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Women with low libido: correlation of decreased androgen levels
with female sexual function index
B Turna
1
*, E Apaydin
1
, B Semerci
1
, B Altay
1
, N Cikili
1
and O Nazli
1
1
Urology Department, Ege University Faculty of Medicine, Bornova, Izmir, Turkey
The aim of the present study was to investigate a possible correlation between decreased androgen
levels and female sexual function index (FSFI) in women with low libido and compare these
findings with normal age-matched subjects. In total, 20 premenopausal women with low libido
(mean age 36.7; range 24–51 y) and 20 postmenopausal women with low libido (mean age 54;
45–70 y), and 20 premenopausal healthy women (mean age 32.2; range 21–51 y) and 20
postmenopausal healthy women (mean age 53.5; range 48–60 y) as controls were enrolled in the
current study. Women with low libido had symptoms for at least 6 months and were in stable
relationships. All premenopausal patients had regular menstrual cycles and all postmenopausal
patients and controls were on estrogen replacement therapy. None of the patients were taking birth
control pills, corticosteroids or had a history of chronic medical illnesses. All completed the FSFI
and Beck’s Depression Inventory (BDI) questionnaires. Hormones measured included: cortisol; T3,
T4 and TSH; estradiol; total and free testosterone; dehydroepiandrosterone sulfate (DHEA-S); sex
hormone binding globulin (SHBG). We performed statistical analysis by parametric and
nonparametric comparisons and correlations, as appropriate. We found significant differences
between the women with low libido and the controls in total testosterone, free testosterone and
DHEA-S levels and full-scale FSFI score for both pre- and postmenopausal women (Po0.05). In
addition, decreased total testosterone, free testosterone and DHEA-S levels positively correlated
with full-scale FSFI score and FSFI-desire, FSFI-arousal, FSFI-lubrication and FSFI-orgasm scores
(Po0.05). Our data suggest that women with low libido have lower androgen levels compared to
age-matched normal control groups and their decreased androgen levels correlate positively with
female sexual function index domains.
International Journal of Impotence Research (2005) 17, 148–153. doi:10.1038/sj.ijir.3901294
Published online 9 December 2004
Keywords: low libido; androgen level; female sexual desire disorder; female sexual function index
Introduction
Increasing interest is being shown in the role of
androgens in female health and well being; however,
the presence of androgen deficiency states and their
clinical diagnosis and management is still a con-
troversial matter.
For the last two decades, low desire has been
the most common sexual problem of women.
Female sexual dysfunction studies have started to
focus on biological and classification aspects of this
problem.
1
Several studies have shown a decrease in sexual
desire symptoms with androgen replacement ther-
apy where adequate levels of estrogen are present.
2,3
For several decades, testosterone has increasingly
been given to naturally postmenopausal or castrated
women when estrogen replacement did not change
decreased libido caused by a decrease in ovarian
steroid production.
4–6
A recent study has shown
that premenopausal women could have decreased
testosterone levels and still have regular menstrual
cycles.
7
Riley and Riley
8
have also shown a correla-
tion between low testosterone levels and decreased
libido in younger women who complain of a lack of
sexual desire.
Since Rosen et al
9
developed and validated a brief
and reliable self-report measure of sexual function-
ing in women, this questionnaire has been popular
Received 13 February 2004; revised 22 September 2004;
accepted 22 September 2004
*Correspondence: B Turna, Urology Department, Ege
University Faculty of Medicine, 35100 Bornova, Izmir,
Turkey.
E-mail: bturna33@hotmail.com
International Journal of Impotence Research (2005) 17, 148–153
&
2005 Nature Publishing Group All rights reserved 0955-9930/05 $30.00
www.nature.com/ijir
in evaluating the key dimensions of female sexual
dysfunction.
In fact, little information is available about what
constitutes an abnormal androgen level in pre- and
postmenopausal women and whether those values
directly correlate with sexual function index do-
mains.
