Testosterone belongs to the family of hormones known as androgens. Although they are often called male hormones, that is a complete misnomer. True, men have significantly more testosterone than women do. But women have 10 times more testosterone than estrogen.
In fact, almost all the estrogen in the female body starts out as testosterone. An enzyme called aromatase converts the testosterone in the ovaries to estrogen.
Besides testosterone, the androgens include dehydroepiandrosterone sulphate (DHEAS), dehydroepiandrosterone (DHEA), androstenedione, and dihydrotestosterone (DHT). Only DHT and testosterone are biologically active. In other words, they can bind to the androgen receptors in cells to produce a particular effect, such as increased sex drive or muscle mass. DHEAS, DHEA, and androstenedione are more like prehormones, in that they must be converted to testosterone to be biologically active. Otherwise, they don’t fit the androgen receptors.
Yet these three hormones are no less important than the rest of the androgens. DHEAS and DHEA, for example, serve as the body’s testosterone reservoir. If they run low, a testosterone shortage will develop. Conversely, if DHEAS and DHEA rise, testosterone will follow suit.
DHEAS and DHEA are manufactured in the adrenal glands, which lie on top of the kidneys, and are secreted into the blood. Once there, the hormones travel to all the major organs, where they can be converted to testosterone. Though the majority of a woman’s testosterone is made in the ovaries, some of it comes from the adrenal glands as well as from the conversion of DHEAS and DHEA in other bodily tissues.
We need to discuss just one more piece of the testosterone puzzle so you have a complete picture of how the hormone works in your body. A good amount of testosterone binds to a protein called sex hormone binding globulin (SHBG). When this happens, the testosterone becomes biologically inactive. The active form of the hormone, called unbound or free testosterone, accounts for only a small percentage—approximately 2 percent—of all the testosterone in your body. As we will discuss later, measuring your free testosterone level is the most accurate way to determine whether your low libido has a hormonal cause.
Now that you have an understanding of androgens, let’s talk about androgen deficiency. As we mentioned earlier, DHEAS and DHEA are manufactured by the adrenal glands. In women, DHEAS and DHEA production peaks in the midteens, then begins a lifelong decline. By the time a woman reaches her forties, her DHEAS level is only 60 percent of what it once was. From there, it continues to drop at a rate of about 5 percent a year. A 70-year-old woman has only about 20 percent of the DHEAS that she had when she was younger.
Likewise, testosterone peaks when women are in their midtwenties and declines steadily thereafter. A woman in her forties has only half as much circulating testosterone as she had in her twenties. Although levels of the hormone continue to drop throughout a woman’s life, menopause does not speed up the process. The same cannot be said for estrogen, which falls precipitously during menopause.
Because a woman’s androgen supply dwindles with age, it makes sense that her libido might lose some steam, too. This may be natural, but it isn’t necessarily desirable—or healthy. Though the sexual changes tend to occur gradually, they can be emotionally damaging in the long run.
Maria is a 46-year-old surgical recovery-room nurse at a world-renowned medical center. When she started having heavy, long, irregular periods, she knew that she could ask for advice from the dozen or so gynecologists she had met in the operative suite. Maria chose the best surgeon of the bunch. He suggested a vaginal hysterectomy. “After all,” he joked, “to cut is to cure.”
Maria was familiar with the procedure; she had taken care of dozens of women who had undergone the same surgery. As she was so sick of her periods, she quickly agreed. “Can we do it tomorrow?” she asked.
Her gynecologist also offered to remove her ovaries as a prophylactic measure to prevent ovarian cancer. “You may as well,” Maria replied. “I’m finished with them.”
The operation was successful. Maria went home the next day and was back to work in 3 weeks. Little did she realize that her sex life would never be the same.
Besides aging, a woman’s androgen levels can decline because of certain medical conditions, medications, and surgical procedures. The most common procedure that reduces both testosterone and estrogen is an oophorectomy, or removal of the ovaries. Gynecologists often perform oophorectomies to treat benign ovarian cysts. Or they may take the ovaries out if they remove the uterus. This procedure, called a hysterectomy, is the second most common medical operation among reproductive-age women. The usual justification for removing healthy ovaries during a hysterectomy is that it may prevent ovarian cancer.
Unfortunately, too many women don’t realize that an oophorectomy amounts to surgical castration. Urologists are much less likely to remove a man’s testes to treat benign growths or as a preventive measure. So why have oophorectomies become so routine? We suspect that many gynecologists simply ignore their clients’ sexuality, or they’re unfamiliar with the importance of testosterone to the female libido.
