Introduction

Menopause is a natural biological process that affects women’s lives physically, mentally and sexually [1]. The global population of postmenopausal women is growing. In 2021, women aged 50 and over accounted for 26% of all women and girls [2]. Approximately one-third of women’s lives are postmenopausal, and almost all studies show that the vast majority of women and men are in good health and continue to be sexually interested and active with a suitable partner throughout their lives [3].

In Addis (2006), examining the sexual activities and behaviors of 2109 women between the ages of 40 and 69, it was shown that a significant proportion, approximately 75%, remained engaged in sexual activity despite the typical decline in sexual performance associated with advancing age. [3]. Sexual satisfaction is a component of human sexuality that occurs at the end of the sexual response cycle [5]. Sexual satisfaction is one of the recognized sexual rights, and everyone has the right to a satisfying and enjoyable relationship [6].

According to Hudson (1981), sexual satisfaction is the degree of harmony and contentment with sex [4]. In developing the idea of interpersonal exchange, Lawrence and Bayer (1992) define sexual pleasure as an emotional response arising from a subjective evaluation of the positive and negative aspects of a person’s sexual relations [5]. Sex researchers are interested in sex life satisfaction for two reasons: first, sexual satisfaction provides a mechanism for assessing the performance of relationship partners [6]; second, it has been found that sexual satisfaction is a predictive factor for various relationship dimensions, including marital quality and stability [7, 8].

Estrogen, which is vital in sexual desire, is one of the influential variables in sexual satisfaction. Estrogen aids in the elasticity of pelvic tissues for sexual intercourse. Vaginal dryness can occur when estrogen is not produced sufficiently before menopause. In addition, other factors influencing sexual satisfaction are physical sexual performance, such as stability in orgasm or frequency or time of orgasm [9]. Furthermore, aging-related diseases reduce sexual desire, physiological response to the sexual cycle, and, as a result, sexual satisfaction [10, 11].

Menopausal women have a very different concept of sexual satisfaction than premenopausal women, and this difference is due to aging and physical, hormonal, cultural, and psychological changes. Examining the concept of sexual satisfaction from the perspective of menopausal women is critical for sexual education and sexual therapy because the type of education and the content of education are very different from those before menopause due to menopausal changes [12–14].

In general, there is little information and no consensus on the concept and definition of perceived sexual satisfaction in menopause [9–11].

According to Schwartz and Young (2009), the absence of a consensus definition and the existence of multiple definitions of the term "sexual satisfaction" have led researchers to conduct individual assessments rather than those based on feelings and behavior. According to Schwartz and Young, cases that separate specific elements from the psychological structure are relatively unknown in the literature on sexual satisfaction. Regardless of the truth of this issue and the possibility that sexual satisfaction research will continue in the same manner, a comparison of Schwartz and Young’s statements with other studies reveals an important point: researchers should not rely on the idea that satisfaction is inherently subjective and that everyone knows what it means [10, 11].

As McClelland (2010) pointed out, the study of sexual satisfaction is not complete and most research has been conducted using self-reinforcing definitions of sexual satisfaction to measure the construct of sexual satisfaction [15]. When researchers disagree on the meaning of a concept, conducting coherent research yields a clear definition [21]. When the goal is to create and generalize accurately about a phenomenon with little information, an integrative review can be used [22]. Accordingly, integrative review has been advocated as necessary for evidence-based practice initiatives in nursing [16, 17]. Several studies have been conducted regarding sexual satisfaction in menopause. However, since no study summarized all of these cases and presented them coherently, as well as a lack of a single and coherent definition of sexual satisfaction in menopause, the current integrated review study was conducted to come up with the concept of sexual satisfaction in menopause.

Materials and methods

The study was carried out using an integrated review of data obtained from secondary sources, utilizing Whittemore and Knafl’s method of bibliographic search [17]. Conducting an integrative review, which examines the articles in the reference for similarities and differences, is one of the most effective ways to begin a study. A clearer and more comprehensive comprehension of the concept is achieved through the use of this approach [18]. The five steps of Whittemore and Knafl’s method are as follows: Problem identification stage, literature search, data evaluation, data analysis, and presentation [17].

