Treatment of Sexual Dysfunction After Menopause
Abstract & Commentary
Synopsis: In postmenopausal patients with sexual dysfunction, it is still unclear which, if any, therapy is indicated.
Source: Modelska K, Cummings S. Am J Obstet Gynecol. 2003;188:286-293.
Modelska and Cummings performed a thorough search of both electronic and manual databases to identify all randomized and placebo-controlled trials (RCTs) of treatment for female sexual dysfunction (FSD) in postmenopausal women published since 1990. Only 6 RCTs evaluating the effects of various therapies on sexual functioning in postmenopausal women have been published. Of these, 3 used hormone replacement, 2 used tibolone, and 1 evaluated the use of sildenafil citrate (Viagra). A summary of the findings includes: an estrogen/progestin therapy improves sexual desire and arousal, combined estrogen/androgen increases sexual sensation, desire, and frequency of intercourse, transdermal testosterone increases the frequency of sexual activity and orgasm, sildenafil does not demonstrate improvement in sexual response in women with female sexual arousal disorder (FSAD). Results with tibolone remain inconclusive. Modelska and Cummings conclude that it remains unclear which groups of postmenopausal patients with FSD do/do not benefit from these therapies.
Comment by Frank W. Ling, MD
Let’s be honest: this topic is a tough one for all of us in practice. For some of us, we figure that if we don’t ask, then she won’t tell. For others, the approach is to ask (since we’ve been taught to do so), but we don’t know what to do with the information when we get it. In some cases, it’s a matter of a business decision—ie, there isn’t enough time to address these concerns. Hopefully the case never occurs in which the clinician simply denies the reality that a postmenopausal patient can have sexual issues. This may have been the case a generation or so ago, but surely that outdated attitude has long ago exited our collective clinical mindset.
FSD is defined as a persistent/recurring decrease in sex drive or an aversion to sexual activity, difficulty becoming aroused, inability to reach orgasm, or pain during sexual intercourse. It is estimated that up to half of women in the United States have FSD. Many therapies are used in our practices to attempt to address FSDs, but they are not supported by adequate evidence. In the absence of very much evidence-based clinical information, the physician and patient will continue to struggle to identify treatments that both might help while not causing harm.
Since patients do not always raise issues of sexual functioning as concerns, it is incumbent on the clinician to routinely include this in the well-woman evaluation. Even when patients do not specifically complain of sexual problems, it has been estimated that up to 1 in 6 have concerns in this area. The routine questions of "Are you sexually active?" and "Do you have any concerns about your sexual functioning?" take little time, but offer great insight. Even if the patient does not answer in the affirmative now, the very fact that her provider asked and continues to ask as routinely, sends the message that her sexual concerns do matter and have importance. If you, as the clinician, do not feel comfortable in dealing with the problem, it should be relatively straightforward to get the patient to people or agencies who can help. Just identifying and validating the problem may prove to be a great service to the patient whose sexual concerns were heretofore left unaddressed.
This study confirms what many suspected: there are precious few RCTs addressing FSD. From the few that do exist, no conclusions can be drawn. The physician should be prudent in prescribing treatments that are not proven, but also understanding when patients express a desire to pursue untested treatments. We should be the patient’s advocate in any and all cases.
Dr. Ling, UT Medical Group, is Professor and Chair, Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN.