Jump to No FDA Approved Treatments
Jump to Androgen Replacement Therapy: Benefits & Risks
Jump to Low sexual desire--is it all in her head
Jump to What is Normal, I Mean Typical
Jump to Absence of Motivation - What's a Woman to Do?
Jump to Tibolone - A Menopausal Prescription Medication
Jump to Beyond Hormone Replacement Therapy
Unfortunately, little has changed since I wrote the article about androgens & androgen deficiency in 2006, and subsequently updated and expanded it in 2009, nor since my original writings on the subject a decade ago. I realize this is contrary to women's hopes and expectations, and media hype. The medical community is still trying to understand and define "normal" female sexual function, and concurrently sexual dissatisfaction and dysfunction [1][3][4][5][6][9][15][16][22][25][30][31][33].
"[T]he news was constantly saying and the pharmaceutical industry was constantly saying, 'We've got the drug, it's just around the corner. It will be approved.' And I waited nine years and there still is no drug that is FDA-approved."
— Liz Canner, Mother Jones - February 2011
At present, female sexual dysfunction and dissatisfaction are for the most part based on a woman's perceptions and expectations of what is normal and abnormal, because science cannot accurately test and measure them. If a woman believes she is broken, then she is, as her believes can lead to distress and stress, which have adverse physical manifestations [5]. Though, decreased sexual ability doesn't always lead to adverse feelings or pursuit of medical care, even among women who are formally diagnosed with Hypoactive Sexual Desire Disorder (HSDD) [3][15].
If you can make a woman believe she is broken or abnormal, you have created a potential customer. Some believe pharmaceutical companies are using the media to create as many potential customers as possible. They want "Female Viagra" to be as profitable as "Viagra," and indeed the media is more than willing to make the connection.
"FDA Nixes "Female Viagra" Flibanserin"
— CBS News, June 2010
"Female Viagra Ineffective"
— Jessica Ward Jones, MD, MPH, June 2010
""Viagra for Women" on the British Market"
— Mother Jones, April 2007
Are So Many Women Truly Broken?
When slightly more than 2 out of 5 women believed their experience of sex was abnormal, even prior to 2001, a decade ago, half the battle was already won, for those seeking to profit from female sexual dissatisfaction, beliefs, and mores [14]. While it makes for a great and often repeated headline, this high percentage brings into question whether what women believe and expect is true and realistic. Or is the medical community and media defining too many women as dysfunctional? Is it a question of personal perception, medical definition, or both?
If the medical community hasn't been able to define "normal," how are women able too, by indicating their experience isn't? What is leading so many women to believe they are abnormal, and potentially in need of medical treatment; excluding symptoms related to pain and discomfort? Some women may want their experience of sex to return to what it had been in the past, even if their peers experience the same change(s) [15]. From a medical perspective, change isn't necessarily abnormal, even if we don't like it, and typically we don't like change. This said, understandably, women may not want to accept a decreased quality of life, for half their life. In addition, many women have partners who desire, or even demand, regular sexual experiences, and within American culture, and to varying degrees in others, the woman is expected to fulfill those expectations.
"Women were more likely to have sought formal help if they were married/cohabiting,..."
— Maserejian et al. [15]
Like in the Movies Please
There truly is no shortcut to sexual nirvana, what ever that is, if it truly exists, for more than a fleeting moment. While we may like the idea of never ending orgasm (mentioned in video), we all need to come back to a neutral state at some point, or experience harm. But the idea sure makes a great selling point!
No Direct Link
Having ruled out a direct and predictable link between sex hormone levels and female sexual satisfaction and dysfunction, attention has now turned to other potential causes [6][9][13][20]. These other potential causes include medical, environmental, surgical, and psychological factors [5][9][14][16][19][22][24][28]. It is these numerous contributing factors, which may have no quick and easy medical treatment associated with them, that has made developing a treatment for women's sexual desire concerns so challenging and time consuming.
"Drug companies have tried more than two dozen times to come up with a treatment to reawaken a woman's sex life."
