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. 2024 Sep 27;34(5):1543–1554. doi: 10.1111/jocn.17436

Women's Experiences of Intimate and Sexual Relationships During Menopause: A Qualitative Synthesis

Hatice Bulut 1,✉, Sharron Hinchliff 2, Parveen Ali 2,3, Hilary Piercy 4
PMCID: PMC12037939  PMID: 39334554

ABSTRACT

Aim

The aim of this literature review was to explore women's experiences of their intimate and sexual relationships during menopause.

Background

Evidence shows that the menopause transition can be a difficult time for women due to symptoms of menopause. There is little research evidence about how menopause‐related symptoms impact women's intimate and sexual relationships.

Method

A qualitative synthesis was carried out on research published between May 2005 and July 2023 using five electronic databases: ASSIA, CINAHL, PubMed, PsycINFO and Web of Science. We also searched Google Scholar and used backward and forward chaining methods to identify results not listed in the databases and ensure that no relevant literature was omitted.

Results

Eighteen qualitative studies were included in this review. Six main themes were identified: the meaning of menopause to women in different cultures; factors affecting women's sexual lives; changes in sexual desire and orgasm; talking about sexual issues; women's attempts to overcome the impact of ageing and menopause on their sexual lives; and concerns about partner sexual satisfaction during the menopause.

Conclusion

During the menopause transition, women can experience sexual difficulties that have an impact on their lives and intimate relationships. Qualitative studies showed that sexual changes associated with menopause can be difficult to manage and must be viewed in the social and cultural contexts of the women's lives.

Relevance to Clinical Practice

The results of this review will be of interest to nurses to assess patient needs while offering health services to women in menopause. In addition, the results can be used to inform education and support programmes for women.

Reporting Method

We have adhered to relevant EQUATOR guidelines and used the PRISMA‐ScR reporting method. No patient or public contribution was required for this study.

Keywords: intimate relationships, menopause, qualitative synthesis, sexuality

Summary.

  • Menopause is a natural phenomenon, but it influences women's sexuality and sexual response phenomenon, but it influences women's sexuality and sexual response.

  • There is little qualitative research to understand the sexual experiences of women during the menopause.

  • Nurses can play an important role in ensuring that menopausal women's needs are assessed and addressed appropriately.

1. Introduction

Menopause indicates the end of a woman's natural reproductive life. Menopause is defined as the permanent termination of menstruation caused by loss of ovarian follicular activity (WHO 2022). For a woman, the experience of menopause is highly personal and hence the prevalence and frequency of menopausal symptoms, particularly vasomotor symptoms (VMS), are influenced by personal differences, their past experiences and environmental factors (Monteleone et al. 2018). Menopause occurs in stages. The term ‘pre‐menopause’ is often used ambiguously, either to refer to the 1 or 2 years immediately before menopause or to refer to the whole of the reproductive period (several decades) prior to the onset of the menopause. The term ‘peri‐menopause’ refers to the time immediately prior to the menopause (when the endocrinological, biological and clinical features of approaching the menopause commence) and the first year of the menopause (when menstrual periods have ceased). The term ‘post‐menopause’ refers to the final menstrual period, regardless of whether the menopause was induced or spontaneous (WHO 1996).

Premature menopause is defined as menopause occurring before age of 40 years (Deeks et al. 2011; Shuster et al. 2010; North American Menopause Society 2007; Boughton 2002), resulting in significant impact on the physical and emotional well‐being of women (Deeks et al. 2011; Boughton 2002). Premature menopause, whether spontaneous or induced, is acknowledged as a condition where women, at an age significantly younger the average, encounter a deficiency in oestrogen. It is now accepted that such women face an increased risk of early morbidity and mortality (Shuster et al. 2010).

While menopause is a natural phenomenon that many women experience, it can influence their sexuality and sexual response (Basson 2005). Changes in sexual activity and behaviour are commonly observed during the menopausal transition. The menopause transition is the period preceding women's last menopausal period, usually starting at age of 40s and ending at last menopausal period when women are then in postmenopause (Harlow et al. 2012).

Sexual dysfunction can arise during the menopausal transition and afterwards, primarily attributed to hormonal changes. Women's sexual dysfunction is a complex issue with multiple causes and dimensions (Ambler, Bieber, and Diamond 2012). It is defined as problems in sexual response or pleasure which cause significant difficulties (Shepardson and Carey 2016). Menopause can exert a notable influence on women's sexual and intimate relationships, which in turn can have a negative impact on psychological well‐being and intimate relationships.

Quantitative studies have found that women report a range of positive, negative or neutral opinions towards sexuality around the menopause (Dasgupta and Ray 2017; Bello and Daramola 2016; Nappi and Nijland 2008; Peeyananjarassri et al. 2008). Women experience sexual changes such as a decreased sex drive which could affect their individual lives (Nappi and Nijland 2008). Examples of positive attitudes towards menopause reported in the literature were the end of menstruation (Bello and Daramola 2016; Berterö 2003; Ballard, Kuh, and Wadsworth 2001) and the lack of the risk of becoming pregnant (Bello and Daramola 2016) and that, in some cultures, women are seen as more valuable as they age (Dasgupta and Ray 2017). Negative attitudes were related to feeling incomplete as a woman, desiring to have children but no longer being able to (Bello and Daramola 2016) and feeling less attractive due to bodily changes after menopause (Dasgupta and Ray 2017).

