“Harry was taking the boat out alone, moving slowly but deliberately through the San Diego channel just as dawn was breaking… As he passed the landmark high-rise hotel, he was riveted by the sight of a tall woman standing stark naked in her room, just barely in view, in the throes of sexual ecstasy…
She was masturbating against the edge of a door, arching her back as she rubbed herself, her gyrations becoming more intense. He was mesmerized, forgetting where he was, what he was doing.
He could almost reach out and touch her through the magnified lens, captivated by the idea of watching her without her knowing. He was so immersed in the experience, leaning over the transom for a last look, he tumbled into the water.”
- Theresa Crenshaw “The Alchemy of Love and Lust”
The above passage was a true story told to Crenshaw, a pioneering sex therapist and expert on sex hormones, by an embarrassed friend. He was on a serious fishing voyage that day. And his “hormones” almost cost him a small fortune when his work-boat (a yacht for catching yellowtail) sailed on without him. Not only that, but somehow during the fall into the water, he sustained three cracked ribs and a broken arm!
Oh, the power of our hormones!
Our sex hormones influence every element of our bodies and our brains. And yes, they make us do dumb things that we’re embarrassed to admit. That cute guy with the blue eyes, hot six-pack, and no job that you almost married?
Yup. That was your hormones talkin’, girlfriend!
They play a huge role in our sexuality, and our very existence as a species hinges on their working properly. The reason you are here today is that somebody’s hormones got riled up enough to perpetuate the gene pool. And here you sit, the reproductive proof of at least one of your parent’s hormonal randiness.
Our hormones and our sexual desire naturally decline somewhat with age. This does make us smarter about dating partners (sometimes), but it’s still a fact that nobody likes. Now that I’m in menopause, I’m having to grapple with this issue in a major way.
Over the last few years, as my periods have grown more erratic, my sex drive has crashed like a bad IPO.
So, as I sit here contemplating my options regarding hormone replacement therapy, I decided to revisit and dive deeper into the research I did for my graduate dissertation on female sexual dysfunction. I had a lot of questions swirling around in my head. Here are the big three:
- How do hormones work in the female body?
- How much are women’s infamous desire issues hormone-related?
- How does hormone replacement work?
This article will attempt to answer these questions. Disclaimer: I’m not a physician. Talk to your doctor about any kind of hormone replacement therapy.
Just What is a Hormone? Meet the Cast of Characters
To get you started understanding your biochemistry, let me give you a visual of what would happen if your major sex hormones threw a party and everybody came?
It’s a Friday night in the grand ballroom of a swanky hotel in Somewhere, USA. There’s music, dancing, rich food, and good wine. What’s not to love? The party-goers mingle and dance as the band plays. At the buffet table, brawny Testosterone is checking out the hot babes and scarfing down the chicken wings, while a dolled up Estrogen with her curves and cleavage sashays around the room flirting with all the party-goers. DHEA, an androgynous molecule who goes both ways, pontificates on the current political climate, while mopey Progesterone hides in a corner and naps…
Confused? This will make more sense as we go on.
All hormones are chemical messengers, released by our endocrine glands, that travel through the circulatory system and regulate a variety of bodily processes and behaviors.
The primary sex hormones are steroids and are all synthesized from cholesterol, which first converts into pregnenolone (2). Our hormones are constantly transforming, interacting, and opposing one another in a carefully orchestrated dance.
There are three star players in this ballgame: estrogen, progesterone, and testosterone. But there are also side players (DHEA, DHEAS) that aren’t talked about as much that have a profound influence on women’s desire and response.
Progesterone (The Two-Faced Bitch)
Progesterone rises irritably from her nap and immediately regrets the decision. A pudgy, be-speckled young hormone, she notices Testosterone checking her out and thinks with disgust, “That douche-bag will do anybody”. But Progesterone isn’t taking the bite. She isn’t interested in sex most days, though sometimes she is. She is usually confused and isn’t sure who she is or what she needs. Most of time, she just wants a nap.
I will begin this journey with a discussion of progesterone. Primarily, because estrogen and testosterone spend so much time in the limelight. Yes, E and T are the Arnold Schwarzenegger and Marilyn Monroe of the hormone world respectively.