Sometimes an oophorectomy is necessary. Still, we believe that before any woman agrees to this procedure, she should discuss all the alternatives with her physician and opt to preserve her ovaries, if possible. Removal of both ovaries causes an immediate 50 percent reduction in circulating testosterone, with a more than 80 percent reduction in circulating estrogen. The abrupt drop in both hormones may profoundly affect not only a woman’s libido but also other aspects of her health.
The Maryland Women’s Health Study, which surveyed more than 1,000 women before and after their hysterectomies, showed that those who had undergone concurrent oophorectomies were two-thirds less likely to experience orgasm 12 months after the procedure. In another retrospective study of 100 women, those whose ovaries were removed during their hysterectomies reported more anxiety and depression, reduced psychological well-being, and diminished sex drive as compared with those who kept their ovaries.
A third study, published in the medical journal Menopause, found that women who underwent oophorectomies experienced a global decline in their sexual function. This included a reduction in sexual thoughts and desires, diminished arousal, decreased frequency of intercourse, fewer orgasms, and less satisfaction with their intimate relationships.
We should point out that the precipitous drop in testosterone that accompanies an oophorectomy does not undermine libido in all women. Why might this be so?
As we explained in chapter 6, testosterone, estrogen, and dopa-mine affect libido in different ways. A woman whose sex drive is more testosterone dependent may enjoy sex because of the intense physical pleasure that it provides. For a woman whose sex drive is more estrogen dependent, the main motivation for sex could be the emotional bond that she feels with her partner. A woman whose sex drive is more dopamine dependent likely is drawn to the “psychological high” that she gets from sex. In the latter two cases, even a large drop in testosterone may not cause a significant decline in libido.
Of course, most women do not fit neatly into one of these three categories. So a drop in testosterone may not diminish their libidos as much as change their experience of sex. In fact, most women find that as they mature and their androgen levels naturally decline, they are less focused on physical pleasure and orgasm. Instead, they perceive more value in the emotional aspects of making love to their partners.
Jessie is a 36-year-old mother of two and a stand-up comic in the comedy clubs of New York City. This is her story in her own words.
“A few years after the birth of my second child, my periods started to get out of control. Every month for the week before my period, I would become severely moody. I alternated between laughing, crying, and screaming—sometimes in the same sentence.
“On the first day of my cycle, my cramps would be so bad, all I could do was crawl into bed with a heating pad on my stomach. I would get migraines. I was miserable.
“My gynecologist suggested birth control pills to smooth out my hormones. I had been on the Pill before—from the time I started college until I missed a couple of pills, had a few too many drinks, and got pregnant with my first child. I thought it was a great idea.
“The Pill worked almost immediately. By my third pack of pills, I felt much better. But by my sixth pack, I felt neutered. No sex drive—none, nil, nada. I got more thrills from my electric toothbrush than from my vibrator.
“I ran back to my doctor. Something was wrong, very wrong. I begged her to fix me. She suggested that it might be the Pill. ‘No way, it couldn’t be the Pill,’ I told her. ‘I had been on the Pill in college, and I had a very healthy sex drive!’ She changed my prescription anyway. Within a few months, my sex drive was back. Thank God!”
Many women are surprised to learn that birth control pills can have an adverse effect on their libidos. Taking oral contraceptives reduces free testosterone by increasing SHBG. The elevated SHBG does not change a woman’s total testosterone, but it decreases the amount that’s biologically active.
Incidentally, this is why oral contraceptives have been approved for the treatment of moderate acne. A reduction in free testosterone will help prevent breakouts because free testosterone and DHT are partially responsible for sebum secretions by hair follicles on the surface of the skin. Sebum is an oily substance that bacteria thrive on. Less sebum means fewer bacteria, which in turn minimizes infection in the hair follicles. A woman is less likely to develop acne as a result.
So why doesn’t every woman who takes birth control pills report a decline in libido? First, a woman’s desire to have sex actually may increase when she is protected from unwanted pregnancy. Second, the drop in free testosterone may not be enough to alter the sex drive of a woman in her twenties, because she has a naturally high level of testosterone at that age. It would be a different story for a woman in her early forties, whose testosterone and DHEAS have dropped significantly. Taking birth control pills might push her free testosterone below the threshold necessary for a healthy libido. Third, as we mentioned before, libido isn’t always testosterone dependent.
Incidentally, menopausal women on hormone replacement therapy also will experience a decline in free testosterone. Just like oral contraceptives, hormone replacement therapy increases SHBG, thereby reducing free testosterone.
Most physicians are not well-versed in androgens or androgen deficiency. If you want to check your levels of these hormones, you may need to ask for a test. You have several options, though some are more reliable than others.
