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Hormone replacement therapy (menopause) page:

Data from numerous studies have consistently found that HRT leads to improvements in several aspects of menopausal symptomology, including aspects of sexual dysfunction. Sexuality is a critical aspect of quality of life for the large majority of menopausal women; therefore, any features of the menopausal transition that can negatively affect a woman’s sexuality have the ability to significantly alter her quality of life. The most prevalent of female sexual dysfunctions liked to menopause include lack of desire and low libido, both of which can be explained by changes in hormonal physiology.

Improvements in sexual pain, vaginal lubrication, and orgasm are found to be statistically different from those using HRT. Estrogens have positive effects of mood, sexual function, target end organs, and cognitive function. It has also been shown to prevent amyloid plaque formation, oxiadative stress, or deterioration of the cholinergic neurotransmitter system, all of which contribute to the etiology of Alzheimer’s Disease .There are several options of HRTs for women. These can include the use of estrogens alone (ERT), a combination of estrogens with one of several progestins as HRT, or the combination of estrogens, progestins, and androgens as HRT.

HRT and sexuality
Menopause is the permanent cessation of menstruation resulting from loss of ovarian follicular activity. Menopause can be divided into early and late transition periods, also known as perimenopause and postmenopause. Each stage is marked by changes in hormonal patterns, which can induce menopausal symptoms. It is possible to induce menopause prematurely by surgically removing the ovary or ovaries (oophorectomy). This is often done as a consequence of ovarian failure, such as ovarian or uterine cancers. The most common side effects of the menopausal transition are: lack of sexual desire or libido, lack of sexual arousal, and vaginal dryness. The modification of women’s physiology can lead to changes in her sexual response, the development of sexual dysfunctions, and changes in her levels of sexual desire

It is commonly perceived that once women near the end of their reproductive years and enter menopause that this equates to the end of her sexual life. However, especially since women today are living one third or more of their lives in a postmenopausal state, maintaining, if not improving, their quality of life, of which their sexuality can be a key determinant, is of importance. A recent study of sexual activities among women aged 40-69 revealed that 75% of women are sexually active at this age; this indicates that the sexual health and satisfaction of menopausal women are an aspect of sexual health and quality of life that is worthy of attention by health care professionals. A major complaint among postmenopoausal women is decreased libido, and many may seek medical consultation for this. Several hormonal changes take place during the menopausal period, including a decrease in estrogen levels and an increase in follicle-stimulating hormone. For most women, the majority of change occurs during the late perimenopausal and postmenopausal stages. Decrease in other hormones such as the sex hormone-binding globulim (SHBG) and inhibin (A and B) also take place in the postmenopausal period. Testosterone, a hormone more commonly associated with males, is also present in women. It peaks at age 30, but declines with age, so there is little variation across the lifetime and during the menopausal transition. In surgically induced menopause, instead of the levels of estrogens and testosterone slowly declining over time, they decline very sharply, resulting in more severe symptoms.

In menopausal women, sexual functioning can impact several dimensions of a woman’s life, including her physical, psychological, and mental well-being. During the onset of menopause, sexuality can be a critical issue in determining whether one begins to experience changes in their sexual response cycle. Both age- and menopause-related events can affect the integrity of a woman’s biological systems involved in the sexual response cycle, which include hormone environment, neuro-muscular substrates, and vascular supplies. Therefore, it can be appropriate to make use of HRT, especially in women with low or declining quality of life due to sexual difficulties.

Current research that has examined the impact of menopause on women’s self-reported sexual satisfaction indicates that 50.3% of women experience some sexual disturbance in one of five domains, and 33.7% experience disturbances in two of the domains. Of these were desire, orgasm, lubrication, and arousal disturbances. With regards to arousal, they found a significant negative association between age and arousal, in that as women aged they were more likely to report lower arousal scores. In the desire and orgasm domains, 38% of women reported a disturbances in their desire, and 17% reported a disturbance in their orgasm capabilities; of the 17%, 14% were premenopausal, 15.2% were postmenopausal and taking a form of HRT, and 22% were postmenopausal not on a form of HRT. Eight percent of women reported disturbances lubricating during sexual activity- 14.3% in the premenopausal group, 30% in the postmenopausal group not using a HRT, and 11.7% among those postmenopausal women using HRT. Lastly, 21% of women reported pain as a disturbance in their sexual satisfaction- the premenopausal group at 14.3%, the postmenopausal women using HRT at 13.3% and the group with the highest rates, similarly to the other results, was the postmenopausal women not taking HRT at 34%. This study concluded that there was a significant decline in sexual function related to menopause in the pain and lubrication domains.

