Pharmacotherapy to Improve Sexual Health after Menopause

Sexual problems are among the most frequently presented health concerns of women attending menopause clinics. For some women, but by no means all, menopause brings a decrease in sexual activity. Common sexual complaints include loss of desire, decreased frequency of sexual activity, painful intercourse, diminished sexual responsiveness, and dysfunctions of the male partner. Sexual function is influenced not only by biologic but also by nonbiologic factors. Medical management of female sexual dysfunction so far is primarily based on hormone replacement therapy.Psychosexual therapy and other sex therapy techniques can be very useful. Hence those women who have always enjoyed the emotional and physical intimacy that love-making brings in their young age, there is absolutely no reason whatsoever, medical or otherwise, why the menopause should deprive them of sexual pleasure.

Key words:

Sex, Menopause, HRT

Introduction:

Sexual problems are among the most frequently presented health concerns of
women attending menopause clinics as there is a dramatic decline in female sexual
functioning with the natural menopausal transition ¹. The sexuality
of older women is perhaps the most neglected area in the clinical practise².
 The extents to which health professionals currently receive exposure to
training in human sexuality as well as the way in which female sexual complaints
are handled in the medical setting remain ambiguous. The inflow of patients
with sexual function complaints only will increase, and it is time for doctors
to start acknowledging women's sexuality with the same importance as given to
other problems³. It is true that menopausal symptoms can affect your
sex life, but menopause status has a smaller impact on sexual functioning than
health or other factors⁴. The findings of one study has revealed
that the menopausal state did not affect the sexual behavior, and psychological
state of women between the ages of 40 and 60 years, but the increase in anxiety
and depression scores affected the sexual life in a negative manner⁵.Even
patients hesitate to ask sex related questions and therefore many myths remain
related to sex after menopause. Hence this issues need to be addressed.

Sexual physiology:

The female sexual response cycle consists of three phases: desire, arousal,
and orgasm. Various organs of the external and internal genitalia e.g. vagina,
clitoris, labia minora, vestibular bulbs, pelvic floor muscles and uterus contribute
to female sexual function. During sexual arousal, genital blood flow and sensation
are increased. The vaginal canal is moistened (lubrication). During orgasm,
there is rhythmical contraction of the uterus and pelvic floor muscles. Within
the central nervous system, hypothalamic, limbic-hippocampal structures play
a central role for sexual arousal. Sexual arousal largely depends on the sympathetic
nervous system. Moreover, nonadrenergic/noncholinergic neurotransmitters (NANC),
e.g. vasoactive intestinal polypeptide (VIP) and nitric oxide (NO), are involved
in smooth muscle relaxation and enhancement of genital blood flow. Furthermore,
various hormones may influence female sexual function. Estrogen has a significant
role in maintaining vaginal mucosal epithelium as well as sensory thresholds
and genital blood flow. Androgens primarily affect sexual desire, arousal, orgasm
and the overall sense of well-being ⁶.

Sexual complaints after menopause:

For some women, but by no means all, menopause brings a decrease in sexual
activity. A majority of women experience some change in sexual function during
the years immediately before and after the menopause. Common sexual complaints
include loss of desire, decreased frequency of sexual activity, painful intercourse,
diminished sexual responsiveness, and dysfunctions of the male partner⁷.

Reduced hormone levels and sexual activity after menopause:

Reduced hormone levels cause subtle changes in the genital tissues and are
thought to be linked also to a decline in sexual interest. Lower estrogen levels
decrease the blood supply to the vagina and the nerves and glands surrounding
it. This makes delicate tissues thinner, drier, and less able to produce secretions
to comfortably lubricate before and during intercourse. The lack of lubrication
and support for the vaginal walls can reduce arousal during sex and increase
friction, which in turn may produce soreness, burning or irritation. Loss of
libido is very common around and after the menopause; many women complain that
after the menopause they simply lose their desire for sex. Night
sweats and hot flushes can be counterproductive to relaxation and romance. Irregular
periods can make the timing of spontaneous love-making difficult. Stress incontinence
can sometimes arise during love-making itself .Psychological symptoms such as
mood swings, insomnia and depression can compound physical effects⁸.
However, it can also inhibit sexual functioning by limiting the availability
of free testosterone). In addition, age-related changes in peripheral nerves,
blood vessels, and muscle tissue probably also affect sexual functioning
in women as they do in men. If hormone levels and general health
are normal, the orgasmic reflex in older women is preserved. Older
women remain capable of multiple orgasms, but they may fatigue sooner
than when they were younger, and sensation may be lessened. In addition,
achieving orgasm usually requires a longer duration of physical stimulation
for older women⁹. Hence, sexual arousal, including sensory perception,
central and peripheral nerve discharge, peripheral blood flow, and the capacity
to develop muscle tension, as well as sexual desire and frequency of sexual
activity, can all be influenced by ovarian hormone levels. Sexual
function is influenced not only by biologic but also by nonbiologic factors.
Sexual function is also influenced by the interplay of psychological, sociocultural,
and interpersonal factors⁷.

Management

Research has concluded the multivariate nature of human sexuality. It is important that in the treatment and understanding of the menopausal woman who presents with sexual dysfunction, that both physiological and psychosocial factors are considered¹⁰. Therefore, a comprehensive approach, addressing both the physiological and psychological factors is instrumental to the evaluation of female patients with sexual complaint¹¹

HRT:

Medical management of female sexual dysfunction so far is primarily based on
hormone replacement therapy. HRT can improve many symptoms of the menopause
that can hinder a satisfactory sex life. Vaginal dryness, loss of lubrication,
soreness, irritation and vulnerability to bacterial infections and thrush may
all be vastly improved by HRT. Hot flushes and night sweats may also be banished.
It is uncertain whether diminished sexual desire, arousal, orgasm and
overall sexual satisfaction improve as a direct result of taking HRT^12,
13. Application of estrogen cream locally results in decreased pain and
burning during intercourse⁶.