— CBS News, June 2010
The challenge of developing a suitable medication is exasperated by the complexity and sensitivity of the female body. The female sexual experience is altered not only by the type of medication prescribed, but also the amount, and more isn't always better, as a result of a delicate balance between excitatory and inhibitory systems of the body [16][23][24][28]. Picture a balanced scale, if one side begins to dominate the other, balance and control are lost. This sensitivity is demonstrated by the results of testing two different dosages of an oral contraceptive [23]. In this instance, the lower dosage was found to improve sexual satisfaction, not the higher dosage.
Despite the lack of a direct link between sex hormones and HSDD and sexual dysfunction, at least one American company is still trying to have a testosterone treatment approved by the FDA, as after all, Britian has one [35].
"BioSante Pharmaceuticals, Inc. today announced top-line results from its two pivotal Phase III LibiGel (testosterone gel) efficacy trials. Initial analysis of the data from these trials shows that the trials did not meet the co-primary or secondary endpoints."
— MarketWatch, December 14, 2011
Some are challenging the FDA's special requirements set for the treatment of HSDD, which the above trials did not achieve [1].
As of January 1, 2012, there are no FDA approved treatments for Hypoactive Sexual Desire Disorder (HSDD) [7][Medscape.com]. This diagnosis is associated with decreased or absent sexual desire, that results in personal distress. This definition is not agreed upon by the medical community [25][27][31]. This creates a challenge for doctors, when their patients come to them for treatment, expecting treatment, perhaps as a result of media reports and rumor, as there are no formal treatment options and guidelines. The general practitioner, and their patients, are frequently left in the dark [15][26].
"[M]ost women had a strong desire to "feel like a normal person again"
— Maserejian et al. [15]
Doctors, likely acting in good faith, or not wanting to lose patients or a patient's trust, make an educated guess, and prescribe a medication that may work, but has never been proven to work reliably, nor not cause harm. In England, a testosterone patch is being prescribed by doctors when less than 1 out of 3 patients meet the manufacturer's full prescribing criteria [35]. The doctors likely have no other prescription option available, so the solution becomes, one size fits all.
"However, the women on placebo also perceived a significant benefit and satisfying events rose for them as well, from 2.7 times a month to 3.7."
— Jessica Ward Jones, MD, MPH, June 2010
Which brings up the placebo affect [17][37]. When one medication was being evaluated as a potential treatment for HSDD, 2 out of 5 women given the placebo reported a positive outcome [7]. The medication was 63% affective. Does this mean 23% of women truly benefited from the medication, and 40% believed they had? If the majority of women benefit, why not prescribe it? Because of the potential for adverse side affects, and potentially high cost. I suspect many of the over-the-counter sexual enhancers available today are nothing more than overpriced placebos, that may alter a couple's sexual interactions.
"Women say they already knew that drugs aren't' the answer - although they agree there is a problem."
— CBS News, June 2010
While some may want to take a pill and feel "cured," the true answer and solution is perhaps something more benign, but time consuming and requiring of sexual communication with their partner(s) and doctor [10][26]. While we like to talk about sex, we don't like to talk about sex with the appropriate people. I get the impression a woman's girlfriends know more about the couple's sex life than the woman's sexual partner, and certainly more than her doctor. There is a barrier to disclosure with her partner and doctor, one that doesn't exist with her girlfriends. Women are perhaps fearful of displeasing their partner and facing rejection, and perhaps the same applies to their doctor.
Androgen Replacement Therapy: Benefits & Risks
My prior comments about the benefits and risks of androgen replacement therapy still appear to be true today, now with up to four years of treatment history available to more fully judge benefit and risk [11][13][29][34][36][37]. Though, not everyone agrees [7][12][37]. Based on at least one study, there is no increased risk of breast cancer [11].
As I stated prior, you can ring a woman's sexual desire bell so loudly she can't possibly ignore it, despite a hurricane of noise, i.e. a multitude of environmental and medical causes for low or absent sexual desire [10][16][18][24][27]. Hormone replacement therapy may not fix a woman, rather conceal the symptoms, and their cause.