The maintenance and improvement of quality of life during the menopausal period is at the core of estrogen and progestin-based hormone therapy. Both HRT and estrogen replacement therapy (ERT) have been shown to enhance sexual desire in a significant percent of women; however, as with all pharmacological treatments, not all women have been responsive, especially those with preexisting sexual difficulties, and the effectiveness of ERT may diminish after long-term use in some women. ERT restores vaginal cells, pH levels, and blood flow to the vagina, all of which are associated with the onset of menopause. Dyspareunia (due to vaginal dryness) appears to be the most responsive component of menopausal women’s sexuality to ERT. It also has been shown to have positive effects on the urinary tract and atrophy and may initially improve libido or sexual sensitivity. Other improvements in areas such as sexual desire, arousal, fantasies, and frequency of coitus and orgasm have also been noted. However, the effectiveness of ERT has been shown to decline in some women after long-term use. A number of studies have found that the combined effects of estrogen/androgen replacement therapy can increase a woman’s motivational aspects of sexual behaviour over and above what can be achieved with estrogen therapy alone. Findings on a relatively new form of HRT called tibolone- a synthetic steroid comprised of estrogenic, androgenic, and progestogenic properties- suggest that it has the ability to improve mood, libido, and somatic symptoms of surgically menopausal women to a greater degree than ERT. In various placebo-controlled studies, improvements in vasomotor symptoms, emotional reactions, sleep disturbances, somatic symptoms, and sexual desire have been observed. However, while this is and has been available in Europe for almost two decades, this has not been approved for use in North America at this point.

Effects of HRT on the sexuality of transsexuals
Cross-sex hormone treatment is an integral component in the medical treatment of transsexuals, as the hormones can lead to decreasing the dichotomy between an individual’s body and their gender identity. Managing long-term hormonal regimens have not been studied and are difficult to estimate because research on the long-term use of hormonal therapy has not been noted. However, it is possible to speculate the outcomes of these therapies on transsexual people based on the knowledge of the current effects of gonadal hormones on sexual functioning in natural men and women.

Firstly, if one is to decrease testosterone in MtF transsexuals, it is likely that sexual desire and arousal would be inhibited; alternatively, if high doses of estrogen negatively impact sexual desire, which has been found in some research with natal women, it is hypothesized that combining androgens with high levels of estrogen would intensify this outcome. Unfortunately, to date there haven’t been any randomized clinical trials looking at the relationship between type and dose of cross-sex hormone therapy, so the relationship between them remains unclear. Typically, the estrogens given to MtF transsexuals were 2-3 times higher than the recommended dose for HRT in postmenopausal women. While pharmokinetic studies indicate that by taking these increased doses it may lead to a higher boost in plasma estradiol levels; however, since the long-term side effects haven’t been studied, the safety of this route is unclear.

As with any pharmacological or hormone treatment, there are potential side effects, which in the case of hormone therapy include changes in sexual functioning. These have the ability to significantly impact sexual functioning, either directly or indirectly through the various side effects, such as cerebrovascular disorders, obesity, and mood fluctuations. In addition, some research has found an onset of diabetes following feminizing hormone therapy, which impairs sexual response. Whatever route an individual and his or her doctor choose to take, it is important to consider both the medical risks of hormone therapy as well as the psychological needs of the patient.

Sexual Dysfunction page

Causes
Research on sexual dysfunction is more difficult in menopausal women because of the changes that are taking place during their specific physiological state. The female sexual response system is complex and even today, not fully understood. The most prevalent of FSDs that have been linked to menopause include lack of desire and libido; these are predominantly associated with hormonal physiology. Specifically, it is the decline in serum estrogens that causes these changes in sexual functioning. Androgen depletion may also play a role, but currently this is less clear. The hormonal changes that take place during the menopausal transition have been suggested to affect women’s sexual response through several mechanisms, some more conclusive than others.

