Sex Cells The effect of hormones on peri- and post- menopausal female sexuality Dr. Cathy Caron November 24, 2011

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1 Sex Cells The effect of hormones on peri- and post- menopausal female sexuality Dr. Cathy Caron November 24, 2011

2 Is sex over at menopause?

3 Older adults are having sex 51% of women ages 50 to 59 report having sex in the past year 36% report having sex at least a few times a month 8% of women over 80 report having had sex in the previous year Sexual problems most common in the over 65 group, but more distressing in the 45 to 65 age group 35% of women vs 13% of men report that sex is not at all important to them Men are more likely to have a partner b/c the women tend to outlive their partners

5 Estrogen Levels Fluctuate Widely During Menopausal Transition Menopause Menopausal Transition* (lasts average of 5 yr) Postmenopause (12 months post-lmp) Early Late Early Late Variable cycle length Perimenopause LMP 2 skipped cycles & interval of amenorrhea Amenorrhea x 12 mos None Premenopausal years Santoro N, et al. J Clin Endocrinol Metab 1996;81: Kronenberg F. Ann N Y Acad Sci 1990;592: Postmenopausal years 5

6 Sexual Changes at Midlife caused by decline in estrogen Irregular periods Hot flashes Insomnia Vaginal dryness Changes in fat distribution Changes in weight?

7 Hypothesis of Thermoregulatory Dysfunction: Core Body Temperature Thresholds Normal Symptomatic Thermo-neutral Zone (homeostatic range) Sweating Shivering Core Body Temp Sweating Upper threshold (Upper set point) Lower threshold (Lower set point) Shivering Body temperature Body temperature Freedman RR. Am J Med 2005;118:124S-130S.

8 Testosterone In women, peaks in the 20 s and then steadily declines Continues to be produced in the ovaries and in the adrenals after menopause By menopause, is about half of the peak level Unknown how much the levels affect libido (studies show no correlation between testosterone level and libido in women)

9 Other changes Changes in pelvic floor (laxity) Breast changes (fat replacement) Skin changes Hair distribution (androgen-sensitive areas) Acne (esp if had acne as a teenager)

10 Sexual Problems Decreased desire Decreased arousal Decreased response/ pleasure Painful intercourse Erectile dysfunction in a male partner

11 Decreased Desire 3 components: drive, belief/expectations about sexuality, and motivation Motivation is the most complex and perhaps the most important factor (Marieve and Jane) Desire declines in most but not all women starting in the late 40 s Role of testosterone unclear Desire declines more in women than in men May cause a problem in the relationship Most common sexual problem reported by women (10%)

12 Marieve 55 year old woman, single Stressful job (EA on Parliament Hill) Suffers from recurrent depression On an SSRI C/o hot flashes, low libido Starts HRT (Activella)

13 Jane 56 year old woman, married Stressful job, federal government Recurrent depression C/o hot flashes, mood swings, low libido Started on HRT (Estragel, prometrium)

14 4 months later... Both Jane and Marieve report improvement in hot flashes, mood symptoms and general well-being Both continue to take their SSRI Both are continuing in their stressful jobs BUT, Marieve reports a surge in her libido whereas Jane reports no interest in sex whatsoever

15 Motivational factors Marieve has found a 45 year old boyfriend Jane continues to be married to a man who pays no attention to her as a woman Next steps: Marieve and I discussed safe sex Offered relationship counseling to Jane who declined it at this time

16 Decreased Desire 3 components: drive, belief/expectations about sexuality, and motivation Motivation is the most complex and perhaps the most important factor (Marieve and Jane) Desire declines in most but not all women starting in the late 40 s Role of testosterone unclear Desire declines more in women than in men May cause a problem in the relationship Most common sexual problem reported by women (10%)

17 Decreased Arousal Lack of estrogen causes decreased blood flow to the vulva, clitoris and vagina Results in lack of lubrication Causes problems in 5% of women More common with women who live with their partner, have had surgical menopause or are in poor health

18 Decreased response and pleasure Decreased blood flow to the clitoris, less sensitive, less vaginal lubrication More difficulty achieving orgasm Orgasm difficulties more common in women over age 45 In turn leads to decrease in desire

