~ Vaginal fluid production during sexual arousal and intercourse is also an estrogen-dependent process. If estrogen is low, there may be a reduction of vaginal fluid, resulting in vaginal dryness and painful intercourse. Because a woman’s level of sexual arousal tends to be judged by the amount and ease of vaginal lubrication achieved, lack of vaginal fluid can lead to the perception that she has low sexual arousal. While sexual arousal may be negatively influenced by the anticipation of pain, libido is not the real issue in these circumstances. Because of the powerful mind-body connection, some women can teach their bodies to lubricate well just by turning themselves on.
~ Progesterone has additional effects on libido that have not been as well studied as those of estrogen but are no less important. Its effect seems largely to be one of maintenance, valuable in keeping a woman’s existing libido from declining. Moreover, as a precursor of estrogen and testosterone, progesterone is important for maintaining high enough levels of these other hormones for optimal sexual pleasure. A normal balance of progesterone also acts as a mood stabilizer and supports normal thyroid function, thereby enhancing the libido both emotionally and metabolically.
The bottom line is this: a deficiency of estrogen and/or progesterone can decrease a woman’s libido by orchestrating physical changes that, quite simply, make the sex act less pleasurable. Dryness and thinning of the vaginal wall can result in physical discomfort during intercourse, as can vaginal muscle spasms. Changes in nerve function can numb ordinarily sensitive body parts, and changes in blood circulation can decrease the physical response when stimulation occurs, making it ever more difficult to reach orgasm.
Research has shown that libido-dampening effects are most likely to occur when a woman’s blood levels of estradiol (our body’s most biologically potent natural estrogen) drop below 50 pmol/l. Salivary estradiol levels can also be used, with 1 pg/ml being the lower end of the threshold for normal sexual function.27 Blood flow to the vulva and vagina is dramatically increased when supplementation brings estradiol back to these levels, and often this is enough to restore sexual response. With the help of a woman’s health care provider, achieving this level is simple. Depending on the individual woman, a transdermal estradiol patch (usually the 0.1 mg strength) or 0.5 to 1 mg oral estradiol taken twice daily is adequate, gentle, and consistent in restoring estradiol levels to that comfortable threshold. And in the early stages of perimenopause, when many women have declines in progesterone levels but estrogen levels that are still within the normal range, ¼ tsp of natural progesterone cream massaged into the hands or soft skin twice a day can have a restorative effect on a subtle downturn in libido.
JEANNETTE: Where Did My Sex Drive Go?
“Dave and I have been through some rough times,” Jeannette said, “but I really feel our relationship has grown along with us—we’re better than ever. The trouble is, I just don’t have any desire to make love. I love Dave, I really do, but I could go the rest of my life without having sex and I wouldn’t care.”
Now forty-five years old, Jeannette had noticed some early signs of perimenopause. She hadn’t had any hot flashes or vaginal dryness, but her periods, which used to come “like clockwork,” were more erratic, and she thought she might have had some night sweats (“either that or I just had on too many covers”).
Hormone testing revealed that Jeannette’s estrogen levels were still well within the rather broad limits of the normal range, but her progesterone level was on the low side, and her testosterone level was significantly below normal for a woman her age. After some discussion, we decided to boost her progesterone levels with a 2 percent natural progesterone cream, ¼ tsp massaged into her hands and wrists twice a day. For her testosterone supplementation, Jeannette opted for an oral testosterone pill. Her prescriptions were filled at a formulary pharmacy. “It made all the difference,” she reported. “I find that I’m in the mood more often, and even if I’m not in the mood, I can get aroused a lot faster than before.”
TESTOSTERONE: THE HORMONE OF DESIRE?
Although much has been written in the popular press about testosterone’s role in sex drive, a deficiency of testosterone is probably the least common cause for a woman’s waning libido, coming in at a distant fourth place behind relationship issues and progesterone and/or estrogen decline. Part of the reason testosterone has gotten so much attention, however—aside from the fact that testosterone is universally thought of as a male hormone—is its very specific effect. While estrogen and progesterone play a supportive role in a woman’s healthy libido, supplemental testosterone can directly and quickly stimulate the sex drive in both men and women if the reason for the diminished libido has to do with lowered testosterone levels.
