Women's Health Community

Dear An:Dear Anon: If there was a product proven to enhance sexual desire ("libido") in women it would be an even greater financial success than the erectile drugs for men! The issue of low desire is one of the most common sexual complaints in women of all ages.

There are two important components to "sex drive" in women. I am not sure which type is present in your wife. The first is arousal. Arousal is about blood flow to the genitals, lubrication, orgasm. The second is libido. Lidido is about desire (thinking, feeling, etc). The medical name for low desire is "hypoactive sexual desire disorder" or HSSD for short.

Arousal tends to be easier to "fix". There are more medications which can be tried for arousal problems than there are for HSSD. HSSD can be linked to some medical conditions (eg depression, low thyroid, drug/alcohol use, and medications such as spironolactone and hormonal birth control methods). There is purported to be a contribution to libido/desire from hormones such as testosterone.

Some researchers have tried "Viagra-type" drugs on women. One well known female researcher (Berman, 2003) gave Viagra to 180 older women who had arousal problems and/or low desire problems. It was found that Viagra was not helpful when HSSD was present. Another researcher (Seagraves 2001 & 2004) treated a total of 92 non-depressed women with the antidepressant Wellbutrin. Unfortunately, the response rate in the first study was only 29%. In the second study it was not helpful.

So were does this leave her? She could be tested for thyroid problems, I would look very closely at her medications. Often after stopping hormone therapy women can develop vaginal pain/dryness. The use of a very low dose vaginal form of estrogen does not increase cancer risk. The estrogen effects target the genital and urinary areas.

In terms of HSDD, there is one small study (Goldstat, 2003) which showed women aged 30-45, without depression or relationship issues, benefited form 10 mg/day of natural testosterone in a cream. This type of treatment is controversial in women who stil have their ovaries. There is also a medication for HSDD which is not hormonal in nature which has been undergoing trials. If you call OHSU ask to speak to the Women's Research Unit--they can let you know if a trial is open.

If your GYN cannot effect a change, or find a cause to be treated, you can be referred to someone with more expertise. This can be a GYN with specialized training or a certified sex therapist. Just be aware that they will want to know if this change in sexuality is a problem for her.

Yours,
Jane

I'm taking HRT since having a hysterectomy and it hasn't restored my libido. Arousal's pretty much gone too. I don't use vaginal estrogen since I'm not that dry but maybe it would be worth a try. Since estrogen by itself doesn't increase cancer risk, I plan to continue taking it even though it doesn't help my sex life because it does help my other symptoms.

Dear Anon: Thanks for taking the time to reply with your experience. I would concur with your opinion, estrogen alone has not been shown to have significant risk except for blood clots in the legs, and an increased risk for stroke (especially in older women). It is also true that most women using a systemic dose of estrogen do not usually need vaginal estrogen.

Here are a couple of things to think about in terms of low libido after hysterectomy:

1. If the ovaries were removed, that means that a primary source of testosterone has been removed as well. My sex researchers believe that testosterone plays a significant role in sex drive/libido. Most menopause experts will concede that low dose testosterone medication may benefit such women.

2. If your estrogen is in pill form (not patch, ring, gel, spray, cream forms) the hormone will go through the liver and increase an another hormone (SHBG) which will "suck up/bind" available testosterone creating lower blood levels.

So where does this leave you? If you do not have ovaries you can ask your GYN about low dose testosterone, and about using a non-oral form of estrogen. If you still have ovaries your can elect to try a non-oral form of estrogen. ...Hope you can find something that improves your sexual quality of life.

Yours,
Jane

Thanks Jane. I'm sad to say - no ovaries. I use transdermal estrogen which is supposed to have lower clotting risk than oral. I've tried testosterone cream which hasn't helped sex drive or response.

Dear Anon: While testosterone is not the universal answer--wouldn't that be nice--be sure of what you are getting in the way of a dose. Some of compounded creams may not deliver the dose. There is a testosterone patch available in Europe (our FDA did not approve it despite two applications and many studies showing efficacy). In the US some GYNs will prescribe "off label" Testim or Androgel. One small packet is a day's dose for a male. In a female that same packet should last five to seven days.

There is another, newer drug which works on HSSD, flibanserin 100 mg, which is not a hormone. Rather it increases dopamine levels. It has not been approved by the US FDA. There is mixed data on the use of another dopamine enhancer ("Wellbutrin") for treatment of HSSD.

Yours,
Jane

Thanks Jane. I too don't understand why the FDA didn't approve Libigel! I guess because it's for women!

Dear An: I would hate to think that was the case. Yet the FDA has not approved a number of "Women's Health" medications which are used in Europe/Australia. One in particular has over 30 years of decent research data to support its use and safety! Ever since the WHI published on hormone therapy the FDA is all about long term safety data. Too bad that the now 10 years of publications on Premarin and Prempro have not modulated those fears--especially for those women using estrogen alone like yourself.

