Genitourinary Syndrome of Menopause 2017-08-21T13:27:07-04:00

Genitourinary Syndrome of Menopause (GSM)


Menopause is a Latin word: meno: menses or menstrual periods; pausis: cessation. It stands for the stoppage of menses that happens around the age of 50.

In the United States, the mean age of menopause is 51 years. The symptoms can begin way into the early 40’s. Many women are menstruating regularly and monthly but will still experience hot flashes and night sweats.

GSM is a collection of genital symptoms (dryness, burning, and irritation), sexual symptoms (lack of lubrication, discomfort or pain, and impaired function), and also urinary symptoms (urgency, dysuria, and recurrent urinary tract infections).

The previous terminologies, vulvovaginal atrophy (VVA) and atrophic vaginitis, address the vulva and vagina only and do not take into account the symptoms of the lower urinary tract, which are among the most important symptoms related to menopause.


Symptoms of menopause:

  • Hot flashes, when the patient perceives intense bodily heat followed by flushing of the face and whole body sweating, is the classic general symptom of menopause. She may also experience night sweats where she is hot at night and needs the fan when it is actually cold.

Symptoms of Genitourinary Syndrome of Menopause:

  • Genital dryness, burning, and irritation

  • Lack of lubrication, discomfort or pain, and impaired sexual function

  • Urinary symptoms as urgency, frequency of urination, dysuria (burning during urination), and recurrent urinary tract infections


Natural menopause is when the changes happen with time, usually after the age of 50. The other type is called iatrogenic or surgical menopause where a patient either undergoes removal of the ovaries or has to have radiation treatment.

Most women who undergo natural menopause see a gradual onset of symptoms. On the other hand, women who undergo surgical removal of the ovaries have a sudden and rapid decline in the hormones and this can result in acute symptoms of menopause.

All the specific symptoms of estrogen decline that affect the female pelvic floor are collectively called Genitourinary Syndrome of Menopause.

Smokers tend to go through menopause earlier. Also, if a patient has had a simple hysterectomy (ovaries preserved), they may still undergo an earlier menopause as the uterine blood flow to the ovaries is cut off. Finally, family history is also important: at what age did the older sister or mother go through “natural” menopause, impacts patient’s age at menopause.

Estrogen stimulates the production of glycogen which is then broken down by the vaginal bacteria (lactobacilli) to lactic acid and this keeps the vaginal pH low (3.5-4.5). As estrogen levels decrease after menopause, there is a lack of glycogen and thereby lactic acid, and thus the vagina becomes more alkaline. The coliform bacteria (such as E coli) which are normally present in the high pH rectal cavity may now colonize the vagina and could lead to frequent urinary tract infections.

  • External genitalia: The prepuce (hood) of the clitoris thins out; there is loss of fullness of the labial lips and loss of pubic hair. With further progression, there may be inflammation/redness of the vulva causing dryness and itching. Severe vulvar redness can make the two sides stick together and lead to vaginal stenosis or rarely may even closeup the vagina (labial agglutination). There may also be urethral prolapse seen as red tissue at the opening of the urethra (urine tube).

  • In the vagina, there is loss of elasticity and loss of the typical vaginal rugae (folds). The vagina then becomes thinner and inflamed. The vaginal surface becomes friable and there may be bleeding on minimal trauma as during intercourse or after a gynecologic examination. The vaginal fluid may be almost absent and the vagina becomes very dry.

Due to these changes, sex becomes very painful and this in turn tightens the pelvic muscles as the woman is literally bracing for pain during sex. The pelvic floor spasm continues even after the sexual act has ended and by itself can result in pelvic pain and discomfort.

  • After menopause, there is progressive and continuous deterioration of the genitourinary anatomy. This is different from the hot flashes and night sweats which go away after a few years.

  • Women seek medical advice only at a point where the situation is intolerable and certain changes have set in that become hard to reverse.

  • It is therefore critical to address these changes promptly and early as it becomes increasingly harder to reverse some of the chromic vaginal changes of menopause.


In Italy, the AGATA study, recruited 913 females, aged 59.3 ± 7.4 years, coming for a routine gynecological examination. Vulvovaginal atrophy was diagnosed in 64.7- 84.2% women. Symptoms reported by women were vaginal dryness (100%), followed by pain during sex, burning, itching, and dysuria. Pain with sexual intercourse associated with the vulvovaginal atrophy was cited as the reason for avoiding sexual intercourse by 55% of women and by 61% of men.

