Recently, three new drugs have been added to the armamentarium for menopausal symptoms and dyspareunia:
• Paroxetine 7.5 mg
• Conjugated estrogens and bazedoxifene
• Ospemifene.
In this article, I present a case-based approach to incorporating these drugs into practice and restoring sexual function in the setting of vulvovaginal atrophy and dyspareunia. As is often the case, decision-making requires sifting through multiple layers of information.
CASE: LOW DESIRE AND DISCOMFORT DURING INTERCOURSE
A 58-year-old patient mentions during her annual visit that she’s not that interested in sex anymore. Her children are grown, she’s been happily married for 28 years, and she enjoys her job and denies any symptoms of depression. She says her relationship with her husband is good and, aside from her low desire, she has no worries about the marriage. Her only medication is paroxetine 7.5 mg/d for management of her moderate hot flashes, which she initiated at her last annual visit. She reports improvement in her sleep and menopausal symptoms as a result. She has an intact uterus.
You perform a pelvic exam and find atrophic vulva and vagina with mild erythema and thinned epithelium. When you ask if she has experienced any discomfort, she reports that she needs to use lubrication for intercourse and that, even with lubrication, she has pain upon penetration and a burning sensation that continues throughout intercourse. She also reports that it seems to take her much longer to achieve arousal than in the past, and she often fails to reach orgasm.
How would you manage this patient?
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