The Journal of Sexual Medicine, 2023, 20, 1270–1273

https://doi.org/10.1093/jsxmed/qdad113
Expert Opinion

Couplepause: deconstructing sick menopause and

andropause during midlife
Serge Rozenberg, MD, PhD1 , Rossella E. Nappi, MD, PhD2 ,3 , Katrin Schaudig, MD, PhD4 ,

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Emmanuele A. Jannini, MD5 ,* , Annamaria G.E. Giraldi, MD, PhD6
1 Department of Obstetrics and Gynecology, CHU St Pierre, Université libre de Bruxelles and Vrije Universiteit Brussel, Brussel, Belgium
2 Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
3 Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS San Matteo Foundation, Pavia, Italy
4 Hormone Hamburg Gynecological Endocrinology, German Menopause Society, Hamburg, Germany
5 Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
6 Department of Clinical Medicine, Copenhagen University Hospital, Copenhagen, 1353, Denmark

*Corresponding author: Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier, 1 E Tower South, Floor 4, Room E413, 00133, Roma,
Italy. Email: eajannini@gmail.com
Keywords: couplepause; menopause; late-onset hypogonadism; andropause.

Introduction therefore necessary to consider other biopsychosocial aspects

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 Sex-
ual 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 Clin-
icians 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 hypog-
onadism (LOH) can affect the general and sexual health of
both members of the couple. In this natural aging process, it is
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.
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 frustra-
tion.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 conse-
quences of the hormonal and age-related changes that can

Received: May 11, 2023. Revised: August 4, 2023. Accepted: August 9, 2023
© The Author(s) 2023. Published by Oxford University Press on behalf of The International Society of Sexual Medicine.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/lice
nses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For
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The Journal of Sexual Medicine, 2023, Vol 20, Issue 11 1271

Table 1. 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.
Population All women who live sufficiently long experience a final
affected menstrual period, associated with estrogen deficiency.
Menopause is considered a natural occurrence in
women’s lives.9
Andropause/LOH is defined as a decrease in
serum testosterone below the normal range,
accompanied by clinical symptoms.25
Not all men develop testosterone deficiency, and
not all men with below-normal testosterone
levels have clinical symptoms.26,27

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Possible Vasomotor symptoms, loss of concentration, irritability, Erectile dysfunction
changes related arthralgia, osteoporosis, sleeping problems, greater Reduced frequency of morning erections
to hormone fatigue Decreased libido
deficiency Genitourinary syndrome of menopause: genital dryness Impaired ejaculatory and orgasmic function
itching, irritation Loss of pubic hair and other body hair
Dyspareunia9 Decreased endurance, greater fatigue
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
Onset After several years of menopausal transition (loss of Although testosterone levels fall as men age, the
fertility, irregular menses, and large estrogen variations), decline is steady at about 1% a year from around
estrogen decrease is abrupt.24 The mean age of the age of 30 to 40 years.28 In healthy aging men,
menopause is between 50 and 52 years3,4 ; however, it there is a small gradual decline in testosterone;
may vary from 44 to 54 years.3-5 up to the age of 80 years, aging accounts for a
low percentage of hypogonadism.28

Abbreviation: LOH, late-onset hypogonadism.

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/gyne-
cologists, 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).
Diagnosing couplepause
Regarding couplepause, some initiatives of potential interest
can be approached from a multidisciplinary perspective. Based
on evidence and psychometric experience, the recommenda-
tion of the working group is the development of a protocol for
1272 The Journal of Sexual Medicine, 2023, Vol 20, Issue 11

organic changes that occur throughout life and the conse-

quences. 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 interven-
tion 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.

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Figure 1. Follow-up session after couple-thinking: triage method.

