Introduction
More than 447 million people live today in Europe (48% men and 52% women); of them, one-fifth (93 million) is between 50 and 64 years of age. It can be inferred that half of them live in couples; therefore, it can be estimated that there are around 23 million middle-aged couples.1 The physical, psychological, and relational changes faced at middle age and beyond can affect the sexual health of both members of a couple.2 Sexual problems in one partner may in turn worsen the other partner’s sexual health—for example, if the male partner has untreated erectile dysfunction, the female partner may be less motivated to treat vulvovaginal atrophy, and vice versa.2 Clinicians often must address the sexual health needs of a patient, considering the potential impact on the other partner’s health, to fulfill the real-life needs of a couple as a unit.2
To identify the main sexual health problems related to midage and to define the best approach for health care providers to develop a couple approach, a working group was created in 2022 with leading experts in the field. This article summarizes the main findings and discussion of the working group’s first online meeting, which took place on December 21, 2022.
Menopause and andropause/late-onset hypogonadism during midlife
Hormone changes and their effect in the couple
The hormonal changes experienced during midlife have a profound impact on several aspects of health and well-being, involving the sexual, psychological, and social domains.2 Table 1 summarizes the main differences regarding menopause and androgen deficiency in aging males and females.3-7 Beyond the hormonal aspect, living with a partner who is going through menopause or andropause/late-onset hypogonadism (LOH) can affect the general and sexual health of both members of the couple. In this natural aging process, it is therefore necessary to consider other biopsychosocial aspects in the light of the new systems sexology8 that influence sexual and mental health, such as the change in the social role, depression, and the possible appearance of diseases, including cardiovascular disease and prostate or breast cancer.9 As such, addressing sexual health needs during midlife must have the aim to not only improve survival but also pursue healthy aging.
Menopause and andropause/LOH: affected populations, clinical symptoms, and onset.
| Term | Menopause | Andropause/LOH |
|---|---|---|
| Definition | Permanent cessation of menstrual cycles for a year. Physiologically, menopause occurs due to the lack of mature follicles in the ovaries and subsequent reduction in estrogen secretion. | Andropause/LOH is defined as a decrease in serum testosterone below the normal range, accompanied by clinical symptoms.25 |
| Population affected | All women who live sufficiently long experience a final menstrual period, associated with estrogen deficiency. Menopause is considered a natural occurrence in women’s lives.9 | Not all men develop testosterone deficiency, and not all men with below-normal testosterone levels have clinical symptoms.26,27 |
| Possible changes related to hormone deficiency | Vasomotor symptoms, loss of concentration, irritability, arthralgia, osteoporosis, sleeping problems, greater fatigue Genitourinary syndrome of menopause: genital dryness itching, irritation Dyspareunia9 Insufficient lubrication during sexual activity Postcoital bleeding narrowing/shortening of vaginal vault Loss of pubic and other body hair Atrophy of labia and loss of vulvar fat; development of vulvar fissures Other vaginal changes, development of petechiae or ulcerations, recession, phimosis, or excessive exposure of clitoris Hypoactive sexual desire disorder | Erectile dysfunction Reduced frequency of morning erections Decreased libido Impaired ejaculatory and orgasmic function Loss of pubic hair and other body hair Decreased endurance, greater fatigue |
| Onset | After several years of menopausal transition (loss of fertility, irregular menses, and large estrogen variations), estrogen decrease is abrupt.24 The mean age of menopause is between 50 and 52 years3,4; however, it may vary from 44 to 54 years.3-5 | Although testosterone levels fall as men age, the decline is steady at about 1% a year from around the age of 30 to 40 years.28 In healthy aging men, there is a small gradual decline in testosterone; up to the age of 80 years, aging accounts for a low percentage of hypogonadism.28 |
| Term | Menopause | Andropause/LOH |
|---|---|---|
| Definition | Permanent cessation of menstrual cycles for a year. Physiologically, menopause occurs due to the lack of mature follicles in the ovaries and subsequent reduction in estrogen secretion. | Andropause/LOH is defined as a decrease in serum testosterone below the normal range, accompanied by clinical symptoms.25 |
