FACTORS AFFECTING SEXUAL LIFE OF MENOPAUSAL WOMEN: SCOPING REVIEW

: Background: WHO predicts that there will be a menopause explosion in 2030 with around 1.2 billion women aged over 50 years. Most of them (about 80%) live in developing countries. The population of postmenopausal women is increasing by about three percent every year. Although menopause is a normal condition, it turns out that not all women can accept this well, one of which is related to sexual problems. Objective: To determine the factors that influence the sexual life of menopausal women in various countries based on the results of past studies. Method: Scoping Review which adapts the Arskey and O'Malley framework. This study took databases from PubMed, EbscoHost, and ProQuest. Results: There were 20 articles out of 2,415 selected based on inclusion and exclusion criteria. This research has 2 main themes, consisting of physical aspects and psycho-social aspects. Physical aspects that affect the sexual life of menopausal women are hot flushes, vaginal dryness, changes in body shape, insomnia, fatigue, and body image. Meanwhile, psycho-social aspects, in this case, include stress, depression, socio-culture, intimacy with partners, lack of social support, and lack of information and health services for menopausal women. Conclusion: The factors that affect the sexual life of menopausal women are a description of physical


Introduction
The number of women in the world who enter the menopause phase is known to reach approximately 1.94 billion people. The population of women who experience menopause in the world reaches 894 million people and is expected to reach 1.2 billion people by 2030. In other words, there are as many as 1.2 billion women will enter the age of 50 years, which is three times the 2000 census number of postmenopausal women. Most of them (about 80%) live in developing countries and every year the population of postmenopausal women increases by about three percent [1]. In 2021, the total population in Indonesia will reach 270,203.9 million people, consisting of 133.542 million women. Of these women, 16.8 million are women aged 45-55 years who are entering menopause [2]. Menopause is the final phase of the biological process of the menstrual cycle because the ovaries experience a decrease in the production of the hormone estrogen [3]. The average age of postmenopausal women ranges from 40 to 65 years [4]. Menopause is not a disease but a normal condition that will be experienced by all women. Although menopause is a normal condition, it was found that not all women can accept this well, one of which is related to sexuality problems [5]. Sexuality is an important part of women's health and women's quality of life. Many factors can affect women's sexual life, including biological, psychological, and socio-cultural factors. Along with various changes during menopause, this raises various problems, one of which is related to the fulfillment of sexual needs [6]. Based on the above problems, the author would like to review the factors that affect the sexual life of menopausal women.

Method
This review was conducted regarding the clustering method as suggested by Arksey and O'Malley. The stages carried out in a scoping review consist of: (1) identifying scoping review questions, (2) in a scoping review consisting of: (1) identifying scoping review questions, (2) identifying relevant articles, (3) article selection, (4) charting data, (5) compiling, summarizing and reporting the results [7].
Step I: Identifying the scoping review questions Based on the framework above, the Scoping Review question asked is what are the factors that influence the sexual life of menopausal women in terms of physical and psychosocial aspects?
Step II: Identifying relevant articles a. Inclusion Criteria 1) The population in this review are studies or articles about postmenopausal women who still have husbands and are sexually active in various countries, 2) Articles published between 2010-2020, 3) Articles published in English and or Indonesian, 4) Complete articles and can be accessed, 5) Articles discussing the sexuality of menopausal women, 6) Articles discussing factors that affect sexual life in postmenopausal women, both physically and psycho-socially, 7) Peer-reviewed articles, including primary research, review articles (systematic review). or literature review) and reports (eg WHO report).
b. Exclusion criteria 1) Opinion papers, 2) Letters and book reviews, 3) Irrelevant articles or subjects.

c. Database
The database that will be used to identify relevant articles uses three electronic databases, namely PubMed, EbscoHost, and ProQuest.

