Sonia had been having problems with her hormone replacement therapy. She was now aged 45 and had two grown children. Five years ago she had had a hysterectomy and bilateral oophorectomy for endometriosis. Initially it was great, as she had no more pain. The hospital started her on hormone replacement therapy straight away and she never had any menopausal symptoms, but now she did not feel so good and wondered if she needed a higher dose of oestrogen. She was the manager of a small boutique and had a very exhausting job. I noted that she was on the maximum dose of oral medication and suggested that she tried patches to see if she felt any better. She was not clinically depressed, just tired. She seemed to be dull and lifeless in contrast to her highly fashionable clothes. She thanked me half-heartedly and left with a suggestion that I see her again in a couple of months.
Six weeks later she turned up again, clutching a piece cut out of a well-known magazine. “I think this is what I need,” she said, handing me the cutting. It was an article about testosterone for female libido. “I wonder why you think you need that,” I asked?
“I never feel like sex these days. I do it sometimes to please my husband, but I would not mind if I never did it again in my life.”
I asked her when this had started. Apparently sex had been good immediately after the hysterectomy when she had no pain or bleeding. Over the years she had felt less and less like it. She hardly ever got turned on. “My poor husband has to work so hard. He thinks that I have gone off him, although I try to reassure him that this is not so.”
There was no problem in the relationship and no other major life changes. All this information was delivered in a lifeless monotone, which is typical of a consultation about loss of libido. I felt like her husband must feel; I was working very hard and getting nowhere.
“You seem very sad,” I said.
“It’s as if all the feeling was removed with my womb,” she replied.
“Perhaps I should take a look,” I suggested, pointing towards the couch.
She looked a bit puzzled and climbed up, readily removing her beautiful underwear. “How can you examine nothing,” she asked. As I went to look at the vulva she said, “I’ve only felt half a woman since I had my hysterectomy. It’s not that I want any more children but it makes me feel old to not have a womb and to have to take hormone replacement therapy. All my friends from the shop are much younger – I could never tell them that I had to take hormones. My husband is a few years younger than me and I feel that I can’t keep up anymore.”
I quickly completed the vaginal examination and told her that everything was normal and healthy. She got dressed and sat down. We talked about the fact that the sensitive – erotic – areas are not removed by the surgery. We talked about what remained as opposed to what had been taken away. On a different level we discussed how she is still as much a woman despite not having a womb.
She gathered up her things and said, “I had better go now doctor, I have taken up too much of your time.” At the door she said, “I will come back when I need some more pills. I didn’t start the patches. I don’t want my friends to see them when I’m in the gym shower.” We had not discussed the testosterone.
She came back a couple of months later. She was much more buoyant with a spring in her step. Everything was fine and she did not want any change in her hormones. “I have stopped feeling sorry for myself,” she said. “You had better not examine me this time, I had a tattoo done a few weeks ago.”
What had happened in the consultation?
- I neither dismissed her request for testosterone, nor agreed that it would be useful, without looking at the reason for her loss of libido.
- I had noted her sadness and fed this back to her.
- I had suggested an examination, although there was no immediate physical reason for this. It had enabled her to talk about her inner feelings.
- I paid tribute to her loss.