I call testosterone the “confidence hormone”. With men, it’s usually pretty clear the nice level of confidence that testosterone gives them. What a lot of people don’t realize is that the right level of testosterone also can give women a feeling of self-confidence. In the right amount, meaning not too much or too little, testosterone can enhance your libido, ability to reach orgasm, energy level, muscle tone, mental clarity, and overall sense of well-being. Too much can cause crankiness (“short fuse”), acne or facial hair growth. Too little can also cause crankiness, as well as not having the good things listed above.
So, should women receive testosterone supplementation? Now we get to the debate.
I just read a “Point/Counterpoint” article in one of my OB/GYN journals on the topic of testosterone treatment for pre-menopausal women with “HSDD” – hypoactive sexual desire disorder (I know, doctors like to have long fancy names as diagnoses that are actually just descriptions of the problem).1 The “Pro” side was written by a (male) OB/GYN doctor who does think that testosterone therapy can be helpful and a (female) PhD behavioral science professor who thinks that it has not been proven to increase desire and is not worth the risk.
Let me say that luckily there does not seem to be a debate about whether testosterone therapy helps post-menopausal women with libido – most agree that it does. This article focused on “reproductive-aged” women, i.e. pre-menopausal women.
The OB/GYN (MD) doc helpfully outlined 3 situations in which he treats pre-menopausal women with transdermal testosterone (through the skin). The first is in women who have had their ovaries removed. This sudden surgical menopause onset can especially result in HSDD. The second situation is in women with a documented low level of testosterone (less than 20 ng/dl). The third is in women prescribed drugs such as anti-depressants, which commonly cause HSDD.
The behavioral science (PhD) professor argued that studies do not show that testosterone treatment shows a benefit for HSDD in pre-menopausal women, and that there are studies that show an increased risk of breast cancer with this treatment. She also discussed the many situational factors in low sexual desire in women – anxiety, depression, a history of negative sexual experiences, stress, fatigue, and pain with intercourse.
I’ll respond to the PhD first: As with most medical studies, the devil is in the details. I looked very carefully at the 2 studies she said showed an increased risk of breast cancer. I found that in one study the association (NOT necessarily causation) between testosterone level and increased risk of breast cancer was drawn from a calculation that took into account a variety of other risk factors2. Only after this adjusting did it barely reach statistical significance. In the other study, an association was also found between higher natural (not from treatment) levels of testosterone, but this did not even reach statistical significance.3 She also argues that double-blinded studies on the issue of sexual desire are hard to conduct (I agree), and only show that the “efficacy of testosterone therapy for women’s desire problems is modest”.4
As far as responding to the MD, my experience with patients has been similar, and I have found testosterone treatment to be helpful to my pre-menopausal women, and not only in the 3 situations he describes. Basically, I prescribe testosterone for women based on symptoms, most commonly low sex drive, and I have often seen it help. I don’t prescribe it only when there is a low blood testosterone level. I prescribe it as a compounded transdermal gel or as an under-the-tongue dissolvable troche (pronounced “tro-key”). In my practice I have found it rare for a woman to stop using testosterone due to acne or facial hair growth, although it does happen occasionally. Also, one thing I definitely don’t want to do is cause a “libido mismatch” – increasing my patient’s sex drive if she either doesn’t have a partner or doesn’t have a partner who is able or willing to perform sexually.
The “Dr. Liz perspective”: Everything in life is risk versus benefit. A large enough study to give a really clear picture of any breast cancer risk from testosterone treatment in women is probably is not forthcoming, because this is not a big money-maker for any pharmaceutical company (at least not at this point in time). And yes, this treatment does not work in all women, and yes, there may be a “placebo effect” (I’ll blog on this another time). To me, this is not a reason to not use a treatment that may help my patient.
Libido is not just about sex; it’s about drive, motivation and life energy. Testosterone treatment can help women with libido, and that’s usually worth it.
References:
1. McKenzie, L., ed. Should testosterone therapy be used to treat HSDD in reproductive-aged women? Contemporary OB/GYN. 2014;59(12):30-32.
2. Zeleniuch-Jacquotte A, et al. Premenopausal serum androgens and breast cancer risk: a nested case-control study. Breast Cancer Res. 2012;14(1):R32.
3. Fortner, RT, et al. Premenopausal endogenous steroid hormones and bresast cancer risk: results from the Nurses’ Health Study II. Breast Cancer Res. 2013;15(2):R19.
4. Schover, LR. Androgen therapy for loss of desire in women: is the benefit worth the breast cancer risk? Fertil Steril. 2008;90(1):129-140.