Gynecologists hear it every day from patients who are in the throes of midlife. "Doctor, I'm just not interested in sex anymore."
Sure, some decline in sex drive is a natural part of aging for both men and women. But for women it tends to happen sooner -- just about the time they hit menopause -- and well before they're ready to let go of sexual intimacy with their partners.
Many walk into their doctors' offices hoping that a dose of their waning hormones -- testosterone, in particular -- is all they need to find their lost libido. Testosterone has long been known to restore desire, and Intrinsa, the testosterone patch, is widely used in Europe for that very purpose. But experts say that testosterone is a powerful, potentially dangerous treatment when given inappropriately, and that sexual dysfunction in women is more often about life and love than hormones.
"It's the high-stress lives that we all live," said Dr. June LaValleur, a gynecologist and women's health specialist at the University of Minnesota. "And how satisfying is your sexual relationship? If you have a lousy lover, you can have a ton of testosterone and it won't be enough."
Three years ago, the Food and Drug Administration, still reeling from the revelations about the risks of hormone replacement therapy in post-menopausal women, declined to approve Intrinsa because of concerns about its long-term safety. Studies to assess its risks are now under way, but in the meantime testosterone is not approved to treat female sexual dysfunction in this country.
But women still ask for it. And because the hormone is used for other medical purposes, doctors can and do legally prescribe it for sexual dysfunction, an off-label use.
"It's become kind of a snake oil thing," said Dr. Diane Petersen, a gynecologist with Women's Health Consultants in Minneapolis. She and other women's health specialists said they sometimes see female patients who come in with all the signs of too much testosterone -- hair loss, acne, weight gain, high cholesterol or deepened voices.
Some women are getting dangerously high doses from testosterone pellets placed under their skin. Because it is not a regulated pharmaceutical product, it is most often provided by compounding-pharmacies that make up individual doses in cream and gel form that women apply to their arms and legs, doctors said.
But women need very low concentrations, and if not made by experts those creams can easily contain too much, they said.
"It's only as good as the person compounding it," said Dr. Jacqueline Thielen, a doctor at the Women's Health Clinic at the Mayo Clinic in Rochester, Minn. "More is not necessarily better."
Thielen and other women's health experts do prescribe it for some patients. But not often, and it's not the first thing they try.
Doctors said they usually give testosterone only to women who have abnormally low levels, and always in combination with estrogen. That means women who have had their uterus and ovaries removed get it most often because their bodies produce no testosterone.
Women who have reached menopause still produce testosterone for many years, though at lower levels than in their reproductive years.
The Intrinsa patch was tested in women whose ovaries had been removed. Those studies found that women who used the patch regularly for a year said their average number of satisfying sexual experiences increased from three to five per month. But those on a placebo had also had an average increase -- from three to four.
If it had been approved, the patch could have been prescribed off-label to any woman, which is what raised safety concerns at the FDA. Procter & Gamble, which makes Intrinsa, is now conducting safety trials, and is also looking at its effectiveness at increasing libido in post-menopausal women.
But for now, most healthy post-menopausal women are not candidates for testosterone treatment, doctors said. "I would have to say that the majority of the time I can get by without giving patients testosterone," Thielen said.
Even though testosterone is the hormone that contributes to sex drive, in women it often has no relationship to libido, doctors said. Usually it's something else altogether.
LaValleur had one patient who complained that she was disinterested in sex. But when asked about her relationship, she described how she would get nauseated when she came home and saw her husband's pickup truck in the driveway.
Another woman who was going to law school at night and taking care of two kids said her husband just couldn't understand why she wasn't interested in sex when he came home from his regular business trips.
"We have a way different sexual response cycle than men," she said.
Besides, she said, sex drive and the ability to be sexually aroused are two completely different things that relate to different hormones. Testosterone drives interest in sex. During their reproductive years, women's desires fluctuate during their cycles, along with testosterone levels.
But sexual arousal is dictated by estrogen. And even without libido or testosterone, women can be sexually intimate and achieve arousal and orgasm.
Estrogen declines with age, as well, making women's vaginas drier and less elastic. And it's hard to be interested in sex when it hurts. But that's easily treated with lubricants and even estrogen creams, doctors said.
And, of course, sex itself is part of the cure.