Libido and the Menopause

The traditional view that libido decreases after the menopause is mostly true but the reasons are complex. It may be simply the result of ageing or the result of oestrogen deficiency. It may be the response to a less sexually active partner as there are studies that indicate that if post-menopausal women have a sexually enthusiastic partner or partners then her libido is maintained for many years after the menopause.

It is also difficult to understand what libido really is. Coming from the Latin route, "lib-, libet" - to want or to desire - it was not originally a verb related to sex but certainly the contemporary meaning is clearly sexual. But even libido or sex drive relating to women or men has other non-sexual connotations in that it is related to general health, to self-confidence, to energy, and generally how a person feels towards her/his environment and body. It is easy to increase the libido by hormonal therapy and apart from the obvious increase in sexual events, such as fantasies, both intercourse, masturbation and orgasms, there is also the knock-on effect that women are happier and have more energy and give out an aura of being sexually confident. Women speak of the extra advantages that attend an improvement in the libido, particularly their enthusiasm for life, self-confidence at work, and a greater feeling of friendship with their partner.

Libido is a strange mixture of Head, Heart and Hormones and as gynaecologists we can only really influence the hormonal part of this triad. Psychologists and psychiatrists may think they can alter other aspects but the results are less reliable and treatment much more time-consuming. In spite of this the bulk of the literature concerning the treatment of libido loss does not come from gynaecologists nor is it related to hormonal based therapy.

Women after the menopause often have problems of flushes, night sweats, feeling wet and unattractive during the night. They have insomnia and the loss of libido often takes the form of a total rejection of even being touched by their partner. This is very hard for them to understand if they remain very fond of this person and with whom they have lived happily for 30 years. There may also be vaginal dryness due to the atrophy of oestrogen deficiency linked to dry intercourse and painful intercourse. These are often the physical causes of loss of libido.

It is often claimed that women have a loss of libido after hysterectomy but this should not occur even if the ovaries are removed if proper HRT is given. This is contrary to the message given in every women's journal in articles about hysterectomy which always indicate that the operation causes depression, loss of sexuality, marital disharmony and so on when the reality is that every single randomised scientific trial has shown that hysterectomy with appropriate HRT is associated with less anxiety, less depression, better sexuality and better general health scores. It is very odd that journalists continue to produce this fashionable but increasingly dishonest message about hysterectomy. Ovarian deficiency following oophorectomy will, of course, produce the predictable menopausal symptoms and the loss of ovarian androgens will produce the Female Androgen Deficiency Syndrome (FADS) of loss of libido, loss of energy, depression, loss of concentration, and even headaches. This occurs frequently after hysterectomy without the adequate and appropriate hormone replacement therapy but it is unknown how often it occurs in normal, middle-aged women who have not had a hysterectomy or oophorectomy. It is probably quite common but is ignored by most doctors who prescribe HRT and virtually all psychologists and psychiatrists who are not familiar with the use of hormones.

With the usual menopausal woman it is easy to treat hot flushes and sweats and its resultant insomnia by oestrogens and also to treat the atrophic vaginitis which causes painful intercourse by local or systemic oestrogens. This is a clear domino effect removing the most familiar and characteristic symptoms of prolonged oestrogen deficiency. Most people with these clear symptoms of the menopause would be helped by oestrogens alone.

However, there remains a group without vaginal dryness and without vasomotor symptoms who have this incomprehensible loss of libido. They may also be helped by oestrogen but the most effective treatment is by the addition of testosterone which, although available by many routes - tablets, injections, creams, and gels, is only licensed for use in women as a hormone implant. This is best given with oestrogen and the usual dose is oestradiol 50 mgs and testosterone 100 mgs and this should be repeated every six months. The improvement in libido occurs within a week and lasts for about five months at which time the implant should be repeated. In patients who have had a hysterectomy, this treatment is all that is required. Women with a uterus will need to have cyclical progestogen such as Provera 5 mgs for the first ten days of each calendar month to produce a regular bleed or they can have progestogen in the uterus as a Mirena intra-uterine system which will protect the endometrium and also suppress the periods.

Loss of libido is a common, distressing but treatable condition in the menopausal woman. For women who have no objection to hormones, oestrogen with or without testosterone, should be - in my view - the first-line treatment.