In short
Treatment order matters more than treatment choice. Three principles run through everything here.
- Treat pain first. In a woman with painful sex after menopause and low desire, the pain is treated first and the desire is then reassessed. It often resolves.
- Non drug treatment comes first. Every drug treatment for female sexual dysfunction except those for vaginal atrophy has limited efficacy and real side effects.
- Sex therapy before medication. 65 per cent of 365 couples described sex therapy as successful.
Treatment Overview
Why is order the main principle?
Because improving one problem frequently improves another. Successfully treating sexual pain often improves interest, arousal and orgasm at the same time.
So in a woman with painful sex after menopause who also reports low desire, the genitourinary syndrome of menopause is treated first, and the desire is reassessed afterwards. Treating both at once makes it impossible to know what worked.
What treats the pain?
Local oestrogen, where the cause is menopausal tissue change. It is used in low dose vaginally rather than systemically when the symptoms are genital only, and it can be continued indefinitely, including after systemic hormone therapy has stopped.
Where the cause is pelvic floor hypertonus, the treatment is different again. Instruction in the use of vaginal dilators is highly effective for most cases of provoked pelvic floor hypertonus and painful sex, and that is delivered by a therapist rather than by a prescription.
Why does the route of systemic oestrogen matter?
| Oral oestrogen | Raises sex hormone binding globulin, which lowers free testosterone |
| Transdermal oestrogen | At normal doses, does not affect the binding protein and has minimal effect on free testosterone |
| The evidence | In recently menopausal women, transdermal oestradiol improved the overall sexual function score against placebo, while oral did not |
Which is why transdermal is advised for a menopausal woman with sexual concerns starting oestrogen therapy.
What comes before medication?
- Treating the associated conditions. Treating arthritis pain, urinary incontinence or anaemia can improve sexual interest and response on its own
- Adjusting medication. Low desire or difficulty with orgasm on an SSRI can sometimes be eliminated by switching antidepressant
- Sex therapy or couples counselling. Considered a prerequisite to a trial of drug treatment for most women, given how safe and how effective it is
- Treating the partner’s problem, where there is one
What about testosterone for women, honestly?
Randomised trials in over 1500 menopausal women with distressing low desire and no other cause found a testosterone patch increased satisfying sexual activity, desire and arousal against placebo.
The size of that effect was about one extra satisfying sexual event in four weeks. Two manufacturer trials of a testosterone gel found no significant effect at all, despite achieving similar blood levels. Compounded testosterone creams and gels are not used, since their dosing is unreliable.
How is progress measured?
Against your goals, set before treatment starts, rather than against a hormone level or a general impression. That also allows expectations to be set honestly at the outset, because most sexual problems have no quick fix and there is usually a period of trial and error.
Who Is a Good Candidate?
- Sex has become painful or dry, which is the most treatable of the four problems
- Desire, arousal or orgasm changed at an identifiable point
- You are on oral oestrogen and sexual function has not improved
- You started an antidepressant and sexual function changed afterwards
- You have another condition, such as incontinence, anaemia or joint pain, that may be contributing
- Bleeding after sex, or any bleeding after the menopause, which needs assessment first
- A new lump, ulcer or skin change on the vulva
- Any sexual activity you feel pressured into, or a history of abuse, which deserves proper support rather than a treatment plan
What Happens During the Consultation
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1
The full picture, before any treatment
Most women with a sexual concern have issues affecting more than one aspect. A complaint of low desire often turns out to include arousal problems or pain, and treating the wrong one first wastes months.
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2
Your goals, stated before treatment starts
Progress is measured against what you actually want, not against a score or a hormone level. This is also where expectations are set honestly, including that improvement usually takes trial and error.
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3
The treatable contributors
Medication, particularly SSRIs. Other conditions such as incontinence, anaemia or joint pain. Thyroid and prolactin where indicated. And the partner's sexual function, where there is a partner.
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4
Sequence, agreed together
Pain first, then reassess. Non drug options before drug ones. Referral to a sex therapist, couples counsellor or pelvic floor physiotherapist arranged where that is the right treatment rather than a fallback.
Program Structure & Follow-Up
What follow up looks like
It depends entirely on what was treated first, which is the point of getting the sequence right.
