Menopause and Sexual Dysfunction

Human sexuality is a hugely complex issue, and here no pretence is made to address the entire subject – whole books can and have been written on the topic. However, there can be no doubting that the menopausal transition affects female sexuality.

On a positive note, some women are liberated by the absence of fear of pregnancy, while others feel that their maturity is such that they understand their bodies and know what they want. They may be in good mature relationships with their partner, have more time on the hands especially if the children have flown the nest, and overall for many women / couples all these factors make for a better sexual encounter in the menopausal transition. However, for many women the decline in sex hormones is associated with a negative impact on sexual function.

Here are some of the reasons that there is an impairment of sexuality:

  • Lack of oestrogen results in vaginal dryness, causing discomfort and even pain during sexual intercourse. This leads many women to avoid intimacy.
  • Night sweats and hot flushes are not exactly conducive to a romantic interlude – the woman may feel an intolerable heat, often accompanied by profuse sweating, and even a feeling of claustrophobia. Bed covers / blankets are cast to one side, only to be followed by feeling cold.
  • Around the menopausal transition some women will experience irregular periods, interfering with the spontaneity of loving-making that may be an important feature of intimacy for many a couple.
  • The occasional woman may experience stress urinary incontinence during intercourse, and this could be very off-putting for some.
  • Some women become self-conscious because of physical changes that occur during the menopausal transition – these include a dry skin, changes in the shape of their breasts, a gradual redistribution of weight away from their breasts towards their waistline – the so-called “middle-age spread” is an unfortunate reality, and despite rigorous exercise and dieting women find it difficult to shift this weight. A sense of loss of their “allure” and physical attractiveness to their partners hardly encourages women to seek the intimacy they may have taken for granted in their younger days.
  • The emotional changes that can occur in some women also contribute to impaired sexual function – the mood swings, the tendency to depression, the feelings of wanting to be alone, the sense of global anxiety and loss of self-confidence: all these factors can impact negatively on female sexuality.
  • While the occasional woman experiences an enhancement in libidio, for the majority of women a loss of libido is a common accompaniment of the “change”. Sexuality being so complex, the cause of this loss of libido is likely to be due to a combination of a multitude of factors, including those mentioned above. However, it is also thought that the decline in testosterone level, in particular, leads to loss of libido.

The challenge of menopausal sexual dysfunction is exacerbated by the fact that women often hesitate to seek help – they may find it embarrassing to do so, or may consider that it is “just part of the ageing process” for which nothing can be done.

While it is true to say that no hormone or tablet could ever mend a fractured relationship, in the absence of such fracture there are a whole multitude of interventions that could go a long way towards resolving the sexual dysfunction seen in the menopausal transition.

Hormone replacement therapy is hugely effective: local oestrogen cream is very effective at relieving vaginal dryness and therefore the discomfort and / or pain that some women experience; systematic HRT can eradicate many of the symptoms described above that contribute to the sexual dysfunction – the hot flushes and night sweats, the mood lability, the dry skin etc etc. Other measures that women should consider include relationship counselling, and complementary activities such as yoga and acupuncture.

A role for testosterone in menopausal sexual dysfunction

For many a woman, the mention of “testosterone” conjures up masculinity, “a male hormone”, unwanted body hair, perhaps voice changes – “will I turn into a man?”. What is often not realised is that women actually produce testosterone (but of course not to the same levels as men), and that this testosterone is just as vital as the other sex hormones (oestrogen, progesterone etc) that they produce. Indeed, women produce three times as much testosterone as oestrogen before the menopause.

The levels of testosterone in the female body gradually reduce with age, and fall precipitously / very abruptly if ovaries are removed at the time of hysterectomy, or for any other reason (because the majority of the testosterone is produced in the ovaries). The decline in testosterone may cause women to desire sex less often, and when they do have sex, it is often not as pleasurable as it used to be, even though they still desire their partner.

There is some evidence also that having lower testosterone levels also affects women’s mood, and increase their risk of becoming depressed. It therefore stands to reason that testosterone is likely a crucial component of HRT, and that current approaches that emphasize on the replacement of oestrogen without testosterone may be misguided and inadequate. A full discussion of these issues is beyond the scope of this resume, and indeed a lot of research is required as many of these issues are yet to be fully understood.

Watch the video on testosterone here - Testosterone

Read the latest International Menopause Society consensus on use of testosterone in women Read here

Effects of testosterone given as HRT: The general current practice is to offer testosterone to women in woman loss of libido and poor energy levels are major features of the symptoms of their menopause – the vast majority of women benefit immensely, with evidence showing that testosterone improves general well-being, emotions, mood, energy, concentration and of course libido. It can also provide benefits to the skin and hair.

It is an important hormone for muscle strength and stamina too. Many women report better quality sleep, and some even report changes to the type and quality of their dreams, while others report a sense of an improvement in their eye sight – some of these are of course anecdotal reports, and it is not suggested that every woman will experience these benefits.

How testosterone is given: At the Menopause Clinic London testosterone ( click here ) is usually given as an implant inserted in the fat layer under the skin on the buttock, abdomen or mons pubis. A local anaesthetic is given, and then a tiny cut made in the skin, through which a special instrument is used to insert the implant. All this takes less than 10 minutes, and the if a stitch is applied to the wound, it is usually one that dissolves and does not need removal at a later stage.

Each implant usually lasts 6 months. Testosterone can also be given as a gel to rub into the skin. This appears to be the route favoured on the continent, such as in France, but these gels are also available in the UK, and many menopause specialists prescribe them. There are pros and cons where implants versus gels are concerned – in the end the effectiveness of the treatment, and the woman’s preference, determines the manner in which the testosterone is administered.

Side effects from using testosterone: There are usually no side effects with testosterone treatment. Very occasionally some women notice some increased hair growth in the area in which they have rubbed the gel. This can be avoided by changing the area of skin on which the gel is rubbed. Testosterone gel is currently not licensed for use in women in the UK. However, it is prescribed by many menopause experts do prescribe it as it has proven benefits in many clinical trials. It is also very safe. When given as implants women occasionally report an increase in body hair, the most annoying for them being facial hair. However, there are interventions, such as electrolysis, which are very effective at dealing with the unwanted hair.

Having experienced the benefits of testosterone, many a woman would rather deal with the hair than stop using the testosterone. Finally, an extremely rare side effect is a change in voice – usually a deepening: if this happens testosterone should be discontinued, and the change in voice usually resolves over time.

More research is needed! It is arguably true to say that the beneficial effects of testosterone are under-estimated, but it is also true to say the potential for any deleterious effects may not be fully understood. There is therefore a clear need for well-designed studies to allow a better evidence base for this potentially important hormone in the treatment of women during the menopausal transition. Currently testosterone is not licensed for use in women in the UK – research my enable this situation to change.

Have you had treatment for breast cancer and are suffering from vaginal dryness or irritation?

Some low dose vaginal oestrogen preparations are safe to use for symptoms such as vaginal dryness, irritation and painful sex even if you have had breast cancer in the past.

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