Will testosterone (or anything else) help my sex drive?

This is an issue many women are reluctant to bring up during their annual physicals. Even though I am a woman physician, I don’t get asked this question much. Many women are embarrassed to talk about this intimate part of their lives, and in this day and age of having limited time for visits, it is a topic that sits pretty low on the priority list when it comes to matters that physicians bring up.

Libido is the technical term for sex drive. A low libido can be a problem for women at any age, but tends to be more of an issue after menopause, the time when women’s hormones dramatically drop. The loss of estrogen causes thinning and dryness of the vaginal lining, as well as a loss of elasticity. These changes can make intercourse uncomfortable, which obviously will decrease a woman’s interest in having sex. Estrogen therapy can greatly improve the health of the vaginal tissues, which can make sex more pleasant, but estrogen, per se, has not been shown to have any other significant impact on libido.

This is because it is testosterone that is generally believed to be the main driver that increases libido. Although women do produce some testosterone, men have exponentially more of this hormone than women at all phases of life. So it is no wonder that men tend to have much stronger sex drives than women. Frequently this disparity in interest poses major problems for couples, and many women (and their partners) would welcome something that would at least ignite an occasional spark that incites a desire to be back-in-the-honeymoon phase of their lives.

So the question arises, what is out there that may help a woman’s libido? And, is there any role for testosterone in addition to estrogen and progesterone as part of an HRT regimen?

Women’s bodies begin producing testosterone early in life. In fact, all of our estrogen is actually derived from male hormones! The ovary converts testosterone precursors into our main type of estrogen which is estradiol. Testosterone production ramps up during adolescence and tends to fluctuate throughout the month during the menstrual cycle, peaking at the time of ovulation. (This makes sense, doesn’t it?)

Interestingly, around age 35 or so, the production of testosterone begins to decline in women and by the time they reach menopause, the level has dropped to about as low as it gets. So, unlike estrogen and progesterone, which drop dramatically at the time of menopause, the testosterone level has already reached fairly low levels when women reach the age of 50. The exception to this would be in the case of a woman thrown into menopause by having her ovaries removed. Since over half of the testosterone made in women is derived from the ovaries – these women do suffer an abrupt loss.

But the question remains whether or not testosterone treatment should be considered in women as they age. There have been a substantial number of studies that have shown that women treated with low doses of testosterone have demonstrated an improvement not only in libido but in achieving orgasms and overall “satisfying sexual episodes.” But despite this research, the FDA has not approved any testosterone products for women because of a lack of long-term studies on its efficacy, as well as safety.

The testosterone produced in the body is not very effective when taken orally, so synthetic testosterone drugs have been developed. This form, known as methyl-testosterone, has been associated with adverse effects on cholesterol levels as well as on liver function. Testosterone applied to the skin, however, may have minimal downsides. The principle adverse effects in women using it are primarily an increase in hair growth and oily skin (remember the changes you may have noticed going through puberty?)

So while those in conventional medical practices are being cautious, many naturopathic providers and anti-aging clinics do endorse testosterone therapy for women. They prescribe low-dose products designed to be applied to the skin. These products are produced by compounding pharmacies. And while there are many reputable and reliable pharmacies of this type, they do not come under strict FDA oversight. So, there have been pharmacies that have produced products that contain impurities or inaccurate ingredients. This has made many conventional doctors leery of recommending them.

So, is there anything else out there that may improve a woman’s libido?

Another male-type hormone produced in the body is DHEA. DHEA has been produced in pill form and is available over the counter, and has been marketed as a nutritional supplement. It is not FDA-approved as a treatment for libido. However, some health care providers recommend a trial of 25 to 50 mg daily, because its male-like properties may stimulate libido. However, a large review of many studies did not conclude it to be effective, and it can lead to some unwanted hair growth and other male-like side effects.

A vaginal cream composed of DHEA, called prasterone, appeared on the market in 2017. This was approved as a treatment for postmenopausal vaginal thinning and dryness, but some studies have suggested it may improve sexual functioning because it is converted into testosterone inside the vaginal cells. The presumption is that a little testosterone gets into the circulation which may have an effect on libido, plus the testosterone produced inside the vagina may help sexual functioning.

Women have asked me if drugs like Viagra can help their libido. The many drugs like this on the market improve a man’s ability to have successful erections, but they do not specifically affect libido. Drugs like these have been tested in women and do not improve libido, or even appear to improve sexual function.

The first drug to appear on the market specifically to improve low sexual desire in women appeared in 2015 by the name of Flibanserin (Addyi). It is a drug that affects serotonin production. (You may be aware that drugs that increase serotonin, like Prozac, can decrease sexual desire.) Studies have shown that the benefit of this drug has been marginal at best and it is associated with side effects such as dizziness and nausea. It is designed to be taken on a daily basis, and can have serious adverse effects if taken with alcohol. And finally, it is not approved for postmenopausal women!

In 2019 bremelanotide (Vyleesi) was approved by the FDA as a drug to enhance sexual desire. It must be taken by injection (like giving yourself an insulin shot) shortly before intercourse. It is not clear how this drug actually works to improve libido, and the benefit is modest. Up to 40% of women have experienced nausea as a side effect. It also is not approved for postmenopausal women and it may increase blood pressure.

So, the bottom line is that there is no magic bullet for libido for women. The drugs on the market are not that promising. Testosterone may be beneficial and many menopause experts feel that a trial of low-dose testosterone topical cream is not unreasonable, and let women decide for themselves if they see a benefit. The problem is where to obtain a reliable product. The doses in male products, like Androgel, contain substantially higher concentrations than would be advisable for women. A reputable compounding pharmacy is an option. There is a topical testosterone product for women that is available in Australia – so I am looking forward to reading about how this goes with widespread use down under!