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When testosterone deficiency appears to be the cause of sexual dysfunction, low dosages of testosterone can restore functioning. Studies show that women who receive both supplemental estrogen and testosterone after a total hysterectomy have greater libido than those given either estrogen alone or a placebo (7).

The genital tissue may be unresponsive to supplemental testosterone at first because of atrophy or a lack of testosterone receptors (3). Therefore, it is often preferable to begin by applying testosterone or methyltestosterone directly to the vulva once a day in a cream base. After a week or two the cream should be applied to the inner thigh or wrist five days a week, alternating with the vulva twice a week, at a dosage of .25 to 1 mg per day (Roentsch G, personal communication, Dec 1999). Some patients prefer to switch to either a fraction of a methyltestosterone pill designed for men a few times a week, a specially compounded methyltestosterone pill in dosages suitable for women (.25 to 1 mg per day), or a testosterone skin patch (Testoderm TTS) for men, which delivers 5 mg in a 24-hour period; women need to wear the patch for only one to four hours a day. Unlike methyltestosterone, however, testosterone itself has the advantage of allowing for the measurement of blood levels.

For women at risk for breast cancer who need to avoid estrogen intake, methyltestosterone taken orally is preferable because it cannot be converted as easily to estrogen as testosterone itself. In fact, some patients respond better to methyltestosterone than to testosterone, because testosterone stimulates the production of SHBG by virtue of its conversion to estrogen (Roentsch G, personal communication, Feb 2000). A combination pill of methyltestosterone and conjugated estrogens is also available (Estratest). Clinical experience has shown that if the response wanes after a few weeks or months, a two-week drug holiday may restore the hormone's effectiveness. Some women will need testosterone supplementation for the rest of their lives to maintain sexual functioning, whereas others may require it for a year or less.

Dosages should be kept as low as possible to avoid side effects, which may include not only enlargement of the clitoris but also weight gain, liver damage, reduced levels of high density (good) cholesterol, acne, irritability, and male secondary sexual characteristics such as facial hair, lowered voice, and male pattern hair loss. These side effects rarely occur at the low doses necessary for women. Information on long-term effects, optimal dosages, routes of delivery, and potential risks (including cancer and cardiovascular disease) are lacking, and research in these areas is urgently needed. Because female sexual dysfunction is not yet an approved indication for use of any form of testosterone, patients should sign consent forms and be monitored frequently.

Clinicians are beginning to administer other medications that have not yet undergone placebo-controlled studies in women with sexual dysfunction. In the media, anecdotal reports of the positive effects of sildenafil (Viagra) on women's sexual arousal abound. Preliminary studies suggest that postmenopausal women respond to sildenafil with heightened arousal and lubrication and an increased flow of blood to the vagina and clitoris (8). Some women who hesitate to take a pill to enhance sexual functioning will accept the idea of using topical sildenafil cream (9). For women receiving testosterone supplementation, the occasional use of sildenafil may help to keep the dosage of testosterone at a minimum.

Other medications that have been noted in case reports to heighten female arousal when used topically include prostaglandin E1 (10) and a combination of aminophylline, ergoloid mesylate, and isosorbide dinitrate (9). The same effect has been observed with the topical application of pentoxifylline, natural progesterone, dehydroepiandrosterone (DHEA) and L-arginine, individually or in combination (Roentsch G, personal communication, Mar 2000). In addition, a specific combination of herbs and spices first described 2,000 years ago in the Kama Sutra, the ancient Indian sexuality text, has recently been marketed as a topical aphrodisiac for women (ProSensual). Further information about these agents may be obtained on the first author's Web site (www.sensualrx.com).

Again, all of these medications and alternative substances have not been studied systematically for postmenopausal sexual dysfunction and are not routinely administered by sex therapists. Because these drugs are associated with side effects and are not FDA approved, patients using them need to be educated and monitored frequently.

The basic principles of sex therapy apply in the treatment of older women and their partners. Sexual problems that have a psychological component are best treated with specific psychosexual therapy after any physical causes have been addressed. Very commonly, sexual problems that begin with minor physical impairments or changes can escalate and lead to a progressive sexual disability.

For example, a woman at midlife may become less sexually responsive because of declining levels of hormones and reduced lubrication. For the first time in her marriage, she may have difficulty achieving orgasm through intercourse alone, and she is embarrassed about discussing it with her husband. He senses her lack of enthusiasm and finds it difficult to sustain an erection. He stops initiating sexual activity, which results in his wife's feeling rejected. In this way, a sexual problem that begins with subtle age-related biologic changes ultimately can lead to abstinence, diminished quality of life, depression, and, quite possibly, an affair or a divorce.

In addition, many women who previously relied passively on their husbands to bring them to orgasm by delaying ejaculation and prolonging intercourse need to learn to rely on other types of stimulation. Viewing adult videotapes portraying older couples engaging in a variety of sexual activities may enable receptive couples to vary their sexual repertoire (11). A new genre of these videos portrays sex in a more realistic manner designed to appeal to women (Femme Productions, Carrboro, NC).

Often, it becomes important for husbands to learn to be gentler, more patient, and more flexible in their approach to lovemaking. Although both men and women enjoy compliments, older women seem particularly sensitive to reassurance about their desirability. In addition, raising the level of sexual stimulation with vibrators, lubricants, and other sexual aids may be helpful. Many patients, unaware of recent improvements in lubricants, continue to use the inferior products they used in the past.

Other sex therapy techniques include sexual fantasy training, masturbation exercises alone and with a partner, taking turns giving and receiving sexual pleasure, identifying and overcoming cultural inhibitions, improving communication, and sensual massage. Treatment is best administered by clinicians trained in sex therapy. However, physicians without specialized training can do much to educate patients and guide them to self-help literature (12,13) and videos and to dispel harmful misconceptions.

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