| Population affected | All women who live sufficiently long experience a final menstrual period, associated with estrogen deficiency. Menopause is considered a natural occurrence in women’s lives.9 | Not all men develop testosterone deficiency, and not all men with below-normal testosterone levels have clinical symptoms.26,27 |
| Possible changes related to hormone deficiency | Vasomotor symptoms, loss of concentration, irritability, arthralgia, osteoporosis, sleeping problems, greater fatigue Genitourinary syndrome of menopause: genital dryness itching, irritation Dyspareunia9 Insufficient lubrication during sexual activity Postcoital bleeding narrowing/shortening of vaginal vault Loss of pubic and other body hair Atrophy of labia and loss of vulvar fat; development of vulvar fissures Other vaginal changes, development of petechiae or ulcerations, recession, phimosis, or excessive exposure of clitoris Hypoactive sexual desire disorder | Erectile dysfunction Reduced frequency of morning erections Decreased libido Impaired ejaculatory and orgasmic function Loss of pubic hair and other body hair Decreased endurance, greater fatigue |
| Onset | After several years of menopausal transition (loss of fertility, irregular menses, and large estrogen variations), estrogen decrease is abrupt.24 The mean age of menopause is between 50 and 52 years3,4; however, it may vary from 44 to 54 years.3-5 | Although testosterone levels fall as men age, the decline is steady at about 1% a year from around the age of 30 to 40 years.28 In healthy aging men, there is a small gradual decline in testosterone; up to the age of 80 years, aging accounts for a low percentage of hypogonadism.28 |
Abbreviation: LOH, late-onset hypogonadism.
Menopause and andropause/LOH: affected populations, clinical symptoms, and onset.
| Term | Menopause | Andropause/LOH |
|---|---|---|
| Definition | Permanent cessation of menstrual cycles for a year. Physiologically, menopause occurs due to the lack of mature follicles in the ovaries and subsequent reduction in estrogen secretion. | Andropause/LOH is defined as a decrease in serum testosterone below the normal range, accompanied by clinical symptoms.25 |
| Population affected | All women who live sufficiently long experience a final menstrual period, associated with estrogen deficiency. Menopause is considered a natural occurrence in women’s lives.9 | Not all men develop testosterone deficiency, and not all men with below-normal testosterone levels have clinical symptoms.26,27 |
| Possible changes related to hormone deficiency | Vasomotor symptoms, loss of concentration, irritability, arthralgia, osteoporosis, sleeping problems, greater fatigue Genitourinary syndrome of menopause: genital dryness itching, irritation Dyspareunia9 Insufficient lubrication during sexual activity Postcoital bleeding narrowing/shortening of vaginal vault Loss of pubic and other body hair Atrophy of labia and loss of vulvar fat; development of vulvar fissures Other vaginal changes, development of petechiae or ulcerations, recession, phimosis, or excessive exposure of clitoris Hypoactive sexual desire disorder | Erectile dysfunction Reduced frequency of morning erections Decreased libido Impaired ejaculatory and orgasmic function Loss of pubic hair and other body hair Decreased endurance, greater fatigue |
| Onset | After several years of menopausal transition (loss of fertility, irregular menses, and large estrogen variations), estrogen decrease is abrupt.24 The mean age of menopause is between 50 and 52 years3,4; however, it may vary from 44 to 54 years.3-5 | Although testosterone levels fall as men age, the decline is steady at about 1% a year from around the age of 30 to 40 years.28 In healthy aging men, there is a small gradual decline in testosterone; up to the age of 80 years, aging accounts for a low percentage of hypogonadism.28 |
| Term | Menopause | Andropause/LOH |
|---|---|---|
| Definition | Permanent cessation of menstrual cycles for a year. Physiologically, menopause occurs due to the lack of mature follicles in the ovaries and subsequent reduction in estrogen secretion. | Andropause/LOH is defined as a decrease in serum testosterone below the normal range, accompanied by clinical symptoms.25 |
| Population affected | All women who live sufficiently long experience a final menstrual period, associated with estrogen deficiency. Menopause is considered a natural occurrence in women’s lives.9 | Not all men develop testosterone deficiency, and not all men with below-normal testosterone levels have clinical symptoms.26,27 |