As we discussed earlier, although total testosterone is important, free testosterone is the most clinically significant value. Unfortunately, measuring a woman’s free testosterone is difficult. The tests currently offered by the major commercial laboratories in the United States were developed for men, because men have much higher levels of circulating testosterone. This means that what’s considered “normal” for the tests is based on the testosterone levels of men, not women. Any test loses accuracy when measuring levels far beyond its normal range.
This becomes a more significant issue when you consider that free testosterone accounts for only about 2 percent of a woman’s total testosterone. In other words, free testosterone is even further outside the normal range that the tests are designed to measure.
Most experts agree that the test most often recommended for women, the analog free-testosterone assay, is not especially reliable. Better tests exist, but often they’re available only to women who are taking part in research studies. Still, with a little perseverance, you may be able to obtain a more accurate reading if you work with your doctor to send your blood sample to a specialty lab.
The best of the available tests are the equilibrium dialysis assay and the bioavailable testosterone assay. If you are unable to obtain either of these, your next choice (and the one we use most frequently) is the Free & Bioavailable Testosterone calculator, which is available at www.issam.ch/freetesto.htm. This is a combination of three tests—total testosterone, albumin, and SHBG.
Before scheduling a test of your free testosterone, we suggest that you consider three important issues. First, your physician may want to measure your salivary testosterone, because a saliva sample is easier—and less painful—than a blood sample. But most experts agree that salivary testosterone is not accurate enough to identify a testosterone deficiency. Second, some experts believe that a woman’s testosterone production varies throughout the day, peaking in the morning. For this reason, we recommend that you schedule your test between 8 A.M. and noon. Third, you may want to ask your doctor to check your DHEAS and DHEA as well. Later in this chapter, we’ll explain how you can raise your testosterone by taking supplemental DHEA.
Once you have the results of your test, you’ll need to know how to interpret them. Before we explain our guidelines, we must acknowledge that few published studies have examined normal androgen levels in women. Because these data are lacking, we do not have a set level below which we automatically prescribe supplemental androgens.
The good news is that large-scale studies to determine normal androgen levels for women are under way. Until the results of these studies are available, we suspect androgen deficiency if we see a total testosterone reading of less than 25 nanograms per deciliter (ng/dl) in premenopausal women or less than 20 ng/dl in postmenopausal women. If you use the Free & Bioavailable Testosterone calculator mentioned on the previous page, a free testosterone of less than 0.6 ng/dl in women younger than 30 years old or less than 0.4 ng/dl in women greater than 30 years of age is another red flag. So is a DHEAS reading of less than 150 ng/dl.
Of course, every woman is unique, even in terms of her androgen makeup. But in general, if a client’s androgen levels are even slightly below what we consider normal, and she is showing other symptoms of androgen deficiency, we may try low-dose androgen supplementation to see if it helps her libido.
Bear in mind that many symptoms of androgen deficiency are nonspecific and could just as easily be linked to other medical problems. This is why we never recommend supplementation to a client until we have performed a thorough physical and psychological evaluation.
If we diagnose androgen deficiency in a client, our next step is to review the treatment options with her. Many are available, but unfortunately, none of them is ideal. Scientists are working to develop a safer and more effective alternative. In the meantime, we have a couple of treatment protocols that we feel comfortable recommending, and several that we do not.
On the pharmaceutical front, the FDA has given its approval to only one androgen medication. It’s a combination of estrogen and methyl testosterone, sold under the brand name Estratest. For decades, postmenopausal women have taken Estratest to get relief from recalcitrant hot flashes. The drug is not approved as a treatment for low libido, so its use for this purpose would be off-label. In early 2009, Solvay, the company that manufactures Estratest, decided to stop distributing this drug.
The methyl testosterone in Estratest is a derivative of the hormone, rather than the natural form. We are not disappointed with Solvay’s decision as we have always advised our patients to steer clear of methyl testosterone for several reasons. First, the hormone alters a woman’s cholesterol profile by lowering her HDL, the “good” cholesterol that prevents heart disease, and raising her LDL, the “bad” cholesterol responsible for facilitating the artery damage that can lead to heart attack or stroke. Second, the tests mentioned earlier cannot measure methyl testosterone, so monitoring levels of the hormone is difficult. Third, research has shown that large doses of methyl testosterone can harm the liver.
In Europe and Australia, researchers have developed a method of implanting testosterone pellets under the skin. It requires a surgical procedure, which raises the risk of infection. In addition, the pellets last only a few months, which severely limits their convenience for general use. Currently, the FDA has not approved this treatment for women in the United States.
