Q I’m 61 and I had a hysterectomy nine years ago. Since then my libido has plummeted. I don’t want HRT – would you recommend testosterone patches?

DR THOMAS STUTTAFORD

A Thirty years ago gynaecologists had no doubts that any change in a woman’s libido after hysterectomy was entirely psychological. Hysterectomies, it was explained, usually occurred at a time when the pressures on women were increased by changes in the family structure and professional life. Women coping with domestic and social turmoil are simultaneously hit by the hormonal storms associated with the end of reproductive years. Gynaecologists reasoned that for a woman already depressed by the menopause, a hysterectomy could be seen as final evidence that fertility, sexual allure and youth were over.

Postoperative loss of libido was seen as symptomatic of a patient’s general mood. This opinion was reinforced by the suggestions that the uterus was usually redundant before surgery and anyway it was hard to prove that it ever had responded to sexual stimulation. Furthermore, although the vagina was fractionally shorter after surgery it was still of adequate length, and scarring leaving it narrowed was also unusual.

Problems once considered entirely psychological are often shown later to have a physical component. In only a minority can they be shown to be entirely one or the other. One important observation on sexual response after hysterectomy was that women who were unusually phlegmatic about the menopause and hysterectomies and had a well-established sex life were as likely as more highly strung patients to find that a hysterectomy obliterated their usual response to sex. An unexpected finding in cases where orgasms and libido were reduced was that the women were more likely to have been operated on by exceptionally conscientious gynaecologists who carefully checked the para and preaortic lymph glands. The nerve supply around these glands is frail and vulnerable to damage during exploration of the glands.

Other research on physical causes for posthysterectomy changes concerns the cuff at the top of the vagina. This is often removed during surgery, possibly resulting in increased deep pain (dyspareunia) from thrusting during intercourse. Upper vaginal surgery may also interfere with the reflex that causes the vagina to balloon out when a woman is aroused. Its absence may increase discomfort. Finally, if a hysterectomy damages the blood supply to the pelvic organs, including the ovaries, libido could well be affected even if the ovaries are not removed.

Local HRT treatment is often acceptable to women even if generalised HRT is not. Testosterone patches can supplement local HRT. These patches, called Intrinsa, were initially introduced for women who had had an early menopause after surgical hysterectomy. Research has shown that removing the ovaries can reduce a woman’s testosterone level by about 50 per cent. As the testosterone-oestrogen balance is all-important in determining female libido, this usually affects their sexual responsiveness. A trial incorporating 533 women who had lost sexual desire after hysterectomy and a similar number of controls demonstrated that testosterone patches were well tolerated and increased libido to a notable extent in a statistically significant number. The number of women experiencing disappointing sex that left them feeling unhappy was also markedly reduced.

Dr Thomas Stuttaford, The Times doctor, spent many years working in a genitourinary clinic

SUZI GODSON

A The average age for the onset of menopause is 51, give or take several years either way. The removal of the uterus and the ovaries during a total hysterectomy induces a surgical menopause which is much more sudden and therefore more distressing than the gradual changes a woman would experience during the span of a natural menopause.

Because reduced hormone levels can cause unpleasant symptoms, hormone replacement therapy (HRT) is usually recommended after a hysterectomy. However, although millions of women take it every day, many others have mixed feelings about it. Besides the negative research (in 1997 a huge trial testing various brands of HRT in the United States was halted because it was felt that the health risks outweighed the possible benefits), many women are put off by the fact that HRT only delays, rather than prevents, menopause. The symptoms return when you stop taking the tablets.

Declining hormones have a detrimental effect on libido and testosterone can sometimes help. It is available in two forms: an implant and a patch. The implant stays in for three months, but lots of women report negative side-effects. A friend of mine grew a beard, broke out in spots and started shouting at her husband. The patch is called Intrinsa and was approved for private prescription in the UK last year. It has been hailed in the press as the answer to female sexual apathy, but don’t believe the hype. First, Intrinsa is not recommended for use by women over 61, and, secondly, your doctor should write you a prescription for it only if you take it in conjunction with HRT. If not, the prescription is considered to be “off licence” and Procter & Gamble, the manufacturer, would not be responsible for any side-effects. The FDA in the US and the Scottish Medicines Consortium have not licensed Intrinsa because Procter & Gamble’s clinical trials monitored women over only a one-year period.

So what are the other options? Well, there’s the Eros suction device. This, in my opinion, feels like having the most sensitive part of your anatomy sucked into a Dyson, but it is the only FDA-approved device to aid female sexual dysfunction, and in a study of 15 women by Boston University, 80 per cent reported increased sexual satisfaction.

Linda Parkinson-Hardman, the director of the Hysterectomy Association (www.hysterectomy-association.org.uk), says that “diet helps tremendously” and recommends New Natural Alternatives to HRT, by Marilyn Glenville (Kyle Cathie, £10.99). She also suggests herbal supplements of Agnus Castus, Dong Quai and Motherwort with vitamin C and a three-week course of vitamin E taken daily both orally and in the vagina. To alleviate dryness she suggests vaginal tablets and pessaries with small amounts of oestrogen. If you want to avoid hormones completely, there are many lubricants on the market. Sylk bills itself as the natural solution for menopausal women, but Yes (www.yesyesyes.org), an organic high-performance, lubricant gets the thumbs up from the Hysterectomy Association. To read more, log on to forums at www.hysterectomy-association.org.uk

Suzi Godson is author of The Sex Book (Cassell, £16.99) and The Body Bible (Penguin, £16.99)

E-mail your sexual dilemmas to body&soul@thetimes.co.uk or write to Body&Soul, The Times, 1 Pennington Street, London E98 1TT

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