Low,Libido
A low libido (sexual drive) can result from many
things, but let me say at the outset that this is a new area of open
discussion -- yes, once again. A friend who subscribes to Menopause News
called to tell me that Oprah Winfrey's afternoon program on the subject
was terrific and I should watch it when 4:00 arrived on the West Coast.
She reminded me that we were the generation of women who had not talked
about sex; our mothers did not have bodies after all, just as they had not
had menopause! We laughed heartily. I had forgotten we began less than a
decade ago with that legacy. And now Oprah was talking about low sex drive
on national television to millions of viewers.
I was astounded to learn from Oprah that 40 million American women are
troubled by low libido. And she pointed out, most of those women are in
their 20s, 30s, and 40s! And we thought we had a problem! Many women in
their letters to M-News pointed out they had enjoyed wonderful sex -- before
menopause.
Oprah and her guests oversimplified the problem of low libido, I thought,
and its global solution. The 2% testosterone proprionate cream Judith
Reichman, M.D., recommended was presented as a magic potion. The cream will,
undoubtedly, help some women. But I do think these women should know that
they are one large scientific experiment. Certainly testosterone cream has
its place and I have written about it in the past (see MNews, Mar./Apr. 1996).
The present issue carries an interview with Susan Rako, M.D., an acknowledged
expert on the subject So, clearly I believe there is a place for it. But what
of a woman whose problem is psychological?
We have so little research on the subject of low libido, for both women and
men, but we do know some "medical" reasons for it. Lack of sexual desire can
be a side effect of certain prescription drugs, antihypertensives; antidepressant
and antianxiety drugs: adrenergic-receptor blockers (alpha and beta blockers),
and chemotherapy. Ironically, some birth control pills may be the culprit. If
you think low libido might be a side effect to a drug either you or your husband
is taking, discuss it with your doctor.
As Oprah and her guests believe, low sex drive can be caused by a testosterone
deficiency. As for an "imbalance" in hormones, we're still in the process of
determining how standard hormone numbers translate into the way you feel. We
haven't really determined if "normal" for you in your mind or in your doctor's
mind is your level at age 35 or age 55.
You can best determine what feels right and comfortable for you. Reading
subscriber letters describing how low libido affected them illustrates how
complex the problem is. It was interesting to read that for some women estrogen
helped libido and for others it did not. According to the research, estrogen will
restore vaginal tissue, but will probably not improve libido or lubrication.
Low Libido May Be Linked to Anticipation of Pain
Sometimes because vaginal tissue becomes more fragile as
estrogen diminishes or because of sexual inactivity, a woman may become tense
anticipating irritation or pain during lovemaking. Many women begin to produce
less lubrication as they age and would find a lubricant (Astroglide, Comfort,
K-Y Jelly, Replens, or oils) helpful. A lubricant will not repair vaginal tissue
that has dunned or lengthen a vagina that has grown shorter, but it will ease
intercourse friction.
The most commonly used medication for vaginal atrophy, obtained by prescription
from a physician, is Premarin vaginal cream. Unlike a lubricant, an estrogen
vaginal cream will improve a sore vagina by building up thin walls and it may
increase moisture. However, it is best used on a nonintercourse night. Premarin
(conjugated equine estrogens) has been the most widely studied, but two other
vaginal creams are available -- Ogen (estrone) and Estrace (estradiol).
You might want to discuss the vaginal cream dosages carefully with your physician
as one letterwriter did because lower dosages than are currently recommended by
physicians or drug companies are effective. For example, an applicator full of
Premarin would give a woman twice the dose of an oral pill! And the vagina absorbs
the estrogen more readily, making it more potent still. You can use as little as
one-eighth of an applicator, which translates to 0.3 mg (the typical oral dose of
Premarin is 0.625 mg). One gram of Estrace cream translates into one-tenth of a 1
mg Estrace pill.
One doctor has recommended that the cream be placed either by applicator or
finger on the inner vagina lips at the end of the vagina where soreness often
results from penetration. After five to ten days, the soreness should disappear
Thereafter the cream can be used two or three times a week. Because lubrication
may not reach premenopausal levels, you might still need to use a lubricant.
The question of the systemic absorption of a vaginal estrogen cream is not
well-researched. To be safe, if you have a uterus, you would do well to have the
thickness of your uterine wall (the endometrium) checked after a few months, or
take 10 days of a progestogen after a few months to guard against endometrial
cancer.
Having a healthy, elastic vagina is a prerequisite to happy sex. You certainly
should be able to determine if you are avoiding sex because you are physically
discomforted. Beyond that, your low libido may be due to psychological reasons
or insufficient testosterone.
Insufficient Testosterone May Affect Libido
This is a subject that women and their doctors find difficult
to discuss. If as Dr. Rako points out in her interview, nothing you do -- fantasize
about your partner or someone else, masturbate, look at pictures, buy new
undergarments -- you name it -- has no effect, it may be your testosterone and
not your partner or your relationship. It may well be insufficient testosterone.
We generally associate testosterone with men, but women also produce it albeit
in smaller amounts. It is sometimes called an androgen, which is the name of
the hormone category, and it is produced in a woman's ovaries and adrenal
glands. It is carried in the blood and is attached to proteins. Because estrogen
and testosterone attach to the same proteins, taking estrogen can sometimes
result in lowered testosterone.
Because hormones are so fleeting, measurement numbers might not tell the whole
story. You might want to try a testosterone cream or an oral tablet that combines
estrogen and methyltestosterone and see if the old you returns. Premarin with
methyltestosterone has 5.0 or 10.0 mg testosterone combined with estrogen and
according to Dr. Rako this is 20 to 40 times more testosterone than most women
need. Estratest H.S. (the H.S. means half strength) combines 1.25 mg methyltestosterone
with 0.625 mg estrogen. Even with this lower amount, it might still be too much
for you and you may prefer more flexibility with the dosing of each hormone. A
testosterone cream will give you more control over the amount you use and might
be a better choice.
Testosterone cream will bypass the liver initially because it does not go through
the digestion process as an oral tablet would, but you will have to find a doctor
willing to contact a compounding pharmacy to make up a special prescription (see
"Compounding Pharmacies") because at the moment there is not a commercially
available product. Testosterone cream may not work for you if you have aging
testosterone receptors or a reduced enzyme function.
Doctors have been reluctant to prescribe testosterone because of its side effects:
lowered voice, acne, enlarged clitoris, hair on the chest or face. It is unlikely
that any woman would miss these effects -- hair on my chinny-chin-chin can also
be a notorious menopausal joy. If you take more than your body is accustomed to
you may find yourself easily provoked to anger, irritable, hungry or depressed.
On the other hand, your testosterone may be low if you have excessively dry skin,
diminished pubic hair, loss of sexual desire, less sensitive genitals and nipples,
loss of muscle tone, drop in mental acuity and general loss of buoyancy and
feelings of well-being.
Methyltestosterone is not the same as the "natural" testosterone that your body
produces. However, "natural" testosterone converts readily to estradiol in your
body, so it is more difficult to control the dosage. Additionally, some women
who are at risk for breast cancer want to keep their estradiol levels down. The
most effective dose of methyltestosterone is 0.25 to 0.75 mg, with most women
benefitting from a 0.50 dose. A woman should try such a low dose for several
weeks before increasing it. If her low libido is related to some other reason
or if her problem is not the amount of testosterone, increasing the dose will
have no effect.
Testosterone can also be formulated in sublingual (under the tongue) tablets
or in a gel. Because oral testosterone is toxic to the liver in large amounts,
other delivery systems are recommended. Anyone with a liver disorder should not
take testosterone.
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