Decreased Sex Drive After Ovariectomy

Question

My question relates to concerns of a close friend. She recently had a complete hysterectomy (ovaries also removed). She's 48 years old. She was immediately put on a Vivelle-50 estrogen patch (twice weekly). It's now almost 12 weeks later and she finds herself to have a much reduced interest in sex (compared to before the surgery). She wonders if this could be due to hormonal changes, physiological (will improve with healing/ time), or psychological. I mentioned your expertise in the hormonal area. Do you have any thoughts on this issue that might help or that she could discuss with her GP?

Answer

Decreased sexual interest after ovariectomy and hysterectomy is complex and common. It has many reasons. First there are surgical changes such as a less strong orgasm because uterine contractions contribute to the sensation or less lubrication because the cervical glands are no longer present to make slippery mucus. There are also hormonal reasons such as lower levels of ovarian testosterone and the inability to make progesterone. However, the estrogen patch she is taking is giving her a natural dose of estrogen.

The third important reason for a low sex drive after ovariectomy is that she has been through major surgery and lost parts of her body that are symbolically important. Even if she made a careful choice about the surgery, or felt that she had no other options, adjustment to these changes takes time.

Now for some suggestions. I approve of the patch because transdermal estrogen is probably less likely than oral estrogen to cause blood clots. I'd suggest that she ask her family doctor to add oral micronized progesterone in a dose of 300 mg at bedtime to her current estrogen. I’d give progesterone two reasons: 1) this is the dose of progesterone the ovary normally makes; 2) women after ovariectomy have bone loss despite estrogen and calcium therapy (1). Progesterone will add to the positive effects of estrogen on spinal bone density (2). I'd also encourage high dose (2000 mg/d) calcium and 800 IU vitamin D plus all the usual healthy bone behaviours.

If the low sexual interest persists, after say another three months I'd suggest she ask her family doctor for Andriol® or Testoderm®. These are low doses of testosterone that may replace the ovarian testosterone she is missing. The dose of Andriol® is 40 mg a day taken with fatty food (to aid absorption) once a day for five days every month. The dose of Testoderm® is to wear the full dose (male equivalent) patch for four hours a day (removing it and storing against waxed paper) for five days a month. Although testosterone plays a small role in women’s sex drive, it may be useful and she is now without this natural source of testosterone.
I’d suggest that she take the estrogen and progesterone until she is 50 or 51 and then taper and stop the estrogen. (See “Coming off Ovarian Hormone Therapy”.) The testosterone therapy should be taken only until her normal sexual response returns or be stopped after three months if it doesn’t appear helpful. Progesterone is safe to take for many years, especially if she has hot flushes or night sweats.

There’s some good news I recently learned about ovariectomy or even hysterectomy without removal of the ovaries that I’d like you to share with your friend. These surgeries are associated with a significantly lower risk for breast cancer (3).

Hope this is helpful. All the best to you.

Reference List

1. Prior JC, Vigna YM, Wark JD, Eyre DR, Lentle BC, Li DKB et al. Premenopausal ovariectomy-related bone loss: a randomized, double-blind one year trial of conjugated estrogen or medroxyprogesterone acetate. J Bone Min Res 1997; 12(11):1851-1863.

2. Lindsay R, Gallagher JC, Kleerekoper M, Pickar JH. Effect of lower doses of conjugated equine estrogens with and without medroxyprogesterone acetate on bone in early postmenopausal women. JAMA 2002; 287:2668-2676.

3. Kreiger N, Sloan M, Cotterchio M, Kirsh V. The risk of breast cancer following reproductive surgery. Eur J Cancer 1999; 35:97-101.