Hormonal Therapy for Male and Female Sexual Dysfunction
Understanding low sex Drive and its Therapy With Bioidentical Testosterone Subcutaneous Pellets
A reduction in sex drive is noticed by many women starting as early as their mid 30’s and hitting rock bottom by the time that their menstrual periods stop. According to the National Health and Social Life Study in 1999, one third of all women surveyed reported a lack of sexual interest. Other statistics claim an incidence of low libido is 50% in the 30-60 year old female population studied. Although low sexual drive does occur in younger women under the age of 30 years, in most women the decline in libido usually parallels the progressive reduction of ovarian hormone production of both testosterone and estrogen as a woman traverses her perimenopausal years on the way to the menopause.
Because of the parallel course of the decline in hormone production in women as they age and the reduction in libido, it is safe to say that a deficiency of female hormones-estrogen and testosterone-is a major cause of diminished or absent sexual drive in a large percentage of women. Some of the other possible causes of loss of interest in sex include psychologic and relationship problems, sexual trauma and side effects of medications such as birth control pills and antidepressants. In most instances, these factors can easily be ruled out, leaving a deficiency in female hormones as the most likely culprit responsible for the disappearance of libido.
As a state of hormone deficiency, libido can be restored to a state of relative normalcy by supplying the deficient hormones in adequate doses to be effective in relieving symptoms, without producing side effects. To illustrate how the evaluation of a woman consulting a physician about her loss of interest in sex might proceed, please read this case study which is, unfortunately, all too typical.
A Clinical Case Study on Loss of Libido
A 38 year old divorcee, in good health, made an appointment with her gynecologist seeking help with a progressive decline in her libido over the past three to four years. Her periods are regular and she stated that her libido has always been “healthy”, desiring sex 3-4 times per week. She denies prior history of sexual trauma or postpartum depression. Her only surgery was a tubal ligation 5 years ago after a vaginal delivery of her second child. This woman has a history of hypothyroidism, starting after the birth of her first child. She takes Synthroid 125 mcg/day and is currently asymptomatic, with her TSH levels always being low since starting thyroid medication. She denies taking any other medications, including antidepressants and medications for anxiety, as well as statins and beta-blockers. Her current relationship began 3 years ago. Although she finds her partner attractive and claims to be “totally in love with him”, her state of sexual desire is low. She stated that she accommodates him sexually but rarely initiates intimacy. After hearing her clinical history, the doctor orders the usual battery of hormone tests: FSH, LH, Estradiol, Prolactin,TSH and Total Testosterone levels.
When she came for her follow-up appointment to discuss her blood test results, she was told that all her results were normal, including her total testosterone level, which was in the middle of the “normal” range. She was then told something that she did not want to hear; that since her testosterone levels were normal, hormone treatment with testosterone would be unlikely to improve her sex drive.Then to make matters worse, she was given a referral to a sex therapist for treatment, the implication being that since nothing was wrong with her hormonally, the problem must be in her head!
This lady’s problem should have been approached in a totally different manner. It was quite obvious from the woman's medical history that psychological or relationship issues were not the cause of her low libido. By not paying adequate attention to this patient’s clinical history and by not factoring in the details of the patient’s perception of her relationship into the diagnostic process, the physician’s inappropriate referral for sex therapy could have been avoided. With social and psychiatric causes ruled out by process of elimination, a state of hormonal deficiency has to be the most likely cause of her loss of libido.
Contained in her medical history are three overlooked medical causes that were contributing factors to this lady’s ovarian hormonal deficiency which were the root causes of her low libido. The first is a condition called the Post Tubal Ligation Syndrome, in which women experience a variety of perimenopausal symptoms, among which is lowered sex drive after having their “tubes tied”. This occurs because of an interruption in the blood supply to the ovaries which unavoidably occurs in the process of removing portions of the fallopian tubes. This results in a decrease in ovarian estrogen and testosterone production which produces symptoms of hormonal deficiency. In one study, 16% of women under the age of 33 years old reported that they had a loss of sex drive after having their tubal ligations.
The other possible contributing causes of female hormonal deficiency are this woman’s age and her history of hypothyroidism. Due to her age, it is possible that this lady could have already started her natural perimenopause. Many women, whose periods stop by the age of 45, will start experiencing perimenopausal symptoms at the age of 35, ten years prior to their last menstrual period. In many women, a reduction in libido is the earliest sign that the perimenopausal period has started. Also many women with hypothyroidism, specifically those with Hashimoto’s Thyroiditis, tend to undergo an earlier menopause than women who do not have hypothyroidism. Although this lady was not tested for antithyroid antibodies to determine if she had Hashimoto’s, which is the most common cause of hypothyroidism in women. Due to the frequency of this condition in the female population, it is more than likely that hypothyroidism may also have played a role in causing ovarian hormonal deficiency that contributed to her low libido. Nevertheless, this lady should have a comprehensive battery of thyroid blood tests, including both antithyroid antibody tests, as well as a thyroid sonogram. The symptoms of hypothyroidism are often intensified at the time of perimenopause and the dose of thyroid medication often needs to be increased to eliminate troublesome symptoms.