 What is more likely is that testosterone has a much more significant effect on libido than oestrogen. Many studies have suggested that low-dose testosterone is effective and well worth trying for postmenopausal women who have low sexual drive. Currently, many specialists consider giving women with low sex drive a short trial of oral methyltestosterone together with conjugated equine oestrogens. This treatment is closely supervised and given in low dose for a short duration to minimise the risk of side effects. Testosterone therapy seems of particular value for women who have a surgical menopause at a relatively young age¹⁴. The genital tissue may be unresponsive to supplemental testosterone at first because of atrophy or a lack of testosterone receptors. Therefore, it is often preferable to begin by applying testosterone or methyltestosterone directly to the vulva once a day in a cream base⁹.

Preliminary studies suggest that postmenopausal women respond to
sildenafil with heightened arousal and lubrication and an increased
flow of blood to the vagina and clitoris¹⁵. Some women
who hesitate to take a pill to enhance sexual functioning will accept
the idea of using topical sildenafil cream¹⁶. Other medications that
have been noted in case reports to heighten female arousal when used
topically include prostaglandin E₁ and a combination of
aminophylline, ergoloid mesylate, and isosorbide dinitrate.

Psychosexual therapy can be very useful. After the menopause, touching
and intimacy often become more important than the physical pleasure of penetrative
sex. This need to touch and be touched, physically and emotionally, is well
worth nurturing. Such contact offers reassurance and comfort and the opportunity
to show tenderness, companionship and love. Around the menopause, the physical
focus of sex tends to be overtaken by the emotional, social and spiritual ingredients
of love, as the couple and the relationship become more mature. Remember that
there are many expressions of love other than sexual intercourse and all can
boost confidence and enhance feelings of self-esteem and worth.

Other sex therapy techniques include sexual fantasy training,masturbation
exercises alone and with a partner, taking turnsgiving and receiving
sexual pleasure, identifying and overcomingcultural inhibitions,
improving communication, and sensual massage.Treatment is best administered
by clinicians trained in sex therapy ⁹.

In conclusion, those women who have always enjoyed the emotional and
physical intimacy that love-making brings in their young age, there is absolutely
no reason whatsoever, medical or otherwise, why the menopause should deprive
them of this pleasure.

References

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13.Pearce MJ, Hawton K.Psychological and sexual aspects of the menopause and
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14.Sherwin B, Gelfand M: Differential symptom response to parenteral estrogen
and/or androgen administration in the surgical menopause. American Journal
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15.Berman J, Goldstein I, Werbin T, et al. Double-blind, placebo-controlled
study with crossover to assess effect of sildenafil on physiological parameters
of the female sexual response. Presented at the annual meeting of the American
Urological Association, May 1-6, 1999, Dallas, Tex

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Vishal  Tandon* , Sudhaa Sharma.

Dr Vishal Tandon received doctorate in Pharmacology from Nagpur University,
Maharashtra (India). He authored and/or coauthored over 40 publications in many
national and international journals. His research interests include herbal drug
screening, especially working on plant vitex negundo. He is currently working
as Senior demonstrator, Post graduate department of pharmacology and therapeutics,
GMC, Jammu (J&K)-India. His current job responsibilities include teaching
UG/PG classes as well as supervising research.

Currently he is Editorial Secretary for JK-SCIENCE,
Journal of Medical Education &Research. This journal is indexed in Excerpta
Medica/EMBASE, Ulrich periodical Dictionary& Indian Science Abstract and
also he is Secretary to Indian Rheumatology Association-J&K CHAPTER. He
is life member of Indian
Pharmacological society , Association of Physiologist and Pharmacologist
of India and Indian
Rheumatology Association .

*Author for Correspondense:

Dr Vishal. R. Tandon (MD) (Senior Demonstrator) , Post Graduate Department
of Pharmacology & Therapeutics GMC, Jammu (J&K) India - 180001. E-mail:
dr_vishaltandon@yahoo.com Phone: 9419195126.

Dr Sudhaa Sharma is working presently as Assistant
professor, Post Graduate epartment of Obstetrics & Gynaecology, Govt Medical
College, Jammu (J&K) India – 180001.She is Director Editor, JK-SCIENCE,
Journal of Medical Education &Research. She also bears the post of Secretary,
Indian Menopause Society, Jammu chapter. She has published many articles in
national and international journals of her specialty. She is also a pear reviewer
of FOGSI .Dr Sudhaa Sharma bears the folowing important
postions.She is Member Editorial Board,Asian Journal
of obstetrics &Gyanaecology,Member national governing
council,Indian menopause society and she is Secretary
and head,Indian menopause society jammu chapter.She is
also the Member Family welfare committee as well as
Member AIDS Committee,FOGSI.She bears the post of Vice
president,Indian Rheumatology association Jammu &
Kashmir chapter and Treasurer,Jammu obstetrics &
Gynaecological Society(FOGSI)

Corresponding address:

Dr Sudhaa Sharma (Secretary, IMS Jammu chapter)

Assistant professor, Post Graduate Department of Obstetrics &
Gynaecology, Govt Medical College, Jammu (J&K) India - 180001.