Q: Is there an arousal product that's not irritating?

You say that your wife suffers from lichen sclerosus, a condition that creates skin tissue that is thinner than usual (and is a higher risk for postmenopausal women). Warming oils and lubricants, unfortunately, create discomfort rather than arousal for her. I'm not aware of an option in that category that would work for her, since the ingredients that make them effective--usually something minty or peppery--will almost certainly cause an adverse reaction.

Plain lubricants won't cause that reaction; those we include in our product collection should be well-tolerated by lichen sclerosus patients.

There are a couple of other options you and your wife could explore for arousal. The use of testosterone has been beneficial for 50 to 60 percent of the women in my practice who've tried it. Testosterone is by prescription and off-label for women, which means a discussion with her health care provider is required.

Other prescription options include localized estrogen, Osphena, or Intrarosa (a recently available FDA-approved choice). Any of these would increase blood supply by "estrogenizing" the genitals, which can improve arousal and orgasm as well.

Congratulations on undertaking this exploration together! Good communication and mutual support are so important to shared intimacy.

Testosterone Therapy: A Voice from the Trenches

Ever have a medical professional say to you, “This procedure is a piece of cake. You’ll be back on your feet in a couple days,” only to be popping Tylenol and cursing the day you were born fully a week later?

Ever step off the plane into a throng of strangers and realize you really should have researched this off-the-beaten-track destination a whole lot more before you booked the flight?

I don’t know about you, but before I venture into uncharted territory, whether It’s a medical procedure or a new travel destination, I like to talk to someone who’s “been there,” who knows what she’s talking about and is willing to tell it straight. The voice of experience is always reassuring.

So for Part 2 of our discussion on testosterone therapy, we bring you the voice of one of my patients who is on testosterone therapy and who was kind enough to share her experience with us.

Each woman's menopause story is unique.As I mentioned in Part 1, in my clinical experience about 40 percent of women aren’t helped by testosterone therapy at all. A few others experience unpleasant side effects, and others still, like this patient, experience additional positive effects. While each woman’s experience is unique, many really do benefit from small dosages of the hormone.

Here’s a Q&A from one who did. Let’s call her Elaine.

MiddlesexMD: What were your expectations of menopause? Did you have a general idea of what to expect?

Elaine: The only idea I had of menopause was what is popularized by general media: hot flashes, temperamental moodiness, weight gain, fatigue, dry vagina, low sex drive. I didn’t want that to be my experience, and I decided I would do all I could not to have that be my story, but I really didn’t know what that would mean. Lucky for me, I have a smart, proactive health care provider that has always felt like she was on my team with my health story.

MiddlesexMD: What was your experience of menopause?

Elaine: My complaints were: intermittent feelings of anxiety, which I had never experienced before. Also I experienced somewhat diminished sex drive, but worse than that, when my hubby and I did have sex, it was SO MUCH WORK to achieve orgasm for me. Exhausting. I am so glad I am a runner and in good shape, because there is no way an out-of-shape me could even hope to work that hard without having a heart attack!

Then finally the orgasm was very flat and not very satisfying. Also I experienced some mild general fatigue; almost daily I would require a 10-minute nap, which never bothered me, but was relatively new to me.

MiddlesexMD: What was the problem--or set of problems--that you wanted to solve by seeking medical help?

Elaine: I described the symptoms listed above (anxiety, diminished sex drive, flat orgasm, some fatigue), without really expecting a solution. I expected Dr. Barb to say, “Yep, that’s menopause! Most women experience those things.” I thought she might recommend some herbal remedies, at most. I was obviously delighted with the solution she prescribed!

MiddlesexMD: What was the impact on your relationship of the symptoms that you had?

Elaine: My sex drive is improved, and the quality of orgasm is VERY much improved. Also, it doesn’t take forever for me to achieve orgasm. I almost never require a nap anymore, can’t think of the last time I took one, actually.

MiddlesexMD: Any other effects of testosterone therapy for you?

Elaine: The following are the unexpected effects: My anxiety symptoms, which were mild, are gone. I have noticed that mentally I feel more assured; I am able to more clearly see the forest for the trees; I am able to make confident decisions more quickly. I also have noticed that I am less likely to worry about whether people agree with me, or if they like what I have to say. I feel I can make intelligent decisions without being bogged down by wondering how my responses are received and if people agree or like me more or less for what I say.