| Possible changes related to hormone deficiency | Vasomotor symptoms, loss of concentration, irritability, arthralgia, osteoporosis, sleeping problems, greater fatigue Genitourinary syndrome of menopause: genital dryness itching, irritation Dyspareunia9 Insufficient lubrication during sexual activity Postcoital bleeding narrowing/shortening of vaginal vault Loss of pubic and other body hair Atrophy of labia and loss of vulvar fat; development of vulvar fissures Other vaginal changes, development of petechiae or ulcerations, recession, phimosis, or excessive exposure of clitoris Hypoactive sexual desire disorder | Erectile dysfunction Reduced frequency of morning erections Decreased libido Impaired ejaculatory and orgasmic function Loss of pubic hair and other body hair Decreased endurance, greater fatigue |
| Onset | After several years of menopausal transition (loss of fertility, irregular menses, and large estrogen variations), estrogen decrease is abrupt.24 The mean age of menopause is between 50 and 52 years3,4; however, it may vary from 44 to 54 years.3-5 | Although testosterone levels fall as men age, the decline is steady at about 1% a year from around the age of 30 to 40 years.28 In healthy aging men, there is a small gradual decline in testosterone; up to the age of 80 years, aging accounts for a low percentage of hypogonadism.28 |
Abbreviation: LOH, late-onset hypogonadism.
Sexual dysfunction
Middle age is a time of transition for men and women. As both are faced with the expectation of a healthy sexual life at that age, its lack may cause anxiety.10 The perception of sexual dysfunction is highly conditioned by gender. In many instances, men are not aware of the changes associated with andropause/LOH, and this can lead to frustration at the loss of their sexual function. Moreover, they may not seek professional help, and in this situation, their female partners may feel ashamed or guilty.11-13 Conversely, for women, menopause is expected and is commonly assumed as a natural process; therefore, professional help is not always sought, in spite of symptoms.14 Consequently, many women may continue to have sexual intercourse with pain and without desire; in other instances, sexual relations are ceased, with the associated loss of intimacy. A decrease in sexuality felt for one or both members of the couple can create a loss in bonding that, in the absence of resources, leads to frustration.15 Pharmacologic treatment can solve some of the most frustrating problems related to sexual health (dryness, erectile dysfunction) but not all of the challenges for the couple at the time of andropause/LOH and menopause, as a lack of desire is difficult to treat in many instances.16
Couplepause: definition
Couplepause (couple transition or renewal) refers to consequences of the hormonal and age-related changes that can lead to an alteration of sexual functionality in the couple.17 The purposes of this new term include (1) to meet an unmet need of the physicians and patients dealing with it, (2) to focus on what happens to the person who is experiencing these changes, and (3) to address how the partner and one’s relationship are affected. In reference to the couplepause concept or term, it has been criticized primarily because, in the English language, it could be taken as “a pause in the couple”; it is thus necessary to reorient the term toward a couple transition or renewal. Second, it seems to refer to 2 individuals who have been in a long and happy relationship, and it also somewhat implies heterosexuality. We suggest that experts in sexual medicine, andrologists, obstetricians/gynecologists, endocrinologists, urologists, and other physicians and psychosexologists who treat menopause or andropause symptoms begin thinking in terms of couplepause: a new paradigm that considers the needs of the aging couple as a whole, in keeping with a holistic perspective.17
While dealing with couplepause, partners may have a deeper problem than just hormonal decline. Many factors may play a role, such as hormonal changes, relationship problems, social strength modifications, and concomitant diseases. For those couples who have been sexually active for many years and experience a cessation of intercourse, the mechanism may be primarily related to the lack of sexual hormones.18 However, in instances in which sexual activity ceased long before menopause/androgen deficiency, it could imply other physical or relational/intrapsychic problems. The duration of the relationship is also very conditioning. A survey reported that 50-year-old women in a new relation have intercourse more often than 30-year-old women who are in an established relation for >10 years.19 As such, the newly found relationship can condition a change that overcomes the hormonal deficit associated with menopause. Mental health changes are not solely dependent on hormones; however, the absence of hormones directly affects mood and the evolution of psychiatric conditions.20-22