With an increase in life expectancy, by 2050 it is estimated that the number of women over the age of 60 will exceed 1 billion (World Health Organization 2023). The median age at natural menopause is between 49 and 52 years of age (Takahashi and Johnson 2015; Morabia and Costanza 1998). In 2019, the average life expectancy worldwide was 73.4 years (WHO 2019). The number of women in the menopause transition is therefore high and will continue to grow. For this reason, it is important to understand women's experiences of menopause. However, this type of research is lacking, in comparison to the quantitative biomedical research literature, especially research focussing on intimacy and sexuality during menopause from women's own perspectives. There is no review in the literature that summarises the evidence taken from qualitative findings around women's experiences of their intimate and sexual relationships in the context of menopause. It is therefore important to capture the richness and complexity of the phenomenon investigated by carrying out a qualitative synthesis review.

As there is little qualitative research to understand the sexual experiences of women during the menopause transition, it is useful to nurses and allied health professionals if we aggregate the available qualitative evidence on sex at menopause. Nurses play a significant role in improving women's health, including sexual health, by providing advice and support (Tremayne and Norton 2017). Nurses support women in different areas of healthcare, therefore, it is beneficial that nurses possess the knowledge and expertise required to assess women's sexuality. Such knowledge will not only enhance their skills but also support effective clinical practice. Understanding menopausal sexuality is of importance due to the significant role nurses play, especially in providing holistic patient care. Nurses contribute significantly to improving patient outcomes and quality of life by enhancing their ability to provide comprehensive support and guidance to women at this stage.

This review offers comprehensive insights on this matter to all healthcare professionals, enabling them to develop a more nuanced comprehension of women's sexuality during the menopausal phase.

1.1. Aims

The purpose of this review was to perform a qualitative synthesis of the literature to explore women's experiences of their intimate and sexual relationships in the context of menopause.

2. Methods

A synthesis of qualitative studies was conducted to obtain a preliminary assessment of the size and scope of the existing research literature (Grant and Booth 2009), map the literature in a comprehensive and systematic way (Halas et al. 2015) and identify gaps and explain concepts of the research conducted (Munn et al. 2018). We used Arksey and O'Malley's framework for conducting this review (Arksey and O'Malley 2005). Thematic analysis as proposed by Braun and Clarke (2006) was used to provide a narrative synthesis of the data. The preferred reporting items for systematic reviews and meta‐analyses extension for scoping reviews (PRISMA‐ScR) Checklist (Tricco et al. 2018) (Appendix S1) was also adhered to.

A review question was developed using PICO (population, interest, comparison and outcome) question development framework criteria adopted by the Cochrane Collaboration (O'Connor, Green, and Higgins 2008). All elements of PICO do not have to be used in a search, but population and interest are almost always included and often merged with a number of terms for study (Fineout‐Overholt and Johnston 2005; Table 1).

TABLE 1.

PIO format.

Population Intervention Outcome
Women Menopause after 12 months of amenorrhea Impact on sex; relationship; intimacy
Alternative terms
Female Effects
Females Effect
Woman Impacts
Lady/Ladies Sex
Older woman Intimacy
Menopausal women Relationship
Sexual relationship
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2.1. Inclusion and Exclusion Criteria

Inclusion and exclusion criteria were applied to help determine the focus and scope of the review (Aveyard 2014). The criteria were considered when selecting the studies for review published in English language, anywhere in the world, between January 2005 and July 2023. This review included empirical studies focusing on menopause (natural menopause in healthy women, excluding those with chronic diseases or addictions), relationships and sex and published qualitative studies in English peer‐reviewed journals (Table 2).

TABLE 2.

Inclusion and exclusion criteria.

Inclusion criteria Exclusion criteria
Empirical research studies focusing on menopause, relationships and sex Studies focused only on treatment methods, ill women, specific illnesses or addictions
Publications written in English Publications not written in English
Studies published in peer‐reviewed journals
Studies published between 2005 and 2023
Type of studies: qualitative Type of studies: quantitative, randomised control trial, quasi‐experimental, case–control and cohort studies
Literature reviews, nonempirical work, thought pieces and commentaries
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2.2. Search Strategy

A comprehensive literature search using the five major search engines, which were ASSIA, CINAHL, PubMed, PsycINFO and Web of Science, was conducted. These are well‐known databases which capture the breadth of the international health sciences literature. We also searched Google Scholar and used backward (referring to the reference lists of relevant articles) and forward chaining (referring to articles which cited relevant articles) to increase the number of results, to identify results not listed in the databases and to ensure that no relevant literature was omitted.

Keywords used in the search were ‘menopause’, ‘Postmenopausal women’, ‘Relationship’, ‘sex’, ‘relationship*’, ‘intima*’, ‘menopause and intimacy’, ‘menopause AND relationship AND sex’, ‘postmenopausal women AND sex AND relationship*’, ‘postmenopausal women AND intima*’ and ‘postmenopausal women AND intima* AND relationship*’. Attention was paid to ensure that relevant studies were not missed due to differences in the terminology and between British and American English.