They are powerful molecules that can sculpt a man out of a boy and a woman out of a girl. But let’s not forget the oft-ignored middle sister: Progesterone, the Jan Brady of female hormones, screaming “Estrogen, Estrogen, Estrogen!” (I’m dating myself here).
Progesterone is the first link in the chain that starts with cholesterol and leads to testosterone and estrogen. It is a precursor to both these hormones, and it is produced in the ovaries and the adrenals.
Progesterone is synthesized in the ruptured egg follicle (the corpus luteum) during the second part of a woman’s menstrual cycle (the luteal phase). I call it a two-faced bitch because it is something of a paradox.
On one hand, it is soothing and sedating; on the other hand, it is implicated in the moody emotional upsets and Twinkie binges of PMS!
Progesterone’s affect on the female libido is similarly confusing. The high levels of the hormone present in the late luteal phase lower desire and have a host of unfortunate side effects. Elevated levels of progesterone dampen genital sensations and reduce sensitivity to oxytocin (a hormone that increases sexual functioning and promotes bonding) (3).
Because progesterone is an anti-convulsant and orgasm is a seizure, when progesterone levels are high, your orgasms may feel more like a hiccup than a toe-curling sheet grabbing explosion.
Now, you know why your orgasms aren’t always worth the effort!
Progesterone decreases both testosterone and dopamine levels — two major instigators of sexual desire. (3). However, for some women just the opposite happens, the high levels of progesterone in the luteal phase increase desire (4).
As women age, progesterone is the first hormone to take a noticeable dive. Given its contrary nature, this might sound like a good thing, but it’s not. Women in perimenopause (the period leading up to menopause) often become estrogen dominant with low levels of progesterone. As women get older, we don’t ovulate every cycle. This means that we don’t make progesterone because we don’t make a corpus luteum.
Some experts believe that it is the deficiency of progesterone ( luteal phase defect, LPD) that leads to the weight gain, night sweats, and the emotional rollercoaster that some women experience in the years preceding menopause. Progesterone promotes both healthy sleep and a healthy thyroid (5).
At high doses, particularly in conjunction with estrogen, it has pain-relieving properties. Both these hormones are elevated when a woman is pregnant and this can create a state called “pregnancy analgesia” — which isn’t a bad thing when you’re carrying an 8-pound bowling ball in your body for 9 months (6–7).
Progesterone is important in its oppositional role to estrogen. Like a bouncer in a bar, it keeps estrogen from trashing the place. Estrogen thickens the uterine lining, while progesterone keeps it from growing amok.
Sometimes, LPD occurs due to high-stress levels. When you are stressed out, your body uses a lot of cortisol which is manufactured in your adrenal glands.
And guess what makes cortisol?
Progesterone. Stress uses up more cortisol than your adrenals can make. Eventually, your depleted, maxed-out body starts borrowing from Peter to pay Paul and dips into the pregnenolone/progesterone piggy bank (5).
The great pregnenolone steal occurs when your body prioritizes cortisol production at the expense of progesterone production. This will leave you high and dry — as well as cranky, irritable, sleep-deprived, and most decidedly NOT horny.
This is a situation I know all too well. Perimenopause started sometime in my early 40s and left me foggy-brained, exhausted, and uninterested in sex (I would have turned Ryan Gosling down). I tossed and turned most nights, counting both sheep and my rapidly multiplying grey hairs.
None of the deep breathing or relaxation exercises that had helped me sleep in the past would calm my frayed nerves. I thought I was going nuts and started using progesterone. I started with progesterone cream and then moved to an oral form.
Progesterone cream has become popular with perimenopausal women in desperate need of some zzzs in the last few years due to the popularity of books such as Dr. John R. Lee’s What Your Doctor May Not Tell You About Premenopause.
Research on its usage is mixed. Progesterone traditionally hasn’t been a very easy hormone to replace. For one, when taken by mouth, it tends to be rapidly metabolized (and de-activated by the liver and gut) but doesn’t absorb well transdermally either (9).
Other studies have found better results. However, oral micronized progesterone (Prometrium) is better utilized by the body. This version of the hormone breaks the molecule down first into crystals and then into finer particles that our bodies are capable of absorbing (11).
