Today, we’re speaking to Dr Stephen Gibbons, Consultant Clinical Biochemist at Leeds Teaching Hospitals NHS Trust, and Dr Clare Spencer, GP Partner and Menopause Specialist at the Meanwood Group Practice in Leeds.

Title of paper: Optimising testosterone therapy in patients with hypoactive sexual desire disorder

Available at: https://doi.org/10.3399/bjgp25X741321

Transcript

This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.

Speaker A

00:00:00 .400 - 00:01:08 .824

Hello and welcome to BJJP interviews and welcome to our new season of the podcast. Hope you all had a great break over Easter and thanks again for listening to this podcast today.

My name is Nada Khan and I'm one of the associate editors of the BJTP. In today's episode, we're speaking to Dr. Stephen Gibbons, consultant clinical biochemist at Leeds Teaching Hospital NHS Trust, and Dr.

Claire Spencer, a GP partner and menopause specialist at the Meanwood Group Practice in Leeds. We're here to talk about the recent clinical practice paper published here in the bjgp.

The paper is titled Optimizing Testosterone Therapy in Patients with Hypoactive Sexual Desire Disorder. So thanks, Stephen and Claire, for joining me here today.

It's great to talk to you about this paper, especially because it's in an area of a lot of interest to patients and clinicians in general practice wondering what to do about testosterone prescribing.

I guess I wanted to kick things off, Stephen, really, by asking, what made you start investigating testosterone replacement in patients with hypoactive sexual desire disorder?

Speaker B

00:01:08 .952 - 00:03:09 .662

So it was actually a conversation with a colleague at work over coffee and she mentioned to me that she'd noted quite a lot of high testosterone in females of a particular age and she was asking why that might be. So I explained it's probably because of TRT in this condition called hsdd, but that was kind of quite anecdotal at that point.

So we thought we'd do a clinical audit. So myself and two colleagues, Kia and eloise, we audited 100 patients from Leeds.

So we looked at a sample of 100 patients on TRT for HSDD and we audited them against the British Menopause Society guidance, which state that you should do a pre testosterone measurement and then you should check at at six to eight weeks, I believe. And what we found is that actually there was quite poor compliance with the BMS guidance. And at this point we felt a little bit out of our depth.

But we thought, well, this is quite alarming. Probably the most alarming thing was the number of patients with a really high testosterone that weren't adequately followed up.

So we thought, right, let's bring some clinical experts in at this point. So that's when we got in touch with Dr. Spencer and Dr. Jasim and Dr. Wal Ford, who's also on the paper.

She's a consultant endocrinologist at Leeds, and we kind of had a look at the data and we all agreed that, you know, there were significant findings. And the question was why?

Because there are quite comprehensive guidance out there from the bms, but I think we all felt that potentially they lacked some of the finer detail. Potentially in some areas they were a little vague. So that's when we came up with these additional recommendations.

And they're certainly not supposed to replace the BMS guidance, but it's a supplementary kind of recommendations to support the BMS guidance. So that's where we started, really.

Speaker A

00:03:09 .766 - 00:03:18 .014

And I guess if we just dial this back a bit. Can you or Claire talk us through what is hypoactive sexual desire disorder and how common is it?

Speaker B

00:03:18 .102 - 00:04:38 .868

So hsdd, essentially, it's a condition where they get persistent absence of sexual dis. Desires or fantasies. So you might.

Some people might term it low libido, I suppose, but the difference between low libido and HSDD is that in HSDD there's an emotional component, so emotional distress. And it doesn't just affect women, of course. This affects both males and females. But the prevalence seems to be much higher in females between.

Between about 15 and 20% of females will experience HSDD. In males, it's probably slightly lower, around 5%. And I mean, Claire may expand on this, but we don't actually fully understand the causes, really.

Probably multifactorial. There's certainly associations with physical conditions, things like diabetes and thyroid disorders.

There is an association with hormonal imbalances, estradiol and testosterone, although the evidence is not as strong as one might think for testosterone. Certain medications can be associated with hsdd, things like antidepressants and then psychological issues.

So anxiety, depression and current or previous relationship problems.

Speaker A

00:04:38 .964 - 00:04:51 .368

And Claire, you are a menopause specialist, and I think the question that lots of people are probably wondering about is, is this an issue amongst women who are going through perimenopause or menopause as well?

Speaker C

00:04:51 .564 - 00:06:31 .562

Yes, it's an incredibly common condition or symptom of the perimenopause and menopause. And as Stephen said so brilliantly, there are so many reasons behind that. So HSDD is obviously the far more severe end of the spectrum.

But depending on which study you read, anywhere between 40 and 60% will complain of.

Women will complain of low libido in the menopause, and obviously that then needs unpicking as to whether that's the more severe end of the spectrum or incredibly common. And this does happen to men as well as women, I think it's worth calling out. But in the menopause, a very common cause would be final symptoms.

So in the menopause, with the loss of estrogen. Up to two thirds of women will develop vaginal dryness, soreness, irritation, lack of lubrication, painful or discomfort during intercourse.

And that can have a really significant impact then on libido. And so there are some very specific causes related to the menopause.

Also, if we think about all of the myriad of symptoms of the menopause, so including hot flushes, night sweats, lower mood, low motivation, many women gain weight in the menopause. Again, you can see how that then impacts and add to that anxiety, loss of resilience, you know, and the sort of more psychosocial factors.

Plus layer on top of that, often women have been in a relationship for many, many years. You can see that there are additional challenges also. So it's a really common and distressing issue.

Speaker A

00:06:31 .746 - 00:06:46 .874

And I think the question that maybe lots of gps will have, I think, is what are the current guidelines around using testosterone? And Stephen, you mentioned the BMS guidelines, the British Menopause Society. So what are the current guidelines telling us about using testosterone?

Speaker C

00:06:47 .002 - 00:08:47 .795

So if we think about the NICE guidance for menopause first, that's NG23 and that has been recently updated, the new Update published in November 2024. And so nice say that testosterone can be used for low libido in the menopause in adequately estrogenized women.

So basically women on hrt, because actually HRT containing estrogen plus or minus progesterogen can be helpful in managing libido. Libido and estrogen definitely has a really important part to play.

But NICE say that testosterone can be added if you've managed the vaginal symptoms, if you've managed menopause symptoms. If women are taking hrt, then you can add testosterone.

On top of that, the British Menopause Society have really helpfully published guidance also, which goes into a little more detail on the practicalities of prescribing and monitoring.

And so the British Menopause Society would recommend that total testosterone is checked as a baseline and then pragmatically at around three months and then six to 12 months after that, again highlighting that this is predominantly prescribed for women on HRT and highlighting the importance of managing as much as you can the other symptoms that might be having an impact on libido.

Also, it can be really difficult because, as we both said, there are so many factors that can impact and sometimes you do have to take more of a pragmatic approach and manage symptoms as best you can. Plus there may be a psychological aspect that needs to be approached through talking therapies plus testosterone on top of it.

So complex issues, complex answers, often multifactorial approach is needed.

Speaker A

00:08:47 .907 - 00:09:11 .660

And I guess what you've done here, as you mentioned, Stephen, was to develop local guidelines to help clinicians to guide testosterone testing.

And I'd recommend to people listening to take a look at the full paper, which will be linked in the show notes that give the specific guidelines that you've described and developed. But can you give us a bit of a summary of what GP should