The aim of the present study was to establish a
possible relation between serum androgen hormone
levels (total testosterone (total T), free testosterone
(free T), dehydroepiandrosterone sulfate (DHEA-S))
and Female Sexual Function Index (FSFI) domains
and full-scale scores in pre- and postmenopausal
women with low libido. In addition to this, all these
findings were compared with pre- and postmeno-
pausal healthy controls.
Materials and methods
Between October 2002 and March 2003, 107 women
from Ege University Urology and Gynecology &
Menopause Clinics were evaluated during initial
consultation of sexual dysfunction. A total of 40
women with a chief complaint of decreased sexual
desire were then selected for this study. A total of 20
premenopausal women with low libido (mean age
36.7; range 24–51 y) and 20 postmenopausal women
with low libido (mean age 54; 45–70 y) were
enrolled in the current study. Women with low
libido had symptoms for at least 6 months and were
in stable relationships. All premenopausal patients
had regular menstrual cycles and all postmenopau-
sal patients and controls were on estrogen replace-
ment therapy (ERT). Five postmenopausal patients
had a history of total abdominal hysterectomy with
bilateral salpingo-oophorectomy (TAH and BSO),
whereas 15 postmenopausal patients had natural
menopause. Patients with surgical menopause were
on 0.625 mg conjugated estrogen and patients with
natural menopause were on 0.625 mg conjugated
estrogen and 2.5 mg medroxyprogesterone acetate
treatment. None of the patients were taking birth
control pills, corticosteroids or had a history of
chronic medical illnesses. Patients with a history
of classic adrenal insufficiency, thyroid disease,
major depression, chronic fatigue syndrome, chronic
metabolic disease, radiotherapy and chemotherapy
history were excluded from the study. All the
participants indicated their weight in kilograms
and height in centimeters. All women who partici-
pated in the study signed an informed consent.
All women completed Beck’s Depression Inven-
tory (BDI) and FSFI (score range 4–95). Patients with
total BDI score over 21 were excluded (BDI score
range: 0–63). We used the FSFI questionnaire for the
study, as FSFI is a validated and reliable 19 item
questionnaire with six domains (desire (1–2), arou-
sal (3–6), lubrication (7–10), orgasm (11–13), satis-
faction (14–16), pain (17–19)), which has been
developed as a brief, multidimensional, self-report
instrument for assessing the key dimensions of
sexual function in women.
Hormones measured were cortisol; T3, T4 and
TSH; estradiol; sex hormone binding globulin
(SHBG); total and free testosterone; DHEA-S. This
was carried out in the middle of the menstrual cycle
(days 8–15) for all premenopausal women. Blood
was drawn from all women between 0800 and 1200
and stored at 201C for a period of 1–30 days until
assayed. All tests were performed in the Ege
University Endocrinology Laboratory in a single
continuous hormone assay for each hormone.
Hormones were measured by commercially avail-
able RIA kits. Total testosterone analysis was
performed by direct Automated Chemiluminescence
Sytem (Bayer Diagnostics, New York) with a normal
range of 14–76 ng/ml. Free testosterone was deter-
mined by direct analog free testosterone radio-
immunoassay (DSL-4900, TX, USA) with a normal
range of 0.6–3 pg/ml. DHEA-S analysis was carried
out by direct RIA (DSL-3500, TX, USA) with a
normal range of 35–450 mg/dl. SHBG analysis was
determined by immunoassay (DPC, Los Angeles)
with a normal range of 18–114 nmol/l. The sensitiv-
ity of the assays was expressed as a minimal amount
of the hormones distinguishable from the zero
sample with 95% probability and the intra-assay
and interassay coefficients of variation for total T,
free T, DHEA-S and SHBG were 5.8 and 6.1, 5.3 and
6, 4.5 and 5.5, and 2.8 and 6.9%, respectively.
In total, 40 healthy women from Ege University
staff were included in the study as volunteers.
Of them, 20 premenopausal (mean age 32.2; range
21–51 y) and 20 postmenopausal (mean age 53.5; range
48–60 y) healthy women formed the control group.
