If you spend much time talking with women about menopause, eventually you’ll hear the question of testosterone: to take or not to take?

Dr. Rebecca Dunsmoor-Su, ob/gyn and genneve Director of Health, helped us understand the whys and why nots of testosterone and DHEA. You can see a longer discussion of testosterone, DHEA, and other menopausal issues by watching her Physician Webinar on the subject.

Why do some women in menopause or perimenopause consider taking testosterone?

What are the advantages women hope to get from the male hormone?

First, it’s important to understand that women’s bodies naturally make some testosterone. It’s produced in the ovaries, and has some beneficial affects on the female body. Female testosterone deficiency is a common effect of menopause, and can have negative effects on women.

In fact, says Dr. Rebecca, women’s bodies continue producing testosterone even after menopause, if the woman still has her ovaries (hence the occasional coarse facial hair we discover as we get older), declining only slightly.

There are a couple of reasons women consider testosterone, including to retain muscle mass and bone, and to combat fatigue (neither of which have been studied well in postmenopausal women). However, the most common reason is probably to revive a flagging libido.

How much sex is “normal”?

Before we tackle testosterone, we need to understand what we’re solving for. Women say they just want to be “normal,” but there is no standard definition for “normal.” If we were to believe popular culture, everyone but us is regularly having mind-blowing, life-changing sex. Spoiler alert: probably not.

If you’re considering medication in order to feel “normal,” the good news is “normal” is entirely up to you. If you’re happy with a few times a year or several times a week, congratulations! You’re normal.  

It’s important to establish this, because most medications for libido are for women experiencing what’s known as Hypoactive Sexual Desire Disorder (HSDD) – when a woman is genuinely distressed by her lack of sexual desire. Much of the research has been on women in this category, so if that’s not your problem, the results and medication that come from these studies may not be appropriate for you.

Does testosterone revive desire?

Fortunately, says Dr. Rebecca, there have been about 35 trials of around 5000 women, looking at the effects of testosterone and testosterone plus hormone replacement therapy (HRT). So at least there’s some information, though more would be better.

Pros: When “T” is administered, studies show a slight increase in sexual desire, even in women who were not currently partnered at the time of the study. If women do see improvement and don’t experience side effects, they can probably be on T for up to 7 years without additional health concerns.

Cons: One of the issues with T is that it’s hard to know how much to give a woman, largely because it's difficult to know what the normal level of testosterone in a specific woman is. An individual’s levels may vary, and from woman to woman, there can be a wide range of amount of T in the blood. Because there are side effects (acne at lower doses; loss of head hair and growth of body hair at higher doses, as well as irreversible deepening on the voice), docs should start women out at a pretty low dose. So, testosterone dosage for women is hard enough to gauge; testosterone dosage for menopause is really tricky.

Maybes: T may be anti-tumor growth, meaning it may have a beneficial effect for women with breast cancer, but more research is needed to know if this holds up. T also benefits vaginal tissues if a woman is dealing with dryness; however, Dr. Rebecca says, DHEA may be more effective than T (more on DHEA in a moment).

More maybes: T’s affects on muscle mass and bone density just aren’t proven, so because there aren’t many long-term studies on women and testosterone, most doctors choose other routes to deal with those symptoms. Finally, T’s affect on the heart is uncertain. While it may not damage the heart directly, women on T show an increase in bad cholesterol (LDL) and a decrease in good HDL, which may indicate cardiovascular issues down the line.

What about DHEA and desire?

DHEA or dehydroepiandrosterone is naturally produced by the body’s adrenal glands, though like many things in our bodies, production decreases with age. DHEA is a “precursor” hormone, meaning the body naturally converts it to testosterone and estrogen.

Many women swear by oral DHEA for a whole host of benefits, but it’s important to be sure you’re taking the right stuff at the right doses for the right reasons. All hormones come with risks, and DHEA is no exception.

A major concern about DHEA for our Director of Health, is the very limited number of studies we have on its effects and side effects. Worse, a Cochrane Review (a cumulative research study based on compiling results from many smaller studies) revealed that many of the existing studies on DHEA were so deeply flawed they couldn’t even be considered.

Pros: The studies showed some women may have very mildly improved sexual function.

Cons: Many women get their oral DHEA in the vitamin aisle at the grocery store or GNC. These are not pharmaceutical-grade medications, says Dr. Rebecca, while the studies were based on meds that are. So what you get OTC at the store is probably not going to be strong enough to do much good. Also, in most studies the drug didn’t improve participants’ feelings of health or well-being, nor did it show significant improvement of menopause symptoms. And finally, DHEA may have the same side effects as T, primarily acne and facial hair growth.

At this point, says Dr. Rebecca, there’s just not enough information to know if taking this orally is safe OR effective, let alone both.

The vaginal DHEA suppository called Intrarosa is a good therapy for women with the atrophic changes of menopause. It turns into testosterone and estrogen in the vaginal cells. It is most helpful in women who have low T for a variety of reasons, but most commonly because they no longer have their ovaries.  It is not really absorbed systemically, so  it will not impact libido, except by making intercourse more comfortable. If you have normal postmenopausal ovaries, it may add no benefit over estrogen, and as it must be taken daily, it’s fairly expensive.

What FDA-approved remedies are there?

Unfortunately, there’s just not a lot out there for women with Hypoactive Sexual Desire Disorder, says Dr. Rebecca.

  1. Assuming you have no negative effects nor any type of hormone-sensitive cancer risk, it might be worth giving T a try.
  2. Addyi. This drug has been approved by the FDA for treatment of HSDD. However, there are a few things to consider. One, it’s been approved for premenopausal women. While it’s possible to find docs willing to go “off label” to prescribe it for post-meno women, you should proceed with caution, since the effects are even less understood. The effectiveness is very slight, raising desire marginally at best. Finally, it has side effects that are made worse by alcohol, to the point that women are required to sign a contract agreeing not to drink alcohol while taking Addyi.

Dr. Rebecca doesn’t recommend Addyi because at this point it seems the cons outweigh the very slight possibility of a pro.

Don’t overlook other reasons

Finally, Dr. Rebecca says, it’s important to remember that libido in women is extremely complex and anyone struggling with desire should also take a close look the psycho/sexual aspects at play.

Are you bored with routine sexual activity with a longtime partner? Consider toys, sexy books or movies, a vibrator, etc.

Does the dissatisfaction go deeper than desire? If so, a sex therapist or other counselor may provide the necessary treatment better than the pharmacy can.

 If the issue is pain during intercourse, look at lubes, moisturizers, vaginal hormonal creams; see a pelvic physical therapist or try a set of vaginal dilators to gently increase comfort with penetration.

If you want to be having more sex, communication is probably your first step. Talk with your partner, a therapist, your doc or ob/gyn to uncover the reasons your desire doesn’t match your desired desire, so to speak.

Are you having issues with libido or have you found a solution that works for you? Please share! Comment below, or find us on Facebook or in Midlife & Menopause Solutions, our Facebook group. You can also join us, anonymously, if you prefer, on our community forums.