If pain was treated first
- Local oestrogen reviewed at six to eight weeks for symptom improvement
- Desire and arousal formally reassessed after the pain has settled, not before
- Local oestrogen can be continued indefinitely if it is helping
If a medication was changed
- Reviewed at four to six weeks, both for sexual function and for the condition the drug was treating
- The mood disorder is not left untreated to solve the sexual problem
If referral was made
Sex therapy and couples counselling take time and often involve specific exercises between sessions. Progress is reviewed against your goals rather than at a fixed interval.
Who else is involved
With your consent, treatment is coordinated with anyone else looking after you, such as a gynaecologist, oncologist or psychiatrist. Referrals to a sex therapist, psychotherapist or pelvic floor physiotherapist are often part of the plan rather than a sign it has failed.
Benefits, Limits & Safety
What works best
The interventions with the strongest track record are not drugs.
- Sex therapy. 65 per cent of 365 couples treated for a range of sexual dysfunctions described the treatment as successful
- Vaginal dilator instruction, highly effective for most cases of provoked pelvic floor hypertonus and painful sex
- Local oestrogen for genitourinary syndrome of menopause
- Sensate focus exercises, which shift the goal away from intercourse and orgasm
The honest limits of drug treatment
Every currently available drug treatment for female sexual dysfunction, other than the approved treatments for vaginal atrophy, has limited efficacy and comes with side effects and potential risks.
That is why drug treatment is reserved for women who meet the criteria for a sexual disorder and for whom non drug options have not worked, rather than being the opening move.
Why the evidence base is weaker than it should be
- Studies use different measures, so results cannot easily be compared
- Event logs count satisfying encounters but do not capture interest or distress
- Most conditions affect more than one aspect of sexuality, and most treatments do too, so isolating an effect is difficult
The most useful thing to hear
Where you are content with your own level of interest but distressed by a mismatch with a partner, that is a relationship problem rather than your sexual problem, and it is often effectively managed by couples counselling and sex therapy.
What is not offered
Compounded testosterone creams, ointments and gels, saliva hormone testing, systemic DHEA in women without adrenal insufficiency, and drug treatment before non drug options have had a fair trial.
What works
Sex therapy, described as successful by 65 per cent of 365 couples. Local oestrogen for pain. Dilator instruction for pelvic floor hypertonus.
Progress measured against your goals
Set before treatment starts, rather than against a hormone level. Pain reviewed at six to eight weeks, medication changes at four to six.
Not offered
Compounded testosterone preparations, saliva hormone testing, systemic DHEA without adrenal insufficiency, and drug treatment before non drug options have been tried.
Cost & Program Investment
The consultation is quoted individually and any tests are quoted before they are ordered. Local oestrogen and other prescriptions are ordinary medicines at pharmacy prices. Referral to a sex therapist, couples counsellor or pelvic floor physiotherapist is a normal part of the plan rather than an admission of failure, and where it is the right treatment it is arranged and its cost explained before you commit.
Frequently Asked Questions
With pain, if there is any. Treating sexual pain often improves interest, arousal and orgasm at the same time, so the pain is treated first and the desire reassessed afterwards.
No, if the symptoms are genital only. Low dose vaginal oestrogen treats it locally and can be continued indefinitely, including after systemic hormone therapy has stopped.
Patch or gel, where sexual concerns are part of the reason. Oral oestrogen raises the binding protein and lowers free testosterone, and in one trial transdermal improved sexual function while oral did not.
There are drug options, but all of them, other than treatments for vaginal atrophy, have limited efficacy and carry side effects. They are reserved for women who meet the criteria for a disorder and for whom non drug approaches have not worked.
Because it works and it is safe. 65 per cent of couples in one study described sex therapy as successful, and consultation with a sex therapist is generally considered a prerequisite before trying drug treatment.
Not necessarily. If you are content with your own level of interest and the distress comes from the mismatch, that is a relationship issue rather than a sexual dysfunction, and couples counselling manages it effectively.
Not routinely. Trials in menopausal women with distressing low desire showed a real but small effect, about one additional satisfying event in four weeks, and gel trials found no effect. Compounded testosterone preparations are not used at all.
Evidence
Where this information comes from
Every figure on this page is taken from the sources below. All of them are free to read, so you can check them yourself.
This page is general medical information and does not replace a personal consultation. Trial results are averages across large groups, not a prediction for any one person.