In short
Hormones are blamed for far more sexual problems than they cause, and the ones that matter are not always the obvious ones.
- In men: testosterone, but also prolactin, thyroid and oestradiol. All four are checked in low desire.
- In women: oestrogen matters, mainly through vaginal and vulval tissue. Testosterone levels do not correlate with sexual function in most studies.
- The route matters. Oral oestrogen raises the binding protein and lowers free testosterone. Transdermal does not, and improved sexual function where oral did not.
Condition Overview
Which hormones matter in men?
Four are worth measuring in a man with low desire: testosterone, prolactin, thyroid function and oestradiol. Low testosterone, high prolactin, low oestradiol, and both an underactive and an overactive thyroid have all been associated with low libido.
Testosterone is the one people know about, and it does matter. In a meta analysis of 14 trials in 2298 men, testosterone therapy improved erectile function against placebo, and the largest improvement was in men with more severe deficiency, below 231 ng/dL.
But it is not the usual answer. In one series of 1022 men with ED, persistently low testosterone was present in 4 per cent under 50 and 9 per cent over 50, and hyperprolactinaemia in 1 per cent.
Which hormones matter in women?
Mainly oestrogen, and mainly through the tissue rather than through desire directly. Falling oestradiol in the menopause transition was associated with vaginal dryness and painful sex.
In the same study, no aspect of sexual function correlated with any androgen measured: total testosterone, free testosterone index or DHEA-S.
| Oestrogen in women | Clear effect, largely via vulvovaginal tissue, dryness and pain |
| Testosterone in women | Levels do not reliably correlate with function. Ovarian production stays fairly constant through natural menopause |
| Prolactin in women | Associated with lower desire, arousal, lubrication, orgasm and satisfaction |
| Thyroid in women | Overt overactive thyroid roughly doubled the risk of sexual dysfunction |
The point most clinics miss about the route
Oral oestrogen raises sex hormone binding globulin, which lowers free testosterone. Transdermal oestrogen at normal doses does not.
In a study of recently menopausal women, transdermal oestradiol improved the overall sexual function score against placebo, while oral oestradiol did not. Binding globulin was unchanged on the patch and rose on the tablet.
That is a concrete reason to prefer transdermal oestrogen in a woman with sexual concerns, and it is the kind of detail that gets lost when hormones are treated as one category.
What about testosterone for women?
The honest version. Several randomised trials in over 1500 menopausal women with distressing low desire and no other cause found that a testosterone patch increased satisfying sexual activity, desire and arousal against placebo.
The size of that effect was roughly one additional satisfying sexual event in four weeks. Two manufacturer trials of a testosterone gel found no significant increase at all, despite similar blood levels.
Clear benefit only appears at doses that push levels toward the male range, which brings its own problems. That is why routine testosterone is not recommended for women.
When are hormones the wrong explanation?
Frequently. New sexual dysfunction at natural menopause should not be attributed to testosterone, because ovarian testosterone production stays relatively constant across the transition.
Relationship factors, mood, fatigue, medication and pain all outrank hormones as causes, and none of them shows up on a hormone panel.
When to See a Doctor
- Desire has dropped alongside other symptoms suggesting a hormonal cause: fatigue, mood change, temperature intolerance
- You have been told your hormones are the cause but only testosterone was measured
- You are on oral oestrogen and sexual function has not improved
- Vaginal dryness or pain with sex started around the menopause
- You are being offered testosterone and want the actual evidence for it
- Milky discharge from the breasts in either sex, which needs prolactin checked promptly
- Headaches with visual field changes, which can indicate a pituitary problem
- In men, loss of body hair, breast enlargement or shrinking testicles, which point to a hormonal cause needing proper assessment
How Dr. Felix Assesses This
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1
Which part of sexual function has changed
Desire, arousal, orgasm or pain. They have different causes and different treatments, and hormones affect them unevenly. Pain in particular usually has a tissue cause rather than a desire cause.
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2
The right hormones, not all of them
In men with low desire: testosterone, prolactin, thyroid function and oestradiol. In women: thyroid and prolactin where indicated, and an assessment of oestrogen status from symptoms and examination rather than from a single level.
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3
Everything that is not hormonal
Medication, particularly SSRIs, antipsychotics, benzodiazepines and opioids. Mood, fatigue, sleep, alcohol, and relationship factors, which outrank hormones as causes in most people.
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4
Confirming before treating
A low testosterone in a man is repeated with LH and prolactin before treatment. In women, a hormone level is rarely the basis for a decision at all, because levels correlate poorly with function.
Treatment Options
Libido Optimization Program
Why is this page sceptical? Because the market sells hormones for a problem that is usually not hormonal, and because…
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Men’s Sexual Health Consultation
The three categories Erectile dysfunction Vascular, neurological, local penile, hormonal, drug induced or psychological causes Low desire Testosterone deficiency, stress,…
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Women’s Sexual Health Consultation
Why is order the main principle? Because improving one problem frequently improves another. Successfully treating sexual pain often improves interest,…
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Sexual Wellness Program
Who is this for? People with problems affecting more than one aspect of sexual function, couples where both have a…
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Why Early Treatment Can Matter
What actually responds to hormone treatment?
