Sexuality and surgical menopause

This is, perhaps more than any other topic to do with surgical menopause, a great worry for women and it is correspondingly fraught with misinformation, myths, sales pitches, and wishful thinking. As with many things to do with our hormones, women come here hoping to find simple answers, a magic remedy to restore things as they once were (or, at least, as we wish they had been), and instead find that it is considerably more complicated than that. We're sorry to have to burst that bubble right here at the top, but if simplistic answers are what you are looking for, you will not find that here.

What we're going to do here, then, is talk through some of the things that are important to libido and sexual response, and then look at how we can work our way through those things to develop our own answers to the question of how we can each restore and maintain libido after our surgeries.

Anatomy


The first requirement for sexual arousal and response is having the actual anatomical structures that are necessary to experience them. That maybe sounds overly simplistic, but bear with us: we've had surgery and surgery in real life is not as clear and straightforward as those little graphics in that pamphlet your doctor gave you.
 
In a real belly, things are crowded together. There may be scarring from whatever previous abdominal procedures we might have had, or from the problems that led us to choose a hysterectomy. And not everyone is exactly identical. Most of us have most of the same things in fairly much the same places, but it's not exact: this woman's nerve may be right here while another's is slightly over there.

Further, not every surgeon is equally skilled, especially when it comes to vaginal or laparoscopic procedures where access is trickier or where there is a great deal of scarring or other complexity to be sifted through. While they may do a fine job of identifying what they came for, the major organs to be removed, they may be less skilled at identifying and leaving intact those things that are not to be removed.

And, finally, not every surgeon feels that surgically menopaused women should have their sexuality preserved. Whether they see it as a personal crusade to help reduce the moral affront of non-reproductive women enjoying sex or whether they genuinely believe they are saving us from the indignity of having what they view as shameful feelings, they may make a decision for us that reflects their own values, without consulting us, and accordingly be less than scrupulous about preserving those nerves and other structures required for sexual response.

For most women reading this, it may be too late to do anything about their anatomical integrity. Certainly if you are still in the preoperative planning stage and reading this, you should discuss preserving needed sexual structures with your surgeon, frankly and fully, to be sure that you feel confident that your surgeon will follow your wishes in this regard. If he does not seem willing to do so, well, there are many other surgeons in the world.

What if you are postop, though, and wondering about this? This is not the first thing to work on because, let us hasten to assure you, this is not a common outcome of a hysterectomy. It is more likely to be so for a more complex surgery that affects more than "just" removing the uterus (say, extensive endo with heavy scarring, or a radical hyst). It's probably not the first thing on the troubleshooting list. But it is a possibility that will ultimately need to be considered if hormonal balance measures are ineffective. It's an aspect that many people skip right over, but since it's a make-or-break part of the whole situation, we have to keep it in mind even when we turn our efforts to the more common situations first.

Systemic estrogen


So if the anatomy provides for the basic mechanical equipment for sexuality, it's estrogen that powers it.

Surprised? Thinking that we were going to jump right ahead to testosterone? Nope. That's the single most common error in troubleshooting libido and while we'll get to testosterone eventually, what we're doing here is setting out a hierarchy of needs, each of which builds upon the other in providing for full sexual function. And it's estrogen that really powers full female sexuality.

We rely on estrogen to help things throughout our body function normally. Estrogen is so fundamental to our bodies that even men produce and require some estrogen for normal health. While we no longer require enough estrogen to support fertility once we reach menopause, we do still have other, non-fertile needs that must have estrogen to function. And many of those needs specifically relate back to libido.

You can read elsewhere on this site about how estrogen is needed to support normal brain chemical balance. If our brain's needs for estrogen are not met, we are subject to disturbances of mood and thinking and sensation that probably won't let us relax into feelings of arousal and sexuality. So before we can experience libido, we have to have healthy brains that can feel inclination and completion.

