The document discusses menopause and how it can impact sexual function and desire due to changes in hormone levels. It notes that while hormones play a role, other factors like relationships, mental health, and medication can also influence low sex drive. Treatment options presented include vaginal moisturizers, hormone replacement therapy (including local estrogen for vaginal symptoms), and potentially testosterone therapy under a doctor's guidance. Seeking help from a medical professional or therapist is encouraged to address both physical and psychological aspects.

1. MENOPAUSE AND HRT

2. Menopause, Sexual Pleasure and HRT
Are you struggling with symptoms of the menopause?
Is this impacting on your relationship, your experience of sex, on your work or
family life?
Please be reassured you are not alone. The good news is treatment is available
which will be tailored to meet your needs.
There has been much recent publicity about the perimenopause, menopause and
hormone replacement therapy. While for some women menopause can be
freeing, for many women it is accompanied by difficult symptoms: hot flushes,
night sweats, mood changes, sleep disturbance and brain fog to name just a few.

3. Many women also experience genital symptoms and sexual difficulties but often
don’t seek help for them or discuss them with healthcare providers. This can be
because of shame or embarrassment for both women and doctors. Most doctors
and nurses haven’t had training on discussing sexual difficulties, and therefore
both patients and doctors can feel uncomfortable talking about sex in medical
consultations.
Research shows most patients (both men and women) want to be asked about
genital and sexual symptoms. Doctors and patients often collude in ignoring
sexual difficulties despite them having a big impact on people’s lives and
long-term health. At the Leger Clinic, we understand how important it is to have
a doctor who is comfortable and skilled in dealing with sexual difficulties.

4. The Menopause and Sexual Function
As women go through the perimenopause (the years in the lead up to a woman’s
final period), hormone levels vary enormously. By the time of menopause, the
amount of oestrogen in the body has reduced significantly. Testosterone
decreases by about 25% between the ages of 30 and 50. The reduced oestrogen
and testosterone leads to decrease blood flow to the vagina, vulva and breasts.
The vaginal lining (mucosa) becomes significantly thinner. The clitoris shrinks
and becomes less sensitive. As well as affecting the vulva and vagina, oestrogen
is also important for bladder health. As oestrogen levels fall, the bladder thins
with weakening of the muscles which control the bladder.

5. These changes can lead to symptoms including:
● vulval itching
● vaginal dryness and reduced lubrication
● reduced sensation & sensitivity from sex
● pain during sex
● reduced sexual desire
● urinary problems such as needing to go to the toilet frequently, urinary
incontinence and frequent urinary infections

6. What might be the cause of my low sex drive? Is it hormonal?
Hormones are obviously an important factor. The changes described above can
mean sex is less pleasurable or even painful, which leads to an anticipation of
pain and discomfort, which reduces the desire for sex.
However, hormones are not the only factor. There can be many other factors at
play. Some examples include:
● relationship difficulties & differences in sexual desire within couples
● how we feel about our bodies as we age
● anxiety about sex and sexual arousal

7. ● sex not being very rewarding, having sex which doesn’t meet our sexual
needs
● cultural and social norms about what is ‘normal’
● our understanding of how desire and sex drive should be
● illness including cancer and medical treatment
● childbirth & fertility issues
● wider mental health issues such as anxiety and stress
● medication, including antidepressants, hormonal contraceptives,
medications for bladder issues

8. These are just some examples. It’s important to put things into this wider context
when thinking about medication as oestrogen and testosterone won’t address
many of these wider factors. Working through some of these factors with a sex
and relationship therapist can be helpful to untangle what might be going on for
you. You can find a list of therapists on our website HERE

9. Hypoactive Sexual Desire Disorder
Hypoactive sexual desire is the formal diagnosis for absent or very reduced desire
or motivation to engage in sex, which has happened over a period of several
months and is causing significant distress. Despite it being common, a smaller
number of women are distressed by low sexual desire and only some of those
seek help for it. However cultural norms around expectations, what is ‘normal’
and allowed play a big part in what we expect of our bodies and the help we’re
willing to ask for.

10. Now for the good news – what treatment is available?
It can seem like it’s all very difficult and overwhelming but there is hope. There
are lots of things which can help, getting you back to feeling yourself again as
well as improve your experience of sex.
Firstly, just by noticing and asking questions such as “what’s happened to my sex
drive?!” you can become more aware of what is going on in your body, mind,
relationship, and sex life and find a way forward. Usually an approach which
addresses different aspects of your current experience at once is the most helpful.
Exploring with a psychosexual therapist, or through books, apps and websites as
well as ensuring biological aspects are treated is often helpful.

11. Vaginal Moisturisers
Vaginal moisturisers and pH balanced vaginal lubricants can significantly
improve symptoms. Examples are those made by:
Systemic HRT
For symptoms which are related to hormonal changes, hormone replacement
therapy can really help. Systemic HRT which consists of a topical (skin) patch or
gel or an oral tablet can replace low oestrogen. If you still have a womb, then you
will also need a progesterone to protect the lining of the womb, usually in the
form of a tablet or a hormonal coil.

12. Topical (vulvovaginal) HRT
Topical oestrogen delivered locally to the vagina and vulva is helpful in reducing
symptoms of itching, burning, pain during sex and urinary symptoms. Topical
oestrogen is incredibly safe as the dose is so low and so little is absorbed into the
rest of the body. Sometimes local oestrogen is needed in combination with a
systemic (tablet or skin based) HRT.

13. Is HRT safe?
We know that HRT is incredibly safe for the vast majority of women, with no
increased risk of breast cancer for the first five years or clots in the legs or lungs
with the safest form of HRT. In fact, for most women the benefits of HRT
outweigh any risks particularly when started within ten years of menopause.
HRT has been shown to be protective for bones, brain and heart health as well as
giving women their life back and relieving difficult symptoms.

14. What about testosterone?
Current guidelines recommend that hormone replacement therapy with
oestrogen (in combination with progesterone if needed) should be used first
before considering testosterone.
Some people don’t absorb hormones through the skin as well as others, and so it
is always worth doing a blood test to check oestrogen levels on HRT and your
natural testosterone level before considering adding testosterone replacement.
For some women, adequate oestrogen replacement stops vulval & vaginal
irritation which stops sex being painful. This then leads to an increase in sexual
pleasure and desire.

15. However, if despite adequate oestrogen and if there are no obvious other
psychological, social or relationship factors causing low desire, it is reasonable to
have a trial of testosterone therapy to see if this helps symptoms. This is usually a
testosterone gel applied to the skin each day, equivalent to an eighth of the dose
for men. There are very few risks to testosterone therapy as long as it is under the
supervision of an experienced doctor, with monitoring of blood testosterone
levels after three weeks or so, to check levels don’t become too high.

16. At the Leger Clinic we have doctors who are very experienced with HRT and
testosterone replacement in women. We are always happy to talk through what
might be the right treatment approach for you. Sometimes a trial of 3-6 months’
of testosterone replacement therapy can be helpful to assess any response. It can
always be stopped with very little risk of side effects if it has not improved
symptoms.
Further sources of help and information:
You might find these books useful guides:

17. Come As You Are – Emily Nagoski
Mind the Gap – Karen Gurney
Becoming Cliterate – Laurie Mintz
Secret Garden – Nancy Friday