d. Literature searching
Article searches are carried out using Boolean, including AND, OR, NOT, and Trunction as a link to combine or exclude keywords in the search, so that more focused and relevant results are obtained. The keywords entered to search for English articles are (sexual OR sexuality OR "sexual life" OR "sexual health" OR "sexual function" OR "sexual dysfunction" OR "sexual physical" OR "sexual psychology" OR "sexual activity" OR "sexual behavior" OR "sexual problem" OR "sexual frequency" OR "sexual desire" OR "sexual satisfaction") AND (menopause OR menopausal OR climacteric OR climacteric OR "midlife" OR "middle age" OR "older age" OR aging)) NOT (hysterectomy OR "early menopause"). The keywords used to search for Indonesian articles are (menopause, sexuality; menopause, sexual;).
Step III: Article selection The data filtering process was performed by using a PRISMA flowchart. Step IV: Data charting Data from 20 articles are included in a table with main criteria such as research location, study population, research objectives, methodology, and important findings or recommendations. The author records the information independently and compares the data studied. Step V: Presentation of data/results, discussions, and conclusions The themes included in the purpose of this article cover physical and psycho-social aspects. The sub-themes for the theme of the physical aspect include hot flushes, vaginal dryness, changes in body shape, insomnia, fatigue, and body image. Meanwhile, the subthemes on the psycho-social aspects are stress, depression, socio-culture, partner intimacy, social support, and lack of information and health services.

Physical aspect a. Hot flushes
Based on the research findings obtained from 3 articles, it was found that age at menopause is one of the risk factors that affect the symptoms of hot flushes. The age of 45-54 years is the age at which menopausal women experience symptoms of hot flushes. This happens because of a decrease in the hormone estrogen which in turn affects the regulation of body temperature and sleep cycles. In addition, excessive alcohol consumption is also another factor that can affect the incidence of hot flushes in postmenopausal women [27].
Hot flushes are one of the factors that affect the quality of sexual life in menopausal women who are active or not sexually active. Hot flushes negatively affect the quality of life of middle-aged women, related to health, including sexual behavior [ [6]. The hot feeling makes it difficult for postmenopausal women to sleep and the effect can reduce energy in having sexual relations with their partners [28]. This symptom reduces and interferes with concentration power in having sex so that menopausal women very worry if their husbands don't like their condition, which often feels hot and sweaty [29].

b. Dryness of the vagina
Changes in the reproductive organs during menopause can cause disturbances in sexual behavior for women who experience menopause. These disorders occur in the lining of the vaginal wall as the vagina becomes dry and less elastic due to decreased levels of the hormone estrogen [30]. This causes pain and discomfort during sexual intercourse, causing a reluctance to have sexual intercourse or a lack of desire to have sexual intercourse [31].
Based on the findings of 3 articles discussing vaginal dryness, it was found that the use of lubricants can reduce vaginal dryness complaints in postmenopausal women. This is following the results of a study [32] that stated that sexual satisfaction and sexual function increased after using lubricants. Vaginal lubricants are effective for reducing discomfort in postmenopausal women who experience symptoms of mild to moderate vaginal dryness during sexual intercourse, especially for those who do not opt for estrogen therapy, either for medical or personal reasons [33].
Menopause causes disruption of the vaginal epithelium, supporting tissues, and elasticity of the vaginal wall. The vaginal epithelium contains many estrogen receptors which are very helpful in reducing pain in sexual intercourse [30]. The need to change their partner's beliefs about sexual relations during menopause and have to look for different and new types of relationships so as not to become a boring and monotonous relationship is one of the ways to improve the quality of sexual relations in husband and wife [19].

c. Changes in body shape
Body changes experienced by menopausal women trigger a person to lose feelings sexually. This is due to a bad body image in which a postmenopausal woman cannot accept the changes that occur so that she feels less attractive for sexual intercourse [34]. Although menopausal women experience changes in body shape, this can be helped by their partners who always make sure that they still look attractive. Women who are unable to accept changes about their bodies say that this concern will harm their sexual satisfaction, while women with high self-confidence and feel attractive, tend to have better sexual satisfaction, even in the face of body changes [11].

d. Insomnia
Biological and psychological changes in women going through menopause have been linked to sleep and sex problems. The study showed that in postmenopausal women, sleep problems are directly related to sexual problems and it has been proven that the number of hours of sleep of less than 7-8 hours can damage a person's libido [35]. Lack of sleep causes hormonal changes which then manifest as poorer sexual function. This theory suggests that androgen deficiency influences changes in sleep quality and sexual response [36]. Insomnia makes a person tired, even they feel they do not have enough energy to enjoy their sexual activity. This causes a lack of intimacy in women who have gone through menopause [28].

