Sexual Pharmacology

Hormones are often considered mainstay interventions that can improve sexual function. Systemic and local hormonal replacement with estrogen, progesterone, and testosterone remain key components in the management of female sexual dysfunction. Estrogen is one of many important hormones that is necessary for sexual function in women. Central arousal in the brain, peripheral tissues, and pelvic sexual region is dependent on estrogen levels. Some tissues are also very dependent on testosterone levels. Systemic hormonal replacement can be achieved with a variety of products either taken orally (by mouth), transdermally (through a skin patch), or intravaginally (in the vagina). There are many products on the market and they come in a variety of strengths and with different delivery systems—there are pills, gels, rings, tablets, and mists, among others. It is always critical to discuss your specific health background with your medical provider to decide what is best for you. Some of the popular hormones are Premarin, PremPro (Wyeth Pharmaceuticals), Activella (Novonordisk), and Vivelle Dot (Novartis). Creams include Premarin Vaginal Cream (Wyeth Pharmaceuticals) and Estrace Cream (Warner Chicott Pharmaceuticals).

Vaginal atrophy/ dryness is a serious medical issue associated with a drop in estrogen levels in the genital area.

For women who have an intact uterus, the standard of medical care is to add a progestin[1] agent to the regime; this prevents endometrial hyperplasia, or overgrowth of the uterine lining, and is widely accepted to help in the prevention of endometrial cancer. With the emerging data from the Woman's Health Initiative study, whereby hormones have had a small linkage to the possible development of cancer, there are growing concerns about hormones and potential associated risks of cardiovascular events or breast cancer. Risks and benefit profiles should be discussed with your healthcare and sexual medicine specialist.

What is vaginal dryness and how does it affect sexuality? What can be done?

Vaginal atrophy/ dryness is a serious medical issue associated with a drop in estrogen levels in the genital area. Many women suffer in silence with this condition. It can lead to decreased

vaginal elasticity, pliability, and stretchability. Many women with severe atrophy or dryness suffer from painful intercourse and also frequent urinary tract infections.

Goldstein and associates address the issues of vaginal atrophy, its pathophysiology, and its resulting impact on female sexual health and function. Vaginal dryness not only occurs in mature women who have undergone menopause. Women who breast-feed, those who take certain medications, and those who suffer from a variety of other medical conditions can all suffer from vaginal dryness. Vaginal dryness can lead to painful intercourse, which then leads to avoidant behavior and results in lowered interest.

Women who suffer from atrophy should have an appropriate physical examination by a trained specialist. Vaginal atrophy and dryness is relatively easy to diagnose both by history and physical examination. Women complain of pain, irritation, discomfort in the vulva and vagina, and are fearful of pelvic and digital examinations. Sometimes, after detailed questioning, women often relay additional sexual complaints such as painful intercourse, lowered libido, and increased urinary tract infections. On clinical physical examination, the vagina is dry, pale, frail, and lacks the normal ridges and folds, elasticity, and pliability of a healthy vagina. There is minimal lubrication and the tissues are easily traumatized with pelvic examination. There can be petechiae, or small hemorrhages on the lining.

There are many choices for therapy, ranging from using vaginal moisturizers and lubricants to minimally absorbed vaginal estrogens. Replens or vitamin E can be applied to the vaginal area and can help hydrate the vaginal tissues. Lubricants without flavors, colors, and warming additives can and should be used during intercourse. Products such as petroleum jelly, extra virgin olive oil, and other household products should be avoided because they can change the natural balance of vaginal bacteria. If you are shy or perhaps embarrassed about purchasing lubrication products at a local store, try Drugstore.com, which offers discrete packaging and won't fill your inbox with loads of spam.

Local treatment options for vaginal atrophy, where the product is placed within the vaginal area, include the use of local vaginal estrogens. They come in a variety of preparations including creams, rings, and tablets. The 17 beta estradiol tablets (Vagifem by NovoNordisk Pharmaceuticals) is an excellent choice for intravaginal dryness; it is safe, convenient, and well tolerated by women who are active. New lower doses should soon be available and show same efficacy. Creams, like Premarin Vaginal cream are also helpful for vulvovaginal dryness and discomfort, and this cream has an approved indication for this condition. Many women find introital discomfort troublesome, and these estrogen creams can be soothing and reverse symtomatolgy. This product as well will have some recent data published on new lower doses and minimal absorption profiles. The author has also recently published a small case series in the Journal of Sexual Medicine on the use of Premarin Vaginal cream as a potential orgasmic enhancer when rubbed directly into the clitoral tissue.

Although there is no one correct answer for how long you should or could remain on these products, clinically as long as you have symptoms and impaired quality of life or distress as a result of the complaints, treatment should continue. Interestingly, the North American Menopause Society (NAMS) discusses special populations including women who have had a malignancy and recommends that those without hormonally sensitive tumors be treated similarly to those who have vaginal atrophy with routine management. However, for those with hormonally sensitive tumors, such as breast carcinoma or endometrial cancer, treatment should be individualized and extensively discussed with their oncology and management teams.

You and your healthcare provider should discuss treatment options based on your preferences and his or her clinical expertise. Presently, adding a progestogen to the minimally absorbed local vaginal estrogen products is not warranted, and there is not enough data to support annual endometrial sampling or transvaginal ultrasound in women without symptoms.

Women's healthcare advocates often call vaginal dryness and its symptoms the silent epidemic because women are living longer. Because women are expected to live about one-third of their lives in menopause, quality-of-life concerns become paramount.

  • [1] A synthetic form of progesterone often used in birth control pills and hormone therapy.
 
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