Many studies have demonstrated the dramatic changes in sexual functioning that can take place during this transition phase. Studies have found that as many as 25% of menopausal women are unable to experience orgasm, 20% reported no pleasure with sex, and another 20% had lubrication difficulties. While there has been controversy over whether these are due to the natural causes of aging or whether they’re specific to the menopause transition, it seems like most studies have come to the conclusion that decreases in sexual interest and sexual satisfaction are due to menopause. Furthermore, one study found that all aspects of sexual life were significantly compromised in postmenopausal women without hormone replacement therapy (HRT) compared to both menstruating women and postmenopausal women with HRT.

Hormone replacement therapy has the ability to stagnate and even improve a woman’s sexual satisfaction. Estrogens are responsible for the maintenance of collagen, elastic fibers, and vasoculature of the urogenital tract, all of which are important in maintaining vaginal structure and functional integrity; they are also important for maintaining vaginal pH and moisture levels, both of which aid in keeping the tissues lubricated and protected. Prolonged estrogen deficiency leads to atrophy, fibrosis, and reduced blood flow to the urogenital tract, which is what causes menopausal symptoms such as vaginal dryness and pain related to sexual activity and/or intercourse. It has been consistently demonstrated that women with lower sexual functioning have lower estradiol levels.

Even though ERTs and HRTs have been shown to be effective for the treatment of vaginal atrophy, there hasn’t been consistent evidence to suggest that these therapies increase sexual desire or sexual activity, therefore, many women with sexual dysfunctions remain unresponsive. There are two broad categories that address the management of sexual well being during menopause: pharmacological treatments that focus on correcting these difficulties, and psychological interventions. Because of the complexity of the female reproductive system, which includes a psychological aspect, it isn’t surprising that a female Viagra hasn’t been found to work in women. Not surprisingly, both the treatment and management of sexual functioning during the menopausal period should be unique to the individual based on her health history and her current needs.

Aging
This is another area of controversy- whether or not aging directly affects women’s sexual functioning during menopause. However, many studies including Hayes and Dennerstein’s critical review, have demonstrated that aging has a powerful impact on sexual function and dysfunction in women, specifically in the areas of desire, sexual interest, and frequency of orgasm. In addition, Dennerstien and colleagues found that the primary predictor of sexual response throughout menopause is prior sexual functioning. This means that it is important to understand how the physiological changes in men and women can affect their sexual desire. Despite the seemingly negative impact that menopause can have on sexuality and sexual functioning, sexual confidence and wellbeing can improve with age and menopausal status. Furthermore, the impact that a relationship status can have on quality of life is often underestimated.

Testosterones, along with its metabolite, dihydrotesosterone, are extremely important to normal sexual functioning in men and women. Dihydrotestosterone is the most prevalent androgen in both men and women. Testosterone levels in women at age 60 are, on average, about half of what they were before women were 40. Although this decline is gradual for most women, those who’ve undergone bilateral oophorectomy experience a sudden drop in testosterone levels; this is because the ovaries produce 40% of the body’s circulating testosterone. Sexual desire has been related to three separate components- drive, beliefs and values, and motivation. Particularly in postmenopausal women, drive fades and is not longer the initital step in a woman’s sexual response (if it ever was).

Several theories have looked at female sexual dysfunction, from medical to psychological perspectives. Three social psychological theories include: the self-perception theory, the overjustification hypothesis, and the insufficient justification hypothesis: 1.Self-perception theory: people make attributions about their own attitudes, feelings, and behaviours by relying on their observations of external behaviours and the circumstances in which those behaviours occur 2. Overjustification hypothesis: when an external reward is given to a person for performing an intrinsically rewarding activity, the person’s intrinsic interest will decrease 3. Insufficient justification: based on the classic cognitive dissonance theory (inconsistency between two cognitions or between a cognition and a behavior will create such discomfort) in that they will alter one of the cognitions or behaviours to restore consistency and reduce distress

The importance of how a woman perceives her behavior should not be underestimated. Many women perceived sex as a chore as opposed to a pleasurable experience, and they tend to consider themselves sexually inadequate, which in turn, does not motivate them to engage in sexual activity {. Several factors influence a women’s perception of her sexual life. These can include: race, gender, ethnicity, educational background, socioeconomic status, sexual orientation, financial resources, culture, and religion. Cultural differences are also present in how women view menopause and it’s impact on health, self-image, and sexuality. A study has found that African American women are the most optimistic about menopausal life; Caucasian women are the most anxious, Asian women are the most inhibited about their symptoms, and Hispanic women are the most stoic.

