HRT and Sexuality
Menopause is the permanent cessation of menstruation resulting from loss of ovarian follicular activity. Menopause can be divided into early and late transition periods, also known as perimenopause and postmenopause. Each stage is marked by changes in hormonal patterns, which can induce menopausal symptoms. It is possible to induce menopause prematurely by surgically removing the ovary or ovaries (oophorectomy). This is often done as a consequence of ovarian failure, such as ovarian or uterine cancers. The most common side effects of the menopausal transition are: lack of sexual desire or libido, lack of sexual arousal, and vaginal dryness. The modification of women’s physiology can lead to changes in her sexual response, the development of sexual dysfunctions, and changes in her levels of sexual desire.
It is commonly perceived that once women near the end of their reproductive years and enter menopause that this equates to the end of her sexual life. However, especially since women today are living one third or more of their lives in a postmenopausal state, maintaining, if not improving, their quality of life, of which their sexuality can be a key determinant, is of importance. A recent study of sexual activities among women aged 40–69 revealed that 75% of women are sexually active at this age; this indicates that the sexual health and satisfaction of menopausal women are an aspect of sexual health and quality of life that is worthy of attention by health care professionals. A major complaint among postmenopoausal women is decreased libido, and many may seek medical consultation for this. Several hormonal changes take place during the menopausal period, including a decrease in estrogen levels and an increase in follicle-stimulating hormone. For most women, the majority of change occurs during the late perimenopausal and postmenopausal stages. Decrease in other hormones such as the sex hormone-binding globulim (SHBG) and inhibin (A and B) also take place in the postmenopausal period. Testosterone, a hormone more commonly associated with males, is also present in women. It peaks at age 30, but declines with age, so there is little variation across the lifetime and during the menopausal transition. However, in surgically induced menopause, instead of the levels of estrogens and testosterone slowly declining over time, they decline very sharply, resulting in more severe symptoms.
In menopausal women, sexual functioning can impact several dimensions of a woman’s life, including her physical, psychological, and mental well-being. During the onset of menopause, sexuality can be a critical issue in determining whether one begins to experience changes in their sexual response cycle. Both age- and menopause-related events can affect the integrity of a woman’s biological systems involved in the sexual response cycle, which include hormone environment, neuro-muscular substrates, and vascular supplies. Therefore, it can be appropriate to make use of HRT, especially in women with low or declining quality of life due to sexual difficulties.
Current research that has examined the impact of menopause on women’s self-reported sexual satisfaction indicates that 50.3% of women experience some sexual disturbance in one of five domains, and 33.7% experience disturbances in two of the domains. Of these were desire, orgasm, lubrication, and arousal disturbances. With regards to arousal, they found a significant negative association between age and arousal, in that as women aged they were more likely to report lower arousal scores. In the desire and orgasm domains, 38% of women reported a disturbances in their desire, and 17% reported a disturbance in their orgasm capabilities; of the 17%, 14% were premenopausal, 15.2% were postmenopausal and taking a form of HRT, and 22% were postmenopausal not on a form of HRT. Eight percent of women reported disturbances lubricating during sexual activity; 14.3% in the premenopausal group, 30% in the postmenopausal group not using a HRT, and 11.7% among those postmenopausal women using HRT. Lastly, 21% of women reported pain as a disturbance in their sexual satisfaction- the premenopausal group at 14.3%, the postmenopausal women using HRT at 13.3% and the group with the highest rates, similarly to the other results, was the postmenopausal women not taking HRT at 34%. This study concluded that there was a significant decline in sexual function related to menopause in the pain and lubrication domains.
The maintenance and improvement of quality of life during the menopausal period is at the core of estrogen and progestin-based hormone therapy. Both HRT and estrogen replacement therapy (ERT) have been shown to enhance sexual desire in a significant percent of women; however, as with all pharmacological treatments, not all women have been responsive, especially those with preexisting sexual difficulties. ERT restores vaginal cells, pH levels, and blood flow to the vagina, all of which are associated with the onset of menopause. Dyspareunia (due to vaginal dryness) appears to be the most responsive component of menopausal women’s sexuality to ERT. It also has been shown to have positive effects on the urinary tract and atrophy and may initially improve libido or sexual sensitivity. Other improvements in areas such as sexual desire, arousal, fantasies, and frequency of coitus and orgasm have also been noted. However, the effectiveness of ERT has been shown to decline in some women after long-term use. A number of studies have found that the combined effects of estrogen/androgen replacement therapy can increase a woman’s motivational aspects of sexual behaviour over and above what can be achieved with estrogen therapy alone. Findings on a relatively new form of HRT called tibolone- a synthetic steroid with estrogenic, androgenic, and progestogenic properties- suggest that it has the ability to improve mood, libido, and somatic symptoms of surgically menopausal women to a greater degree than ERT. In various placebo-controlled studies, improvements in vasomotor symptoms, emotional reactions, sleep disturbances, somatic symptoms, and sexual desire have been observed. However, while this is and has been available in Europe for almost two decades, this has not been approved for use in North America at this point.
Read more about this topic: Hormone Replacement Therapy (menopause)