e. Fatigue
Activities carried out as a woman who takes care of children and husband make a woman have a dual role, especially if the woman is also a career woman, making it easier for a postmenopausal woman to reach the peak of fatigue. Fatigue also occurs due to lack of sleep or insomnia causing a prolonged feeling of tiredness [37]. The sexual activity takes time and effort. The stamina that is drained due to work, taking care of children and husband, lack of sleep and rest, will simultaneously make menopausal women experience physical exhaustion. This causes a decrease in sexual desire. Fatigue is the biggest reason for refusing sexual activity with her husband [38].

f. Body image
Body image is closely related to personality and the way individuals perceive themselves greatly impacts their psychological aspects [39]. Changes in appearance and function experienced by some postmenopausal women, such as changes in body weight and shape, sleep disturbances due to night sweats, and signs of aging such as changes in skin, hair, and sexual function, may affect the way women perceive their bodies [40].
Women's body image and attractiveness decline during middle age and will interfere with their sexual life. However, this can be overcome by accepting the changes during menopause by your partner and understanding their current condition. This effort will increase positive feelings about oneself in postmenopausal women and improve body image in women as well as being effective for improving sexual relations [19]. Furthermore, it would be better if the community also played a role in a woman's menopause. The community needs to have the initiative to take a positive approach to the roles and changes in women who enter menopause. This kind of effort is expected to give them an image that is accepted by the community as well as valuable for them and their partners. Significantly, it is effective to improve the quality of their sexual intercourse [19].

Psycho-social aspect a. Stressed
At the beginning of menopause, women will experience stress, one of which is related to the quality of sexual relations. However, stress tends to decrease over time because a new hormonal balance has been achieved in the female body [41]. Stress experienced by menopausal women is because they are not ready to face menopause. Menopausal women will not experience problems in having sex with their life partners if they are ready to face and overcome all the changes that occur during menopause [42]. Fluctuations in hormone levels during menopause can affect a woman's mental health, which in turn can lead to decreased libido. Changes in hormone levels that women may experience during menopause can make them irritable or depressed, so they have less coping with stress in their daily lives. Sex is not only considered a physical activity but also involves emotions or feelings. Therefore, the stress felt by a person tends to make them view sex as a negative activity and realize that this forms a habit that prohibits enjoying sexual activities [43].

b. Depression
Depression is generally twice as likely to affect women as men and broadly indicates an increased risk in women during a phase of hormonal changes such as menopause [44]. On the other hand, positive and negative perceptions about menopause are known to directly affect the severity of menopausal symptoms [45]. This in turn can affect the tendency to depression as a negative and positive emotional response when facing menopause as well as being directly related to an increase in menopausal symptoms [46].
Menopausal women have been shown to tend to develop anxiety and depression due to sexual satisfaction. Changes in sexuality at the age of menopause are influenced by anxiety when facing the age of menopause and the myth that is widely circulated in society which states that a woman's sexual life has ended when she enters menopause [47]. The effect of depressive symptoms in postmenopausal women will indirectly affect the quality of sexual life. Women with better quality of sexual life will experience mild menopausal symptoms compared to women with poor quality of sexual life [3]. Although menopause can affect sexuality due to physical and psychological consequences, other findings suggest that postmenopausal women may still have good sexual satisfaction [23].

c. Socio-cultural
Menopausal women with low levels of education showed a greater rate of sexual dysfunction (78.9%), while women with higher education facilitated themselves to access information and seek medical help 2.7 times more often to reduce anxiety [48]. Family structure was also found to influence a woman's menopause. Women living with large families may not have privacy and separate spaces for sexual activity and may share these rooms with children and other families [49].
Work also affects a woman's menopause. Menopausal women who have jobs say that work keeps them busy so they don't have time to think about any symptoms they are experiencing [18]. The results of other studies show that the level of income also significantly influences the psychosocial and sexual domains [50]. Sexual activity is closely related to culture, society, and emotional values. Some people think that women's attractiveness is only determined by their reproductive ability. Menopausal women are underappreciated in society because of their inability to reproduce again. This kind of societal view should be changed to help and encourage postmenopausal women to consider themselves attractive. This can further affect their sexual relationship and satisfaction [51].

