Aside from relieving hot flashes and preventing osteoporosis, estrogen can improve genital Sensation and decrease pain and burning during intercourse. It is recommended that the lowest dosage of estrogen necessary for control of symptoms should be used.
With oral estradiol, the usual initial dosage is 0.05-2.0 mg/d, which is then adjusted as needed. Transdermal estrogen is available in patches (0.025 mg-0.1 mg), and the usual initial dosage is 0.0375 mg twice a week, alsoadjusted as needed.
While the Women's Health Initiative clinical trial stated that the overall health risks exceeded the benefits from use of combined estrogen plus progestin in healthy postmenopausal women, each woman must be assessed for risks versus benefits of HRT and the appropriate regimen prescribed for her needs.
In response to the Women's Health Initiative study, the American College of Obstetricians and Gynecologists (ACOG) commented on several points of concern regarding the study, including these: First, while the risk of breast cancer and cardiovascular disease increased, the magnitude of actual risk was small, less than one-tenth of a percent per year. Second, no increased risk of breast cancer was reported with estrogen-only use. Finally, the study tested only one drug regimen (conjugated equine estrogen0.625 mg/d and medroxyprogesterone acetate (Prempro) 2.5 mg/d).
ACOG further stated that HRT for the treatment of actute menopausal symptoms, when indicated, continues to be appropriate for short-term use (up to 4 years) without an apparent increase in risk of breast cancer. In menopausal women and in those who have had an oophorectomy, complaints of vaginal irritation, pain, or dryness can be relieved with a vaginally delivered estrogen (Estrace, Ogen, Premarin, etc.). There is also a vaginal estradiol ring (Estring) that delivers continuous low-dose estrogen locally and may be occasionally prescribed for breast cancer patients and others who are unable to use oral or transdermal estrogen. Topical estrogen is also available as a tablet (Vagifem), which delivers low-dose estrogen locally for relief of vaginal symptoms.
Androgen replacement therapy: Androgens are known to have a variety of physiologic and behavioral functions with beneficial effects on sexual desire. Some researchers of sexual dysfunction have shown that androgen deficiency syndrome can be alleviated with androgen replacement therapy. Randomized controlled trials studying the efficacy of combined estrogen-androgen preparations on sexual function in postmenopausal women have concluded that these agents induced a greater sense of energy and well-being with fewer adverse effects compared with estrogen alone.
A potential indication for combined estrogen-androgen treatment would be decreased libido occurring during perimenopause or postmenopause, specifically in woman who reports being previously satisfied with her level of libido.
Transdermal testosterone (Testoderm, Androderm) has also been tested in w omen with impaired sexual functioning. In a recent trial, 75 women who had undergone oophorectomy were randomized to receive oral estrogen therapy plus placebo or low- (150 microgram/d) or high-dose (300 microgram/d) transdermal testosterone. Sexual function and psychological well-being were significantly improved in the higher-dose group compared with the placebo group. A critical question that should be explored involved the appropriate levels of serum androgens required for adequate symptomatic improvement.
Topical testosterone propionate cream 2% can be used in women who have complaints of vaginal dryness and diminished genital sensation. A testosterone gel (AndroGel 1%) is also available. These topical formulations can be applied up to three times a week. Heightened clitoral sensitivity, decreased vaginal dryness, and increased libido have been reported with the 2% testosterone cream.
Oral methyltestosterone is available alone (Android, Oreton Methyl, Testred) or in combination with estrogen (Estratest). Experts have noted a lack of analytical sensitivity and reliability with current, commercially available androgen assays for women, however. Thus, without an adequate diagnostic test to assess androgen deficiency, it is difficult for clinicians to treat the disease in women. Assays are now being developed to detect lower levels of free testosterone in women.
Recent work has focused on over-the-counter dehydroepiandrosterone (DHEA), one of the major currently available androgen supplements, as a form of testosterone replacement. Preliminary results in women with androgen insufficiency suggest that DHEA improves desire, arousal, lubrication, satisfaction, and ability to achieve orgasm. Bear in mind that such androgenic dietary supplements do not require regulatory review, nor have they undergone formal trials of efficacy and safety, and for these reasons should be sued with caution.
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