The REal Women’s Views of Treatment Options for Menopausal Vaginal ChangEs (REVIVE) survey of 3046 postmenopausal women with VVA symptoms in the US found the most common symptoms to be dryness (55% of participants), pain at sex (44%), and irritation (37%), and these symptoms affected enjoyment of sex in over half (59%) of participants. Also, women reported that their vaginal symptoms negatively affected enjoyment of sexual activity (59%), sleep (24%), and overall enjoyment of life (23%).

The Vaginal Health: Insights, Views, and Attitudes (VIVA) international survey obtained information from 3520 postmenopausal women aged 55–65 years found that 80% of women with genital atrophy considered its impact on their lives to be negative, 75% reported negative consequences in their sexual life, 68% reported that it made them feel less sexual, 33% reported negative effects on their marriage or relationship, and 26% reported a negative impact on their self-esteem.

The CLOSER (Clarifying Vaginal Atrophy’s Impact on Sex and Relationships) study found that vaginal discomfort had a direct, negative impact on the intimacy of both partners (women, 58%; men, 78%) and resulted in a loss of libido/sex desire (64% women and 52% men).

  • GSM is very prevalent and affects more than 50% of post-menopausal women.

  • It affects both the woman and her male partner equally

  • GSM affects not only the physical well-being but also the mental well-being and negatively impacts self-esteem and marital relationships.

  • Both women patients and healthcare providers do not feel comfortable talking about this condition.

  • The US VIVA study showed that almost 50% of women with symptoms of GSM did not consult a healthcare provider.


This is mainly based upon the patient’s complaints, her age, age of menopause and the clinical findings on examination listed above.  

  • We perform a thorough assessment of the vagina to look for vaginal fluid, elasticity, vaginal folds, redness or petechiae (red blood dots) along the vaginal wall. We also assess the vaginal opening (genital hiatus) and assess for vaginal narrowing (stenosis). We then focus on the clitoris and the vulva to look for irritation and loss of fat. Finally, we assess the pelvic muscles to see if they are abnormally tight. We also assess the pH of the vagina.

  • We do certain specific tests that include keeping a bladder log, we assess if there is blood in the urine and if so, we may do a cystoscopy (look inside the bladder with a telescope).


GSM is a chronic, age-dependent condition that progressively worsens and if left untreated, leads to worsening sexual dysfunction and urogynecological consequences such as urgency, frequency, and urinary tract infections. Over time if left untreated, certain irreversible changes, such as vaginal narrowing and pelvic floor spasm, will set in that become hard to reverse.

Therefore the most important thing is to institute treatment early and maintain it throughout life.

Goals of treatment:

  • Educate patients as to what to expect after menopause.

  • The healthcare provider should communicate freely with the patients without making them feel awkward about their sexuality and the changes that they may be noticing after menopause.

  • Encourage women to talk about this and prepare to manage this from their 40’s.

  • Make the patients aware of their different treatment options available to them singly or in combination.

  • Healthcare providers should encourage patients to talk about their sexual history at every visit.

  • Involve the patient AND her sexual partner in these discussions so that the couple feels comfortable to discuss these issues between them. Singling out the female patient and not involving the partner may make it hard for the patient to explain to him as to what is going on and what is expected of them, especially in the bedroom.

  • Impress upon the patient that the treatment has to be done on an ongoing basis as this is a progressive condition. This should be adjusted at set intervals based upon patient’s symptoms and complaints.

  • Provide the patient validated questionnaires that can be checked for comparison once treatment has been instituted.

Treatment options available for GSM

We tailor the management based upon the patient’s history, family history, gynecologic history, surgeries and medications. It is also important to assess how long has this problem of menopausal change been going on. Some women may have undergone removal of the ovaries in their 30’s and now at 50 years of age they are already 20 years without estrogen.

We look at how severe the changes are on gynecologic examination. Based upon history and examination, we then discuss the options with the patients in a fair and unbiased manner based upon facts and evidence.

Finally and most importantly, we always take into consideration the patient’s beliefs, her and her partner’s desires and we respect their hesitations and fears. Our final management protocol is appropriately tailored to the need of that particular patient.