If a woman with a uterus is taking estrogen, it absolutely essential to include progesterone with her hormone replacement regimen. Estrogen is proliferative, as mentioned before, it thickens the uterine lining. If a woman doesn’t have a uterus, progesterone replacement isn’t necessary.
Progesterone: Points to Remember
• Is the “pregnancy hormone” because it prepares the body for pregnancy.
• Is highest during the luteal phase: the second half of the menstrual cycle.
• Is a possible factor in PMS.
• Is soothing and promotes sleep.
• Dulls sexual sensations, blunts orgasm, and can reduce sex drive.
• Is pain-reducing and anti-convulsant.
• Keeps the uterine lining from becoming too thick.
• Research suggests that progesterone isn’t well absorbed transdermally.
DHEA (The Androgynous David Bowie Hormone)
He’s young, he’s lean, and today, he feels terrific! But then, he always feels good. DHEA has enjoyed all the political debate at the party (he has a really sharp mind), the music, and the food, (good food is easy to enjoy when you don’t gain weight!) and the dancing (he has tons of energy). Estrogen is a really fun dance partner. DHEA is so easily bored though, so now, it’s time for a change…
If testosterone is a chemical Arnold Schwarzenegger, then DHEA (dehydroepiandrosterone) is David Bowie, a shape-shifting precursor hormone that morphs into both estrogen and testosterone depending on its mood. DHEA occurs in two varieties: DHEA, and DHEAS (a sulfonated version of the hormone). DHEA is produced in both adrenal glands and in the ovaries, while DHEAS is synthesized in the adrenal cortex (12).
We are loaded with the stuff at birth, and it remains the most abundant hormone in the body throughout the lifespan. From the ages of about 8 to 14, both boys and girls enter adrenarche.
This is a time when adrenal androgens (DHEA, DHEAS, androstenedione) surge and we develop pubic hair, body odor, and other signs of puberty (12).
DHEA reaches its peak when we are around 25. After our mid-twenties, DHEA drops steadily, a process referred to as andropause. It is present in both men and women at similar levels but is more associated with desire and sexual response in women (3, 12).
In an Australian study of 1,423 women, between the ages of 18 and 75, it was found that low scores on a self-report measure of sexual functioning correlated with having serum DHEA levels below the 10th percentile for a woman’s age (13).
Hormonal birth control pills and alcohol lower DHEA as do medical conditions such as lupus, rheumatoid arthritis, ovarian cancer, and Alzheimer’s disease.
DHEA is lower in obese women and women who have had children. Interestingly, Bupropion (Wellbutrin) may increase levels of the hormone, as can transcendental meditation, intense exercise, and oddly smoking (3, 5).
Over the last 20 or so years, there has been an increased interest in using DHEA as a kind of anti-aging remedy. It has been hyped as a “fountain of youth” that can keep you young, strong, lean, and cognitively intact. This may or may not be hype. The reality is that DHEA is a mystery molecule that isn’t understood very well.
There have been a few studies using DHEA to manage menopausal symptoms that looked promising. One small study examined a 25mg DHEA supplementation in 20 postmenopausal women and found an increase in hormone levels and a reduction in menopausal symptoms comparable to traditional estrogen/progesterone therapy. (14)
However, when scientists have studied DHEA’s affect on women’s sexual issues, the results have been mixed. The research in this area is problematic and limited to small poorly designed studies (15).
One area where DHEA shines is its ability to alleviate vaginal atrophy, which led to the FDA approved drug Intrarosa (Prasterone). This is a vaginal insert that helps strengthen the vaginal lining and improves lubrication without thickening the endometrium or increasing systemic hormone levels. If you’re too broke to afford Intrarosa and your insurance won’t cover it, you could always try Bezwecken DHEA cubes on Amazon.
DHEA: Points to Remember
• Can convert into estrogen, progesterone, and testosterone.
• Peaks around age 25 and steadily declines with age.
• Is More involved with female sexual desire and functioning than male.
• Wellbutrin (Bupropion) raises levels of DHEA.
• Is currently being used to treat vaginal atrophy.
• Is involved in pheromone production.
