Sex, Hormones, and Menopause

There is an underappreciated distinction that exists regarding sexual problems women experience, and menopause serves as a very pivotal event which separates the two most frequent scenarios healthcare providers encounter. The most frequent complaint regarding sexual dysfunction in the healthy, normal premenopausal women is that of decreased libido (low sex drive). The patient usually recounts that her sex life was very gratifying previously but that something dreadful must be going on because she currently has lost all interest in sex. The patient often relates she has a “wonderful partner, delightful children”, a terrific lifestyle BUT”…. Although she has normal menstrual cycles, generally feels well and is on no medication, she is convinced she either has a hormonal imbalance or a serious medical illness. Because of all the media hype and popularity of “hormonal imbalances”, these women request detailed laboratory testing (ie “testosterone levels” etc) and despite normal hormone values they still want medication to improve their sex life. In contrast to the premenopausal patient, the postmenopausal woman typically complains of diminished pleasure during sex or frank pain with intercourse—especially at the entrance to the vagina—and this IS typically related to hormonal insufficiency. When the healthcare provider readily confirms the cause of discomfort (the shrinkage of the vagina is usually quite obvious on pelvic examination) the suggestion of hormone supplementation is usually met with skepticism because of a misconception that it will induce cancer or cause heart disease. The premenopausal woman is hormonally replete yet she wants medication while the postmenopausal woman needs it but is afraid to take it!