Dr. Rosemary Basson (biography and disclosures)
What care gaps I have noticed
Postmenopausal vulvovaginal atrophy (VVA) is typically associated with vaginal dryness and dyspareunia but can also reduce genital sexual sensitivity. How commonly this occurs is unclear as women are rarely asked and may falsely assume it is inevitable post menopause. Those who do question this loss tell their physicians that sexual genital stimulation is no longer arousing and no longer leads to any orgasms of any intensity. While local (vaginal) estrogen therapy is effective in treating dyspareunia and dryness, it may not restore the genital sexual sensitivity and Genital Sexual Arousal Disorder is diagnosed. Management has been unclear.
Data that answer these gaps
Recent studies have shown that the local delivery of the main precursor hormone of testosterone and estrogen, namely dehydroepiandrosterone (DHEA) into the vagina effectively treats dyspareunia and dryness from VVA but can also restore genital sexual sensitivity so that orgasms are more easily obtained and are more intense[i]. Using accurate mass spectrometry methods, serum levels of estrogen and testosterone did not increase. Serum levels of DHEA did increase but not to levels seen in younger women (DHEA decreases from age 35 to 65 by some 60%[ii]). The dose associated with improved sexual sensitivity in addition to improved dryness/ dyspareunia was 13 mg at night, with benefit occurring by 12 weeks. Further study is needed to confirm these results but clinical experience at UBC Sexual Medicine is positive: compounding pharmacies have not reported any difficulty with formulating the DHEA for vaginal placement.
What I recommend (practice tip)
Always review the medical history to exclude generalised disease e.g. multiple sclerosis underlying the symptoms of lost genital sexual sensitivity. Examine to exclude a vulvar dystrophy causing the loss of sensitivity (e.g. lichen sclerosis). Look for signs to confirm VVA but remember that subjective symptoms and objective signs of VVA correlate poorly[iii]. Recently psychological factors rather than estrogen levels were shown to moderate symptoms when VVA is present[iv]. Prescribe local estrogen initially: clinical experience is that sometimes the estradiol ring (releasing 7.5 μg daily), or compounded estriol (0.5mg per vagina twice weekly) is more effective than the more convenient 10 μg twice weekly estradiol vaginal tablet. When sexual sensitivity is not restored consider switching to investigational vaginal DHEA to deliver local estrogen and testosterone to vulvar and vaginal tissues. After reading the researchi, and explaining this is investigational but considered safe as no systemic hormone is given, Family Physicians can request compounding pharmacies to make either vaginal suppositories or cream as detailed in the RCTi. If benefit is insufficient by 4 months, switch back to local estrogen for continued benefit to the dryness and dyspareunia. For the ongoing loss of sensitivity, women can be advised that mindfulness practice has recently been shown to improve genital sexual sensitivity in healthy women[v] and in those with past gynecological cancer[vi].
References: (Article requests require a login ID with CPSBC or UBC)
[i] Labrie F, Archer D, Bouchard C, Fortier M, Cusan L, Gomez JL, et al. Effect on intravaginal dehydroepiandrosterone (Prasterone) on libido and sexual dysfunction in postmenopausal women. Menopause 2009;16:923-931. (View with UBC or CPSBC)
[ii] Labrie F, Bélanger A, Tusan L, Cusan L, Candas B. Marked decline in serum concentrations of adrenal C19 sex steroid precursors and conjugated androgen metabolites during aging. J Clin Endocrinol Metab 1997;82:2396-2402. (View)
[iii] Indhavivadhana S, LeerasiriP, Rattanachaiyanont M et al. Vaginal atrophy and sexual dysfunction in current users of systemic postmenopausal hormone therapy. J Med Assoc Thai 2010;3:667-75.
[iv] Kao A, Binik Y, Amsel R et al. Biopsychosocial predictors of postmenopausal dyspareunia: the role of steroid hormones, vulvovaginal atrophy, cognitive-emotional factors and dyadic adjustment. J Sex Med 2012;9:2057-76. (View with UBC or request from CPSBC)
[v] Brotto LA, Basson R, Luria M. A mindfulness-based group psychoeducational intervention targeting Sexual Arousal Disorder in women. J Sex Med 2008;5(7):1646-59. (View with UBC or request from CPSBC)
[vi] Brotto L, Heiman J, Goff B, Greer B, Lentz G, Swisher E, et al. A psychoeducational intervention for sexual dysfunction in women with gynecologic cancer. Arch Sex Behav 2008; 37(2):317-29. (View with UBC or CPSBC)