Estrogen therapy

Local (vaginal) and not oral estrogen is the treatment of choice if the only symptom is GSM. If the patient has other symptoms such as hot flashes and night sweats then oral estrogen may also be given.

Different estrogen preparations available:
Estrace vaginal cream, Vagifem vaginal tablet, Estring vaginal ring and Premarin vaginal cream are the most commonly used vaginal estrogen preparations.

All estrogen preparations are equally effective in relieving the symptoms of vaginal atrophy.

What is a black box warning?
A black box warning is the strictest warning put in the labeling of prescription drugs or drug products by the Food and Drug Administration (FDA) when there is reasonable evidence of an association of a serious hazard with the drug.

Does estrogen have a black box warning and what is it?
After the release of the WHI (Women’s Health Initiative) data, the US Food and Drug Administration (FDA) enforced a “black box” warning on postmenopausal hormone use in women which mentions about increased risks of heart disease, heart attacks, stroke, blood clots and breast cancer in postmenopausal women.

What should a woman do to make sure that she does not have any contraindications?
It is important to be aware of this above list of contraindications. Also, it is important to discuss certain other issues with Dr. Khandwala and his team such as if there is history of fibrocystic breast disease or a strong family history of blood clots or stroke or breast cancer. Is there any history of abnormal vaginal bleeding that should always be checked out before starting estrogen.

Does estrogen cause uterine cancer?
If estrogen is given alone for a long period of time there is a potential risk of uterine cancer. Hence we are very careful when administering estrogen alone in women who have not undergone a hysterectomy.

Do I need any specific tests done periodically when I am on estrogen?
Based upon your history and your family history, you may need additional testing (surveillance). Please make sure that you always provide to your healthcare provider the details of your personal, medical, family history and a list of all your medications.

How long should estrogen treatment be continued?
Since GSM is a chronic condition, therapy should be continued without interruption, because signs and symptoms will come back once the treatment is stopped. The frequency of treatment may change as eventually the patient could be just on maintenance dose and not daily dose therapy.

Is it safe to continue estrogen treatment for a long period of time? Is there any specific monitoring that is required when on estrogen therapy?
For local estrogen therapy, the safety data only goes up to 12 months. This does not mean that it becomes unsafe after that time.

The latest North American Menopause Society position paper recommends that if a woman is at high risk of endometrial cancer or is using a higher dose of vaginal estrogens, transvaginal ultrasound or intermittent progestogen therapy may be considered. The same paper states that with appropriate clinical surveillance, vaginal estrogens can be continued as long as bothersome symptoms are present.

What do you do in your practice?
We assess each patient individually and determine their risk benefit profile. For example patients who are obese and diabetic may be at increased risk of uterine cancer and they may qualify for an annual uterine ultrasound.  We also adjust the treatment based upon any new medical information or treatment options.

  • Undiagnosed abnormal genital bleeding.

  • Known, suspected, or history of breast cancer

  • Known or suspected estrogen-dependent cancers such as that of the uterus

  • Deep vein thrombosis, pulmonary embolism or a history of these conditions

  • Arterial thromboembolic disease such as stroke, myocardial infarction-heart disease

  • Liver dysfunction or disease

MonaLisa Touch This is a fractional CO2 laser that is equipped with a HiScanDot scanning system which delivers laser energy in a uniform, accurate and controlled manner that creates patterns of micro-wounds that results in stimulation of collagen and a subsequent emergence of new healthy more youthful tissue.

What is the DEKA pulse?
The DEKA pulse shape is specifically designed for vaginal treatment with the MonaLisa Touch laser. it involves a two-part laser that provides a suitable thermal energy transfer to the connective tissue and the vaginal lining in order to stimulate the reparative process.

How much time does the DEKA pulse firing take?
This is done in milliseconds! It is impossible to even gauge how quick and precise it is. The power is transmitted just for that short time. The depth of penetration of the laser is only 200 microns.

Vagina under microscope after menopause

As can be seen in this picture the surface lining is very thin. The underlying tissue also lacks the (deep pink) connective tissue ground substance that is important for the nutrition of the vaginal lining and maintenance of the elasticity and stretchability of the vagina.