Stage 2. Literature search

A comprehensive search for an integrative review typically involves using a minimum of two to three strategies to identify the greatest number of eligible primary source [17, 19]. The investigation was carried out using the international databases as follows:

Google Scholar, CINAHL, Embase, Medline via OVID, Psych INFO, Web of Science, Cochrane, ScienceDirect, ProQuest, and Scopus. Search keywords were (“postmenopausal”, “menopause”, “postmenopausal women”, “aged”, “older adults”, “older women”, “Midlife”, “middle-aged”), and (“sex* satisfy*”, “satisfy* sex*”, “satisfaction with sex”, “sexual satisfaction”, “Dissatisfaction”) and (“concept”, “meaning”, “dimensions”, “predictors”, “affecting factors”). Keywords were combined using the Boolean operators “AND” and “OR”. This study had several search stages. After reviewing the articles, the following dimensions and concepts were searched for: “gender, socio-cultural factors, relational factors, positive emotions, sexual desire, mental factors, orgasm, sense of security, sexual performance, emotional intimacy, self-esteem, body image, dyspareunia, vaginal dryness, socioeconomic status, marital satisfaction, life satisfaction”.

The integrated review literature search was conducted without regard to time limits until March 30, 2024. The literature search was carried out by the four-step preferred reporting for systematic reviews and meta-analyses PRISMA flow diagram [20], as shown in Fig 1.

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Fig 1. Shows the PRISMA flow diagram.

https://doi.org/10.1371/journal.pone.0306207.g001

In addition to conducting a manual search of Google Scholar and midwifery, psychology, and mental health textbooks were studied as well for articles about the concept of sexual satisfaction in postmenopausal women. Two independent researchers conducted the literature search and assessed the eligibility of the articles (the first author and the corresponding author). An assessment was conducted on the titles and abstracts of the acquired articles, and those that failed the eligibility criteria were omitted. Articles published in reputable academic journals and directly relevant to the goals and research questions met the inclusion criteria. The study’s exclusion criteria included articles or journals that were irrelevant, as well as short articles such as editor’s comments, suggested comments, abstracts, and articles presented at conferences. We used the articles in international databases without any language-based limitations.

Articles completely related to the purpose of the concept analysis stage are selected in the final evaluation stage of the articles by preparing questions about the purpose of the research.

The initial literature search yielded 4662 records, of which 2603 were deemed unnecessary due to being duplicates. The software End Note was utilized to identify and eliminate duplicate records. The titles and abstracts of the remaining articles were assessed during the screening phase, during which 1608 articles were deemed irrelevant to the study’s objectives and inquiries and were therefore excluded. 451 articles were also omitted on account of their ineligibility. In the end, 62 articles were incorporated into the research. The Persian language articles in Scopus and Cochrane were retained, and a Chinese article with an English summary was translated and included in the research. The literature search yielded three textbooks relevant to the study’s objectives and inquiries.

Stage 3. Data evaluation

The 62 articles included in the integrative review were clinical trials, reviews, descriptive studies, cohort, systematic reviews, qualitative studies, a cross-sectional and three books. Table 1 shows the characteristics of the included studies. Classification of articles was done based on timing. The full-texts of all these articles were assessed using the checklists of the Mixed Methods Appraisal Tool (MMAT) 2018 and the MMAT is a critical appraisal tool designed for the appraisal stage of systematic mixed studies reviews, i.e. reviews that include qualitative, quantitative, and mixed methods studies. It permits to appraise the methodological quality of five categories of studies: qualitative research, randomized controlled trials, non-randomized studies, quantitative descriptive studies, and mixed methods studies [21].

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Table 1. Characteristics of included studies.

https://doi.org/10.1371/journal.pone.0306207.t001

The PRISMA 2020 Checklist was utilized for the evaluation of articles. The PRISMA checklist comprises 27 items that pertain to the content of a systematic review and meta-analysis. It encompasses sections such as abstract, methods, results, discussion, and financial resources [22]. The scoring method for this checklist is as follows: each item mentioned in the articles receives a score of one, while items not mentioned receive a score of zero. The score range is from 0 to 20. Articles with a low score (less than 10) were excluded from the study using this checklist. During the final evaluation stage, articles that are directly relevant to the purpose of the concept analysis stage are chosen. The following questions were also used for eligibility assessment: “Do the articles describe and define sexual satisfaction in postmenopausal women?”, “Do these articles address the characteristics of sexual satisfaction in menopausal women?”