"Possible causes may include stress, relationship problems, anger, or a lack of intimacy with sex partners. There are also known medical causes including side effects of certain medications including some antidepressants, blood pressure medications, and birth control pills. Menopause may also decrease sexual arousal and stimulation, as well as depression."
— Jessica Ward Jones, MD, MPH, June 2010
Some women may want to feel sexual despite enormous workplace stress, relational conflict, medical conditions, and increased age. To overcome this enormous ambient noise, the level of androgens may have to be raised to greater than normal levels, causing adverse side affects. Some less than ideal experiences, like a little increased body hair, may be considered acceptable to some women, given the perceived positive affect on their sexual experience.
While women can make informed decisions for themselves, we don't always know their motivations, and ability to access risk, especially if they are trying to please an abusive or economically supportive partner. There is also the possibility that some women, who experience relativity intense sexual desire, may pursue even greater desire and physical pleasure, because they perceive their level of sexual enjoyment and fulfillment are less than that of their peers, and/or women in movies and porn. If the sparks don't fly during sex, some women may assume something is wrong with them, and seek/demand medical treatment. If you believe in a medical diagnosis of "sexual addiction," then a sex addict may pursue ever more intense sexual experiences, regardless of consequences.
A red flag I see, a study found that among women who have been diagnosed with HSDD, women currently prescribed greater than 5 different medications were more likely to seek treatment for their HSDD [15]. It is very unlikely all the different combinations of medications have been tested, and found to be compatible and safe. Many of these women are being treated for depression, which brings into question which treatment is truly working, if any. The medications may very well counteract one another, as some antidepressant medications adversely effect sexual function, some enhance it; two different medications at the same time may balance each other [8][18]. Some combinations may lead women to believe they have been cured, because they feel better, are happier, and happy people tend to be more sexual and enjoy sex more. The perceived outcome may be positive even if there has been no resolution of somatic (relating to the body) symptoms.
"Low sexual desire--is it all in her head?"
One medical article asks, "Low sexual desire--is it all in her head?" [16]. The politically incorrect answer is, sometimes yes, as a result of how women process information, which I believe can be blamed on genetics and their environment [4]. Genetics provide protective mental processes, their environment the conflicting messages and adverse experiences. Don't touch that area we do not bother to name, be sexual, but not too sexual, enjoy it, but don't enjoy it too much, hearing the "S" word a few too times, your partner's needs take precedence, she is single, something must be wrong with her, etc. As I stated above, what women "believe" can and does alter their health, and as a result their sexual experiences.
Making HSDD a Brain Disorder
"[F]libanserin is an antidepressant to treat vague symptoms by targeting the brain."
— CBS News, June 2010
"I
describe how this diagnosis embodies long-standing fascination with female
libido, a contemporary focus on female hypersexuality, and commercial interest of
the pharmaceutical industry and its medical allies to reify [to consider the abstract concept of] low sexual urge as a
pathological disorder [disease] in women."
— Jutel, A. April 2010 Source
Some are trying to use mind altering medications to treat female sexual dysfunction. When I went back through the medical articles that I had flagged for indicating promising results, they all turned out to be for antidepressant medications, with one exception [2][7][17][21][44]. If a woman "feels" better, she must be cured, correct? It is already alarming to me that 1 out of 4 American women are being prescribed a mind altering medication, but some would like to see that increase.
Are so many women truly in need of "treatment," or is this an indication of a much broader social issue? Are we returning to the hysteria era of old, when a woman's sexual fulfillment was literally placed in her doctor's hands? Can all women's symptoms and complaints be lumped together and treated as one? Will treatment this time around be in the form of a pill, rather than genital manipulation and surgery?
