In 1998 Elizabeth “Liddy” Dole, wife of former U.S. senator and presidential candidate Bob Dole, fielded an unusual question during a news conference. Her husband had just told the world on Larry King Live that he was in clinical trials for a new erectile dysfunction pill known as Viagra, calling it a “great drug.” The next day, a reporter asked Liddy Dole, then president of the American Red Cross, what advice she had about the pill. She knew the question was coming, and she echoed her husband’s words, boldly replying, “It’s a great drug, okay?”
That may have been the one and only example of a question to a woman during Viagra’s debut. The excited reporting about the drug at the time focused almost exclusively on men’s sexual desire during their golden years. One urologist in Florida even encapsulated the prevailing attitude in an interview with the New York Times, saying that older men “typically” were still interested in sex but older women were not, so the new, superpopular Viagra pill left the man “all dressed up with nowhere to go.”
More than 20 years later, researchers are starting to pick apart these assumptions about women and sexual desire. One team recently reported that the brains of women and men show similar spontaneous responses to visual sexually arousing cues, challenging common beliefs about differences between the sexes. At the core of these convictions is the controversial idea, formally proposed by Rosemary Basson of the University of British Columbia in 2002, that many women may not experience spontaneous arousal and instead need some coaxing to feel amorous.
What the evidence really shows, says Susan Davis, director of the Women’s Health Research Program at Monash University in Australia, is that women diagnosed with female sexual dysfunction, or FSD, tend to confirm a lack of spontaneous arousal. But women without FSD do not report such issues, she says. An absence of desire is not an inevitable facet of aging for women, Davis says. There’s a name for the condition in which women lose that spontaneous urge and interest: hypoactive sexual desire disorder, one form of FSD.
Previous studies have suggested that testosterone may be an effective therapy for low sexual desire in women, but data on other impacts, such as mood, and on the optimal delivery method were limited. Last week Davis and her colleagues published results in Lancet Diabetes & Endocrinology confirming that for women with this condition, testosterone therapy can be effective. Unlike Viagra, it is not an acute treatment for overcoming physical difficulties and triggering in-the-moment arousal but rather a method of reinstating a desire for sex, Davis says.
In its large analysis of 46 studies reporting results of testosterone therapy in 8,480 women, the research team found the treatment had positive effects on desire and pleasure and also reduced anxiety about sex.
Both men and women naturally produce testosterone, which wanes with age in both sexes, contributing to dwindling sexual urges. It is not surprising that the effects of testosterone replacement in women echo those in men. The catch is that because this therapy and related research are primarily geared toward men, no one is quite sure what the long-term risks are for women, Davis says. The studies simply have not been done.
Davis and her colleagues confirmed that the short-term side effects of testosterone therapy in women include acne, increased hair growth and, in some cases, a boost in “bad” cholesterol. But crucially, they found that using a skin patch to deliver testosterone instead of oral administration limits the cholesterol increase.
Rossella Nappi, a professor of obstetrics and gynecology at Italy’s University of Pavia and the associated San Matteo Hospital, who was not involved in the study, wrote an editorial that accompanies the publication of these new results. She says that the findings are definitive about testosterone’s potential to reverse hypoactive sexual desire disorder but notes that psychological and social factors can contribute to dampened interest as well.
Some earlier studies had also hinted that testosterone therapy itself might act on some psychological factors. Clinicians sometimes prescribe testosterone to women off-label because of presumed benefits for cognition, mood, bone density or muscle strength. But Davis and her team found no effects of the hormone on any of these measures, including mood or sense of well-being. “This is one example [demonstrating] that testosterone is being promoted for a vast array of supposed indications [for which, we show, it] cannot be presently justified,” she says.
“The number of women who truly qualify for it medically is low,” says Jennifer Gunter, an obstetrician and gynecologist in the San Francisco Bay Area, who was not involved in the work. “It is only recommended for postmenopausal women [when] no other cause [of low desire] can be identified and relationship issues have been ruled out.” Even in such cases, Gunter adds, it is important to tell the patient that there are no long-term safety data.
Everyone seems to agree that the question of what testosterone therapy does in the long term urgently needs more attention. One big concern is whether or not this hormone therapy boosts a woman’s risk for breast cancer, because studies are scant. “I have to say that we do not know what we do not know” about these risks, Nappi says. “It is really not possible to make any final conclusions with the data we have.”
When asked about the best evidence-based approach to this therapy, Davis parries a bit, noting that a publication is due to appear in September. This “Global Consensus Position Statement for the Use of Testosterone in Women” has been endorsed by more than a dozen major medical societies, she says, and it “provides very clear recommendations for clinical practitioners.”
Yet other gaps remain. Among the thousands of women in the studies Davis and her colleagues analyzed, 95 percent were postmenopausal. Only 226 were premenopausal, and this population needs more attention in terms of testosterone therapy, too, Davis says. The U.S. Food and Drug Administration has approved a couple of treatments for low sexual desire in premenopausal women. One is Vyleesi, which must be injected 45 minutes before expected sexual activity, and its common side effects include nausea and vomiting. The other is Addyi, a pill that also must be taken just before sexual activity, but women are warned to avoid alcohol at least two hours before ingesting the drug and in the hours after. For many women, these current therapies, with their side effects and caveats, still leave something to be desired.