Sex & Libido With HRT

Appointments with Dr. N can be made by calling (248) 644-7200 and speaking to Caroline

This section addresses the role of sex hormones in maintaining libido and sexual function. It discusses how a natural, or surgical menopause, or medications may affect your sexual experience and provides treatment lisa-editedoptions to restore your sexual desire and function.

There just doesn’t seem to be any way of getting around it. If you’re menopausal and want to be at your optimum sexually, you need to replace your hormones. Menopausal women, without the benefit of hormone replacement, may be capable of enjoyable and satisfying sex. They may be capable of great sex. But ultimately they loose the potential, as least as far as sex is concerned, to be the best they can be.

A healthy lifestyle, a positive attitude, exercise, a loving, giving, patient and understanding partner …all are important. But, they cannot substitute for adequate hormone levels. It is clear and unequivocal; the integrity of the sexual experience is dependent on sex hormones.

WHAT IS DESIRE PHASE DISORDER?

Diminished hormone levels interfere with optimum sexual function by their affect on sexual desire and hormonally sensitive tissues.

Sexual desire, or libido, consists of thinking about sex, fantasizing about sex, the development of "sexual tension" and the awareness of a need for sexual release. Some people may call feeling this way as being "horny". It motivates us to initiate and participate in sex and if circumstances require, search for a sexual partner.

Lack of, or diminished sexual desire and loss of sexual motivation is sometimes referred to as a "desire phase" disorder.

ARE THERE DIFFERENCES IN HOW WOMEN ARE AFFECTED?

A postmenopausal woman’s decrease in libido can range widely, from a barely noticeable fall in sexual interest to a "sexual aversion" where the very thought of being touched in a sexual context is repulsive. A number of patients have told me, " I feel dead from the waist down", to describe their lack of sexual interest. Several who were affected to a lesser extent have shared, that although they really had no interest in sex or in initiating sexual contact, once they were aroused by sexual direct stimulation, the sexual activity was enjoyable and orgasm was possible. Not all women are concerned over their loss of libido and have no interest in restoring it. It is like not being hungry, you're not worried about eating. Other women are devastated by their loss of sexual desire are interested in pursuing any reasonable treatment that will allow them to regain their previous sexuality.

Unfortunately, many women who express a concern about a lowered sex drive are referred to a psychiatrist, counselor or psychologist, before even a cursory analysis of their hormonal status and/or Hormone replacement therapy program is considered. Certainly, stressful life events, health, psychological or relationship problems influence libido, but these factors should only be considered along with the menopausal woman’s hormonal status.

WHAT CAUSES A DECLINE IN SEXUAL DESIRE?

The decline in sexual desire is likely a direct result of diminished sex hormone levels on the brain itself. Although estrogen plays a part, the hormone that has been shown to be most closely associated with sex-drive is testosterone.

The ovary, although incapable of producing estrogen after a "natural" menopause, may continue to produce significant amounts of testosterone for several years. This is the reason why many women maintain a good sex-drive for a considerable length of time. These testosterone levels provide additional benefits to the naturally menopausal woman. Tissues of the body are able to convert some of this circulating testosterone to estrogen. This is the mechanism by which naturally menopausal women have fewer and less severe symptoms and health problems usually attributed to sex hormone deficiency. If a postmenopausal woman were to undergo removal of her ovaries, this benefit would be lost.

WHAT ABOUT PREMENOPAUSAL WOMEN WHO HAVE HAD A HYSTERECTOMY?

If the surgery is performed prior to menopause and the ovaries are preserved and their hormone secretion is unaffected, there may be no change in libido following the post-operative healing period. In fact, some women experience a post-surgical increase in sexual desire if prior to the surgery they had been distracted by heavy bleeding or significant pelvic pain. There is evidence, however that in this group of patients, ovarian failure occurs up to 50% of the time within 3 years following the surgery. If this happens, a diminished libido and other menopausal symptoms would reflect the decline in hormone levels. Unfortunately, some physicians are not aware of the frequency of ovarian failure following hysterectomy. I have seen many patients who were in this category whose physicians refused to believe their loss of desire and sexual issues were related to their surgery.

If the surgery is performed prior to menopause and the ovaries are removed, the fall in estrogen and testosterone levels is abrupt and severe. As would be expected this type of surgically induced menopause almost always, results in a dramatic fall in sexual desire.

