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Treating the Sexual Symptoms of Menopause

The post-World War II baby boomers who stirred up the sexual revolution of the 1960s and 1970s are spearheading a new sexual revolution as they enter midlife. Not only are they talking about sexual dysfunction, openly, for the first time, they're doing something about it. Women entering menopause are realizing they don't have to suffer in silence with their sexual problems, and many are seeking help long before problems become chronic.

Making the Proper Diagnosis

The first step in treating midlife sexual dysfunction is a complete medical exam and a careful history taken by a physician who specializes in this area. This can be a gynecologist, a urogynecologist, or a psychiatrist who treats sexual dysfunction. Don't be put off by the idea of seeing a psychiatrist. The source of sexual problems can be both physical and psychological-for example, the combined effects of depression and pain due to thinning of vaginal tissue. It's difficult to treat the body without attending to the mind as well, stresses Barbara Bartlik, MD, a clinical assistant professor of psychiatry at the Weill Medical College of Cornell University and a member of the staff of the Human Sexuality Program at New York-Presbyterian Hospital.

The physical problems that can interfere with sexual response and enjoyment at midlife are numerous. Among them: vulvodynia, a chronic pain syndrome of the vulva that affects 150,000 to 200,000 women; vaginismus, involuntary vaginal muscle contractions that make intercourse difficult, if not impossible; and atrophic vaginitis, the painful drying of genital tissues that accompanies estrogen loss after menopause. For some women, the problem may be low levels of the male hormone testosterone. Psychological problems like depression or anxiety can also impact sexuality.

"While low testosterone can cause low libido, lack of lubrication, and other sexual problems in midlife, difficulties in a relationship can also affect the desire for sex," says Bartlik. "Blood tests can identify women who have low testosterone. If a woman is found to have normal levels of testosterone but complains of low libido, we have to look elsewhere for the source of the problem."

The most common diagnosable sexual problems in women include:

— Hypoactive Sexual Desire: low libido.

— Female Sexual Arousal Disorder (FSAD): impairment of specific responses to sexual stimulation that affect lubrication and blood flow to the genital area.

— Female Orgasmic Disorder: orgasm occurs with difficulty or not at all.

— Dyspareunia: painful intercourse, often caused by atrophic vaginitis.

Finding the Right Solution

A variety of treatments are available today for female sexual dysfunction, but choosing the right approach requires careful medical evaluation as described above. In some cases, a first step may be adjusting the patient's chronic medications. For example, women with high blood pressure and diabetes may suffer difficulties with sexual arousal due to the effects of medication as well as problems with small blood vessels that hamper blood flow to the genital area. In treating hypertension, finding a medication that does not hamper sexual functioning is important. Likewise, certain antidepressants are known to have the potential to cause sexual problems as side effects. If a woman needs antidepressants, for example, buproprion (Wellbutrin) and nefazodone (Serzone) have fewer sexual side effects than the Prozac-type medications known as selective serotonin reuptake inhibitors.

In many cases, a combination of sex therapy and other therapies is very effective. "Just giving a pill may not be enough to resolve sexual difficulties," says Bartlik. "If there are relationship issues, medications won't help, but couples counseling can help resolve the problems. Sex therapy uses specific exercises to enhance both communication and sexual pleasure. If a sexual problem is due to depression, talk therapy or antidepressants may help resolve the underlying cause. If the sexual problem is due to low levels of testosterone, replacing the hormone while simultaneously going into sex therapy counseling may be effective. Both modalities work together to improve a woman's sex life."

Available Treatments for Female Sexual Dysfunction

Estrogen Replacement — Drying of vaginal tissues is a common problem among women during perimenopause and women who are not taking estrogen after menopause. Tissues in the genital area have estrogen receptors, and without estrogen for prolonged periods, these tissues thin and atrophy. These effects can be largely reversed through estrogen replacement therapy, which can be accomplished in several ways. Pills or patches can be used to deliver estrogen for the treatment or prevention of a variety of menopause-related conditions. But women also have the option of using a local therapy designed specifically for vaginal problems. The newest of these is VagiFem (Pharmacia), an estrogen-containing tablet that is inserted into the vagina twice weekly to treat thinned or irritated tissue. Other products include vaginal creams and Estring (Pharmacia), a flexible plastic vaginal ring that releases 2 milligrams of beta-estradiol. It's replaced every three months and can help restore vaginal tissues to their normal state. Estratest (Solvay Pharmaceuticals), a combination of estrogen and testosterone approved for treating menopausal symptoms, has been shown to help boost libido in some women.

