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Changes at Midlife
Sexual Problems at Midlife
Causes of Sexual Problems
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Androgen therapy. Although androgens are the hormones that promote male sexual characteristics, they are also present in women and play an important role in women’s sexual response, as noted earlier. Levels of the main androgen, testosterone, peak in women in their 20s and gradually fall after that, although whether this age-related decline reduces sex drive is controversial.
Testosterone. It’s believed that very low levels of testosterone may contribute to reduced libido and weaker orgasmic response in some women. This has led to interest in studying whether testosterone therapy (delivered by skin patch, topical gel or spray, or subcutaneous pellet) might be a safe and effective treatment for low sexual desire in postmenopausal women, although no testosterone products are approved for treating sexual problems in women in the United States or Canada.
No testosterone products are approved for treating sexual problems in women in the United States or Canada.
Studies have shown that testosterone delivered by skin patch increases sexual desire and the frequency of satisfying sex among carefully selected postmenopausal women with low desire that causes them distress. Common side effects include acne and increased facial and body hair. Rare effects seen with high doses of testosterone might include permanent deepening of the voice, weight gain, liver problems, enlargement of the clitoris, and a small decline in good cholesterol.
The testosterone patch is approved in Europe for treating low sexual desire associated with distress in surgically menopausal women who are also on estrogen therapy, but the United States and Canada are waiting for further long-term safety data before deciding on approval. Because testosterone is converted to estrogen in the blood, some experts think that testosterone therapy might carry some of the long-term risks associated with systemic estrogen therapy, such as increased risk of breast cancer or heart disease, although this remains uncertain.
Be aware that prescription testosterone products developed for men, such as Androderm, Testoderm, and Androgel, contain doses of testosterone that are inappropriate for women. Sometimes, however, these products are prescribed off-label for women at approximately 1/10th the daily dose that is prescribed for men.
DHEA. Another natural androgen hormone, dehydroepiandrosterone (DHEA), is available as a nonprescription supplement pill in the United States. Because DHEA is converted to testosterone and estrogen in the body, it has been marketed as a way to improve libido, vaginal atrophy, arousal, and orgasm in women. However, these claims have not been endorsed by government regulators and are backed by limited and mixed evidence. More information is also needed on the long-term safety of DHEA, which has been associated with many of the same side effects in women as testosterone.
Intravaginal DHEA may hold promise, but more study is needed.
A recent clinical study in postmenopausal women in Canada found that an intravaginal tablet form of DHEA improved all aspects of female sexual function—desire, arousal, orgasm, and pain—compared with placebo.18 This experimental topical form of DHEA did so without raising blood levels of estrogen, testosterone, or DHEA beyond their normal postmenopausal ranges. This suggests that intravaginal DHEA may hold promise as a safe and effective therapy for sexual problems in postmenopausal women, but more study and menopause information is needed.
Antidepressants: bupropion and flibanserin. As noted earlier, the SSRI antidepressants reduce sexual desire and response in some patients who take them for depression and anxiety. In contrast, the antidepressant bupropion (Wellbutrin), which works in a different way from SSRIs, was found to improve sexual functioning compared with placebo in a small study of nondepressed women and men with desire and arousal difficulties. This finding is interesting but requires more study to confirm it before bupropion should be used specifically for treating sexual problems. In the meantime, bupropion may be a good antidepressant option for women with depression who are concerned about sexual side effects.
The experimental drug flibanserin also was studied as an antidepressant before being tested more widely for use in increasing libido in women with low desire. Although the drug showed promise at one point, the company developing flibanserin discontinued its development in October 2010 after a US Food and Drug Administration panel recommended that it not be approved because it produced only small improvements in response rates compared with placebo and was associated with several side effects.
Viagra for women? After Viagra burst onto the market so successfully a number of years ago, many researchers hoped that it and similar drugs for erectile dysfunction, Levitra and Cialis, might improve women’s sexual function in much the same way they helped men’s. After all, since these pills, known as PDE-5 inhibitors, restored erections in men by increasing blood flow to the penis, why couldn’t they restore desire or arousal in women by improving blood flow to the vagina? Despite the hope, clinical studies found that while PDE-5 inhibitors did increase genital blood flow in women, for most women this did not result in any real increase in desire or arousal compared with placebo. Althought PDE-5 inhibitors generally are thought to be no better than placebo for women with sexual problems, one specific group of women may benefit from a trial of these drugs. In women who had satisfactory sex lives before developing sexual problems after starting an SSRI antidepressant (such as Prozac), Viagra improved sexual function more than placebo tablets.19
Alternative therapies for sexual problems: buyer beware
You see them all over the Internet and at health food stores: herbs, supplements, and other “natural” products touted to improve your sexual performance or satisfaction. You may know their names well—ginkgo biloba, Zestril, Avlimil, among many others—but not what to make of them.
Keep in mind that these herbal supplements and creams sold over the counter or online are not regulated by the US Food and Drug Administration and have generally not been well studied. The upshot is that their safety and effectiveness is largely unknown. There are not even reliable ways to know whether these unregulated products contain what they say they do. Also, “natural” is not the same as “harmless,” since herbals can cause side effects and interact with other medications or foods.
If you do decide to use an alternative therapy, be sure to tell your healthcare provider so that he or she can be on the lookout for side effects and interactions.