3.1 Med.treatment
Medical help for sexual dysfunctions in men can be pharmaco therapeutic (e.g. androgen replacement in cases of hypogonadism, a PDE5 inhibitor for erectile dysfunction or clomipramine for ejaculatio praecox), or mechanical (ring, vacuum pump or prostheses) for erectile dysfunction. Dyspareunia in women requires a causal approach wherever possible. Artificial insemination with the partner’s semen as a ‘bedroom procedure’ can be a useful adjunct to the treatment of couples with problems stemming from the woman’s vaginismus or dyspareunia in either partner. Continued attempts at intercourse with the sole aim of procreating can stand in the way of the successful treatment of couples with dyspareunia or problems involving sexual arousal and desire. It is therefore advisable to separate the sexual problem from the desire to become pregnant, although the latter does increase the chance of successful therapy for vaginismus. If it is suspected that sex hormone deficiency is contributing to reduced libido or arousal problems, psychosexual therapy can be supplemented with hormone therapy. Systemic or transdermal administration of an oestrogen supplement is used to treat typical menopausal complaints and vaginal atrophy in women with an intact uterus, usually in combination with a progestogen. Tibolon (Livial®) is a tissue-specific pharmacon containing oestrogen and progestogen, which also has androgen properties. It is registered and approved for use in hormone suppletion therapy in postmenopausal women with complaints linked to an oestrogen deficiency. Tibolon has been shown to have a positive effect in reducing sexual complaints, comparable or slightly better than treatment using an oestrogen plus a progestogen alone. Until recently, there were no testosterone preparations specifically for women. Recently Intrinsa®, a transdermal testosterone patch became available for women who had undergone a bilateral oophorectomy plus hysterectomy and were also being treated with estrogens (Bijl, 2009). The patch is however contra-indicated for use in conjunction with oral conjugated equine estrogens. At present, only limited safety information is available; there is no data on the safety of use for a period longer than three years. For this reason, treatment should only be initiated by a specialist. Both the efficacy and safety of the treatment should be assessed on a regular basis, say, every six months, whereupon the decision whether or not to continue can be taken. The only substantial data available at this time relates to the use of the testosterone patch in women who have been rendered postmenopausal by a surgical procedure. The effects of the patch have yet to be studied in other groups who may be expected to show androgen deficiency, such as women with premature ovarian failure, Turner’s syndrome or iatrogenic menopause further to radiotherapy or chemotherapy. Patients who have undergone a bilateral oophorectomy to reduce the risk of breast cancer are not yet eligible for hormone suppletion, Tibolon treatment or the testosterone patch due to incomplete knowledge about the effects on hormone-sensitive breast tissue.
Although testosterone suppletion can help patients with androgen deficiency to recover central and peripheral sensitivity to sexual stimuli, it is usually not enough on its own. If the problems are long standing, it will often be necessary to help both patient and partner to discover or rediscover sexual stimuli which promote arousal, to strengthen the reward component of sexual activity in the form of pleasurable sexual feelings, to mitigate any negative emotions associated with sex, and to restore effective communication and intimacy to their relationship. In general we may state that medical interventions, as advanced as they may be, are often nothing more than technical solutions to what is in essence an emotional problem. Medical options remain important because they can often help the patient to deal with long-term exposure to the problematic situation, which is by far the most important therapeutic factor in conditions such as anxiety disorders. However, there is an important condition: the principle of ‘do no harm’. This cannot be guaranteed where a medical or surgical procedure is irreversible, as many are. This forms the limiting factor whereby the patient’s decision to opt for a medical-technical solution should be subject to counseling to ensure fully informed consent.