2.3. Data Management and Extraction

A total of 7188 studies were retrieved, as indicated in the flow diagram (Figure 1). These studies were imported into the Mendeley reference manager. The title and abstract of each article were reviewed to determine their eligibility. In some cases, more detailed information was required to assess the suitability of certain articles, leading to a thorough reading of the full articles. After removing 1524 duplicates, 5664 articles remained. Among these, 5546 nonrelevant studies were excluded following a review of their titles, abstracts and full texts. A total of 86 full‐text articles were assessed for eligibility, but 68 were subsequently excluded for various reasons (not meeting eligibility criteria (n = 32) and not fitting eligible study design or research type criteria (n = 36)). This left 18 qualitative articles which were reviewed.

FIGURE 1.

FIGURE 1

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Flow chart of the initial inclusion process for literature. [Colour figure can be viewed at wileyonlinelibrary.com]

The included studies centred around natural menopause in healthy women, excluding those with chronic diseases or addictions. These studies explored various facets such as menopause, sexuality, relationships, sexual problems, intimacy and experiences related to sexual life. Qualitative studies that delved into perspectives, attitudes, understandings and experiences concerning menopause and sexuality were encompassed in this review.

The excluded studies focused upon issues such as surgical menopause, women with diverse health conditions like polycystic ovary syndrome, breast cancer, heart disease, migraine, diabetes, obesity, Alzheimer disease, depression in women in menopause, or women with HIV infection, colorectal cancer, alcohol consumption or depressive conditions. Studies involving women undergoing specific treatments such as hormone replacement therapy, oral contraceptives, vitamin D, serum parathyroid hormone and sex therapy techniques were also excluded. Furthermore, quantitative and experimental studies, as well as literature reviews, nonempirical work, thought pieces and commentaries, were not considered. Additionally, publications with quantitative studies including RCTs, quasi‐experimental, case–control and cohort designs were excluded. The inclusion criteria emphasised a qualitative exploration of the menopause, sexuality and relationship experiences in healthy women while excluding studies that primarily assessed medical treatments or targeted specific illnesses or populations.

Research into the impacts of surgical menopause indicates that if a hysterectomy is performed for benign conditions, it can have a positive effect on psychological well‐being and sexual function. Conversely, women with a history of depression or sexual issues before surgery are more likely to experience negative changes in their psychological state and sexual desires afterwards (Shifren and Avis 2007). Additionally, a positive correlation has been observed between experiencing multiple sexual functionality problems and perceiving higher intensity levels of menopausal symptoms, particularly among women who undergo menopause as a result of surgical procedures (Topatan and Yildiz 2012). Since surgical menopause or health problems may have an impact on women's menopause experiences, such an exclusion was deemed appropriate in the analysis of the data because it may cause confusion in the experiences of healthy women who went through menopause naturally.

This literature review was performed as part of PhD study. The literature search, screening and analysis were undertaken by HB, and the coauthors (SH, PA and HP) were involved throughout the process, providing regular feedback and reviewing the details and progress of the search.

2.4. Data Analysis

Literature selection process began with extracting and tabulating information from studies. A data collection table was created to collect and record general data about the studies. To facilitate examination of the included studies, separate extraction tables for qualitative studies were prepared. Relevant information such as the aims of the study, its design, its country, setting and geographical location, the sampling method, the participants, data collection and data analysis were extracted. The findings from the qualitative studies were analysed and key themes were identified. The flowchart of the study selection process is shown in Figure 1.

3. Results

The key findings obtained from the review are presented in six main themes which are as follows: the meaning of menopause to women in different cultures; factors affecting women's sexual lives; changes in sexual desire and orgasm; talking about sexual issues; women's attempts to overcome the impact of ageing and menopause on their sexual lives; and concerns about partner sexual satisfaction during the menopause. These themes interconnect and will be discussed in the following sections.

3.1. Description of Qualitative Studies: Setting, Population and Design

Eighteen qualitative studies were included in this review. These studies had been conducted in 11 countries: Australia (Ussher, Perz, and Parton 2015), Brazil (Feltrin and Velho 2014), China (Ling, Wong, and Ho 2008), Indonesia (Vidayanti and Retnaningsih 2020), Iran (Moghasemi et al. 2018; Ghazanfarpour, Khadivzadeh, and Roudsari 2018), Italy (Faccio et al. 2017), the Republic of Ireland (Hyde et al. 2011), Sweden (Lycke and Brorsson 2023), Taiwan (Yang et al. 2016), the United Kingdom (Bellamy, Gott, and Hincliff 2013; Hincliff, Gott, and Wylie 2012; Hincliff, Gott, and Ingleton 2010; Hincliff and Gott 2008) and the United States (Thomas et al. 2020, 2022; Nosek, Kennedy, and Gudmundsdottir 2012; Wood, Mansfield, and Koch 2007).