In the context of heterosexual relationships, one of the main reasons for the decline in sexual activity among these couples is the male partner experiencing ED. This can be very distressing for the male partner, causing poor body image and it can also be a major source of low desire for these men. In aging women, it is natural for the vagina to narrow and become atrophied. If a woman has not been participating in sexual activity regularly (in particular, those activities involving vaginal penetration) with her partner, if she does decide to engage in penetrative intercourse, she will not be able to immediately accommodate a penis without risking pain or injury. This can turn into a vicious cycle, often leading to female sexual dysfunction.

Treatment for females
Androgen therapy is one method of pharmacological treatments that has been used for HDDD. This is generally more common among women who have had an oophorectomy or who are in a postmenopausal state. However, like most treatments, this is also controversial. One study found that after a 24-week trial, those women taking androgens had significantly higher scores of sexual desire compared to a placebo group. As with all pharmacological drugs, there are side effects in using androgens, which include hirutism, acne, ploycythaemia, increased high-density lipoproteins, cardiovascular risks, and endometrial hyperplasia is a possibility in women without hysterectomy. This is another area in which long-term use has not been demonstrated. Alternative treatments include topical estrogen creams and gels can be applied to the vulva or vagina area to treat vaginal dryness and atrophy.

Androgen Replacement Therapy page:

General info section
Although androgen therapy has the ability to suppress or reverse the effects of hypogonadism, it is still unclear whether androgen therapy would have a significant benefit on otherwise healthy older men. Hypogonadism is a disease in which the body is unable to produce normal amounts of testosterone due to a problem with the testicles or with the pituitary gland that controls the testicles. ART can be administered as injections, patches, gel, or tablet form.

Androgen therapy use in women
Androgen therapy is one method of pharmacological treatments that has been used for HDDD. This is generally more common among women who have had an oophorectomy or who are in a postmenopausal state. However, like most hormonal treatments, this is also controversial and opponents argue that the clinical significance is marginal. Especially among women with surgically induced menopause, the addition of androgens appears to improve libido, enjoyment, ability to reach orgasm, and initiation of sex. One study found that after a 24-week trial, those women taking androgens had significantly higher scores of sexual desire compared to a placebo group. As with all pharmacological drugs, there are side effects in using androgens, which include hirutism, acne, ploycythaemia, increased high-density lipoproteins, cardiovascular risks, and endometrial hyperplasia is a possibility in women without hysterectomy. This is another area in which long-term use has not been demonstrated. In Europe, a patch has been approved for surgically menopausal and postmenopausal women; however, this has not been approved by the FDA in the United States as of yet.

Androgen Deprivation/ Suppression Therapy page:

Effects on men's sexuality
Normal male sexuality seems to depend upon very specific and complicated hormonal patterns that are not completely understood. One study suggests that ADT can alter the hormonal balance necessary for male sexual activity. As men age, testosterone levels decrease by about 1% a year after age 30; however, it is important to determine whether low testosterone is due to normal aging, or to a disease, such as hypogonadism. Testosterone plays a significant role in sexual functioning; therefore, naturally declining levels of testosterone can lead to reduction in normal sexual functioning. Further decreases in serum testosterone can have a negative impact on normal sexual function, leading to a decline in quality of life.

Erectile dysfunction is not uncommon after radical prostatectomy and men who undergo ADT in addition to this are likely to show further decline in their ability to engage in penetrative intercourse, as well as their desire to do so. A study looking at the differences of using GnRH-A (and androgen suppressant) or an orchiectomy report differences in sexual interest, the experience of erections, and the prevalence of participating in sexual activity. Men reporting no sexual interest increased from 27.6% to 63.6% after orchiectomy, and from 31.7% to 58.0% after GnRH-A; men who experienced no erections increased from 35.0% to 78.6%; and men who did not report engaging in sexual activity increased from 47.9% to 82.8% after orchiectomy and 45.0% to 80.2%. This study suggests that the GnRH-A and orchiectomy had similar effects on sexual functioning. A vicious cycle whereby lowering testosterone levels leads to decreased sexual activity, which in turn cause both free and total testosterone levels to decline even further. This demonstrates the importance of androgens for maintaining sexual structures and functions.