Dr. Rosemary Basson (biography and disclosures)
Frequently asked questions I’ve noticed
We receive many referrals for assessment and treatment of women with low sexual desire and ‘low serum testosterone levels’. Although men with repeatedly low serum testosterone levels typically have low sexual desire, no such link has been identified in women. Women’s testosterone production does decrease with age – the component derived from peripheral conversion of adrenal (and ovarian) precursor hormones, most notably DHEA, declines by some two-thirds by ages 60 to 70, and testosterone production from post-menopausal ovaries is highly variable (zero after surgical menopause). Given a lessening of women’s sexual desire with age is reported in most studies, it had been assumed that when testosterone assays accurate at the lower ranges found in women became available, a link between low testosterone and low sexual desire might be identified. When peripheral intracellular production of testosterone from DHEA could be measured, such a link might be even more obvious.
Data that answers these questions
Now published is a study of 245 women, carefully assessed by extensive structured interview as well as standard questionnaires with and without hypoactive sexual desire disorder (HSDD)[1]. Using “gold standard” assays – i.e. mass spectrometry methods no group difference was found in serum testosterone. Moreover, serum androgen metabolites (a measure of intracellular testosterone as well as ovarian testosterone), also measured by mass spectrometry methods was similar in both groups. Additionally, there are now three prospective studies of prophylactic bilateral salpingo oophorectomy (BSO) at the time of hysterectomy needed for benign disease in perimenopausal women. None of the women receiving elective BSO (plus hysterectomy) acquired sexual dysfunction in the subsequent three to five years[2][3][4]. As well, epidemiological studies of prevalence of HSDD in menopausal women show that although distress about having low sexual desire is increased in surgically menopausal women, the prevalence of low sexual desire per se is not increased compared to naturally menopausal women of the same age[5].
Practice tips
It is recommended not to request serum testosterone levels in women looking for low levels:
1) Clinically available assays are not accurate at the low levels found in women
2) Intracellular testosterone is not measured by serum levels of testosterone
3) There is no evidence that low testosterone is linked to low desire when accurate testosterone assessment (including that made within the peripheral cells) is used.
This recent research shows that supplementing testosterone off-label to women with low sexual desire is not scientifically based and is still recommended against by the American Endocrine Society[6] in part due to absence of long-term safety/efficacy data. For review of (investigational) t-therapy in women see Basson R. Testosterone Therapy for Reduced Sexual Libido in Women. Ther Adv Endocrinol Metab 1(4):155-164, 2010[7].
Reassuring women that “hormonal imbalance” is not proven to be a likely cause of low sexual desire allows them to focus on the known correlates i.e. mood especially depression, sexual self-image, feelings for the partner[8][9][10] and the presence of any sexual dysfunction in the woman herself e.g. dyspareunia or dysfunction in the partner, especially erectile dysfunction in a male partner[11].
References: (Note: Article requests require a login ID with CPSBC or UBC)
1. Basson R, Brotto LA, Petkau J, Labrie F. Role of androgens in women’s sexual dysfunction. Menopause 17(5):962-971, 2010 (View article with CPSBC or UBC)
2. Aziz A, Brannstrom M, Bergquist C, Silfverstople G: Perimenopausal androgen decline after oophorectomy does not influence sexuality or psychological well-being. Fertil Steril 83:1021–1028, 2005 (View article with CPSBC or UBC)
3. Farquhar CM, Harvey SA, Yu Y, Sadler L, Stewart AW: A prospective study of three years of outcomes after hysterectomy with and without oophorectomy. Am J Obstet Gynecol 194:711–717, 2006 (View article with CPSBC or UBC)
4. Teplin V, Vittinghoff E, Lin F, Learman LA, Richter HE, Kuppermann M. Oophorectomy in premenopausal women: health-related quality of life and sexual functioning. Obstet Gynecol 109:347–354, 2007 (View article with CPSBC or UBC)
5. West SL, D’Aloisio AA, Agans RP, Kalsbeek WD, Borisov NN, Thorp JM. Prevalence of low sexual desire and hypoactive sexual desire disorder in a nationally representative sample of US women. Arch Intern Med 168:1441–1449, 2008 (View article with CPSBC or UBC)
6. Wierman ME, Basson R, Davis SR, Khosla S, Miller K, Rosner W, et al. Androgen therapy in women: an Endocrine Society Clinical Practice Guideline. J Clin Enocrinol Metab 1:3697-3710, 2006 (View article with CPSBC or UBC)
