For low libido, is estrogen or progesterone recommended?

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Elsevier ClinicalKey Derived Clinical Overview

• Treat underlying medical, gynecologic, or psychologic conditions. • Address comorbidities and overall health status (i.e., weight loss). • Increase physical activity (associated with increased satisfaction and sexual engagement). • For medication-induced conditions, decrease dose or change medication. • For postmenopausal women or those with hypoestrogenism, try estrogen replacement therapy with or without progestin. Local vaginal estrogen therapy is preferred over systemic therapy. Transdermal estradiol is superior to oral estradiol for improving sexual function because oral estradiol increases circulating sex hormone-binding globulin (SHBG) and lowers free testosterone, thus effecting libido adversely. Estrogen replacement is associated with improvements in dyspareunia and vaginal dryness. • For postmenopausal vaginal and/or vulvar atrophy, ospemifene has been associated with improved sexual function. • Transdermal testosterone therapy: Results show increase in satisfying sexual activity and sexual desire. Must weigh risks (hirsutism, acne, virilization, and cardiovascular complications) vs. benefits of use. • Bupropion was shown to benefit patients experiencing antidepressant-induced sexual dysfunction. A Cochrane review showed that 150 mg twice daily had significantly higher scores on the Female Sexual Function Index. • Flibanserin (Addyi): A nonhormonal treatment for HSDD. It is an agonist at serotonin 5-HT receptors and an antagonist at 5-HT2Areceptors. Its mechanism of action in treating HSDD is unknown. The recommended dose is 100 mg once daily at bed time. Side effects include hypotension, syncope, and central nervous system (CNS) depression. Consumption of alcohol increases risk of side effects and is contraindicated. • Ospemifene: A selective estrogen receptor agonist/antagonist can be used in postmenopausal women who are experiencing a hypoestrogen state.

2.

Food and Drug Administration (DailyMed).

Publish date: July 1, 2023.

Dosage And Administration DOSAGE AND ADMINISTRATION When estrogen is prescribed for a postmenopausal woman with a uterus, a progestin should also be initiated to reduce the risk of endometrial cancer. A woman without a uterus does not need progestin. Use of estrogen, alone or in combination with a progestin, should be with the lowest effective dose and for the shortest duration consistent with treatment goals and risks for the individual woman. Patients should be reevaluated periodically as clinically appropriate (e.g., 3-month to 6-month intervals) to determine if treatment is still necessary (see BOXED WARNINGS and WARNINGS ). For women who have a uterus, adequate diagnostic measures, such as endometrial sampling, when indicated, should be undertaken to rule out malignancy in cases of undiagnosed persistent or recurring abnormal vaginal bleeding. Patients should be started at the lowest dose for the indication. 1. For treatment of moderate to severe vasomotor symptoms, vulval and vaginal atrophy associated with the menopause, the lowest dose and regimen that will control symptoms should be chosen and medication should be discontinued as promptly as possible. Attempts to discontinue or taper medication should be made at 3-month to 6-month intervals. The usual initial dosage range is 1 to 2 mg daily of estradiol adjusted as necessary to control presenting symptoms. The minimal effective dose for maintenance therapy should be determined by titration. Administration should be cyclic (e.g., 3 weeks on and 1 week off). 2. For treatment of female hypoestrogenism due to hypogonadism, castration, or primary ovarian failure. Treatment is usually initiated with a dose of 1 to 2 mg daily of estradiol, adjusted as necessary to control presenting symptoms; the minimal effective dose for maintenance therapy should be determined by titration. 3. For treatment of breast cancer, for palliation only, in appropriately selected women and men with metastatic disease. Suggested dosage is 10 mg three times daily for a period of at least three months. 4. For treatment of advanced androgen-dependent carcinoma of the prostate, for palliation only. Suggested dosage is 1 to 2 mg three times daily.

