Do you need the hormone of desire?

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Testosterone isn't just a guy thing anymore. Here's a woman's guide

Joan listened with part embarrassment and part envy as Phyllis, her co-worker, sat over lunch, toying with her Caesar salad and telling her how she feels like a newlywed again. Well, almost. Since she began taking testosterone along with her estrogen therapy, her sex drive--or what her doctor called her libido--had gotten a much needed wake-up call. No more flannel nightgowns and baggy pajamas. No more thinking that making love is about as exciting as having the oil changed in the car. And she's hearing no complaints from her husband, either!

Joan went back to her office wondering why her own doctor had never mentioned testosterone and if she should ask her about it. Even though the estrogen she's been taking has cured her hot flashes and annoying vaginal dryness, she and her husband haven't been making love as often as usual, and he's complained that he has to make all the moves. He even wondered if she didn't find him attractive anymore.

Trouble was, she just didn't feel sexy like she used to and didn't know why. Could it be the extra weight she put on last winter? Or did she and her husband just need a romantic getaway? One thing she's sure about is that she misses the feeling of excitement she used to get when her husband wore that sexy cologne. Maybe testosterone will jump-start her stalled love life, she thought. It worked for Phyllis.
What's testosterone got to do with it?

If testosterone is what's responsible for guys' big muscles, beards, hairy chests, and sex drive, then what's Phyllis doing taking it? Women and testosterone seem like an unlikely pair, yet a woman's ovaries and adrenal glands do produce small amounts of testosterone--about one-twentieth of what men have. Every woman going through menopause experiences a drop not only in estrogen production but also in testosterone as her ovaries slow down. The research isn't clear about exactly what role this drop in testosterone plays in a woman's sexuality--if any. But for some women, diminishing sex drive can't be explained in any other way.

Which brings up the question that if diminished testosterone--assumed to be the classic hormone driving libido in men--has to do with diminished sex drive, will replacing that testosterone make your sex life bounce back? Well, maybe. For some women like Phyllis, testosterone seems to put desire on the rebound. Although for others it doesn't. Researchers know that some women who have their ovaries removed at the time of a hysterectomy experience a sudden and very noticeable drop in their sex drive, which is alleviated when they're given testosterone. This has led researchers to think that women who go through natural menopause and find their sex drive in a nosedive may also respond to testosterone. In fact, a recent small study from Australia has shown promising results in such women who were given testosterone over a two-year period to enhance libido (Maturitas, April 1995). But a lot more work is needed to confirm these findings. When it comes right down to it, scientists don't know what effects taking testosterone over the long run will have, either--few large, long-term studies have been done. (See "What We Know So Far About His Hormone and Her Libido," p. 158.)

Yet a growing number of women like Phyllis and Joan are being offered testosterone--or asking for it--with the expectation that it will do what their estrogen replacement

hasn't--put their sex drive back into high gear. And for many it is working like nothing else has. This growing body of anecdotal evidence is not easy to dismiss. Nor are the numbers. According to IMS America, a healthcare and pharmaceutical information company, 2,504,000 prescriptions were filled in 1996 for Estratest, an estrogen/methyltestosterone combination pill. Some women say they wouldn't live without it. "In my experience, many women who are taking testosterone stay on it as if it were a religion," says James Simon, MD, former chief of reproductive endocrinology at Georgetown University in Washington, DC and medical director of the Women's Health Research Center in Laurel, MD.

Where does this leave the medical community? Some gynecologists make testosterone a first choice in hormone therapy for women who are troubled by a decline in sex drive. Others are more wary and only turn to it as a last resort because of the lack of long-term studies and the potential side effects, including acne, unwanted facial hair, oily skin, and even a deepening of the voice in rare instances. (Then again, sounding like Kathleen Turner might not be all that bad.) Of even greater concern appears to be testosterone's tendency to lower HDL (good) cholesterol levels, especially if taken in pill form.

So is testosterone a well-kept secret that your doctor hasn't told you about or is it an as-yet-to-be-proven quick pharmacologic fix--one of those "cures" we Americans find so appealing? In other words, will it save your marriage or just send you running to the store for a tube of Clearasil? Here's how to know.
There's more to libido than hormones

Before you blame low testosterone for bedroom blues in your relationship, consider some other culprits that can snuff out sexual desire.

"There's this commonsense belief that your hormones drive your libido. But we're clearly more than the sum of our hormones," according to Nanette Santoro, MD, associate professor of obstetrics and gynecology at New Jersey Medical School, Newark. "The biggest influence on sexual desire is between our ears--namely our minds."