No studies were excluded at this stage.

Stage 4. Data analysis

In research studies, data analysis necessitates the sorting, coding, categorizing, and summarizing of information derived from primary sources. Its purpose is to arrive at a unified and cohesive conclusion regarding the research problem and to present the data in a comprehensive and unbiased manner. Integrated surveys utilize the same analysis strategies and data analysis. The four steps of this method are data reduction, data display, data comparison, and conclusion drawing and verification [17, 85].

For data management, the initial and subsequent phases, which included data reduction and data presentation, implemented a general classification system. Before classifying the data according to the time of publication in Table 1, the data were evaluated according to the type of evidence to facilitate the analysis of the integrated review. By examining the extracted data case by case, units were taken into account and systematically coded. The codes were shown in Table 2. Table 2 shows the categories and subcategories of the antecedents, attributes, and consequences of the concept of sexual satisfaction in menopause. Codes were compared repeatedly, and similar codes were assigned to subcategories and then main categories. The results were divided into the major categories of definitions, characteristics, antecedents, and consequences in the fourth step. MAXQDA 10 software was used for data management [17, 86].

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Table 2. The categories and subcategories of the antecedents, attributes and consequences of the concept of sexual satisfaction in menopause.

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Results

During the integrative review of the 62 articles, 3 books and 580 codes about Sexual satisfaction in menopause were extracted (Table 1). The results showed that there were several, non-inclusive definitions of sexual satisfaction during menopause. To give a better understanding of the concept, its attributes, antecedents, and consequences were extracted (Table 2). Through the analysis of the explicit and the implicit definitions sexual satisfaction during menopause five antecedents were identified for the concept.

Discussion

An integrative review is a specific method that summarizes past empirical or theoretical literature to provide a more comprehensive understanding of a particular phenomenon or healthcare problem. This integrated study aims to examine sexual satisfaction in postmenopausal women and identify its antecedents, characteristics, and unique consequences during this time in women’s lives.

Antecedents are factors that must have existed before the concept’s occurrence. The antecedents helped the researcher understand the background and social context of the used concept, resulting in its refinement [88]. This study evaluated the antecedents of sexual satisfaction in menopause on a broad scale, encompassing external, internal, and interactive factors, a collection of perceptions, beliefs, and behaviors that are heavily influenced by underlying factors (individual and contextual variables, patterns of interpersonal interactions, variables related to spouses, psychological variables, cultural and religious values, and beliefs) that influence sexual satisfaction in menopause.

According to Walfisch et al.’s (1984) also discovered that various background factors influence women’s sexual satisfaction [23]. Age is an important factor in predicting women’s sexual satisfaction, and most research indicates that aging-related variables reduce sexual satisfaction [70, 89, 90]. Byers and Rahman (2014) discovered in a review that the age-related decline in sexual satisfaction is caused by other demographic or sexual variables associated with older age, such as partner habituation and health status [89]. According to Trompeter’s study, nearly half (47.5%) of women over 80 reported sexual satisfaction almost always. In this study, sexual activity was not always required for sexual satisfaction. Those who were not sexually active may have found sexual satisfaction through long-term intimacy, such as touching or caressing [41].

The research findings indicate that economic and social factors are additional underlying factors that impact the concept of sexual satisfaction. Among older women, factors such as residence are important for sexual satisfaction [70]. Good economic status can significantly increase sexual performance and sexual satisfaction [43]. Women who work have more self-confidence because they are financially independent and have more sexual desire than housewives, which affects sexual satisfaction. The sexual arousal of postmenopausal women and their husbands increases as their education level rises, which can lead to an increase in sexual satisfaction [37]. However, it should be noted that as couples’ educational status rises, they may have higher expectations for sexual satisfaction, and when these expectations are not met, they may experience sexual dissatisfaction [55].

