Sex and the menopause

Professor Isaac Manyonda (MRCOG, Consultant Gynaecologist) and Dr Vikram Talaulikar (MRCOG, Specialist in Reproductive Health), take a look at the changes in libido and sexual satisfaction during the menopause and what can be done about it.

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 doubt that the menopausal transition affects female sexuality.

On a positive note, some women are liberated by the absence of the 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 relationships with their partner, have more time on the hands (especially if the children have flown the nest). 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.

Sexual dysfunction during the menopause may be a result of vaginal atrophy, hot flushes / night sweats, irregular periods or bladder problems.

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 and a gradual redistribution of weight away from their breasts towards their waistline. The so-called 'middle-age spread' can be an unfortunate reality. Despite rigorous exercise and dieting women find it difficult to shift this weight. This may have an impact on how a woman views herself which could affect her levels of self-confidence.

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.

Whilst the occasional woman experiences an enhancement in libido, for the majority of women a loss of libido is a common accompaniment to this life transition. 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.

Whilst it is true to say that no hormone or tablet could ever mend a fractured relationship, in the absence of such a fracture there is a whole multitude of interventions that could go a long way towards resolving the sexual dysfunction seen in the menopausal transition. This, in itself, can help to lessen or even avoid relationship problems.

Hormone replacement therapy (HRT) is hugely effective - local oestrogen creams or pessaries are very effective at relieving vaginal dryness and therefore the discomfort and / or pain that some women experience. Some low-dose vaginal oestrogen preparations are safe to use for symptoms such as vaginal dryness, irritation and painful sex, even with history of breast cancer in the past.

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. Open and honest conversations with partners is particularly important at this time and can add to the depth of relationships. Complementary activities such as yoga and acupuncture could also be considered.

A role for testosterone in menopausal sexual dysfunction

For many women, 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 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 level of testosterone in the female body gradually reduces with age and fall very abruptly / precipitously 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 also some evidence that having lower testosterone levels affects women's mood and increases their risk of becoming depressed. It therefore stands to reason that testosterone is likely to be a crucial component of HRT and that current approaches that have an emphasis on the replacement of oestrogen without testosterone may be misguided and inadequate. A full discussion of these issues is beyond the scope of this article and, indeed, a lot of research is still required, as many of the issues are yet to be fully understood.

Effects of testosterone given as HRT

The general current practice is to offer testosterone to women where loss of libido and poor energy levels are major features of the symptoms of their menopause.

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 anecdotal reports and it is not suggested that every woman will experience these benefits.

How testosterone is given

Testosterone can be 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 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 favored on the continent (such as in France), but these gels are also available in the UK and many menopause specialists prescribe them.

Another novel way of administering testosterone is through oral / submucosal lozenges twice every day.

There are pros and cons where implants versus gels or lozenges 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 and 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 women would rather deal with the hair than stop using the testosterone.

It is arguably true to say that the beneficial effects of testosterone are under-estimated. 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.

echo For more information, you can contact Professor Manyonda and Mr Talaulikar at the Menopause Clinic, London