The total FSFI score for each patient in the control
group was above 60. None of the control patients
had a history of adrenal insufficiency, thyroid
disease, major depression, radiotherapy, chemother-
apy or any systemic chronic diseases. In addition to
this, none of the postmenopausal controls had a
history of TAH and BSO and they were all on
0.625 mg of conjugated estrogen and 2.5 mg medroxy-
progesterone acetate treatment.
Student’s t-test, Two-way analysis of variance,
Pearson correlation analysis and Spearman rank
correlation analysis were used for statistical analysis.
To show the statistically significant difference
between groups, a minimum of 40 patients and 40
controls were required to achieve 80% power for the
current study.
Results
The mean ages of the patients population and
control group were 45.3710.9 y (range 24–70 y)
and 42.67 12.6 y (range 21–60 y), respectively. The
Correlation between decreased androgen levels and female sexual function index
B Turna et al
149
International Journal of Impotence Research
mean age of the 20 premenopausal patients was
36.776.9 y (range 24–51 y), whereas the mean age
of the postmenopausal patients was 5476.4 y (range
45–70 y). The mean age of the premenopausal
healthy women was 32.279 y (range 21–51 y) and
the mean age of the 20 postmenopausal healthy
women was 53.574.6 y (range 48–60 y). Mean ages
between the controls and patients did not show
statistical difference (P40.05). All of the patients
had experienced decreased libido for a period of
more than 6 months.
The mean BMI values for premenopausal controls,
premenopausal patients, postmenopausal controls
and postmenopausal patients were 22.2, 23.1, 24.9
and 25.6 kg/m
2
, respectively. The BMI between
premenopausal controls and patients did not show
statistical difference, and similarly the BMI between
postmenopausal participants did not show any
statistical difference (P40.05). All the patients’
and controls’ SHBG levels were within normal
levels (range 36–99 nmol/l).
The means and standard deviations (s.d.) for total
testosterone, free testosterone and DHEA-S are listed
in Table 1, separated by menopausal status as well
as decade for both the patients and the control
group.
The androgen levels in our patients were signifi-
cantly lower than our control population (Po0.05).
In Figure 1, the mean total testosterone (ng/ml)
levels for all patients and controls are given
according to menopause status and decade. There
was no statistical difference in both patients and
controls in their menopause status. Therefore,
statistical analysis was performed for patients and
controls. There was a statistical difference in both
groups for mean total testosterone levels (Po0.05).
Figure 2 shows the mean free testosterone (pg/ml)
levels for patients and controls separated according
Table 1 Androgen levels (mean7s.d.) in women with decreased libido and healthy controls
Age N Total testosterone (ng/ml) Free testosterone (pg/ml) DHEA-S (mg/dl)
Patients Control Patients Control Patients Control Patients Control
Premenopause
20–29 3 8 36.674.2 65731.8 0.9670.4 2.470.2 93.6730.2 274.57138.9
30–39 9 7 4076.3 60711.3 1.870.6 2.3470.1 159.4748.3 252.8773.7
40–49 7 4 52.8713.8 65719.7 1.6470.6 2.170.1 152.4758.2 2597128.6
50–59 1 1 4077.7 70713.4 2.370 2.370 103737.2 1777100.8
Postmenopause
40–49 5 8 5274.2 6078.4 170.5 1.3570.1 109.8757.1 2307101.8
50–59 11 9 42.779 56.675.7 1.1870.5 270.2 132757.4 132.6748.9
60–69 3 3 36.6714.8 5077 1.270.3 1.970 90.6762.3 95753.7
70–79 1 — 3070 — 1.170—6870—
Figure 1 Mean total testosterone (ng/ml) levels for all patients
and controls are given according to menopause status and decade.
Figure 2 Mean free testosterone (pg/ml) levels for patients and
controls are given separated according to menopause status and
decade.