7. Basson R. Testosterone Therapy for Reduced Sexual Libido in Women. Ther Adv Endocrinol Metab 1(4):155-164, 2010 (View article with CPSBC or UBC)
8. Bancroft J, Loftus J, Long JS. Distress about sex: A national survey of women in heterosexual relationships. Arch Sex Behav 32:193-211, 2003 (View article with CPSBC or UBC)
9. Laumann EO, Das A, Waite LJ. Sexual dysfunction among older adults: prevalence and risk factors from a nationally representative U.S. probability sample of men and women 57-85 years of age. J Sex Med 2008;5:2300-11 (View article with CPSBC or UBC)
10. Dennerstein L, Guthrie JR, Hayes RD, DeRogatis LR, Lehert P. Sexual function, dysfunction, and sexual distress in a prospective, population-based sample of mid-aged Australian-born women. J Sex Med 2008;5:2291-99. (View article with CPSBC or UBC)
11. Chevret-Méasson M, Lavallée E, Troy S, Arnould B, Oudin S, Cuzin B. Improvement in quality of sexual life in female partners of men with erectile dysfunction treated with sildenafil citrate: findings of the index of sexual life (ISL) in a couple study. J Sex Med 2009;6:761-769 (View article with CPSBC or UBC)
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Interesting and informative. I will use this information in my practice.
It has long been my practice to tell older women concerned about decreasing libido that, compared to men, women are complex beings and that hormones play a relatively small role in any discussion of sexual desire. This kind of statement is usually well received and often leads to comments as to how simplistic men are!
need more information. But is there harm is giving low dose testosterone to women who has low level of testosterone?
very useful evidence in dealing with unreasonable demands
This article by Dr. Basson very clearly shows the point to be made and will definitely change my answers to the question of whether Andriol should be prescribed to increase feminine libido.
This will quiet some unreasonable “demands” by patients.
I fully agree that these findings are significant. Since at least 50% of women respond reasonably to male hormone in a number of different formulations, the placebo effect must be quite strong.
Very helpful to respond to women and questions on testosterone supplementation.
This article will help me in how I will answer patients’ questions in the future.
I normally don’t order a testosterone in womens lo libido but if a patient pressures me to do this I will have amunition to refuse and explore other aerwas as suggested
Interesting and helpful study results.
The ‘low level’ in the serum may or may not reflect low intracellular testosterone production. Even if it did low desire has not been shown to correlate with any accurate measure of testosterone activity in women – serum measure, intracrine measure or total intracrine plus serum. As well, there are no long term safety data (published data to 2 years on small number of women plus industry data to 3 years. But women’s sexual lives usually continue for as long as there is an active partner.
Dr. Basson
Rosemary, Thanks for the fact-filled evidence. I will certainly use the discussion in my consults with patients.
having seen the side effects of testosterone use in women (many not reversible with stopping) I have not used it. It is very helpful to have a study that backs up what I have observed over the years – minimal help. Also nice to have ammunition to dissuade patients that insist on using it after they have seen something on TV indicating it will solve all their female sexual problems!
What about a local testosterone cream? seems to be effective for many post menopausal women who have no other changes ie relationship or physical issues
thanks for the review, will keep your tips in mind
excellent, didnt order this test before. ‘low” Testosterone doesnt even correlate with desire in otherwise normal men
never did order this in women…giving testosterone for this problem always seemed to me carry more risk then benefits.
Not finding low levels of testosterone in women correlated with libido does not answer the question whether testosterone supplementation would help. The answer is yes according to a NEJM study -though modest.
‘http://www.nejm.org/doi/full/10.1056/NEJMoa0707302
I deal with chronic pain cases and find invariably that women pain patients have unmeasurable androgen levels. Supplementation seems to help their pains though can’t say about libido…
testosterone is a very important hormone for women, especially in terms of staying fit, lean, and sexually active. visit this site http://www.bio-identical-testosterone.com/ this might help those who suffers from low testosterone.