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Guideline No. 422d: Menopause and Sexuality

Published:September 15, 2021DOI:https://doi.org/10.1016/j.jogc.2021.09.005

      ABSTRACT

      Objective

      Provide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence.

      Target Population

      Perimenopausal and postmenopausal women.

      Benefits, Harms, and Costs

      Target population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment.

      Evidence

      Databases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002–2020, and MeSH search terms were specific for each topic developed through the 7 chapters.

      Validation Methods

      The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

      Intended Audience

      physicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population.

      SUMMARY STATEMENTS

      • 1
        Low sexual desire in combination with distress is most common in women in mid-life (high).
      • 2
        Vaginal atrophy is a common cause of sexual pain in menopausal women (high).
      • 3
        Sexual dysfunction in menopausal women can be categorized as disorders involving desire, arousal, pain, and orgasm. These categories often overlap (high).
      • 4
        A brief sexual history is part of the evaluation of menopausal women (moderate).
      • 5
        The treatment of sexual dysfunctions involves a multifaceted approach that addresses medical, psychological, and relationship issues (high).
      • 6
        Local estrogen therapy treats genitourinary syndrome of menopause (high).
      • 7
        Pelvic physiotherapy is an excellent adjuvant treatment for hypercontracted pelvic floor muscles (often referred to as vaginismus) and genito-pelvic pain (low).
      • 8
        Flibanserin has been shown to improve desire in women (moderate).
      • 9
        Transdermal testosterone has been shown to increase desire, arousal, and satisfying sexual events, and to decrease personal distress (high).
      • 10
        Psychological therapies, including cognitive behavioural therapy, mindfulness-based therapy, couples’ therapy, and sexual therapies, are useful for treating sexual dysfunctions (moderate).
      • 11
        Sexual dysfunction is common in patients with depression, those on selective serotonin reuptake inhibitors (SSRIs), women with primary ovarian insufficiency, and those with a history of breast cancer (high).

      RECOMMENDATIONS

      • 1
        The patient's problem should be categorized as related to desire, arousal, pain, or orgasm, in order to facilitate treatment and to triage care (strong, moderate).
      • 2
        Health care providers should include a sexual screening history and physical examination in the initial evaluation of menopausal women (strong, low).
      • 3
        Vaginal estrogens, lubricants and moisturizers, vaginal dehydroepiandrosterone, and ospemifene may be used as treatments for vaginal atrophy related to menopause (strong, high).
      • 4
        For postmenopausal women with hypoactive sexual desire disorder, the best current options include managing pain, addressing any biopsychological factors, counselling, and prescribing transdermal testosterone (off-label) or flibanserin (strong, moderate).
      • 5
        Patients with breast cancer and symptomatic genitourinary syndrome of menopause can be offered local vaginal estrogen if local lubricants and moisturizers are ineffective, after consulting with the patient's oncologist (conditional, moderate).

      Keywords

      ABBREVIATIONS:

      DHEA (dehydroepiandrosterone), FSAD (female sexual arousal disorder), GSM (genitourinary syndrome of menopause), PLISSIT (Permission, Limited Information, Specific Suggestions, and Intensive Therapy), HSDD (hypoactive sexual desire disorder), SSRI (selective serotonin reuptake inhibitors)
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