Estrogen (Marilyn Monroe: The Venus Hormone)
Estrogen holds court on the dance floor. She is having a ball flirting and dancing. Her ample backside swings with the rhythm of the music, while her satiny skin glows. Estrogen is a total package deal with a quick wit and a strong mind. But yeah, her physical allure doesn’t hurt either. She’s impossible to ignore. Her laugh is contagious, and her hourglass curves make all her dance partners weak in the knees. She’s not afraid to make a fool of herself ether, and she falls down a few times while dancing. But that’s okay, her bones are strong and resilient. She notices Testosterone checking her out by the buffet. Wow, he is soo gorgeous and sexy, he makes her all tingly. She can feel her panties getting moist. Um…
Estrogen, the Marilyn Monroe of hormones, dominates the first half of a woman’s menstrual cycle and is opposed by progesterone in the second half. Estrogen comes in three forms: estradiol (E2), estriol (E3) and estrone (E1). Estradiol is the most biologically active hormone for premenopausal women, while estrone is more active after menopause. Estriol is primarily active during pregnancy (2).
Remember what I said about hormones being shapeshifters? One of the most fascinating facts in human physiology has got to be the fact that estradiol, the hormone most associated with femininity, is synthesized from testosterone (16).
Estrogen is responsible for more than just breasts and baby-making. It affects every part of a woman’s body and brain, and it has a profound impact on her sexual functioning. It is responsible for maintaining pelvic blood flow, the creation of vaginal lubrication, as well as the maintenance of genital tissue (17).
When estrogen is in short supply, women struggle with diminished genital and nipple sensitivity, difficulty achieving orgasm, increased sexual pain, and inadequate lubrication (17). Women with low estrogen are at risk for vaginal atrophy, which has to be among the most delightful aspects of aging (NOT).
Another issue I am intimately familiar with.
As I moved deeper into the menopausal rabbit hole, I experience vaginal irritation, dryness, and constant UTIs, all of which were due to estrogen bidding me a fond farewell. When estrogen leaves the building, the vaginal lining (the epithelium) gets thinner, the vagina itself may shrink and lose muscle tone and elasticity.
And as for those persistent UTIs that bedevil menopausal women like me, they are due to the increase in vaginal pH. When the vagina becomes more alkaline, it kills off good bacteria, leaving a woman a sitting duck for a number of vaginal and urinary tract infections.
Remember this, a happy pussy is an acidic one (ideal pH 3.8–4.2).
The normal level of estradiol in a menstruating woman’s body is around 50 to 400 picograms per milliliter (pg/mL). This fluctuates with the menstrual cycle. Below this threshold, and there is an increased risk for the problems mentioned above. When women are in menopause, estradiol levels are often as low as 10–20 (pg/mL) (17).
Estrogen: The True Lady of Lust?
Testosterone, the loud and proud androgen, is usually assumed to be the sexual mover and shaker for both men and women. Estrogen, it has been argued, just gives a woman a wet vagina, the motivation to use it comes from her testosterone.
This is the view expressed by Theresa Crenshaw in The Alchemy of Love and Lust. In contrast to men, she argues that women have four sexual drives 1. Active (aggressive) 2. Receptive (passive) 3. Proceptive (seductive) and 4. Adverse (reverse). These drives are representative of our hormonal makeup.
She differentiates along standard party lines and claims that testosterone fuels women’s active sex drive, while estrogen fuels the receptive and proceptive drives. According to Crenshaw, ever contrary progesterone doesn’t fuel anything but a nap (the adverse drive).
However, some researchers believe that estrogen’s role is underestimated in female desire and that the conversion of testosterone to free estrogen in women might play a major role in female desire. (18). “Free” in this case means a hormone that is biologically active and available for our bodies to use.
According to Emory professors, Cappelletti and Wallen, for most female mammals the most important hormone governing sexual behavior is estrogen. That would make human females rather weird and unique if our sexuality was testosterone-driven.
Plus, research does show that estrogen alone is capable of increasing desire in women(19).
Mode of delivery (e.g., by mouth, or transdermal) is an important and possibly overlooked factor when looking into HRT. One major problem with oral estrogen’s like Premarin (aside from the fact they’re made of horse pee!) is that when estrogen is taken by mouth it raises levels of SHBG (sex hormone-binding globulin).
SHBG is a protein secreted by the liver that binds both estrogen and androgens. It prefers androgens. This means that it will reduce free androgens and estrogens, both of which are associated with sex drive.
