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). 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. 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.
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 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.
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 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.
References: (Note: Article requests require a login ID 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)
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)