Not all of the studies solely include pre‐, peri‐ or postmenopausal women; some of them included the perspectives of healthcare professionals (Ghazanfarpour, Khadivzadeh, and Roudsari 2018; Faccio et al. 2017). Twelve studies involved perimenopausal, postmenopausal and women in menopause; four studies had participants who were women from different age groups. The ages of participants ranged from 20 to 83 years. One study was with midwives and general practitioners and one study included both women and men as well as health practitioners (gynaecologists and psychologists).

The data from all of the studies had been collected using individual interviews and focus groups. Sample sizes ranged from 12 to 146 participants. Different data analysis methods were used in the studies, including the phenomenological approach, grounded theory, thematic analysis, content analysis, Foucauldian discourse analysis, ethnographic material, template analysis, a material discursive framework, a narrative analysis methodology and Graneheim and Lundman's approach (see Appendices S2 and S3) (Table 3).

TABLE 3.

Description of qualitative studies.

Countries Participants Data collection Sample size Age range Data analysis methods
Australia, Brazil, China, Indonesia, Iran, Italy, the Republic of Ireland, Sweden, Taiwan, the UK and the US Perimenopausal, postmenopausal women, women in menopause, men, midwives, general practitioners, health practitioners Individual interviews, focus groups 12 to 146 20 to 83 years Phenomenological approach, grounded theory, thematic analysis, content analysis, Foucauldian discourse analysis, ethnographic material, template analysis, material discursive framework, narrative analysis methodology and Graneheim and Lundman's approach
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3.1.1. The Meaning of Menopause to Women in Different Cultures

The findings of this review demonstrate that menopause had both positive and negative meanings for women across different countries: Iran, China, Australia, Taiwan and Sweden respectively (Lycke and Brorsson 2023; Moghasemi et al. 2018; Yang et al. 2016; Ussher, Perz, and Parton 2015; Ling, Wong, and Ho 2008). For example, Moghasemi et al. (2018) found that some participants had a positive opinion as they believed that there would be no unwanted pregnancies and no need to interrupt sexual intercourse due to menstrual bleeding. In contrast, some participants in that study believed that menopause caused health problems such as backache and removed the possibility of having children. Similarly, Ling, Wong, and Ho (2008) and Lycke and Brorsson (2023) reported that some women in menopause experienced a sense of relief, as they were no longer burdened with concerns about the risk of pregnancy, the hassles of menstruation and the necessity for contraceptive measures. With this, most participants emphasised that menopause triggered numerous hormonal and physiological changes. Consequently, some participants expressed sentiments such as ‘I feel like half a man’ after experiencing menopause (Ling, Wong, and Ho 2008) and some women associated menopause with the concept of older age. On the positive side, advancing age often brings about increased wisdom and self‐confidence, and on the negative side, it can entail changes in physical appearance that come with the ageing body (Lycke and Brorsson 2023).

These results echo those reported by Yang et al. (2016), who found that Taiwanese peri‐ and postmenopausal women saw menstruation as a symbol of femininity and stated that they did not feel like women after menopause; for them, menopause was seen as the loss of a sense of femininity and loss of interest in sex such as only having sexual activity twice a year.

Other studies had similar findings. Ussher, Perz, and Parton (2015) found that some Australian women perceived menopause positively because it meant the end of menstruation and getting pregnant, whereas others saw it negatively since they connected menopause with increasing age. However, it is important to be aware that the sample here included women who had different kinds of menopause experiences, such as premature menopause caused by cancer treatment. Nevertheless, the authors offered no explanation for the similarities between the participants' opinions: women might have a negative experience if their menopause is premature or medically induced. For instance, since some women in the study had premature menopause after cancer treatment, which was unexpected, they thought that it came too early. Also, premature menopause represented feeling old for some of these women.

3.1.2. Factors Affecting Women's Sexual Lives

The three subthemes in this theme intersect: the effect of menopausal symptoms and health problems, changes in body image and nonmenopausal factors. They highlight how the women's lived experiences of the menopause transition can influence their sexual and intimate relationships, and that the latter cannot be detached from the social contexts of the women's lives.

3.1.2.1. The Impact of Menopausal Symptoms and Health Problems

This review identified that menopausal symptoms such as decreased sexual desire and vaginal dryness can have a significant impact on women's sexuality (Ghazanfarpour, Khadivzadeh, and Roudsari 2018; Yang et al. 2016; Ling, Wong, and Ho 2008; Wood, Mansfield, and Koch 2007). It has also shown that hormonal and physiological changes in the form of hot flushes, vaginal dryness (Yang et al. 2016; Ghazanfarpour, Khadivzadeh, and Roudsari 2018; Ling, Wong, and Ho 2008), pain during vaginal penetration and mood changes negatively affect women's willingness to engage in sexual intercourse. A qualitative study conducted in Indonesia found that more than half of the sample reported experiencing negative changes in their sexual relations during the postmenopausal period. Similar to the findings of previous studies, the main reason for this was decreased libido, vaginal dryness and pain during sexual intercourse due to vaginal discomfort (Vidayanti and Retnaningsih 2020). In the study by Thomas et al. (2020), the participants reported that one of the most common causes of low libido was vaginal symptoms, and this is the main sexual problem they would prefer to have treated (Thomas et al. 2020).

