To the Editor We read with interest the findings from the longitudinal cohort study by Thomas and colleagues,1 dissociating midlife sexual activity from the classic norms of the Female Sexual Function Index. Rather than focusing on the events in a sexual response cycle, more accurate estimates of sexual function for women aged 40 to 65 years will require a number of measurement tools that take into consideration events such as relationship issues, sexual interest, desire, satisfaction, and/or personal distress from any cause. A woman’s participation in sexual activity often stems from reasons beyond her own interest, and therefore coital frequency would be an inadequate determinant of her sexual health.2 Physical, emotional and socioenvironmental factors are major determinants on women’s sexual function; subjectively, mood or sleep disturbances, fatigue, medical, psychological issues, and partner’s health-related outcomes may be important confounders.3 Some contextual factors not duly credited would include the physical and/or emotional drain of caring for an elderly parent or children in the same household and the lack of privacy therein. Aside from menopausal hormonal and vaginal changes, emotional, social, and cultural taboos or boundaries often exert a significant impact on how women react to sexuality as they age. It is therefore not surprising to find a third of postmenopausal Asian women in our clinical cohort completely asexual for considerable lengths of time, yet were not distressed to seek medical advice.4 In a conservative society, hugging, kissing, or any other form of physical intimacy is construed as a prelude to sexual intercourse and thereby avoided. It was in the initial years of sexual health assessment that frequency-based measures were used as primary end points for women’s sexual functioning.5 This emphasis underwent a paradigm shift, together with inclusion of personal distress and quality of life as additional pertinent outcomes, and the reporting of functional changes presently dates back to 6 months, giving a wider window. With the understanding that a woman’s sexual response waxes and wanes in the context of widespread influences in the familial and sociocultural setting in addition to health- or couple-related factors, it appears that more than a single tool would be required for a holistic sexual assessment. Adding a simple, structured questionnaire to standard validated instrument(s) in a face-to-face interview may be a proactive approach, to be adopted by the physicians caring for these women with extended life-span requirements. The chosen items may also be useful in delineating the etiology and customizing intervention.