Correlation between decreased androgen levels and female sexual function index
B Turna et al
150
International Journal of Impotence Research
to menopause status and decade. There was a
statistical difference for menopause status for both
patients and controls (Po0.05). However, this
difference had similar effects in both groups so
there was no statistical interaction. As a result, there
was a significant difference in both groups for mean
free testosterone levels (Po0.05).
The mean DHEA-S levels for patients and con-
trols, separated by menopause status and decade,
are given in Figure 3. Statistical difference was
significant for menopausal status for both patients
and healthy women (Po0.05). However, this differ-
ence did not have a similar effect in both groups;
therefore, there was a statistical interaction. In
addition, there was no statistical difference for mean
DHEA-S levels for pre- and postmenopausal patients
(P40.05). In contrast, there was a statistical differ-
ence in mean DHEA-S levels for pre- and post-
menopausal women (Po0.05).
When age and androgen hormones were com-
pared via statistical correlation analysis, there was
no correlation between age and total testosterone
levels, whereas there was a negative correlation
between free testosterone and DHEA-S levels
(Po0.05).
The comparison for total FSFI scores between
patients and controls showed statistical difference
(Po0.05). The mean (7s.d.) total FSFI score for
patients was 63.4 (711.4), but the mean (7s.d.) total
FSFI score for healthy women was 80.6 (77.7).
When FSFI domains (desire, arousal, lubrication,
orgasm, satisfaction, pain) were compared sepa-
rately for both patients and healthy women, there
was a significant difference between the two groups
in all the components of FSFI except pain (Po0.05).
In our study population, mean (7s.d.), desire
domain scores were 5.2 (72.2), 8 (73.1), 7.5
(72.4), 4.7 (71.9), for premenopausal patients,
premenopausal controls, postmenopausal patients
and postmenopausal controls, respectively, and
there was a significant difference between patients
and healthy women (Po0.05).
We found a significant positive correlation be-
tween serum androgen levels and each FSFI do-
main, including the full-scale score with the
exception of pain. In the correlation analysis of
total FSFI scores and androgen hormones, the levels
of total testosterone, free testosterone and DHEA-S
showed a positive correlation with total FSFI scores
(Po0.05) (Figure 4a–c). Moreover, there was a
Figure 3 Mean dehydroepiandrosterone (DHEA-S) levels for
patients and controls are given separated by menopause status
and decade.
0
20
40
60
80
100
0123
Free testosterone
FSFI
0
10
20
30
40
50
60
70
80
90
100
0 20406080
Total testosterone (ng/ml)
FSFI
Patients group
Control group
Patients group
Control group
Patients group
Control group
0
20
40
60
80
100
0 200 400 600
DHEA-sulfate (ug/dl)
FSFI
*p< 0.05
*p< 0.05
*p< 0.05
a
b
c
Figure 4 Correlation of (a) total testosterone, (b) free testosterone
and (c) DHEA-S levels with total FSFI scores.
Correlation between decreased androgen levels and female sexual function index
B Turna et al
151
International Journal of Impotence Research
positive correlation between total testosterone levels
and all FSFI domains except pain (Po0.05). Simi-
larly, there was a positive correlation between
DHEA-S levels and all FSFI domains except pain
(Po0.05). Free testosterone levels also had a
positive correlation with all FSFI domains except
satisfaction and pain (Po0.05).
Discussion
Our results have primarily shown that both pre-
women and postmenopausal women with low
libido have decreased levels of total testosterone,
free testosterone and DHEA-S levels compared
to age-matched healthy volunteers with comparable
BMI and menopause status. Secondly, healthy
women reported higher FSFI scores compared
to the women with low libido. Lastly, all androgen
levels positively correlated with FSFI domains
except pain.
It is worth noting that the figures in this study do
not show standard deviations.
Tazuke et al
10
found no change in total testoster-
one in postmenopausal women on estrogen therapy
but found lower free testosterone and DHEA-S
levels. In contrast, Guay and Jacobson
11
did not
find any significant differences between the free T
and DHEA-S levels in postmenopausal women on
ERT or not. As this is a controversial issue, we
selected postmenopausal patients on ERT so that
possible hormonal imbalances could not be attrib-
uted to estrogen alone. It is important to note that
postmenopausal patients in our study are a hetero-
geneous group, as five (one quarter) of the post-
menopausal cases had a history of TAH and BSO.
