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by Patricia Yarberry Allen, MD | bio

Last year, a patient came to me with what is a fairly common complaint among women in the menopausal transition.

The patient, who I’ll call Susan, is 48. After her period stopped, about 18 months prior to contacting me, she had experienced some hot flashes and night sweats, but nothing too bothersome.

But she was carrying a secret she didn’t even want to tell friends: She had completely lost interest in sex. Indeed, she and her husband had not had sex for six months.

Susan’s marriage – and her sex life – had up until recently been excellent, but around the time Susan’s libido started to disappear, she visited her gynecologist, complaining about pain and itching.

The gynecologist reported that Susan had small tears around the vaginal opening and that her vaginal tissue was “atrophic.” The word understandably bothered Susan. She said it made her feel very old.

Her gynecologist suggested hormone therapy, but Susan wanted to avoid hormones. The doctor prescribed estrogen cream, to insert vaginally three times a week, and suggested Susan use K-Y jelly for lubrication with intercourse.

Susan told me the estrogen cream made the burning worse, and intercourse, even with the K-Y jelly, was still impossible.

“It really made me sad that I have to give up such an important part of intimacy, but I can not tolerate the pain,” Susan said. “My husband has tried to be understanding, but we seem to be drifting apart. Is there anything that can be done?”

* * * * *

Discovery

When a woman has been orgasmic and enjoyed her love life with her partner and has a good relationship with that person, then we assume that the loss of interest in sex is not a function of a suddenly unsatisfactory sexual relationship or marriage.

Women do lose interest in sex when they associate it with pain. Often women in the menopausal transition just assume that pain with intercourse is inevitable and that loss of interest in sex as a consequence of this is normal.

To figure out the source of Susan’s pain, I needed to run some tests. In the meantime, I recommended that she and her husband begin a courtship to build up their intimacy.

We know that Vitamin D deficiency is an epidemic in this country. Vitamin D comes primarily from sunlight or from supplements. We smartly wear sunblock, hats and sunglasses in the summer, but doing so limits our absorption of Vitamin D through the skin. In the winter most people get almost no Vitamin D. And some people have malabsorption issues that make it difficult for them to benefit from supplements, certainly at the low doses currently used.

The good news is that many doctors and scientists are very focused on the role that Vitamin D plays in good health. As a gynecologist, I am particularly interested in the way that Vitamin D improves the genital tissue. It seems to work by converting aging cells into healthier cells.

I suggested that Susan undergo the following blood tests:

Vit D 25 hydroxy
Vit D 1,24 dihydroxy
Serum calcium
Parathyroid hormone

I also asked Susan if she had ever had a kidney stone (no), or if she had been told that she has a problem with parathyroid hormone levels or leaking calcium into the urine (again, no). The parathyroid hormone is responsible for controlling calcium and Vitamin D balance in the blood; it can pull calcium from the bones, making the bones weaker. And if calcium is leaking into the urine, it can cause a Vitamin D deficiency, which is noticeable in both the blood and tissue.

When I received the test results, as I suspected Susan’s Vitamin D levels were quite low, which were causing an elevation of her parathyroid hormone.

The calcium level was normal, so this was likely a secondary hyperparathyroidism, which can be corrected by replacement of Vitamin D3, the active form of this vitamin.

Treatment

Based on the results, I recommended Vitamin D3 – 5,000 IU three times a week for six weeks.

After six weeks of treatment, Susan’s genital tissue was re-examined. I repeated the blood tests and added a 24-hour urine test for calcium to make sure that the Vitamin D treatment had not unmasked more serious endocrine problems. (Excess calcium in the urine can cause kidney stones, and too much calcium in the blood – we’re talking about a really significant amount – can be a serious medical problem.)

The blood and urine tests showed that the calcium level was still normal, the Vitamin D levels were normal and the parathyroid level had normalized since the Vitamin D had been replaced. All the results were a positive sign that we were headed in the right direction.

Moreover, the genital tissue was no longer as dry, pale and delicate. So far, it was an excellent response to treatment.

Now we were ready to add the second step – vaginal estrogen therapy. I suggested a safe form of bio-identical estrogen, estradiol, which is formulated to be used as a tiny pill that is inserted vaginally.