Couple-thinking: when and how
In middle-aged couples, there is often a shared need for diagnosis and treatment. This is the main reason for having a new taxonomic entity such as couplepause.17 With regard to couple counseling and whether in the office of a general practitioner, andrologist, or gynecologist, the lack of time and/or the need for specific training is very common. In such cases, the physician may simply identify the problem and refer the couple to a specialized counselor or expert. Yet, if it is assumed that relationship problems are prevalent and couple care clearly appears as advantageous, it is necessary to change the paradigm and train professionals in this approach to couple-thinking. A good way to start is to focus on the follow-up visit, which can confirm whether the therapeutic solutions are useful or more intensive measures are required. The panel of experts of this working group suggests the use of a triage method, based on the color code like a traffic light (Figure 1).
Follow-up session after couple-thinking: triage method.
Diagnosing couplepause
Regarding couplepause, some initiatives of potential interest can be approached from a multidisciplinary perspective. Based on evidence and psychometric experience, the recommendation of the working group is the development of a protocol for the diagnosis of couplepause. This would allow us to quantify the prevalence for which, despite the presence of sexual dysfunction, there is no real commitment of the couple as a whole. The resulting information could be used in communication to health professionals and the public. With regard to generation of evidence and after having defined the research question, it would be interesting to analyze recent published surveys and, based on the information available, determine what data are missing. For that, a thorough search should be conducted in different databases, including heterosexual and homosexual couples.
Data collection
A prospective sample survey should be designed to allow detailed analysis of all the sexual changes that men and women experience during midlife, including all sexual orientation. The survey should be carried out with the participation of a multidisciplinary group of physicians and health experts, including gynecologists, urologists, psychiatrists, and psychologists. It is also critical to determine whether what is happening in their lives is different from what the specialists suppose. In this sense, mixed methods (survey and personal interviews) may be necessary to approach the analysis. In summary, it is essential to create a viable and scientifically sound tool that allows the collection of data in multiple countries and the understanding of different cultural backgrounds.
Target population
Under the assumption that the prevalence of the problem is likely to be high and underestimated, it is essential to ensure that the target population is correctly identified. In this sense, it will be critical to collect the data of individuals who agree to participate, as well as those who refuse and the reasons behind the refusal, to avoid response bias.
How to increase the couple implication: breaking barriers
Barriers in seeking medical help and discussing sexual issues dramatically affect the ability of the doctor to help patients in couplepause. The aims to be pursued in breaking these barriers should be as follows: (1) focusing on a midlife couple model in which menopause and andropause/LOH are de-emphasized and defining this period as a new beginning, promoting a healthy sex life and overall well-being; (2) enhancing education so that men and women understand the changes in function and sexual behavior associated with aging, thereby becoming more involved in symptom control and self-care to make the necessary changes together and more effectively. Regarding educational interventions, the development of materials for couples could help them understand the organic changes that occur throughout life and the consequences. Health professionals should acquire basic skills to address sexual health during consultation with one or both members of the couple. It would be necessary to provide targeted training by speciality.23 The most complex intervention would always be intensive therapy, in which the couple is treated jointly. In conclusion, it appears that educational efforts directed not only to the patients but also for the doctors involved in diagnosing and treating couplepause appear to be the best strategy to deal with this frequent condition.