Awareness of the menopause process can cause changes in attitudes and thoughts about sex, reduce anxiety, and assist a person in adapting to menopause while increasing sexual satisfaction [37].

Postmenopausal women who are supported and educated by health care providers are more sexually satisfied. which was consistent with the research results of Abedi et al. (2017) and Kurlychek et al. (1979) [14, 49]. Furthermore, a cause-and-effect relationship exists between sexual satisfaction and lifestyle factors. The study by Movahed et al. (2019) demonstrated that a person’s attitude toward menopause, sexual activity, and sexual satisfaction is influenced by their lifestyle. Therefore, women who live a healthy lifestyle with regular physical activity will have more sexual satisfaction [63], while age-related diseases, sexual desire, and the physiological response of the sexual cycle will reduce sexual satisfaction [34]. Insomnia, for example, has been shown to reduce women’s sexual desire and satisfaction [26]. Physical well-being is defined as a low risk of illness and disability, mental well-being as high cognitive and physical functional capacity, and emotional and social well-being as active engagement with life, all of which have a direct positive relationship with sexual satisfaction [38], which is consistent with the findings of our study.

Our research findings align with the notion that the occurrence and frequency of orgasm before menopause are significant indicators of sexual satisfaction following menopause. Heiman et al.’s (2011) study in five countries showed that the level of sexual performance before menopause significantly influences sexual satisfaction [39].

The pattern of interpersonal interactions is one of the factors influencing sexual satisfaction, with the assumption that women invest more in more committed relationship [34]. People check, determine, and judge their level of sexual satisfaction based on marital satisfaction. It is possible to argue that primary marital satisfaction is necessary for a satisfying benefit from sexual relations with a spouse, particularly for women [91]. In menopause, the relationship between sexual satisfaction and marital satisfaction is a two-way street; that is, marital satisfaction predicts subsequent sexual satisfaction, and satisfaction with sexual satisfaction is associated with increased marital satisfaction. People usually base their level of sexual satisfaction on marital satisfaction, and love between couples increases sexual satisfaction [34, 44], which is consistent with the findings of our study.

Another finding of this study was the effect of violence and social support on sexual satisfaction during menopause. However, low relationship satisfaction can be viewed as both a cause and an effect of violence. The problem of domestic violence among couples worsens with age. Intimacy and sexual satisfaction between spouses are destroyed by sexual and nonsexual violence [55, 92]. When women feel more supported, they have higher sexual satisfaction [93]. Social support is defined as a person’s evaluation of support and feeling of belonging [43]. When emotional self-disclosure and awareness of each other are established, sexual satisfaction is achieved [60]. Lack of knowledge about the wife’s menopause and sexual issues impacts sexual satisfaction [48].

The results of our research showed that men’s sexual dysfunction causes dissatisfaction in menopausal women. Researchers have shown that erectile dysfunction leads to dissatisfaction in women [67, 91].

The findings of this study revealed that culture has a significant impact on sexual satisfaction in postmenopausal women. Parke (1991) demonstrated that culture influences attitudes and beliefs about sexuality and sexual relationships. As a result, cultural beliefs can sometimes interfere with normal sexual function and cause harm, so addressing this issue is critical and necessary [94]. Cultural values and norms also influence sexual expression and satisfaction. For instance, in religious and patriarchal cultures like Asian societies, expressing sexual desires, especially for women, is considered inappropriate and a threat to the integrity of the family and society, leading to low sexual satisfaction [34]. Based on this, culture has a significant impact on gender and sexual satisfaction or dissatisfaction [63], which is consistent with the findings of our study.

In a review by del Mar Sánchez-Fuentes et al. (2014) the effect of religion on sexual satisfaction varied between studies. For example, some researchers discovered that higher religious beliefs were associated with lower satisfaction in white participants, whereas others discovered no discernible differences in sexual satisfaction by religion [90]. It has also been discovered that having a non-religious childhood correlates with higher sexual satisfaction in women [95]. However, women who attend church often report greater sexual satisfaction [24].

