (such as conflicts leading to separation/divorce) in the past six months. Furthermore, inclusion criteria for experts included having more than 2 years of work experience and a history of providing services in the field of sexual health to women-post menopause. Unwillingness to continue participation in the study was the sole criterion for exclusion.

Data collection

Data were collected through semi-structured interviews. The main researcher conducted all interviews. Sampling took place from July 2022 to December of the same year, ensuring maximum diversity in terms of age, education level, socio-economic status, duration of menopause, occupation, and work experience. Informed consent for participation in the study was obtained from all participants. All interviews were conducted in a calm, private environment, providing the necessary psychological security for the participants. Interviews with women-post menopause began with general questions such as “What is your perspective on sexual relationships?” If the interviewees’ discussions moved away from the topic under investigation, the researcher redirected their attention to the desired subject, with a question extracted from their statements. The interview process involved probing questions such as “Can you elaborate more on this? Can you clarify this further? What experiences have you had in this regard?” to facilitate a clearer understanding of the concept for both the researcher and the participants. Some eexamples of questions for interview with women post-menopause and experts are shown in Table 1. All interviews were recorded, thoroughly transcribed, and then subjected to analysis. The duration of interviews ranged from 35 to 65 min. Richness of data was achieved after interviewing 24 participants [22].

Table 1 Examples of interview questions with women post menopause and experts

Data analysis

The data analysis process followed the recommended stages by Lundman and Graneheim [23]. Initially, the researcher transcribed the interview text verbatim into Microsoft Word 2018 software and conducted the data analysis concurrently. To understand the interview content, the text was read multiple times, and coding units considered the most significant part of content analysis were determined. The entire text was regarded as the unit of analysis, and smaller segments, including a word, phrase, sentence, or paragraph with relevant meaning or concept related to the study question, were considered meaningful units. While preserving the original concept, the meaningful units were condensed into compact expressions and then coded. The codes were placed into subcategories based on their similarities and differences. Similar subcategories were grouped together to form categories. Finally, considering the hidden meanings within the categories, themes emerged, and the main concepts revealed [23, 24].

Rigor of the data

In this research, Lincoln and Guba’s criteria, including data credibility, confirmability, dependability, and transferability were considered to ensure the accuracy and reliability of the data. Methods such as reviewing the data for prolonged engagement, obtaining participants’ feedback, and the experts revising codes and categorization based on their input were employed to confirm credibility. For confirmability, several interview transcripts, the coding process, and the extraction of themes were made available to other expert researchers in qualitative research for review. Furthermore, maintaining documentation related to the study in a way that allows others to follow the process, contributed to the confirmability of this research. To ensure the dependability of the data, code-recode, and external checking were applied. To enhance the transferability of the data, attempts were made to clarify the complete description of the participants and the research process [23].

Ethical considerations

At the beginning of each interview, the researcher introduced herself to the participants and explained the research objectives. Subsequently, written informed consent was obtained from the participants. Participants were assured that their audio files would be kept confidential. Sufficient information was provided regarding the voluntary nature of participation in the research and the option to withdraw from the study at any stage. Throughout the study, participants’ names were kept confidential, and they were mentioned by specific codes.

This study received ethical approval with the code IR.SBMU.PHARMACY.REC.1402.187 from the Ethics Committee of Shahid Beheshti University of Medical Sciences.

Findings

Seventeen women post-menopause and 7 experts participated in the study. The mean age was 52.29 and 45.42 respectively. Further characteristics of the participants are shown in Table 2, and Table 3.

Table 2 Characteristics of the women post menopause

Table 3 Characteristics of the experts

The data analysis resulted in the extraction of 341 codes, 24 subcategories, and 8 categories. Ultimately, 3 themes were identified as follows: “maintaining and enhancing the position of sexual relationships”, “deepening sexual relationships and expanding intimacy”, and “improving communication skills with the spouse” (Table 4).

Table 4 Subcategories, main categories, and extracted themes

Theme 1- maintaining and enhancing the position of sexual relationships

Women post-menopause and experts paid particular attention to maintaining and continuing sexual relationships during postmenopausal period. This aspect emphasizes the importance of prioritizing and valuing sexual relationships during this phase of life. It highlights the need to ensure that these connections remain an essential part of their lives and contribute to their overall well-being. It appears that the continuation of sexual relationships during this period is one of the suitable approaches for strengthening and promoting couple’s romantic relationships. This theme encompasses categories such as the importance and necessity of sexual relationships, a sense of health and tranquility, and the positive repercussions of sexual relationships on the health of the couple and the family. A participant with a 6-year postmenopausal history expressed:

“I don’t think we should equate the cessation of sexual relations with the end of menstruation. It is something that has ended, but sexual relations must continue” (p15).

