Low Testosterone = Low Sex Drive

BY MARK SCHOLZ, MD

Call me an adolescent, but I think men’s egos are hugely impacted by their ability to satisfy their spouse’s sexual needs. But what if there is no “need” that needs gratification? What if your postmenopausal wife could care less about sex? While there are various other reasons besides hormonal ones for poor sexual dynamics—two obvious ones are relationship issues and sub-optimal function of the anatomy—this article is about the one quintessential ingredient for sexual interest: normal hormone levels in the blood.  What can be confusing is that hormone levels and anatomic function both decline as we get older. Therefore, ferreting out the reason for a low libido level may be confusing.

Other than to acknowledge their obvious importance, I won’t comment on how healthy relational dynamics are a prerequisite for romance. Obviously you ain’t gonna feel sexy if you’re angry at your partner.  Nor will I spend any more than the following paragraph discussing methods to restore anatomic function.  These themes have been thoroughly expounded by other writers. This blog is about how normal levels of testosterone are essential for normal sexual activity in both men and women.     

Anatomic Sexual Issues
Men with erectile difficulties often successfully resume normal function with help from Viagra and Cialis. When these pills are ineffective, prostaglandin injections will often restore erections.  For women in the postmenopausal state, when the ovaries stop producing estrogen, genital atrophy develops, resulting in uncomfortable sexual relations.  Topical estrogen creams are usually corrective.  

Testosterone, the Essential Hormone of Romance

The unbreakable link between testosterone and libido can be illustrated by recalling the baffling behavior of older teenage males when viewed through the lens of younger prepubescent eyes.  Back when I was 10 or 11, I remember being mystified by the behavior of the older boys who for no explicable reason had suddenly become girl crazy.  Now, however,  as an adult experiencing the effects of my own internal testosterone production, I readily confess, it’s no longer a mystery.

Testosterone, which fires up after puberty, works like a literal “on/off” switch for sexual desire.  High levels increase genital sensitivity and heat up sexual desire for both men and women.  When testosterone is low, sexual apathy sets in.  In fact, to a person without testosterone, sexual activity seems totally nonsensical.  As a prostate oncologist with extensive experience administering testosterone-lowering drugs to treat patients with prostate cancer, I am constantly in contact with men who have libido at zero levels. Amazingly, without testosterone, even men don’t want sex. 

Diagnosing My Wife

Familiarity with how my hormonally-deprived patients were wrestling with the effects of low testosterone must have helped me figure out what was happening when my wife’s libido suddenly changed after menopause. She, conversely, was oblivious.

I presented her with an impassioned argument and cajoled her into visiting a doctor specializing in bioidentical hormone replacement.  My diagnosis of inadequate testosterone was quickly confirmed.  The doctor (who my wife subsequently fired) overdosed her with a hefty 4-month testosterone injection. Honestly, it was almost too much of a good thing. For her, living with a male-level libido was painfully distracting (all of us guys can easily relate).

It was no surprise to me that, after the 4-month shot wore off, she became very mistrustful of bioidentical hormones. Eventually, she mustered the courage to consult a second physician who upon hearing her history wisely initiated the bioidentical hormones at a much lower dose.  Small upward adjustments in dose have led to restoration of her libido without untoward side effects.

Beyond normalization of libido, my wife reports another important benefit: improved energy levels. When asked about this, she says the increased energy is comparable to a cup of coffee, but without the caffeine jitters.  Medical studies evaluating testosterone replacement have also shown that raising testosterone levels is associated with improved blood sugar control in people with diabetes.

The setting of the sun on a previously healthy romantic relationship is assumed to be a part of the normal aging process. And of course there are a variety of potential causes besides low testosterone levels in the blood.  However, when testosterone levels are suppressed, the absence of motivation for sexual activity is almost guaranteed.  People need to be aware that both men and women can potentially reignite sexual interest back to youthful levels with skillful replacement therapy.

Preventing Hormone Therapy Side Effects

BY MARK SCHOLZ, MD

Side effects vary from patient to patient and are influenced by types of testosterone inactivation pharmaceuticals (TIP) used, and by the duration of treatment. However, a number of interventions are available that can substantially reduce these adverse side effects.

