Hormone Therapy for Sexual Function in Postmenopausal Women

Does hormone therapy improve sexual function in postmenopausal women?

In early postmenopausal women (within 5 years of their last menstrual period), systemic estrogen slightly improves sexual function (i.e., desire, arousal, lubrication, orgasm, satisfaction, and pain). (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.) However, it is not clear whether other types of hormone therapy—including systemic estrogen combined with progesterone—improve sexual function in postmenopausal women. There is insufficient evidence to support the use of systemic hormone therapy in postmenopausal women for sexual function alone; however, in women with vasomotor symptoms, the use of systemic estrogen therapy for other indications may result in a slight improvement in sexual function. The benefits of hormone therapy for postmenopausal women should be balanced with the risks.¹

The menopausal transition brings a multitude of problematic symptoms, including vasomotor symptoms, sleep and mood changes, and sexual dysfunction. Sexual dysfunction during this period can include low sex drive or desire, poor vaginal lubrication, dyspareunia, and the inability to achieve an orgasm. Current guidelines suggest that for women younger than 60 years or within 10 years of menopause onset without contraindications, the benefit-risk ratio for systemic hormone therapy for vasomotor symptoms of menopause is favorable^2,3; however, the effect of systemic hormone therapy on sexual function is unclear. The authors of this Cochrane review sought to evaluate the effect of hormone therapy on sexual function in postmenopausal women.

This Cochrane review included 23,299 participants in 36 randomized controlled trials conducted globally, including 16 studies in the United States.¹ The primary outcome was the effect of hormone therapy on sexual function as measured by validated scoring systems. Ten studies included early postmenopausal women with or without menopausal symptoms. The remaining 26 studies included participants with more than 5 years since their last menstrual period regardless of menopausal symptoms; they were considered unselected postmenopausal women. Significant variations in medications, treatment protocols, and questionnaires were used. Approximately one-half of the 36 studies compared estrogen alone to control therapy, most including systemic-dose estrogen in the form of oral, transdermal, or high-dose vaginal. The other half of the studies compared different types of hormone therapy with control treatments (including systemic estrogen combined with progesterone, selective estrogen receptor modulators, or synthetic steroids).

In the subgroup of early postmenopausal women, estrogen alone compared with no intervention slightly improved the sexual function composite score after 12 weeks of treatment (standardized mean difference = 0.50; 95% CI, 0.04 to 0.96; three studies; 699 participants; moderate-quality evidence). The sexual function composite score measured the combined effect of estrogen on sexual function, including desire, arousal, lubrication, orgasm, satisfaction, and pain, with a higher score indicating improved sexual function. Estrogen appeared to positively affect the domains of lubrication, pain, and satisfaction, although these findings are based on two studies and therefore considered low-quality evidence. In the subgroup of unselected postmenopausal women, estrogen alone did not significantly affect the sexual function composite score.

The effect of other types of hormone therapy (including estrogen combined with progesterone, selective estrogen receptor modulators, or synthetic steroids) was uncertain due to limited data. The risk of bias was high for many of the studies included in this meta-analysis because many were supported by the pharmaceutical industry or the manufacturer of the studied drug. Adverse effects were not evaluated in this review; however, systemic estrogen therapy may have been associated with breast soreness, and in a small subset of women at high risk, it may have been related to an increased risk of venous thromboembolism and breast cancer.³

There is insufficient evidence to routinely recommend the use of systemic hormone therapy for the treatment of postmenopausal sexual dysfunction. Low-dose systemic hormone therapy can be considered as an alternative for women with dyspareunia due to genitourinary syndrome of menopause and vasomotor symptoms of menopause. The American College of Obstetricians and Gynecologists and the North American Menopause Society recommend low-dose vaginal estrogen for the treatment of female sexual dysfunction due to genitourinary syndrome of menopause.^4,5 Other treatment options include ospemifene (Osphena) or intravaginal prasterone (Intrarosa) for dyspareunia associated with menopause or short-term use of transdermal testosterone for postmenopausal women with sexual interest and arousal disorders. Clinicians should engage in shared decision-making about the risks and benefits of systemic hormone therapy with their patients before initiating treatment.

The practice recommendations in this activity are available at https://www.cochrane.org/CD009672.