Susan started taking Vagifem three times a week for four weeks and then followed up for another examination of the genital tissue. More improvement was noticeable.

Maintenance

To continue to see positive results, I recommended to Susan that she continue the Vagifem and Vitamin D3 – 5,000 IU twice a week – along with a 1,000 mg of calcium in divided doses twice a day. Calcium is needed for Vitamin D to be effective.

All of us need 1,200 mg of calcium daily. We naturally lose 600 mg every day, and our ability to absorb calcium becomes more inefficient as we age. If a patient is getting at least part of her calcium requirement from diet, she may only need to supplement with 500 mg of calcium daily. It’s also important to drink at least six glasses of water every day when taking calcium supplements, to prevent kidney stones.

While all of the above turned out to be the right medical program for Susan, we still needed to address Susan’s sexual intimacy with her partner. It had now been almost nine months. The longer we abstain from sex, the more difficult it may be to resume an intimate relationship. (The old adage “use it or lose it” comes to mind here!)

Patients who were orgasmic prior to loss of interest in sex can benefit from recharging their sexual batteries by becoming orgasmic alone before moving into the partnered act. A vibrator used with lubrication may be useful at first. A British company, Myla, offers a number of styles. Many women prefer the Pebble since it looks like a small hand held massage device … just in case it gets left out for someone to see!

After Susan was comfortable with her ability to be orgasmic, I suggested she let her partner know she was interested in resuming their sex life. I also recommended that they use a lubricant each and every time they have intercourse.

A week ago I got an e-mail from Susan.

“I’ve recovered such an important part of my life,” she said, declaring that not only is she sexually active once again, but she feels much more like herself.

* * * * *

Have a question about sex, women’s health or the menopausal transition? Write to askdrpat@womensvoicesforchange.org.

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  • Nathan January 8, 2008 at 12:57 am

    What might it be if it’s a woman in her mid 20’s and not menopausal? It started the 1st time we had sex. My wife and I have talked to tons of doctors, had tests, scans, etc. and still have no real hope for a normal sex life. There seem to be so many things that could be causing it and no clear cut way to know exactly what it is and what to do about it. We use tons of lubrication and foreplay. It is better when she’s really in the mood and enjoying it, but the pain (burning mostly) is still there.

    Reply
  • Dr. Pat Allen December 19, 2007 at 2:50 pm

    Higher doses of vitamin D used in this regimen need to be monitored by a doctor, since there is the possibility that it can elevate urinary excretion of calcium and blood levels of calcium.
    For the first six weeks of intensive vitamin D replacement, I suggest that you avoid calcium supplements for this reason. It is unlikely that anything unusual will happen with vitamin D in high doses, without extra calcium, for this short period of time.

    Reply
  • Carolle December 19, 2007 at 2:44 pm

    When you do the treatment for the first six weeks Vitamin D3 – 5000 IU 3 times week for six weeks. Do you also take the calcium daily?

    Reply
  • Dr. Pat Allen March 22, 2007 at 6:01 pm

    This is an excellent question since it allows me to discuss the safety differences between systemic hormone therapy and local vaginal therapy.
    Vaginal estrogen given in the form of Vagifem, a tablet that is inserted into the vagina, is generally not absorbed into the blood stream. We monitor each patient’s response to absorption of Vagifem by doing a blood test for estradiol 12 hours after the patient has inserted the vaginal tablet. Since there is no significant level of estrogen in the blood stream, this form of local therapy can never cause a heart attack.
    There is evidence that some patients may be at risk for cardiovascular risk from systemic hormone therapy. Certain genetic mutations that predispose to an increase risk for blood clots, obesity, hypertension, diabetes, or previous blood clots are some of the reasons that we believe that estrogen can increase the risk of stroke, blood clots and heart attack.
    Progesterone is not needed generally with low dose vaginal estrogen therapy. Progesterone is only used to prevent endometrial cancer from systemic hormone therapy use.
    Thanks for reading our blog. I hope these answers are helpful.

    Reply
  • Helene De Rade Campbell March 22, 2007 at 2:48 pm

    Doesn’t your patient take some form of progesterone? I was under the impression that taking only estrogen causes a risk of heart attacks.

    Reply