How can a lack of sex drive be addressed in a patient on hormone replacement therapy (HRT) with estradiol and progesterone following a hysterectomy?

Addressing Low Sex Drive in a Post-Hysterectomy Patient on HRT

Testosterone supplementation should be considered for Shona to address her lack of sex drive while continuing her current estrogen and progesterone HRT regimen following hysterectomy. 1, 2

Assessment of Sexual Dysfunction

• Sexual dysfunction, particularly low desire, is common in women following hysterectomy and is often multifactorial in nature 1
• Screening should include assessment of specific sexual concerns, relationship factors, and psychological factors that may be contributing to the lack of sex drive 1
• A thorough evaluation should determine if the issue is primarily related to:
  • Hormonal factors (inadequate estrogen or testosterone levels)
  • Physical discomfort during intercourse
  • Psychological factors (body image, depression, anxiety)
  • Relationship issues 1

Hormonal Considerations

• Following hysterectomy, hormone replacement therapy with estrogen alone (without progesterone) is typically sufficient since there is no uterus requiring protection from endometrial hyperplasia 1
• However, if Shona is currently on both estradiol and progesterone without issues, there is no immediate need to discontinue the progesterone 1
• Low testosterone levels may be a significant contributor to decreased libido in post-hysterectomy patients 1, 2
• Testosterone plays an excitatory role in female sexual desire, while serotonin, prolactin, and opioids play inhibitory roles 3

Treatment Options

First-line Approaches:

• Testosterone therapy: Consider adding testosterone supplementation to her current HRT regimen

  • Exogenous testosterone has demonstrated efficacy in treating loss of desire in postmenopausal women 4
  • Supraphysiological levels of testosterone combined with estrogen therapy have shown the most benefit for increasing sexual desire 2
  • Patients should be counseled that testosterone is not FDA-approved for this purpose and has limited long-term safety data 4

• Optimize current HRT: Ensure estrogen dosage is adequate

  • Estrogen-only therapies that produce periovulatory levels of circulating estradiol increase sexual desire in postmenopausal women 2
  • Consider transdermal estradiol if not already using this route, as it provides more stable hormone levels 1

Second-line Approaches:

• Bupropion: Consider off-label use if testosterone is contraindicated or ineffective

  • Has been shown to improve desire in some women with and without depression 4
  • May be particularly helpful if concurrent depression is present

• Flibanserin: FDA-approved for premenopausal women with hypoactive sexual desire disorder

  • Limited data in postmenopausal women, but may be considered 1
  • Results in approximately one additional satisfying sexual event every two months 1

• Bremelanotide: FDA-approved for premenopausal women with low sexual desire

  • Not extensively studied in cancer survivors or post-hysterectomy patients, but may be an option 1

Non-Pharmacological Interventions

• Sexual counseling: Referral to a sex therapist or counselor with expertise in post-hysterectomy sexual issues 1
• Education: Provide information about normal changes in sexual function following hysterectomy 1
• Vaginal moisturizers and lubricants: If vaginal dryness is contributing to discomfort 1
• Pelvic floor physical therapy: May help with any pain or discomfort during intercourse 1

Important Considerations

• Sexual activity itself may help increase testosterone levels naturally, creating a positive feedback loop 5
• Psychosexual issues are common after gynecological procedures and may persist even after successful hormonal treatment 1
• If vaginal dryness is contributing to discomfort during intercourse, vaginal moisturizers and lubricants should be recommended 1

Monitoring and Follow-up

• Schedule follow-up in 3 months to assess response to treatment 1
• Monitor for side effects of testosterone therapy, including acne, hirsutism, voice changes, and lipid profile changes 2
• If testosterone is prescribed, regular monitoring of serum testosterone levels is recommended to maintain within therapeutic range 2

Potential Pitfalls

• Avoid assuming that estrogen alone will address sexual desire issues; testosterone often plays a crucial role in female sexual desire 2
• Be aware that psychosocial factors may be as important as hormonal factors in addressing sexual dysfunction 1, 3
• Do not overlook the possibility that current medications may be contributing to low libido 4