Popularized by the media, many women are interested in using “bioidentical hormones” for treatment of menopausal symptoms. Bioidentical generally refers to hormones structurally identical to “natural” hormones made by the ovary, including estradiol and progesterone. FDA-approved oral and transdermal estradiol products are available in a wide range of doses, as is an oral form of micronized progesterone (Prometrium, 100 to 200 mg per day). Progesterone should be taken at bedtime, as it may cause drowsiness. There is potentially significant increased risk and no known benefit to the use of custom-compounded bioidentical hormone therapy formulations, preparations that are “custom” mixed and packaged by a compounding pharmacist for an individual patient (see Table 34.1 for approved hormone therapy formulations).
Contraindications to hormone therapy use include known or suspected breast or endometrial cancer, undiagnosed abnormal genital bleeding, cardiovascular disease (including coronary heart disease, cerebrovascular disease, and thromboembolic disorders), and active liver or gallbladder disease. Relative contraindications include high-risk states for the above disorders. These situations require a thoughtful assessment of potential risks and benefits and documentation of informed patient consent before treatment.
Sexual problems are highly prevalent, reported in approximately 40% of US women, with 12% reporting a sexual problem associated with personal distress (71). Although sexual problems generally increase with aging, distressing sexual problems peak in midlife women (aged 45 to 64) and are lowest in women 65 years or older. The etiology of female sexual dysfunction is often multifactorial, including depression or anxiety, relationship conﬂict, stress, fatigue, prior abuse, medications, or physical problems that make sexual activity uncomfortable, such as endometriosis or atrophic vaginitis. The impact of the menopausal transition on sexual function was examined in a prospective, longitudinal cohort study of approximately 3,000 women who were pre-or perimenopausal at baseline and followed for 6 years. Pain during sexual intercourse increased and sexual desire decreased over the menopausal transition, but other factors were unaffected, including sexual arousal, frequency, and pleasure (72). In contrast to menopausal factors, which were unrelated to most aspects of sexual functioning, age, social, health, and psychological factors were strongly linked.
Hormone Therapy Estrogen therapy is very effective in treating vaginal dryness and dyspareunia; however, a significant effect of estrogen therapy on sexual interest, arousal, and orgasmic response, independent from its role in treating menopausal symptoms, is not supported by evidence. A woman with distressing low libido concurrent with the onset of bothersome night sweats, sleep disruption, and fatigue likely will experience increased sexual interest with effective treatment of her menopausal symptoms, but this is probably secondary to improved well-being, rather than a direct effect of estrogen therapy on libido. A double-blind, randomized trial of combined oral and vaginal estrogen therapy in 285 sexually active postmenopausal women demonstrated decreased dyspareunia and significant improvements in pleasure of orgasm and sexual interest in women treated with estrogen therapy compared to placebo (73). As this trial used a combination of systemic and vaginal estrogens, it is not possible to determine the relative impact of systemic versus local effects.