treating women's sexual problems

by Chris Steidle, MD

There are two widely divergent schools of thought as to the proper treatment of female sexual dysfunction but as with everything else in life, the best solution probably falls somewhere in between. The most important factor is recognizing that the problem exists and then taking steps to offer treatment options.

One school of thought is the hormonal theory, which proposes that low levels of sex hormones cause female sexual dysfunction and that supplementing the deficient hormones will resolve the dysfunction.

The other school, the vascular theory, is based on the premise that sexual dysfunction in women is related to decreased blood flow seen with age and certain medical conditions. This, in turn, leads to a decrease in pelvic congestion and vaginal blood flow that causes dryness and subsequent female sexual dysfunction.

There is probably a great deal of crossover between these two schools of thoughts and there are probably a fair number of patients who will require both types of treatments to restore proper sexual functioning. This section will cover the hormonal theory of female sexual dysfunction as well as the cause and treatment options.

The hormonal school of thought is based on the fact that during a woman’s lifetime, sex hormones produced in the body play a vital role in the sexual development and functioning, including both sexual and reproductive behaviors. Testosterone, which has always been considered the “male hormone,” also plays a vital role in the normal functioning of women. It is testosterone that triggers the onset of puberty, which in an adolescent girl is the growth of pubic and axillary hair. Sexual sensitivity in the nipples and genital area and the susceptibility to stimulation is a testosterone-related function.

Male hormones are collectively known as androgens in contrast to the female hormones known as estrogens, which can be responsible for a woman’s desire. Testosterone is extremely important to a woman. In addition to contributing to proper sexual functioning, it has also been shown that it contributes dramatically to a woman’s ability to maintain the proper bone growth and bone density. This is one of the new buzzwords for the 90’s since it has been found that osteoporosis or a lack of bone density has become a major health care problem. There has been a great deal of research directed at stimulating bone growth in women to prevent hip fractures from falls that are so common in the elderly.

Testosterone is produced in a woman’s body and it peaks during a woman’s reproductive years. Most of the hormones that circulate in a woman’s body are bound to something called sex hormone binding globulin or SHBG. This means that only a very small amount of testosterone is available for use by the body to maintain these vital functions. This fact is important because if we measure the total testosterone in an obese woman, it may be artificially high; but there is a large amount of testosterone that is bound to the SHBG in fat tissue and is not available for use by the body.

A physician can measure available testosterone by ordering both a free and total testosterone blood test, which can provide both of these levels and aid in the correct diagnosis. As a woman gets closer to menopause, the ovary makes a substantially lower amount of female hormone, estrogen, but also a great deal lower amount of testosterone, as well. As a woman goes through menopause and begins using estrogens in cream or pill form, the estrogens can use up the ability of this sex hormone binding globulin to bind the testosterone. This makes the actual amount of testosterone available for use by the body even less. A lack of testosterone has also been associated with women that have had a total hysterectomy including removal of both ovaries since the ovaries are responsible for producing testosterone.

Low testosterone in a woman is very much like everything else in medicine. If one doesn’t specifically look for this problem, one cannot make a diagnosis. This is true in every field of medicine. If you don’t know about low testosterone and the signs and symptoms related to it, you cannot make this diagnosis. Unfortunately, after a woman has gone through a hysterectomy at an early age for either benign or malignant reasons, she may also undergo a loss of sexual energy and fantasy. Too often the erroneous diagnosis of depression is then made and an anti-depressant is used. Unfortunately, these antidepressants are notorious for causing female sexual dysfunction and can actually make the problem worse than it would be otherwise. Anti-depressants can also decrease the ability to achieve an orgasm and decrease the desire for sexual activity, which compounds the problem.

Some of the signs and symptoms of testosterone deficiency in a woman may include a loss of sexual desire and sexual fantasies or dreams, and decreased response to sexual stimulation in the nipples and the genital area, particularly the clitoris. There may be decreases in the ability to become aroused and the ability to achieve an orgasm. Additionally, there may be a decrease in the sense of well being and a particularly noticeable loss of muscle tone. On examination one may notice thinning or loss of pubic hair and genital atrophy may be present, which is the thinning of the tissues surrounding the vagina. This may include both scarring and cracking that is not typically responsive to female hormones applied to the area in cream form. This condition can lead to extreme difficulty during penetration as well as severe pain. Finally, dry scalp with a loss of hair over certain parts of the head as in so-called male-pattern baldness can be apparent as well.

There is a great deal of scientific evidence that androgens, specifically the male hormone testosterone, are responsible for the sexual drive in females. The real question is when should a clinician recommend male hormone replacement, specifically testosterone, in women? Clinicians that are very knowledgeable would generally agree that in postmenopausal women with decreasing sex drive, testosterone is a very reasonable alternative, especially when a laboratory test shows a low serum testosterone. This is especially true in women who have had removal of their ovaries as part of a hysterectomy. My general guideline is to be sure that we have assessed the sexual drive and that it is actually decreased.

Another very controversial topic is that of testosterone replacement in breast cancer patients. Merely the mention of hormone replacement will send shivers down a breast cancer patient’s spine. It has been drilled into their heads that hormones plus breast cancer equals recurrence and death, and that hormone replacement is not an option. Certainly, we discuss this on a case-by-case basis. Like everything else, these drugs in the wrong hands can become lethal weapons, but used correctly they can be life saving and dramatically improve the quality of our lives.

January 2000