Exploring sexual dysfunction in the menopausal woman

Hormonal and physiologic changes 

During the perimenopausal period, there is a dramatic decline in circulating sex steroids. Estrogen deficiency causes multiple changes in the genitourinary system. There are decreases in skin flushing, muscle tension, vaginal expansion and congestion, Bartholin gland secretion, vaginal lubrication, clitoral reactivity, and uterine contractions with orgasm.

Patients typically report symptoms secondary to these physiologic changes, including vaginal dryness, dyspareunia, and decreased clitoral sensitivity and orgasmic intensity. It is intuitive that the increase in discomfort and decrease in pleasure associated with sexual activity would result in a diminished desire to engage in such activity. Community-based studies have confirmed that vaginal dryness is an independent predictor of decreased libido.3 In most studies, low estrogen levels correlate with an increase in FSD during the perimenopausal years.

Circulating androgens are known to decline during the late reproductive years. Androgen deficiency is associated with loss of libido, decreased sexual fantasy, decreased sensitivity to sexual stimulation, decreased arousability, and decreased capacity of orgasm. However, population-based studies have not demonstrated a clear association between androgen levels and satisfactory sexual function.

Physical changes 

In addition to the physical changes that occur in the genitourinary system as a result of hormonal deficiencies, various other physical changes and conditions may contribute to FSD. These may include arthritis, urinary or bowel difficulties, pelvic surgery and trauma, headaches, neurologic disorders such as multiple sclerosis, and untreated pain syndromes.4 Certain medications can decrease sexual desire and hinder the ability to accomplish orgasm, including some antidepressants, blood pressure medications, antihistamines, and chemotherapy agents.4

Successful patient evaluation 

Open communication between patient and physician is of paramount importance in the management of FSD. Unfortunately, both physicians and patients find it difficult to discuss sex and sexual functioning. According to a large survey, 68% of men and women were concerned that their physician would be uncomfortable discussing sex, and 71% suspected that their physician would dismiss their concerns.5 It is important that care providers integrate a discussion of sexual health into annual gynecologic visits and create an environment in which patients are comfortable raising their concerns (Table 2). [See also “Just ask! Talking to patients about sexual function” in the December 2004 issue of Sexuality, Reproduction & Menopause.]

TABLE 2. Recommendations for discussing sex with patients

	•Initiate discussion — do not expect patient to do so
	•Create appropriate environment Prior to disrobing Non-rushed setting; schedule separate appointment if necessary
	•Convey sense of comfort discussing subject
	•Avoid technical language
	•Offer positive feedback
	•Avoid being judgmental
	•Use open-ended questions Do not suggest answers; however, if required for clarification, give many examples and do not use descending hierarchy for frequency
	•Begin by asking “easier” questions to gain patient's confidence
	•Recognize that behaviors vary from culture to culture
	•Consider patient's sexual orientation
	•Include partner if possible

Adapted from Nusbaum MR, Singh AR, Pyles AA. Sexual healthcare needs of women aged 65 and older. J Am Geriatr Soc 2004;52:117–22.

It is important to obtain a thorough sexual, medical, psychological, and psychosocial history. Key elements include:

TABLE 3. Medications that may affect sexual functioning

	Hormonal medications
	Estrogen therapy
	Androgen therapy
	Gonadotropin-releasing hormone agonists
	Danazol
	Psychoactive medications
	Selective serotonin reuptake inhibitors
	Benzodiazepines
	Barbiturates
	Tricyclic antidepressants
	Antipsychotics
	Lithium
	Cardiovascular medications
	Beta blockers
	Statins
	Spironolactone
	Digoxin
	Clonidine
	Others
	H2-receptor blockers
	Phenytoin sodium
	Indomethacin
	Ketoconazole

Adapted from Phillips NA.Female sexual dysfunction: evaluation and treatment. Am Fam Physician 2000;62:127–42.

A gynecologic examination should be performed focusing on finding evidence for vaginal atrophy or infection, vulvodynia, or deep tenderness. In addition, a general examination should be performed in order to identify comorbidities that may interfere with sexual functioning.