Sexual desire is partly biologically driven by sex hormones like testosterone, or its breakdown products, which stimulate chemical reactions in the brain to create the interest, arousal, and receptiveness for being sexual. It's called spontaneous sexual drive and is most likely the part of libido that is affected by a dip in testosterone at menopause. But two other aspects of libido count as much or maybe more than pure physical drive.

Your perceptions According to Sheryl Kingsberg, PhD, psychologist and assistant professor of reproductive biology at Case Western Reserve University School of Medicine in Cleveland, this is the component that reflects our expectations, perceptions, and beliefs about being sexual. A 55-year-old happily married woman who expects to still be sexual for a long time to come and is comfortable donning a Victoria's Secret nightie in the bedroom in hopes that something will develop, has a higher level of desire than the 60-year-old grandmother of eight who thinks sex at her age is taboo.

Your mood There is also an emotional piece to the libido puzzle. Anger at your husband for bouncing the mortgage check, feeling less desirable because you've put on some weight, or being depressed all have the same effect on sexual desire as a cold shower. And don't overlook "physical" causes: Fatigue from taking care of a sick parent while juggling a full-time job and family responsibilities is enough to sideline desire, too.

If any of these things are at play, "no pill alone will magically transform you from being sexually disinterested to being sexually interested," notes Sandra R. Leiblum, PhD, professor of clinical psychiatry and director of the center for sexual and marital health at the Robert Wood Johnson Medical School, Piscataway, NJ.
So maybe it is for you

So now you're thinking, it's got to be that I'm just low on testosterone, which is easy enough to fix with a prescription. Well, possibly. But don't expect to walk out of the doc's office with a sample package and stop by a lingerie boutique on the way home. That might come later. If testosterone turns out to be for you, here's what to expect instead.

First, if you're not taking estrogen already, your doctor will probably prescribe it, not testosterone, to begin. Often, low libido responds to estrogen alone. Since estrogen is considered a safer hormone, doctors prefer starting with that. Only when a woman complains that her sexual drive still isn't what it used to be after trying estrogen do they consider adding testosterone.

Second, taking testosterone is not a guarantee you'll be dusting off your sexy nighties once again. "Testosterone is a potent hormone, but it's not a wonder drug," says Brian Walsh, MD, Prevention's women's health advisor and meno-pause expert from Brigham and Women's Hospital, Boston. Some women who take it--about 50%, according to his estimates--notice no change in their libido, for reasons that are unclear.

Third, before you begin therapy, your doctor may want to have your cholesterol levels checked--HDL, LDL, and total cholesterol--so you can monitor any negative changes that may occur while taking testosterone. This is good practice anyway, but is particularly important if you are taking testosterone. Some doctors may even recommend a liver-function test if you will be taking testosterone in pill form, because it is metabolized by the liver and in rare cases can impair liver function.

Fourth, you should monitor testosterone's effectiveness by letting your doctor know if you're noticing your libido is on the upswing or if you're experiencing side effects. Surprise: Testosterone isn't usually monitored with regular blood tests. (See "Testing for Testosterone," right.)

Finally, testosterone therapy is similar to estrogen-replacement therapy in that you need to continue taking it to get the benefits. Currently, there aren't any limits on how long doctors are recommending taking testoster-one. The best guideline seems to be to take it as long as it's helping and any side effects are under control.
Then again, maybe not

Testosterone therapy isn't for everyone. You should probably reconsider the testosterone option if you see yourself in any of these situations:

It's been a long, long time "If a patient tells me she has no desire for sex at all, my first question is, 'When did you notice things changed?'" says Barbara Sherwin, PhD, noted hormone researcher at McGill University, Montreal. A woman who can pinpoint the decline in sexual interest to the start of her menopause and who feels it interferes with her sexual quality of life may have good reason to think it's hormonally related and may benefit from testosterone. "But if she says she didn't have that much drive when she was 30, then there's not much reason to believe testosterone would help." Similarly, if sex has always been infrequent or less than satisfying, testosterone is not going to magically cure years of sexual incompatibility or dissatisfaction.

You're at risk for heart trouble Oral testosterone (in the form of methyltestosterone, like Estratest), has been shown to lower HDL levels--the good cholesterol-- but has no significant effect on the bad cholesterol (LDL). Other forms of testosterone--like injections, implants, or the transdermal patch under development--can be expected to do exactly the same things, only to a lesser degree.

