Notes from a Doctor's Practice

Diminished sexual libido or desire to engage in sex is a common and complicated issue for women. Sexual dissatisfaction is common among women and in recent studies 17% to 25% reported sexual dissatisfaction. Two questions that we should ask as healthcare providers are:

1) are you sexually active?

2) Do you have any questions, problems or concerns about your sexual activity?

If the answer to #1 is no then we should ask: does this bother you or your partner? If this is your issue what can we do for you?

How should we approach decreased interest in sex? Women's sexual satisfaction is closely tied to mental health, positive feelings for one's partner, no past abuse and no sexual dysfunction in one's partner. As primary care providers we can address mental health and relationship issues and any sexual dysfunction in the partner. Cognitive behavioral therapy, sex therapy and psychotherapy are all known to be helpful.

What about testosterone? The rationale for using testosterone to improve libido begins with the observation that testosterone levels steadily decline during a woman's lifetime. Some (but not all) studies show a decrease in sexual desire with age. Interestingly, serum testosterone levels have NOT BEEN SHOWN to correlate with women's sexual desire, function, or satisfaction. In other words there is no utility in measuring blood levels of testosterone in women with decreased sexual desire.

Still we have been compelled to look at testosterone supplementation for libido and a recent study published in the Annals of Internal Medicine did just this (http://www.annals.org/cgi/content/abstract/148/8/569?etoc). This study addressed the use of a transdermal testosterone spray to manage sexual dissatisfaction in premenopausal women.

What did they find? The results of this 16-week trial of 3 doses of transdermal testosterone in premenopausal women who had a decline in sexual interest from their younger years found that the number of sexually satisfactory events increased in all 4 groups of the trial, including the placebo group. The small improvements in sexual satisfaction in all groups (including those who received placebo), and the lack of an increasing effect with an increasing dose should make us question whether testosterone had an effect.

What do the results of this study mean for women? Even the authors of the study caution against the widespread use of testosterone in premenopausal women, and I agree. The lack of long-term safety data is another reason for caution. There is some concern about possible links between higher testosterone levels and breast cancer as well as cardiovascular disease. Instead...start with the safer and proven remedies: discuss with your primary care provider your sexual concerns in detail, then address mental health and relationship issues and any sexual dysfunction in the partner. Pursue conventional therapy, such as cognitive behavioral therapy, sex therapy, psychotherapy, and mindfulness techniques. If the conventional therapy fails, testosterone is an option. We should all understand, however, the lack of long-term safety data for testosterone therapy for sexual dissatisfaction.

The enjoyment of sex, although great.

Is in later years said to abate.

This well may be so,But how would I know?

I'm now only seventy-eight. - Anonymous

Dr. O