Sexual Health in the Menopause Presenting Genital Symptoms and Physical Signs of Vaginal Atrophy Symptoms Dryness Itching Burning Dyspareunia Signs on Physical Exam Pale, smooth, or shiny vaginal epithelium Loss of elasticity or turgor of skin Sparsity of pubic hair Dryness of labia Fusion of labia minora Introital stenosis Friable, unrugated epithelium Adapted from Bachmann GA, Nevadunsky NS. Am Fam Physician. 2000;61:3090 6. Burning leukorrhea Vulvar pruritus Feeling of pressure Yellow malodorous discharge Pelvic organ prolapse Rectocele Vulvar dermatoses Vulvar lesions Vulvar patch erythema Petechiae of epithelium 1
Role of Hormones Estrogen No apparent central role, not believed to influence sexual desire Peripheral role Very important in response of vulval/vaginal tissues Deficiency Loss of swelling of vulval structures, lack of lubrication Does not appear to affect increase in blood flow to erectile tissues, just fewer blood vessels present Effect of CEE and CEE/MPA on Vaginal Maturation* n) Change From Baseline % Superfical Cells (median 25 20 15 10 5 Women s HOPE Study Cycle 6 Cycle 13 0 CEE 0.625 mg 0.45 mg 0.3 mg 0.625/ 0.45/ 0.45/ 0.3/ 2.5 mg 2.5 mg 1.5 mg 1.5 mg Treatment Groups CEE/MPA Placebo *P <.05 vs baseline and placebo for all active treatment groups; P <.05 vs CEE 0.625; P <.05 vs CEE 0.3/MPA 1.5. Utian WH, et al. Fertil Steril. 2001;75:1065 79. 2
Introduction Local oestrogen for vaginal atrophy in postmenopausal women Suckling J, Lethaby A, Kennedy R. The Cochrane Library.2009;2. Efficacy and safety of low dose regimens of conjugated estrogens cream administered vaginally Bachman et al. Menopause 2009;16:4 Sexual pain disorders Dyspareunia Recurrent or persistent genital pain associated with sexual intercourse. The disturbance causes marked distress or interpersonal difficulty(dsm IV-TR) 3
Introduction 2007 position statement of The North American Menopause Society First Line Therapy Vaginal lubricants and moisturizers Hormone therapy Systemic Local If urogenital atrophy is the only complaint, this should be the route of administration Safer More effective Menopause 2007;14:357-369 Introduction Vaginal estrogen therapy should be continued as long as distressful symtoms remain. Menopause 2007;14:357-369 4
Postmenopausal Sexual Health: Summary Sexual dysfunction affects many postmenopausal women Physicians and patients may be reluctant to discuss sexual issues Genital atrophy is a major consequence of estrogen deficiency HT is effective in preventing and reversing genital atrophy and associated dyspareunia Hypoactive sexual desire disorder Peaks in women aged 40 60 and surgical menopause Linked to: chronic disease, depression medication Atrophic vaginitis leads to dyspareunia and sexual aversion and lost sexual desire 5
Hypoactive Sexual Desire Co-existing Factors Medications Medical Conditions Partner dysfunctions Psychological Factors Psychological Factors Sexual Abuse 6
Role of Hormones Adrenal: DHEAS, DHEA, androstenedione, Ovary: testosterone,dhea, androstenedione Decrease in adrenal androgen production as women age, beginning in their 30 s Studies are less conclusive regarding ovarian androgen production at midlife and later Role of Hormones Problems Lack of sensitive assays to assess the low testosterone levels found in women Intracellular production of testosterone from circulating DHEA, DHEAS, and androstenedione may be completely used by the cell, therefore not detected by serum assay What do we use as a goal for replacement? Evidence of benefit with replacement of testosterone to mid-range physiologic levels has yet to be determined 7
Studies in surgically menopausal women Braunstein et al Buster et al Simon et al Davis et al Nachtigall et al These studies support the effectiveness of transdermal testosterone for short-term treatment of hypoactive sexual desire disorder(hsdd) in surgically menopausal women, with little evidence to support long-term use(longer than 6 months) 8
Transdermal testosterone Matrix patch Most extensively studied Numerous randomized blinded clinical trials Combined nearly 3000 postmenopausal(surgically induced or naturally) women with HSDD All trials have demonstrated dose related, significant increases in sexual desire with testosterone patches versus placebo when the dose was maintained at 300 micrograms per day or greater 9
Testosterone Safety Minimal prospective long term data RE: cardiovascular effects in women Methyltestosterone/esterified estrogens Decrease in HDL Increase in chol:hdl ratio Decrease in TG Reasonable to check baseline lipids and LFTs. no evidence to guide monitoring. There are no formulations of testosterone FDA approved for women Formulations available from compounding pharmacies Subcutaneous implants, transdermal patches, gels, sublingual drops, capsules 10
Testosterone preparations for use in women available off label or as customized formulations Compounding pharmacies Methlytestosterone 125 mg capsules Methlytestosterone 1.25 mg capsules Topical micronized testosterone 1 mg/0.1ml DHEA 11