IS THERE ANYTHING ELSE THAT CAN CAUSE PROBLEMS WITH MY SEX DRIVE AFTER MENOPAUSE?

Significant health problems, depressive illnesses, relationship problems and certain medications can affect libido.

WHAT ARE SOME OF THE MEDICATIONS THAT CAN CAUSE A PROBLEM?

A class of anti-depressants, SSRI’s frequently depress both libido and potential for orgasm. SSRI’s can do this so effectively in some patients that it is used as a treatment for obsessive sexual preoccupation and premature ejaculation.

I have had several patients express a concern over a fall in their libido who had recently begun treatment with an antidepressant, not realizing that their medication was responsible. Occasionally, delayed ejaculation or inability to ejaculate develops in men who are not aware of this side effect and can lead to conflict in a relationship if the couple is not aware the problem is due to the antidepressant.

Orally administered estrogen replacement medications and oral contraceptives are absorbed by the gastrointestinal tract and reach the liver in a "bolus". This so called "bolus effect", induces the liver to increase its production of a substance, "sex hormone binding globulin" (SHGB) which binds to circulating testosterone, leaving less "unbound" or "free" testosterone available to maintain libido. This is not well known and is often not recognized as a cause for a diminished libido.


HOW EFFECTIVE IS HORMONE REPLACEMENT THERAPY IN MAINTAINING LIBIDO?

It is very effective. Optimum regimens of hormone replacement will almost always maintain or restore libido. This will often take 4-8 weeks of treatment and it helps if you are aware of this ahead of time.

Many women, especially those, who have had a surgical menopause, will need a regimen that includes testosterone replacement. This may include some women who choose an oral regimen due its effect on SHBG levels as described above. Testosterone can be given by most of the routes of administration, including injections, gels and subcutaneous implants. When nothing else seems to work, subcutaneous implants rarely fail to reestablish libido.

In the late 1980’s, a television journalist who had interviewed me for some news segments, which dealt with menopausal issues, called me with a request. He shall remain unnamed for his own protection and journalistic credibility. He wanted to know if I could find a woman for an on-air news segment interview, "over 50", and "still having sex". After a brief period, during which I was recovering from having been rendered speechless, I told him that I was sure I could find someone. We made arrangements for the interview to be shot at my office the following week.

The television journalist and his camera crew appeared at the appointed time. I introduced them to June, an attractive, very sexual, woman of 80, who had been on hormone replacement therapy for over 30 years. The interview was broadcast on the evening news the following day to a potential audience of several million. June was an educated and sophisticated woman who was anything but shy. She informed the journalist and the viewing public, that she enjoyed sex, had intercourse on average twice a week …and was orgasmic.

I was chuckling for days. On the way out she told me that she probably would have had sex more often had she been getting along better with her husband. I was pretty impressed with her. I was pretty impressed with both of them.

Yes …appropriate hormone replacement therapy is very effective in maintaining libido.

Dr. Jerry Nosanchuk is a practicing physician who has specialized in the care of menopausal women for over 30 years.  His office is located in Bingham Farms, Michigan.  Appointments with Dr. Nosanchuk can be made by calling: (248) 644-7200 and speaking to Caroline Monday through Friday from 10AM to 6PM

IMPORTANT: This website is for educational purposes only.  It is not intended to suggest a specific therapy for any individual and must not be construed to establish a physician patient relationship.

Sex and Menopause

 Appointments with Dr. N can be made by calling (248) 644-7200 and speaking to Caroline

 Loss of sexual desire and ability to participate in and enjoy sex is not a normal part of aging. Dr Nosanchuk explains why a menopausal woman's desire to have sex and her capacity to physically participate in sex are  influenced by her menopause... 