Contrary to popular belief, however, testosterone levels do not fall appreciably after menopause. In fact, in most (but not all) women, the postmenopausal ovary secretes more testosterone than the premenopausal ovary. Still, testosterone levels do undergo a gradual decline in some women, beginning in their late twenties and continuing through midlife, and it is possible for levels to dip low enough to quash libido.
Sometimes the decline in testosterone—and hence in libido—is sudden, rather than gradual. This can occur following removal of, or loss of function of, the ovaries. The same can happen if the adrenal glands are exhausted. (See chapter 4.) That’s because the ovaries and the adrenals (as well as the liver and the body fat) all produce the steroid hormones collectively known as androgens, one of which is testosterone. If you’ve had a loss or sudden decrease in ovarian function secondary to chemotherapy, radiation, or surgery, then you may find that your libido dramatically decreases because your body has not had time to shift androgen production to the other body sites that make it. Women with this problem often complain of “not feeling like myself anymore … it’s as if my life energy has somehow gone.” And they lose their libido—their sex energy—as well. The reason this doesn’t happen to all women who lose ovarian function is that some women’s bodies are able to make the move to other androgen production sites without much interruption in the hormonal output. But for those whose bodies don’t adjust as easily, prescription supplemental hormones may be required to restore their androgen levels.
In women with testosterone levels that have declined significantly, for whatever reason, supplemental testosterone often does have a positive effect on libido. Topical testosterone (both in skin patches and transdermal gels) is particularly effective for improving desire in postmenopausal women. The usual dose is 300 mcg per day. While this drug appears to be safe, its long-term safety isn’t yet assured and studies are ongoing. Also, the use of testosterone is associated with some significant side effects, including unwanted hair growth, acne, and sometimes a lowering of the voice. Some studies have shown that 65 percent of menopausal women with depleted testosterone who received testosterone supplementation experienced increases in libido, sexual response, frequency of sexual activity, sexual fantasies, and sensitivity of erogenous zones.28
However, in my experience, results are completely satisfying only if a woman has a positive view of herself and her sexuality and a healthy relationship with her partner. This is particularly true at midlife, when a woman is less likely to sweep resentments under the rug. When her significant relationship is in trouble, testosterone supplementation is much less likely to be effective in stimulating her sex drive.
If, however, you think your decline in libido may be related to lowered levels of testosterone or one of the other androgens, you may want to have your unbound (free) testosterone and/or DHEA levels checked. This can be done through either blood or saliva testing. Ask your physician to submit blood or salivary samples for you, or submit a salivary sample on your own. (Salivary testing is available through a number of different laboratories; see Resources.)
If your levels turn out to be low, your physician can prescribe natural testosterone, available through a formulary pharmacy. Natural testosterone can be used either as a capsule or as a vaginal
cream. The usual starting dose is 1–2 mg every other day, gradually increasing if necessary. Transdermal testosterone is another option. A 2008 study of 814 women showed that it does increase sexual satisfaction, although almost half the study group dropped out eventually because of unwanted hair growth and voice deepening, and four developed breast cancer.29 For women who want to try transdermal testosterone, I recommend starting with less than 300 mcg per day, either as a patch or in a skin cream from a compounding pharmacy. Yet another option is to take the nonprescription supplement DHEA at a dose of 5–10 mg once or twice per day. In some women this hormone, which is a precursor for testosterone, will raise testosterone levels sufficiently to improve a waning sex drive. Currently a great deal of study is being done in this important area.
AIDS TO LUBRICATION
Some women at midlife find that though their libido is fine, they don’t lubricate as much as they’d like. This is easy to address. Just use one of the many over-the-counter lubricants, such as K-Y Jelly. Some women, however, require vaginal estrogen to restore optimal vaginal function. Again, this is a very easy problem to solve.
