Q: Is there a trade-off between hot flash relief and libido?

You're wondering whether your hormone therapy, designed to address your hot flashes, is having an unintended negative effect on your libido. The good news is that adding estrogen is better for sex, in general terms. So you don't have to take back your hot flashes to get your libido back!

The less good news is that libido is sometimes a puzzle to solve. I've found that non-oral estrogen addresses hot flashes with fewer unintended effects on sexual desire. The reason is that oral estrogen enters our systems in ways that affect metabolization in the liver and resulting circulating testosterone levels. And testosterone, though not entirely understood, is as important to women's sexuality as it is to men's!

You might start by changing to non-oral or transdermal estrogen; it will likely take up to 12 weeks to see whether there's an effect. And if that doesn't make enough difference, there are other options you can explore with your health care provider.

Q: What stopped my orgasms?

You mention a variety of things that play a role, all coinciding with the change in hormone levels that comes with menopause, which you'll reach in a few more months (the milestone is one year without menstruation).

The Vagifem that's been prescribed for you should be having some positive effect with vaginal dryness; it should not interfere with orgasm. Vagifem is a very, very low dose of estrogen, delivered directly to the vagina and surrounding tissues. This is partial compensation for the estrogen delivered through the whole body when ovaries are intact and functioning.

SSRIs (selective serotonin reuptake inhibitors, a type of antidepressant), which you mention taking, can be a barrier to orgasm. If you've taken them for a while and only recently have had issues, it could be that the combination of the SSRIs and the lower hormone levels of menopause is now problematic. There is limited evidence that Viagra can help women on SSRIs experience orgasm. It's not just estrogen that declines with menopause: Testosterone also declines. You might talk to your health care provider about testosterone therapy; among my patients, many who trial testosterone note sexual benefits, usually describing more sexual thoughts, more receptivity (a patient recently told me she's "more easily coerced"!), and more accessible orgasms.

You also said that vibrator use has become ineffective for orgasm. Among midlife women, I find that the specific vibrator really counts. There is a definite range of vibration intensity, and as our bodies change, that can make all the difference. Lelo has just doubled the "motor strength" of two of their already powerful (and MiddlesexMD favorites) vibrators for the Gigi2 and Liv2.

Best of luck! My work with women every day says it's worth exploring your options. (And, to take the pressure off, remember that intimacy without orgasm is still intimacy!)

To ask your own question, use the pink “Ask Dr. Barb” button top and center on our website. You’ll receive a confidential reply via email, and your question may be used as the basis for a Q&A post here on our blog. 

Q: Can low-dose hormone therapy affect libido?

Overall, estrogen is helpful to libido and sexual desire. Oral (systemic) estrogen can have the unintended effect of decreasing testosterone, which is linked to libido in women as well as men. The reason is complicated, but has to do with liver metabolism and a binding protein that reduces circulating testosterone.

The approach I take with patients is to use non-oral, transdermal (systemic) estrogen, which bypasses the liver and therefore doesn't affect testosterone levels. I've had patients who couldn't experience orgasm on oral estrogen but could with non-oral estrogen.

And for some women, I do consider adding testosterone. There isn't a product for women, so I use a very low level of male testosterone "off-label" and then monitor blood levels during use. Sometimes, as an alternative, Wellbutrin (buproprion), an anti-depressant, helps restore libido by affecting the neurotransmitter dopamine.

I'm afraid we women are complicated! There are, though, a number of options to experiment with until you've achieved the sex life that makes you happy.

Testosterone: Not Just for Libido Anymore

Can’t remember the name of the new work colleague? Forgot the city your best friend lives in? Can’t recall the movie you saw last week?

Join the club.

A little-known fact about loss of estrogen is that it takes a bit of memory with it when it goes. That’s why memory decline is a common feature in post-menopausal women.

Insult to injury, if you ask me. Let’s face it, at this stage of the game, we can ill-afford to lose any bit of that precious function.

In a new study, however, Australian researchers have found that small daily doses of testosterone gel applied to the upper arm improved verbal memory in postmenopausal women.

Testosterone is an androgen—a male hormone—that governs all kinds of things in men, especially sex drive.

Women produce testosterone, too, in the ovaries and adrenal glands, but in miniscule amounts, and its function is not well understood. Testosterone levels drop quickly as women age until at age 40 a woman usually has about half the level of a 20 year old.

It affects libido and has been used successfully to treat low sexual drive in women, but its long-term effects—or even correct dosages—haven’t been rigorously studied.

Testosterone treatment for women hasn’t been approved in either the U.S. or Canada, so it has to be prescribed “off-label.” That means either the physician prescribes an FDA-approved male pharmaceutical product in very small doses (usually about one-tenth of dose recommended for men) or the hormone is compounded specially by a pharmacist.

In the Australian study, researchers found an intriguing link between verbal memory and testosterone in women. In the study, 92 post-menopausal women (between 55 and 65) were first given standard tests for cognitive function. Then they were randomly assigned to receive either a placebo or dosages of testosterone gel for 26 weeks.

