when there is a sexual opportunity. Guilt about sex and about women having sexual pleasure may be present. If the woman is a new mother, she may feel on one level that sex now is “wrong.” Experiences of assisted reproduction technique or delivery may lead to the woman feeling loss of control; this in turn may lead to a need to regain control in all aspects of her life, which may suppress her sexual feelings. CBT and mindfulness therapies are recommended (94).
Randomized controlled trials of transdermal testosterone for medically and psychiatrically healthy postmenopausal women with low sexual desire were published. Four involved surgically menopausal estrogenized women (95–98). Transdermal testosterone (300 μg) daily significantly increased the frequency of sexually satisfying events (p = .049) compared to placebo. At baseline, these studies showed that the recruited women reported two to three sexually satisfying experiences per month, and these increased to approximately five per month with active drug (300 μgof testosterone), and to four per month with placebo. Using a validated unpublished questionnaire, scores in the desire and arousal scales were significantly increased by active drug in the first three studies (for desire: p = .05 in the first study and .006 in the second, .001 in the third). The fourth smaller study of prescribed transdermal estrogen recruiting women showed significant increase in desire and response scales, but not in the numbers of sexually satisfying events (98). Results from one study of 549 naturally menopausal women receiving oral estrogen and transdermal testosterone were similar (99).
Two studies of transdermal testosterone to estrogen-deficient women showed benefit (100,101). A previous small study showed minimal or no benefit from transdermal testosterone in estrogen-deficient women with past history of cancer (102).
There was minimal benefit from transdermal testosterone when given to premenopausal women in another study of 261 premenopausal women recruited on the basis of loss of their former sexual satisfaction (103).
The criteria for recruitment are a major drawback of the testosterone patch trials. It is not certain that the recruited women had any sexual disorder: the focus consistently was on the frequency of satisfying events in women able to have such experiences—some 50% (98). The participants did not have consistent difficulties or dysfunctions, pointing against a biological cause or need for a biological remedy and pointing toward psychological, relationship, or contextual factors, which are inherently variable. As noted, there was improvement in the secondary end points of desire and response subscales in the (unpublished) validated questionnaires used in all the trials. Increasing the degree of pleasure and arousal currently experienced may not necessarily imply that absent pleasure and absent arousal would be remedied.
Long-term safety issues include those of the combination of testosterone and estrogen and concerns about estrogen itself. Beginning systemic estrogen some 10 years postmenopause is known to increase cardiovascular risk: aromatization of exogenous testosterone to estrogen is likely. For postmenopausal women not receiving estrogen, long-term sequelae of creating a distinctly nonphysiological profile of the testosterone:estrogen ratio are completely unknown. Endogenously high testosterone along with obesity in older women is associated with insulin resistance and increased cardiovascular morbidity (104).
Genital Arousal Disorder There are no approved medications for treating desire and arousal disorders in women. Approval was sought from the U.S. Food and Drug Administration (FDA) for transdermal testosterone but not granted because of theoretical risks to breast tissue and cardiovascular health with only modest benefit. Approval for phosphodiesterase inhibitors was not sought—the larger studies show no benefit of placebo for women’s sexual dysfunction. Off-label use of sildenafil when genital congestion is likely to be impaired by an underlying illness such as diabetes, multiple sclerosis, or spinal cord injury showed some modest benefit to lubrication in small studies (33).