The findings of our study revealed that psychological factors are among the antecedents influencing sexual satisfaction. The transition from the fertile to the infertile period is associated with a variety of physical and psychological symptoms, and women go through a stressful period that can affect all aspects of their lives. According to Dundon and Rellini (2010), in women over the age of 40, mental health has a more significant impact on sexual satisfaction than physical performance [33], and depression, anxiety, and stress problems are all linked to lower sexual satisfaction [89, 90]. Yangın et al. (2008) discovered a negative and significant relationship between loneliness and all sexual components [96]. Sadness, fear, thoughts of failure and separation, frustration, and injury are all significant predictors of sexual dissatisfaction [80].

However, not all studies agree on the exact link between depression and sexual satisfaction. One study found a link between depressive symptoms and lower sexual satisfaction [97].

Concepts are identified by their most frequent occurrences in the texts; defining these characteristics gives the concept the most comprehensive understanding and sets it apart from related concepts [88]. The findings of this study revealed that physical and emotional interaction are important in achieving sexual satisfaction in postmenopausal women. According to Dundon et al.’s (2009) study, sexual satisfaction has two dimensions: emotional and physical [33]. In general, emotional responses include sensations of pleasure, levels of satisfaction or happiness, and pleasant feelings [55]. Relationship happiness, identification, and mutual understanding are the causes and results of sexual satisfaction [35, 39]. In addition, according to Walfisch’s (1984) study, sexual satisfaction in postmenopausal women is influenced by emotional aspects of the relationship and in women, interpersonal relationships and emotional aspects are more influenced by sexual relationships [23]. In explaining these findings, it can be stated that mindful people, particularly during sex, can create harmony between physiological aspects and mental sexual stimulation, and this harmony can have a significant positive effect on women’s sexual experiences [28].

When sexual satisfaction is conceptualized as the sensation of physical gratification, the focus of analysis is primarily on the body and the physical experience. This model places a higher importance on physical and physiological reactions, often highlighting orgasm as the most easily quantifiable indication of sexual satisfaction [33, 65]. Davison et al. (2008) found that having more satisfactory sexual relations increases the number of days of sexual activity and sexual events per month, as well as sexual satisfaction [8]. People who engage in relatively frequent sexual activity report higher levels of sexual satisfaction than those who have less sex [34]. In fact, studies have linked sexual satisfaction to the frequency of sexual relations [39]. In one study, those who were sexually active and satisfied reported higher levels of sexual satisfaction than those who were sexually inactive [30]. The frequency and consistency of sexual activity influence sexual satisfaction during menopause [65], which is consistent with the findings of our study.

The results of this study showed that the fulfillment of expectations has a profound effect on sexual satisfaction. According to Neto (2012), a person’s judgment of sexual satisfaction is formed by comparing her circumstances to the appropriate standards she imagines [98]. Sexual satisfaction in menopause is an assessment of a woman’s level of satisfaction with her sexual life [99]. Philippsohn and Hartmann (2009) define overall sexual satisfaction as a person’s evaluation of sexual life independent of sexual activity [100]. Furthermore, sexual satisfaction can be an interpersonal cost-reward model, considering the amount of cost in the relationship followed by the amount of fulfillment of expectations [33]. McClelland (2010) showed that people’s sexual expectations can vary greatly. When a person’s life is compared to a self-created standard and her conditions match these standards, the person reports high satisfaction [101].

The findings of our research showed that menopausal women deal with behavior and ethics changes, use sex as a tool to express interpersonal relationships, and find sexual satisfaction through emotional fulfillment even in the absence of sexual activity. Non-genital contact and only focusing on the emotional relationship may be important for feeling sexual satisfaction, the perception of intimacy or emotional closeness, and less emphasis on physical acts has a significant effect on sexual satisfaction [8, 35, 36]. They also understand intimacy or emotional closeness and realize that placing less emphasis on physical actions increases sexual satisfaction. Another change in behavior for women during menopause is seeking treatment. When experiencing vaginal dryness, women may engage in various sexual activities aside from vaginal sex or combine therapeutic aids such as lubricants or emotional closeness and place less emphasis on physical actions [45]. The re-emergence of sexual desire in postmenopausal women aids in enhancing sexual satisfaction [11]. Menopausal women aim to lessen menopausal symptoms and enhance menopausal function, according to Niazi’s (2016) [61] review study. Therefore, plants that improve dyspareunia and sexual function can also increase sexual satisfaction (examples include using Tribulus terrestris, fenugreek seeds, fennel, and date pollen) [61], which is consistent with the findings of our study.

