by Susan
Wysocki, RNC, NP, FAAN, 02/13/01
Decreased libido can result from a number of different situations and conditions. It can be
related to medications, including supplements or herbs, illnesses, relationship and other
stressors, as well as simple exhaustion, depression, and lack of time for intimacy.
It is always important to obtain a good baseline history on all possible causes of lack of
libido. It is also important to differentiate if the complaint is due to lack of desire, arousal,
lubrication, satisfaction, or pain.[1] Loss of libido, which includes a general lack of sexual
fantasies and desire, should not be confused with other reasons why a woman might not
be interested in sexual intimacy. These potential causes include conflicts with a partner,
experience with painful intercourse, or other issues that are unrelated to levels of
testosterone or other hormones.
Although not indicated for the treatment of declining libido, the ability of androgens to
improve libido was first noted in the 1940s.[2] The combination of estrogen and
testosterone has several effects on sexuality. The first, related to the estrogen component,
is a decrease in vaginal atrophy, increases in blood flow to the vagina, and increased
lubrication. The addition of androgen appears to be beneficial in terms of increased energy
and increased sense of well-being, as well as an increase in sexual desire and increased
sensitivity to sexual stimulation.[2] While several studies have demonstrated this benefit,[3]
there are many women for whom oral androgen therapy does not seem to work.
Because the half-life of oral methyl testosterone is short (10 to 100 minutes),[4] some
clinicians suggest the periodic administration of oral testosterone vs daily dosing. For
example, a woman might take oral testosterone prior to a "date" weekend or evening.
There are no studies to show the effectiveness of this strategy, but most women
experiencing loss of libido are willing to experiment with dosing schedules. Providing oral
testosterone in periodic vs daily doses substantially reduces the overall dose. Virilizing side
effects such as acne, facial hair, and lowered voice can be produced from testosterone.
However, even if it is taken daily, testosterone supplementation in the physiological range
(2.5-.8 mg per day) does not produce these effects.[5]
Another strategy that has been suggested, in addition to oral testosterone, is to use a small
amount of topical testosterone (1%-2%) applied to the genital mucosa for an initial few
weeks. When the local receptors have been well supplied with testosterone it is thought
that sensation and libido are enhanced.[5] The use of vaginal estrogen creams, tablets, or
the estradiol vaginal ring may also be helpful in restoring vaginal tissue if there is vaginal
atrophy.
Loss of libido in perimenopausal and menopausal women, and particularly among women
who have had their ovaries removed, presents many challenges. The issue has not been
well studied and when it has been often the endpoints look at coitus-related activities rather
than variables like desire and fantasy. The advent of sildenafil (Viagra) opened the
discussion of sexuality for older individuals. More and more women and men are aware
that they are not alone in facing this issue. Regardless of whether clinicians can offer a
"cure," it is important to discuss sexual issues with their clients so that possible solutions
might be found.
References
1.Association of Reproductive Health Professionals. Mature Sexuality: Patient
Realities and Provider Challenges. Clinical Proceedings. September 2000.
2.Rosenberg MJ, King TDN, Timmons MC. Estrogen-androgen for hormone
replacement, a review. J Reprod Med. 1997;42:394-404.
3.Sarrel P, Dobay B, Wiita B. Estrogen and estrogen-androgen replacement in
post-menopausal women dissatisfied with estrogen-only therapy. J Reprod Med.
1998;43:847-856.
4.Estratest and Estratest HS. Physicians' Desk Reference (PDR). 54th ed.
Montvale, NJ: Medical Economics Company; 2000.
5.Rako S. Testosterone deficiency and supplementation for women: What do we
need to know? Menopause Management, September/October. GCS Press, LLC.
1996;5:10-15.