Last week Nick Panay, the Royal College of Obstetricians and Gynaecologists’ (RCOG) spokesman on menopause, suggested that more women experiencing low libido should be offered testosterone on the NHS. Speaking at the Royal College of GPs’ conference in Harrogate, he spoke of how testosterone not only improved sex drive, but energy, wellbeing, muscle strength and stamina too and how frustrating it was having to prescribe it “off-label” to women.
Do we really Need more Testosterone for Women?
Three years ago I would have greeted this news with unbridled enthusiasm. Back then I was taking Testim testosterone gel daily as part of my HRT regimen and enjoying the benefits; my libido had returned, my relationship with my partner of 22 years had subsequently improved, I was feeling fit and the depression that had plagued me for so many years had lifted. It seemed that testosterone was the missing link in my wellbeing, a miracle hormone, and I wanted to spread the word and help other women who needed it get it prescribed by their doctors.
Testosterone for Women does not always Work
But then things changed. My sex drive subsided to near non-existent levels. I was tired all the time and felt as if I’d lost my joie de vivre. Blood tests revealed that my testosterone levels were only slightly above zero in spite of daily doses of the stuff and my oestrogen levels were sky high. In fact, raised oestrogen had resulted in my endometrium (the lining of my uterus) thickening to worrying levels, as well as adenomyosis, which is when endometrial tissue grows into the wall of the uterus causing small pools of blood to form. A thickened endometrium is a symptom of endometrial cancer and so I was scheduled to have a hysteroscopy, a surgical procedure involving a general anaesthetic.
Luckily for me I was cancer free but I felt disillusioned and angry that taking bioidentical hormones, which I had always considered to be safe, had put me in this situation. Attempts to discuss why my testosterone levels were so low with my consultant were met with resistance each time. He was more concerned with the progesterone intolerance symptoms I was experiencing which were making my life a misery. It was at this point I decided that taking HRT was not for me, and so in March this year, after a year of weaning myself off it, I finally stopped taking HRT altogether.
Testosterone is Converted into Oestrogen
Further research on my part revealed several reasons why the testosterone was no longer working. One possibility was dermal fatigue, whereby fat tissue in the skin becomes saturated with the hormones and they stop working. It may also have been because my skin was less absorbent due to my age. But the most likely reason was that the testosterone was being converted into oestrogen. This is what happens naturally anyway – most of the testosterone that women produce in their ovaries is converted into oestrogen, specifically oestradiol.
Testosterone and HRT
What perturbs me about Nick Panay’s call for GPs to prescribe testosterone to women suffering from low libido is that more women will be put onto HRT unnecessarily. Testosterone is normally prescribed as part of a hormone package, i.e. with oestrogen and progesterone (if the woman still has her womb) for the sake of hormone balance. Also, it tends to be menopausal women who complain of low libido and so the cause is thought to be hormonal. There has been very little research into testosterone supplementation on its own in women and the one study I did come across showed incidence of breast cancer. Taking HRT is not to be taken lightly, hormones are very powerful things indeed, and they do come with side-effects; some a little annoying like bloating and monthly periods and others that can be life-threatening and even deadly in the case of strokes or breast cancer.
GP’s Lack Training on Menopause and Hormone Replacement
The problem with Nick Panay saying that testosterone “should be part of the counselling process” for women complaining of low libido is that there is still no form of testosterone available that is approved for the use in women and not likely to be in the foreseeable future, a fact which Pany himself finds “frustrating”.
It’s all very well suggesting that GPs prescribe testosterone off-label but many doctors are not very confident when it comes to the subject of menopause, let alone sex and “off-label” hormone replacement. Many have not received much training in this area as undergraduates and have not chosen to undergo optional training as qualified doctors. In fact, several readers of this website have written to me asking for advice on how much Testim gel to apply as their GP has been unaware or prescribed them the male dosage.
Testosterone Levels and Female Sexuality
But it is the issue of libido and female sexuality that concerns me most. Over the last couple of years testosterone for women has become a hot topic in the media resulting in more women wanting to try it. I get the impression that many women think that testosterone will be a quick fix for their flagging libidos and solve all their problems, but female sexuality is much more complex than that.
Admittedly Nick Panay did tell the Royal College of GPs’ conference: “We’re not saying that female androgen replacement is a universal panacea. We’re not saying it is a female Viagra. Women are, after all, much more complex creatures than men (and do not respond) to the on/off button that Viagra offers.”
In some cases, testosterone will be just what a woman needs, particularly if her lack of sex drive is due to abnormally low testosterone levels after an oophorectomy (surgical removal of the ovaries). But the problem lies in deducing what are normal levels of testosterone for women and how best to measure them. Some women may have naturally high levels of testosterone and others not. Blood tests for testosterone are notoriously unreliable as blood levels fluctuate throughout the day.
