Q&A: Evidence for Testosterone Helping Menopausal Women?
Just because it’s standard practice doesn’t mean it’s evidence-based practice.
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Q: I am a 55yr old menopausal woman and my OB/GYN just drew labs and is trying to convince me to go on [redacted] pellets to increase my testosterone. She says [redacted] is literally saving marriages! I want to give her a copy of Come As Your Are because I feel like she could help women understand that they're not broken and don't need to be "fixed". What is your opinion on women taking testosterone to increase their libido?
A: Oh god please yes do give her a copy of Come As You Are so that she can help women understand that they’re not broken and don’t need to be fixed—but also so that she knows SHE’S not broken and doesn’t need to be fixed! I worry so much about the sex lives of doctors who are still prescribing testosterone for women’s sexual difficulties.
Now, before I go any further, let me make sure everyone who is struggling with desire knows that there is hope. There are evidence-based interventions that improve sexual wellbeing. You know what has strong evidence behind it, as improving sexual wellbeing? Mindfulness! But that doesn’t make any big corporations a lot of money. You know what else works? Sex education!
I asked Google Scholar to show me evidence that the pharmaceutical intervention you mentioned impacts sexual wellbeing. There wasn’t any—which isn’t surprising. There’s no persuasive evidence that testosterone is a helpful intervention for women with low desire.
The handful of studies that have found positive results for any testosterone or other hormone treatments for desire are industry-funded, and I need to see non-industry replications before I discuss those results in public. I wish doctors felt that way too, but pharmaceutical companies feed them nice dinners at conferences, during which they give shiny PowerPoint presentations, and doctors walk out feeling like they’ve finally got an easy solution to a common patient complaint that has left them feeling helpless until now.
And I have sympathy for that experience. Can you imagine how powerful that is for a doctor? Sexual difficulties are a common problem, and people ask their doctors about it, because literally everything in mainstream media tells them to talk to their doctors about it. And doctors themselves believe they’re the right people to ask about sexual difficulties, because that’s what they’re trained to believe. Yet doctors have nothing to offer for the most common sexual difficulty of all, problems with sexual desire. And we all know what it feels like to have someone come to us for help, and we feel like we have nothing to offer.
Now, the reason they have almost nothing that can help is because the vast, overwhelming majority of sexual difficulties, including the vast, overwhelming majority of problems with sexual desire, are not medical problems. They’re relationship problems, psychological problems, or cultural problems. Therapy and education are what help, not a medication.
But therapy and education aren’t what help a doctor feel like they have something to offer patients. So along comes a drug company with their nice dinner and their statistics-filled PowerPoint presentation, and the doctor has been longing to have something to offer their patients… so they buy in. In the case of something like this drug you mention, your doc went through a specific training to get certified to provide treatment with this intervention.
And yet the International Society for the Study of Women's Sexual Health (ISSWSH) Process of Care for Management of Hypoactive Sexual Desire Disorder in Women, published in 2018, offers a decision tree/flow chart of intervention. Here’s what intervention should look like, according to them:
Ask permission to discuss sexual concerns, and focus specifically on women who have concerns with their low sexual desire/interest.
Diagnose by asking about sexual history or using a screening tool to assess low desire
If patient has generalized (not situational) acquired (not life-long) low desire, then assess biopsychosocial factors to identify those that may be potentially modifiable
Intervention begins with education and modification of those identified biopsychosocial factors. (In Come As You Are, I talk about this as context—internal state and external situation)
If HSDD persists, reassess for therapeutic intervention based on menopausal status
In short, their recommended intervention is: education and/or therapy.
They mention testosterone: “Because there are no biomarkers that confirm or exclude HSDD [low desire], laboratory testing—specifically, measurement of testosterone—should not be used to make the diagnosis.”
And what do they mean by education?
“First, provide information on normal sexual functioning. This information may include a description of spontaneous and responsive sexual desire, the role of motivation in sexual desire, the importance of adequate sexual stimulation, the impact of pleasurable sexual experiences on desire, and the influence of age and relationship duration. Second, educate the patient about factors that are derived from the sexual and medical history that may disrupt sexual desire (eg, mood disorders, relationship satisfaction, body image). Third, health care providers may assess motivation for treatment and discuss treatment options.”
There are a few ways to tell if your doctor is talking about an evidence-based intervention or not.
If it’s a pharmaceutical intervention and they haven’t already suggested education or psychotherapy, it’s not an evidence-based intervention.
Second, find out what the clinical outcome is. More frequent sex, greater sexual satisfaction, less pain, these are clinical outcomes. And even the highest-quality research isn’t relevant if its outcome measure isn’t the outcome that matters to you.
“Saves marriages” is not a clinical outcome, it’s what’s known as “anecdotal evidence.” A patient, maybe more than one patient, told her it saved their marriage. You know what also anecdotally saves marriages? Come As You Are! And, unlike testosterone, CAYA doesn’t cause unwanted body hair growth.
Also not a clinical outcome: anything about “libido.” If your doc uses the word libido, ask her what she means, because that is not a term with any clinically defined meaning. Does she mean arousal? Satisfaction? Pleasure? Desire? Responsiveness? Spontaneous sexual thoughts? Spontaneous sexual sensations? Libido is not a medical term, it’s Freudian blatherskite and it frustrates me that physicians still use it.
I’m not saying that asking your doctor about research is easy or even always effective. When it comes to new medical interventions, I ask my providers to show me at least one placebo controlled study measuring the outcome I’m interested in, in a population that includes me. My best-ever provider sent me a study of male veterans on a particular medication and—this is why he’s my best-ever provider—did not get defensive when I pointed out it was a study of men only and I’m not a man and sometimes women have different outcomes.
And if you’re thinking I get away with asking my provider for evidence that what they’re suggesting for me will be effective, just because I’m me… I don’t. My PCP once told me that a patient of hers got some kind of injection in her g-spot and it had revolutionized her sex life. I responded, “I’d want to see a placebo controlled study of that before I recommended it to anyone.” And my doctor looked at my like I’d threatened to slap her. I get that look at least once a year from a doctor, like the time a doctor wanted to talk to me about weight and I resisted and she said, “It’s standard practice to talk to everyone about weight,” and I sighed, “I know. But just because it’s standard practice doesn’t mean it’s evidence-based practice.” Honestly, I say these things as gently as I can, but doctors are NOT used to patients who want to talk about evidence.
Hope that helps!
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