Other areas of our wellbeing are equally important to a background level of comfort that will let us even begin to think about engaging in sex. Women with low estrogen levels often experience crushing fatigue or joint pains, or lack of sleep due to menopausal symptoms may sap their enthusiasm for, well, anything. To try to force sexual interest when we can barely stand to be inside our bodies is going to be a struggle, and that's not what healthy sexuality should be. No matter how much we or our partners want us to resume sexual activity, it shouldn't be a grit-my-teeth-and-carry-on sort of thing.

And estrogen is required for one more aspect of sexuality, and that's feeling like a sexual individual. Whether you call it femininity or desirability or whatever, we need to feel that physicality is desirable. That wholeness of individuality and sensation requires estrogen, and without it, the tenderness and mature sexuality we are looking to regain simply is not there.

But what if you are taking hrt already—isn't that taken care of, then? No. Taking hrt does not mean that you are effectively delivering hormones to your body and that you are delivering the right hormones in the right amounts. HRTs are much more individual than that: every hrt works for some woman, but each woman may find that only a certain few hrts really work well for her. If this concept is new to you because you've started reading this site here, please use our table of contents to explore the rest of the basic hormonal/hrt background we've provided here.

If you are having symptoms of hormone imbalance, then, or if you have unmet hormone needs apparent despite being on hrt, you may not be providing the fundamental underpinnings for sexuality. Just as we must have the physical structures to actually undergo sexual arousal, we must have our basic systemic hormone needs met well enough to desire sex and to feel it. And it is estrogen that provides that hormonal foundation.

Vaginal estrogen


The single most common barrier to full menopausal sexuality is lack of vaginal estrogen. This is where the anatomical structures and our hormones come together, directly at the seat of sexual sensation. Without estrogen here, it's as though the main switch controlling our sexual responsiveness is turned OFF.

Our genitourinary tissues (vagina, bladder, and all their associated nerves, blood vessels, and supporting structures) have a high requirement for estrogen. Without enough estrogen, these tissues lose elasticity, lubrication, sensation, and protective immune response, and they become pale, fragile, thinned and gradually lose function. This situation is called vaginal atrophy and, depending upon the source you read, can affect from 50-75% of all women in menopause, surgical and natural alike.

If you've never heard of vaginal atrophy, don't be surprised: you have plenty of company. Despite this being ridiculously widespread, it's a silent epidemic of deficiency that is ignored by both women and physicians. Why? Because many women are taught to expect that menopause will mean they "dry up down there" and lose sexual interest. They may be embarrassed to raise this subject with their doctor. And their doctor may be equally reluctant to bring up the topic and feel that he's done his job by vaguely inquiring if "everything is alright." While efforts are being made within the health care community to raise awareness of the need to deal with vaginal atrophy, we need to do our part by opening the question with our doctors.

But what if we're already taking hrt? Doesn't that take care of the problem? No, not necessarily. At today's lower doses of hrt, women and their doctors are trying to balance risks and benefits by using just the bare amount that meets a woman's basic systemic hormone needs. That amount, in turn, is very likely not going to be adequate to fully nourish her genitourinary tissues.

The good news about vaginal atrophy is that it is very easily diagnosed by symptoms or visual inspection by your health practitioner. Further, it's easily and very successfully treated with some form of vaginal estrogen supplementation (they all work well, so it's a matter of choosing the method you prefer and can afford).

It takes some weeks to fully reverse the effects of low estrogen on vaginal tissues, depending upon whether you choose a maintenance dose product or a treatment dose product. And it typically requires ongoing low maintenance doses to keep those tissues healthy. But once good health is restored, return of sexual sensation and desire often follow. No matter what else we may do to enhance sexual arousal and response, they are unlikely to work until we have healthy vaginal tissues to experience them. You can read more about vaginal estrogen needs and how to meet them in our discussion of vaginal dryness.

Testosterone


Nothing has greater chic in the hormone world today than testosterone. Estrogen is still on shaky grounds following the massive fear campaign kicked off by superficial interpretations of the results of the Women's Health Initiative Study, despite more recent efforts to provide a more balanced consensus. Progesterone continues to be rejected by many doctors because they fail to understand its uses outside the uterus. But testosterone is in that golden spot enjoyed by estrogen during the middle of the last century, where it is evoked as a magic elixir to cure everything that imbalanced estrogen hrts cannot and not yet overshadowed by any sense of risk (although these risks have been demonstrated by medical research, because they have not been popularized in the media the way estrogen risks have been, they are generally unacknowledged by doctors and women).

