Low libido refers to a woman’s lack of desire for sex and is the most common sexual problem reported by women. Other common difficulties include problems with arousal and orgasm.
Sexual well-being is a complex area of women’s health. Low libido always has more than one cause and it is important to determine whether it is lifelong or recently acquired. In any one woman, low libido may be linked to relationship issues, psychological or hormonal changes and even side-effects of medicine. Hormones are rarely the only factor involved and other factors need to be addressed.
Women often say that menopause makes them feel more self-conscious about their bodies, particularly during sex. Other changes may be occurring in a woman’s life, such as a partner’s midlife issues, teenagers in the house or leaving home and parents dying or requiring care. Many women find that these additional stresses mean that the last thing on their mind is sex. For many women, decreased libido is not seen as a problem in their life. So it only needs to be addressed when it causes personal concern/distress.
A useful reference for both women and their partners is the book “Where Did My Libido Go?” by Dr Rosie King.
Hormones and libido
The drop in oestrogen at menopause commonly results in vaginal changes and a reduction in vaginal secretions may make intercourse uncomfortable or even painful. Management of this with a vaginal oestrogen preparation or a non-hormonal vaginal moisturizer can make a significant difference. Menopausal symptoms which result in sleep disturbance and fatigue will also impact on a woman’s libido. In such circumstances oestrogen therapy can improve libido in some women. In addition to producing oestrogen, the ovaries also produce testosterone. Blood testosterone levels start to fall when women are in their mid twenties so that by the time most women are in their forties their levels are half of what they were in their younger years. For many women this has little effect; however, this decline may be associated with lowered sexual interest in some women. Surgical removal of both ovaries causes approximately a 50% reduction in the level of the hormone testosterone, which may be associated with significant deterioration of sexual desire, particularly in younger women. These women tend to have more severe symptoms than the women who experience natural menopause.
Treatment Options for Low Libido
- Find a doctor who is interested and experienced in treating this aspect of your health.
- Address general health issues, particularly factors that commonly cause fatigue such as iron deficiency and abnormal thyroid function
- Address lifestyle issues and ways of reducing stress in your life
- Consider stresses and tensions in your relationship and possibly relationship counselling.
- Any depression or anxiety may need to be dealt with first.
- Some drugs, especially anti-depressants, can impair sexual responsiveness. Discuss this with your doctor.
- Hormone Replacement Therapy (HRT) or tibolone: Tibolone may be more effective in treating low libido than conventional HRT (see other AMS pamphlets).
- Sometimes a major factor is dryness in the vagina causing pain on intercourse which can be helped by either vaginal oestrogen or HRT
- Some forms of oral oestrogen such as HRT tablets or the oral contraceptive pill can reduce a woman’s own testosterone level so a trial off the pill or changing to a non-oral HRT should be considered if low libido is a problem.
- A trial of testosterone therapy can be appropriate for some women.
Testosterone has been used to treat low libido for several decades but only recently have clinical trials assessed its usefulness and safety in women. One of the major difficulties when researching testosterone in women is the inaccuracy of current hormone blood tests, in addition to the limited knowledge of what the normal levels are in women of different ages. Of note, testosterone levels are not necessarily related to low libido but a blood level should be done prior to starting any testosterone therapy so that women with normal to high levels are not inappropriately treated.
What we know
- Testosterone may improve libido, arousal and sexual satisfaction, mood and energy in some women.
- Low libido may improve with oestrogen therapy alone but in some cases testosterone may also be helpful, especially in women who have had their ovaries removed.
- Oral oestrogen may interfere with the effect of testosterone therapy. Hence the best effect of testosterone is seen in women using non oral oestrogen such as patches or gels.
What we don’t know
- Which women might benefit from testosterone treatment
- Whether testosterone treatment might cause harm: there are few long-term studies evaluating the risk of conditions such as heart disease and breast cancer
Considerations in using testosterone treatment
Although testosterone preparations are available from doctors in Australia, the government drug regulator, the TGA, has not approved it for the specific use of treating low libido in women.
Low dose preparations, which have been shown to be safe in the short term can be used. Unlike ordinary HRT, where blood tests are not normally used to monitor hormone levels, it is important to have blood tests before starting testosterone therapy and regularly while using it. If testosterone is used there is often no effect until 4 to 8 weeks. If there is no benefit after 6 months then therapy should be stopped. In general about 60% of women report a benefit.
Forms of testosterone
- 1% testosterone cream.
There is an approved 1% testosterone cream for women available in Western Australia. It is applied daily to the skin, and sometimes reduced or increased, depending on side effects and blood levels. (Although a 2% strength is available, it is for use in men and when used by women results in testosterone levels approaching the male range and thus it should not be used by women).
These have been a mainstay of therapy for many years for hormone replacement in men, and occasionally in women. As this treatment approach has now been superseded with the availability of transdermal testosterone creams and gels, the testosterone implants are no longer available.
These have been approved in Europe for women who have had their ovaries removed but are not available in Australia other than in a clinical trial.
In general, testosterone products formulated or approved for use in men should not be used in women because of the danger of unpredictable dose excess. This includes tablets, gels and injections.
Side effects of testosterone
Clinical studies show that if used in low doses for short periods of time, testosterone is well tolerated. The most commonly reported side effects are mild acne and increased hair growth. Less common side effects at low doses are weight gain and fluid retention. Serious side effects (rare at low doses) are clitoral enlargement and voice deepening and these can be permanent. We do not know the long term effects of testosterone. We do know that oral testosterone lowers HDL (good) cholesterol whereas testosterone via the skin (cream or patch) does not have this effect.
Who should not use testosterone?
Women who are being treated for hormone related acne, excess body hair or balding (androgenic alopecia) should not use testosterone. Testosterone is not effective for women who have very high levels of a protein in their blood that binds testosterone (sex hormone binding globulin or SHBG). Women who have extremely low levels of this protein (SHBG) are at considerably increased risk of having side effects of testosterone.
Testosterone should not be used by women who have been diagnosed with a hormone dependent cancer, such as breast cancer. Professional singers should also not use testosterone due to the rare but irreversible effect on the voice.
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Content updated February 2012