In a further analysis of this case, the patient’s doctor also made an error in telling the patient that her testosterone levels were normal. The total testosterone test cannot indicate whether a testosterone deficiency actually exists, or whether the testosterone level is adequate to maintain normal biological function, such as a healthy libido. Total testosterone level measures both bound testosterone( 97-98%), which is biologically inactive, and free testosterone(2-3%), which is the biologically active form of the hormone. Therefore, It is basically a measurement of biologically inactive testosterone. Furthermore, 95% of women, regardless of the levels of their libido, will have their total testosterone levels in the laboratory reference range( 5-45). Because the incidence of low libido is between 33-50% of women in a given population, most women with diminished sex drive will have testosterone levels that fall within the reference range. The bottom line is that hormone levels that fall within the reference range does not necessarily mean that a person’s hormone levels are adequate to insure normal biologic functioning. Therefore, the levels of testosterone in the blood are basically useless in proving that a deficiency in testosterone actually exists. The bottom line is that this lady’s clinical symptoms of persistent low sex drive, strongly suggest that the amount of testosterone that she produces naturally is not adequate to support the amount of testosterone required to produce sexual desire and arousal. Since levels of testosterone in the blood do not correlate with libido, the clinical symptom of low sex drive is the obvious key to accurate diagnosis and treatment. Because this lady is symptomatic, she should have been offered a 3-6 month therapeutic trial of testosterone therapy using subcutaneous bioidentical testosterone pellets, rather than a referral to a sex therapist.
In summary, it is critical to understand that there is no correlation between the levels of a woman’s total testosterone in her blood and the strength of her sexual drive. Experience shows that there are women whose testosterone levels are in the lowest percentiles of the reference range and who have high levels of libido, and there are those women whose results fall in the upper 25% of the reference range or whose testosterone levels are even above the upper upper limit of the reference range, who have no sexual interest at all. Even when free testosterone levels or levels of biologically available testosterone are tested, as well as the level of sex hormone binding globulin (SHBG), there is no reliable way to determine testosterone deficiency other than by a woman’s clinical symptoms. In the case of complex hormonal deficiency states, such as female hormonal deficiency and hypothyroidism, a person’s symptoms are of much greater significance than are their blood test results.
It is also important to remember that sex drive starts in the brain, not in the genitals.The centers that control sexual behavior reside in the area of the brain called the thalamus. Stimulated by the female sex hormones produced in the ovaries, brain chemicals, called neurotransmitters, actually control the desire for sexual activity. As seen in the illustration below, certain neurotransmitters stimulate sexual desire, while others inhibit it. In people of reproductive age, the high levels of estrogen and progesterone produced at the time of ovulation trigger the production of two neurotransmitters that basically create libido by producing sensations and feelings that motivate people to want to have sex. Dopamine, which is stimulated by testosterone, is called the pleasure hormone, actually produces pleasurable thoughts, sensations and feelings which creates desire and motivates people to engage in sexual intercourse. Oxytocin, the hormone controlling milk production and breastfeeding, known also as “the cuddle hormone,” is produced at time of orgasm, and creates a sense of emotional bonding after sex. The entire biologic relationship between the ovaries and the brain is orchestrated to facilitate conception in order to perpetuate the human species. People no longer interested in procreation still require the same hormones and neurotransmitters to experience sexual desire and gratification.
The neurotransmitter dopamine is the key to understanding libido. The following is an example of the way in which dopamine secretion works. A person will enjoy a great meal at a new restaurant.They will experience a very high level of pleasure from a large jolt of dopamine. Returning to the same restaurant a few weeks later, and eating the exact same meal, the person found it to be somewhat less enjoyable.This is because eating the same meal will cause a reduction of the dopamine spike, resulting in a less pleasurable dining experience. With each subsequent visit to that restaurant, having the exact same meal becomes less tasty until the person no longer goes back. A reduction in the amount of pleasure is experienced after a reduction in dopamine secretion after successive exposure to the same pleasurable stimulus.
