Research from the Yale Midlife Study showed that leading up to and around the menopause 77% of women reported a loss of libido, 58% experienced vaginal dryness and 39% painful intercourse. Loss of libido is even more common than hot flushes for women in the menopause and many women also have either loss of sensation or physical pain due to vaginal dryness which further contributes to a lack of sex drive. Is this just ‘what happens’ or is there something you can do about it?
There are three main natural therapies that claim relief in two out of three women suffering from these kind of issues. These are (1) natural or bio-identical hormone therapy, (2) the use of medicinal herbs, including Chinese herbal medicine, and (3) nutrition-based strategies.
To research this area I interviewed three experts: Dr Trevor Wing, who specialises in Chinese herbal medicine, Dr Marilyn Glenville PhD, whose approach in primarily herbal and nutritional, and Dr Marion Gluck who specialises in treatment involving bio-identical hormones. All, however, do support their unique and personalised therapies with nutrition and psychological support.
Before looking at their treatments and results it is good to understand what causes these problems. All agree that drop offs in hormones trigger these symptoms. ‘With menopause-related ovarian function decline comes less oestrogen, and much less progesterone. Also, testosterone declines. That leaves only the adrenal glands to provide androgenic (eg testosterone) hormones, and if a person has adrenal fatigue then they will feel tired and low. Women who have had a total hysterectomy are going to have even lower hormone levels.’ Says Glenville. Studies show that testosterone levels often start declining in women from their 30’s.
‘Women start off with less muscle mass than men so any further muscle loss, and conversely, gain in fat makes matters worse. The body tends to lay down more fat post menopause to compensate, since fat cells produce oestrogen.’ she says. According to Dr Wing ‘The ovaries produce oestradiol and once this falls off the muscle’s production of estrone is especially important. If a woman is losing muscle and gaining fat, which ‘soaks up’ circulating hormones that make matters worse.’
According to Dr Gluck ‘The main driver of loss of sensation is low testosterone. The vulva and clitoris contain testosterone receptors and atrophy without enough. The first issue that must be corrected is vaginal dryness because this makes sex painful which is really a turn off.’
All agree, however, that there’s a lot more going on than simply hormonal changes. Gluck points out that ‘All of this can have a profound psychological effect. It is vital that a woman gets to feel they have their sexual body back. Loss of the sense of a woman’s femininity is associated with a decline oestrogen levels. Although lack of hormones has a lot to do with the physiology this is a multifactorial issue involving psychological and lifestyle factors, as well as correcting physiology by balancing hormones. The most important thing is that a woman feels good about herself. Sex drive is mainly in the head. If you are having good sex you look forward to it. If you are not you forget about it.”
Glenville agrees ‘Psychological and emotional aspects are very important in relation to loss of libido, including body image and depression. Of course, if sex becomes more painful a woman can easily become averse to it. Also changes in relationships around that time, for example the children leaving home, are important to consider.’ ‘female sexual dysfunction has to be approached holistically’ says Dr Wing ‘because there are both big physiological and chemical changes going on, and a big psychological adjustment as well. Many women experience a loss of confidence and all this can put a strain on relationships.’
A role for bio-identical hormones?
So, what can you do to help minimize the physiological changes that feed into psychological issues?
Here, our experts disagree on when and whether to use bio-identical hormone replacement. Dr Wing uses them as a last resort ‘in perhaps 5% of my patients. I prefer bio-identical hormones because they have less downsides and are just as, if not more effective’ he says. Marilyn Glenville is opposed to their use except as a last resort. ‘Except for a woman who experiences a premature menopause which happens before the age of 40. I don’t think that women who go through the menopause at the usual age should use HRT in any form because it is trying to replace hormones that are naturally declining, and there is a very definite risk of breast cancer. But with a premature menopause the woman is replacing those hormones that her body should be producing but for whatever reasons is not, so using HRT is different for her.’ Dr Gluck, on the other hand, considers them essential.
All agreed, however, that localized bio-identical creams can be extremely effective for vaginal dryness. ‘Despite all the right nutrients and herbs some women with severe vaginal dryness do need topical oestrogen pessaries or creams. I favour those with more oestriol than oestradiol, which is the more potent and hence the more risky oestrogen. I also recommend natural lubricants to use first of all as some women then find they don’t need the vaginal oestrogen.’says Glenville. Dr Gluck finds ‘the combination of oestrogens (she prescribes a balance of oestradial and estriol), plus progesterone and testosterone works wonders and sorts out dryness. Vagifem is a prescribable vaginal tablet that dissolves locally giving bio-identical oestradiol.’ She also gives testosterone cream applied locally to those with a loss of sensation, once a day. It actually reverses atrophy.” A study involving over 800 women given testosterone (150 or 300mcg a day) or placebo showed increased desire, less distress and more satisfying sexual experiences in those taking either the higher or lower amount of testosterone. The results were described as ‘modest but meaningful’. 1
More controversial is the use of bio-identical hormones as the mainstay of treatment. According to Gluck the key is getting the balance right for the individual. She uses both blood tests, which include all the hormones, but also measure SHGB (sex hormone binding globulin) and ‘free’ hormones to work out available hormones, but also relies substantially on symptoms. Dr Wing also believes in testing ‘I like to work with hormone blood tests. Progesterone, oestrogens and testosterone are all involved, as are the adrenal hormones DHEA and cortisol. I test them all. I’m not a great fan of saliva tests. They can be unreliable. The biggest issue is usually progesterone deficiency.’ Gluck points out that she never gives oestrogens without progesterone to avoid oestrogen dominance. We usually give progesterone as a skin cream or a lozenge which dissolves and absorbs in the mouth.”
