Topical Testosterone for Improvement of Libido

Question

The local compounding pharmacy is now faxing us, asking us to prescribe topical testosterone for improvement of libido. Is this useful? Are there risks?

Answer

Thank you for your question. Whether or not to use testosterone therapy for menopausal women with low libido is a hot topic currently—the North American Menopause Society has also just issued a statement (Menopause 2005;12:497-511).

In understanding sexuality, we need to appreciate how complex it is (1). It includes cultural concepts so deeply buried that they are “true” without warranting any thought. Sexual interest is keyed into unique characteristics of individuals that create responses in another person. And women’s sexuality is different from men’s, not just because culture says so, but also because physiology differs. Healthy sexuality for women is strongly tied to personal safety and trust—yet many women live with the memory of sexual abuse.

And then there are the various physiological aspects of women’s sexuality including the increased sexual interest in the middle of the normal menstrual cycle around the time when cervical mucus is most stretchy and estrogen is reaching its peak. That peak of sexual interest is obliterated by use of the Pill or other hormonal contraceptives.

Then there is the pattern of women’s sexual interest across the life cycle—a maximum in puberty that stays high into the mid-thirties and then decreases slightly. In perimenopause, for no hormonal reason that is clear, sexual interest usually hits an all-time low. This is likely because perimenopausal women are overwhelmed by physiological changes and affected by the cultural negatives related to aging.

For most menopausal women, sexual interest is rarely “front and centre.” Menopausal women rarely initiate sexual activity—the reasons are probably less cultural than biological. However, responsive sexuality continues into old age. Note that 65% of menopausal women who continue to be sexually active do not have bothersome vaginal dryness. Those that do can be effectively treated with very low dose topical estradiol or estriol.

All that being said, what is testosterone’s role in sexuality? Testosterone is the primary testicular hormone for men, but women’s ovaries and adrenals also make small amounts. The lower limit of normal for women’s testosterone is not known. That is, in part, because the assays are simply not sensitive enough. Another reason we don’t know the range of normal for women’s testosterone levels is that we haven’t performed adequate studies in random samples of women of differing ages, socioeconomic, racial and reproductive status.

The life pattern of testosterone for women is broadly known. Levels start to increase in girls about ages 7-8 because the adrenal is making more. When the first period occurs, and especially before ovulation is established, testosterone levels are higher. They stay high through to the mid-30s. After that, testosterone levels in women appear to decrease slightly based on cross-sectional studies by Dr. Henry Burger from Melbourne, Australia. Testosterone levels do not appear to change across perimenopause nor in normal menopause (2). If anything, the testosterone that the ovaries continue to make after menopause is more effective because estrogen-stimulated levels of sex hormone binding globulin have decreased leaving more testosterone free to be active. However, if surgical menopause occurs and both ovaries are removed, testosterone levels decrease (3).

The evidence that testosterone is the primary hormone of sexuality for men has been confirmed in controlled trials of testosterone and men’s sexual responses (4). However, the data for women are sparse. One randomized, double-blind placebo-controlled trial of testosterone therapy for women’s sexuality showed that women taking testosterone compared with placebo were more likely to masturbate but not more likely to have sex with their partner. We also know that some men, despite low testosterone levels, can still maintain their sexual activity and interest if they are partnered and their sexual relationship was established before testosterone levels declined.

Now, to the question you are really asking—should I be treating my menopausal patients with testosterone? The answer is generally No. That’s like trying to fix a problem of engine timing by adding anti-freeze to the radiator. And, testosterone, in a dose appropriate for men, is not safe for women. Testosterone should carry the same contraindications as estrogen—it should not be given for a woman with risks for thrombosis, breast or endometrial cancer. The reason is that testosterone is excreted by being made into estrogen in the body.

The only women for whom testosterone therapy would make hormonal sense are those who have had surgical menopause and are experiencing a low sexual interest. Testosterone therapy, in the very low doses that compounding pharmacists can make, would only be indicated if a woman who had a surgical menopause requests assistance for her sexuality, has no vaginal dryness, and a regular partner with whom she can communicate.

Now you ask, what about the other menopausal women who expect to be interested in intercourse every night—and find they aren’t? It may be that theirs and/or their partner’s expectations are fed by too much Sex in the City! But if a healthy menopausal woman is having trouble becoming aroused, vaginal dryness and relationship problems are not involved, what can you do to be of assistance? First, provide her with a listening ear. Second, encourage the woman to talk with her partner—about foreplay, and especially what feels good and sexy for her. Third, explain to her that responsive sexuality is normal after menopause. And if these are helpful but not sufficient, suggest one of the over-the-counter clitoral creams that are either commercial, or made by compounding pharmacists. These increase blood flow by using arginine or aminophyline, cause clitoral enlargement and sensitivity and thus help a woman to reach orgasm.

Sorry for the long-winded response to your question. I hope this answer is helpful.

Reference List

1. Daniluk JC. Women’s sexuality across the life span. Challenging myths, creative meanings. New York: The Guilford Press, 1998.
2. Burger HG, Dudley EC, Cui J, Dennerstein L, Hopper JL. A prospective longitudinal study of serum testosterone, dehydroepiandrosterone sulfate, and sex hormone-binding globulin levels through the menopause transition. J Clin Endocrinol Metab 2000; 85(8):2832-2838.
3. Laughlin GA, Barrett-Connor E, Kritz-Silverstein D, von Muhlen D. Hysterectomy, oophorectomy, and endogenous sex hormone levels in older women: the Rancho Bernardo Study. J Clin Endocrinol Metab 2000; 85:645-651.
4. Bancroft J, Wu FCW. Changes in erectile responsiveness during androgen replacement therapy. Arch Sex Beh 1983; 12(1):59-67.