During menopause, women’s estrogen levels go through severe fluctuations before eventually stabilizing at a much lower output. The physical manifestations of lowering estrogen levels in women begin with vaginal dryness, progressing to atrophy.
Combined with reduced blood flow to the clitoris, a decline in sensory perception follows. These changes in the functioning of the female genitals contribute to dyspareunia (pain with intercourse or insertion of any device), which makes it harder for women to engage sexually and have pleasurable responses.
The mucous membranes of the lower urogenital tract are also impacted by estrogen production. Adequate estrogen is needed for flow of blood to the vaginal mucosa. Estrogen also supports proliferation of vaginal wall epithelium, smooth muscle fibers, and collagen to maintain the vagina’s rugae. In short, low estrogen levels cause the epithelium to thin, a loss of barrier function, a decrease in vaginal folding, and ultimately, the elasticity of the tissues decreases. These particular symptoms are often associated with VVA2.
Decreased libido and quality of life issues are even more sudden when a woman’s hormones rapidly --rather than gradually -- decline because of chemical menopause or post-surgical events. For instance, young women with bilateral oophorectomy (where both ovaries are removed) tend to have their testosterone levels reduced by 50%. In general, low testosterone levels are associated with low libido, reduced sexual desire, faltering motivation, distress, and reduced sense of well-being. Testosterone is also necessary for modulating clitoral and vaginal physiology to provide genital lubrication, engorgement, and sensation.3 In the four years leading up to menopause, there is a notable decline in testosterone production that continues for two years into menopause.
Dehydroepiandrosterone sulfate (DHEA-S) is the most abundant female sex steroid. It is also an androgen and a testosterone precursor. The use of DHEA therapy has had positive results regarding sexual functioning. In addition, the presence of testosterone is the single most important determinant of sexual factors and mood and has been positively linked to orgasm. Evidence of this comes from studies, including research on healthy midlife and older females that show how testosterone replacement therapy enhances sexual functioning.5
Other studies on bio-identical testosterone replacement therapy and its effectiveness in improving the sexual health of women are promising as well. A Watson Pharmaceutical study demonstrated that women who have undergone total hysterectomy and bilateral oophorectomy show positive results with no serious side effects when treated with bio-identical testosterone.6
Both testosterone and DHEA-S exhibit two mechanisms of action on mood indicators and sexual behavior. One of the mechanisms involves steroid action where they enter the cell’s nucleus and induce protein synthesis and transcription. The effects are slow, meaning it could be weeks before results are seen. The other mechanism is the neurosteroid function, where the steroid acts as a neurotransmitter. The effects of this mechanism can sometimes be seen within an hour if the hormones are taken sublingually.6
In a randomized, double-blind trial, 216 women with moderate to several VVA symptoms were given a 1% dose of DHEA versus a placebo intravaginally. The results showed the treatment groups had 68% improvement in arousal and sexual sensation, 39% improvement in arousal and lubrication, 75%improvement in orgasm, and 57% improvement in dryness during intercourse.2 This BHRT treatment indicates that intravaginal combined androgenic/estrogenic stimulation has significant benefits on sexual function without affecting the brain or extravaginal tissues.
1. Heidari, M. et al. (2019). Sexual Function and Factors Affecting Menopause: A Systematic Review. J Menopausal Med. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6487288/
2. Naumova, I. & Castelo-Branco, C. (2018). Current treatment options for postmenopausalvaginal atrophy. International Journal of Women’s Health. Volume 10: 387–395.
3. AlAwlaqi, A. et al. (2017). Role of hormones in hypoactive sexual desire disorder and current treatment. J Turk Ger Gynecol Assoc. Volume 18: 210-8.
4. Holtorf, K. (2009). The Bioidentical Hormone Debate: Are Bioidentical Hormones (Estradiol, Estriol, and Progesterone) Safer or More Efficacious than Commonly Used Synthetic Versions in Hormone Replacement Therapy? Postgraduate Medicine. Volume 121:1; 1-13.
5. Mernone, L. et al. (2019). Psychobiological factors of sexual functioning in aging women – findings from the women 40+ healthy aging study. Frontiers in Psychology. Volume 10: Article 546.
6. Cutter, C.B. (2004). Androgen deficiency in women: understanding the science, controversy, and art of treating our patients. International Journal of Pharmaceutical Compounding. Vol. 8:1; 16-21.