The problem is that the ovaries produce all these hormones and once the ovarian production declines only fat cells produce estrones. This form of oestrogen cannot be turned into estradiol. So a woman whose ovaries have gone into decline is functionally deficient in oestradiol, progesterone and testosterone. Too much estrone, unopposed by progesterone, encourages breast cancer cell growth. A woman who is overweight and thus has more fat cells, is also usually overproducing insulin due to insulin resistance, and that’s another cancer growth hormone you don’t want too much of.
Dr Wing also prefers bio-identical hormones ‘because they have less downsides and are just as, if not more effective. While oestradiol is the most potent oestrogen in this regard, I always give it with progesterone, which, for many women, works on its own to improve both sex drive and menopausal symptoms. Unopposed oestradiol is not a good idea. Although there is a drop off in testosterone with age I still find that progesterone is the more powerful hormone. It also acts as an androgen and the body can make testosterone from it. I usually have women cycling these hormones, with 14 days on and off.’
One of the main resistances to the use of hormones, bio-identical or synthetic, is the risk of harm of side-effects, becoming dependent on them, or just the concept that it is natural for hormonal levels to decline and thus it is unnatural to supplement them.
One concern is whether starting on hormones means you’ll never get off them. Giving thyroxine, for example, tends to suppress the body’s own production so you need more and more of the exogenous hormone. “This is not the same for ovarian hormones.” Says Marion. “If the ovaries are no longer producing enough you are deficient. “Unlike vitamins, where you may initially need a higher dose to correct a deficiency, the lower the dose for maintenance, if you are low in a hormone you just need enough to correct the deficiency. More often than not I start with a lower dose them build up to the level that works. Women learn what works and adjust accordingly, sometimes not having them every day when they have become largely symptom free. You can, however, get a withdrawal effect is you stop all hormones completely.” It seems to be a matter of educated trial and error to find the right dose and combination.” She estimates that more than half of the women trying this approach regain their libido and sexual enjoyment.
Glenville has a different point of view ‘I don’t think that women who go through the menopause at the usual age should use HRT in any form because it is trying to replace hormones that are naturally declining, and there is a very definite risk of breast cancer. It is interesting to note that, since 2003 in the US, HRT has been re-named Hormone Therapy (HT) omitting the word ‘replacement’ which suggests that the drugs are risk free, which they definitely are not. It has been acknowledged that HRT does not replace hormones that should be there at that time in a woman’s life. There is a reason why the hormones are on the decline and it is not as straightforward as simply replacing like for like. We are implying that Nature has got it wrong. And the big question, especially with bioidentical hormones, is how long does a woman stay on them for, when does she stop?’
Even if you take bio-identical hormones, you cannot be absolutely certain there is no risk because long-term studies haven’t been done. However, there is evidence that combining oestrogen with progesterone is considerably safer than the synthetic progestin– oestrogen combination. Inevitably, randomised trials haven’t been done, but there is a very interesting natural experiment underway in France where both progestins and progesterone are widely used, because some women prefer one and some the other.
Researchers have followed over 80,000 women to see what happens to those in each group, and the result was a convincing win for progesterone, which caused no increase in cancer. Those getting the progestin combination, however, had their risk raised by 69 per cent. Taking oestrogen alone raised the risk by 29 per cent.2 The oral progesterone used in France, is now licensed in the UK for treating the menopause – called Utrogestan. Doctors can also prescribe Pro-juven, a transdermal progesterone cream, as an unlicensed medicine.
There is some fear around testosterone having side effects. I asked Dr Gluck about this: “I have never seen a significant side effect from testosterone. Occasionally, if the dose is to high a woman can feel more irritable or aggressive. Rarely, I have heard of cases of greater hair loss. I’ve never had a patient getting acne, for example. But these are just indications that the dose is wrong. Testosterone is in and out of the body in eight hours so you just lower the dose.” While testosterone can be made in the body from progesterone she prefers to give testosterone. “If you rely on progesterone only you never know how much the body will make. Overall, testosterone is an uplifting hormone. It gives you your drive back. I often give a little DHEA as well, from which the body can also make its own.”
Exercise and weight control is important
Therefore, losing weight is very important, as is exercising. A lack of testosterone accelerates loss of muscle and without muscle you can’t burn fat. So both resistance (muscle building) and aerobic exercise is called for.
