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Just 'not in the mood' lately? Find out why

Dr. Judith Reichman looks at one study that found a connection between male hormone levels and a woman’s desire for sex — or the lack thereof

Nearly half of all women experience a low level of sexual desire, or libido, at some point in their lives. A low male hormone (androgen) level or “female androgen insufficiency” has often been blamed for dwindling (or no) desire, but a recent study published in the Journal of the American Medical Association (JAMA) seems to refute the fact that low male hormone levels are associated with or can be used to predict low sexual function in women. 

“Today” medical contributor Dr. Judith Reichman discusses the clinical importance of these so called “hormones of desire” and whether checking their level will help in the assessment of female sexual dysfunction. 

About the study
It was conducted in Australia where more than 1,000 women between the ages of 18 and 75 were randomly selected through voter registration and phone calls (actually, more than 18,000 were contacted, but only 9 percent finally participated). Women on birth control pills or whose cycles were irregular, who had chronic illnesses, or who were on medications that could affect libido, such as anti-depressants, psychiatric and epilepsy medications, were excluded from the study.

A blood test was done to check the level of several male hormones.  The women also filled out a profile of female sexual function, which helped score their level of sexual desire, arousal and responsiveness.  The researchers found that there was little correlation between testosterone levels and their sexual libido or drive. 

Was it just testosterone or were other male hormones also tested?  What about DHEA?
Most of us think of testosterone when the term “male hormone” is used (and until this past decade, most women also thought that testosterone was more or less a hormone that was exclusive to men). However, both sexes produce testosterone; women just do so at levels that are less than one-tenth that of men. Our testosterone comes from our ovaries and adrenal glands. And most of the testosterone that "floats around in our bodies" (i.e., in our blood) is bound up and rendered inactive by a protein called sex hormone binding globulin (SHBG). In order to estimate true testosterone levels, laboratories now test the amount of SHBG and then calculate the amount of unbound or free testosterone that is present in the blood. But testosterone, bound or unbound, is not our most abundant male hormone; dehydroepiandrosterone (DHEA) is. DHEA is a natural steroid hormone produced by our adrenal glands, and it too is bound (to a sulfate molecule) as it enters our bloodstream; hence it’s designation as DHEAS. When the latter enters the cells of our body, it can be converted to another weak male hormone, called andronstenedione, or to testosterone. 

Testosterone is unable to “do its thing” without undergoing further transformation. Once in a cell, it is converted either to estrogen (yes, a male to female conversion!) or to the potent form of male hormone called dihydrotestosterone, which attaches to the receptors in the cell.  This then allows the cell to participate in the properties we attribute to male hormones:

  • Muscle building
  • Increased bone density
  • Pubic hair growth (and in some cases, unwanted body hair)
  • Oiliness of skin (and acne)
  • Sexual response (in the brain and genital organs)

Did they check all of these male hormones in the study?
They measured total testosterone, free testosterone and DHEAS levels.  Low total and free testosterone levels were not associated with low libido, arousal problems or inability to achieve orgasm in women in all the age groups.

However, women who had low desire and poor sexual response were three to six times more likely to have low DHEAS levels. The researchers pointed out, however, that the majority of women with low DHEAS levels did not report low sexual function; hence, they felt that this latter hormone level should, like testosterone, not be used as a diagnostic tool.

This seems confusing. Doesn’t testosterone supplementation help some women who suffer from low libido and poor sexual response?
Yes. Especially women who, during their reproductive lives, undergo surgical removal of their ovaries and therefore lose an important source of testosterone production. Once women have their ovaries surgically removed or functionally destroyed through radiation or chemotherapy, their libido and sexual response tend to plummet. When given estrogen — only as replacement therapy, they often continue to complain of sexual dysfunction. The addition of testosterone can make a huge difference, reversing their sexual "apathy." Multiple studies have also shown that adding testosterone to estrogen therapy can improve libido in menopausal women. Indeed, the testosterone patch was developed to treat this problem, but it has not obtained FDA approval.  The only form of testosterone that is currently FDA-approved is combined with estrogen in a pill called Estratest. Although approved for treatment of severe menopausal symptoms that do not respond to estrogen alone (and not sexual dysfunction), it is often prescribed to bolster libido in menopausal women. If doctors wish to prescribe male hormones in other forms or without concomitant estrogen, they currently have to do so with testosterone creams, ointments, capsules and drops made by compounding pharmacies.

So if testosterone can be prescribed to increase libido, why won’t measuring testosterone levels predict low libido?
This is only one study and, as we have seen before, one study does not, in the world of medicine, give us the final word. And, as the researchers pointed out, blood levels of testosterone may not reflect what is happening within the cells where the “true” and cellular-active testosterone is produced through conversion from other hormones. 

Finally, there is much more to our sexual response than just male hormones.  I actually wrote a book titled "I’m Not in the Mood" (this was not a personal reflection but was written to help women learn about all the causes of female sexual dysfunction and what could be done to treat them). 

In it, I list the seven sexual saboteurs.  These include:

  • Psychological problems (depression, stress, anxiety and fatigue)
  • Sexual abuse (up to 23 percent of women have suffered some form of abuse)
  • Body image issues (obesity, eating disorders and a sense of not having a body that’s worthy of sex)
  • Couple trouble
  • Medications — the latter includes the estrogen in oral birth control pills or hormone replacement therapy (which can increase production of SHBG and block the activity of testosterone), anti-depressants, tranquilizers, blood pressure lowering medications and anti-epileptic medications
  • Chronic pain and chronic disease — This includes pelvic surgery and urinary incontinence (and fear of losing urine during intercourse).
  • Men —  Either the absence of a partner or a partner who has sexual dysfunction (thought erectile dysfunction medications have come to the aid of many, note that they don’t appear to help sexual response in women)

Sex seems to be a multi-splendid, but also “multi-problemed” phenomena, and it would seem that a single blood test will not help with diagnosis or treatment.
No, the take-home message is, if a woman has sexual problems she should talk to her doctor. If all these other factors have been ruled out, male hormone therapy might be an option, providing there are no contraindications. Testosterone therapy can be helpful for some women, but don’t expect a single hormone to give you all those sex dreams you had when you were young, or make those sex dreams come true.