Question: Why is it necessary to document distress in a patient with low sexual desire? If the patient wants her OB/GYN to treat her, isn't she "distressed" by definition?

Dr. Simon: A woman with low sexual desire who is not concerned or distressed about it does not have a problem. If the patient thinks she is normal and the low libido is not at issue, it's very difficult, if not impossible, for the clinician to improve it. We see women whose partners have referred them to our offices because,in the partners' eyes, the low desire is a problem. However, some of these women, when away from their partners and in the privacy of the exam room, will say, "I'm fine. There's nothing wrong with me. I don't even want it changed." These women may have a problem in their relationships but are not distressed about their level ofdesire.

Dr. Bachmann: A woman may say she's perfectly fine, but her relationship is suffering because she has absolutely no sexual interest and does not care if she ever has a sexual exchange again. Proving education about different types of sexual exchange may help the relationship, even though the woman reports no distress. If the partner is experiencing distress, referring the couple for sex counseling should be offered.

Question: How do you approach young women on oral contraceptives (low-dose monophasic or triphasic) with low libido?

Dr. Simon: Low sexual desire may be a testosterone-related issue in some women receiving oral contraceptives. Even small doses of oral estrogen, and the contraceptive patch or ring, may increase sex hormone binding globulin and reduce free testosterone.When we give fairly estrogen orally in the form of a birth control pill, on the one hand, patients may benefit: their skin clears up, their acne and hirsutism improve (especially if they've had excess hair or sebum production). On the other hand, some women experience a reduction in androgens, which may adversely affect their sex drive.Discontinuation of the estrogen-based contraception is the best option in women who develop low testosterone and related symptoms. A barrier method of contraception should be considered under those circumstances.

Dr. Buster: It may be more difficult to implicate androgens as a contributing factor in women in their 20s who have decreased sexual desire. In many cases, these women have psychiatric disorders, are taking antidepressants, or are experiencing relationship problems. Therefore, it is particularly important that the clinician rule out other potential etiologies in younger women.

Dr. Bachmann: Giving patients with low libido a trial off of the oral contraceptive pill is a way to rule out other issues or other problems, rather than trying 25 different products with the hope that one will provide benefit. I prefer to discontinue the oral contraceptive pill to see how patients function without it.

Question: Do you recommend that estrogen-plus-testosterone therapy be initiated directly after oophorectomy or only after complaints of low libido?

Dr. Bachmann: I wait until the woman complains of sexual problems or other symptoms after oophorectomy that are not corrected with estrogen alone.

Question: What testosterone formulations do you prescribe in your practices for women who are experiencing low sexual desire?

Dr. Bachmann: In my practice, I use combination oral estrogen-androgen therapy, which is available and FDA approved for menopausal symptoms. However, I use it off label for sexual desire problems.

Dr. Buster: I generally prescribe testosterone gel or crystalline pellets. I measure testosterone levels after application of the gel or insertion of the pellets to determine whether the dose has been absorbed. The problem with testosterone gel and pellets is that absorption is erratic and response is unpredictable. Patients usually are instructed to apply the gel in the evening and come to the office the next morning for measurement of their testosterone levels. These levels will be approximately 100 to 120 with an adequate dose; if levels in this range are achieved, patients often benefit from the therapy.

Dr. Simon: I usually see patients previously treated by one or more other clinicians and therefore have had extended or recurrent experience with accepted therapies, such as oral combination estrogen-androgen therapy or testosterone cream. In these patients, I try to prescribe previously unused treatments, which may require some creativity because not many are currently available. First, I ensure that patients are receiving sufficient estrogen. If their estradiol levels are adequate and their vaginas are normal by inspection, I subsequently prescribe 3 monthly intramuscular injections of testosterone enanthate, propionate, or cypionate at a dose of 1 mg/kg. Patients' peak and trough testosterone levels will be monitored, if financially feasible. After this course of therapy, I will evaluate patients' responses. In my experience, the majority of women who have failed several other therapies will also not respond to this approach. However, it is important to show them that they have adequate estrogen and testosterone concentrations in blood, without clinical improvement, so that they will consider addressing other possible causes, such as a history of abuse or problems in their relationships.

Question: What is your experience with compounded testosterone for the treatment of reduced sexual desire in women?

Dr. Bachmann: I am concerned about the lack of quality control with regard to the dosing, safety, and efficacy of agents produced by compounding pharmacies. I do not recommend compounded products because they do not undergo the same scrutiny as marketed products. Although most pharmacies will compound a prescription on occasion, eg, a 2% testosterone propionate in petrolatum, I don't think that the actual compounding from compounding pharmacies is really a good way of prescribing for your patients.

Dr. Simon: I use compounded products only as a last resort when other available products have failed or are unacceptable to the patient. I've used compounded testosterone in gel, ointment, and petrolatum. However, I share Dr. Bachmann's concerns about variability, quality control, supervision, safety, and efficacy. I have had experiences with otherwise reliable compounding pharmacies that produced pellets or gel that contained no testosterone and were therefore completely ineffective.