I feel I am more able to present my true, authentic self/opinions. I am able to make decisions more quickly and with more confidence. I notice I don’t tolerate as much B.S. as I used to. (I am not rude, but I don’t go down that road with people anymore?) I feel somehow more clear and comfortable in my skin. I never expected this, but I love it.

I also have noticed that my muscle tone is improved, nothing freakish or dramatic, but I do notice it. I am running a tad bit faster, and I have more energy after a long run. I am no longer whipped for the day following a long run. I have noticed I have more overall energy, actually. I still sleep well at night, always did. I have experienced no other side-effects, such as extra hair growth or acne. I have noticed no negative side effects, actually.

MiddlesexMD: Does this experience suggest anything that you wish other women knew or were told?

Elaine: It sure makes me happy that I have such a great health care provider who is on the cutting edge with drug therapies, knew about this option, and took the time to explain it to me. I have mentioned it to several friends, and they have never had such a discussion with their health care providers. I wish women knew that all the stories about menopause (icky side effects, moodiness, weight gain, etc.) are not necessarily the experience of every female.

March 14, 2016


HSDD ›   libido ›   testosterone therapy ›  

Testosterone Therapy: Another Set of Socket Wrenches

I love options. Moose Tracks or Mackinaw Island Fudge? Mocha or machiatto? Phillips screwdriver or allen wrench?

Mostly, I like having options for my patients. At this awkward middle-age time of life, issues are complex and solutions are rarely straightforward. So I like to have a toolbox of treatment options to choose from. If one method doesn’t work, maybe another will.

To be clear, I always start with the most natural, straightforward treatment possible, postponing pills, prescriptions, and hormones. To this end, a healthy lifestyle is the first and most important contributor to a good sex life. Along with lavish use of moisturizers, lubricants, toys, and imagination.

But when these things fall short, it’s nice to have options.

Healthy lifestyle first and most important contributor to good sex lifeThat’s what testosterone therapy offers—another tool. Another treatment regimen that might fan a faltering libido and fading intimacy in an otherwise healthy relationship. Like any treatment, this isn’t a silver bullet or a magic pill. In fact, it’s controversial. There just isn’t a lot of research on long-term use or even on how testosterone functions in women. (Spoiler alert: a lot different than in men.) It isn’t FDA-approved, although it’s been prescribed “off-label” for decades in the US and is prescribed legally in Europe and elsewhere.

In women, testosterone is produced at much lower levels than in men, mostly in the ovaries and adrenal glands. As we age, and especially if our ovaries have been removed, testosterone levels drop sharply. This isn’t the only reason for diminishing sexual desire but it may be part of the picture. (In medicalese, a distressing loss of libido is called hyposexual desire disorder—HSDD.)

Since declining testosterone levels, menopause, and HSDD tend to happen in tandem, maybe a causal link exists among them, so the thinking goes. Obviously, it’s more complicated than that, but for some women, a little testosterone boost just seems to work. As a recent bulletin from Harvard Medical School states: “…in some but not all studies, testosterone therapy has been shown to be an effective treatment for HSDD in carefully selected postmenopausal women.” In my clinical experience, testosterone therapy improves libido, desire, and/or the ability to orgasm in about 60 percent of the women who take it.

So, what are those “carefully selected” qualities that make a patient a good candidate for testosterone therapy?

First, testosterone won’t cure difficulties in a relationship that may be contributing to intimacy problems. Other libido-killers include depression, fatigue, anxiety, certain medications, and the usual menopausal suspects: loss of estrogen, night sweats.

In the absence of physical or psychological factors, women who are distressed by their lack of libido (the classic definition of HSDD) might find relief with a little extra testosterone in their system. I monitor blood levels during treatment with the goal of restoring testosterone to the level you probably had when you were 25 years old.

Some women (about 20-30 percent of my patients) experience some added benefits, such as improved mood and more energy, while another 10 to 15 percent have less positive side effects, like unwanted hair growth or acne. And for about 40 percent of my patients, testosterone therapy isn’t helpful at all.

Testosterone can be safely applied topically; I usually prescribe a gel, the same FDA-approved topical gel that is used by men, but at one-tenth the dose, which I find offers a safe and consistent delivery of the medication.

For some women, testosterone is a game-changer and for others, not so much. Since the potential benefit is so positive and the detriment is minimal, in my opinion, testosterone therapy is a solid treatment option. A woman who’s tried it will tell her story in our next blog post.