In the United States, Wood, Mansfield, and Koch (2007) reported that symptoms such as severe hot flashes made women nervous and less interested in sex. Additionally, women's health problems such as vaginal fistula or their partner's health problems such as diabetes, hypertension, cardiac problems and some medications (Ghazanfarpour, Khadivzadeh, and Roudsari 2018), kidney problems and cardiovascular illnesses (Ling, Wong, and Ho 2008) had an impact on sexual performance and the regularity of sexual intercourse. For instance, one postmenopausal woman was ashamed because of a vaginal fistula and had concerns about flatulence during intercourse and so avoided sexual encounters (Ghazanfarpour, Khadivzadeh, and Roudsari 2018). All of these studies, from various countries, tell us that menopausal symptoms and health problems point to the need to consider the impact of menopause on sexuality.

3.1.2.2. Changes in Body Image at the Menopause Transition

With the menopausal transition, some women reported experiencing a negative body image, did not feel comfortable being naked in front of their partners and did not want to share a bed with their partners (Ghazanfarpour, Khadivzadeh, and Roudsari 2018). However, the authors did not explain exactly why women had a negative body image during menopause (Ghazanfarpour, Khadivzadeh, and Roudsari 2018). Similarly, Ussher, Perz, and Parton (2015) found that women worried that their partners would not find them attractive after menopause and this in itself affected their own sexual desire and activity level. In addition, a study conducted in the United States by Thomas et al. (2020) reported that women's concerns about their changing body image due to age‐related or menopausal weight gain reduced their libido which led to them feeling less feminine and less attractive.

3.1.2.3. Family and Other Nonmenopausal Factors That Influence Sexuality

Some of the studies demonstrated that women's sexual lives are affected not only by menopausal factors but also by the experiences of their past and present life and relationships (Ghazanfarpour, Khadivzadeh, and Roudsari 2018; Feltrin and Velho 2014; Hyde et al. 2011). For example, in the Republic of Ireland, 25 postmenopausal women in Hyde et al.'s (2011) study linked past and present experiences of relationships and life stressors. For example, a history of abuse during childhood and current problems, such as having a child with drug addiction, could affect their present sexual relationship. Thomas et al. (2020) also found that stress in life such as worries about children caused a decrease in women's libido. Feltrin and Velho (2014) suggested that even if sexual problems are related to menopause, women might also be affected by events which occurred when they were younger. These current and past life experiences and stressors meant that women could not think of sex because of their responsibilities. For example, the obligations of their daughter's wedding preparations, to look after their grandchildren and the divorce and separation of their children often had a negative impact (Ghazanfarpour, Khadivzadeh, and Roudsari 2018). Likewise, in Australia, Ussher, Perz, and Parton (2015) concluded that sexual difficulties or disinterest in sex were related more to psychosocial factors than hormonal factors and Hincliff, Gott, and Ingleton (2010) found that women's sexual life during menopause was affected by not only biological factors but also psychosocial factors such as women's sexual history and issues with their current partners. Taken together, these results indicate the importance of the biopsychosocial approach to menopause.

After qualitative interviews with women aged 50 and over in the United Kingdom, Hinchliff and Gott (2008) reported that some women viewed their level of sexual desire as connected with hormonal changes as well as in response to the desire of their male partner. They found that women discussed the effect of various factors such as religious beliefs, parental attitudes, past and present relationships and partnerships in influencing and changing the importance of sexual activity. Bellamy et al. (2013) reported that whereas some women expressed that their sexual problems were physical, others believed that physical and psychological factors played a role. Nosek, Kennedy, and Gudmundsdottir (2012) found that the relationships women had with themselves, their partners, their work colleagues and family members had an impact on menopause‐related problems, especially emotional imbalance and a lack of sexual desire. Interestingly, in one study the most common cause of low libido among postmenopausal women was reported to be erectile dysfunction in their partners (Thomas et al. 2020). One of the reasons for this was that the woman did not have enough time to reach orgasm since her partner could not maintain an erection for a long time (Thomas et al. 2020). These findings imply that the sexual lives of women at midlife and menopause are influenced by many intersecting factors and not just the symptoms of menopause.

Evidence from these studies shows that women can feel a sense of responsibility for sex with their partners and view it as necessary for relationship stability (Yang et al. 2016; Ussher, Perz, and Parton 2015; Hincliff, Gott, and Ingleton 2010; Wood, Mansfield, and Koch 2007). For instance, in qualitative interviews with 18 pre‐ and postmenopausal women in Taiwan, Yang et al. (2016) reported that some women believed that the sexual needs of their partners should be met without regard to their own wishes. Similarly, in studies conducted in Western societies, some women believed that sex is a woman's obligation and that she therefore has to respond to her partner's sexual needs (Wood, Mansfield, and Koch 2007; Hincliff, Gott, and Ingleton 2010). Indeed, women continued to engage in sexual intercourse even if they had little desire for it because they thought it was important for their relationship (Ussher, Perz, and Parton 2015). Hincliff, Gott, and Wylie (2012) reported that women with sexual problems such as no desire and/or sexual pain engaged in sexual intercourse for a variety of reasons, such as anxiety that their partners might seek another woman, not knowing what else to do and to satisfy their own sexual pleasures although they felt unwilling and knew that sexual intercourse would cause pain. Interestingly, the studies also showed that women can feel guilty about not meeting their partners' sexual needs due to low sexual desire at menopause (Yang et al. 2016; Hyde et al. 2011). In addition, two qualitative studies in different countries, China (Ling, Wong, and Ho 2008) and the Republic of Ireland (Hyde et al. 2011), showed that women thought that men needed more sex than women. They believe that men have a biological urge to engage in sexual activity more than women and that they spend more time thinking about, preparing and prioritising sexual activity, while women are preoccupied with household chores.