19 Pain during intercourse Lack of lubrication Thinning of vaginal tissues Vagina becomes smaller and shorter Introitus narrows Anticipation of pain leads to decrease in arousal and also in desire Up to 45% of post-menopausal women report pain with intercourse May be other causes as seen in younger women vestibulitis, vulvodynia, adhesions, lichen sclerosis

20 Erectile Dysfunction Very common as males age. Up to 50% have difficulty maintaining an erection sufficient for intercourse at age 75 But, now we have effective treatment Can cause problems when erections are restored to men and couple has not been having intercourse

22 Incontinence Stress incontinence or urge incontinence Can cause embarrassing leaking during intercourse Use of pads can cause vulvar irritation May empty bladder before intercourse Kegel s may help May also use a pessary during intercourse (Hodge or ring)

23 Hot Flashes and Night Sweats Extremely common (30 to 80% of women) Can last many years (as long as 10 years) Can cause couples to sleep in separate beds Interfere with sleep, causing fatigue and lack of interest in sex Can worsen depression Effective treatments exist

24 Other medical problems Diabetes, hypertension and CAD cause decreased blood flow to the genitals, which in turn causes decreased arousal Some medications reduce libido (beta-blockers, ACE inhibitors, SSRI s) Diuretics can cause arousal problems ARB s seem to increase libido Chemotherapy causes an abrupt menopause Arimidex reduces estrogen levels, can cause severe symptoms and joint pains OA can also cause problems with sexual activity

25 ARB vs Beta Blocker Fogari et al, Am J Hypertension, Jan 2004;17(1): postmenopausal women, aged 51 to 55 years with mild to moderate HT Randomized to valsarten or atenolol, given 10 item sexual behaviour inventory 16 weeks, BP lowered equally in both groups ARB women reported a 38% increase in sexual desire, 45% increase in sexual behaviour and a 51% increase in sexual fantasies Atenolol women reported an 18% decrease in sexual desire and a 23% decrease in sexual fantasies

26 Depression Peri- and Post-menopause is a very vulnerable period for depression Depression causes low desire and arousal (as well as poor sleep) SSRIs have sexual side effects decreased desire, arousal, orgasm problems Wellbutrin seems to have fewer sexual side effects, as does Cymbalta Can use Wellbutrin in combination with another SSRI

27 Mood Increased vulnerability to depression in perimenopause Harvard Study of Mood & Cycles (Cohen, 2006) found that premenopausal women with no lifetime history of major depression who entered the perimenopause were twice as likely to develop significant depressive symptoms as women who remained premenopausal Risk appeared to be increased in women with vasomotor symptoms

28 Other reports such as the SWAN study, a multiethnic community-based cohort of pre- and perimenopausal women confirmed that mood symptoms are more likely to occur in perimenopausal than premenopausal women (Bromberger et al 2004). Schmidt et al (2004) followed 29 asymptomatic premenopausal women for 5 yrs until LMP - 9/12 new episodes of depression were during late perimenopause)

29 Stress Teenagers at home, lack of privacy Empty nest Financial stresses of kids in university Boomerang kids Aging parents Work demands Health worries

30 Poor Body Image Self and/or partner less attractive

31 Relationship Problems Poor communication Boredom Infidelity Abuse Lack of a partner Anxiety about a new partner

32 Case Study Victoria, 50 year old woman Had an endometrial ablation for menorrhagia 3 years ago Occasional night sweats, not particularly bothersome, no hot flashes Very stressful job (ADM level job with federal government) Married 25 years, likes her husband 2 teenaged daughters

33 Case study, continued Very demanding widowed mother Only sibling lives in Europe Has been very active all her life, but stopped about 2 years ago because of job, depression and a cycling accident History of MDE 2 years ago, still on Celexa C/o no libido Starting to think about retirement

34 Case Study (cont d) Finances not a worry Teenagers are doing well No history of abuse No problems with vaginal dryness Not sure if she s menopausal or not

35 Treatment for sexual problems Quit smoking Lose weight Eat a healthy diet Exercise Get enough sleep Avoid excess alcohol

