Two new menopause guidelines on sexuality highlight new treatments

Two new guidelines released by the Society of Obstetricians and Gynaecologists of Canada (SOGC) are the first of seven to be published over the next two months as part of the overall Menopause Guidelines. They present new treatments as well as a deeper understanding of menopause. “It’s an exciting area of change,” said Dr. Wendy Wolfman, a professor of medicine at the University of Toronto (U of T). New research and treatments have come to light since the previous guidelines were published in 2014. For example, research has uncovered specific cells that are responsible for hot flashes, and new drugs targeting thermoregulation in menopause are now in phase-2 and phase-3 research trials. Menopause and Sexuality and Menopause and Genitourinary Health were published in the JOGC. Additional guidelines, to come later this month and in November, address pharmacotherapy, vasomotor disorders, bone health, cognition and mood, and breast health during menopause. Their release dates are close to World Menopause Day on October 18. The guidelines point out doctors should pay attention to menopause and post-menopausal issues in their patients as many experience symptoms that adversely affect quality of life and well-being. The average time women experience vasomotor symptoms is recognized as being seven years. Forty per cent of women still have symptoms into their 60s, and 10% to 15% into their 70s. “The topic of menopause is often trivialized and many women don’t get treatments that could help alleviate their symptoms,” said Dr Wolfman. Part of this was likely fallout from the Women’s Health Initiative (WHI) study in 2002 which led to a dramatic drop in the use of hormone replacement therapy (HRT), she said. When it comes to use of HRT, which can be highly beneficial to many patients, doctors need to take the time to talk to their patients, and discuss the possible risks. Many women experience severe menopausal symptoms that impact their ability to function. Depending on the individual, symptoms can impact their ability to sleep, trigger mood swings, decrease sexual desire, lead to tissue changes that cause genitourinary syndrome, dyspareunia and more. Silent changes include acceleration of bone loss, cardiovascular changes and fat distribution. “Only the individual patient can put that all together and decide whether she is willing to undertake that small risk for an improvement in all those other healthcare measures. The majority of my own patients who are suffering would say that it’s not a choice,” she said. Menopause and Sexuality addresses sexual desire, sexual dysfunctions, related genitourinary syndromes, painful intercourse and a variety of new treatment options not available in the previous guideline published in 2014. According to the guidelines, the most common sexual problems in women in mid-life are loss of libido and dyspareunia, and the problems are common. Options include managing pain, addressing biopsychological factors, counselling. Transdermal testosterone could be prescribed (off-label), or the new drug flibanserin (this is approved in pre-menopausal women with evidence in postmenopausal women). Flibanserin, approved by Health Canada in 2018, is an oral medication used when a decreased and low sexual desire which is causing personal distress is not caused by a relationship problems, medical condition, a psychiatrist disorder, or other medicines. It lowers serotonin in the brain and increases norepinephrine and dopamine, but it can cause a drop in blood pressure and dizziness. New-onset dyspareunia that is caused by genitourinary syndrome of menopause can be treated with moisturizers, lubricants, vaginal estrogens, vaginal dehydroepiandrosterone (DHEA), or ospemifene (an estrogen agonist-antagonist which has tissue-selective effects). Ospemifene was approved for use by Health Canada just this year. When there’s a decline in estrogen (as well as testosterone) during menopause, lubrication in the vagina decreases. There are changes in the actual anatomy, Dr. Wolfman told the Medical Post in an interview. “There is a reduction in the elasticity of the vagina as well as collagen in the vaginal wall and shrinkage of the vulvar tissue. About 50% of women have this problem within three years of menopause and 70% by the age of 70. When it’s bad, these changes can cause burning, itching, pain, which can be quite severe in older women who have never been treated,” she said. The affected tissues have high concentrations of receptors for estrogen, which includes the vulva, the vagina, the pelvic floor and the bladder. Eleven medical organizations have recommended testosterone as a therapeutic option for new, distressing decreased sexual desire at menopause Dr. Wolfman said. There are cautions. “There is no approved testosterone in Canada for women. If someone uses testosterone, they have to reduce the amount of male hormone by a tenth because that’s how much testosterone women would normally produce. Testosterone is a normal female hormone. Use of testosterone products must be monitored,” she said. Try other approaches before meds “Were not suggesting everyone use of these drugs. They’re not a quick panacea and they don’t work for everyone,” she said. Decreased sexual desire can be triggered by one of many causes. “When we look at why a woman has decreased desire, we look at her relationship, her past sexual history, medications, whether she has pain with sex, the stress she’s under and many other factors. Each one can have an independent effect,” she said. A good evaluation is essential before deciding the individual course of treatment. The guidelines also describe new treatments that are in the pipeline, some of which have already been considered for approval. “I find the Menopause and Sexuality guideline well balanced and that it takes a wholistic approach,” said Dr. Nicolette Caccia, an associate professor of obstetrics and gynecology at the U of T. She was not involved in the writing of the guideline. “I like the fact it really codifies the problems with sexual dysfunction and that it talks about sexual dysfunction as a matter of personal distress. Not everyone is bothered by decreased desire,” she said. While the guideline introduces new medications, it is very clear that other approaches should be tried first. “Female sexual desire is very complex and so the approach to it has to be complex,” she said.

Two new menopause guidelines on sexuality highlight new treatments

Register for free access or login.

Related Topics