3.1.3. Changes in Sexual Desire and Orgasm

There were mixed findings when it came to sexual desire at the menopause. Studies conducted in China and the Republic of Ireland showed that postmenopausal women experienced reduced sexual desire with menopause (Ling, Wong, and Ho 2008; Hyde et al. 2011). Hincliff, Gott, and Wylie (2012) reported that women talked about various tactics such as being busy with housework, saying that they were tired, in pain or going to bed early or late to avoid sexual intercourse due to a lack of sexual desire. Yang et al. (2016) reported that most women in their study (72%) stated that they had a change in their feelings about their sex life after menopause. However, not all women experienced a decrease in sexual function. For instance, studies in the United Kingdom and Australia found that sexual desire and frequency of sexual intercourse increased during menopause (Hincliff, Gott, and Ingleton 2010; Ussher, Perz, and Parton 2015).

3.1.4. Talking About Sexual Issues

Talking about sexual issues was a key theme and included talking with healthcare providers and with other people, such as friends.

3.1.4.1. Talking About Sexual Concerns With Healthcare Providers

The evidence from this review suggests that women experience a lack of adequate discussions about sex and ageing, particularly in interactions with their doctors (Thomas et al. 2022; Feltrin and Velho 2014; Wood, Mansfield, and Koch 2007). In a study conducted with postmenopausal women in the United States, Wood, Mansfield, and Koch (2007) found that almost all the participants said that they talked with doctors or other health practitioners only about menopausal issues such as vaginal dryness, vaginal pain or discomfort. But when women told doctors about their sexual concerns, the doctors gave them very little useful information to reduce their problems. Similarly, in a study conducted with postmenopausal women in Southern China, Ling, Wong, and Ho (2008) found that most of the participants said that doctors did not ask about their sexual concerns during regular physical check‐ups.

In Brazil, a study conducted with women in menopause outpatients at a Women's Healthcare Centre by Feltrin and Velho (2014) found that some women believed that doctors did not consider issues such as lack of sexual desire as important and that doctors believed that the menopause was a disease to be treated caused by hormonal changes. In Iran, Ghazanfarpour, Khadivzadeh, and Roudsari (2018) reported that women preferred to seek help about sexual issues from friends, peers or traditional medical practitioners instead of healthcare providers.

These findings tell us that there is little adequate communication between healthcare providers and women in menopause on sexual issues. Also, sexual issues are not sufficiently spoken about, women do not get enough information and do not always feel comfortable talking about sexual issues with healthcare providers. More importantly, some doctors see menopause solely as a physiological phenomenon even though it is a complex issue with both physiological and psychological implications.

3.1.4.2. Talking About Sexual Concerns With People Other Than Healthcare Providers

The studies suggested that most women do not generally talk about sexual difficulties with other people. Two key reasons for this were the topic being taboo (Wood, Mansfield, and Koch 2007) and the fear of being judged (Ling, Wong, and Ho 2008). Generally, they did not talk to their female friends (Wood, Mansfield, and Koch 2007) or romantic partners (Feltrin and Velho 2014). Communication is important for women because one study found that women who were able to talk about sex with their partners were less likely to have sexual desire problems and were more satisfied with their sexual experiences (Wood, Mansfield, and Koch 2007). Another finding was the fear of stigmatisation, which was an obstacle for Chinese women to discuss sexuality and not seek medical help (Ling, Wong, and Ho 2008). That study indicated that social value judgements can potentially interfere with seeking social support and medical advice for sexual matters. It is clear, therefore, that cultural barriers can make talking about sex generally more of a taboo.

3.1.5. Women's Attempts to Overcome the Impact of Ageing and Menopause on Their Sexual Lives

This review also identified that women seek various strategies to avoid the physical discomfort of sexual intercourse or the lack of sexual desire (Ghazanfarpour, Khadivzadeh, and Roudsari 2018; Moghasemi et al. 2018; Yang et al. 2016). For example, peri‐ and postmenopausal women developed a range of personal strategies to reduce their problems by taking hormone replacement, watching adult films, communicating and adjusting sexual positions and increasing their daily exercise (Yang et al. 2016). Women also used different strategies such as faking orgasms, getting help from friends or from traditional medicine, and perhaps because of culture, a few women in menopause spoke of an emotional and sexual gap with their husbands and described visiting charm writers to use magic or similar techniques to bring their husbands closer (Ghazanfarpour, Khadivzadeh, and Roudsari 2018). Another study in Iran reported that the majority of the participants took several initiatives including wearing make‐up, face massage and cosmetic surgery, such as liposuction and pelvic prolapse repair for cystocele to increase their sexual attraction and own sexual interest (Moghasemi et al. 2018). Participants in a recent study reported that they were looking for a solution by increasing healthy nutrition and physical activity while struggling with the sexual changes they experienced (Vidayanti and Retnaningsih 2020). These results show the strategies used by Iranian, Indonesian and Taiwanese women can be similar, thus it would be useful to know if women from other cultures do the same.