Vagina after MonaLisa treatment

The vaginal epithelium is thick and is now formed of many cell layers (20–40). The lower part of the epithelium is now indented by the underlying rich connective tissue creating numerous papilla or projections. This tissue has increased water content that not only hydrates the lining but also allows for an easier movement of nutrients from the blood vessels to tissues. the MonaLisa laser also activates the heat shock proteins (HSPs), specifically HSP47, which are critical for collagen biosynthesis. Collagen is important for maintaining the strength and the pliability (elasticity) of the vaginal tissues.
Thus, in 1-3 treatment cycles the negative changes of menopause on the vaginal epithelium and the support tissues of the pelvis are almost completely reversed.

What is involved in the actual procedure?
This is almost like a speculum examination. The laser probe is inserted into the vagina and the laser is activated while rotating the probe inside the vagina. Within 3-4 minutes the vaginal cavity is completely treated. The probe is then changed and the vulva (opening of the vagina) is treated.

Where is the procedure done?
It is done in our office in one of the exam rooms.

How long does the procedure take?
Each treatment takes about 5 minute. Patients receive three treatments, spaced six weeks apart.

Does the procedure hurt?
The procedure does not require anesthesia. Local anesthetic ointment is applied to the vaginal opening only if this area is also to be treated. Some patients may experience slight discomfort the first time the probe is inserted if there is severe vaginal narrowing or dryness, but the actual treatment is not painful.

Do I need to prepare or do anything prior to the procedure?
Make sure that you do not use anything inside the vagina for at least 48 hours prior to the MonaLisa Treatment. The laser does not work well if there is water as it is absorbed by water. We therefore wipe the local anesthetic from the vulva prior to treatment.

For which patients is this treatment appropriate?
The MonaLisa Touch is appropriate for all postmenopausal women experiencing symptoms of GSM.

Is this procedure safe for women with breast cancer?
Yes, the MonaLisa Touch therapy is particularly well suited for patients (like those with breast cancer) who cannot take, or prefer not to take estrogen therapy.

Will the procedure be covered by insurance?
At this time, the procedure in not covered by insurance. However, if you have a Health Savings Account (HSA) or Flexible Spending Account (FSA), contact your insurance company for eligibility.

When will I see results?
Most patients feel improvement after the very first treatment, although the procedure calls for three treatments that are generally spaced over an 18-week period.

Once this is successful, how long does it last?
Patients should expect to come back annually for one maintenance treatment.

What are my limitations after the procedure is done?
Patients should refrain from sexual activity for 2-3 days.

  1. In 30 women followed for a year, 92% were satisfied with their treatment. All GSM symptoms: dysuria, burning, itching, dryness, dyspareunia significantly improved with the MonaLisa laser therapy.
  2. An Italian study observed that 85% of women who were not sexually active resumed intercourse just after one treatment cycle. Also all symptoms of GSM improved significantly. All patients had significant improvement in their quality of life and satisfaction scores.

What is a SERM?
A SERM or selective estrogen receptor modulator is a medication that works on select estrogen receptors only. For example the breast cancer drug Tamoxifen blocks the effects of estrogen on breast tissue but may act like estrogen and stimulate the lining of the uterus. Thus the SERM acts like estrogen on certain body parts and either have no estrogen function or may oppose estrogen action on other body parts. Hence they are selective in their function.

What is Ospemifene or Osphena?
It is a selective estrogen receptor modulator (SERM) that has positive effects on vaginal tissue without any effects on the breast tissue.

What is Osphena used for?
Osphena has been shown to significantly reduce the symptoms of dyspareunia and vaginal dryness compared with placebo.

How is it administered?
It is given as an oral tablet of 60 mg daily.

What are the side effects of Osphena?
The adverse events most commonly reported are hot flushes and muscle cramps.

When is Osphena contraindicated?
Contraindications include estrogen-dependent neoplasia (breast and endometrium), active or previous VTE, stroke or myocardial infarction and undiagnosed vaginal bleeding.

Has Osphena been shown to be safe over the long term?
The long-term safety of Osphena up to 1 year demonstrated no clinical or significant adverse effects on the uterine lining. No data exists beyond 1 year.


What is the difference between lubricants and moisturizers?
Lubricants relieve vaginal dryness and discomfort during sexual activity, providing short-term relief from vaginal dryness and dyspareunia. Vaginal moisturizers are intended to be used primarily for the relief of vaginal dryness on a day-to-day basis, to provide comfort and offer long-term benefits.