Some acknowledged the positive outcomes of continuing and maintaining sexual relationships during postmenopause, including peace of mind and well-being. In this regard, a participant who was 4 years postmenopause expressed:

“ Although I am a stressful person, I can concentrate after sex, and I think that sex reduces my stress and makes me feel relaxed " (p1).

One of the experts also stated:

“The sexual activity of a post-menopausal woman, aside from being a component of her sexual and reproductive rights, plays a fundamental role in her physical and mental well-being” (p21).

One additional positive outcome of the continuation or maintenance of sexual relationships between spouses during the postmenopausal period is the health and well-being of the couple, contributing to the overall health of their family. A participant with a 6-year postmenopausal history believed:

“Intimate relations are highly beneficial, fostering an increase in affection and love between spouses.” (p16).

Theme 2- deepening sexual relationships and expanding intimacy

Based on the study results, it seems that attention to the deepening of sexual relationships and expanding intimacy is one of the effective measures for improving the sexual relationships of couples during postmenopausal period. This theme highlights the significance of fostering emotional and physical closeness, which can lead to a more fulfilling and satisfying relationship. Women post-menopause can experience a more profound level of intimacy by deepening the connection which can lead to increased satisfaction and happiness in their relationships. By promoting intimate sexual relationships, focusing on love-making and foreplay, diversifying sexual experiences, and infusing excitement into sexual relationships, a high-quality sexual life can be achieved for women post-menopause. The interviews suggest that promoting intimate sexual relationships, including sexual awareness of the couple, attention to each other’s sexual characteristics, and mutual participation, serves as a foundation for enhancing intimate sexual relationships. One of the experts stated:

“The intimacy in sexual relations should persist, and individuals should not perceive the aging process, graying hair, wrinkles on the face, or the altered self-image due to aging as reasons to refrain from intimacy in sexual relations with their spouse. It is very important to pay attention to the fact that sexual intimacy between couples should not be interrupted with age and menopause” (p23).

A participant with a history of 6 years of postmenopausal period acknowledged:

“My spouse and I try to repeat positive experiences; for instance, when a good incident occurs, we share it with laughter and humor. In fact, we try to maintain our close relationship, and I think it has positive effects on our sexual relationships” (p15).

In this regard, one of the experts stated:

“Spouses ought to discuss their sexual desires and needs openly, addressing what brings them joy or discomfort. In fact, they should familiarize themselves with each other’s sexual needs in a constructive manner” (p21).

According to participants, the necessity of preparation for engaging in sexual relations, the importance of identifying and enhancing stimuli for entering into sexual relationships, focusing, and sexual fantasies are considered effective approaches in improving the sexual life of women post-menopause.

A participant with 6 years of postmenopausal experience emphasized the importance of focusing during sexual relationships to derive pleasure:

“It is crucial to focus during sexual relationships and concentrate our thoughts so that we can derive sufficient pleasure from the established relationship” (p16).

An expert stated:

“It is better for spouses to initiate by preparing each other and engaging in pleasant activities, such as kissing the neck and exploring other parts of the body. Overall, engaging in activities that are enjoyable for both individuals is recommended” (p18).

Another expert stated:

“The physical contact between partners inherently constitutes sex, and this contact can be elevated, particularly in private settings, progressing to intimate engagement involving sexual organs. And it may, or may not, lead to orgasm. This period necessitates the utilization of various other stimuli, such as subjects, fantasies, games, and effective use of touch, smell, etc., to induce arousal. A deliberate plan and preparation in advance are required for a more special expression of affection from the spouse to induce arousal” (p21).

In terms of diversification and infusing excitement into sexual relationships, the role of sexual enthusiasm, such as playful humor in the conversations of the couples was discussed. Matters related to the significance of motivational actions and creating a positive atmosphere for the enhancement of sexual life were addressed. A participant with 8 years of postmenopause experience expressed:

“Now that we have aged, we should seek diversity. I believe one should wear very good clothes, be stylish, and consider variety in her attire, all of which have a significant impact on sexual relationships. For example, if you wear the same outfit at home all the time, your husband will ask, ‘What kind of clothes is this that you’re wearing? Dress up!’ Because he knows that wearing stylish clothes means you are livelier, more attractive, and will even have better sexual relationships” (p8).