Author contributions
All authors contributed extensively to the work presented in this article. All authors contributed significantly to the conception, design, or acquisition of data or the analysis and interpretation of data. All authors participated in drafting, reviewing, and/or revising the manuscript and have approved its submission.
CRediT author Statement
S Rozenberg (Conceptualization-Equal, Data curation-Equal, Formal analysis-Equal, Funding acquisition-Equal, Investigation-Equal, Methodology-Equal, Project administration-Equal, Resources-Equal, Software-Equal, Supervision-Equal, Validation-Equal, Visualization-Equal, Writing – original draft-Equal, Writing – review & editing-Equal), RE Nappi (Conceptualization-Equal, Data curation-Equal, Formal analysis-Equal, Funding acquisition-Equal, Investigation-Equal, Methodology-Equal, Project administration-Equal, Resources-Equal, Software-Equal, Supervision-Equal, Validation-Equal, Visualization-Equal, Writing – original draft-Equal, Writing – review & editing-Equal), K Schaudig (Conceptualization-Equal, Data curation-Equal, Formal analysis-Equal, Funding acquisition-Equal, Investigation-Equal, Methodology-Equal, Project administration-Equal, Resources-Equal, Software-Equal, Supervision-Equal, Validation-Equal, Visualization-Equal, Writing – original draft-Equal, Writing – review & editing-Equal), Emmanuele A. Jannini (Conceptualization-Equal, Data curation-Equal, Formal analysis-Equal, Funding acquisition-Equal, Investigation-Equal, Methodology-Equal, Project administration-Equal, Resources-Equal, Software-Equal, Supervision-Equal, Validation-Equal, Visualization-Equal, Writing – original draft-Equal, Writing – review & editing-Equal), Annamaria Giraldi (Conceptualization-Equal, Data curation-Equal, Formal analysis-Equal, Funding acquisition-Equal, Investigation-Equal, Methodology-Equal, Project administration-Equal, Resources-Equal, Software-Equal, Supervision-Equal, Validation-Equal, Visualization-Equal, Writing – original draft-Equal, Writing – review & editing-Equal).
Funding
Writing assistance was provided by Content Ed Net with funding from Viatris.
Conflicts of interest
S.R. has received travel and consultancy fees from Viatris, Abbott, Bayer, Eurogenerics, Gedeon Richter, Takeda, Theramex, UCB, and Will-Pharma. R.E.N. had financial relationships as a lecturer, advisory board member, and/or consultant with Boehringer Ingelheim, Ely Lilly, Endoceutics, Merck Sharpe & Dohme, Palatin Technologies, Pfizer Inc, Procter & Gamble Co, TEVA Women’s Health Inc, and Zambon SpA. At present, she has ongoing relationships with Astellas, Bayer HealthCare AG, Exceltis, Fidia, Gedeon Richter, HRA Pharma, Merck & Co, Novo Nordisk, Shionogi Limited, Theramex, and Viatris. K.S. has received honoraria for lectures or participation in advisory boards as well as reimbursement for travel expenses and research funding by the following companies: Astellas Pharma GmbH, Bayer-Jenapharm GmbH, Bésins Pharma GmbH, Exeltis GmbH, Gedeon Richter Pharma GmbH, Hexal, Laborarztpraxis Rhein-Main, Organon, Viatris GmbH, Novo Nordisk, and Theramex. E.A.J. is a speaker and consultant of Bayer, Ibsa, Menarini, Pfizer, Shionogi, and Viatris. A.G.E.G. has received honoraria for lectures or participation in advisory boards or as a consultant by the following companies: Viatris, Eli Lilly, Pfizer, Sandoz, Futura Medical/Exeron, Astellas, Novo Nordic, Freya, and Lundbeck.