Therefore, this fact might impinge on androgen
levels independently, as will the taking of estrogen
alone vs estrogen and progesterone hormone ther-
apy.
The second group of patients we studied were
otherwise healthy premenopausal women with low
sexual desire. As low sexual desire might be caused
by other factors such as oral contraceptives, corti-
costeroids, depression and chronic medical ill-
nesses, we ensured our selected patient and
control groups did not have any of these condi-
tions.
12
Laumann et al
13
evaluated the incidence of sexual
dysfunction both in men and women and found that
the mean incidence of decreased sexual desire in
women was 32%. Guay and Jacobson
11
then estab-
lished that 70% of women complaining of decreased
libido have lower testosterone levels. These results
indicate that this problem is not rare. In fact,
Munarriz et al
14
have shown that treatment for
androgen insufficiency and female sexual dysfunc-
tion by androgen replacement therapy is safe and
effective.
The absence of precise definitions of androgen
deficiency, unknown normal ranges for androgens
and nuances in the sensitivity of the various assays
have made research on androgens and libido in
women difficult to interpret. For this reason, we
compared our findings with a similar healthy group.
In addition, establishing normal ranges of testoster-
one in women is difficult, and also free and
bioavailable testosterone assays are new and there
are numerous variations in technique. The normal
ranges created by the companies producing the RIA
kits are often made using a limited number of
patients. Although a larger patient and control
population must be enrolled to try and obtain
ultimate conclusions, we found significant differ-
ences on androgens between the two groups
(Po0.05).
As described earlier, blood was withdrawn in the
midcycle between 0800 and 1200. The reason for
this is that most researchers feel that androgens
elevate to a peak near midcycle during this morning
period.
15
Several reports seem to underline a significant
decline in androgens throughout the life span and
a significant impact of the body weight over the
hormonal profile and sexual activity; our patients
and controls were accurately matched for both age
and BMI.
16,17
Androgens in the female are derived from the
adrenal gland (25%), the ovary (25%) and periph-
eral conversion of precursor hormones (50%).
18
As
suggested by Guay and Jacobson,
11
the fact that both
testosterone and DHEA-S are decreased in these
patients brings up the possibility that there may be a
decreased conversion in DHEA-S from its precursor
steroid.
FSFI was designed to be a clinical trials assess-
ment instrument that addresses the multidimen-
sional nature of female sexual function. The
comparison for total FSFI scores between patients
and controls showed statistical difference (Po0.05).
In the comparison of patients and healthy women,
there was a significant difference between the two
groups for all the components of FSFI except pain
(Po0.05). One possible criticism of our study might
be that postmenopausal patients were heteroge-
neous (constituted of both surgical and natural
menopause patients) to allow direct comparison of
the patients and controls.
Recently, Nappi et al
19
showed the positive
relationship between serum allopregnanolone and
free T levels and each FSFI domain including the
full-scale score except pain.
Similarly in our study, FSFI scores and androgen
hormone correlation analysis showed that total
testosterone, free testosterone and DHEA-S levels
had positive correlation with total FSFI scores and
each FSFI domain except pain.
In conclusion, our data suggest that women with
low libido have lower androgen levels compared to
Correlation between decreased androgen levels and female sexual function index
B Turna et al
152
International Journal of Impotence Research
age-matched normal control groups. We found that
this problem also occurs in younger regularly
menstruating women who are not on oral contra-
ceptives. As all postmenopausal women in our
study were on ERT, the low libido in these patients
could well be attributed to decreased androgens.
These women with apparently normal ovarian
function might be suffering from adrenal deficiency
as DHEA-S is produced from the adrenal gland.
Lastly, it is possible to evaluate decreased androgen
levels using self-report questionnaires.
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