At the end of the treatment period, the women receiving testosterone had higher levels of the hormone in their system, and they scored 1.6 times better in tests of verbal memory (recalling words from a list). Scores on other tests remained the same between the two groups.

While these results aren’t game-changers, they do represent one of those incremental steps that can lead to significant advances. “This is the first large, placebo-controlled study of the effects of testosterone on mental skills in postmenopausal women who are not on estrogen therapy," said Dr. Susan Davis, principal investigator in the study.

Since there is currently no treatment for memory loss, and since women suffer from dementia in greater numbers than men, this link between testosterone and memory could be an important finding.

Not to mention the potential side effect of improved libido.

An Update on Testosterone Therapy

Recently, Dr. Sheryl Kingsberg, chief of behavioral medicine at University Hospitals Case Medical Center, professor in Reproductive Biology and Psychiatry at Case Western Reserve University, and a MiddlesexMD advisor, was interviewed by Dr. Michael Krychman, another MiddlesexMD advisor, for an online feature about the state of testosterone therapy for women.

Since we were able to be a fly on the wall, here’s the takeaway:

Despite a few advances in the research, the general state of affairs surrounding testosterone therapy for women remains fairly untested and inconsistent.

Unlike in Europe, which has approved Proctor & Gamble’s testosterone patch for women, the US Food and Drug Administration has no approved testosterone therapies. Women who receive testosterone therapy in the US get it “off-label,” meaning that either products designed for men are prescribed in small doses for women, or it’s compounded by a pharmacist without regulation or oversight. And that’s the way it’s been done in the US for decades.

In the meantime, research on testosterone products for women proceeds in fits and starts, and there simply hasn’t been a lot of it. Two large efficacy trials of BioSante Pharmaceuticals’ new LibiGel testosterone product found no significant difference between it and a placebo. The company is continuing with five-year safety trials, however, to determine if long-term use causes adverse health effects in women—specifically, cardiovascular disease or breast cancer.

“They’re moving forward with the [safety] trial, so that is hugely exciting,” says Sheryl.

The goal of testosterone treatment is to return a woman’s testosterone to pre-menopausal levels; treatment protocols for clinicians are fairly undefined, although the North American Menopause Society has recently updated its practice guidelines. Most blood tests aren’t sensitive enough to pick up such low levels of testosterone, and there’s no correlation between blood testosterone levels and libido. That means that while blood tests to establish baseline levels can be helpful, a clinician has to rely on observation and the patient’s reported experience.

And determining whether a woman is a good candidate for testosterone therapy also remains something of an art as well as a science.

“Testosterone is an important option for women—but it’s not for every woman,” says Sheryl. “We know that testosterone therapy won’t necessarily be effective in all women, so it’s important not only to measure efficacy and safety, but also to think about other treatment options.

“The first thing a clinician needs to assess is which women would really make use of testosterone replacement, and which women have something else going on,” she adds.

Good candidates are women who have lost their biological drive for sex, which is the classic definition of hypoactive sexual desire disorder: They have no desire, no fantasies, no dreams, no “hunger for sex,” as opposed to women who may have lost interest in sex, but who may have relationship issues or other stressors in their lives.

Because of the dearth of research and treatment protocols, clinicians should monitor their patients who are on testosterone therapy to make sure that it’s both effective and at safe levels, although, as Sheryl points out, the amount of testosterone in most treatments is very low.

And despite the frustrating lack of options and research surrounding testosterone therapy, women who are troubled by low libido shouldn’t be embarrassed about asking for help. “Hypoactive sexual desire disorder is the most common sexual problem across all ages,” says Sheryl. “About 10 percent of women have it, and they deserve to be assessed and treated because sex is important to overall health and quality of life.”

Q: Can I revive my sex drive and orgasm after a hysterectomy?

There are a number of pieces to this puzzle--we women are complicated! First, because your hysterectomy was "complete," you no longer have ovaries, which are a major source of testosterone (up to 50 percent) for women. Losing that testosterone can be a major hit to women's desire, arousal, and orgasm. Some women benefit from adding back testosterone, but it's not FDA-approved in the U.S. and not all practitioners are familiar or comfortable with prescribing it for women.

If you're taking oral estrogen, some complicated biochemistry is at play that can further decrease your testosterone. Replacing estrogen by a means other than oral--skin patch, spray, gel--is important.

If you're not taking estrogen, orally or otherwise, that may be a contributing factor, too. Losing estrogen leads to less blood supply to the genitals, which makes arousal and orgasm more difficult.  Localized vaginal estrogen works for many women, and it's not absorbed system-wide.

Beyond the hormonal pieces of this puzzle, I often recommend warming lubricants or arousal oils, which use a stimulant to bring more blood supply to the genitals. Using a vibrator can also help; the more intense stimulation can make a difference. And I encourage women to explore self-stimulation: What you require now may be different from what it was, and the better you understand yourself, the more you can help your partner meet your needs.

