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.

Testosterone for Men and Women

BY MARK SCHOLZ, MD

Testosterone is really cool. It improves concentration, energy, strength, and libido. Both men and women experience enhanced performance with higher testosterone levels.  The problem is that testosterone tends to decline with age.  Also, testosterone-blocking therapy to treat prostate cancer can have lingering effects, even after the treatment is stopped.  For women, testosterone levels often decline sharply after menopause.

Low testosterone causes many undesirable effects including muscle atrophy, weight gain, tiredness, osteoporosis, low libido and impotence.  Absent testosterone in women* is usually a secondary effect of menopause, so it usually occurs in conjunction with low estrogen. In women the loss of estrogen and testosterone causes weight gain, tiredness, osteoporosis vaginal atrophy and low libido.

Judicious administration of testosterone in men and a combination of estrogen and testosterone in women, can dramatically improve quality of life. Bioidentical hormone therapy is the term often used by the doctors who specialize in this area.  The idea is to restore hormone levels back to normal.

Risks of Testosterone Therapy
As might be expected, like any powerful tool, misuse of testosterone can be dangerous. Administering testosterone in men with prostate cancer is controversial (see below).  However, there are also risks even in men without prostate cancer.  One reason is that when testosterone is administered to men estrogen levels also rise.  Higher estrogen in men may increase the risk of heart attacks and strokes. Therefore, estrogen levels should be monitored and compensatory treatment with Femara®, an estrogen blocking pill, may be necessary in some cases.

In men, testosterone may also cause an excessive increase in the red blood cell count (RBC). Overly high RBC levels have also been linked to higher risks of heart attack or stroke. The RBC count, therefore, needs to be monitored by measuring the hematocrit, a component of the complete blood count (CBC). If the hematocrit rises above 50% men should consider lowering their testosterone dosage or undergoing a phlebotomy (donating a unit of blood).  In women, excessive amounts of testosterone can cause masculinization.  Estrogen replacement also slightly increases the risk of breast and uterine cancer.  Obviously a full discussion of all the risks and benefits is essential before starting treatment.

Administering bioidentical hormones is as much an art as a science. The hormones themselves are delivered in the form of creams, pills or shots. Studies show that the measurement of hormone levels in the blood stream or in saliva is moderately helpful for guiding the selection of an appropriate dosage. A better indication of proper dosage, however, is the subjective sense of well-being reported by the person receiving the treatment. Therefore, starting hormone therapy should proceed slowly with an incremental escalation of dose while closely observing for the appearance of side effects.

Giving Testosterone to Men with Prostate Cancer
Denying every man with a history of prostate cancer from receiving testosterone is ridiculous. Studies clearly show that about half the men in their 50s and almost all men in their 80s harbor minor forms of prostate cancer; most is low-grade and harmless.  Almost all of these men have substantial testosterone coursing through their blood (from their testicles).  They seem to do just fine. As long as men are regularly screened to ensure the absence of clinically significant prostate cancer, the risks of restoring low levels of testosterone back to normal should be quite low.

Living Longer and Living Better
Just in our lifetimes we are observing a dramatic enhancement of human longevity.  When I was in oncology training at USC just twenty-five years ago, the attitude toward a patient’s death while in his in early 70s would have been, “He lived a full life.”  That attitude is no longer accepted.  Now men and women are not only living longer, they are retaining substantial youthfulness into their 80s. As part of an overall health program that includes diet, exercise and appropriate healthcare, restoring sex hormone levels back to normal can be transformational.  Since giving small amounts of testosterone to females is a foreign idea to many people, in my next blog I will elaborate on this concept further.

* Premenopausal women normally have testosterone in their blood, albeit at much lower levels than men.

Partners

BY RALPH BLUM

When your partner is diagnosed with prostate cancer you will undoubtedly experience a tidal wave of emotions, including the devastating fear that he might die. At the same time as you are trying to get a hold on your own fears, you also want to support and reassure your partner—who is struggling with the same shock and fear. It’s a tough act to balance, and it’s only too easy to repress or ignore your own feelings and needs.                                          

Often, it seems, men are more intimidated by health problems than women are, and when your partner is first diagnosed with prostate cancer you may find that it is up to you to ask the important questions in the doctor’s office while your partner sits there in apparent—usually temporary--shock. Moreover most men are conditioned not to talk about their fears and anxieties, and you may fall into the trap of struggling to remain upbeat, of hiding your own fears from him. While it is helpful to be as positive as you can, it is equally helpful to encourage him to express his feelings, and to talk openly together about his concerns that the cancer treatment is going to affect your relationship. One of his main fears will be of becoming impotent. It is not easy for men to understand that there is more to intimacy than erections.

There are many ways in which you can help your partner, in addition to giving him your love and support as he decides on his best treatment option. You can help him by learning everything you can about the disease and the various treatments so that you can discuss with him the sensitive issues and side effects involved. You can help him with other choices, such as choosing which doctor will perform his treatment. And you can help by driving him to treatments, picking up his medications at the pharmacy, and by keeping track of all his test results, x-rays and medical records, so that if the need arises to consult another doctor, he will have everything ready to take with him.

However, it is vital that you not neglect your own health (which it’s very easy to do!) or give up your own life and center everything around your partner and the cancer. Above all, take time out from thinking about the disease. Go out to dinner and to movies with your partner. Take weekends off and travel to favorite haunts. Enjoy, as much as possible the activities you have always liked to share. Indeed, the vow is “In sickness and in health.” But refuse to permit your whole live be held hostage to this condition.

It would be presumptuous of me to even attempt to address the real loneliness and frustration women feel from the lack of sex. My partner, Jeanne, however, is fierce on the subject.

“The women at the PCRI Conference all complained about it,” she told me. “But they feel they cannot reveal their feelings to a husband who is, I quote, ‘dealing with cancer, for God’s sake!’

When I asked Jeanne what she’d want to tell men, she said, “Curl up and just snuggle. No attempt at sex. Just relax. Hold each other, and listen as you begin to breath together. Try spooning. Meaning, lie curled up tummy to back. It’s called ‘the Embrace Meditation. . .’ There, that’s a start.”

I asked her, “Anything else you’d want to say to all the partners?”

“Yes. Let him know that helping him will actually help you to feel better, more confident, even more safe.”

As I was writing this, I remembered something that really helped me, something Jeanne told me right at the beginning, when I was first diagnosed, “Here’s what I feel,” she said.  “We both have prostate cancer. We’re in this together.”