Prime Time - Jane Fonda [100]
Dr. Warren, like other gynecologists I spoke with, feels that it is almost inevitable that postmenopausal women who are not on estrogen will suffer vaginal dryness and atrophy. As she described it, “There are three layers to the vagina. The top layer completely disappears and the other two layers shrink, and you lose collagen as well, so the vagina starts to shrink.” There are also urinary symptoms associated with age due to thinning of the urethral lining. Dr. Marianne Legato, in her book Eve’s Rib: The New Science of Gender-Specific Medicine and How It Can Save Your Life, says that a reliable way for doctors to determine if a woman has enough estrogen is to “examine a sample of her vaginal lining under the microscope: A well-estrogenized lining is many layers thick.”5 If there is a lack of estrogen, the vagina will no longer be plump and juicy, but it can be treated with vaginal estrogen that lubricates the bladder as well. One medication that I use is Vagifem. It acts on the vaginal tissues only and is not absorbed into the bloodstream. Vaginal estrogen creams and a vaginal ring with estrogen are also available. Dr. Warren notes that the creams should be given in low doses and that both they and the ring are thought to be low-risk when appropriately used.
When women choose to take HT, those who have a uterus should take both estrogen and progesterone, to protect them from endometrial cancer; those who have had their uterus removed should take estrogen only. Besides strengthening bone and improving the skin, the hair, the brain, and the health of the vagina (which reduces pain during intercourse), HT may also increase sexual desire.
I strongly urge older women to have their blood tested for hormone levels, not just estrogen but free testosterone as well. Testing for free testosterone is not an automatic. You have to ask for it, as doctors are just learning to test older women for testosterone deficiency. In discussing the bottoming out of sexual desire in women, The Psychiatric Annals: The Journal of Continuing Psychiatric Education re-ported, “It has been postulated that, ‘No matter how hard a woman might try to assemble the building blocks of healthy sexual functioning—the required amount of the hormones, a loving partner, adequate stimulation, possibly a good sexual fantasy—it cannot work if she does not have the basic foundation of enough testosterone.’ ”6
Dr. Brizendine has been prescribing testosterone replacement for her women patients since 1994. She says that sexual dysfunction in women is often an above-the-waist matter, residing in the brain. The upsides of testosterone replacement are increased libido and the sensitivity of the genitals, especially the clitoris; heightened energy; and better mood, mental acuity, and muscle and bone growth. The downsides may include lower voice, facial hair, body odor, acne, and thinning hair. The particular form of testosterone that can actually get into your brain and cause an upswing of libido is known as “free testosterone.” The normal range of free testosterone for a woman—the amount thought necessary to maintain her sexual interest—is 20 to 70 of what are called picograms per milliliter. “Here’s the thing,” says Dr. Brizendine. “If you were to start taking estrogen in the form of an oral birth control pill or oral hormone replacement, it goes straight to your liver and makes more of this big, sticky globular protein called SHBG, or sex hormone binding globulin. I think of it as a big, sticky teddy bear that goes around in your bloodstream and gobbles up all of your testosterone, and then your testosterone isn’t free anymore. So you may have a good total testosterone level as a woman, but if you don’t have any that is free, you don’t have any that can get into your brain. The normal range for your sex hormone binding globulin is 100 to 150. If you are getting a workup for low libido, you want to know the level of free testosterone, because that is what counts in terms of your sex drive in the brain.” (Remember: The brain is the biggest sex organ.) Dr. Marianne