Best of luck! It will be worth the time and effort to revive this part of yourself!

Q: What does higher libido in perimenopause mean to my future?

Libido is, at best, complicated. Testosterone is the hormone that is linked to libido for women as well as men. After about age 25, our testosterone levels are slowly dropping. It’s estimated that a 50-year-old has about half the testosterone she once had.

I see this phenomenon with increased libido in perimenopause from time to time. Testosterone interacts with other circulating hormones, and it seems to be the relative balance and interaction of these hormones, not the absolute levels of each, that for some women works very favorably during perimenopause. Relatively speaking, testosterone may have some “dominance,” even though the levels are lower than they used to be. Enjoy!

There are some other possible factors: Obese women tend to have slightly higher testosterone levels, and some women have had weight gain in perimenopause. Or, because we’re complicated sexual creatures, it could be the empty nest or something else entirely (for some, the absence of "that bothersome uterus").

In general, women do experience a loss of libido with menopause, but the loss is not uniform across the board. We can hope you are that woman who doesn’t lose interest. In the meantime, seize the moment!

If you’re wondering when you might move from perimenopause to menopause, I’m afraid we can’t accurately predict that timing. We can only say that women, on average, become menopausal about age 50. Ninety percent of women have four to eight years of changed—and changing—menstrual patterns before becoming menopausal. Blood work is accurate in understanding estrogen, progesterone, and FSH levels for the day of the test, but it doesn’t accurately predict anything. Testosterone levels have fewer day-to-day fluctuations, so accurate measures can be made.

Perimenopause is a time to tune into your body, because as you move into menopause, your symptoms will be the best indicator of what’s actually happening.

Testosterone: Not for Men Only

Testosterone, of course, is the hormone that makes guys hairy, muscular, and sexual. But testosterone isn’t only for guys. Women produce it, too, but at much lower levels, and for us, the effects are less linear and more subtle: More testosterone doesn’t necessarily mean more libido. Yet, in many studies, a little touch of testosterone has been strongly linked to a better sex life for women.

So, what’s the big deal about testosterone, anyway? What’s its role in women’s sexuality, and what are the pros and cons of testosterone therapy for women?

First, a refresher: The most common cause of pain with intercourse for the peri-menopausal and menopausal woman is vaginal dryness that comes from the absence of estrogen—in medical terms, vaginal atrophy.  The solutions are to restore vaginal estrogen (available by prescription) or restore moisture with regular use of non-hormonal, over the counter options, like Yes or Lubrigyn.

So while estrogen is primary, we also produce testosterone—mainly in our ovaries, and only at about one-tenth the level as in men. Testosterone levels peak in our 20s and early 30s and steadily decline until, surprise!, we’ve lost about 80 percent of our testosterone-producing power after menopause. Women whose ovaries are removed are also cast immediately into “surgically induced menopause.” While we may still be sexual creatures, we’re no longer procreative creatures, so the hormonal stream is reduced to a trickle.

Enter testosterone therapy. Testosterone may be one rabbit in the bag of tricks that addresses the single biggest sexual complaint in women: lack of interest. Testosterone has been called the “hormone of desire” for women. “Women need estrogen for lubrication and comfort during sex. But they need testosterone to feel desire in the first place,” according to author and “Today” show correspondent Judith Reichman  in a 2005 “Washington Post” article. In many studies over the years, replacing testosterone has been linked to greater sexual desire, more intense orgasm, and improved sexual performance in women. There’s evidence that it might also improve muscle tone and increase energy levels and mental acuity.

Yet, it’s still only available “off-label,” meaning that there’s no pharmaceutical brand approved by the Food and Drug Administration (FDA).  Testosterone can be prescribed by using the male FDA-approved products, at significantly lesser dosing regimens, or by compounding at pharmacies. Testosterone, in natural or synthetic form, is available in long-lasting injections, pellets, patches, and transdermal creams or gels. Oral testosterone or testosterone pills are not recommended because they are metabolized by the liver and the possible changes that result from that.

Testosterone therapy remains controversial. Unlike in men, there’s no direct relationship between libido and blood testosterone levels in women. A woman can have a good sex drive with low testosterone or no interest in sex with high testosterone levels. Additionally, appropriate levels of testosterone for women have been hard to establish since we produce so little of it. Measuring testosterone levels in women is difficult, because of the very low levels and other factors that affect the circulating testosterone. The use of testosterone in women is usually well-tolerated but side effects may include acne and unwanted hair growth. The phase III clinical trials for testosterone use in women appear as though testosterone use in women will be safe, but finalization of these studies and FDA approval are still pending.

Before beginning testosterone therapy, it’s important to address other causes of loss of libido, such as depression, medications, painful intercourse, lack of emotional intimacy, or chronic stress. But, if lack of interest in sex or the inability to experience orgasm continues to be a problem for you or in your relationship, testosterone therapy might be something to explore with your health care provider.