One of the experts stated:

“Considering that women in this period likely have experienced a minimum of 20 to 30 years of married life, it is essential for them to preserve vitality in their relationships. Typically, the initial steps individuals in middle age take to enhance their marital relationships involve motivational interventions. It is necessary to instill motivation in the individual to encourage a willingness to make changes in their sexual behaviors and relationship with their spouse” (p22).

Theme 3- improving communication skills with the spouse

This theme is derived from the categories of: expressing desires and needs and conversation with the language of love. Effective communication plays a crucial role in addressing concerns, expectations, and desires between partners. By fostering open and honest dialogue, women post-menopause and their spouses can better understand each other’s needs, leading to a stronger bond and more enjoyable experiences. The articulation of needs in sexual relationships can lead to an enhancement in the quality of sexual relationships. Additionally, it appears that disrupted interactions between spouses may have an adverse effect on sexual relationships.

From the participants’ perspective, expressing sexual desires leads to a deeper understanding between spouses and fosters a better sense of satisfaction in sexual life. One participant stated:

“ I think that I get sexual pleasure when I express my desire and need” (p11).

One of the experts stated:

“Primarily, couples need to engage in a conversation about their sexual relationships, expressing their desires and needs” (p22).

It appears that discussions about sexual matters and emotional relationships among spouses, or in other words, conversation with the language of love, contribute to the enhancement of overall marital relations, ultimately leading to an improvement in their sexual relationships. In this regard, an expert expressed:

“It is beneficial for couples to create opportunities for discussing sexual matters openly to improve their sexual relations. For instance, suggesting certain attire or behaviors is a positive approach” (p21).

A participant with a 6-year history of postmenopause stated:

“In my opinion, sexual relations constitute a dyadic relationship, wherein each party must communicate their love emotions to the other” (p16).

Discussion

While the existing literature has covered various aspects of menopausal women’s quality of life, our study provided a new concept that can help enrich women’s sexual lives, which in turn could lead to the improvement of the quality of women’s sexual lives. Three significant themes emerged from the study: “maintaining and enhancing the position of sexual relationships”, “deepening sexual relationships and expanding intimacy”, and “improving communication skills with the spouse”. These themes highlight the importance of prioritizing sexual relationships, fostering emotional and physical closeness, and promoting open communication in maintaining and enhancing intimacy in the post-menopausal period.

The results of the current research emphasize the significance of continuing sexual relationships during post-menopause, as it contributes to the overall well-being of both spouses and the family. By maintaining these connections, women post-menopause can experience a sense of peace and mental tranquility, which in turn benefits their partners and the family unit. The findings of the study by Nappi et al. (2014) demonstrated that a healthy sexual relationship during post-menopause is a fundamental component of women’s life. The care for women post-menopause should encompass attention to sexual changes associated with menopause, counseling to overcome potential sexual issues during this period, general education, awareness of menopausal symptoms, promoting health, paying attention to partner, and individual treatment to preserve the sexual relationships of women post-menopause [7]. Sexual health for women is a priority for the World Health Organization, as unfavorable sexual function can cause concerns for couples about their married life [25]. The findings also highlighted the need to recognize the positive outcomes of continuing sexual relationships, such as increased affection and love between spouses, and the importance of sexual relationships as part of postmenopausal women’s sexual and reproductive rights. Sexual relationships are an important factor in marital happiness, and if unsatisfactory, they can contribute to feelings of dissatisfaction and insecurity [26]. Sexual disorders result in the deterioration of mental health in families, creating or exacerbating mutual psychological problems. Many conflicts, controversies, and marital disputes can be attributed to these disorders [26, 27]. Additionally, it has been demonstrated that the sexual relationships of couples contribute to the improvement of physical health and the quality of marital life [28], aligning with the results of our study.

According to the present research, deepening sexual relationships and expanding intimate sexual relationships between couples, fostering lovemaking, and diversifying sexual experiences are appropriate approaches to improving individuals’ sexual lives and leading to a more fulfilling and satisfying relationship during post-menopausal period. By promoting intimate sexual relationships, focusing on foreplay, and infusing excitement into sexual relationships, women post-menopause can experience a higher quality of sexual life. The participants and experts suggest that fostering emotional and physical closeness, open communication of needs and desires, and engaging in activities that bring joy to both partners can contribute to enhancing intimate sexual relationships. Sexual intimacy is a complex matter that requires special attention, involving sharing romantic experiences, the need for physical contact, sexual intercourse, and relationships that are designed to arouse, stimulate, and satisfy sexual desires. If couples are aware of their differences in terms of demands and preferences in sexual intercourse, they can address them properly before their relationship encounters difficulties. Conversely, if couples are not aware of their sexual intimacy, often becomes a source of problems and conflict [29]. Happy and intimate couples tend to derive more pleasure from sexual intimacy and, as a result, become even happier and more satisfied [30, 31]. Intimacy, expressing love, and receiving love are essential components of marital life, often acquired through sexual interactions [32]. It is shown that couples with excellent relationships are less likely to experience sexual disorders. Conversely, as the relationship quality deteriorates the incidence of sexual dysfunctions increase [32]. Additionally, it has been shown that for many elderly individuals, physical closeness and intimacy may be more important than sexual activity [33].

