Testosterone and the Midlife Woman: It's Not Just About the Hormone

Testosterone. It's a buzzword lately, especially in discussions about women's health and menopause. As a menopause specialist, Dr Lorraine is often asked to prescribe testosterone. Simply treating with testosterone without thinking about the whole person is not always helpful. We need to consider the whole patient – the 'biopsychosocial' factors that contribute to a woman's experience of sexuality and well-being.

The Biopsychosocial Lens: Seeing the Whole Picture

Biological: This includes the biological changes happening in the body during menopause, like hormonal shifts and physical health. While testosterone is an important hormone for women, the decrease is not as drastic in perimenopause as often believe, it decreases gradually from the age of around 20. It's not the sole reason for changes in sexuality during menopause. Think of testosterone as one piece of the puzzle, not the entire picture.

Psychological: This encompasses a woman's mental and emotional state: her identity, self-esteem, anxiety, depression, body image, and any past traumas.

Social: This includes relationships, cultural norms, societal expectations, and experiences of ageing.

We need to evaluate all three to provide a holistic treatment.

Testosterone: What's the Hype?

Testosterone is used for treating low libido, and specifically 'hypoactive sexual dysfunction disorder' in women. It has good evidence for this. In the media testosterone has been linked to improved cognition, reducing brain fog, and improving muscle mass.  Anecdotally patients do report these changes, but it is not backed up by evidence and it cannot be prescribed for these indications.

When prescribing testosterone, we aim to improve levels back to where they were in your 20s and 30s, and we do not chase a specific blood test level. We use libido improvement as the benchmark for treatment.

Testosterone is prescribed off license, meaning that the manufacturers were not intending it to be used for women, and so it has not been designed for women. The British Menopause Society do approve it's use, and we do use it regularly for treating low libido in women. It comes in a male preparation in the NHS prescriptions- as sachets of gel that need to be split between 8-10 days, or gel applied 3 x per week. There is a female formulation, Adrofeme, which comes as a cream with a daily applicator. Androfeme is  licensed for women in Australia but the licensing has not caught up here yet in the UK. It is available as a private prescription in the UK but costs approximately £1 per day. 

Monitoring: Blood tests are crucial! We check levels before starting and around 8 weeks later and adjust to maintain a correct female physiological range.

Optimising Oestrogen First: This is key. We don't start testosterone until oestrogen levels are optimised. This includes addressing vaginal dryness and discomfort. Topical oestrogen is essential for healthy genital tissue and pleasurable sexual activity. It will alleviate discomfort, bleeding, infection, and pain during or after sex. HRT should always be initiated before considering testosterone.

It's also important to note that around 50% of patients stop using testosterone, often because it doesn't provide the desired impact.

The "Normal" Conversation: Unpacking Societal Expectations

Let's be honest: our ideas about "normal" sex are heavily influenced by society, friends, family, and the media. These influences shape our understanding of what's considered acceptable or desirable in terms of sexual repertoire, frequency, monogamy, and sexual preferences.

These ideas also affect our perception of sex during midlife, after having children, or after illness, and about infidelity, divorce, or bereavement.

Often, Dr Lorraine see's women who feel ashamed or experience low self-esteem when their experiences don't align with these expectations.

The Monogamy Myth: Monogamy can be challenging, especially when it comes to spontaneous desire. There can be pressure to maintain sexual availability and interest, which can feel externally imposed and make it hard to connect with your own desires.

Have you ever heard of the "orgasm gap"? It's a real thing. Studies have shown that both men and women on their own can bring themselves to orgasm, 95% of the time. With men and women in long term relationships, the rate for women goes down to 65%, whereas men's stays at 95%. In hookup sex for women the rate goes down to 18%. This happens because often, our minds and behaviours are focused on what sex should look like (often penetration-focused), rather than focusing on what we need.

Menopause brings about significant physiological changes that can impact sexual function:

Breasts: Reduced blood flow can lead to decreased sensation.

Pelvis: Less blood flow means less fullness during arousal and responsiveness.

Vagina: The vaginal mucosa thins and loses lubrication, turnover of cells decreases, losing glycogen, walls becoming thinner by 2/3rds, lactobacilli is lost, increasing susceptibility to infection. 

Clitoris: Reduced blood flow and decreased sensitivity, less volume of clitoral tissues, reduced night time erections.

Muscles: Overactive muscles, such as vaginismus, or weakness from prolapse, contribute to pain and discomfort.

These changes can lead to pain during sex, tears and splits, bladder problems, a longer time to reach climax and possibly less pleasurable orgasms.

Here are some steps to address the physical challenges:

HRT: Discuss with your clinician if you are suitable for HRT, or if your dose has been optimised.

Medications: Consider a medication review with your doctor. Some medications can affect sexual function. In particular; antidepressants (which can reduce blood flow to the vagina) and antihistamines (which can dry tissues).

Topical Treatments: Use emollients, massage and moisturize daily. Vulval and vaginal oestrogens are very effective for improving blood flow, firming and lubricating the tissue and improving sensitivity which can have a positive impact on sexual function. A combination of water or oil-based lubricants are also helpful.

Gynae Physio: Seek help from a gynecological physiotherapist if you have a pelvic floor that feels too tight or having symptoms of prolapse.

Onward referral to a sex therapist or clinical sexologist if the above measures do not help.

Is low libido due to physical issues, or do physical issues stem from low libido? It's often a combination of both. Painful sex, infections, numbness, and diminished arousal can all contribute to a lack of desire.

Desire in Long-Term Relationships

Maintaining desire in long-term relationships can be challenging. Familiarity can make it hard to create the erotic tension needed to drive curiosity and desire. Esther Perel's work in "Mating in Captivity" highlights this.

To combat this try to work together to understand the challenges, work for newness within the relationship, allow for growth, cultivate curiosity, practice sensate focus, prolonged hugging, and eye contact. Some of my patients find an intimate WhatsApp chat can be helpful for connection.

Types of Desire: Not all desire is the same. Helen Kaplan identifies different types of sexual desire:

Hormonally driven desire: This is akin to hunger and often experienced in early relationships.

Receptive or responsive desire: This arises from external cues, which lead to arousal, and the expectation of pleasure.

If sex feels like an obligation, is boring, or isn't very good, no amount of testosterone will fix it. Noticing and prioritising your own needs is crucial.

Stress is a major libido killer. The anticipation of pain or feeling self-conscious about your body can trigger the release of cortisol, which acts as a sexual blocker. When we're stressed, our sympathetic nervous system (fight or flight) is activated, and arousal goes out the window.

To try to combat this; try to recognise when you are in an emergency state. A heavy work load and emotional load can block awareness of what our body might want in terms of pleasure. We need to try to re-establish the parasympathetic nervous system (rest and digest) to be able to recognise what our bodies like as pleasure. Recognising our own needs, connecting with our bodies rather than overthinking, practicing mindfulness can all help. It is often helpful to shift the focus away from penetration, and think of sex as a buffet where every part has equal value. 

As a menopause specialist, Dr Lorraine loves helping her patients feel better. Low libido can have a huge impact on quality of life, and it feels great to help improve this area of her patients life. By considering the biopsychosocial factors, optimising hormone levels, addressing physical challenges, and reclaiming pleasure, women can navigate these changes and enjoy a fulfilling sex life at any age.

For menopause awareness month we are offering 10% off appointments with Dr Lorraine for

October and November.

Usually £195, now £175

for an hours initial consultation.

You can book by clicking on the link below.

Book Here