The findings of our research showed that the concept of sexual satisfaction is influenced by the change in sexual capacity during menopause. Movahed’s (2019) study found that 35% of postmenopausal women had sex less than once a month, while 45% had sex once or twice a month [63]. Similarly, Merghati-Khoei et al (2014). discovered that libido decreased or disappeared in 94.5% of 200 cases following menopause [102]. Islam et al. (2018) reviewed 34 related articles, including 24,743 Asian women, and concluded that low libido is common in the postmenopausal population [103]. According to women’s reports, menopause can cause various issues that affect their sex lives, such as vaginal dryness, painful intercourse, decreased libido and arousal, and difficulty reaching orgasm [67]. A study on middle-aged Australian women revealed that menopause led to a decrease in arousal, orgasm, and sexual pleasure for all women. Specifically, menopause was associated with increased pain during intercourse, decreased sexual desire and frequency, and less positive feelings towards their sexual partner [34].

Menopause affects women physically, psychologically, and socially. After menopause, women experience a significant decrease in sexual activity and libido, as well as anxiety as a result of their reluctance. Indeed, menopause-related psychological damage has an impact on sexual satisfaction [57]. Middle-aged women may be especially vulnerable to decreased sexual satisfaction due to the increased risk of psychological disorders associated with menopause [33]. Lack of self-confidence caused by a negative body image has a direct relationship with sexual satisfaction and is one of the psychological factors that suffer during menopause [57], which is consistent with the findings of our study.

Sexual satisfaction increases with the rehabilitation program [76] as does mental health improvement [30]. Changing attitudes toward sex, as well as sexual changes associated with aging and menopause, are also significant predictors of sexual satisfaction [8]. Strengthening emotional relationships, increasing intimacy between husband and wife, increasing self-confidence, improving physical and mental health, and raising awareness about the menopause process and the resulting physiological changes will make entering this stage of life more pleasant and lead to greater sexual satisfaction [24], which is consistent with the findings of our study.

The strengths of the present study were the integrated review design in all types of studies and the inclusion of studies without historical restrictions. The limitations of the research were data analysis and interpretation of findings with a subjective approach.

Conclusion

Antecedents of sexual satisfaction in menopause are a broad self-evaluation of external, internal, and interactive factors. A collection of perceptions, beliefs, and behaviors that are heavily influenced by underlying factors (individual and contextual variables, interpersonal interaction patterns, spouse-related variables, psychological variables, cultural and religious values, and beliefs). In this regard, the concept of sexual satisfaction in menopause is a subjective (emotional interaction) and objective (physical interaction) concept that is conditioned by the fulfilment of expectations and the reconstruction of sexual relations while also being influenced by the change in sexual capacity during menopause. As a result, the couple’s physical health improves, as does their mental health, allowing the marital relationship to continue satisfactorily. This integrated review provided a clear understanding of sexual satisfaction in postmenopausal women, the results of which can be used both in theory and practice. The characteristics of the concept of sexual satisfaction were identified in the research findings. These features in the study it provides a deeper insight into the sexual satisfaction of postmenopausal women. It also helps sex therapists to correctly diagnose sexual dissatisfaction in women. Our scientific findings can be a foundation for future research to increase sexual satisfaction in postmenopausal women. Considering the distinct concept of sexual satisfaction in postmenopausal women, a qualitative study regarding sexual satisfaction in postmenopausal women and the creation of a questionnaire specifically for this age group is suggested.

Acknowledgments

The authors thank the Head of Graduate Studies of Mashhad University of Medical Sciences, Director of the Department of Nursing and Midwifery, Mashhad, Iran.