It is normal for testosterone levels to start declining with age; in women they are highest when we are in our twenties and by our forties our levels have usually halved. During perimenopause testosterone levels continue to steadily decline, unlike oestrogen and progesterone levels which drop more dramatically and can fluctuate unpredictably. In other words, it is normal for women in their forties and beyond to have low testosterone levels. It is not normal to have the same levels as a 25 year-old in midlife.
Testosterone may not be that Important
The importance of testosterone in female sexual desire is debatable. Researchers looked at data from the US-based Study of Women’s Health around the Nation (SWAN) and analysed the relationship between reproductive hormones and sexual function during the menopausal transition. They found that women with higher levels of testosterone and/or DHEAS – a precursor to testosterone – felt sexual desire more frequently and masturbated more often. But the researchers deduced that associations between hormone levels and sexual function were “fairly subtle” especially as women who reported having fewer sad moods and higher levels of satisfaction in their relationships also reported better sexual function. This led them to conclude that testosterone has a very limited role to play and that women’s relationships, emotional health and other psychosocial factors are intricately linked to sexual function and may be stronger than any hormonal influence.
The Placebo Effect
Part of the problem with treating low female sexual desire with drugs is the placebo effect. In studies done on the use of testosterone patches by women the placebo effect was considerable. In one study 31% of women receiving the placebo reported ‘meaningful treatment benefit’ compared with 52% of women receiving the active testosterone patch and when it came to reports of increased sexual desire and activity the differences in the two groups weren’t significant.
It turns out that when women believe they’re taking something that will help their sex lives they’re more willing to have sex even if they’re not in the mood, more willing to focus on how their partner is stimulating them and to ask their partner to do things they prefer. So, part of the placebo effect may be due to better communication between the women in the study and their partners.
Testosterone trials on women with low sexual desire are further complicated by the fact that the testosterone has improved their general wellbeing and energy levels and it’s their improved mood which puts women in the mood for sex and not the other way round. After all, the link between depression and low desire has long been established. Female sexuality is a complex subject and when it comes to desire and arousal it’s hard to pin it down to a single hormone when so many other factors are at play.
The Search for Female Viagra
Last year there was a lot of excitement in the press when a new drug Flibanserin, marketed as Addyi, was launched in the USA. Pharmaceutical companies had been looking for a female equivalent of Viagra ever since Viagra was launched in 1998 and became a multi-million dollar best-seller. Trials of Viagra on women proved that increasing vaginal blood flow did not make women feel increased sexual desire. After that they tried testosterone on women, thinking low libido was primarily a hormonal problem, with some success but the consequences of long-term testosterone use in women are unknown.
Finally, it was decided that female low libido was primarily a brain chemical problem. Flibanserin works by boosting levels of the neurotransmitters dopamine and norepinephrine in the brain and decreasing serotonin. Unfortunately, this drug has some very unpleasant side-effects and in trials it only resulted in half to one more sexually satisfying event per month.
Reasons for Low Libido in Women
A myriad of reasons explain why women may experience a lack of sexual desire and low testosterone is only one of them. Physical causes of low libido include anxiety and depression, stress, exhaustion, an underactive thyroid, diabetes, iron deficiency anaemia, pain and certain medications including high blood pressure treatment, antidepressants and the contraceptive pill. And then there are the psychological causes of low libido the most common of which are body image issues and relationship problems, including women being bored in long-term monogamous relationships.
Researchers from Germany found that a woman’s sex drive begins to plummet once she is in a secure relationship. Four years into a relationship, less than half of 30-year-old women wanted regular sex whereas men’s libido remained the same. Many women who’ve been married for 20 or 30 years often complain of low libido. But the moment they find themselves divorced and with a new lover, their libido returns to levels they experienced when they were young.
It is also important that we take into account that people have different sex drives, some are high others are low and this can lead to desire discrepancy in couples. But because a woman doesn’t want sex as often as her partner, doesn’t mean she is dysfunctional and should be prescribed testosterone.
Ageing and Sexual Satisfaction
There is no doubt that ageing affects our hormone levels but that doesn’t mean we can’t have a good sex life. After all, it should be the quality of sex that matters, not the quantity. Many women say that even though their libido is lower, their sex lives are much more satisfying as they’ve got older. This may be to do with the fact that women are more satisfied with their lives in general, able to communicate with their partners, more sexually confident and happy with who they are.
Sexual Response Models
Over the past couple of years I’ve been researching a book on the menopause and by far the most valuable thing I’ve learned is that men and women have different sexual responses. Ever since Masters and Johnson created their model of Human Sexual Response in 1966 it has been believed that for both women and men and sexual response begins with sexual desire in the form of sexual thoughts, fantasies or an urge, desire leads to arousal, then to orgasm and finally resolution. This model is an established part of our culture.
But in 2002, Rosemary Basson, a professor at the University of British Columbia presented a new model of women’s sexual response. Basson argued that for women sexual arousal is often more about mental excitement rather than an awareness of what is happening in our genitals.