J

There certainly appears to be a gender bias in medicine based on all the drug ads for men's health, sexual and otherwise — Viagra, Cialis, Androgel, etc. And very few men have had their testicles removed, nor their prostate for that matter. Yet there are plenty of women who've had their ovaries and/or uterus removed and are then told that they shouldn't take hormones past a certain age or timeframe. And there's not even an FDA approved testosterone to replace the T their ovaries made.



A friend's daughter who just finished her second year of med school was told that estrogen is bad. It seems to me that sex hormone deficiency brought on by surgical or induced menopause is much more detrimental to health than taking hormones to replace what was lost. There are even some doctors who recommend that women who've been forced into menopause from gynecological or other cancers take hormones, for both quality of life and overall health. Many providers seem to have latched onto the flawed WHI findings and lump all HRT's into one basket, estrogen/progestin, estrogen-only, transdermal vs. oral, etc.



I've read some guidelines for Rx'ing HRT that don't even differentiate between surgical and natural menopause yet they're quite different and should be treated as such.

Dear Anon_6061: Hear, hear! You seem to be well informed about the important differences between types of menopause, oophorectomy/not, and the disparate outcome data in the estrogen only arm of WHI/estrogen/progestin arm. Fortunately most GYNs will continue to prescribe hormone therapy when indicated. This is in current contrast to the message given to internists and family practice MDs both in their training and CME programs. I sincerely hope that this will become a more balanced view over the next ten years.

Thanks for your thoughts,
Jane

I had total hystorectomy at age 39 I am now age 65 and my sex life is better than when I had all my original parts, I have strong orgasums and a strong desire, I was worried about lose of sex drive before I had the surgery but didn't have a choice and was very surprized when afterwords everything still worked. I do know that alot of your sex drive is in your mind so don't give up on yourself.

I had a complete hysterectomy 8 years ago at the age of 36 and I no longer take an everyday HRT pill becuase of the weight gain mainly since I suffer from Bulimia. But becuase of this my GYN put me on "Vagifem" which is a veginal estrogen for my dryness and pain during intercourse. This did help my dryness and pain, however I still have a low libido. I just don't care to have sex anymore. It bothers me a lot and it bothers my husband more, especially since I had a VERY high libido before my surgery. I do definitely prefer the vagifem, but if there is something I can take to help my libido - my hubby & I sure would be happy!!!

Dear An (and cutetammi): As cutetammi noted, some women do go through total hysterectomy and do not notice an appreciable change in sexual function. Yet others find a significant loss.

An_247278, you are correct, the Vagifem is a super small dose of estrogen, but it is enough to improve vaginal tissue thickness and lubrication. Historically we used to tell women that after total hysterectomy they needed to be on a therapeutic dose of systemic estrogen before trying testosterone. More recently, in the clinical trials of the testosterone patch, women with low desire were given the patch (or a placebo) without being on estrogen. In other clinical trials the testosterone patch was tried on women who still had their ovaries after hysterectomy. The results suggested that there was an improvement in some parts of sexual function---but this was not true for every woman.

Bottom line, since this is a problem for you (not just your spouse) please go talk with your GYN. They might refer you to a sex therapist and/or consider a trial of other medications (eg testosterone or Wellbutrin) which are off label for treating low desire. Your GYN can also look for other medical conditions which can bring down desire (eg low thyroid, heart disease, depression, etc.).

In Support,
Jane

Dear cutetammi,: I am a 50 year old female who carries the BRCA2 gene which puts me at a higher risk for ovarian and breast cancer. I am faced with the decision of preventative surgery removing my ovaries, tubes and uterus. My husband and I have a very good sex life and I am so afraid that by removing all of the hormone producing organs that our and especially my pleasure will be no more. I am not ready to give that up. I was glad to read that you still have strong desire and can also achieve orgasms. I have a fear that that will be impossible for me if I do go through with the surgery. You said you had a complete hysterectomy, did this include the removal of your ovaries?

I would also love to hear from any doctors or nurses out there who know if it is at all possible to achieve orgasms after having all parts removed.

Thank You for your comments in advance.

Hi Jane Harrison Hohner RN RNP

I've had a full hysterectomy(no ovaries) and taking the HRT vitdell dot patch. I've been on it for about 2 1/2 months and still have vaginal dryness, low libido and intercourse is very uncomfortable without lubricant. how can i restore my own natural lube in my own body. before my surgery in April 2012, I was very active in the bedrm with my fiance. He understands my situation and is very supportive and I love him very much for that but when im pleasing him i want to be pleased also; achieving an orgasms is almost impossible and i want it back, please help....