Testosterone Replacement — As noted above, a deficiency of testosterone can cause low libido, lack of lubrication, and other sexual problems in midlife. Replacement testosterone, in the form of patches like Intrinsa (Proctor & Gamble) or a gel such as Tostrelle (Cellegy), may help boost libido in women with testosterone deficiency, but such use has not been approved by the FDA. A study in the September 7, 2000, New England Journal of Medicine reported that a testosterone patch improved sexual functioning and psychological well-being among women who had undergone surgical menopause and were taking replacement estrogen. In a small placebo-controlled trial reported in the February 2000 Archives of General Psychiatry, a testosterone pill placed under the tongue had positive effects on genital arousal in eight women exposed to sexual stimuli.

These studies are encouraging, but testosterone also has side effects, including acne, hair growth, and increased "bad" cholesterol. There are no guidelines yet for administering testosterone to women, notes Bartlik. The American College of Obstetricians and Gynecologists (ACOG) urges physicians to use caution when prescribing testosterone. The long-term effects of testosterone replacement therapy are unknown.

Dietary Supplements — There are a number of dietary supplements sold over-the-counter that may help sexual performance. ArginMax (Daily Wellness Company) is one of the few that has been researched in clinical trials. It contains L-arginine, American ginseng, damiana leaf, ginkgo biloba, vitamins, and niacin. L-arginine is a building block of nitric oxide which, among other things, helps relax smooth muscle in blood vessels, allowing enough blood flow for engorgement of genital tissues. Some studies suggest that ginseng boosts the conversion of L-arginine to nitric oxide and that ginkgo aids microvascular circulation. Damiana leaf is said to be a sexual stimulant.

A pilot study of ArginMax, conducted by Mary Lake Polan, MD, PhD, chair of Obstetrics and Gynecology at Stanford University, randomized 49 women aged 25 to 70 to four weeks of the supplement or placebo. Among the women taking ArginMax, 76% experienced increased sexual desire, 60% reported increased clitoral sensation during stimulation, and over 50% reported more frequent orgasms. Around a third of those taking placebo also reported improvement in sexual function; a similar result occurred in the testosterone patch study, and is an indication of the emotional component of sexual problems, according to Bartlik. Women prone to bleeding problems and women taking blood thinners should not take supplements containing gingko because of its anti-coagulant effects.

Dehydroepiandrosterone (DHEA) — DHEA is a hormone produced by the adrenal glands and converted by the body into estrogen and testosterone. Levels of DHEA begin declining after about age 30, and some experts believe taking DHEA as a supplement will elevate estrogen and testosterone. DHEA is said to have some effects on libido.

EROS-CTD (Clitoral Therapy Device, UroMetrics, Inc) — This small device, approved last April by the FDA, features a small plastic cup and a small, battery-operated vacuum pump. The cup is placed directly upon the clitoris, and the pump creates gentle suction to draw blood into the area. The clitoris becomes engorged, resulting in improved vaginal lubrication and enhanced ability to achieve orgasm. Trials of the EROS-CTD in women with sexual dysfunction "showed significant improvement in arousal, lubrication, orgasmic ability, and overall pleasure," notes Bartlik, It costs around $350.

Vaginal Lubricants — Women plagued by vaginal dryness before and during menopause, who don't want to take hormones, can find a variety of lubricants on drugstore shelves. Among the available lubricants that can relieve symptoms of dryness and help make sex pleasurable again: Astroglide (Biofilm, Inc), Vagisil Intimate Moisturizer (Combe), Replens (Columbia Laboratories), KY Jelly, and K-Y Long-Lasting (Ortho) These are water-based products and can be used with condoms.

More help on the way

A number of new products are now being tested for treating female sexual dysfunction, including vasodilator creams; testosterone patches; a cream made from an African tree bark combined with nitric oxide; and a synthetic oral steroid, Livial (Organon), used in Europe for treating menopausal symptoms.

"A few years ago we had very little to offer women for sexual problems, but now the options are increasing," says Bartlik. "That pharmaceutical companies are now sponsoring studies of topical creams, patches, and medications for sexual dysfunction in women is a very hopeful sign."

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