Let us state right here that we are not opposed to the use of testosterone and that we are profoundly grateful for pioneering research done on the topic. Just a few decades ago, it wasn't even proven that women produced their own testosterone and that it had a role in female hormone balance. But much of what was written then is overly simplistic in the light of what we know today about hormone needs and risks. Testosterone can be an answer, but it is not, alas, the answer.

Early research showed that women in menopause often had low testosterone levels and when menopausal women were given testosterone supplements, they scored higher on many measures related to sexual function. As more women used testosterone, it was also discovered that many of their lingering complaints about lack of energy and strength, even on estrogen hrts, were resolved. So, magic elixir, right?

No. At the same time, more detailed research was not only pointing out the cardiovascular and cancer risks that testosterone use might involve, but it was also showing that women who were low in estrogen were using their testosterone not to do testosterone work, but as raw material to convert to estrogen. In other words, for women who have not achieved good hormone balance on their estrogen hrts, testosterone is just another source of estrogen and the improvements that they experienced were due to their estrogen needs being more fully met rather than any effect specific to testosterone.

So how does this fit into working on libido loss? The very important lesson we can take from this research is that until we know that our estrogen needs are fully and satisfactorily met, we cannot know whether or not we are going to get any benefit from the addition of testosterone to our hrt.

Yes, we know this flies in the face of what compounding pharmacists, who insist they can fix every single hormone imbalance at once, will tell us and it certainly is not what the pharmaceutical companies who manufacture testosterone products want us to believe. That is, however, why the major professional society of endocrinologists, the doctors who are the specialists on hormones and how they function in the body, have said in their position paper on using hrts, that
Androgen deficiency should be diagnosed only in women with adequate estrogen status.
But wait—does that mean that there is no role for testosterone in treating female libido? What about all those glowing press releases about that new patch and how it helps so many women? The US Food and Drug Administration held off approval of that patch in the US because of concerns about risks, even though it had been approved and for sale for some time in the EU. As of 2014, however, not only has the US FDA rejected the patch licensure application, but Intrinsa, the European patch, is no longer on the market there (although the reasons for the withdrawal have been questioned).

Of course there is a role for testosterone in women: if there were not, we wouldn't produce it ourselves. But don't be swayed by those who want to sell you something: that's really all about them, not you. For all of the women who responded favorably to the tests for that new patch, there were also women who did not. In fact, testosterone supplementation is effective only for a percentage of women, no matter how it's administered.

We need, then, to look at those who didn't respond just as much as those who did. And, based on research and interpretation of our understanding of hormone physiology, it looks clear that the simple answer is that if a woman doesn't need more testosterone, more is not going to help her. Doesn't that sound a lot like what we say about the other hormones? Exactly: with testosterone, as with every other ovarian hormone, we need only enough to meet our needs; anything more only adds to our risks, not our benefits. If we have enough testosterone already (or would have if we weren't using it to make estrogen out of), more isn't going to make it work any better.

In fact, more testosterone not only raises those risks mentioned above but doesn't really provide for the sexuality we're looking for, even though it may increase our urges. Here's how one of our message list members who was working on her libido with testosterone described the difference:
With testosterone, it looks like it addresses one part of the sexual libido thing — genital stimulation and desire for it — but not the desire for intimacy.... I can vouch for this statement from personal experience — for me that sums up how I felt 100%.

Pulling it all together


Yeah, yeah, you may be saying, but how do I use all of this to troubleshoot my libido? Let's look at that now.

