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Around 50% of postmenopausal women suffer from sexual dysfunction, with a loss of libido as the most common complaint (affecting 43%). As life expectancy increases, healthy women may live over a third of their lives after the menopause and wish to remain sexually active into their 70s and beyond. It’s therefore important to address low libido and its potential consequences on women and their relationships. This article was included in issue 81 (summer 2019) of The Menopause Exchange newsletter.

Changes in libido
Loss of sexual desire is complex. The menopause can affect women physically, psychologically and socially, with hormonal and non-hormonal factors potentially affecting libido.

Hormonal factors
Falling levels of oestrogen have direct and indirect effects on sexual function. A lack of oestrogen reduces the elasticity of the vaginal walls, and women frequently complain of vaginal dryness. The vaginal tissue thins, increasing the risk of trauma, discomfort and pain during sex. A more alkaline environment in the vagina can lead to infections, such as thrush and bacterial vaginosis (overgrowth of bacteria), increasing discomfort, discharge and odour. A loss of oestrogen worsens urinary urgency (a sudden urge to pee) and/or incontinence, which can cause embarrassment, low self-esteem and avoidance of sex. Night sweats can lead to poor sleep patterns and tiredness. Hormonal changes can directly reduce genital sensitivity and the strength of orgasms. These factors reduce sexual desire and, if not addressed, may cause deep-rooted sexual problems.

Testosterone is made by the ovaries and adrenal glands. This hormone plays a role in libido, sexual arousal and orgasm, increasing specific chemical messengers in the brain. It affects mood, thinking and reasoning, energy levels, muscle and bone strength and bladder and vaginal health. Testosterone levels gradually fall in women from the mid-30s, although women experience a rapid decline after a surgical or medical menopause and lower levels after an early menopause.

Non-hormonal factors
Factors impacting on sex drive include relationship problems, medical or physical ailments and lifestyle. A loss of libido may be associated with other sexual disorders, such as genital pain or orgasmic disorders. Some medicines, such as antidepressants, and mental health problems such as stress, anxiety or depression can suppress libido.

Physical changes, such as weight gain and alterations in body shape, adversely affect self-image leading to poor self-esteem and a detrimental effect on sex lives. Additionally, it’s not uncommon for the menopause to coincide with additional life pressures, such as managing teenage children, looking after elderly relatives or handling high-pressure jobs.

Management options
A holistic individualised approach is needed, taking into account women’s concerns and current evidence-based treatment options. Tailored support and a sensitive approach will help.

HRT products: Hormone replacement therapy (HRT) may have a positive effect on wellbeing, confidence and sex drive. Women with a loss of libido may benefit by switching from tablets to an oestrogen patch or gel as these don’t lower testosterone to the same extent. Tibolone, a synthetic HRT preparation breaking down into oestrogen and progestogen, also provides an androgen that can improve libido in some women.

Testosterone gels or creams: These are used to help improve libido and energy levels. Research shows that two in every three women have a good response to testosterone compared to placebo. No testosterone products are licensed for UK women seen in NHS settings. Previously a testosterone patch and implant were available for those after a surgical menopause and taking HRT. These have been discontinued for commercial not safety reasons. Androfeme cream can be prescribed privately by UK doctors.

Specialists normally start testosterone therapy alongside HRT, prescribing low doses of testosterone gels that are licensed for men. Blood tests may be taken in the first few weeks to check testosterone levels. Examples of products being used ‘off label’ include Testogel (1% testosterone gel in 5.0g sachets containing 50mg testosterone) and Tostran (2% testosterone gel in a canister containing 60g). Off-label refers to medicines used to treat people with a condition other than the one the medicine was approved for. This isn’t uncommon in clinical practice where products have been found to be effective and safe in research studies and from experience of use.

It can take up to 12 weeks to see a benefit with testosterone. Long-term users should have yearly assessments looking at the risks and benefits. Symptom relief and lack of side effects can be used to assess any response. Keeping testosterone within the normal female range reduces potential side effects, such as increased body hair, hair loss, acne and, very rarely, deepening of the voice. Sometimes (as with HRT) testosterone shouldn’t be prescribed, such as in active liver disease and previous hormone-sensitive breast cancer. Further research studies are needed to investigate long term safety.

Local treatment: Local vaginal oestrogen is safe and effective for vaginal dryness and thinning. It’s delivered using a vaginal ring, pessary or cream, either alone or with vaginal moisturisers, lubricants or systemic HRT.

Psychosexual counselling: Therapists may help to tease out women’s feelings and triggers and allow time for reflection, resulting in a deeper understanding of underlying relationship issues that affect sexual desire.

About the authors
Dr Katherine Gilmore is a specialty registrar in Community Sexual and Reproductive Health at the New Croft Centre integrated sexual health service in Newcastle upon Tyne. Dr Diana Mansour is a consultant in community gynaecology and reproductive healthcare in Newcastle upon Tyne and Senior Vice President for the Faculty of Sexual and Reproductive Healthcare. Her areas of expertise include menopause management and the prescribing of HRT to women with complex medical needs.

Created Summer 2019

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