While alcohol is a great depressor of testosterone in men Gluck says that many women she treats finds that they can no longer tolerate much alcohol so may not be in excess. According to Glenville ‘Women start off with less muscle mass than men so any further muscle loss, and conversely, gain in fat makes matters worse. The body tends to lay down more fat post menopause to compensate, since fat cells produce oestrogen. Exercise, especially resistance training, is associated with increased testosterone and also serves to stimulate metabolic rate, all of which helps to counteract weight gain.’
Support adrenal function
A stressed out lifestyle with too much caffeine, alcohol and stress, or drug use, is going to take its toll so it is important to build up a woman’s overall health and adrenal function, which is linked to low levels of testosterone and progesterone, as is excess alcohol. Glenville recommends vitamin C and B vitamins, plus Siberian ginseng. Both damiana and maca can help to give a boost to energy and sex drive. Dr Wing’s favourite herb for supporting adrenal function is Ginseng. But, as with all herbs and supplements, you have to have good quality and the right dose, he says.
Phytoestrogens and soya
Glenville also recommends phytoestrogen supplements. ‘Phytoeostrogens have had a bad press because people don’t understand that they are regulators – both agonists and antagonists in much the same way the currently in vogue SERM drugs (Selective Estrogen Receptor Modulators) are. They stimulate oestrogen receptors where needed, and have a blocking effect on receptors in the breast and womb. This because they stimulate the beta-receptors, but not the alpha- receptors which stimulate growth. This is why phytoestrogenic foods, such as soy and other beans, can have a protective effect against breast cancer.’ Most hormonal health experts do recommend supplementing phytoestrogens, either derived from soya or red clover, as part of an overall strategy.
Her two most effective herbs are black cohosh and agnus castus which stimulates receptors in the pituitary gland. Wing points out that most western oriented practitioners tend to rely on single herbs such as black cohosh and agnus castus but he finds the personalized Chinese herbs are more effective.
Of course, testing individualized chinese medical herb preparations doesn’t lend itself to double-blind trials which are, in any event, expensive. I asked Wing for any studies to support chinese herbs. One showed that the particular formula was 29% more effective than placebo, while HRT was 50% more effective, in reducing hot flushes.3 Another showed no difference to placebo.4 However, a wide variety of Chinese herbs have been shown to have oestrogenic activity which would explains their effect.5
However, just because a substance is a herb doesn’t mean there are no risks. A study exposing breast cancer cells to various herbs found that dong quai and ginseng promoted growth, while black cohosh and licorice did not.6
Black cohosh may also have the potential for generating liver problems and is best given and taken under the guidance of a suitably qualified practitioner.
Optimum Nutrition is the first step
All the experts I interviewed agree that getting a person’s nutrition optimal is the first step. According to Glenville there are key nutrients such as zinc, selenium, the omega 3s plus vitamins that are essential for supporting hormonal balance. Vitamin C and B vitamins are vital for adrenal function and the body’s production of hormones. A low GL diet keeps insulin levels in check, as well as weight. Alcohol and stimulants are best kept to a minimum, especially in those with signs of adrenal burn out.
Whether you choose to try herbs or bio-identical hormones it is best to get tested first and guided by an expert who can assess your individual needs.
Dr Trevor Wing practises near Richmond.
Marion Gluck is one of a number of doctors using bio-identical hormones in London who can prescribe individually formulated combinations of bio-identical hormones from the compounding pharmacist. There is a list of doctors in the UK who prescribe at www.specialist-pharmacy.com/doctors
At the Marion Gluck Clinic at 61 Wimpole Street, London W1 (Tel: 0207 402 2151) Dr Jan Toledano specializes in sexual health.
Also read my book Balance Your Hormones and take a look at Female Balance which I designed for menstural and menopausal women, and is on offer in June.
1 Davis S et al., ‘Testosterone for libido in postmenopausal women’, New England Journal of Medicine, 2008, 359(19):2005-17
2 Fournier A, et al., ‘Unequal risks for breast cancer associated with different hormonereplacement therapies: results from the E3N cohort study’, Breast Cancer Res Treat,2008;107(1):103–11
3 Kwee SH et al., ‘The effect of Chinese herbal medicines (CHM) on menopausalsymptoms compared to hormone replacement therapy (HRT) andplacebo’, Maturitas, Volume 58, Issue 1, 20 September 2007, Pages 83–90
4 Davis SR et al., ‘The effects of Chinese medicinal herbs on postmenopausal vasomotor symptoms of Australian women’, Med J Aust, 2001; 174 (2): 68-71
5 Zhanga CZ et al., ‘In vitro estrogenic activities of Chinese medicinal plants traditionally used for the management of menopausal symptoms’, J Ethnopharmacol, 2005 Apr 26;98(3):295-300
6 Amato P et al., ‘Estrogenic activity of herbs commonly used as remedies for menopausal symptoms’, Menopause, 2002 Mar-Apr;9(2):145-50