Libido and the Menopause

It is a time when the children leave home. The focus has always been the children and suddenly she is left with a man she has almost forgotten. Perhaps she and her husband have nothing in common anymore. Body image changes. She may have gained weight or feels that she looks old and unattractive. Self confidence drops. If she is not taking hormones she may feel tired, depressed and have vaginal dryness. All these things may affect libido. Sexuality is still strongly linked to the idea of youth and beauty.

Up to 40% of postmenopausal women experience low sexual desire. Common complaints are loss of desire, decreased frequency of sexual activity, painful intercourse, diminished sexual response and dysfunction of the male partner.

Although these experiences are problematic they are often not discussed with the doctor. A survey of doctors said that they were reluctant to bring up the subject for several reasons. The main ones were time constraints, embarrassment and lack of effective treatment. Yet a caring doctor who is willing to listen may contribute greatly to the quality of life and sexual life of postmenopausal women.

In postmenopausal women between 44 and 55 the frequency of sexual activity is significantly lower than in premenopausal women of the same age. This suggests that it is not only lifestyle changes that are playing a role. If the problem is physiological shouldn't there be a treatment?

In the reproductive age group testosterone is produced by the adrenal gland (25%), the ovaries (25%) and the peripheral conversion of circulating androgens (50%). Ninety nine % of testosterone of circulating testosterone is protein bound mainly to Sex Hormone Binding Globulin SHBG. The bound portion can have no effect on receptors. As women age, the adrenal production of androgens declines. The ovarian production of testosterone stays the same but production of other androgens is decreased. Circulating testosterone is decreased further. Women in their 50's have a testosterone level half that of a 30 year old. Women undergoing bilateral oophorectomy or removal of both ovaries will have a sudden 50% drop in their testosterone levels.

Despite this there is no direct correlation between testosterone levels and sexual function. Commercially available assays of testosterone do not have the precision to measure low levels because they were designed to determine high values in androgen producing tumours.

Sexual Disorders are categorised into:
  • Hypoactive Sexual Desire Disorder HSDD
  • Arousal Disorders
  • Orgasmic Disorders
  • Sexual Pain Disorders
The problem must be persistent and result in distress. The categories may occur individually or in combination egg dyspareunia or painful intercourse leading to decreased desire or HSDD.

Counselling would include advice about improving self image e.g.: joining an exercise class, improving communication skills between partners and changing routine. Making time for one's self is important in recognising that you as a person are important.

In the menopause the vaginal skin becomes thin and dry sometimes to the point of making penetration impossible. This will obviously decrease desire but is very easily treatable with vaginal estrogen even if systemic estrogen is contraindicated for instance in a patient with breast cancer. Apart from improving vaginal atrophy estrogen treatment does not in itself increase libido. Systemic estrogens increase sex hormone binding globulin (SHBG) and decrease free testosterone levels. This will reduce libido. Different forms of estrogen have a varying effect. The patch will increase SHBG by only 12% while some oral forms increase it by 100%. The patch should be better for libido.

Testosterone therapy on the other hand has been shown to enhance sexual function in postmenopausal women. In a crossover study in 1985 using 200mg testosterone emendate 53 women with surgically induced menopause were treated with testosterone alone or in combination with estrogen or with estrogen alone. Testosterone recipients had a significant improvements and libido after 6 weeks persisting for 24 weeks. The serum testosterone levels were slightly above normal limits 117%.. In another study 50mg estradiol and/or testosterone 50mg implants were used. Again the testosterone group had significant increase in sexual activity, pleasure, satisfaction and frequency of orgasms compared to the estrogen only group. Serum testosterone levels remained within normal range. Oral testosterone was also effective but the serum levels were supraphysiologic reaching 231%.

The testosterone patch has received much attention recently. Either oral or transdermal estrogen has been combined with a testosterone patch. Although the 150 mcg patch is not effective, the 300mcg patch works well and there is no advantage in using the 450mcg patch. The 300mcg patch keeps testosterone levels within normal limits.

Testosterone does not seem to have an effect on vasomotor symptoms like hot flushes. There seems to be a positive effect on general feeling of wellbeing but whether this is sustained over time is unsure. Testosterone improves bone density when used in combination with estrogen more than estrogen alone.

Oral testosterone reduces the good cholesterol HDL. With other routes of administration there is no difference in cholesterol in women receiving only estrogen or estrogen and testosterone combined. Testosterone does not affect clotting profiles or carbohydrate metabolism.

Hirsutism or male type hair growth, deepening of the voice and acne will be a problem if high doses are used. This is mainly a problem using oral testosterone. The effects are reversible.

In a study using testosterone implants there was no effect on weight, liver functions or blood pressure over 3 years.

No randomised study has gone on long enough to evaluate breast cancer risk. In an observational study over 5.8 years breast cancer incidence was not different in the estrogen and testosterone group, the estrogen group or the placebo group. It is thought that testosterone may be protective as it inhibits breast cell induced proliferation by estrogen.

CANDIDATES FOR TESTOSTERONE THERAPY

Testosterone assays are not helpful in identifying women who will benefit from testosterone treatment. Depression, social and relationship factors, pathology such thyroid disease or anemia as well as vaginal atrophy must be identified. Contraindications for testosterone would include androgenic alopecia, acne or hirsutism.

TESTOSTERONE THERAPIES

ORAL: Micronised testosterone is not well absorbed.The unpredictable absorption, high levels and wide variation make oral treatment undesirable

PATCHES: Well studied safe effective but unfortunately not available in South Africa

INTRAMUSCULAR TESTOSTERONE: Very high peak then very low levels

IMPLANTS: suitable post hysterectomy combined with estrogen.

GELS AND EMULSIONS Absorption can be erratic. Testosterone cream 10mg/day to skin increased testosterone levels and improved well being mood and sexual function. The most common complaints are that they are messy and may cause local irritation.

In conclusion testosterone is effective but the best way of using it is not available in South Africa. Are there any other alternatives?

LIVIFEM (TIBOLONE)

Tibolone is a synthetic compound that has estrogenic, progestogenic and androgenic properties. It is widely used as hormonal replacement therapy as it is safe and effective with minimal side effects. It does not cause venous thromboembolism but in older women as with other hormonal preparations there is a slight increased incidence of stroke. There have been several studies that show that it improves sexual function when compared to estrogen therapy alone.

ANDROGENIC PROGESTOGENS

If a menopausal woman has not had a hysterectomy she will need to have estrogen progesterone combination therapy. A progesterone that has androgenic properties can be chosen. Norethisterone Acetate or NETA has androgenic properties. When Kliogest and Livifem were compared both improved sexual function.

SUMMARY

Loss of libido is common in the postmenopausal period. Although social factors may be present there is a dramatic decrease in circulating testosterone in the menopausal period. Testosterone therapy is problematic at present in South Africa because the patch is not yet available. Other therapies with androgenic properties have been shown to be effective.

Contact Details

Dr. Alice Shaw
Pr No.:1606263


dralice@aliceshaw.co.za
Tel: 044 384 0926
Fax: 044 384 0970