The results demonstrate the importance of the role of effective communication in addressing concerns, expectations, and desires between partners. By fostering open and honest dialogue, women post-menopause and their spouses can better understand each other’s needs, leading to a stronger bond and more enjoyable experiences. Improving interpersonal communication skills between spouses constitute one of the influential factors in sexual relationships. In addition to the quality of the relationship between spouses, women’s sexual inclination towards interactions experienced with their partners is contingent upon such dynamics. In fact, women’s sexual inclination is intricately linked to the communication and dynamics of the relationship with their partners [34]. The articulation of needs and conversation with the language of love in sexual relationships can lead to an enhancement in the quality of sexual relationships. Disrupted interactions between spouses may have an adverse effect on sexual relationships, highlighting the importance of open communication in maintaining intimacy. Participants believed that marital relationships play a role in the quality of individuals’ sexual lives, a finding congruent with other studies [35,36,37]. It appears that desirable interpersonal relationships between spouses contribute more to the satisfaction of marital life than the frequency of sexual relations [36]. According to the results of Morad’s study (2022), provided that women achieve emotional readiness before entering the menopausal stage, including being seen by their spouses, being respected, and understanding each other both physically and mentally, their sexual function does not undergo significant changes in postmenopausal period. It may be argued that commitment and love are highly crucial for sexual relationships during this stage [38]. After many years of marital life, what becomes significant in a sexual relationship is being seen and accepted by the partner. This aspect propels couples towards experiencing the pleasure of being together and cultivating a desirable sexual relationship with one another. In such a context, the acceptance of menopause as a natural stage of life is fostered, and couples come to believe that every moment of togetherness is valuable. The focus shifts from merely achieving orgasm to unifying as a couple and deriving pleasure from one another [38].

The findings demonstrate that sexual life enrichment in postmenopausal period is a multifaceted issue that requires attention to various aspects, such as maintaining sexual relationships, deepening intimacy, and enhancing communication skills.

Strengths and limitations

The present study represents the first attempt to elucidate the concept of enriching the sexual life of women post-menopause which is crucial for improving their sexual well-being. Applying a qualitative approach allowed a deep exploration of participants’ experiences, perspectives, and insights into the complexities of this concept. This approach enabled a rich understanding of the themes and categories identified. We included participants with varying menopausal histories, ranging from 2 to 10 years. This diverse representation provided a more comprehensive understanding of the experiences and challenges faced by women post-menopause across different timeframes and it could increase transferability of our study. Furthermore, incorporating the views of experts in the field added credibility to the study and provided valuable insights from professionals who have extensive knowledge about the topic. As with any qualitative research, the researcher’s influence on the participants and the interpretation of the data cannot be entirely ruled out. To minimize this potential limitation, the researcher maintained reflexivity and transparency in the data analysis process. Moreover, the age of the experts may have limited their understanding of the lived reality of post-menopause, as they may not have had personal experience with the condition themselves. The experts’ experience was not specifically focused on working with women post-menopause, which could impact the findings. Another limitation is that this was a heteronormative demographic, and it is unclear how the findings could be extrapolated to same-sex couples.

Conclusion

In conclusion, this study offers valuable insights into women’s post-menopause sexual life enrichment by focusing on maintaining and enhancing sexual relationships, deepening sexual relationship and expanding intimacy, and improving communication skills with the spouse. Such efforts result in feelings of security, health, and tranquility, ultimately yielding positive repercussions on the health of the couple and the family. The present study serves as a foundation for further research in this under-researched area, ultimately aiming to improve the sexual well-being and overall quality of life for postmenopausal women and their partners. By focusing on enriching their sexual lives, women post-menopause can experience greater satisfaction, improved communication, and stronger bonds with their partners, ultimately contributing to their overall health and happiness. These insights can contribute to the development of interventions and support systems that cater to the unique needs of women post-menopause.