36 Smoking Nicotine effectively lowers circulating estrogen Increases vaginal atrophy Increases pelvic organ prolapse Can cause pain, which inhibits both desire and arousal Also can directly affect arousal by reducing clitoral blood flow

37 Improve body image Weight Loss Improve sense of well-being Improve sensate focus Reduce risk of CAD, HT, DM, cancer (WHI) Interestingly, very thin women have a higher incidence of low libido, possibly b/c of lower estrogen levels

38 Exercise Benefits from weight loss associated with exercise as noted above Improves mood May increase clitoral blood flow Some exercises specifically target genital blood flow (yoga)

39 Sleep Sleep problems reported in 43% of perimenopausal vs 31% of premenopausal women Insomnia worsened by hot flashes and night sweats Night sweats can lead to separate beds, which leads to less cuddling, which leads to less sex Alcohol increases frequency of night sweats (red wine!)?in men as well

40 Treatment for desire problems Look at relationship issues Sex therapy/ counseling Review drugs that might be decreasing libido antihypertensives, SSRI s Consider changing to SSRI to bupropion, ACE to ARB (Dusing et al, 2003) Testosterone supplementation? DHEA? Yoga

41 Testosterone supplementation An off-label use Testosterone patch used in Europe with some success in women also on Estrogen Difficult to cut the men s patch (oozes) Can use Androgel 1 pump q1 to 2 days

42 DHEA Available as a tablet in US and some Canadian pharmacies Controversial re safety/ efficacy. Great enthusiasm in the 1990 s but failed to live up to potential However, vaginal ovules (Prasterone) currently in phase 3 clinical trials in Canada Labrie et al showed significant improvement in all 4 areas of sexual dysfunction with no increase in serum levels

43 Prasterone 2 studies published in Menopause: the Journal of the North American Menopause Society in 2009 Showed a rapid and efficient reversal of all the symptoms and signs of vaginal atrophy with no or minimal changes in serum steroids Primary safety data is lacking. There is a trial which will report in June 2012 with its primary outcomes as safety endpoints.

44 What about viagra? Does increase blood flow to the clitoris, however, this does not lead to increased desire nor increased arousal Has shown to be effective in women with previously normal desire who developed low libido after being started on SSRI s (Numberg, JAMA 2008) An off label use. Doses are the same as for men (50 to 100mg).

45 Treatment for vaginal atrophy ESTROGEN Topical tends to work best Ring, Premarin cream or Vagifem tablets Ring and tablets, dose controlled. Cream, can use more (1 applicator nightly x 2 weeks) then back off to maintenance dose Can also use systemic estrogen

46 Treatment for vaginal atrophy Water-based lubricants (eg Astroglide) Moisturizers (Replens) Vibrators or dilators plus premarin cream Regular sexual activity

47 Treatment for arousal difficulties Treat vaginal atrophy Eros -CTD

48 Vibrators Treatment of arousal difficulties Bupropion (increases dopamine). J of Clinical Psychopharmacology, Non-depressed women with hypoactive sexual desire disorder, improved sexual arousal, orgasm completion and sexual satisfaction Viagra increases blood flow Yoga

49 Sex therapy Yoga Orgasm difficulties

50 Yoga One study showing yoga s effectiveness treating desire, arousal, orgasm, sexual pain 40 participants at a 12 week yoga camp Filled out a questionnaire before and after the yoga program ¾ of them reported an improvement in sexual functioning in all 4 areas No control group

51 Yoga No specific pose that does the trick Requires a consistent practice There are sequences of poses recommended for menopause Can recommend a class or a book or DVD Women s Book of Yoga and Health by Linda Sparrowe and Patricia Walden

52 Sexual pain problems Vaginal moisturizers, lubricants Vaginal estrogen Sex therapy/ counseling Vaginal dilators Pelvic floor physiotherapy Kegel exercises Symptom-specific medications Yoga

53 Discussed goals Back to Victoria After much discussion, we agreed on a treatment plan Reduced hours at work (2 days per week) Begin exercise program Continue Celexa for now, might consider switching to bupropion Check hormone levels (FSH and estradiol)

54 Play Date nights Vacations Toys Surprises

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