NATALIE: Sustaining Ongoing Relationships
Natalie first came to see me when she was fifty-two. Her husband, Brad, accompanied her on her visit. Natalie’s health was good, but she had been having problems with intercourse. She couldn’t seem to get lubricated before intercourse, which made lovemaking difficult. And she had also had a couple of episodes of urinary burning and frequency that felt like urinary tract infections (UTIs).
As I watched Brad and Natalie interact, it was clear that although Brad was uncomfortable talking about the situation, he was genuinely concerned about his wife. He didn’t want to hurt her, but he couldn’t understand what had gone wrong with their lovemaking. And both expressed fear that their sexual problem could spread, causing them to become distant from each other in general. I performed a pelvic examination on Natalie and found that her vaginal wall was significantly thinned, which would make it less resilient and more sensitive to irritation and discomfort from the stretching and friction inevitable during intercourse. Her vaginal thinning also explained the UTI symptoms, given that vaginal thinning is associated with thinning and irritation of the outer third of the urethral passage as well. Natalie’s exam also showed an obvious lack of natural lubrication, which would make intercourse more traumatic for her and less pleasurable for both partners. Suspecting that Natalie was in perimenopause, I took a vaginal sample and sent it to the lab for what is known as a “maturation index,” a test to see how many cells are well estrogenized and how many aren’t. I also had her estrogen, progesterone, and testosterone levels tested. Her testosterone was well within normal range, but her estrogen and progesterone were low. Her maturation index confirmed that she had what is called atrophic vaginitis, a term that simply refers to a lack of estrogen in the cells of the vaginal lining, making it thin and inflamed.
I explained to Natalie her treatment options and ultimately prescribed estriol cream for the vagina, plus progesterone cream to be applied anywhere on her skin. By retesting her levels and adjusting her dosage according to how she felt, over a three-month period we established optimal baseline estrogen and progesterone levels for that particular stage of Natalie’s life. In a follow-up visit within a month, Natalie reported that their sex life was “back to normal.” This is exactly what I had expected would happen. Treating bona fide perimenopausal vaginal dryness and thinning is safe, easy, and very effective.
GRACE: Beginning a New Relationship
Grace was fifty-five when she came to see me for a checkup. Her husband, with whom she’d enjoyed a monogamous relationship for twenty years, had died five years before. Her marriage had been a happy and fulfilling one, and she did not actively look for a new partner after his death. She enjoyed a busy life teaching tennis, gardening, and traveling. But then she was reintroduced to a man who had been one of her boyfriends in high school and whom she hadn’t seen for many years. He, too, was widowed—his wife had died several years before. Since he lived in Utah and she in Maine, they began writing letters and calling each other. Her visit to me was prompted by his invitation to come out to his ranch to spend a few weeks. He had told her he wanted her to consider marrying him. Though she wasn’t exactly planning on having sex with him during her visit, she wanted to be prepared. Like many women, Grace was worried that her vagina had “shriveled up” from so many years of disuse. I assured her that her vagina was designed to be functional for her entire life, even though it might need some initial help after years of abstinence. (This is not always the case. Women who pleasure themselves in ways that involve vaginal penetration often maintain excellent vaginal function even when not in a relationship that involves sexual intercourse. And of course, many women achieve orgasm and good vaginal lubrication without penetration.)
Grace had been postmenopausal for five years and had decided not to take hormone replacement therapy because her bone density was excellent, and she wanted to avoid any increased risk for breast cancer.
On pelvic exam, however, Grace’s vagina looked a bit reddened, and the lining, called the vaginal mucosa, appeared somewhat thin. Sometimes this condition is associated with painful intercourse, and sometimes it is not—it depends on the individual. When women are fully aroused, lubrication is often adequate without hormonal assistance. It was entirely possible that Grace would be able to have intercourse with no problem at all, but on the other hand, given the newness of her situation, I felt it was best if she had a couple of options. Grace agreed that she didn’t want to take chances. Though she had not experienced any sensation of vaginal dryness or discomfort for the past ten years, she wanted to be sure that she’d be able to have comfortable intercourse.