All this having been said, some antidepressant medications may enhance a woman's sexual experiences [21]. The questions are, are the medications addressing a chemical deficiency, does it work significantly better than placebo, and does it have a good likelihood of working (efficacy)? Antidepressant medications should primarily be used to treat depression, not sexual dysfunction or dissatisfaction. The risks are, some women may be motivated to try anything that is rumored to work, and some doctors may be willing to prescribe a quick fix. This later motive being a possible reason for the number of women on antidepressant medications. Do the potential benefits truly outweigh the potential risks?
Women currently being treated for depression with an antidepressant medication that results in sexual dysfunction or dissatisfaction may benefit from taking the medication bupropion, along with their current medication [8][18].
What is Normal, I Mean Typical?
"Stereotyped
[narrowly defined] sexual behavior and coitus occur normally
only in estrous, while human female
receptivity or proceptivity [motivation] can occur over the
entire ovarian cycle, during pregnancy, and in the
postmenopausal period, thus demonstrating first
the relative freedom from hormonal control,
and, second, the epigenetic [non-genetic] influence of both cognitive
[the result of perception and learning and reasoning] and sociocultural [social and cultural] factors."
— Salonia et al., Source
The concept "normal" has no place is the discussion of female sexuality, even though we may use it frequently. We all want to be "normal," to some degree, though many value their individuality, to the extent that it still allows them to be accepted by their peers. Instead, there is a very broad range of experiences, there is only diversity. Let me demonstrate. When women are asked, "At what age did you have your first menstrual period?" their response is:
| 1% (8) | 8 | |
| 4% (28) | 9 | |
| 11% (62) | 10 | |
| 23% (132) | 11 | |
| 26% (150) | 12 | |
| 19% (108) | 13 | |
| 7% (45) | 14 | |
| 2% (15) | 15 | |
| 0% (5) | 16 | |
| 0% (1) | 17 | |
| 0% (0) | 18 | |
| 0% (3) | I have never experienced menstruation | |
| 1% (6) | I cannot experience menstruation for anatomical reasons | |
| 0% (0) | I cannot experience menstruation for hormonal reasons |
Their responses form a "normal distribution" pattern, commonly referred to as a "bell curve." The onset of menstruation is almost completely under biological rather than social control, excluding the influence social prosperity or impoverishment may have, which influences a girl's overall health. On average, girls experience their first menstrual period at the age of 12.5-12.8. Are women who experienced menarche before or after this age considered abnormal? Absolutely not, we consider a broad range of experiences, ages, to be "typical." All the women who responded to this question are typical, even those who cannot experience menstruation for anatomical reasons, as their anatomy makes it expected and therefore "typical." If someone doesn't have a uterus, should we expect them to experience menstruation?
Doctors, acting under the influence of society, have defined limits to what is considered the typical age range during which the onset of menstruation is expected. They did this by defining the atypical, as a result of defining what is considered precocious and delayed onset of menstruation. Society, parents, and individuals, more so than perhaps doctors and science, are disturbed by early or late onset of menstruation. Doctors are under pressure from society to do the same with female sexuality and desire, to define typical levels of sexual desire, by defining the atypical. Some individuals and groups may want to see a very broad range of experiences defined as atypical, and in need of medical treatment.
Do we expect the experience of female sexual desire to differ from the above graph, and normal distribution? Female sexual desire is after all a biological function, though likely with a greater psychological component; I'm not aware that menstruation motivates women to do anything.
On a scale of one to ten, should women always choose "five" to describe their level of sexual desire? Not too much or too little, but just the right amount? Reminds us of a fairytale doesn't it! When women are asked about their level of sexual desire, they indicate it is:
| 4% (23) | Much less than that of my peers | |
| 7% (42) | Less than that of my peers | |
| 25% (145) | Equal to that of my peers | |
| 35% (202) | Greater than that of my peers | |
| 19% (108) | Much greater than that of my peers | |
| 0% (0) | I do not experience sexual desire | |
| 7% (45) | I am not sure | |
| 0% (0) | Other |
If all the women were the equivalent of a "5," wouldn't everyone have chosen "Equal to that of my peers"? Only 1 out of 4 did. 1 out of 10 believe their level of desire is less than that of their peers, 2 out of 4 believe it is greater. Here is the truly interesting thing, by what definition or measure of sexual desire do they make this determination? I've overheard some very personal girl talk, but how do you accurately relate something as intangible as sexual desire? Their choice of answers was, more than likely, based on perceived rather than objective measures of sexual desire.
