Midlife is a time of change for women. During the menopause there is a reduction in oestrogen and testosterone levels. The latter is more marked after an oophorectomy. It is thought that oestrogen may have a direct effect on libido and also on sexual arousal and lubrication. There is also the domino effect, which occurs when vasomotor symptoms induce tiredness and irritability with a secondary loss of desire. Periods may be erratic, frequent, and often heavy, which can also interfere with sexual function.
There are many conflicting studies on the value of hormone replacement therapy (hormone replacement therapy) in treating loss of libido in the menopausal woman. Some studies show that oestrogen replacement plus or minus additional testosterone improve libido, whilst others do not. Testosterone seems to be particularly helpful in castrated women. Some studies have shown that the addition of progesterone is detrimental to libido. Many studies have been small numbers and are inconclusive. A meta-analysis of sexuality and menopause research concluded that this was a difficult task to do because of the diffuse nature of the studies; the author concluded that hormones, both exogenous and endogenous, have some importance in peri-/postmenopausal sexuality. The most important factor is that the doctor considers each patient as an individual. If loss of libido coincides with the menopause and there are not other factors involved, a trial of hormone replacement therapy may be appropriate, especially if there are other indications.
Women who do not have hormone replacement therapy may develop atrophic vaginitis, vaginal dryness, and soreness. Urinary problems such as stress incontinence may also be a deterrent to sexual activity. Many women who do not want to take systemic oestrogen can use vaginal preparations to alleviate vaginal and urinary symptoms. As there is very little systemic absorption of milder topical oestrogens, these products may even be used in women with hormone-dependent cancers who have severe vaginal soreness following an iatrogenically produced menopause. There are also commercially available vaginal moisturizers and lubricants to help with intercourse.
Psychosexual problems are also common at the menopause. Some women may be delighted to be at the end of their reproductive lives with a cessation of periods, whilst others may mourn the loss of fertility and see it as the onset of old age. Intercourse can no longer be for reproduction. Some women may think that sex is no longer decent and may either seek the doctor’s permission to continue or even to stop. Women may be experiencing the death or illness of their own parents for whom they may have to take on a caring role. Their children and grandchildren may be having difficulties and they may be trying to hold down a full-time job in the midst of this.
Partners may also have problems affecting their sexual function. Men may be made redundant or realize that they have not achieved their potential. They may also start to experience sexual dysfunction related to illness such as diabetes or heart disease. If a relationship has been stormy, these extra burdens can make it worse. All these confounding factors make it difficult to analyse the effects of hormones on sexual function at the menopause.
It may be easier for women to bring a sexual difficulty to the doctor under the guise of a menopausal problem than for either member of the partnership to come directly for help. Women who find it hard to talk to their own doctor about sexual matters may get themselves referred to a menopause clinic ostensibly to discuss a problem with hormone replacement therapy. It is important in these clinics, whether in hospital, community, or primary care setting – to ask women routinely about sexual problems. Women may be too embarrassed to mention their prolapse, their haemorrhoids, or their vulval eczema and there are often surprises on genital examination.