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What are the medical treatments for sexual problems in women?

One of my clients told me she had experienced a decrease in her sex drive and that she had read about taking testosterone for this problem. Can you tell us something about medical treatment of sexual problems in women?

    A LACK OF LIBIDO — absent sex drive — is not at all unusual in women. Perhaps as many as a fifth of women feel their sex drive is too low. Some of this is due to a misconception about normal sexuality: while characters in movies or TV may always seem to be hopping into bed, real life is much less exciting.

    A usual sexual frequency for married couples is 1 to 2 times a week, maybe less when there are small children or demanding work schedules or both. It is normal not to feel interest in sex at some times.

    Lack of sexual appetite is less common in men than women, and a man’s libido is much less likely to be affected by fatigue or stress. This can result in partners having different levels of desire. Sometimes a woman simply wants sex less often than her mate. There may also be a lack of relaxed and private time together.

    Sexual expression is an important part of relationships and it may require changing the routine so as to permit time alone for the partners when they are rested. Sometimes there are conflicts in the relationship which need to be addressed for the sexual aspect to improve. Although a few find anger exciting, for most people it is a turn-off.

    It is quite common for women to experience lack of desire apart from the above circumstances. Sometimes this is a long term problem. There are many women for whom sex has never been of major importance — they may not miss sex, but feel pressure from their partner. Others experience a relatively sudden loss of interest and miss the pleasure and satisfaction which sex once held for them. Sometimes this happens after hysterectomy with removal of the ovaries; there is some evidence that this can be due to loss of the testosterone produced by the ovaries. Some women in this situation find that their sex drive is restored when they are given testosterone.

    At the present time, there are no really ideal testosterone preparations available for women. A combination of methyltestosterone and esterified estrogens (Estratest® and Estratest HS® (available in the U.S. but not in Canada) has been widely used for loss of libido associated with removal of the ovaries, or with natural menopause. These medications do work for some (but by no means all) women with reduced sex drive.

    Androgenic side effects are a concern with testosterone. I have seen several women with scalp hair loss, increased facial or body hair, or oily skin and acne resulting from taking testosterone. Those who already are troubled by these problems need to be aware that taking testosterone may make them worse. The androgenic effects of Estratest and Estratest HS are usually mild in my experience — especially with the HS (half-strength) form — and many women do not have any of these effects.

    The situation may be worse with non-standardized preparations compounded by pharmacies that specialize in hormonal preparations. I have seen two women who developed testosterone levels as high as those in men after applying testosterone cream or gel. I recommend against using any of these non-standard preparations. A skin patch is being developed which gives consistent levels of testosterone comparable to those present in pre-menopausal women. I have done research on the patch with grant support from the sponsor; it seems promising and research on it is continuing.

    It is important to realize that testosterone is not the only factor affecting female sexual response. Estrogen, while it does not stimulate desire, is necessary for comfortable intercourse because the vaginal tissues are thin and dry in its absence. Lubricants help sometimes but not always because while they moisten the vaginal mucosa, they do not make it thicker and stronger as estrogen does.

    Recently there has been considerable interest in sildenafil (Viagra®). This was recently introduced in the U.S. and is expected to be released in Canada soon. Its indication now is for erection problems in men. Men who have not been able to become erect for a variety of reasons, often can with the help of sildenafil. This may also be helpful for some women whose genital tissues are not very sensitive to stimulation. By improving blood flow to this area, sildenafil may make the tissues more responsive. Studies are currently being carried out, but it is too soon to know how helpful it will be for women.

    Until recently the main treatment for sexual disfunction was educational and psychological. Sex therapy was pioneered by Masters and Johnson and refined by the late Dr. Helen Singer Kaplan. It involves teaching people to understand the sexual responses of their partners and themselves. This is best done by therapists trained in the specific methods. It may be extremely helpful for some couples. The trend at the present time however is to seek pharmacological treatments for sexual problems. We now have some medications that work and it is likely that the next decade will bring new agents for helping those with sexual problems.

    It is important to point out that some commonly used medications can inhibit sexual desire. Most common are the new anti-depressants such as fluoxetine (Prozac®), sertraline (Zoloft®) and paroxetine (Paxil®). These may decrease sexual desire and performance in up to a fifth of people taking them. Some anti-hypertensives can affect sexual performance also. Finally, a number of diseases (e.g. diabetes) can affect sexual responsiveness, so the first step in dealing with a sexual problem is to get a medical evaluation.

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