Article By Tara Ellison
~ September 2021 ~ As menopause hit, I found I wasn’t as interested in intimacy as I used to be. Sex started to feel like a box that needed to be checked a couple of times a week, and that was causing problems in my marriage.
But it wasn’t just sex. I felt was slowing down in many areas. After hot flashes in my 40s had sent me running to the gynecologist for help, I’d been using bioidentical creams to balance my declining hormones.
When, at 51, I confided to a friend that I’d had limited success with what my doctor prescribed, she said that she was thriving on something called hormonal “pellets.” I grilled her about them and then made an appointment with her practitioner, an internal medicine doctor.
He ordered extensive lab work, which showed that my testosterone levels were very low, which can happen with aging. The doctor said I had two options: do nothing, which he said would eventually likely lead to loss of muscle, decreased bone density and a host of other health complications. Or up my testosterone.
Testosterone therapy for women is a hotly debated subject. Studies suggest that testosterone can heighten libido in women with hypoactive sexual desire disorder (HSDD), at least in the short term.
A recent statement by a group of international medical societies involved with women’s health endorsed the use of testosterone therapy in women for HSDD, and specifically excluded pellets and injectables as “not recommended.” It also cautioned there was not enough data to support the use of testosterone therapy for cognitive performance.
Women make between four to 10 times as much testosterone as estrogen, which the body can convert to estrogen. Despite its significance, no testosterone products designed for women are on the market and approved by the Food and Drug Administration. (Two non-testosterone, libido-focused drugs are available for premenopausal women.)
For men, the benefits of testosterone are well-documented — improved mood, sexual function and stronger bones — and more than 30 FDA-approved products are available, according to the agency. But long-term studies in women are lacking, including the effects on those who have a history of breast or uterine cancers and liver or cardiovascular disease. Although studies say testosterone is widely used in women, its use is considered off-label.
The pellets my doctor proposed are unregulated, and not recommended by the North American Menopause Society (NAMS) because of their high doses of testosterone and unpredictable absorption.
“There are a lot of misconceptions for the potential benefits of testosterone,” said Cynthia A. Stuenkel, clinical professor of medicine at the University of California at San Diego’s School of Medicine and past president of NAMS. “You’re going to lose fat mass. You’re going to gain muscle mass. You’re going to think more clearly. You’re going to reduce your risk of breast cancer. You’re going to improve your mood, and I think the global consensus pretty much dispels those proposed benefits.”
But I was desperate to feel better and at the time wasn’t deterred by some possible side effects, which included acne, facial hair growth and a lowered voice. And my friend was clearly convinced testosterone had helped her. The tiny dissolvable pellets, containing estrogen and testosterone, were inserted beneath the skin on my mid-buttock and would last between three to five months. If I developed any side effect, on the next re-up date we could adjust the dose or discontinue, my doctor said.
The insertion process took less than 10 minutes and about five days to kick in. I didn’t have to wait long to see improvement.
Within weeks, I was feeling good — my brain felt clearer — and my libido was in full swing again. It was hard to pass my husband in the kitchen without reaching over to touch him.
I can’t rule out a placebo effect of course, but having a jolt of testosterone seemed to make me more focused — I got things done. One morning in the magnifying mirror, however, I noticed a definite uptick in facial hair.
My husband liked the increased sexual activity and joked that he didn’t have to endure discussions about my feelings anymore since I had gotten more direct in my conversations with him.
I also found I was more driven to work. Just generally, I felt more confident and it seemed like people responded to me differently because of that. And rather than being finely attuned to my spouse’s desires, I was pursuing my own. Was all this biochemical or, again, could it have been a placebo effect?
I reached out to Sari van Anders, a professor of psychology, gender studies and neuroscience at Queen’s University in Canada, whose research interests include connections between women’s sexual desire and testosterone. I asked her whether the stereotypical masculine traits I seemed to be experiencing could be a placebo.
“There are strong placebo effects for sexuality in research on aids for sexuality and research on testosterone,” she said. “Our culture has long painted women’s sexuality as a problem; when women have lower desire than men, the women’s desire is seen as too low or ‘hypoactive’ and, when their desire is higher than male partners, the women’s desire is seen as too high or ‘out of control.’ As a result, medical and other interventions for women’s sexuality, especially desire, are best viewed with a healthy skepticism: Are these interventions addressing a problem within the women or a problem created by gendered norms? Should the solution address women and their bodies or gendered prescriptions?”
Women and the waxing and waning of sexual desire is a complex and tricky subject.
