Positive sexual function is critical for women during midlife. It can enhance personal quality of life, quality of relationships and improve longevity. Sexuality after menopause is a concern for all women. Yet for some, sexual dysfunction can be a serious issue. It is key for healthcare professionals to recognise this and to open dialogue around sexual health with at risk women.
At EMAS 2019, Dr. Rossella Nappi explained that sexual dysfunction often presents as low desire, low arousal and orgasmic dysfunction with or without sexual pain. It is a common problem. In one study 36% menopausal women reported reduced sex drive, while 21% reported vaginal pain, dryness or discomfort.  In another 45.9% women reported poor orgasm or satisfaction. 
The cause can often be hard to directly locate. Menopausal symptoms are generally considered to relate to a ‘domino effect’ where one symptom often causes another. Sexual dysfunction during menopause is also thought to be closely aligned to the domino effect. Genitourinary problems, poor physical health and negative emotional symptoms can all combine to contribute to sexual dysfunction.
The role of Vulva Vaginal Atrophy
While the causes can be multifactorial, Vulva Vaginal Atrophy (VVA) and Genitourinary Syndrome of Menopause (GSM) are often to blame. Women with sexual dysfunction are 3.84 times more likely to have VVA than women without sexual dysfunction. 
VVA symptoms include vaginal dryness, itching and irritation. Dr. Nappi explained that VVA symptoms have a real burden not only on sex but also on general quality of life.
The need for open conversations
Women and healthcare professionals are often reluctant to discuss sexual problems, meaning that sufferers can go untreated and quality of life and quality of relationships are affected. It is key for healthcare professionals to open the dialogue to provide or facilitate appropriate treatment for those who need it.
Treating sexual dysfunction
Combining medical and psychotherapeutic treatments can be effective when treating sexual dysfunction. 
Psychological concerns such as depression and poor self image can be key drivers in sexual dysfunction, therefore psychosexual or sexual counselling may have a beneficial effect. Any psychotherapy should be focussed on the primary factors affecting sexual factors and those most distressing to the woman. 
There are many medical treatments that are also recommended. In his presentation, Dr. Neoklis Georgopoulos suggested that estrogen vaginal gels are effective for symptoms such as vaginal dryness, dyspareunia, vaginal atrophy or urogenital symptoms. Hormone Replacement Therapy is also key in treating sexual dysfunction, while Tibolone has shown improvement on vaginal dryness and libido.
As a general rule, treatment for sexual dysfunction should be individualised based on each patient, to ensure that the causes are being effectively addressed.
 Rossella E. Nappi, Francesca Albani, Patrizia Vaccaro. et al. Use of the Italian translation of the Female Sexual Function Index (FSFI) in routine gynecological practice, Gynecological Endocrinology, 2008; 24:4, 214-219, DOI: 10.1080/09513590801925596
 Nappi RE, Baldaro Verde J, Polatti F, et al. Self-reported sexual symptoms in women attending menopause clinics. J Obstet Gynecol Invest 2002; 53: 181–187
 Levine KB, Williams RE, Hartmann KE. Vulvovaginal atrophy is strongly associated with female sexual dysfunction among sexually active postmenopausal women. Menopause. 2008;15(4 Pt 1):661-6.
 J. A. Simon, S. R. Davis, S. E. Althof, et al. Sexual well-being after menopause: AnInternational Menopause Society White Paper, Climacteric, 2018. DOI: 10.1080/13697137.2018.1482647