In contrast to estrogen therapy, androgen therapy is consistently shown to improve sexual function in selected populations of postmenopausal women (74–76). Potential risks of androgen therapy include hirsutism, acne, irreversible deepening of the voice, and adverse changes in liver function and lipids. As most androgens are aromatized to estrogens, there is potential for an increased risk of cardiovascular events or breast cancer. A transdermal testosterone patch is approved in Europe for the treatment of hypoactive sexual desire disorder in surgically post-menopausal women using concomitant estrogen therapy. An advisory panel of the FDA did not recommend approval in the United States pending additional data on long-term safety.
Alternatives to Hormone Therapy
Although vaginal atrophy and dyspareunia respond very well to estrogen therapy, most other sexual problems may be effectively treated without hormones. Relationship quality and conﬂict, stress, and fatigue predict sexual satisfaction, so couples often benefit from counseling, lifestyle changes, and prescribed “date nights.” Women and their partners should be referred to sex therapists who provide education, materials, counseling, and instruction in specific exercises (77). In one study, 65% of 365 couples undergoing sex therapy for a range of sexual dysfunctions described their treatment as successful (78). Underlying depression and anxiety should be treated, and antidepressant medication may need adjustment. Bupropion may be an alternative to SSRIs, and one small, double-blind study reported increased sexual pleasure, arousal, and orgasm in nondepressed women with distressing low desire treated with bupropion (79). Sildenafil citrate may benefit women who develop problems with arousal and orgasmic response on SSRIs but generally is no more effective than placebo for most female sexual problems (80,81).
Despite the fact that sexual problems are common, the majority of women with distressing sexual problems do not seek formal care, but when they do, it is typically the woman, rather than the physician, who initiates the conversation (82,83). Clinicians should routinely ask their menopausal patients whether vaginal dryness, dyspareunia, or another bothersome sexual problem is present, as many effective interventions are available.
There are many options available to address the health and quality of life concerns of menopausal women. The primary indication for hormone therapy is the alleviation of hot ﬂashes and associated symptoms. Women must be informed of the potential risks and benefits of all therapeutic options. Care should be individualized based on a woman’s medical history, needs, and preferences.
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