Based on documents like that endocrinologists' position paper and the experiences of women like you who have come to our discussion forums to work on these issues for themselves, here's the order of addressing our hormone needs that seems to be the most efficient and likely to work.
  1. Meet systemic estrogen needs. If we are not fully meeting our needs, we don't have the basic foundation to experience sexuality. For women who do not want to or are not able to take hormones, it's important to choose an SSRI (if that's being used in place of hrt) that does not have a libido-suppressing effect. Only once we are at a systemic and brain balance are we ready to work further on restoring libido.
  2. Meet vaginal estrogen needs. If you have dryness or burning or other vaginal symptoms, you may be suffering from low estrogen to that area. Even if you are not, if you are taking systemic hrt you may not be fully nourishing those tissues. So the first step in troubleshooting this aspect of libido is to ask your doctor for an exam (we're talking visual exam—not a painful or especially invasive test) and discussion of vaginal estrogen needs, and raise the question of whether or not you might benefit from some vaginal estrogen. Yes, this may be embarrassing. But many doctors are very willing to discuss this topic with you even if they too are not sure how to open the dialog. So take that first step and you may well find that things are very much easier after that.
         Vaginal estrogen needs are critical to sexual function and are very easy to supplement successfully. For many women, this has been the step that has restored sexual function. Yes, just this simple.
  3. Meet testosterone needs. This comes third on our list because it will be ineffective if the other two needs are not met first. And rather than just launching into trying testosterone, this is where we'll reverse our usual stance that questions the value of hormone level tests: it's a good idea to have our circulating blood levels of free testosterone tested. It's a simple blood test that your doctor can order done by a lab.
         While the normal levels are a range, not an absolute, they will give you some guidance as to whether or not you are near adequate in production. Many women are perfectly capable of meeting their testosterone needs by adrenal output, so it isn't unusual to find that supplementation isn't really needed to reach normal levels once it's not all going to produce estrogen. If we have normal testosterone levels, adding more testosterone is more likely to push us into excess—with its associated significant health risks—than to improve the action of testosterone. So a rule of thumb is that we should test first and only bother with supplementation if we show a demonstrated testosterone shortfall after our estrogen needs are properly met.
         It's also a good idea, because it relates to our cardiovascular risk profile and how testosterone raises those risks, to have our cholesterol and other blood lipids checked when beginning testosterone supplementation. Treatment of elevated levels may be required in order to use testosterone safely, so it's easier to get this additional blood test up front than to find out only after we've had that heart attack.
         We're not going to spell out the different testosterone options and how to use them, since they vary from country to country and to some extent are personal preference. There's more on that on our various testosterone and hrt pages, which you can find in the table of contents.
  4. Consider whether there has been anatomical damage during surgery. This is the last step in the process. If we find that we've got our estrogen needs well met, both systemically and vaginally, and we find that either we don't need more testosterone or that the testosterone we take doesn't make enough difference, then we need to consider whether we have had some sort of damage during surgery that is preventing us from sensing or responding to sexual stimulation. This is a complicated topic, and may require visits to more than one doctor. As a general rule, taking this up with the surgeon who performed our hysterectomy is often not particularly helpful—this doctor may just feel that we're attacking his competence or planning a lawsuit, and he may respond defensively, putting the blame back on us. Since blame has little effective value at this point, that is not an especially satisfying strategy for solving our problem. Instead, many women find workups from specialists on pelvic floor medicine helpful, who may refer them on to neurologists or other surgical specialists depending upon the specific problems identified. It is possible to have some surgical damages corrected, so keeping an open mind going into this process is important: it can take time, but it doesn't mean that you won't ever regain sexual sensation.
So, a long discussion of possibilities and steps, and that's probably not the sort of answer you were hoping for. We'd all like to believe that the magic, whether it's testosterone or some obscure herbal remedy not-available-in-stores, will instantly restore us to the sexual appetites and capabilities of an eager 20-year-old. But in fact, as so many things to do with surgical menopause, it's more complicated than that and there are no universal answers that work for all women. Still, the things we have outlined above can help you work through the possibilities in an orderly fashion that has worked for many women. Whether your own answer is in estrogen or testosterone or in surgical repairs, there probably is a good answer out there for you. It just takes some work and experimentation and careful recording in your meno journal.