In a randomized, controlled study of 670 women comparing transdermal estrogen therapy with oral (Premarin), it was found that transdermal estrogen improved sexual functioning according to scores on a self-report measure. Women who used horse pee (Premarin) showed no improvement in sexual functioning and presumably had to come up with some new hobbies (20).
As a side note, I keep visualizing a poor, pregnant mare being badgered by some pharmaceutical rep going, “Just pee in the bucket Seabiscuit; we need the money!” But I digress…
Bioidentical Hormone Replacement
Women who are interested in HRT often opt for bioidentical hormones. They have become popular for a few reasons. In 2002, the WHI (Women’s Health Initiative) study dropped a bombshell on the world’s menopausal women and linked hormone replacement with a 26% increased risk of breast cancer and an increased risk of cardiovascular events and stroke. Within three months of published reports of the dire findings, prescriptions for hormone therapy (HT) dropped by 63% (21).
Also, popular books like The Sexy Years by Suzanne Somers have promoted the use of compounded bioidenticals instead of FDA approved drugs. Compounded bioidentical hormone therapy (CBHT) is custom formulated by a compounding pharmacy and tailored to the individual. They are often perceived as safer and more natural.
What Are Bioidentical Hormones?
From my readings, this may be short-sighted. First up, let’s talk about what bioidentical hormones are. According to the Endocrine Society, bioidentical hormones are “compounds that have exactly the same chemical and molecular structure as hormones that are produced in the human body.”
They are often plant-derived in comparison to the Premarin and Provera (used in the WHI study), which is a synthetic estrogen synthesized from conjugated horse urine and synthetic progestin respectively.
Note that Premarin could be considered “natural” given the fact there’s nothing more natural than horse pee! However, it isn’t identical to what your body makes.
Bioidentical progesterone is made from diosgenin that is derived from wild Mexican yam or soy, while bioidentical estrogen is often synthesized from soy. Both bioidenticals, like all hormone therapies, are extensively processed in a lab (22).
The Endocrine Society’s definition is broad and doesn’t refer to the sourcing, manufacturing, or delivery method of bioidenticals. This definition can refer to both FDA approved HRT as well as non-FDA approved hormone replacement.
There is no evidence that bioidenticals are safer than synthetic hormones. Nor, is there isn’t any evidence supporting CBHT as a better alternative. With CBHT there are issues regarding dosage, purity, and strength.
According to an article in The Mayo Clinic Proceedings, “Compounded hormone preparations are not required to undergo the rigorous safety and efficacy studies required of FDA-approved HT and can demonstrate wide variation in active and inactive ingredients.” (21).
There are several FDA approved bioidentical hormones that are on the market. They differ from CBHT in that they have some science behind them and they are carefully formulated and manufactured according to strict specifications (21).
Is Hormone Therapy Safe?
I think it depends on who you ask and what you read. It also depends on your particular situation. I recommend any woman interested in hormone replacement do some serious study on this issue. The WHI study scared the bejesus out of women, their doctors, and created a lot of hysteria. There were several issues with that study that are beyond the scope of this article.
One book I recommend is Menopause: Change, Choice, and HRT by Australian physician Dr. Barry Wren. He goes into detail about the WHI study and its shortcomings, including the fact that the women who participated in the study were older (average age 63), smokers/former smokers, overweight/obese, and in poor health.
There is a critical “window of opportunity” for women to go on HRT. It is recommended that women do it within ten years of their last period. Primarily, because going for many years without estrogen can cause permanent changes to the body that HRT could exacerbate.
For example, estrogen helps prevent cholesterol from building up in your arteries. After you have been without it for a while, your arteries will likely have some damage. Taking an estrogen, particularly in oral form, increases the presence of liver proteins that cause blood to clot.
This factor, combined with arthroscopic buildup, could lead to an increased risk of stroke or heart attack. But taking estrogen before arterial damage has occurred, and within the 10-year window of opportunity, might reduce your risk of heart attack or stroke (23).
Estrogen: Points to Remember
- Maintains the vaginal lining, promotes pelvic blood-flow, orgasm, and lubrication.
- Protects against Alzheimer’s disease.
- Protects the heart.