The intramuscular injection of testosterone esters is a well-established and widely accepted treatment for men. Now physicians are offering the injections to women, albeit with much smaller doses of the hormone. After an injection, the amount of testosterone in the blood remains high for a number of days. The huge downside is that it can climb well above the normal range for women, leading to side effects such as permanent clitoral enlargement, male pattern baldness, acne, and deepening of the voice.
So now that we’ve identified which forms of androgen supplementation we don’t like, you may be wondering which forms we do like. One is oral DHEA, which has been the focus of significant research. The idea is that if you increase a woman’s supply of pre-hormones, her body will convert them to testosterone. Oral DHEA is available in health food stores, pharmacies, and supermarkets without a prescription.
We follow a protocol established by André Guay, M.D., at the Lahey Clinic in Peabody, Massachusetts, starting with 50 milligrams of DHEA each morning. In 2 months, you should check your levels of total and free testosterone. If your free testosterone is between 0.4 ng/dl and 0.6 ng/dl, you can stay at the current dosage. If the hormone is below 0.4 ng/dl, you should increase your dosage to 75 milligrams of DHEA a day. Continue checking your testosterone every 2 to 3 months. If necessary, you can take up to 100 milligrams of DHEA a day.
We have one very important caveat about using DHEA that you should be aware of. Because DHEA is classified as a nutritional supplement and not a medication, it is not subjected to FDA regulation. As you might imagine, product quality varies widely. In fact, a recent analysis of 17 different brands by ConsumerLab.com found that three brands actually contained no DHEA. Most had between 60 and 80 percent of the amount of DHEA listed on the label, but one exceeded its stated dosage by 149 percent.
For this reason, we recommend sticking with one brand of DHEA—we prefer Vitamin Shoppe or Natrol—and monitoring your free testosterone every 3 months, if not more often. We also recommend checking your cholesterol profile every 6 months and your liver function once a year. Most important, you must use effective birth control while on DHEA or any other form of androgen supplementation, as these hormones can harm a fetus.
Besides oral DHEA, we often prescribe a 0.2 percent testosterone gel or ointment (compounded in a penetrating base) to our clients with androgen deficiency. The advantage of this preparation, which can be made by a compounding pharmacist, is that it can be combined with estrogen (0.01 percent estradiol) and applied directly to the vulva and clitoris. Although no one has published research on this preparation, our clients who use it typically notice improvement in clitoral sensation and vaginal lubrication within about a month. It seems especially helpful after pelvic surgery.
Our regimen is an adaptation of one developed by Judith Reichman, M.D., a nationally known gynecologist who teaches and practices at Cedars-Sinai Medical Center and the University of California, Los Angeles. We recommend applying 1 gram of the hormone preparation every night for 4 weeks, then cutting back to two or three times a week. While using the preparation, you should check your total and free testosterone after the first 2 months, then every 3 months. As with oral DHEA, we suggest testing your cholesterol profile every 6 months and your liver function once a year.
As a side note, our Sexual Wellness Center is one of several dozen clinics around the world conducting a large-scale clinical trial for a testosterone patch designed especially for women. The results of this study were very promising, and the testosterone patch called Intrinsa was approved for sale in Europe in 2007. Unfortunately, the American FDA has not approved Intrinsa because they believe that there was not enough long-term safety data. In addition, the FDA decided that the appropriate way to determine the effectiveness of the patch was to count the number of “sexual events” per month. During the trial, women had an increase of only one “sexual event” per month. The FDA decided that this was not meaningful; however, we strongly disagree. We believe that there is a big difference between a woman who has sex three times a month to make her partner happy as compared with a woman who has sex four times a month because she wants to. Procter & Gamble, the maker of Intrinsa, continues to gather long-term safety data to present to the FDA. In addition, BioSante, another pharmaceutical company, is doing similar studies on a testosterone gel for women called LibiGel.
Liza met Cole on a beach in sunny southern California. She was an 18year-old college coed. He was 24, a blond James Dean type—completely different from the yuppie wanna-be’s that populated the campus at Southern Cal. He even drove a beat-up ’67 Mustang convertible. Though he was quiet and often sullen, Liza imagined that he had grand, exotic dreams.
Their relationship was not much more than sex on the beach or in the back of Cole’s car. But after one memorable lovemaking session in front of a raging bonfire (and a few other amorous couples)—combined with the intoxicating effects of a few beers and a couple of joints—they drove all night to Las Vegas and got married.
Liza’s vision of an exotic and adventurous life with Cole quickly began to fade. He made a few halfhearted attempts to land small acting parts in Hollywood, but he was easily discouraged. He spent more time on the beach drinking and hanging out with his buddies. Liza had to work two jobs to support the family, which grew to include twin girls.
