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Ricki Pollycove, M.D.

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Testosterone and Sex: What Women Should Be Talking About

Posted: 01/26/11 07:50 AM ET

Scuttlebutt among well-informed women is all about the enhancing effects of testosterone and sex. Internet advertisements abound. Girlfriends email blog bits back and forth. But most women never had a discussion with their health care professional about this topic. How come?

Some accuse "the system" of chauvinistically serving the interests of men only, developing drugs to enhance their necessary and all-important erections while American women are left with no FDA-approved products to improve sexual function. As frustrating as this state of affairs is for many women, it is not simply the result of a sinister "boy's club" plot to suppress women's wildness.

There are many complexities to the science regarding testosterone and its androgen cousins. (An androgen is a hormone that has testosterone-like effects.) There are many natural androgens made by our bodies, others that are synthetic, made by pharmaceutical companies. Some of the progesterone-like hormones in contraceptives can act a bit like testosterone in some tissues while causing anti-androgenic effects in others (mentioned in the previous blog).

The actual science of measuring testosterone (T) in women is where a lot of our problems begin. The levels found naturally in women are less than a tenth of those produced by 30-something aged men. With such a small female range of "normal," the individual difference between our cyclic high point (right around ovulation in menstruating women not using hormonal contraception) and the pre-menstrual period low is relatively small. And on top of this, the T levels between different women vary considerably. And to make it an even tougher puzzle to solve, a particular T level, as measured by the most accurate blood testing methods, does not correlate with better or worse sexual satisfaction when different women are compared to each other. So even if you get the best "gold standard" testosterone blood test and "know your numbers" it may not correlate with your personal experience one way or another. And, by the way, the use of saliva testing for T is worthless in my opinion and the opinions of most RE specialists.

Women who seek improved sexual function and consult a specialist in female hormones (called Reproductive Endocrinologists, or RE docs for short) are likely to get a blood test, often to find out that their levels of testosterone are considered "normal." Disagreement exists between specialists about which T assay is best, what a particular level of T indicates, total T and protein-bound T as measures of hormone level adequacy, and at what level does science support T supplementation. [Related research, Jan L Shifren, M.D.]

Depending on the T hormone study (often conducted by departments of psychiatry, where sexuality research is most at home in our culture), the strongest statement that stands up to rigorous science is that among women who complain of lackluster sexual functioning, added T can be of statistically significant benefit IF their blood levels of T are below the middle third of the normal range. Part of the problem is how doctors research and measure sexual experience in women.

For example, a few years ago our FDA denied approval for the T-patch for women (called Intrinsa, developed by Procter and Gamble) while it was approved by pharmaceutical review boards throughout the EU. Why is that? Are American women different or is our FDA's measure of drug efficacy different from the Europeans? It was not an efficacy issue in the final analysis, and there were no worries about getting too hairy or acne-ridden, that doomed the FDA-drug application to non-approval. It really came down to the FDA wanting longer term trials in menopausal women to reassure there were no adverse effects with regard to heart disease and breast cancer risk.

Studies in women are more difficult as compared to men. Male measures of orgasm/ejaculation are clear cut end points of sexual satisfaction whereas women have a less defined description of what constitutes satisfying sex with a partner. With the mix of issues surrounding T measurement, absolute levels of T not correlating well with an individual woman's sexual function and the placebo effect being very powerful with regard to sexual performance (30 to 40 percent improvement with the dummy pills or creams), it's no wonder we are still stuck with a huge difference of opinion between professionals who take care of women's hormonal balance.

Studying the medical literature and discussing this clouded field of science with hundreds of women in my practice over the past 30 years, there is a lot we can do to make things better. First, is how much spontaneous and deliberate attention (desire) does sex receive in a woman's life, day to day? A recent FDA decision was not to approve Flibanserin, the only drug that looked promising for the treatment of low sexual desire, "HSDD," (Hypoactive Sexual Desire Disorder). If a woman reports few or no sexual fantasies, no horny dreams, she may have HSDD. To add to our troubles, the ability to achieve orgasm is not highly correlated with T levels, as stated previously. So what should be done medically, behaviorally, short and long term, with a variety of sexual dissatisfactions?

It may indeed be valuable to learn if your T level is in the lowest third of women, as this group is significantly improved with some added T support. But the chances are that your blood levels are in the middle or upper third group of women. You can try DHEA (over the counter) as T support if your blood T level is mid range or at the bottom third. You may risk getting more pimples, especially on chin, nose, forehead and areas around the mouth with rising T levels, even when in normal ranges. And too much T is NOT a good thing! Beyond skin and hair changes (like zits and balding at the temples) there is a higher risk for a variety of diseases, like cardiovascular disease risk, stroke and liver tumors with over doing it with T. Ideally, work with a supportive professional, find out what your situation is medically, and then get the proper advice about things that are likely to help you achieve greater sexual satisfaction.

The good news is that behavior modification can be a big help for many women. Don't take the lap top to bed. Don't watch TV in bed, dozing off next to your partner once again without so much as a good cuddle. And if you experience a frustratingly slow response to foreplay, how about reading a book such as "For Each Other," (Lonnie Barbach, Ph.D.) and see how much time you take. Are you actually allowing arousal/foreplay activities before you hit the annoyance level? So go ahead, take a combined approach of a medical and hormone evaluation plus enjoy the full spectrum of behavior modification activities, new fragrances, bath oils, dusting powder, mood music, candle light, flowers, a vibrator perhaps ... whatever suggests romance to you. If we are to enjoy living with our partner beyond acting like parallel parked cars in a garage, it requires intentional efforts long term.

This can be a time to enhance your "auto" solo sexuality as well. Many studies agree that vibrator use correlates positively with all measures of improved sexual function in women (J Sex Med. 2009 July; 6(7): 1857-66. Epub 2009 May 7. "Prevalence and characteristics of vibrator use by women in the United States: Results from a nationally representative study." Herbenick D, et al.)

One of my single patients told me years ago about turning the corner on her solo sexual satisfaction. After learning that her hormones were all "normal," she went home, lit a votive candle for herself, put on romantic Sade music, took a luxuriously long lavender bath, and got out the KY-Silk-E lube, and activated her Hitachi magic wand. She liberated herself to joyful private personal tenderness, instead of feeling sorry for herself. I added, "You just can't regret the sexually transmitted disease exposure you have not had." We chuckled at the profundity of the irony. Something our culture does not necessarily encourage: self sufficiency!

We can take good loving care of ourselves on many levels; a lovely part of being a healthy and self-accepting woman. So get ready for a happy Valentine's Day, whether coupled or not. And don't just focus on Testosterone as it may be less of a factor than we once thought.