By Dr. Lori Brotto

If you’ve been following the conversation about menopause lately, you’ve probably been hearing a lot more about testosterone.

On September 17, the U.S. Food and Drug Administration (FDA) is holding a public workshop devoted specifically to testosterone use in menopausal women. In Canada and the USA, testosterone for the treatment of distressing low sexual desire is not government approved, and is prescribed “off-label”. Researchers, clinicians, patients and other experts will come together to discuss what we know, what we still don’t know, and where the science needs to go next.

I welcome this conversation.

For far too long, women’s sexual health has been understudied, undertreated and, frankly, too often dismissed. Women experiencing a distressing loss of sexual desire deserve more research, more attention and more treatment options.

But as testosterone receives more attention, there’s something I believe is equally important for women to understand:

Sexual desire has never been just about hormones.

So, does testosterone help with desire?

For many women, yes.

There is solid evidence that testosterone can improve sexual desire in some postmenopausal women experiencing hypoactive sexual desire disorder, or HSDD—a persistent loss of sexual desire that causes personal distress.

But the situation is complicated by the fact that a woman’s blood levels of testosterone will not tell you if she has low desire, nor whether she will benefit from testosterone treatment. It isn’t a simple matter of measuring a level, discovering it is “low,” and replacing what is missing.

In fact, clinical guidelines do not recommend using a testosterone level to diagnose HSDD. Understanding why a woman is experiencing low desire requires looking at the much bigger picture.

And that’s because desire itself is much more complex.

Desire happens in the brain and the body

Hormones matter. So do physical changes associated with menopause, pain, medications, sleep and other health conditions.

But our sexual response is also influenced by stress, mood, attention, body image, our relationships, past experiences, beliefs and expectations about sex, culture, religion, and what is happening in our lives.

And these things don’t exist in separate boxes. They interact.

Imagine, for example, that sex has become painful. You may begin anticipating that pain before sex even starts. Perhaps you find yourself worrying about whether it will hurt again. Your attention shifts from anticipating pleasure to monitoring your body for the first sign of pain. You may become less aroused, which causes you to be vigilant for signs of pain even more. This turns off the sexual response and results, not surprisingly, in the sex being uncomfortable. Eventually, you may find yourself avoiding sex, and other forms of intimacy, altogether.

There may have been a very real physical reason the cycle started. But over time, the brain becomes part of that cycle too.

That doesn’t mean the problem is “in your head.” The brain is part of the body—and it plays an essential role in sexual response. It is time we stop seeing the brain and body as separate entities when it comes to sexual response.

For many women, simply understanding this can be revelatory.

This is also why psychological treatments work

I have spent over 25 years studying treatments for women experiencing sexual difficulties, particularly cognitive behavioural therapy (CBT) and mindfulness-based therapy.

Sometimes the word “psychological” makes women hesitate. They understandably wonder whether we are suggesting that what they are experiencing isn’t physical or isn’t real.

We aren’t.

Psychological treatments give us another way to influence the sexual-response system.

CBT can help women recognize and change patterns of thinking and behaviour that may be getting in the way of sexual response. Mindfulness can help women become more present, shift attention away from distracting or critical thoughts, and reconnect with sensations in their bodies.

These approaches don’t negate the role of hormones. And using them doesn’t mean a woman shouldn’t also receive treatment for pain, genitourinary syndrome of menopause, medication side effects, or other medical issues.

Quite the opposite.

It doesn’t have to be testosterone or something else

One of the things I hope comes from the growing conversation about testosterone is a greater understanding that women have options.

For one woman, testosterone may be an appropriate part of treatment. For another, addressing pain may be the priority. Someone else may benefit from CBT because she has a range of problematic thoughts. Another may benefit from mindfulness because she has lost the connection with her body sensations from years of chronic stress. And many women may benefit from more than one approach.

This is what we mean when we talk about taking a biopsychosocial approach to women’s sexual health: understanding the biological, psychological, relationship, environmental, and social factors that may be contributing, and treating the woman rather than simply treating a number on a laboratory test.

The FDA workshop is an important opportunity to examine what we know about testosterone, including its potential benefits, how it should be measured and used, and the questions that remain about long-term safety. It is also an opportunity to discern who might be a candidate for this treatment.

I’m glad those questions are being asked.

But as this conversation grows, I hope we don’t replace one overly simple explanation—“It’s just menopause”—with another:

“It’s just testosterone.”

Women’s sexual desire deserves a much richer conversation than that.

Giving women more ways to get help

One of the reasons we created eSense was to make evidence-based psychological treatments for women’s sexual concerns more accessible.

eSense grew out of more than two decades of research into CBT and mindfulness-based treatments for women experiencing concerns with desire, arousal, sexual pain, and sexual distress. We took approaches traditionally delivered with a therapist in a private office, and translated them into a private, self-directed online program that women can work through at home.

It isn’t intended to replace medical care, hormone therapy, pelvic health treatment, or other appropriate treatments. It gives women another evidence-based option—and one that can be used on its own or alongside other care.

Because ultimately, I don’t think the goal should be to decide whether hormones or psychological treatments are the answer.

The goal should be for women to understand that effective treatments exist, to understand their options, and to be able to access the care that’s right for them.

Hormones matter. The brain matters. Relationships and life context matter. Women deserve the whole picture.