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Comment and Controversy

What to do for postmenopausal dyspareunia

July 2009 · Vol. 21, No. 07
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Dr. Alan Altman’s article on postmenopausal dyspareunia was informative but short on suggestions.

Estrogen-deficient dyspareunia may be present long before the woman enters menopause. The perineum loses its glistening pink-grayness and turns orangey and dryish.

My suggestions, derived from over three decades of practice, are:

  • Tell the patient that TLC (i.e., foreplay) is essential.
  • Consider systemic estrogen, i.e., estradiol 1 mg orally or by injection, if it isn’t contraindicated.
  • Regarding local treatment, remember that lubricants alone do not foster growth of estrogen-dependent epithelium. To make your own local estrogen cream, add estradiol cypionate to the lubricant of your choice.
  • Two patients wanted to try sildenafil for low libido, but reported that although the clitoris got warm and the vagina got “juicier,” the drug did not enhance their libido. Consider esterified estrogens and methyltestosterone (Estratest) or a small dose (e.g., 0.3 cc) of intramuscular testosterone cypionate. Be sure to use the smallest dose possible.

Not all estrogens are alike. Premarin may be suitable for postmenopausal mares. I prefer to prescribe estradiol because that’s what the ovaries produce. It can be used as tablets, cream, patch, or injectable.

Yasuo Ishida, MD
St. Louis, Mo

Dr. Altman responds:

When using systemic estradiol, I prefer the nonoral route via patch, gel, ring, or mist, and I tend to avoid both oral and injectable formulations. I would add that oral micronized progesterone does not diminish vaginal blood flow as medroxyprogesterone acetate has been shown to do.

Sildenafil may have a beneficial effect on patients who have arousal disorders, as shown in the literature describing use of testosterone “gates,” but is unlikely to have any direct effect on low libido.

In my teaching, I recommend using estrogen first for low libido, prior to any testosterone. Once vaginal dryness and dyspareunia are corrected, the libido often resurfaces, thanks to freedom from discomfort and pain and the return of pleasure.

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