What are the different types of lubricants?
A wide variety of personal lubricants are commercially available, either as water, silicone, mineral oil, or plant oil-based products, and are applied to the vagina and vulva (and the partner’s penis if required) prior to sex. Lubricants act rapidly to provide short-term relief from vaginal dryness and related pain during sex. They are particularly beneficial for women whose vaginal dryness is a concern only or mainly during sex. Water-based lubricants have the advantage of being non-staining, have fewer irritative effects on the vagina and do not affect the latex condoms.

Goals of Lubricants/Moisturizers

  • Rehydrate vaginal tissues

  • Lubricate dry vaginal tissues without causing irritation

  • Maintain or lower vaginal pH

  • Avoid potential endocrine disruptors (i.e. parabens preservatives)


Vaginal moisturizers rehydrate dry mucosal tissue and are absorbed into the vaginal epithelium and adhere to the vaginal lining, thereby mimicking natural vaginal secretions. Vaginal moisturizers are intended to be used for the non-hormonal improvement of vaginal dryness and they are applied regularly, from every day to once every 2–3 days. Their frequency of use is directly proportional to the severity of atrophy (i.e. the more severe the atrophy, the more frequent the application), and their effects are more long-term than those of lubricants, lasting 2–3 days. Vaginal moisturizers provide this longer relief by hydrating the epithelium (osmolality) and lowering the vaginal pH, thereby maintaining vaginal moisture and acidity.

They are therefore particularly beneficial not only for women with symptoms of GSM that cause pain during sexual activity, but also for women who are not necessarily sexually active, but experience day-to-day discomfort due to dryness.

The WHO recommends that the osmolality of a personal lubricant/moisturizer should not exceed 380 mOsm/kg, in order to minimize any risk of epithelial damage; however, because most of the commercially available preparations greatly exceed this value, an upper limit of 1200 mOsm/kg is generally deemed acceptable in practice. Greater osmolality of personal lubricant/moisturizer may cause irritation and tissue damage.

It is important to also understand what other individual components are present in the lubricant/moisturizer as they may also have some deleterious influence on the vaginal epithelium.

Parabens are found in some personal lubricants, such as KY Jelly, Replens and Astroglide. Parabens are weakly estrogenic compounds and there is some debate as to whether they present an endocrine-disrupting risk. Ideally they should be avoided in women with estrogen sensitive breast cancer.

Glycols serve as humectants/emollients in lubricants, and glycerol/glycerine and propylene glycol are the most common. High concentration of glycols could increase the osmolality of the lubricant beyond that stipulated by the WHO and this can cause vaginal wall irritation.

Antibacterials such as nonoxynol-9, chlorhexidine in personal lubricants can cause inflammation of the genital mucosa and may increase the susceptibility to sexually transmitted infections and bacterial vaginosis.

Therefore it is important to understand not only the osmolality and pH of the lubricants/moisturizers but also the constituents.

These are plastic or rubbery round-tipped cylinders that come in sets ranging in diameter from about 3/4 inch to the width of a fully erect penis. They are used to stretch and relax the vaginal muscles and can be helpful in treating either vaginal stenosis (constriction or tightening) or vaginismus (involuntary tightening of the pelvic muscles).

What is the goal of vaginal dilator therapy?
A key part of treating vaginismus or genitopelvic pain penetration disorder (GPPPD) is learning how to relax the tight vaginal muscles to regain control over them. Dilator therapy aims to teach a woman that she is in control of her body and what enters it. By retraining her body and regaining control of her pelvic muscles, she can free her body from feeling that it has to protect her by tightening the vaginal muscles to prevent penetration. A physical therapist or cognitive-behavioral therapist may teach the relaxation techniques.

How to use the dilators:
For vaginal stenosis, women simply perform dilator therapy at home at their own pace during practice sessions of 5 to 10 minutes daily.

Instructions for dilator therapy may vary, but one method is to start with the largest dilator that comfortably fits into your vagina. The dilator should always be comfortable, as any discomfort may increase the possibility of involuntary tightening of the vaginal muscles (vaginismus). After putting a small amount of lubricant on the dilator, place it gently into the vagina. It doesn’t have to go all the way in to stretch the opening; halfway in will work. Slowly move the dilator in and out of your vagina, leaving it in for 1 to 2 minutes each time. Spend about 5 minutes on these exercises while you recline with a book, listen to relaxing music, or watch television. Perform these exercises once or twice a day until the dilator is no longer stretching your vagina. Then repeat the process with the next larger dilator.