Such is the nature of human sexuality. Testosterone stimulates dopamine secretion, thereby increasing libido, but only until the point of dopamine burnout. In some couples, dopamine burnout may take years to occur, in others, initial passion will burn out rather quickly when the stores of dopamine in one of the partners becomes expended. In cases of sexual addiction, only sex with a new partner causes a dopamine spike, which compels the sexual addict to always seek new sexual partners in order to experience sexual gratification. In cases of porn addiction, a loss of libido for actual sex often occurs in men after watching a lot of porn because they can no longer produce a dopamine surge that would normally result from actual sexual contact with their female partner. It might be surprising to learn that a recent study found that 60% of women and 90% of men watch porn.
There are drugs, such as cocaine and methamphetamine that stimulate libido because they are potent stimulators of dopamine release. Because of their power to flood the brain with dopamine, they are highly addictive, but eventually the dopamine rush progressively becomes extinguished and there is a total loss of sexual desire and functioning. These drugs should never be used because of the possibility that Fentanyl could have been added to the pill.
The antidepressant medication Wellbutrin (Bupropion) is the only drug for depression that stimulates dopamine and improves libido. Since many women having depression are treated with Prozac, Lexapro and Effexor and experience a loss of libido from these antidepressants, changing to Bupropion might be beneficial in restoring their libido, if not otherwise contraindicated. Unfortunately, the dopamine molecule is too large to pass through the blood brain barrier, so it cannot be used in pill or injectable form to treat low libido.
Because testosterone is a direct stimulator of dopamine production in the brain, if there are no contraindications to its use, testosterone replacement therapy should be the first line of treatment for low libido in both women and in men. The issue is to find the ideal dose of testosterone that increases libido while, at the same time, minimizing its potential side effects.Testosterone pellets maintain a steady level of hormones in the body. With testosterone injections, there are peaks and troughs in the blood levels of testosterone. Testosterone injections are not recommended for women because the high levels of the testosterone peaks in the blood cause side effects, such as skin eruptions and excess body and facial hair.
The dosage of testosterone pellets for women ranges between 100mg to 200mg for a three-four month period. The pellet doses for men is between 800mg to 2400mg for 5-6 months before pellets need to be reimplanted. The dose of testosterone most women require to notice an increase in libido is usually between 125mg and 150mg pellets. Four to six weeks after pellet implantation, total testosterone levels in the blood should be 50-125 mg above the top of the reference range to notice positive changes in libido. In order to boost sex drive, it is necessary to boost the levels of testosterone substantially above the top of the laboratory reference ranges for both total and free testosterone.The measurement of post pellet testosterone levels is to insure that there is adequate hormonal absorption and not for the purpose of adjusting dose. As was mentioned previously, the levels of testosterone in the blood are basically worthless both in diagnosing testosterone deficiency and in determining the ideal dose of testosterone to restore libido. A woman’s symptoms are the best and only diagnostic and therapeutic tool for treating low libido. Testosterone doses can be raised with the next round of pellets if libido was not increased by the starting dose.
There are, however, two medications for low libido that have FDA approval for premenopausal women, but can be used off label in postmenopausal ladies and men. Bremelanotide (Vyleese) is a peptide hormone that stimulates desire and gratification in women and increases libido and enables erections in men with sexual dysfunction. Also known as PT-141, it is a neuropeptide hormone that activates melanocortin receptors in the brain. Among several biologic functions it controls, melanocortins affect tanning of the skin and sexual function. It is a prescription medication given by self injection and works quite well for both sexes. Its most common side effects are nausea, usually fleeting, and dizziness. Because it is a neuropeptide that controls pigmentation, areas of hyperpigmentation that are not reversible may appear.
The other FDA approved medication for low libido in women is called Addyi (Flibanserin), is also known as the “little pink pill.” It is taken orally every evening. The drug works in the brain by inhibiting the brain neurotransmitter Serotonin, which blocks desire and stimulates dopamine, which is the “pleasure hormone.” Clinical trials showed that approximately 60% of women had an increase in satisfactory sexual encounters as compared to women treated with placebos.
In summary, libido is a great mystery, driven by hormones, neurotransmitters and hormone receptors located deep in the brain, creating intense feelings that make people want to make love or want to make babies. Libido is also a part of the joy of life. When it is gone, it may sorely be missed or it can slip away without a backwards glance. No matter what your sex, if you are an individual who acutely feels the loss of their sexuality, a first step to consider is testosterone replacement therapy via bioidentical subcutaneous pellets. Not only will it enhance the quality of your life by supplying renewed physical and mental strength, but it also confers protection from osteoporosis as well as reduces the incidence of breast cancer, cardiac disease and dementia.