"If a woman has a high risk for heart disease and an adverse blood lipid profile to begin with, I would be very cautious about giving testosterone to her," says Dr. Simon.

It's always possible that even small amounts of testosterone could negate some of the estrogen's beneficial effects on the cardiovascular system by lowering the body's HDL cholesterol. But there is some evidence, according to Dr. Simon, that the benefits of taking estrogen that don't have to do with cholesterol--such as its reported ability to increase blood flow to the heart--may be preserved even when testosterone is added. If your decreased sexual desire is really compromising your quality of life, however, you may decide to make the tradeoff.

You say "no way" to certain side effects Even though most women experience no side effects, a small percentage of women do. They can be an inconvenience, at best, or disturbing enough to make them discontinue taking testosterone. (See "Potential Side Effects," below.) So it may mean a tradeoff between some hair growth on your upper lip, acne, or even hair loss and an improved sexual quality of life. Only you can decide what you're comfortable with.

You're not convinced Testosterone is a latecomer onto the research scene, so there are still lots of questions regarding optimum doses, subtle, long-term effects on women's bodies, and even its effectiveness in treating libido. (To find out what we do know about testosterone's effect on libido, see "What We Know So Far About His Hormone and Her Libido," left.)

Estratest, an oral prescription drug containing methyltestosterone and estrogen, has been available in the United States for over 30 years. It is one of many drugs available today that predate current Food and Drug Administration stringent guidelines governing the way drugs are reviewed and approved. And, according to the package insert, it is only indicated as a treatment for hot flashes in postmenopausal women, not as a libido enhancer. So you have to be willing to live with a little uncertainty. No one knows for sure yet what effects taking testosterone will have 30 years down the road.
More to come?

For the right woman, though, testosterone can have a dramatic effect on her sexual well-being and quality of life. Researchers like Dr. Sherwin are trying to uncover why women make testosterone and what role it plays in their bodies. Some doctors believe its presence is just incidental. "People get very emotional about women and sexuality," says Dr. Sherwin. "They feel that you're not supposed to muck around with female desire and that it doesn't really matter." But much more research is needed to know just what the risks and benefits of testosterone are. Hopefully the answers are not far off.

What to do in the meantime? "Most of us are doing the best we can with limited data," says Elizabeth Ginsburg, MD, assistant professor of obstetrics, gynecology, and reproductive biology at Brigham and Women's Hospital, Boston. "Low libido is a consistent enough complaint that I'm convinced it's a real phenomenon that happens to some women after menopause. You have to take a patient with complaints very seriously."

Which means seeing your doctor if you think testosterone would help you. Together you can decide if you're the right candidate.

SOURCES: Elizabeth Ginsberg, MD, assistant professor of obstetrics, gynecology, and reproductive biology, Brigham and Women's Hospital, Boston; Janet Hall, MD, assistant unit chief, reproductive endocrinology unit, Massachusetts General Hospital, Boston; Sheryl Kingsberg, PhD, assistant professor of obstetrics, gynecology, and psychology, Case Western Reserve University, Cleveland; Sandra R. Leiblum, PhD, professor of clinical psychiatry and director, center for sexual and marital health, Robert Wood Johnson Medical School, Piscataway, NJ; Christopher Longcope, MD, professor of obstetrics, gynecology, and medicine, University of Massachusetts Medical Center, Worcester; Nanette Santoro, MD, associate professor obstetrics and gynecology, UMDNJ-New Jersey Medical School, Newark; Barbara Sherwin, PhD, professor of psychology, obstetrics, and gynecology, McGill University, Montreal; James Simon, MD, former chief of reproductive endocrinology at Georgetown University, Washington, DC, and medical director, Women's Health Research Center, Laurel, MD; Brian Walsh, MD, director, menopause clinic, and assistant professor of obstetrics, gynecology, and reproductive biology, Brigham and Women's Hospital, Boston.

PHOTOS (COLOR): A man and woman

HOW DOCS GIVE TESTOSTERONE

PILL The most available and best tested form of testosterone supplementation in the United States is a tablet that combines estrogen and methyltestosterone--a synthetic version of testosterone. It comes in two strengths and is taken daily.

SHOTS Some physicians prefer intramuscular injections of testosterone given every three to four weeks. This allows them to adjust the dose to fit the individual. But shots seem to create a peak and valley effect; side effects kick up during the peak phase, and withdrawal symptoms show up as the testosterone quickly wears off.