Dr. Buster: The principal advantage of compounded testosterone is that the formulation involves a single, simple, naturally occurring molecule. It is testosterone. Testosterone made in the human body is exactly the same as that made in the compounded material. When you deliver it through the skin, you deliver it at approximately the same rate at which it is made naturally. I also like compounded testosterone because when it is discontinued, it is immediately cleared from the system and its effects disappear rapidly. Because compounding pharmacies can make mistakes, when I prescribe compounded testosterone gel, I measure hormone levels after initiating therapy.

Question: In recent clinical trials of the transdermal testosterone patch, did investigators find an increase in cholesterol levels with testosterone therapy?

Dr. Simon: No significant effect on cholesterol levels was found. Such an effect was not expected because a non-oral testosterone formulation was administered. Similarly, the transdermal testosterone patch had little impact on clotting factors and sex hormone binding globulin.

Question: Most women die of cardiovascular disease (ie, stroke and heart attack). How will testosterone therapy affect mortality rates in women?

Dr. Buster: We don't yet know because long-term studies haven't been conducted. I don't expect that testosterone administered in doses approximating the physiologic levels observed in normal premenopausal women will be deleterious.

Dr. Bachmann: I agree that this therapy should not be deleterious. No serious negative effects have been reported in the small cohorts of women that have received testosterone and estrogen for long periods of time from their physicians.

Question: How does testosterone therapy affect liver function?

Dr. Bachmann: Concerns about testosterone and liver dysfunction arose in the 1950s, 1960s, and 1970s when very high doses of oral androgens were used. These high doses did affect liver function. At the doses that we're using now, liver function is not an issue. In many clinical studies, lower doses of methyltestosterone have been used, as well as transdermal testosterone, without liver dysfunction.

Dr. Buster: Some of the reports of liver dysfunction, even cirrhosis, were associated with very large doses of methyltestosterone used to build muscle mass. One of the major benefits of using a percutaneous system is that the doses delivered are similar to what is produced normally in a premenopausal woman. Large doses are not needed to deliver hormone into the circulation with a percutaneous system.

Question: Can you give testosterone to a patient with a history of breast cancer?

Dr. Bachmann: I think that's a 2-part question. One relates to the medical issues and the other is the liability issues related to the conversion of androgen to estrogen and subsequent increase in estrogen levels. I do use testosterone in women who have had breast cancer and I monitor their levels. The minimal amount of testosterone should be prescribed that will have the desired effect.

Dr. Buster: Many women with breast cancer receive tamoxifen. Testosterone therapy in these women may be problematic because it may disrupt tamoxifen treatment and alter its potential benefits. However, I certainly would be willing to provide testosterone as long as the patient understands the risk involved.

Question: What laboratory tests do you order before initiating testosterone therapy in women with low sexual desire?

Dr. Buster: I do not measure testosterone levels to make a diagnosis because I don't find them helpful. When I prescribe testosterone therapy, I'll measure total testosterone levels at baseline and after treatment is initiated to make sure there's a difference. I just want to know that the testosterone administered via a transdermal delivery system is being absorbed. I do not request liver function tests because steroids administered percutaneously do not pass through the liver and therefore do not affect live function.

Dr. Simon: I perform a fairly complete, but routine, battery of diagnostic tests that would be appropriate for any postmenopausal woman to make sure that the patient is generally healthy. If the results of these screening tests are unremarkable, I also as a rule do not measure testosterone, primarily because I don't believe that most commercial laboratories know how to do a testosterone assay in women.

Dr. Bachmann: In addition, if you order the tests of testosterone levels, you're committed to following those values and counseling the patient accordingly, which adds to the time and expense but doesn't really enhance the medical management of the patient's problem.

Question: Do the herbal or other alternative products provide any benefit to women with low sexual desire?

Dr. Buster: It's impossible to know the answer because these products have not yet been adequately studied in randomized, prospective, controlled clinical trials.

Dr. Bachmann: Emerging data suggest that some of the herbals may actually be detrimental, especially when contaminants, such as heavy metals, accidentally enter into the product along with the active ingredients.

Dr. Simon: The non-hormonal herbal product Avlimil, which contains black cohosh, sage leaf, red rasberry leaf, kudzu root, red clover extract, etc, has been highly promoted as a treatment for female sexual dysfunction, but it has only been evaluated in one very small clinical trial and is relatively costly.

Question: Do you think a woman who has always experienced sexual interest problems is a good patient for the general OB/GYN or should she be referred?

Dr. Bachmann: I would not feel completely comfortable treating a woman who has never had sexual desire. A patient who has a longstanding sexual problem, beginning in pubescence, is probably someone who has many issues other than medical ones thatneed to be addressed.

Dr. Buster: I agree but would like to add that the older woman who previously had a pleasurable sexual life and then lost it often is a very good patient for the gynecologist. In this type of patient, treatment is likely to be very simple and straightforward, eg, treating an underlying disorder such as depression or replacing hormones that may have been diminished after menopause.