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12 August 2005
Androgen Insufficiency, Testosterone and Female Libido
by Angie Rankman 
Sexual function is a complex and intricately balanced combination of hormones, social expectations and physiological responses. When problems arise in female sexual function, it’s easy to see how diagnosis and treatment could become difficult.
Much of the scientific research conducted on female sexual function centers around androgen levels. In one of her early studies, Susan Davis, Director of the Jean Hailes Research Unit in Australia, said that: “Androgens are quantitatively the predominant sex steroid in women,” with the most significant biologically active androgen being testosterone. Predictably, correlations were made between androgen levels, levels of free testosterone or total testosterone, and sexual frequency and libido. But the results of numerous clinical trials and studies have provided researchers with mixed results. In many cases androgen therapy, used to counteract the effects of androgen insufficiency, has improved the quality of life of women. However, diagnosis and treatment are still inexact sciences. The scientific theories that both diagnosis and treatment are based upon are in a state of constant flux. It is the science itself that makes the task of providing answers for androgen insufficiency such a challenge to researchers. Davis herself has conducted two separate studies that appear to contradict one another. And recent discoveries mean that current androgen research may have to make room for studies exploring the genetic level of androgen insufficiencies.
Despite the apparent contradictions, drug companies have found the link between androgen levels and female sex drive an invitation to produce drugs that imply a universal, one-size-fits-all normality to female sexuality. The term female sexual dysfunction, for example, was coined by drug companies to describe a whole raft of sexual issues experienced by women, demonstrating a concerted effort on their part to generalize sexual dysfunction in women. Many commentators and researchers believe that portraying sexual difficulties as a dysfunction will encourage doctors to prescribe drugs that change sexual function, when attention should be paid to other aspects of the patient's life. It's also likely to make women think they have some sort of malfunction when they do not. It seems that the intent of drug companies is to normalize the idea that women should always want or need to be sexually active. In fact, some women find that testosterone treatment induces an unwelcome rise in sexual fantasies, masturbation and sex drive. In which case an increased sex drive becomes an adverse side-effect of androgen therapy.
This does little to deter drug companies looking to turn a profit, however, and a recent study funded by Procter & Gamble Pharmaceuticals is testament to this. The study was centered on the idea that although some women see improvements in sexual functioning with estrogen therapy alone, some researchers suggest that the combination of estrogen and testosterone is more effective in preserving libido. The study was met with skepticism from other health professionals, who claimed that the study relied heavily on very modest results reflected in questionnaire responses provided by the subjects involved, as well as a methodology that misrepresented the study’s final statistics. It is certainly true that some women find that testosterone therapy has given them a new lease on life. Many say that not only has their libido been restored to a normal level, but their general wellbeing and outlook on life has improved. Critics of studies similar to Procter & Gamble’s need only look at research that claims no information in regard to a woman’s sexual state can be associated with androgen levels.
Accurate diagnosis would be of considerable help in counteracting the exploitation and murky definition of female sexual dysfunction. But there still seems to be a great deal of ground to be made up in this regard. Davis’s most recent study shows that current diagnosis using testosterone levels and DHEAS (a natural steroid hormone) is inadequate, which may mean that many women are prescribed treatment without it being necessary.
Davis appreciates just how difficult accurate diagnosis of sexual function can be. In 2004, for example, Davis said: "We found a strong relationship between the low scores for desire, arousal and responsiveness and low DHEAS levels in women under 45.” Davis also added that: “Although multiple factors contribute to sexual interest we have demonstrated that low DHEAS is more likely in a woman experiencing low sexual desire and arousal than in other women. The findings from this study are absolutely fundamental to developing a sound clinical approach to the assessment of women presenting with low libido.” This year, however, Davis revealed in anew study that: “Our findings do not support a diagnostically useful role for the measurement of DHEAS. This is because despite the increased likelihood that women with low sexual function have a low DHEAS level, the majority of women with a low DHEAS level did not report low sexual function.”
Confusing? It certainly seems to be but Davis explains that her findings do not contradict studies that show women benefit from androgen therapy, as in many cases the treatment does work. She says her research deals specifically with diagnosis and how to identify women with forms of sexual dysfunction and the reasons and causes behind a loss of libido and associated symptoms. This may be unsettling and confusing for women, but the science is good and we can see a progression. However, it may also demonstrate that a universal approach to sexual dysfunction is inappropriate, as the problems seem to be influenced by a multitude of variables. Doctors may forever be chasing their tails in trying to match the medication with the patient exhibiting certain symptoms of androgen insufficiency with only limited success. It gives the impression of being a very hit and miss affair. This scattergun approach to treating androgen insufficiency may yet be superseded by new research that shows androgen insufficiency can be treated at a genetic level.
Kate Dunn, Lynn Cherkas and Tim Spector, at St Thomas’ Hospital in London, claim that the results of a recent twin study on the female orgasm “show that the wide variation in orgasmic dysfunction in females has a genetic basis and cannot be attributed solely to cultural influences. These results should stimulate further research into the biological and perhaps evolutionary processes governing female sexual function.” Their research follows in the footsteps of a growing number of studies that are exploring the source of many disorders that begin at the genetic level. While the study specifically focused on the female orgasm, the findings may eventually shed some light on androgen insufficiency. The researchers said that their present results show “genetic factors are the predominant measurable influence on female orgasmic function [and] will perhaps stimulate more research into understanding the underlying biological basis of the female orgasm and sexual dysfunction.”
So on a purely speculative level; it may be possible that female androgen insufficiency could be treated at a genetic level. Dr David Corey, a professor of pharmacology and biochemistry, explains how: “Virtually every disease starts at the level of malfunctioning gene expression, or viral or bacterial gene expression. One could easily turn on or off gene expression, as well as think about ways to correct genetic disease by changing mutant gene sequences back to normal. Those types of things now look a lot more feasible." If this were possible it would remove the need to try and match medications to patients needs, because if the problems were treated at a genetic level the body would have a greater chance of self-regulating androgen levels throughout a woman’s lifetime. It may also provide a greater understanding of female sexual expression and the many forms that this takes, rather than the narrowly defined ones that are currently being focused on.
While this brief account of the current state of androgen insufficiency and its treatments does not offer any answers, it may engender some realistic expectations in regard to the diagnosis and treatment of androgen insufficiency. One should be cautious and discriminating in the diagnosis and choices of treatment for androgen insufficiency. In short, maintain a healthy skepticism.
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