Even though sex had been the foundation of their relationship, Liza noticed that she wasn’t all that interested anymore. She mentioned her declining libido to her gynecologist, who diagnosed a low testosterone level after running some tests. Liza received a prescription for a testosterone cream to help restore her sex drive.
Ever the optimist, Liza believed that if their sex life improved, Cole might change his behavior—spending time at home rather than with his friends, becoming a more attentive father and husband, maybe even getting a job. Though she used the cream religiously, her libido did not improve.
Then Liza caught Cole having sex with another woman on the beach, only a few blocks from where she had met him 3 years before. Devastated by his betrayal, she realized that their marriage would never be what she had hoped for. She filed for divorce.
Did Liza lose interest in sex because of low testosterone? And shouldn’t testosterone supplementation have helped her sex drive? In our opinion, the answer to both questions is no. Low testosterone was the result of Liza’s poor marriage, not the cause of it.
From the beginning, Liza had mistaken Cole’s dark, brooding nature for adventurous sophistication. In truth, it revealed a fundamental inability to communicate effectively and to form deep emotional attachments. Liza realized this subconsciously long before she acknowledged it consciously. This is why her sex drive waned long before she filed for divorce.
To understand the impact of all this on Liza’s testosterone level, we must acknowledge the mind-body connection—that is, the interplay between our emotions and our physical health. Modern medicine long ignored this relationship, but compelling new research is changing many opinions. For example, one recent study found that women who are under stress are more susceptible to infections. Another confirmed that people who are depressed have a lower survival rate after a major illness.
Findings like these clearly illustrate how our minds can affect our bodies. This is another reason why we feel so strongly about conducting a thorough physical and psychological evaluation before we consider androgen supplementation—even if a client has low testosterone.
As we’ve said throughout this book, our experience has taught us that low libido generally results from a host of factors, not just a single problem like androgen deficiency. Still, we’ve seen androgen supplementation make a dramatic difference for many women. In some cases, it’s all that’s necessary to restore a healthy sex drive. That certainly was true for Carla, one of our clients.
Both Carla and Charles had been married before. Though neither of them had any intention of ever marrying again, they eventually moved in together and settled into a comfortable and loving partnership.
Carla and Charles admitted that their life was rather mundane. Still, they could say with all honesty that they felt content. They also agreed that their sex life was not nearly as tepid as other aspects of their relationship. In fact, Carla described sex with Charles as “explosive and hot.” So both of them were surprised when her sex drive began to wane.
At first, Carla almost completely stopped masturbating. Even when sex had been plentiful, she had enjoyed the pleasures of self-stimulation. Over time, she initiated sex less frequently. And if Charles made advances, Carla often would perform oral sex instead of having intercourse.
Because the changes happened so gradually, and because Carla found other ways to be intimate with Charles, her diminished libido never became an issue. Then one day, she found a videotape of the two of them making love. They had made the tape a few months after moving in together.
Carla sat on her bed sobbing as she watched the video over and over. She realized how far she had fallen from her sexual prime. And at that very moment, she resolved to become that sexy woman again—no matter what it took.
First, she needed to figure out what had happened to her sex drive, which had been so strong for so long. She found some health references at the local library, but they weren’t very helpful. Then she tried the Internet. Searching the words “decreased libido,” she found the Sexual Wellness Center. Even though our clinic was 400 miles away, she couldn’t make an appointment soon enough.
After performing a thorough medical evaluation, I (Dr. Goldstein) concluded that Carla’s low libido had resulted from an androgen deficiency. Her free testosterone, measured by an equilibrium dialysis assay, was 0.3 ng/dl; her DHEAS was 77 ng/dl. As she was not taking any medications and had no underlying medical conditions, I suspected that the decline in her hormone levels was age-related.
I prescribed a compounded testosterone-estrogen gel, which Carla began using right away. Within a few weeks, she noticed an improvement. She even dreamed about sex, something she hadn’t done in several years.
When we checked Carla’s free testosterone 2 months into her treatment, it measured 0.7 ng/dl—an increase of more than 100 percent. As Carla lived about 8 hours from the Sexual Wellness Center, her regular gynecologist continued to monitor her free testosterone every 3 months. It stabilized at around 1 ng/dl.
Carla did not experience any adverse effects from the hormone supplementation. Her cholesterol profile and liver function remained healthy. This is exactly what we expected, as her free testosterone was well within the normal range.
A year and a half later, I received an invitation to a book signing for Charles’s latest work. Attached to the invitation was a handwritten note: “Charles took much longer to write this than usual. We had forgotten how much time we used to spend in bed (wink, wink). This was an accommodation he was all too happy to make. Thank you so very much!”