Commentary: Female sexual dysfunction is a real but complex problemBMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c5336 (Published 30 September 2010) Cite this as: BMJ 2010;341:c5336
All rapid responses
Granted that this is a difficult problem, there is no need to
complicate it more than necessary. An inquiry about sexual health should
be part of routine history-taking in all post-menopausal women, a
significant proportion of whom will complain of some sexual difficulty. In
some, this may be due to dyspareunia, often with dysuria, which may be
correctable with vaginal oestrogen. However, in others there is a primary
loss of libido, often dating from menopause and frequently associated with
low serum androgens, notably DHEAS and testosterone.
It is still not sufficiently widely appreciated that post-menopausal
women depend on their adrenals for their androgens and oestrogens.
Although there may still be some testosterone produced by the ovaries of
postmenopausal women(1), adrenal DHEAS is probably the main source of
their testosterone which falls with age in parallel with the fall in DHEA.
Loss of libido in post-menopausal women is frequently associated with very
low serum androgens, comparable to those seen in patients with Addison's
Disease in whom low libido is known to respond to DHEA 50 mg daily (2). It
has been my practice to use the same treatment in non-Addisonian post
menopausal women who give a convincing history of loss of libido, are in a
stable relationship and have serum DHEAS below 2 mu mol/L and testosterone
below 1 nmol/L (or undetectable). Since DHEA is not registered in
Australia, I have done this on the written authority of the Australian
Therapeutic Goods Administration with frequent success. In my first 14
patients meeting these criteria who completed 12 months' treatment, the
serum DHEAS rose from 0.94 (sd 0.68) to 7.39 (3.36) mu mol/L and the
testosterone from 0.38 (0.27) to 2.46 (0.92) nmol/L (both P < .001).
Apart from occasional acne, the only convincing side effect in over 50
patients was in one who developed exacerbation of arthritic back pain
which resolved on stopping the treatment.
The negative outcomes with DHEA reported in a recent review (3) are
probably attributable to poor selection of cases and failure to wait long
enough to see the effect. I must repeat that there needs to be a
convincing history of reduced libido associated with unequivocally low
androgens and that it may be 6-8 weeks before the treatment takes effect
due to the large size of the DHEAS pool into which the DHEA is diluted.
Most of the patients need vaginal oestrogen as well but vaginal oestrogen
alone is not effective.
One reason why this physiological treatment has not been more widely
adopted may be that DHEA, like Calcium and Vitamin D, cannot be patented
and is too cheap to interest the pharmaceutical industry.
AO, MD, FRACP, DSC
Emeritus Consultant in Endocrinology
Director, Endocrine Bone Densitometry Service
Royal Adelaide Hospital,
Adelaide, South Australia
1. Fogle R, Stanczyk F, Zhang X, Paulson R. Ovarian androgen production in
postmenpausal women. J. Clin. Endocrinol. Metab. 2007 92:3040-3043
2. Arlt W, Callies F, Van Vlijmen J, et al. Dehydroepiandrosterone
replacement in women with adrenal insufficiency. N.E.J.M. 1999 341:1013-
3. Panjari M, Davis, S R. DHEA therapy for women: Effect on sexual
function and wellbeing. Hum Reprod Update 2007 13:239-248.
Competing interests: No competing interests
Female sexual dysfunction is common among many women, and as they cannot discuss the problem with anybody, not even their close friends or family
doctors, special counseling is required. It is better that the partner
should bring it out to medical personnel, either a psychologist or
psychiatrist. Then only is it possible to solve the problem. The reasons
are variable from couple to couple.
Competing interests: sexual disfunction