From the Guidelines
For vaginal dryness and decreased libido after hysterectomy, a combination approach is recommended, starting with non-hormonal options and considering hormonal therapies as needed, with the goal of improving symptoms while minimizing risks to morbidity, mortality, and quality of life. The most recent and highest quality study, 1, suggests that vaginal estrogen is the most effective treatment for vaginal dryness leading to sexual dysfunction and has been shown to be effective in treating itching, discomfort, and painful intercourse in postmenopausal individuals. Some key considerations for treatment include:
- Starting with a vaginal moisturizer like Replens or K-Y Liquibeads used 2-3 times weekly, along with a water-based lubricant such as K-Y Jelly or Astroglide during sexual activity.
- Considering low-dose vaginal estrogen therapy such as Vagifem tablets (10 mcg estradiol, inserted twice weekly), Estring (a silicone ring replaced every 90 days), or Estrace cream (0.5-1 g applied 2-3 times weekly) if non-hormonal options provide insufficient relief.
- Addressing libido concerns by addressing vaginal dryness, and considering testosterone therapy in some cases, though it's off-label for women.
- The importance of psychological factors, with counseling or sex therapy being beneficial, and regular sexual activity helping to maintain vaginal health. The evidence from 1 also highlights the safety of vaginal estrogen in postmenopausal survivors of hormone receptor-positive breast cancer receiving aromatase inhibitor therapy, with no evidence of a higher risk of breast cancer-specific mortality. Additionally, the study suggests that vaginal androgens, such as DHEA, can be considered for vaginal dryness or pain with sexual activity, but with caution in survivors receiving aromatase inhibitor therapy. Overall, the treatment approach should be individualized, taking into account the patient's specific situation and medical history, and discussing options with a healthcare provider to determine the most appropriate treatment.
From the FDA Drug Label
Treatment of moderate to severe symptoms of vulvar and vaginal atrophy associated with the menopause. When prescribing solely for the treatment of symptoms of vulvar and vaginal atrophy, topical vaginal products should be considered.
The treatment for vaginal dryness and decrease in libido post hysterectomy may be addressed with estradiol (PV), as it is indicated for the treatment of moderate to severe symptoms of vulvar and vaginal atrophy associated with the menopause. However, it is recommended to consider topical vaginal products for this specific condition.
- The lowest effective dose should be used, and medication should be discontinued as promptly as possible.
- Patients should be reevaluated periodically (e.g., 3-month to 6-month intervals) to determine if treatment is still necessary 2. Since the patient has undergone a hysterectomy, the risk of endometrial cancer is not a concern, and progestin is not required 2.
From the Research
Treatment Options for Vaginal Dryness and Decreased Libido Post Hysterectomy
- Estrogen replacement therapy (ERT) has been shown to be effective in improving vaginal dryness and sexual desire in postmenopausal women 3.
- Topical estrogen therapy has been found to be more effective than oral estrogen therapy in improving vaginal dryness and dyspareunia, with significant improvements in vaginal blood flow and sexual function 4.
- The addition of androgen to ERT has been shown to be helpful in women whose sexual difficulties remain unresponsive to ERT alone 3.
- Transdermal estrogen regimens have been found to be safe and effective in improving vaginal health and reducing symptoms such as pain, vaginal fetid discharge, and swelling after vaginal hysterectomy 5.
Benefits and Safety of Estrogen Therapy
- Estrogen therapy has been shown to improve vaginal health and sexual functioning in postmenopausal women, with significant reductions in vaginal dryness, dyspareunia, and vaginal bleeding associated with sexual activity 6.
- Local vaginal therapy with estrogen creams, rings, or tablets may be more appropriate for women without other indications for systemic estrogen therapy, as it is highly effective in reversing vaginal atrophy and improving vaginal symptomatology 6.
- Emerging treatments, such as ultra-low-dose vaginal estradiol tablets, new selective estrogen receptor modulators (SERMs), and intravaginal dehydroepiandrosterone (DHEA), are promising options for postmenopausal women with vaginal atrophy and sexual dysfunction 6.
Sexual Functioning After Hysterectomy
- A prospective study found that sexual functioning improved overall after hysterectomy, with significant increases in the frequency of sexual relations and decreases in dyspareunia, vaginal dryness, and low libido 7.
- However, prehysterectomy depression was associated with experiencing dyspareunia, vaginal dryness, low libido, and not experiencing orgasms after hysterectomy, highlighting the importance of addressing mental health issues in the treatment of sexual dysfunction 7.