Interestingly enough, when the choice of answers is changed, far more choose the equivalent of a "5," by choosing "About right."
| 3% (19) | Much lower than it should be | |
| 8% (48) | Lower than it should be | |
| 56% (316) | About right | |
| 19% (107) | Greater than it should be | |
| 7% (41) | Much greater than it should be | |
| 0% (0) | I do not experience sexual desire | |
| 4% (26) | I am not sure | |
| 1% (6) | Other |
While many believe they experience greater sexual desire than their peers, they are comfortable with their experience. The number of women who believe their level of desire is less than that of their peers, and lower than it should be, remains the same at 11%, which is, perhaps coincidently, around the same percentage that experience HSDD [14][28]. There is no great epidemic of low desire, amongst the participants in the survey, though the media acts otherwise.
Note: A survey with a small number of participants (n=150) obviously looks at the experiences of a different segment of the population, as low sexual desire is indicated by 26%, yet when the same survey had a greater number of participants (n=596), the percentage was 12%. Surveys can have a lot of population bias associated with them.
Here is where is gets truly interesting. When I ask women how they know they are experiencing sexual desire, they indicate a wide range of indicators/experiences. When I created the survey, I made an educated guess and provided 36 possible indications of sexual desire, some having a physical, measurable, and observable manifestation, others are psychological and the result of perception alone. Women as a whole experience them all, and likely more. How in tune are women with their peer's sexuality to know how much sexual desire they truly experience, given all its different manifestations?
| 89% (501) | I experience physical sexual arousal | |
| 85% (476) | I experience mental sexual arousal | |
| 51% (290) | I experience an increased heart/pulse rate | |
| 45% (254) | I experience butterflies in my stomach | |
| 67% (379) | I experience vaginal lubrication, immediately | |
| 59% (333) | I experience vaginal lubrication, after a period of time | |
| 63% (355) | I have a feeling, mental | |
| 71% (401) | I have a feeling, physical | |
| 55% (312) | I just know | |
| 73% (412) | My mind focuses on sexual thoughts | |
| 55% (309) | I can't think of anything but sex | |
| 54% (305) | I feel my vulva/labia become engorged with blood | |
| 46% (258) | I feel my clitoris become erect | |
| 47% (263) | I feel my clitoris change, it feels different | |
| 71% (399) | I feel my clitoris throb or pulse | |
| 54% (303) | I feel my nipples become erect | |
| 42% (235) | I feel flushed in the face | |
| 21% (118) | I break out in sex flush, all over my body | |
| 35% (197) | My body temperature increases | |
| 60% (339) | I feel my vagina contract | |
| 12% (70) | My vision changes | |
| 32% (179) | I become breathless | |
| 27% (154) | My level of perspiration increases | |
| 31% (178) | The muscles of my body constrict or twitch | |
| 59% (331) | I desire to be near someone | |
| 69% (387) | I desire to touch someone | |
| 65% (364) | I desire to hold or be held by someone | |
| 5% (28) | I feel like a truck has hit me | |
| 10% (58) | I feel like I am being carried away | |
| 12% (67) | I want to swoon, faint, or pass out | |
| 20% (115) | I become weak in the knees | |
| 42% (238) | I feel drawn towards someone | |
| 76% (425) | I have naughty thoughts | |
| 78% (439) | I imagine myself having sex with someone | |
| 62% (349) | I have sex on the brain | |
| 34% (194) | I feel deeply in love | |
| 0% (2) | I am not sure | |
| 0% (1) | I do not experience sexual desire | |
| 2% (15) | Other |
Do you perceive sexual desire the same as your peers, do you express it in the same manner? Do women around the world experience and express sexual desire in the same manner [31]? The participants in my surveys are predominately young educated women, and as a group, even they don't perceive sexual desire the same. The current definition of HSDD assumes so, but some disagree with this assumption [16][31].
