Menopause and loss of libido (sexual desire)
Low libido affects women of all ages, with a peak in associated distress around the menopause, becoming less prevalent in the 60s.
In this blog post by Hormone Health Associate Dr Imogen Shaw, we will explore the effects of low libido and the treatment options including testosterone therapy.
The three principal hormones involved in female reproductive life are:
- Androgens (various testosterone-like hormones).
The levels drop as the ovaries gradually fail to produce sufficient hormones to create a menstrual cycle, usually from 45-55 years.
Its primary function is to oppose the effects of estrogen on the lining of the womb, preventing overgrowth and generating periods.
The levels in females decline more gradually with age from mid-20s, are generally in the lower end of the normal female range by the 40s, and do not change abruptly at the time of natural menopause or decrease after the menopause.
It is thought that androgens play a role in female sexual function. Still, the extent of the role is uncertain, as studies that measure serum hormone levels in women show the correlation between testosterone concentrations and sexual function is weak. For example, women with relatively high testosterone levels, such as in polycystic ovary syndrome, do not see beneficial sexual effects.
In women sexual problems can be caused by many factors:
1) Pain during sex
Some women experience pain with sex as they get older or go through menopause. This is usually due to a lack of vaginal lubrication, causing dryness. This is easily treated with the use of vaginal lubricants during sex. (eg. Astroglide, Sylk). If a lubricant is insufficient, a vaginal moisturiser can be added, used several times a week, but not necessarily during sex (e.g. YES, Replens).
2) Not becoming aroused or “excited” during sex or not having an orgasm.
This can be due to a loss of clitoral sensation after the menopause. A testosterone-like pessary (Prasterone) can help increase sensation.
3) Not wanting sex (also called low desire or low libido).
There are often multiple factors involved in libido. The main factors associated with a satisfying sex life are physical and psychological well-being, and the quality of the relationship. It is always worth initially thinking of measures that women can take to improve their health and relationships, which are likely to positively impact their sex life.
Lifestyle changes that increase physical and emotional well-being, reduce fatigue, and stress, and strengthen the partnership often positively affect sexual function.
A session of couples counselling or thinking about ways to restore excitement into the relationship, such as spending a night away from home, trying a new sexual position, or using a vibrator, can be beneficial in long-term relationships.
Other causes of low libido
Low libido can also be due to the onset of a medical condition or a side effect of certain medicines, e.g., medicines to treat depression or heart disease sometimes cause sexual problems.
Fatigue and stress contribute significantly to low libido and sexual problems. For example:
- Childcare and other responsibilities
It is important to have enough “me-time”. Reducing stress through exercise, yoga, and other relaxation techniques may help.
A woman’s view of her own body affects her sexual interest. Many factors may impact negative body image. Patients who are overweight and in whom body image issues contribute to sexual dysfunction can be assisted with weight loss. In addition, many patients see improvements in their sex lives when they initiate a regular exercise program.
How can we help?
I find that optimising a menopausal women’s estrogen replacement so that she has no remaining menopausal symptoms, is sleeping well and has a stable mood, together with ensuring no vaginal dryness or pain with intercourse, has the most benefit in restoring libido.
If all these factors have been dealt with satisfactorily, but a woman still has a distressing lack of libido that interferes with relationships, I will offer a 3-month trial of testosterone replacement.
I always counsel about the lack of long-term safety studies with testosterone and the potential side effects of increased facial hair, acne, and possible weight gain. More permanent virilising changes (e.g., voice deepening, clitoral enlargement) are rare and only occur with excessive dosing outside the normal female range.
Some testosterone is aromatised to estrogens, although in the short term, testosterone therapy does not appear to affect women’s breast health adversely.
What about testosterone?
Did you know…
Available data do not show testosterone to be beneficial for cognitive function, well-being, mood, bone density, lean body mass or muscle strength, despite claims to the contrary on social media, websites or in the media.
The long-term effects of testosterone replacement remain uncertain as there is no safety data for testosterone in female doses beyond 24 months of treatment.
Testosterone therapy, in doses within the normal female range, has shown a beneficial effect on sexual function, including an average of one satisfying sexual event per month and increases in sexual desire, arousal, orgasmic function, pleasure, and sexual responsiveness.
At present, there are no licensed female testosterone preparations in the UK. We, therefore, prescribe, off-label, an approved male formulation using a tenth of the male dose to maintain hormone concentrations in the physiologic female range. Another option is the female testosterone cream (Androfeme) produced in Australia, which can be prescribed privately. We then monitor women carefully, looking for their clinical response to treatment and signs of androgen excess, with a blood testosterone level every six months, to screen for overuse. If women do not see any benefit by six months of treatment, I stop prescribing as they are unlikely to see any more results.
While the media may have given testosterone therapy for menopausal women significant emphasis, the evidence supporting its use, particularly concerning libido, is not as strong as it may appear. The risks and benefits of testosterone therapy need to be thoroughly evaluated, and personalised treatment approaches should be considered.
If you have any questions or concerns about testosterone therapy or any other aspect of your health, please do not hesitate to schedule an appointment with us. We are here to provide you with the most accurate information and guidance.