Disturbance of sexual desire or sexual function was given as the primary reason for scheduling the initial appointment by approximately half of the menopausal patients seen in my office. Almost all of these patients had seen at least one physician prior to coming to my office and most two or more. Many women had sought out the services of a female physician in the belief that another woman would be more knowledgeable about menopausal issues and more sympathetic to their problems. Several each year came from out of state. Most ranged in age from 35-60, although some were as young as their 20's and some in their 70's. Almost all of the patients had had at least one unsuccessful treatment attempt by a physician. Half of these women related, that a physician had told them that since appropriate bedtreatment had been provided and was unsuccessful, that their sexual problems "couldn't possibly" be related to menopause, or "maybe you're having a problem in your relationship", or "maybe you need to see a therapist" The most severe and life altering sexual problems were experienced by women who had undergone a "surgical menopause", especially if one or both ovaries were removed during the procedure. Almost all of the women who had undergone a hysterectomy had been assured that there would be no unpleasant effects following the surgery which could not be resolved with HRT, if needed. Many are unsuccessful in their repeated attempts to find someone who can help them, provide a rational explanation for their problems, or even believe them. Even though they are certain initially, that their sexual problems are due to their menopause/hysterectomy, many women begin to doubt themselves. They start to wonder if ..."maybe all those people are right, maybe I am crazy and all this is in my head". Ultimately, hopeless and feeling betrayed, they begin to doubt that their previous sexual state will ever be regained ...and stop looking.

Does all this seem a little strange and difficult to believe? 

Unfortunately, for many women it's a frighteningly familiar scenario.

It is possible for almost all of these women to regain their previous sexuality if the alterations in function are secondary to menopause, irrespective if it's natural or surgical. The "gold standard" for determining if the changes are secondary to menopause is simple; if you had a great sex life prior to menopause and following menopause you don't and you think it's related to your menopause ... you're probably right. If anyone tells you otherwise, they are almost always going to be wrong.

WHAT ARE THE EFFECTS OF MENOPAUSE ON A WOMAN'S SEXUALITY?

A menopausal woman's desire to have sex and her capacity to physically participate in sex are both affected by her menopause. This not to imply that the majority of women do not continue to function sexually following menopause, but rather that they are no longer able to achieve their optimum sexuality.

WHY DOES THIS HAPPEN?

These changes are a direct result of the alterations in sex hormone levels that precede and accompany menopause and are not related to aging. They are almost always preventable and/or reversible by appropriate HRT.

IS THIS A PROBLEM FOR EVERY WOMAN?

Yes ...and no.

Sex is an important quality of life issue for menopausal women but as with most things everyone has their own agenda.

To begin with, not every premenopausal woman has a strong sex-drive and the transition to a state of lessened sexual interest may not present a significant problem.

Some women who were highly libidinous and sexually active premenopausally, may welcome a diminished sex drive as it may present the opportunity for a less distracting life-experience. Some menopausal women reflect that they would prefer acts of intimacy such as "cuddling" as opposed to intercourse. In addition, a lower libido may lessen the sexual tension presented by fewer opportunities for sexual expression, as there is a diminishing pool of available companions due to increasing rates of sexual dysfunction, health problems and death. Health issues, divorce, alterations in living environment dictated by advancing age or finances, perceptions of aging, changes in body image and self esteem play a part as well.

However, it's important to not lose sight of how influential sex hormone levels are as a determinant of sexual attitudes and behavior. The catch-22 of low hormone levels that result in a diminished sexual interest is that there is no compelling need for those affected to remedy the situation, as they are usually quite content. Unfortunately, their partner may not be so content. Shared sexual intimacy in the context of a committed relationship enhances the existing spiritual bond and even subtle changes in pre-existing patterns of sexual behavior and response are readily discernable by a partner and can be a source of distress. This can result in significant conflict in a relationship and is compounded by the frequent perception that the changes are an inevitable aspect of aging, unaware of the role diminishing hormone levels has played or the potential value of HRT if desired.

I am reminded of a patient who was referred to me in the mid-80's for treatment of Osteoporosis. She was a widow, about 60 years old and had been without the benefit of HRT for several years having experienced a natural menopause in her late 40's. As part of her treatment program I prescribed a program of HRT. Her initial patient interview had revealed that she had a diminished sex drive and I mentioned that the HRT might increase her libido. She responded angrily, "I don't care about that". I continued to see her for follow-up care and about six months later she came in with a male friend, who had been her grocer, in tow. They looked like teenagers, faces flushed and holding hands as they revealed plans for their impending marriage. It was a very educational moment for me. Hormones, or lack of them are capable of having potent effects on sexual attitudes and behavior.

Part 2 - Sex & Libido - Hormone Replacement Therapy

This section addresses the role of sex hormones in maintaining libido and sexual function. It discusses the manner in which a natural, or surgical menopause, or medications may affect the sexual experience and provides treatment options to restore sexual desire and function.

IMPORTANT: This website is for educational purposes only.  It is not intended to suggest a specific therapy for any individual and must not be construed to establish a physician patient relationship.