Intercourse will be most comfortable if you can successfully use the dilator that is just slightly larger than your partner.

If you have intercourse often, you may not need to use the dilator anymore. If you have intercourse less than once a week, you may need to use the dilator in between to maintain what you have accomplished. Dilators are also useful when partners are separated for a while or when one partner is ill and not able to have intercourse.

All of the lifestyle practices that promote better sexual function in women—weight loss, exercise, eating right, stopping smoking, moderation in alcohol use, adequate sleep—do the same in men. In fact, the most common sexual disorder in men at midlife and beyond—erectile dysfunction—is often linked to having an excess waistline, vascular problems, heart disease, or diabetes. For that reason, practices like stopping smoking, maintaining a healthy weight, and exercising are particularly important to sexual health in men. Don’t be shy about nudging your partner toward healthier practices!

  • Getting his erectile dysfunction treated. Men have it lucky: there are a host of effective treatments for erectile dysfunction, from the oral drugs Viagra, Levitra, and Cialis to injected drugs, pellet drugs, and devices like the vacuum pump and penile band. The biggest obstacle may be getting your partner to mention his erection difficulties to his healthcare provider in the first place.

  • Addressing ejaculation problems.Early or premature ejaculation is a common and frustrating problem in men, although it’s less common as men age and gain more sexual experience.

  • Joining the patient in couples counseling or sex therapy.

Other issues to address with your partner: 

  1. Prevent sexually transmitted infections: Once you’ve reached menopause, just because you can’t get pregnant doesn’t mean you can’t contract a sexually transmitted infection (STI). In fact, women with severe vaginal atrophy who are sexually active may be at increased risk for STIs since their dry, thin vaginal tissue is susceptible to small tears where infection can begin. Discuss sexual histories with your partner, and don’t let embarrassment compromise your health.
    Always insist that a male partner use a condom for genital, oral, and anal sex unless you are in a long-term, mutually monogamous relationship. Never use petroleum-based products like Vaseline or baby oil to lubricate condoms because they can cause condoms to break.
    Don’t let a male partner’s erection difficulties keep him from using a condom. If all else fails, get a female condom.
  1. Schedule regular date nights.
  2. Plan a mini-trip away from home.
  3. Toy around.Use sex toys that address both the partners’ needs. Experiment with different gadgets to see which is best that suits you and your partner.
  4. Venture beyond the usual. Try new positions, different times of the day, or different rooms in the house.
  5. Plan an erotic surprise.The surprise might be making your partner’s favorite dish for dinner or preparing a candlelit bath for two or greeting your partner at the door wearing nothing but a _______ (use your imagination).
  6. Indulge your senses.Create an environment for you and your partner that engages all of your senses. You might try silk robes, seductive music or reading the kama Sutra.
  7. Be romantic and playful.Slow dance. Read poetry to each other. Leave hidden love notes. Tickle each other. Cuddle and laugh. At its most basic, sex is a form of play and an expression of love.

Lifestyle modification: Smoking is clearly a risk factor for the genitourinary syndrome because it accelerates estrogen deprivation. A BMI greater than 27 kg per meter square and no physical exercise also leads to an increase risk of vaginal symptoms possibly because there is less vascular supply to the genitourinary area.

Sexual intercourse or masturbation decreases symptoms related to vaginal atrophy by improving elasticity and lubrication and increasing vascularization due to mechanical stimulus and therefore an improvement in symptoms such as dyspareunia.

Should one use sex toys such as a vibrator?
This is entirely up to the couple. Some of these gadgets allow for a very quick arousal especially in women who have dryness and manual stimulation could become painful. There are a lot of options and places to find these gadgets.

It is important to note that these act more as additional helpers to the main treatment of GSM.

Yoga can improve women’s sexual function, according to a 2009 study published in the Journal of Sexual Medicine. The study involved sexually active women ages 22 to 55 who followed a 12-week regimen of an hour of yoga each day followed by breathing and relaxation exercises. The study showed that their sexual function scores improved by the end of the program across all six of the areas studied—desire, arousal, lubrication, orgasm, satisfaction, and pain. The biggest improvements were in women ages 45 or older. About 3 in 4 of the women reported that their sex lives improved after completing the yoga program.