None of the indicators are experienced by all women, yet all were experienced by some women. Are some atypical experiences? Only one person, despite 11% indicating they experience less sexual desire than their peers and personal expectation, indicate they don't experience sexual desire in any form. (If you don't experience sexual desire, are you motivated to take part in a survey about it?)
As a doctor, how do you know what questions to ask to determine if your patient is experiencing sexual desire? Or do you simply expect a yes or no answer? How do we determine if a woman knows what sexual desire is? It is possible for a woman exhibiting the indications of sexual desire, sexual arousal and behavioral changes, to not know she is. What if it is a problem of perception, not desire [4]? Is a pill going to fix her? Perhaps we can make her happy, but can we provide a pharmaceutical solution to her lack of perception?
I still haven't defined "typical" female sexual desire have I, or even atypical sexual desire. Defining too little or too much sexual desire should be easy, shouldn't it? Does the typical 20 year old woman experience the same level of sexual desire as the typical 60 year old woman? Should they? Should a woman who has had her ovaries surgically removed (oophorectomy) experience the same level of desire as one who hasn't, regardless of age? Should a woman who is experiencing significant stress be as sexual as a woman who isn't? Should women experiencing chronic disease experience the same sexual desire as those who don't? I know many wished they could, but is it realistic and possible, even with medication?
Keep in mind, sex requires a fully functional body, all the different bodily systems must be working correctly. Which means addressing one deficiency doesn't necessarily mean sexual function will be fully restored, especially if increasing age and disease decrease overall bodily function.
Now consider this, some within each of the groups I have identified are happy experiencing no sexual desire, while others wished they experienced no sexual desire. How do we account for this? While individuals, and/or their partner, may not like low or absent sexual desire, our species likely benefits from it. If everyone is busy making babies, who is going to care for them, provide for the nonsexual needs of the species? As I have recounted, I witnessed a coworker experiencing so much sexual desire it adversely affected her ability to work; I'm sure the same applies to men, as I have been distracted by sexual thoughts.
Do all the women who have experienced life and health changing events notice a change in their sexual responses? If they have, do they care, feel distressed and stressed, seek medical treatment? The answer is no. One study found that only half of women who had been formally diagnosed with HSDD were motivated to seek treatment [15]. Taking all this into account, how do we define, typical and atypical, who requires medical treatment and who doesn't? Do we leave it solely up to the individual to decide? Who do we find a solution for first? An even more unpleasant question, seldom asked in public, who as a group has the means of paying the very high costs of developing a treatment solution?
Absence of Motivation - What's a Woman to Do?
Sexual desire is the motivation to participate in sex, reproduce. Hormonally initiated sex drive is only one form of sexual motivation. Women perceive and indicate it isn't a significant factor in their motivation to engage in sex. Should we be surprised then that pharmacologic solutions aren't a reliable solution?
As women indicate, there are many other forms of motivation, some being in the form of reward. If you benefit from a sexual experience, you should be motivated to do it again, and the greater the reward, the greater the motivation. I indicate this, the multiple forms of motivation, and the influence of rewarding/non-rewarding sexual experiences, in my female sexual arousal flow chart, which shows the female sexual response cycle in a circular rather than linear form. A linear model of female sexual response has clear beginning and ending points, which don't actually exist. A woman's sexual response is intimately related to everything about her, in a continuum from the moment of conception onward.
Before women seek medical treatment for low or absent sexual desire, it would be beneficial for them to consider why they experience little or no motivation for, and reward from, sexual activities. If it is as women indicate, that biology plays only a small part in their sexual experiences, then there is only a small chance there is a biological solution.
If you go to your doctor seeking a solution to the wrong problem, you either wont be provided a solution, or it will not work. Or it works because of the placebo affect, the expectation for change that causes change. A woman may also hear things from her medical provider she doesn't like, is offended by, or isn't open too. If the problem is truly a lack of motivation and reward, then the answer isn't at your doctor's office, it is within you AND your partner.