Loss of Libido
Libido is an emotional attraction to the opposite sex (in most cases). Libido is not the same thing as potency, which is defined as the ability to get an erection. TIP causes loss of libido about 90% of the time.  Libido returns when TIP is stopped though some men say libido after TIP is chronically diminished. Loss of libido and the cessation of sexual activity has wide ranging ramifications far beyond the intended scope of this blog. Specialists in sexual counseling are available and can be of great assistance.

Erectile Atrophy
Whether or not couples continue to have sexual intercourse after treatment, we counsel men to induce daily erections to counteract the risk of penis shrinkage. Cialis or Viagra should be taken daily.  If this fails to restore the normal pattern of nighttime erections then either a vacuum pump or injection therapy should be considered.  

Muscle Atrophy
Muscle mass can be maintained with a strength training program. Walking, aerobics, and stretching are healthy but accomplish little toward building muscle mass. Strength training that is effective requires a program similar to that undertaken by body builders.  Ideally, strength training requires a minimum of two, one-hour sessions weekly during which all the major muscle groups are exercised: Pectorals, Deltoids, Biceps, Triceps, Latissimus dorsi, Upper and lower back muscles, Abdominals, Gluteus, Quadriceps, Hamstrings, and Calf muscles. Three sets of 10-12 repetitions should be undertaken with weight selected to result in muscle failure toward the end of the third set.

Fatigue and Lassitude

Tiredness and weakness from TIP are a direct result of muscle loss and reversible with strength training. Strength training is very effective for counteracting fatigue. Men who begin strength training when they initiate TIP will not only forestall tiredness, they can actually increase their strength.

Osteoporosis
TIP causes accelerated calcium loss from the bones, termed osteoporosis. Untreated bone loss can result in hip and spine fractures. Osteoporosis can be prevented with medications such as Prolia, Xgeva, Zometa, Boniva, Actonel and Fosamax which should be initiated when TIP is started.  See the booklet titled Osteoporosis available** soon at www.prostateoncology.com for further details.  

Hot Flashes
Hot flashes occur in about two-thirds of men on TIP. When severe, a progesterone injection (depo provera) can dramatically reduce hot flashes. Other prescription medications, which are effective about half the time, are low dose Effexor, a medication approved for the treatment of depression, and Neurontin, a medication approved to prevent seizures. Transdermal estrogen patches are very effective but sometimes cause breast enlargement or nipple tenderness.

Weight Gain
TIP slows metabolism causing weight gain. Keeping a stable weight is easier than trying to lose weight. It is wise to evaluate your diet at the time of starting TIP to see if fat and sugar intake can be reduced. See the brochure about diet from the PCRI for more details.

Breast Growth
Breast growth (even without estrogen patches) occurs frequently in men treated with Casodex monotherapy and less frequently, about one-third of the time, in men treated with other forms of TIP. If there is any evidence for breast growth or nipple tenderness, therapy with an estrogen blocking pill called Femara should be started immediately.  Alternatively, a short course of radiation to the nipples can be administered prior to starting TIP.  

Anemia
Blood is a mixture of red cells and "serum" (water). When the proportion of red cell is diminished it is termed anemia. Severe anemia can cause shortness of breath. Milder degrees cause fatigue. Anemia reverses when TIP is stopped. If anemia is severe, it can be corrected with a medication called Aranesp. Iron is not beneficial.

Arthritis
Joint pains particularly in the hands but sometimes in other joints are common and often improve with glucosamine, Motrin or Celebrex.

Liver Changes
Casodex and Flutamide occasionally cause serious liver problems. This is detected by blood tests that need to be done routinely after starting TIP. The problem is easily reversible if detected early and the medication is stopped.  

Mood Swings
Men on TIP occasionally mention increased intensity in their emotions. Some find this effect unpleasant whereas others enjoy it. For men with the former attitude, low doses of medications such as Zoloft or Paxil can reverse the unpleasant feelings.

Final Thoughts
My general impression after many years treating men with TIP is that treatment is quite tolerable if side effects are expertly managed. Preventative measures such as weight lifting and diet are critically important. Checking blood tests for anemia and liver function is essential. Side effects like joint pains, hot flashes, depression, emotional swings, breast enlargement and impotence can be greatly reduced with judicious medical care.

**email us to receive Osteoporsis booklet -- mail@prostateoncology.com