Many women who are completely sexually functional do not experience spontaneous sexual desire unless it is the beginning of a relationship or they’ve been separated from their partner. This is completely normal.
Women, particularly women in long-term relationships, usually feel sexual arousal and desire only after they have chosen to put themselves in a sexual situation, not before. In other words, just because a woman has no conscious desire for sex, does not mean that sexual arousal is not possible. It most certainly is.
Reasons why Women have Sex
Researchers Cindy Meston and David Buss at the University of Texas at Austin identified 237 distinct reasons or motivations why women have sex. Unlike men, who may respond to a visual stimulus and experience a sexual urge with noticeable effects, women may have sex because they want to feel close to their partner, to feel loved or needed, to cure a headache, to barter for a gift or to boost their self-confidence. In contrast to the Masters and Johnson model, feeling sexual desire is only one of many reasons why a woman might be motivated to have sex.
Low libido is Normal for Women
It’s no wonder so many women feel that their libido is under threat given the stressful lives we lead, the responsibilities we have as women looking after our careers, children, partners, parents, homes, health and our sex lives. Could it be that rather than our libidos being low, that our creative energy or drive is being channelled elsewhere, away from the bedroom into all the other areas of our lives demanding our attention?
Statistics vary, with some studies saying 55% of women have low libido while Nick Panay believes that loss of libido affects 15% of menopausal women. One survey of 1805 postmenopausal women in six European countries found that 34% of women reported having a reduced sex drive, with low sexual desire most likely to be experienced by women in the UK.
More researchers are agreeing that a lack of spontaneous sexual desire is normal for most women, especially if women are in long-term relationships or don’t have a partner, but women are being made to feel that there is something wrong with them if they have a low libido.
HSDD and the Medicalisation of Female Libido
In today’s highly sexualised society women are supposed to look young forever and be sexually available until the day we die. Women in popular media have libidos that we are all meant to aspire to and emulate. If we’re not up for it then there’s something wrong with us; we’re labelled dysfunctional and told we need to take hormones. It is debatable whether or not a low libido should even be seen as a medical problem if it’s the norm for so many women.
Hypoactive Sexual Desire Disorder (HSDD) or low libido is listed in the 4th edition of the psychiatrists’ bible, the Diagnostics and Statistical Manual of Mental Disorders (DSM IV) although in the most recent edition it has been changed to Female Sexual Interest/Arousal Disorder (FSI/AD). The reason it’s included as a mental disorder is because it can cause ‘marked distress or interpersonal difficulty’ and it is this matter of ‘distress’ that makes low libido a medical condition that can be treated with pharmaceuticals.
Natural ways to Increase Testosterone Levels
Testosterone may be a quick fix for restoring libido but there are simple things you can do to increase your testosterone levels and sex drive naturally. Obvious things like getting enough sleep, not drinking too much alcohol or eating sugar and controlling the stress in your life. Exercise increases testosterone levels as does having sex. When it comes to diet, women in particular need to make sure they are getting enough iron. And if none if this appeals, you could always try the power poses suggested by Harvard social psychologist Amy Cuddy. Standing in a ‘Wonder Woman’ pose for 2 minutes was shown to increase testosterone levels by 20% and decrease cortisol (the stress hormone) levels by 25%. Not bad for 2 minutes of effort!
We need more Education around Female Sexuality
It’s been six months since I stopped taking HRT including testosterone and for the first couple of months I felt very unwell. I’ve got used to having hot flushes and night sweats and the fact that I have very little libido to speak of. But I feel so much better knowing that there is nothing abnormal about how I feel. I understand now that if I make time to be intimate with partner and allow myself to relax into the situation, chances are I will become aroused and have an enjoyable sexual experience.
I am not dismissing the fact that for some women lack of libido is a very distressing situation, particularly if it is impacting upon their relationship or if they have been very sexual in the past and feel that they have lost an important part of themselves. It is very easy to feel that you’re abnormal or to worry that your partner is going to leave you for another (younger) woman who does have a libido. Women don’t need to feel sexual desire before having sex but I fear many women don’t realise that this is normal and when they compare themselves to their partner, particularly if their partner is a man, they may believe there is something wrong with their libido or they are lacking in testosterone.
Rather than women feeling inadequate and doctors prescribing hormones, we should be taught the reality about female sexuality and all its complexities.
It is time to stop thinking men and women are the same sexually when it comes to sex drive and arousal. We are not and as long as male standards are applied to women, women are going to feel inadequate and under pressure to perform.
Testosterone for women may be a temporary fix for a distressing problem but education about female sexuality is a more enduring and empowering solution.
Testosterone on NHS ‘could help boost women’s libido’ http://www.bbc.co.uk/news/health-37588549
I was quoted in this article in the Daily Mail: Should women get testosterone by the NHS to boost their sex drives? Experts divide over the use of male hormones to cure sexual desire disorder