You may have to fix yourself, rather than expecting others to do it for you. You must invest the time and energy to find the solution. I realize this may not be a popular answer with women, or pharmaceutical companies. Every individual's circumstances are unique, as the above referenced medical articles indicate, so there is no simple answer I or your medical provider can provide.
Sexual motivation is not the same as sexual ability. Menopause, natural, surgical, or chemical, may reduce or remove sexual ability. A doctor may be able to address these biological limitations, but hormone replacement therapy (HRT) does have know risk factors, and whether HRT is appropriate depends on the individual. If there is motivation, but little or no physical ability, then consider non-reproductive forms of sex.
Tibolone - A Menopausal Prescription Medication
"Tibolone, a synthetic steroid with estrogenic, androgenic, and progestational
properties..."
— Liu JH. [52]
Tibolone is an all-in-one hormonal replacement therapy medication. It acts like estrogens, progesterone, and androgens. Each woman's body determines exactly how the medication is utilized. For a given dosage, each woman's unique body chemistry ultimately determines utilization, perhaps significantly. As a result, the produced results, good and bad, likely vary greatly between individuals.
Estrogen and progesterone replacement therapies are associated with their own and combined risk and benefit factors, and this applies to varying degree when the method of delivery is Tibolone [39][43][47][48][49]. Tibolone may alter those risks and benefits, because of the method of delivery, and because the added presence of androgens.
"For a new chemical entity, tibolone had a very long development period
of 25 years before it was finally approved for the treatment of climacteric
[menopausal] complaints. The reasons for this long development were its complex and fast
metabolism and the poor standardization and sensitivity of analytical techniques
and clinical methods."
—Kloosterboer HJ. [38]
As I mention above, many of the body's systems require a delicate balance between excitation and inhibition. Replacing a third hormone should produce benefit, but as with estrogen and progesterone, there are sometimes benefits to their decreased levels after natural, versus surgical, menopause. Unfortunately, reproductive hormones are associated with increased risk factors, particularly cancers and vascular events.
If decreased and low hormone levels are the cause of sexual dissatisfaction and dysfunction then returning them to higher yet normal levels should, and frequently does, but not always, alleviate those symptoms. Tibolone does improve sexual function and quality of life, but with adverse risk factors, some of which are potentially significant [44][45][51][52]. Based on the potential risks, I can't recommend the use of Tibolone to women in general [40][41][42][46][47][48][49][50][51]. Each woman and her doctor need to assess her current quality of life and unique risk factors. If no other option, or no better option exists, a woman's quality of life needs may prevail over known risk factors.
Beyond Hormone Replacement Therapy
In some cases, hormonal therapy may not be an option, leaving only medications that alter brain function. Though these alone wont work if a woman's body is no longer prepared for partnered sex, specifically vaginal intercourse, requiring a properly prepared vulva and vagina. Antidepressant medications alone will not resolve symptoms related to atrophic vaginitis and dyspareunia. In this case, perhaps alternatives to reproductive sex, something the older generations, and not so older generations, may not consider or be initially open too. Most of us still consider sex to be "sex." Testosterone therapy alone may relieve issues related to desire for partnered activities, and non-coital activities may fulfill both partner's sexual and nonsexual desires. Obviously, it is a very complex subject to address.
Mild discomfort during vaginal intercourse may be relieved by the use of sexual lubricants. If a woman hasn't engaged in regular sexual experiences for an extended period, a very gradual recommencement of sexual activity may be required. A woman's body may need to experience regular and repeated episodes of sexual arousal prior to being prepared for vaginal intercourse. A woman may need to masturbate, not necessarily to orgasm, on a regular basis, for a period of time, prior to exploring partnered sex once again. A woman's partner can provide the stimulation, provided they can do so in an appropriate manner, without expectation of reciprocation. If symptoms related to atrophic vaginitis, particularly pain, cuts, and tears, are experienced, a doctor should be consulted.
