Dr. James Simon discusses the importance of sexual health during menopause and encourages clinicians to open up the conversation with patients. He discusses several treatment options and resources with Dr. Marla Shapiro.
Dr. Marla Shapiro:
Hello, I’m Dr. Marla Shapiro. I’m a past president of the North American Menopause Society and today I’m joined by Dr. Jim Simon, who is also a past president of the North American Menopause Society. For our healthcare practitioners who may not know you, please tell us who you are.
Dr. Jim Simon:
Thank you. I’m happy to be here. I’m Dr. Jim Simon. I’m a reproductive endocrinologist and clinical professor at George Washington University. I’m the immediate past president of the International Society for the Study of Women’s Sexual Health.
Dr. Marla Shapiro:
That’s where we’re going to start today. We’re going to talk about sexual health because often as healthcare practitioners we’re not trained or we’re not comfortable. So, what are some of the most common issues that we see in women in and around menopause and in menopause when it comes to their sexual health?
Dr. Jim Simon:
So, I like to consider this in three different buckets. It makes it easy for me to keep it straight. So as women transition to menopause, it’s very clear that they have vasomotor symptoms, and disturbed sleep. Disturbed sleep has many downstream consequences, two of which are weight gain and that affects one’s self-image, which has an adverse effect typically on sexual interest. The other is fatigue, which clearly affects one’s interest in any kind of extracurricular, shall we say, activity.
Dr. Jim Simon:
Then the other two buckets are sexual pain, which occurs after menopause most commonly and as women approach their 60th year in particular, and loss of sexual desire as women’s hormones synergize with their loss of sleep.
Dr. Marla Shapiro:
So, for many practitioners and even some of our patients, there’s this bias that this is aging. There are often no questions that are asked by the healthcare practitioner, and women often just assume this is the way it is and don’t bring it up as well. So how do we break that barrier and open the door for the conversation?
Dr. Jim Simon:
So, this is a really critical question because patients don’t bring it up and there’s good scientific evidence that they don’t, and practitioners don’t bring it up and there’s good scientific evidence that they don’t bring it up. So, it’s kind of a Mexican standoff, if you will. No one’s talking about it, so it doesn’t get talked about.
Dr. Jim Simon:
The problem is that someone’s got to break the ice and I really think that it’s got to come from patients. We in practice think that there are many more important things to women. Whether that’s true or not for an individual woman is not the least bit clear. But if women will bring it up, then we have an opportunity to jump in or at least be triggered to go to the library, refer the patient, or learn ourselves and intervene.
Dr. Marla Shapiro:
So, let’s talk about what’s new in sexual medicine because for so many years, multiple drugs for men all over television and media giving it the legitimacy to talk about this. But for women, there is this sense that there’s nothing out there. So, what’s there to talk about anyways?
Dr. Jim Simon:
So, there are a couple of very interesting occurrences that have happened in the last year or so in the answer to this question. The first, and I’ll bring it back to Canada, is that the Canadian government, Health Canada approved the use of flibanserin, which is sometimes called the pink pill for women after menopause and up to age 60.
Dr. Jim Simon:
This is a big deal. There’s been data on this for almost a decade now, yet no approval for women after menopause who clearly need it in higher percentages than younger women. So that’s one thing that’s happened in this last year.
Dr. Marla Shapiro:
Aimed to treat low desire.
Dr. Jim Simon:
Correct. Aimed at treating hypoactive sexual desire disorder, which simply put is low sexual interest or absent sexual interest and wanting to fix it. Being distressed about having lost that sexual desire.
Dr. Jim Simon:
The other two things that happened in this last year or so was an international global consensus paper on the importance of testosterone in menopausal women. We know that women lose estrogen at menopause. They lose testosterone from about age 30 on, becoming more of a crisis as they approach age 60. Testosterone is a pivotal and important hormone for women of all ages.
Dr. Jim Simon:
Then lastly, because there are no approved medications in North America for testosterone therapy in women, there are about 30 in the US for men, the International Society for the Study of Women’s Sexual Health with an international group of experts came out with a how to use testosterone in postmenopausal women. So no practitioner should have to be fiddling around trying to figure it out.
Dr. Marla Shapiro:
So where are we going? We now have this position paper with evidence in science, and very clear indications. It’s not one size fits all every postmenopausal woman needs testosterone. We have flibanserin. Has it opened up the door to more investigations, more products for women’s sexual health, and more let’s get it out into the mainstream?
Dr. Jim Simon:
So, in addition, we also have an injectable as desired treatment in the US for low sexual desire called Bremelanotide, or Vyleesi. It’s on the market and available to add to your list.
Dr. Jim Simon:
But I also want to say that for women who either can’t use those products, or have a contraindication to those products, there are a number of products that have let’s say a side effect of stimulating sexual desire, either at the dose that they’re approved for another indication, or either a lower dose or a higher dose than with knowledge can be brought to bear for an individual woman with low sexual desire to boost that desire.
Dr. Marla Shapiro:
And those medications…
Dr. Jim Simon:
So, they fall into medications that typically affect the neurotransmitters in the brain, increasing dopamine and decreasing serotonin. That’s a pro-sexual effect. Medications like Trazodone at very low doses, which can be used for sleep as well as improving sexual desire.
Dr. Jim Simon:
Buspirone, which is usually considered an anti-anxiety agent, is also pro-sexual in many ways. So, a woman who’s anxious about sex and has low desire because of her anxiety could be treated for both with Buspirone. Bupropion, which is an anti-depressant, but at high doses is known to stimulate sexual interest, and arousal and improve orgasm.
Dr. Marla Shapiro:
Well, I want to thank you for joining us because opening up this conversation, lets our healthcare practitioners know that there are options out there, and if you’re unaware of the options, it’s not that difficult to get that education.
Dr. Jim Simon:
Absolutely. Critically important. For those women who cannot find a knowledgeable provider or whose practitioners wish to get additional information, both the North American Menopause Society and the International Society for the Study of Women’s Sexual Health have found provider functions on their websites and both providers and patients can go there to get some help.
Dr. Marla Shapiro:
Thank you so much for joining us today.
Dr. Jim Simon:
My pleasure. Thank you.