Background: Women often experience changes in sexual function after menopause. Although changes in desire are not inevitable, postmenopausal women consistently experience a decrease in arousal, manifested by decreases in genital perfusion, engorgement, vaginal lubrication, and response to touch and vibration. Many also experience a decrease in the intensity of orgasm.

In addition to the physiologic changes that occur during menopause (most likely because of a drop in estrogen), psychological factors and expectations may also play a role in sexual satisfaction. Iatrogenically, surgical treatment of stress incontinence and hysterectomy have variable effects on sexual function, depending on preoperative factors and surgical technique. Atherosclerosis and hyperglycemia can impair sexual function in women, as can certain medications, such as selective serotonin reuptake inhibitors and dopamine receptor blockers.

Recommendations: Evaluation should include a comprehensive medical, sexual, and psychosocial history. A genital examination should include evaluation of resting pelvic floor muscle tone and voluntary vaginal and anal sphincter tone. Laboratory testing such as testosterone measurement is not indicated. However, targeted testing is appropriate for suspected disorders.

Treatment addressing sexual complaints should take into account the importance of sex to the patient. Other treatment recommendations include addressing unrealistic expectations, using lubricants, and creating romantic environments. Sex therapy can be helpful for psychological problems.

Estrogen improves vaginal lubrication and may improve orgasm. Although high doses of estrogen can achieve central effects that are more broadly beneficial to sexual function, the progesterone required for endometrial protection negates many of these benefits. If estrogens are used in patients who have an intact uterus and no risk factors, transdermal formulations should be prescribed, because oral estrogens increase sex-hormone binding globulin and decrease desire. Vaginal estrogen increases lubrication, may increase vasocongestion, and is safer than systemic estrogen, but long-term use should be avoided. Combination estrogen/testosterone increases sexual desire and responsiveness but lowers high-density lipoprotein cholesterol levels. Using a testosterone patch may avoid this adverse effect and, in combination with systemic estrogen, may improve the number of satisfying sexual episodes.

Other medications that may be helpful include bupropion (Wellbutrin) and phosphodiesterase inhibitors. Bupropion may increase arousal and orgasm completion. Phosphodiesterase inhibitors increase genital perfusion but have no significant effect on arousal. A subgroup of women taking phosphodiesterase inhibitors had improved overall satisfaction with changes in vaginal lubrication, genital sensation, and ability to achieve orgasm. The same cautions that apply to men in the use of these agents are relevant to women.

Several mechanical devices are available. Vibrators supply high-intensity, direct clitoral stimulation. A hand-held vacuum pump also increases clitoral blood flow and has been shown to increase sexual satisfaction. Some data suggest that pelvic floor exercises can be beneficial and can decrease sexual incontinence. New products to improve desire—including androgen delivery systems and dopamine agonists—as well as agents targeting genital arousal are currently in development.