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HORMONES AND SEX
by Geoffrey Redmond, MD

Quick Reference
When sex does not seem right
Psychological treatment
Antidepressants and desire
Medical treatment
Treatment of low sex drive with testosterone: Pros & Cons
Estrogen and sexuality
What about the Blue Pill?
Other medications
If you have experienced loss of sexual desire

As our culture has become more open about sexuality, something surprising has come out: many women feel their sex drive is too low.  Lack of libido — absent sex drive —affects almost a third of women.

Surveys have shown that most people think that others are getting more sex than they are. This shows how unrealistic our culture has become about sexuality. While characters in movies or TV may always seem to be hopping into bed, real life is much less exciting.

A usual sexual frequency for married couples is 1 to 2 times a week, maybe less when there are small children or demanding work schedules or both. It is normal not to feel interest in sex at some times.

Lack of sexual appetite is less common in men than women, and a man’s libido is much less likely to be affected by fatigue or stress. This can result in partners having different levels of desire. Sometimes a woman simply wants sex less often than her mate. There may also be a lack of relaxed and private time together. Women sometimes find it hard to relax to enjoy sex when they are concerned about being overheard.

Sexual expression is an important part of relationships and it may require changing the routine so as to permit time alone for the partners when they are rested. Sometimes there are conflicts in the relationship which need to be addressed for the sexual aspect to improve. Although a few couples find angry arguments exciting, for most people they are a turn-off.

It is quite common for women to experience lack of desire apart from the above circumstances. Sometimes this is a long term problem. There are many women for whom sex has never been of major importance — they may not miss sex, but feel pressure from their partner. For those who have never had a strong sex drive, hormones are unlikely to be the cause.

WHEN SEX DOES NOT SEEM RIGHT
When there is a loss of interest in sex or sex is no longer satisfying, there may be more than one factor involved. In this article, I will discuss the role of hormones and some of the medications which may help. Remember though, the most important thing is to find a sympathetic physician with whom you feel comfortable to work out the causes and treatments. There are medications that help sexual problems but there is no one pill that solves all of them. Treatment must be individualized.

PSYCHOLOGICAL TREATMENT
Until recently the main treatment for sexual dysfunction was educational and psychological. Sex therapy was pioneered by Masters and Johnson and refined by the late Dr. Helen Singer Kaplan. It involves teaching people to understand the sexual responses of their partners and themselves. This is best done by therapists trained in the specific methods. It may be extremely helpful for some couples. The trend at the present time however is to seek medical treatments for sexual problems. We now have some medications that work, at least for some women, and it is likely that the next decade will bring new agents for helping those with sexual problems.

ANTIDEPRESSANTS AND DESIRE
It is important to point out that some commonly used medications can inhibit sexual desire. Most common are the new anti-depressants such as fluoxetine (Prozac^®), sertraline (Zoloft^®) and paroxetine (Paxil^®). These may decrease sexual desire and performance in up to a fifth of people taking them.         Sometimes they simply slow response so it takes longer to become aroused and longer to attain orgasm. Antidepressants can have these effects in both women and men.

Some anti-hypertensives can affect sexual performance also.

MEDICAL TREATMENT OF LOW SEX DRIVE
It is important to point out that a number of diseases (e.g. diabetes) can affect sexual responsiveness, so the first step in dealing with a sexual problem is to get a medical evaluation. In women, the vagina and surrounding tissues absorb considerable impact during intercourse so sometimes conditions in the pelvic area can make intercourse uncomfortable. If part of the problem is pain, a gynecological exam is the first step.

When there has been a relatively sudden loss of interest, hormones may be involved. Some women do not mind the change in interest but others miss the pleasure and satisfaction which sex once held for them. Sometimes this happens after hysterectomy with removal of the ovaries; some think that this can be due to loss of the testosterone produced by the ovaries. Some women in this situation find that their sex drive is restored when they are given testosterone.

TREATMENT OF LOW SEX DRIVE WITH TESTOSTERONE: PROS AND CONS
Testosterone levels usually go down in perimenopause and menopause. Some have advocated the idea that most women should have testosterone “replacement.” There is no evidence to support this. However, some women who experience loss of libido at this point in life do find some help from testosterone. My own view is that trying it for up to 3 months is sometimes reasonable. There is no question that it helps some women but others do not notice any change.

If you are thinking of trying testosterone, you should be aware of possible side effects. A look at other articles on this website will show the problems that testosterone can produce in women. (acne, hirsutism, alopecia, PCOS). If you start having acne, increased hair growth, or loss of scalp hair, you should consider if any benefit from testosterone is worth these effects.

I mentioned trying testosterone for up to 3 months because any benefit will be apparent in that interval. If it does not help, there is no point to continuing.

At the present time, there are no really ideal testosterone preparations available for women. A combination of methyltestosterone and esterified estrogens (Estratest^® and Estratest HS^® (available in the U.S. but not in Canada) has been widely used for loss of libido associated with removal of the ovaries, or with natural menopause. These medications do work for some (but by no means all) women with reduced sex drive.

There are other forms of testosterone that can be used by women but correct dosing is important so they should be prescribed by a physician experienced in this form of treatment.

As I have mentioned, androgenic side effects are a concern with testosterone. I have seen several women with scalp hair loss, increased facial or body hair, or oily skin and acne resulting from taking testosterone. Those women who already are troubled by these problems need to be aware that taking testosterone may make them worse. The androgenic effects of Estratest and Estratest HS are usually mild in my experience — especially with the HS (half-strength) form — and many women do not have any of these effects.

The situation may be worse with non-standardized preparations compounded by pharmacies that specialize in hormonal preparations. I have seen two women who developed testosterone levels as high as those in men after applying testosterone cream or gel. I advise against using any of these non-standard preparations. A skin patch is being developed which gives consistent levels of testosterone comparable to those present in pre-menopausal women. I have done research on the patch with grant support from the sponsor; it seems promising and research on it is continuing.

ESTROGEN AND SEXUALITY
It is important to realize that testosterone is not the only factor affecting women’s sexual response. Estrogen, while it does not stimulate desire, is necessary for comfortable intercourse because the vaginal tissues are thin and dry in its absence. Lubricants help sometimes but not always because while they moisten the vaginal mucosa, they do not make it thicker and stronger as estrogen does. If intercourse becomes uncomfortable in perimenopause or after menopause, low estrogen levels may be the cause.

WHAT ABOUT THE BLUE PILL?
Sildenafil (Viagra^®) definitely helps many men with erection problems. Studies on women are incomplete and it is not labeled for use in women at this time. It brings more blood flow to the genital area and so may make the tissues more responsive. It does seem to help sometimes when low sex drive is due to use of antidepressant medications and possibly in other situations. Studies are currently being carried out, but it is too soon to know how helpful it will be for women. Some women may find it worth a try.

OTHER MEDICATIONS
Many antidepressants can decrease sex drive but one, bupropion (Wellbutrin®), sometimes increases it. Bupropion is not an aphrodisiac, that it is it does not increase sex drive to abnormal levels. It can help some women however.

IF YOU HAVE EXPERIENCED LOSS OF SEXUAL DESIRE
Although we need to have a better understanding of women’s sexual problems, we do have treatments and they often work. Sometimes more than one approach is best because several factors are involved. If you are having problems related to sex – and almost a third of women do – it is worth consulting a sympathetic physician.

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