"Rachel Martin," 76, is like many married women her age: mentally sharp, tuned in to her health and unafraid to ask questions. Like all too many aging women, she is also struggling to find out more about how hormonal changes affect her sexuality — and which treatments are the safest.
Many aging women stopped taking hormone therapy after July 2002. This was when the Women's Health Initiative showed that women aged 50-79 who took a combination of estrogen and progestin, a common hormone replacement therapy (HRT), had a greater risk of breast cancer, stroke, and heart disease. About 6 million American women had been taking this form of HRT, according to this ongoing research project.
Clinicians now generally recommend that women take the lowest possible dose of hormones for the shortest period of time. But this raises an important question for many older women: If they give up hormones, how will this affect their sex life?
"Many doctors assume that women my age will go off hormones without protesting," says Martin, a retired businesswoman who lives in Southern California. "My first worry was that my vaginal dryness would come back, and this would put a damper on my marriage."
Martin grew up in a time when sex was considered a taboo subject. "The media never addresses the topic of sexuality for my age group," she explains. "But I wish that someone would. Hormone treatment is generally associated with the change of life. I'm way past that stage, and I want to hear more about how hormones impact sex after menopause and the risk factors for this treatment."
Like Martin, many older women have difficulty getting the information they need to make informed choices about their ongoing treatment. Below is Martin's story, one that illuminates the concerns of many women in this age group. [Editor's note: This case has been altered slightly for educational purposes.]
Rachel Martin's Story
"In my 40s, I had a myoma [a benign fibroid tumor] on my uterus the size of a tangerine, and I decided not to have surgery, but to watch and wait. When I went into menopause, the fibroid began to shrink, but then intercourse became increasingly uncomfortable. I worried that if I took hormones to address the vaginal dryness, the fibroid might come back, or I might be at risk for uterine or ovarian cancer. [Rachel is wrong about her cancer risk; see Dr. Kagan's comments below.]
"In my mid-50s, I started using a topical estrogen cream, on the recommendation of a female gynecologist. But she was a poor communicator and seemed to resent my concerns about taking any hormones at all. So I changed doctors and was lucky to find a clinician who was very open to my questions.
"My gynecologist explained that I had gone for a long time without any problems, my bones were a concern because I was getting older, and the vaginal dryness was going to continue and make sex unpleasant. He put me on a combination of Premarin and Provera and suggested I keep using the topical estrogen cream.
"In my 60s, I was glad I made this choice. My husband and I had grown closer since we retired, and I was willing to take a slight risk and continue taking hormones in order to maintain our physical relationship.
"Three years ago, at age 73, I was diagnosed with endometrial cancer and underwent a hysterectomy. Because I changed HMOs, I began to see a new gynecologist. This doctor took me off progestin because I no longer needed it to protect the lining of my uterus and suggested that I switch to a low dose, .05 mg estrogen patch, or simply rely on the topical cream I'd been using.
"My gynecologist and I finally decided to reduce my dose of estrogen and slowly taper it off. I cut my patch in half for several weeks and am about to stop using it completely. Since the age of 73, I'd been taking medication to counteract the beginnings of osteoporosis, so I no longer needed oral estrogen for bone density.
"I continue to use vaginal estrogen cream, for without it the old problem starts again, and I have vaginal discomfort during sex. My doctor says only a tiny amount gets absorbed into the rest of the body. I've been on this new regimen for a year and, so far, it's working fine."
Comments from Risa Kagan, MD, menopause specialist and Associate Clinical Professor of Obstetrics and Gynecology and Reproductive Science, University of California Medical Center and Co-Medical Director of The Foundation for Osteoporosis Research and Education (FORE) in Oakland, CA:
Rachel Martin has two misconceptions. First, that there is a link between hormone replacement therapy (HRT) and ovarian cancer—this worried her when she was in her 40s. And second, that the .05 mg patch is a low dose of estrogen.
Contrary to what Rachel thought, there is no definitive correlation between hormone therapy and ovarian cancer. Further, most women with an intact uterus who take HRT (estrogen and progestin) are at very low risk for developing endometrial (uterine) cancers. Unopposed estrogen (with no progestin), however, is associated with a higher risk of endometrial cancer. The good news is that when discovered early, endometrial cancer can be cured with a hysterectomy.
The current data on breast cancer risk: the Women's Health Initiative showed 8 more cases for every 10,000 women taking a combination of estrogen and progestin than in women taking a placebo. The risk of breast cancer for women taking estrogen alone was not found to be significantly different from those taking a placebo after 6.8 years.
Also of interest in this case is the confusion about estrogen dosage. When Rachel was first given the .05 patch, she was told this was a low dose. Today this is considered standard, and there are now significantly lower doses available in pill and patch formulations.
Fortunately, Rachel was able to maintain comfortable vaginal health with a topical cream. But women have two other alternatives: vaginal tablets and a vaginal ring. Both deliver extremely low doses of estrogen to the vagina with minimal systemic absorption. This allows women of all ages, as well as survivors of breast and endometrial cancer, to have pleasurable sex without the risks associated with systemic estrogen use.
For information on sexuality, aging, and menopause, I often refer my patients to the North American Menopause Society, for this web site offers a valuable guidebook on menopause and aging, as well as a reading list that will help women make more informed treatment decisions.
The National Institutes of Health web site outlines the current risks and benefits of hormone therapy.
This article is for educational purposes only and is not intended as a substitute for medical advice. Please consult with a clinician to review any current symptoms and address your medical concerns.