d. The intimacy of the partner
During menopause, the intimate relationship between husband and wife is very important to maintain. Physical and emotional intimacy must be supported by positive communication that is built by husband and wife [16] Lack of physical intimacy is another problem reported by postmenopausal women. Physical intimacy is closeness or sensual touch that includes various kinds of physical contact, including foreplay, noncoital sexual activities such as holding hands, hugging, kissing, and caressing [52]. Although menopausal women experience many negative changes in their sexual function, husbands can accept this situation and maintain harmony in their relationship. The strategy to adapt in this situation is to interact with the husband [22]. Menopausal women also said that it is necessary to encourage partners to communicate more openly about physical discomfort and discuss sexual needs during menopause to promote harmonious relationships between partners [18].

e. Social support
Husbands are considered the main source of emotional support for women during menopause. One form of husband's support, in this case, is to understand the need to cope with the changes experienced by menopausal women. The goal is to address changes related to sexual intercourse after menopause. Efforts are needed to build awareness of the need for some adjustments in sexual intercourse during menopause [53]. Although husbands have experienced changes in their sexual routines, most of them realize that these changes are not solely caused by menopause, but also as a result of the long coexistence of marriage. They have also noticed that their relationship remains loving and intimate in other ways [54]. Husbands have an important role in directing an understanding of menopause to their wives, for example giving emotional attention when their wives are anxious, providing information and support when their wives feel they have lost their sexual attractiveness. Therefore, the husband's support is one of the main factors that can affect the quality of women's sexual life during menopause [55].

f. Lack of information and health services
This lack of information is the main difficulty found by postmenopausal women regarding providing information about improving the quality of sexual life. This problem triggers the lack of individualized care for each postmenopausal woman because not all of them have the same hormonal and physiological changes [56]. It is known that there are still some people who view sexuality as a positive thing, but there are still few health workers and the public who understand this [57].
The problem of sexuality which is still considered taboo by health workers makes menopausal women feel that they are not helped at all in dealing with their sexual problems. This makes them often the subject of neglect and prejudice by health professionals who view them as asexual. Therefore, they assume that health professionals are the ones who are less ready to accept the complaints of menopausal women [8,58].
For postmenopausal women, prejudice and negative societal judgments seriously impair the relationship between health professionals and themselves [8]. These reasons make it important for the role of health workers to understand and provide education related to the theme of sexuality during menopause. The aim is as a strategy to help postmenopausal women to be free from prejudices, taboos, and myths that have been built socio-culturally that women who reach menopause age must stop sexually [8].

Limitations of scoping review
The limitations found in the preparation of this scoping review are as follows: • The articles used in the preparation of this scoping review are articles in English or Indonesian, so there may be articles in languages other than English or Indonesian that are relevant but not detected. • The author only found 1 article originating from Indonesia, so the results of this study cannot necessarily be used as a reference to be applied in Indonesia. • The discussion of menopausal conditions in developing and developed countries in this study is not separated, even though there are quite significant differences that can be found, for example, the use of Hormone Replacement Therapy carried out in developed countries.

Conclusion
The factors that influence the sexual life of menopausal women are a description of the physical and psychological discomfort experienced by them as a result of the changes that took place during that period. Some of the most dominant themes in the articles studied are in terms of physical aspects and psycho-social aspects. Physical aspects, in this case, include hot flushes, vaginal dryness, and body image, while the psycho-social aspects include depression, lack of social support, and lack of information and health services for women during menopause. Almost all participants tend to be shy and closed to discussing sexuality due to cultural influences, public perception, and the lack of health professional roles regarding sexuality during menopause. Future researchers are expected to develop further research on the factors that affect the sexual life of menopausal women, especially in Indonesia so that more relevant research results are found to describe conditions related to this in Indonesia. The results obtained can later be used for program development for postmenopausal women in Indonesia. In addition, further researchers are advised to conduct similar research by comparing research subjects in developed and developing countries.