- Keeps bones strong and prevents osteoporosis.
- Keeps the skin supple and promotes collagen.
- Increases desire.
Testosterone (The Mars Molecule)
Testosterone is all twisted steel and sex appeal. This biochemical Christian Grey looks like he belongs on the cover of a romance novel. And all the ladies swoon at his muscular chassis dripping sweat on the dance floor. His bones are strong and his muscles are lean as he tosses his dance partner around like a rag doll and lifts her with effortless ease. She will be his lover tonight. He’s very sure of that. He’s already had few. His favorite hook-up so far was with Estrogen in the coat closet…
Testosterone, the chemical Alexander Skarsgard (feel free to insert the panty soaker of your choice), is produced in the ovaries (25–50%), the adrenal glands (around 25%), and in the peripheral tissue. Testosterone plays a role in blood flow, sensitivity, sexual fantasies and desire in both men and women. After the early twenties, testosterone declines steadily around menopause (24).
By the time a woman hits 50, her testosterone levels may be half what they were at 25. But the role that testosterone plays in female desire is still poorly understood and a lot is not known (25).
For instance, researchers have had problems identifying an average range for testosterone levels as women age. Women have far lower levels of the hormone than men and blood tests are not sensitive at the lower female range (26).
Another issue is that current laboratory estimates of normal female testosterone levels may have been taken from studies that included women with desire problems. Some researchers have charged that these kinds of difficulties aren’t screened out when establishing baseline levels for normal ranges.
This calls into question whether current estimates of normal female T levels are accurate (27). According to evolutionary psychologist David Buss and sex researcher Cindy Meston, most laboratories list 1.3 to 6.8 picograms as typical (25).
Most studies of women with low desire haven’t found that these women have low testosterone levels. The whole issue is quite perplexing. Some women have normal T levels and low desire, while other women have low T levels and high desire.
Testosterone Dependent Female Desire
But there is a caveat here: there is a subgroup of women whose sexual desire is testosterone dependent. Getting up close and personal with your lady bits at a young age can be a tip-off. Women who masturbate and orgasm earlier than average may be more sensitive to the effects of testosterone.
For these testosterone-dependent women, if T levels drop below a certain threshold — usually in the lower range of normal, they may notice a corresponding dip in desire and sexual functioning (18).
There has never been an FDA approved testosterone treatment for women, even though testosterone was an early contender for the role of “pink Viagra”. Big Pharma played footsie with big T in the form of Intrinsa, a female testosterone patch that was never approved in the states. It is available in Europe.
There is no evidence that taking testosterone alone is a libido booster for most women. According to Cappalletti and Wallen, it is the combination of estrogen with testosterone (at higher than normal levels) that raises desire in postmenopausal women (19).
According to the Princeton consensus on androgen insufficiency, if you are trying to replace your androgens, it is important to have both free and total testosterone levels measured. It is also a good idea to measure the level of circulating SHBG since this determines the bioavailability of testosterone. The most important measurement is the level of free T as measured by equilibrium dialysis, a type of lab assessment. The panel didn’t recommend salivary testing (24)
Women who want to replace testosterone will have to adapt a hormone therapy designed for men. AndroGel is one therapy that has been prescribed off label for women.
Replacing testosterone has proven beneficial in several studies for some women but has its consequences, namely an increase in cardiovascular effects, hair loss, weight gain, and acne (24).
Testosterone: Points to Remember
• Testosterone plays a role in sex drive and energy levels.
• It enhances genital and breast sensitivity.
• Tends to encourage masturbation more than partner sex.
• Increases sexual thoughts and fantasies.
• Increases dopamine levels.
• Plays a role in maintaining bone mass and muscle tone.
• Maintains the structural integrity of the vagina
Well, that’s all I have for now. Every woman will eventually have to make a decision about whether or not to go on HRT. It’s a big issue, and I recommend doing your homework. I am leaning toward HRT because I have no family history of cancer. You might decide something else. But I would encourage you to think seriously about the issue and weigh the pros and cons.
Meanwhile back in the coat closet…
About the Author:
Kaye Smith PhD is a social psychologist, life coach, sex educator and fine art photographer. She is also a crazy cat who drinks too much tea. Check her out at https://kayesmithphd.com/