SUBCUTANEOUS IMPLANTS During an office visit, your doctor can insert small pellets of testosterone through a tiny incision and place them under the skin either on your lower abdomen or in your hip area above the buttocks. They last three to four months as they gradually dissolve.

TRANSDERMAL PATCHES Clinical trials are currently being conducted to test the effectiveness of a new testosterone patch (developed by TheraTech, Inc.) for women. The patch contains testosterone that is chemically identical to what a woman's ovaries produce and delivers it con-tinuously through the skin in such small doses that side effects like acne and facial hair growth are expected to be very minimal.

TESTING FOR TESTOSTERONE

Seems the first thing you should do in wanting to know whether testosterone is for you is to test your current level of the hormone. But it isn't. Experts say these measurements aren't very useful for a number of reasons. First, the test results don't tell you much because testosterone levels vary widely from woman to woman--what's optimal for one woman may be too little for another. Second, there's no way of knowing what your levels were prior to menopause. And third, the methods used for measuring testosterone are not accurate for the low levels of the hormone found in the average woman. (Tests are rarely used before testosterone therapy begins, either--even if a woman's blood level is within the normal physiologic range. If all other reasons for her low libido have been ruled out, her doctor may still try her on testosterone.)

That said, there is one time when a doctor may check your testosterone level: when you're experiencing side effects, which tend to be dose dependent. "The trick is to use very small doses of testosterone so that you are not exceeding a woman's normal physiologic range, you're just bringing her back within that range," says Barbara Sherwin, PhD, noted hormone researcher at McGill University, Montreal.

POTENTIAL SIDE EFFECTS

Cosmetic

1. Oily skin or acne--testosterone steps up production of oil from the sebaceous glands.
2. Increased growth of body hair--you may notice you need to shave your legs more often, or hair grows above your upper lip that's like peach fuzz, or hairs appear on your chin that you need to tweeze out.
3. A lowering of the voice--possible, but appears rare on small doses of testosterone; testosterone is believed to increase the size of the larynx--and it may not return to normal once the hormone is discontinued.

Systemic

1. Liver damage with oral methyltestosterone is possible but rare at low doses.
2. Decrease in HDL levels (with oral testosterone and maybe other forms).
3. Depression and irritability.

WHAT WE KNOW SO FAR ABOUT HIS HORMONE AND HER LIBIDO

So we know that women have testosterone, too. And we know that it doesn't make most women become irresistibly drawn to the TV remote control or prevent them from asking directions. But as for what it does really accomplish, here's what science has found:

What's testosterone doing in a woman's body? Researchers don't really know why women have testosterone and what its function may be. "A lot of the functions of testosterone are mediated through estrogen. Testosterone is converted to estrogen in the brain, but we really don't understand what it does at all levels," according to Janet Hall, MD, of the reproductive endocrinology unit at Massachusetts General Hospital in Boston. So, many researchers remain unconvinced that testosterone has any separate effect other than to increase the available estrogen getting to the center of the brain that controls sexual motivation and drive.

The more testosterone I have, the higher my libido, right? There doesn't appear to be a direct correlation between blood levels of testosterone and measures of sexual desire. With the onset of menopause, the ovaries and adrenal glands produce less testosterone and other androgens (male hormones). As a result, the amount of testosterone circulating in the body is reduced by at least half.

While one woman will react to this change by experiencing a very noticeable drop in desire, another woman may not. Why? "Not every woman requires the same level of testosterone to remain sexually functioning," says James Simon, MD, former chief of reproductive endocrinology at Georgetown University in Washington, DC, and medical director, Women's Health Research Center, Laurel, MD. This drop is also relative to the amount of testosterone that was normal for them to begin with. So pinpointing an absolute level below which a testoster-one deficiency state is created is nearly impossible.

How clear is the evidence that adding testosterone can boost desire? By far the most compelling evidence comes from the work of Barbara Sherwin, PhD, noted hormone researcher at McGill University in Montreal. She has conducted controlled studies of premenopausal women whose ovaries were removed at the time of hysterectomy (this causes immediate menopause and almost completely wipes out testosterone). These women had a big drop in sexual desire. But researchers saw that women who received estrogen and testosterone had a significant increase in libido compared with women taking estrogen alone or a placebo.

Dr. Sherwin's critics say that her studies are not long-term enough and that you can't necessarily generalize the findings to women whose menopause is "natural." Which is why a small Australian study-- one of the best of its kind--looks so interesting: Women whose desires dipped after natural menopause appear to be doing well on a two-year course of testosterone.

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