3.1.6. Concerns About Partner Sexual Satisfaction During the Menopause

The review showed that the majority of Chinese postmenopausal women were concerned that their partners might have extramarital relationships in order to meet unmet sexual needs (Ling, Wong, and Ho 2008). Likewise, in another qualitative study in Taiwan, Yang et al. (2016) reported that some women in menopause had expressed their guilt and concern that their partners or husbands might prefer to have extramarital affairs. This was reported in America too where a study involving postmenopausal women revealed that they were apprehensive about the potential consequences of reduced libido, which could be a diminished emotional closeness with their romantic partners or an inability to satisfy their sexual needs (Thomas et al. 2022).

Some Iranian women were also found to be worried that their spouses had a negative attitude towards menopause because men thought that menopause and older women were ‘unsexy and good‐for‐nothing’ (Moghasemi et al. 2018). Conversely, in Iran, Ghazanfarpour, Khadivzadeh, and Roudsari (2018) found that women were less concerned about this issue. One of the reasons they suggested is that in that culture, men are older than women, and therefore women are less likely to be betrayed by their husbands. The studies reviewed indicate the influence of sociocultural features and gender roles on women's experiences of menopause and suggest that more research is needed to explore concerns and fears about low sexual desire in the relationship.

4. Discussion

This qualitative synthesis explored women's experiences of their intimate and sexual relationships in the context of menopause. Eighteen studies from 11 countries were included and six themes and five subthemes were identified. Key findings show several significant aspects pertaining to the sexual experiences of women in menopause. Primarily, the sexual lives of women in menopause are influenced by not only menopausal symptoms but also psychosocial factors. Furthermore, women in menopause may have difficulty talking to their healthcare providers and other people about their sexual difficulties. Despite these obstacles, menopausal women have found various strategies with individual efforts to overcome the problems they experience in their sexual lives. Moreover, a prevalent finding was that women at menopause can experience anxiety and fear about their relationship and partner's unmet sexual needs. From this review, it seems that gender roles significantly influence how women view and experience menopause, particularly in shaping their perspectives around sex interests and femininity.

Many women in these studies reported an impact on their sense of womanhood after menopause. This is interesting because it tells us something about the gender roles in China and Iran, where the studies were conducted, and the construction of womanhood. For example, it shows us that women's role in those societies is viewed as closely related to fertility. The fact that women lose their reproductive ability because of menopause might cause them to think that they have lost their role in society.

Indeed, previous research has shown that women's perception and experience of menopause seem to be influenced by cultural values and health beliefs (Nappi and Nijland 2008) and older women are seen as more valuable in but only in certain cultures (Dasgupta and Ray 2017). Women after menopause may feel incomplete as a woman (Bello and Daramola 2016), and feel less attractive (Dasgupta and Ray 2017). In some societies, sexuality can be seen as taboo in women's traditional lifestyle of obedience and thus menopause is seen as a reduction of sexuality (Yücel and Eroǧlu 2013). However, women can have a positive view of sexuality in menopause and almost all of them see having sex as something that could continue in some societies (Peeyananjarassri et al. 2008). Spiritual and religious behaviour could also influence their sexual knowledge and attitudes (Golzari et al. 2020). These findings support those of an integrative review of the international literature which emphasised the impact of sociocultural factors on women's perimenopause and menopause experiences (O'Reilly et al. 2023).

The findings of the present review suggest that there is a need for more contextual, longitudinal, multicultural and qualitative research on women's self‐perceptions of sex in menopause. For this reason, in this review, the cultures in which the studies were carried out were specifically stated in the findings section. The present review also highlighted that the sexual lives of women are influenced by various factors related to menopause, such as a decline in oestrogen levels and the resulting symptoms. It is also seen that the influence of ageing, health problems, quality of relationships and nonmenopausal factors. The findings of this review suggest that we need to develop different strategies for understanding and supporting women through menopause if they experience problems, other than just medical treatment. The overall findings indicate that women often shoulder the responsibility for their male partner's sexual pleasure without regard to their own wishes. This finding was clear in studies conducted in different geographical areas and suggests therefore that sociocultural factors and gender roles have a similar impact on women's sexual attitudes and behaviours regardless of their location.

Only a few of the studies reviewed had focused on women's sex lives after menopause and the findings from those were mixed. However, the broader quantitative studies literature found that there is a decrease in sexual desire in women in menopause (Yücel and Eroǧlu 2013; Moghassemi, Ziaei, and Haidari 2011; Nappi and Nijland 2008; Nobre and Pinto‐Gouveia 2006). The findings of the review suggest that there is a diversity with regard to the sexual changes which women can experience at menopause, and this represents a research gap in this area.

