MENOPAUSE AND HRT

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 dont 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
  havent 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 peoples 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 womans 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
  doesnt 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. Its important to
  put things into this wider context when thinking
  about medication as oestrogen and testosterone
  wont 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 were willing to ask for.

10

• Now for the good news what treatment is
  available?
• It can seem like its 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 whats 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 dont 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 dont 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