- Low desire in men with confirmed low testosterone. Testosterone improves libido reliably. Its effect on erections alone is smaller, which is why it is usually combined with a PDE5 inhibitor rather than used alone
- Vaginal dryness and painful sex in women. This responds well to oestrogen, and where the symptoms are genital only, low dose vaginal oestrogen is used rather than systemic
- High prolactin in either sex. Treatable, and it needs finding rather than assuming
- Thyroid disease in either sex
What does not respond
Low desire in a man with normal testosterone does not improve with testosterone. Low desire in a woman at natural menopause is not explained by falling testosterone, because it does not fall much.
Adding DHEA does not improve sexual function in people without adrenal insufficiency. Women with polycystic ovary syndrome have high androgen levels and sexual function that is similar or worse, not better.
The trap of treating a number
Because levels correlate poorly with function, especially in women, treating the number rather than the symptom is easy and usually wrong.
The most common consequence is that the actual cause, an antidepressant, untreated pain, fatigue, or a relationship difficulty, goes unaddressed while hormone doses are adjusted.
What about compounded hormones?
Not prescribed. When compounded products were tested, potency ranged from 67.5 to 268 per cent of the label, and there are regulated equivalents for every hormone in a typical mixture.
Why Early Treatment Can Matter
What actually responds to hormone treatment?
- Low desire in men with confirmed low testosterone. Testosterone improves libido reliably. Its effect on erections alone is smaller, which is why it is usually combined with a PDE5 inhibitor rather than used alone
- Vaginal dryness and painful sex in women. This responds well to oestrogen, and where the symptoms are genital only, low dose vaginal oestrogen is used rather than systemic
- High prolactin in either sex. Treatable, and it needs finding rather than assuming
- Thyroid disease in either sex
What does not respond
Low desire in a man with normal testosterone does not improve with testosterone. Low desire in a woman at natural menopause is not explained by falling testosterone, because it does not fall much.
Adding DHEA does not improve sexual function in people without adrenal insufficiency. Women with polycystic ovary syndrome have high androgen levels and sexual function that is similar or worse, not better.
The trap of treating a number
Because levels correlate poorly with function, especially in women, treating the number rather than the symptom is easy and usually wrong.
The most common consequence is that the actual cause, an antidepressant, untreated pain, fatigue, or a relationship difficulty, goes unaddressed while hormone doses are adjusted.
What about compounded hormones?
Not prescribed. When compounded products were tested, potency ranged from 67.5 to 268 per cent of the label, and there are regulated equivalents for every hormone in a typical mixture.
What hormones do fix
Low desire with confirmed low testosterone in men, vaginal dryness and pain with oestrogen in women, and high prolactin or thyroid disease in either sex.
What gets missed
Medication effects, mood, fatigue, pain and relationship factors, none of which appear on a hormone panel and all of which outrank hormones as causes.
Route matters
Transdermal oestrogen improved sexual function where oral did not, because oral raises the binding protein and lowers free testosterone.
Cost & Consultation Investment
The consultation and any hormone tests are quoted before they are ordered, and the panel is short and directed. Broad hormone screens and saliva testing are not used, because levels correlate poorly with sexual function and mostly generate borderline results. Compounded hormone mixtures are not prescribed. Where treatment is indicated, it is a regulated product bought at pharmacy prices.
Frequently Asked Questions
It can be in men, and it is worth measuring alongside prolactin, thyroid function and oestradiol. But in a large series of men with ED, persistently low testosterone was present in only 4 per cent under 50 and 9 per cent over 50.
Not routinely. Trials in over 1500 menopausal women showed a real but small effect, roughly one extra satisfying sexual event in four weeks, and two manufacturer trials of a gel found no effect at all. Clear benefit appears only at doses that push levels toward the male range.
Probably not. Ovarian testosterone production stays relatively constant across natural menopause, so new sexual dysfunction then should not be attributed to it. Oestrogen, sleep, mood and vaginal symptoms are more likely.
Yes, measurably. Oral oestrogen raises the binding protein and lowers free testosterone. In one study transdermal oestradiol improved the overall sexual function score against placebo while oral did not.
A short directed one is more useful. Broad panels produce borderline results that need chasing, and in women hormone levels correlate poorly with sexual function in most studies.
It does not appear to improve sexual function in people without adrenal insufficiency. In women with adrenal insufficiency the data are inconsistent.
Very possibly. SSRIs cause low desire and difficulty with orgasm in both sexes, and antipsychotics, benzodiazepines and opioids all contribute. This is checked before hormones are blamed.
Evidence
Where this information comes from
Every figure on this page is taken from the sources below. All of them are free to read, so you can check them yourself.
This page is general medical information and does not replace a personal consultation. Trial results are averages across large groups, not a prediction for any one person.