Barbara Seaman

(WOMENSENEWS)–Older women, still reeling from being told that hormone replacement therapy may slightly increase their risk for breast cancer, must now also assess studies indicating that estrogen supplements may also suppress sexual desire.

Natalie DeVane, a spokeswoman for Wyeth Pharmaceuticals, maker of widely used estrogen supplements Prempro and Premarin, acknowledged that both products can suppress a woman’s libido. This reaction is described in the Physicians’ Desk Reference, which contains government-approved information about all pharmaceuticals, as "changes in libido."

The supplements can suppress a woman’s libido because as her ovaries age, they produce both less estrogen and testosterone. It is testosterone that is primarily responsible for sexual desire.

When an older woman takes estrogen supplements, the "estrogen stimulates production of sex hormone-binding globulin, which ties up most of the testosterone you have," explained Dr. Susan Rako, author of "Hormone Of Desire:The Truth About Sexuality, Menopause and Testosterone." A deficiency of testosterone means a deficiency of desire.

Dr. Barbara Bartlik, a New York City psychiatrist and sex therapist, said that "women are three times more likely than men to develop disorders of desire," and that estrogen therapy, which is usually prescribed without added testosterone, may "exacerbate or cause low sexual desire."

‘Men Are Getting Fat and Saggy, Too’

Estrogen as an antidote for sexual desire is not the usual image of HRT–as hormone replacement therapy is known. The use of estrogen has been promoted for decades as a chemical fountain of femininity and near youth.

Dr. David Reuben, author of "Everything You Always Wanted to Know about Sex But Were Afraid to Ask," wrote in 1969 that "as the estrogen is shut off, a woman comes as close as she can to being a man." Dr. Robert Wilson, author of "Feminine Forever," a 1966 best-seller, described the effects of menopause as a "galloping catastrophe," adding that post-menopausal women who took replacement hormones "will be much more pleasant to live with and will not become dull and unattractive."

Reuben’s statements are an example of women’s older years being portrayed with emphatically sexist ugliness, noted Bartlik.

Reuben, she said, "makes it seem that women are turning into men. Men are getting fat and saggy, too. They’re turning into old people, that’s all."

Author Barbara Seaman added that many of those urging women to rely on hormone replacement therapy "preyed" on their fears of aging and loss of sexual attractiveness.

Impact on Libido among Other Unanswered Questions about HRT

It’s not known how many women who take estrogen experience decreased sexual desire. This and many other questions about HRT remain unanswered even though the first estrogen supplement, Premarin, was introduced 60 years ago.

Most women had assumed until July that the benefits and risks of hormone-replacement therapy had been well established. But that month, the National Institutes of Health halted the first double-blind clinical trial of Prempro, a combined form of estrogen and progesterone, because the study found that the women receiving the pills had slightly increased risk of breast cancer.

In October, the U.S. Preventive Services Task Force said the supplements actually raise the risk of heart attack in the first year of use and that they should not be used in the hope of preventing chronic diseases.

The true impact of the hormones on women’s sexuality is less clear because the topic of sex and aging women has not been well-studied, according to the "International Position Paper on Women’s Health and Menopause: A Comprehensive Approach."

This review of all the studies of the subject to date concluded that there "appears to be a decline in sexual function as women age, but whether these changes are due to aging, the hormonal changes of menopause, psychosocial factors or health status remains uncertain."

The review confirmed that hormone-replacement therapy does relieve vaginal dryness, but found that this relief does not lead to greater sexual desire or activity. Bartlik has seen this finding played out in her clinical practice.

"A lot of women who have ceased having intercourse because of vaginal discomfort often feel a renewed sexuality in the first couple of months after going on hormone-replacement therapy," she said. But that change is not long-lasting.

"Down the road," Bartlik said, "after four or six months or a year, they’re not feeling so good any more. They have no desire. They have trouble becoming aroused or are having difficulty having an orgasm."

Alternatives to Hormones Can Help With Uncomfortable Sex

Vaginal discomfort can cause a woman to avoid sex, but women who stop HRT should not assume they will have to live with that pain.

"A woman should not ask herself to put up with having uncomfortable sex," said Dr. Sarah Auchincloss, a psychiatrist who works with breast cancer patients in New York City. "She should be straightforward about talking to her doctor about strategies that can help." Some are old stand-bys such as jellied lubricants, but others are relatively new and little known.

Among these is the Estring, approved by the U.S. Food and Drug Administration in 1996 for relief of atrophy and other vaginal and urinary symptoms in postmenopausal women. It is a flexible ring that resembles a diaphragm without a center and is designed to slowly release the human form of estrogen directly into the vagina. (Prempro and similar products are made from the urine of pregnant mares.) Because use of the Estring results in only a temporary rise in blood levels of estrogen, it is considered safe enough to be prescribed for breast cancer survivors.

Other alternatives include estrogen creams, which, like the Estring, also require a prescription. Non-drug alternatives include regular sexual exercise, including self-stimulation, and drinking lots of water.

Seaman noted that some women "may not want their husband or lover to know they are doing anything" to maintain youthful vaginal lubrication. "They may worry that if the man knows, he might think, ‘Oh, you’re getting old,’ and go look for another woman," said Seaman. For women who have this fear, the privacy of HRT avoids this peril to their relationships.

Seaman has been writing about the dangers of hormones in birth-control pills and HRT for decades and is at work on her fourth book on the subject, "The Greatest Experiment Ever Performed on Women."

She does not advocate that all women stop HRT.

"With breast cancer, you have a 10 out of 100 chance of getting it that goes up to 13 out of 100 if you take estrogen for 10 or more years," she said. "The risk may turn out to be a bit higher, but if you’re really unhappy and suffering a lot from hot flashes and other symptoms, or it really makes a difference to your sex life, then it may be worth it to you to continue."

Rako takes both estrogen and testosterone and strongly supports continuing HRT.

"I can’t imagine what it would be like not to use any hormone supplement myself," she said. "But HRT is not one size fits all. Women should take their time and deal with doctors who test their levels of both estrogen and testosterone before HRT and after they’re on it, to see if they’re getting enough and not too much."

Frances Cerra Whittelsey is an independent writer. She reported on consumer affairs for The New York Times and teaches journalism at Hofstra University.



For more information:

National Institutes of Health–
"International Position Paper on Women’s Health and Menopause:
A Comprehensive Approach" (Acrobat PDF format):

MEDLine Plus–Health Information
Hormone Replacement Therapy
(Links to the latest medical information on HRT, including the clinical trials):

Web site for Dr. Rako’s book "The Hormone of Desire"
(Includes information about testosterone deficiency):