Author contributions
the diagnosis of couplepause. This would allow us to quantify All authors contributed extensively to the work presented
the prevalence for which, despite the presence of sexual dys- in this article. All authors contributed significantly to the
function, there is no real commitment of the couple as a whole. conception, design, or acquisition of data or the analysis and
The resulting information could be used in communication to interpretation of data. All authors participated in drafting,
health professionals and the public. With regard to generation reviewing, and/or revising the manuscript and have approved
of evidence and after having defined the research question, it its submission.
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 CRediT author Statement
different databases, including heterosexual and homosexual
S Rozenberg (Conceptualization-Equal, Data curation-
couples.
Equal, Formal analysis-Equal, Funding acquisition-Equal,
Data collection Investigation-Equal, Methodology-Equal, Project administra-
tion-Equal, Resources-Equal, Software-Equal, Supervision-
A prospective sample survey should be designed to allow
Equal, Validation-Equal, Visualization-Equal, Writing –
detailed analysis of all the sexual changes that men and
original draft-Equal, Writing – review & editing-Equal), RE
women experience during midlife, including all sexual orien-
Nappi (Conceptualization-Equal, Data curation-Equal, For-
tation. The survey should be carried out with the participation
mal analysis-Equal, Funding acquisition-Equal, Investigation-
of a multidisciplinary group of physicians and health experts,
Equal, Methodology-Equal, Project administration-Equal,
including gynecologists, urologists, psychiatrists, and psychol-
Resources-Equal, Software-Equal, Supervision-Equal,
ogists. It is also critical to determine whether what is happen-
Validation-Equal, Visualization-Equal, Writing – original
ing in their lives is different from what the specialists suppose.
draft-Equal, Writing – review & editing-Equal), K Schaudig
In this sense, mixed methods (survey and personal interviews)
(Conceptualization-Equal, Data curation-Equal, Formal
may be necessary to approach the analysis. In summary, it is
analysis-Equal, Funding acquisition-Equal, Investigation-
essential to create a viable and scientifically sound tool that
Equal, Methodology-Equal, Project administration-Equal,
allows the collection of data in multiple countries and the
Resources-Equal, Software-Equal, Supervision-Equal,
understanding of different cultural backgrounds.
Validation-Equal, Visualization-Equal, Writing – original
Target population draft-Equal, Writing – review & editing-Equal), Emmanuele
A. Jannini (Conceptualization-Equal, Data curation-Equal,
Under the assumption that the prevalence of the problem is
Formal analysis-Equal, Funding acquisition-Equal, Investiga-
likely to be high and underestimated, it is essential to ensure
tion-Equal, Methodology-Equal, Project administration-
that the target population is correctly identified. In this sense,
Equal, Resources-Equal, Software-Equal, Supervision-Equal,
it will be critical to collect the data of individuals who agree to
Validation-Equal, Visualization-Equal, Writing – original
participate, as well as those who refuse and the reasons behind
draft-Equal, Writing – review & editing-Equal), Annamaria
the refusal, to avoid response bias.
Giraldi (Conceptualization-Equal, Data curation-Equal, For-
How to increase the couple implication: breaking mal analysis-Equal, Funding acquisition-Equal, Investigation-
barriers Equal, Methodology-Equal, Project administration-Equal,
Resources-Equal, Software-Equal, Supervision-Equal, Valida-
Barriers in seeking medical help and discussing sexual issues
tion-Equal, Visualization-Equal, Writing – original draft-
dramatically affect the ability of the doctor to help patients
Equal, Writing – review & editing-Equal).
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- Funding
emphasized and defining this period as a new beginning, pro-
moting a healthy sex life and overall well-being; (2) enhancing Writing assistance was provided by Content Ed Net with
education so that men and women understand the changes in funding from Viatris.
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 effec- Conflicts of interest
tively. Regarding educational interventions, the development S.R. has received travel and consultancy fees from Viatris,
of materials for couples could help them understand the Abbott, Bayer, Eurogenerics, Gedeon Richter, Takeda,
The Journal of Sexual Medicine, 2023, Vol 20, Issue 11
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.
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