Identifying and treating sexual dysfunction in postmenopausal women: the role of estrogen

Sexual dysfunction is a common, but frequently overlooked, problem in postmenopausal women. At menopause, dramatic decreases in circulating estrogen concentrations cause physiologic changes that may affect sexual function, most notably the development of vulvovaginal atrophy. Vulvovaginal atrophy often leads to vaginal dryness, itching, irritation, reduced lubrication, dyspareunia, and vaginal bleeding associated with sexual activity. Estrogen deficiency also can affect other aspects of sexual function, including reduced vaginal blood flow and a reduced capacity for arousal and orgasm. As estrogen loss is a significant cause of sexual dysfunction in menopausal women, estrogen therapy is a logical treatment option in this population. Although both systemic and local estrogen therapy improve vaginal health and sexual functioning, local vaginal therapy with estrogen creams, rings, or tablets may be more appropriate for women without other indications for systemic estrogen therapy. These therapies are highly effective in reversing vaginal atrophy, improving vaginal symptomatology, and reducing dyspareunia, and may have effects on other dimensions of sexual function. Emerging treatments, such as ultra-low-dose vaginal estradiol tablets, new selective estrogen receptor modulators (SERMs), and intravaginal dehydroepiandrosterone (DHEA) are other promising options for postmenopausal women with vaginal atrophy and sexual dysfunction.