I offered three options: vaginal estrogen cream, the Estring vaginal ring, or a very effective and safe nonhormonal lubricant. Grace chose the vaginal estrogen (estriol) cream so that by the time she got to Utah three weeks later, her vaginal tissue would be very well estrogenized and thicker than it now appeared. She also wanted to come back to see me just before leaving so that I could assess her progress. The hormone estriol is a natural estrogen that does not stimulate the growth of breast or uterine tissue as strongly as the other estrogens, estrone and estradiol. It can be given orally as a pill or locally to relieve vaginal dryness. Given locally in the vagina only, it is safe to use even if you’ve had breast cancer, uterine cancer, or ovarian cancer, or are concerned about getting these estrogen-related problems. Estriol is available by prescription from a formulary pharmacist and has a very beneficial local effect on the estrogen-sensitive tissues of the vagina. All conventional estrogen creams, such as Premarin or Estrace—or estradiol in the vaginal ring called Estring—also work well for vaginal thinning and dryness, but the estrogen in these can act as a growth factor in breast and uterine tissue, which may be of concern if you’ve had cancer in one of these organs. However, at low doses they don’t appear to cause any appreciable problem. Like estriol, these creams can also be very helpful in treating urinary incontinence that stems from localized lack of estrogen.
I prescribed daily use of the cream for one week, to build up what is called the cornified layer of epithelium in the vagina, then one to three applications per week afterward, to maintain the suppleness, resilience, and moistness of her vaginal tissues. I also told her that if she began having regular intercourse, the blood supply to her vagina would increase. This, combined with the repeated stimulation and stretching of her vagina, would result in a much decreased need for the cream—possibly to the point of being able to eliminate it completely, with just a touch of a nonprescription lubricant as needed.
By the way, estriol vaginal cream is also excellent for women who have suffered vaginal narrowing and drying because of radiation treatments. While the tissues of the body are considered “plastic” and can therefore return to near-normal function with regular use, the estriol cream helps in the meantime.
If you opt
for an estrogen cream, don’t expect overnight change. It will take a week or so for the vaginal tissue to be restored and a bit longer for the uppermost part of the vagina to dilate. In the meantime, I recommend lovemaking through oral or manual stimulation of the clitoris, which can be very satisfying and is a good way to keep the blood flow optimal in the pelvis.
Nonprescription Help with Lubrication
With or without the use of prescription estriol, there are several choices of lubrication available that work just fine for relieving vaginal dryness. Good old K-Y Jelly is available at every pharmacy, though this water-soluble lubricant may not be enough for some, and for others it can form an annoying residue. Other lubricants that work very well are Albolene (available in pharmacies) and Emerita’s Personal Moisturizer, which contains a number of soothing herbal extracts such as calendula (available at health food stores or Emerson Ecologics, www.emersonecologics.com). A number of herbal remedies taken systemically can also help restore vaginal lubrication: black cohosh, wild yam, Pueraria mirifica (as Solgar’s PM PhytoGen Complex), dong quai, or chasteberry are good examples. Vitamin E suppositories are effective, too. And many women find that their vaginal resiliency and moisture are restored when they start eating whole soy foods regularly—the higher the daily dose of isoflavones, the more effective. (Note, however, that oil-based lubricants may weaken latex condoms and diaphragms, making them less effective.)
Another key to vaginal health is to become aware of your pelvic floor regularly throughout the day and to do Kegel-type exercises to stimulate and strengthen your pelvic floor muscles (see chapter 8). They’re easy to do, and they can be done anytime, anywhere; nobody can tell what you’re doing. Studies have shown that in addition to increasing blood supply (which will increase vaginal wall thickness as well as lubrication), these exercises can improve libido by increasing clitoral tumescence and sensitivity and increasing the strength of orgasm. As a happy side effect, Kegel exercises also can help prevent, or reverse, urinary incontinence (leakage).
The Wisdom of Menopause Page 42