But I was starting to wonder why there seemed to be fewer options available for women and less research about those options. Was the gender disparity slowing down progress for women’s sexual health?
There seems to be an attitude of, “You’re past menopause, you’re not making babies anymore, what does it matter?” said Sharon J. Parish, a professor of medicine in clinical psychiatry and of clinical medicine at Weill Cornell Medical College.
James Simon, clinical professor at George Washington University and a past-president of both the International Society for the Study of Women’s Sexual Health and NAMS, said “a lot more money” is available for research into men’s sexual health and “where there’s money, you have direct-to-consumer advertising. You have additional research and development. You have glitzy ads and promotions, et cetera., this is not a new subject for men or men’s sexual health.” Viagra, he said, which men can take for their sexual performance issues, just had its 23rd birthday.
He added, “I think women’s sexual health has been largely neglected or put aside or denigrated or minimized because it took more time, was harder to measure, had less money and cachet involved, and it was easy for many in the medical community to do that, and women did not, and still to some degree, do not demand more, and that allows this to perpetuate.”
Six months later, when I saw my gynecologist and said that I was using pellets, she looked alarmed and advised me to get off them as soon as possible. “They’re scary,” she told me and referred me to a recent article and study about worrisome side effects, among them mood swings, abnormal uterine bleeding and also greater likelihood of having to undergo hysterectomy when on the hormonal therapy.
Where you get into trouble is when women are given super high doses of testosterone.
“Keeping the total testosterone in the physiologic range, closer to where women were pre-menopause, without exceeding that level and giving excess testosterone, is the goal,” Parish said. “Pellets are extremely problematic; we don’t support those, because they result in what’s called super-physiologic ranges and can result in toxicity, and we don’t have safety data supporting that.”
Susan R. Davis, an endocrinologist and director of the Women’s Health Research Program in the School of Public Health and Preventive Medicine at Monash University in Melbourne, Australia, said instead of pellets women seeking help “would be better off using a testosterone gel or equivalent that’s approved for men and using a micro dose or a fraction of the dose. . . .
“You can do a blood test to make sure [a woman] is not going over the female limit,” she added. “You can vary the dose, and you can cut back the dose if she starts getting side effects” — unlike pellets, which stop working only after they’ve slowly disintegrated. Once a pellet has been inserted, it’s very hard to get it out if an issue develops.
“I think testosterone is important for women,” Davis said, “but we’ve got to be very cautious how we administer it and we need products approved for women. That’s what we need. It’s a bit like Goldilocks: there’s too much, too little, and just right, and if you use too much it’s bad. Higher doses are actually worse for sexual function. Women start to feel agitated, irritable, negative mood, so too much is bad. So, there is a ‘just right’ dose.”
Stuenkel, past president of NAMS, added: “If you’re going to do it, I think the transdermal preparations [patches that stick on the skin] make sense [since they] are FDA approved” — although for men’s dosing. “And so that’s not great, but I think in many ways it’s safer.”
Yet, for many women, dissatisfied with gels and the like, pellets can seem worth the risk — at least for a trial run.
In my case, I had gone from having no interest in sex to wanting lots of sex. But it hadn’t been the salve that I had imagined.
My relationship with my husband was undergoing a systems update. While I was feeling much better and my behavior reflected that, there were some things about the old operating system that my husband missed. Our relationship had always been a bit “old school” — my world revolved around keeping my man happy. I could take his emotional temperature at a glance. I tried to match his hectic pace, even when I knew I needed rest, and I had always been willing to put his needs before my own. But that wasn’t sustainable over the course of a marriage.
I wondered what if my lack of sexual interest before pellets wasn’t just physiological but reflected the result of needing something different from my relationship to fuel and sustain our intimacy?
Low testosterone didn’t create the problems in my relationship but it made us more aware of them. We had long standing dynamics that needed to shift and change. We needed to have some difficult conversations to help us develop a deeper connection. A more satisfying emotional intimacy that could then naturally lead to increased sexual desire.
Testosterone may make you feel like having sex again but I discovered it’s not a magic bullet to solve everything.
It has been two years and given the long-term safety concerns about the pellets, I’ve decided to give them up when the current batch melts away — but I’m not giving up testosterone entirely. I’m considering using a patch or gel next.
The absorption might not be as effective, but at least I’d have more control over the dosage.
It may not fix everything, but finding the right balance between estrogen and testosterone — one that feels right in both my body and my marriage — seems worth it.
A version of this article originally appeared here on washingtonpost.com