Estrogen therapy 

Estrogen therapy, either local or systemic, has been shown to improve vaginal atrophy and increase vaginal blood flow, lubrication, and sensitivity response. There is no evidence that any specific product or dose is superior to another.

A single randomized trial performed almost a quarter of a century ago reported a positive effect of systemic estrogen on mood and sexuality.6 This was a small crossover trial that failed to include a washout period and used an estrogen dose much higher than that used today. Given these limitations, further research is required to advocate the use of systemic estrogen therapy for the treatment of hypoactive sexual desire.

Androgen therapy 

Androgen therapy has been advocated for treatment of FSD. A number of studies have demonstrated an improvement in sexual functioning in postmenopausal women treated with estrogen and testosterone when compared with those treated with estrogen alone. The majority of these studies were limited by small sample size, lack of blinding, and use of testosterone supplementation at supraphysiologic dosages.7, 8 In addition, most studies were performed in women after oophorectomy, who are at greater risk for FSD than an age-matched population of partnered women.9

Dehydroepiandrosterone (DHEA), an androgen precursor hormone made in the ovaries and adrenal gland, can be converted to testosterone and dihydrotestosterone. The sulfated form, DHEAS, is low in the elderly and those with adrenal insufficiency. Though DHEA supplementation may improve sexual interest in women with adrenal insufficiency, there is no evidence that it affects sexual functioning in healthy women.

Potential adverse effects of androgen therapy include acne, hirsutism, weight gain, deepening of the voice, and a negative impact on liver function and lipid parameters. Parenteral administration appears to be associated with fewer metabolic abnormalities. Because testosterone and DHEA can be aromatized to estrogens, potential risks also include those related to estrogen therapy. Pharmacologic, rather than physiologic, dosages are more likely to be associated with adverse effects.

Although a number of androgen preparations are available, none are currently indicated for the treatment of FSD. The most promising approach appears to be the transdermal testosterone patch or gel. However, dosages currently available are excessive for use in women. Clinical trials evaluating the efficacy of transdermal testosterone in physiologic dosages are under way. [See also “Aging, androgens, and female sexual desire: Can we restore what time takes away?” on page 3 of this issue.]

Other medications and treatments 

Sildenafil citrate (Viagra), which promotes erection by blocking phosphodiesterase 5 (PDE5) activity and causing an accumulation of 31 51 cyclic guanosine monophosphate in the penis, also inhibits PDE5 in clitoral and vaginal smooth muscle, thereby enhancing genital blood flow and vaginal and clitoral engorgement. Although treatment with sildenafil has been well tolerated without serious adverse effects, data regarding its efficacy in treating FSD are mixed.10, 11 One investigation found improvement in genital sensation and satisfaction, though this was not confirmed by other studies.

Topical alprostadil, also a vasoactive agent, has been evaluated for the treatment of FSD. Efficacy was not demonstrated and side effects included mild to moderate burning at the site of application.12 Other vasoactive agents, including yohimbine and apomorphine, are being evaluated. Conclusions regarding the efficacy of sildenafil and other vasoactive agents in the treatment of FSD require additional large, randomized clinical trials.

It has long been known that selective serotonin reuptake inhibitors (SSRIs) are associated with sexual dysfunction. Improvements in sexual functioning have been observed when SSRI therapy was discontinued and bupropion was initiated. Small trials have found that treatment with bupropion improved sexual functioning in nondepressed women with FSD as well as those women with SSRI-induced sexual dysfunction.13 There are no data evaluating the use of bupropion in postmenopausal women.

An FDA-approved clitoral suction device (the EROS-Clitoral Therapy Device, or EROS-CTD) has been shown to increase blood flow to the external genitalia, improving sensation, lubrication, and orgasm. There are no controlled studies evaluating this product. There are also a number of nonprescription products that claim to treat FSD. Although their trade names are intriguing, there are no data demonstrating efficacy. One botanical feminine massage oil (Zestra for Women) was subject to a randomized crossover trial, but there are methodologic flaws in the study. At present, there are no data to advocate the use of these products.