This review highlights the need to improve communication between women in menopause and healthcare providers about sexual issues. The recurrence of similar findings across studies from diverse geographical locations (such as the United States, China, Brazil and Iran) highlights a shared concern among women in menopause. Besides, the studies only addressed the relationships between doctors and women: nursing, as a discipline responsible for caring for people, needs to be involved in such research alongside efforts to support conversations with menopausal women about sexual issues (González‐Soto and Guerrero‐Castañeda 2022).

This may have influenced the results of this review due to the fact that some of the studies included were especially conducted in male‐dominant cultures like Iranian society (Ghazanfarpour, Khadivzadeh, and Roudsari 2018). Additionally, as noted by the authors, upbringing can serve as a barrier to seeking treatment (Ghazanfarpour et al. 2017) because women in menopause may be able to enjoy their sexual life when an open conversation with their sexual partners and medical doctors is ensured and pharmacological treatments are preferred (Yang et al. 2016; Winterich 2003). The findings in this review demonstrate that women in menopause have used various strategies to improve their sex lives rather than medical help like Hormone replacement therapy (HRT). Support programmes such as education can be organised in line with women's need for support other than medical assistance, and in line with these needs. In addition, it can be said that women's reluctance to use HRT and their anxiety about its side effects are seen as an obstacle or a barrier at the point of seeking medical help.

As demonstrated by the review findings, women experience fear of losing their relationships, when they do not satisfy partners sexually, and one of the underlying reasons is sociocultural factors and gender roles. Similarly, Hoga et al. (2015) found that sociocultural factors influence women's sexual experience during the menopause. Healthcare providers and nurses undertake an important task in this sense. They can support women and men to have healthier communication with their partners during the menopause process. It can help couples how to deal with these problems that menopause brings and reflects on both sexuality and relationships.

This review highlights that a lack of knowledge about menopause towards menopause can have a negative impact on coping with the effects of menopause on relationships and intimacy. These results suggest that we need to develop different strategies for understanding and supporting women through menopause if they experience sexual problems, other than just medical treatment.

4.1. Strengths and Limitations

This review has provided insight into the empirical literature on women's experiences of their intimate and sexual relationships in the context of menopause. In particular, it has highlighted how women's experiences of sex and intimacy during the menopause transition can differ and encompass much more than the biological symptoms including the influence of sociocultural factors. While there are variations in these experiences, as well as differences in problem‐solving approaches among women, they nonetheless share common challenges.

However, this literature review has limitations. First, only the English literature is included, which means research published in other languages has not been considered, therefore potentially omitting important information from those sources. Second, the data obtained from the studies in different countries are likely to be affected by culture, race, geographical location and ethnicity because there are cultural differences in the experience and understanding of menopause. Some of the studies were conducted in male‐dominated societies, such as Iran, and this may have influenced the results. When looked at from another perspective, the fact that this review is cross‐cultural and inclusive can also be seen as a strength. Overall, differences in the samples of participants in the studies were observed. For example, the participants in some studies had a wide age range or included men and healthcare professionals as well as women. However, since the evidence of these studies was thought to contribute to the purpose of the review, they were included nonetheless.

5. Conclusion

This review of the qualitative literature has shown that women going through the menopause transition can experience symptoms that have a serious impact on them psychologically and physiologically. The studies have indicated that menopause is unique to every woman and is influenced by many factors. This review has clearly shown that sex and intimacy at menopause should be viewed in a social and cultural context.

6. Relevance to Clinical Practice

The conclusions drawn from this review will provide valuable assistance to nurses in formulating, executing and facilitating comprehensive care strategies for women in the menopause transition. This support is particularly crucial within the context of delivering healthcare services, as it acknowledges that menopause encompasses not only physiological implications but also extends to the intricate interplay of sexual and relational dimensions. Nurses can plan educational activities that take into account the effects of menopause on women's health, utilising the insights provided by the evidence presented in this review. In order to comprehensively understand women during menopause, it is essential not to overlook their distinctive perspectives. This review functions as a valuable resource, empowering nurses to cultivate a holistic understanding of these viewpoints and adeptly address women's sexual needs while taking them into consideration.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Appendix S1

JOCN-34-1543-s003.docx (16.4KB, docx)

Data S1

JOCN-34-1543-s001.docx (84.7KB, docx)

Appendix S2‐S3

JOCN-34-1543-s002.docx (31.6KB, docx)

Funding: This study was conducted as part of a PhD funded by the Republic of Turkey Ministry of National Education. The sponsor had no role in the design and conduct of the study or the preparation or approval of the manuscript.

Data Availability Statement

Data available on request due to privacy/ethical restrictions.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Appendix S1

JOCN-34-1543-s003.docx (16.4KB, docx)

Data S1

JOCN-34-1543-s001.docx (84.7KB, docx)

Appendix S2‐S3

JOCN-34-1543-s002.docx (31.6KB, docx)

Data Availability Statement

Data available on request due to privacy/ethical restrictions.

Articles from Journal of Clinical Nursing are provided here courtesy of Wiley

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