Depressed Libido in the Postmenopausal Woman

Question

I would like some evidence-based medical recommendations regarding the treatment of depressed libido in the postmenopausal woman. Any reference for a current medical review article of this subject would be greatly appreciated.

Response From the Expert

Lorraine Dennerstein, AO, PhD, MBBS, DPM, FRANZCP
Director, Office for Gender and Health, Melbourne, Australia; Professor, Office for Gender and Health, University of Melbourne, Australia

Sexual problems are among the most common complaints of women attending menopause clinics.^[1] Until recently, controversy existed about the role of menopausal or hormonal change in problems of postmenopausal sexual functioning. We know from longitudinal studies that there is a decline in sexual functioning with age and duration of relationship, so that mid-age sexual functioning is expected to decline compared with that of young adults. Large population-based studies such as our own Melbourne Women's Midlife Health Project have demonstrated that those mid-aged women gaining a new partner for whom they have strong positive feelings often report an increase in sexual desire, enjoyment, and arousal.^[2] However, these new partnerships are in the minority.

Our study is one of the very few to have followed a large cohort of women through the menopausal transition with documented hormone levels, menstrual diaries, and a validated measure of sexual functioning. We found that passage through the transition was associated with a huge increase in the percentage of women having scores indicating sexual dysfunction. In the early menopause transition, only 42% of women had scores indicating sexual dysfunction, but late in the transition, when estradiol levels had significantly declined, 88% of women had scores below the cut-off for sexual dysfunction.^[3] As women became postmenopausal, interest in sex (libido) and responsiveness was significantly reduced and vaginal dryness/dyspareunia significantly increased.^[4] Women's feelings towards their partners often became more negative as they passed through the menopausal transition.^[4]

The reduction in sexual functioning was related to the drop in estradiol levels rather than any change in androgens such as testosterone.^[3] In fact, testosterone, which premenopausally is mostly bound tightly to sex hormone binding globulin (SHBG), becomes more available in the body as women pass through the menopausal transition and SHBG levels fall.^[5]

The combination of aging, relationship duration, and declining levels of estradiol increases the risk of sexual dysfunction in postmenopausal women. In all behavioral problems, however, influence of premorbid functioning will be paramount, and those women who had poor sexual functioning during their reproductive lives are more likely to be pushed to a dysfunctional state by the hormonal change.

What are the clinical solutions? Replacement of estradiol might be expected to improve sexual functioning, but there have been very few double-blind, controlled trials of the effects of replacing estradiol on different domains of sexual functioning in naturally postmenopausal women. There have been some studies in bilaterally oophorectomized women. Our own double-blind, randomized trial found a significant effect of estradiol on sexual desire, enjoyment, and orgasmic frequency.^[6] Of course, bilateral oophorectomy removes androgens as well as estradiol, and double-blind trials have found an incremental effect of the addition of testosterone to replacement estradiol in oophorectomized women.^[7] Adding testosterone would also be expected to have positive effects if the free testosterone level is low. Oral estrogens in particular increase SHBG, which will reduce bioavailable androgens. This should be monitored particularly for those women who have borderline or low testosterone levels. If SHBG is increased and bioavailable androgens become very low, this may affect libido.

Last, the clinician needs to be aware that hormonal factors are less powerful in their effects than other factors, particularly the woman's feelings towards her partner and prior sexual functioning. These need to be assessed by obtaining a full history. The principles of sex therapy should be used in conjunction with a psychoendocrine approach.

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