Clinical Pharmacology 12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action Endogenous estrogens are largely responsible for the development and maintenance of the female reproductive system and secondary sexual characteristics. Although circulating estrogens exist in a dynamic equilibrium of metabolic interconversions, estradiol is the principal intracellular human estrogen and is substantially more potent than its metabolites, estrone and estriol, at the receptor level. The primary source of estrogen in normally cycling adult women is the ovarian follicle, which secretes 70 to 500 mcg of estradiol daily, depending on the phase of the menstrual cycle. After menopause, most endogenous estrogen is produced by conversion of androstenedione, which is secreted by the adrenal cortex, to estrone in the peripheral tissues. Thus, estrone and the sulfate conjugated form, estrone sulfate, are the most abundant circulating estrogens in postmenopausal women. Estrogens act through binding to nuclear receptors in estrogen-responsive tissues. To date, two estrogen receptors have been identified. These vary in proportion from tissue to tissue. Circulating estrogens modulate the pituitary secretion of the gonadotropins, luteinizing hormone (LH) and FSH, through a negative feedback mechanism. Estrogens act to reduce the elevated levels of these hormones seen in postmenopausal women.

3.

Food and Drug Administration (DailyMed).

Publish date: March 1, 2024.

Dosage And Administration DOSAGE AND ADMINISTRATION When estrogen is prescribed for a postmenopausal woman with a uterus, a progestin should also be initiated to reduce the risk of endometrial cancer. A woman without a uterus does not need progestin. Use of estrogen, alone or in combination with a progestin, should be with the lowest effective dose and for the shortest duration consistent with treatment goals and risks for the individual woman. Patients should be reevaluated periodically as clinically appropriate (e.g., 3-month to 6-month intervals) to determine if treatment is still necessary (see BOXED WARNINGS and WARNINGS ). For women who have a uterus, adequate diagnostic measures, such as endometrial sampling, when indicated, should be undertaken to rule out malignancy in cases of undiagnosed persistent or recurring abnormal vaginal bleeding. Patients should be started at the lowest dose for the indication. 1. For treatment of moderate to severe vasomotor symptoms, vulval and vaginal atrophy associated with the menopause, the lowest dose and regimen that will control symptoms should be chosen and medication should be discontinued as promptly as possible. Attempts to discontinue or taper medication should be made at 3-month to 6-month intervals. The usual initial dosage range is 1 to 2 mg daily of Estrace (estradiol) adjusted as necessary to control presenting symptoms. The minimal effective dose for maintenance therapy should be determined by titration. Administration should be cyclic (e.g., 3 weeks on and 1 week off). 2. For treatment of female hypoestrogenism due to hypogonadism, castration, or primary ovarian failure. Treatment is usually initiated with a dose of 1 to 2 mg daily of Estrace (estradiol), adjusted as necessary to control presenting symptoms; the minimal effective dose for maintenance therapy should be determined by titration. 3. For treatment of breast cancer, for palliation only, in appropriately selected women and men with metastatic disease. Suggested dosage is 10 mg three times daily for a period of at least three months. 4. For treatment of advanced androgen-dependent carcinoma of the prostate, for palliation only.

4.

Meziou N, Scholfield C, Taylor CA, Armstrong HL. Menopause (New York, N.Y.). 2023;30(6):659-671. doi:10.1097/GME.0000000000002185.

Publish date: June 4, 2023.

FINDINGS: Forty-seven randomized controlled trials (35,912 participants) were included in the systematic review, and 34 randomized controlled trials (15,079 participants) were included in the meta-analysis. The meta-analysis revealed that, in comparison to control, estrogen therapy (standardized mean difference [SMD], 0.16; 95% confidence interval [CI], 0.02 to 0.29; I2 = 59%; 2,925 participants, 16 studies), estrogen plus progestogen therapy (SMD, 0.11; 95% CI, -0.07 to 0.29; I2 = 65%; 2,432 participants, 7 studies), tibolone (SMD, 0.15; 95% CI, 0.02 to 0.28; I2 = 0%; 916 participants, 2 studies), and selective estrogen receptor modulators (SMD, 0.18; 95% CI, 0.06 to 0.30; I2 = 0%; 1,058 participants, 4 studies) may result in no effect to small benefit on sexual function composite score. CONCLUSION AND RELEVANCE: Hormone therapy may slightly improve sexual functioning. This potential small benefit should be considered when discussing treatment options for other menopausal symptoms.