Self-Assessment Tools for Diagnosing Testosterone Deficiency Syndrome (TDS)

Diagnosing a disease of any kind is a complicated process that includes interviewing, physically examining, and testing a patient. The first step is to look at the patient and note her age, weight, and height and whether she looks older or younger than her age, as well as many other tasks that doctors learn to accomplish in the first minute or two of an office visit. The second step involves inquiring about symptoms and their timing and severity. Following that, the doctor performs medical testing (such as blood tests, x-rays, or noting weight changes) to affirm that the diagnosis is correct.

We have adapted this diagnostic process for this book, substituting questionnaires for physician interviews. These questionnaires will tell you whether you are a candidate for laboratory testing and treatment by a physician.

The first questionnaire investigates whether you fit into the age and risk group that can possibly have TDS. Place a check mark next to any statements that apply to you.

I am over 38 years old.
I have had my ovaries removed.
I went through premature menopause before the age of 38.
My ovaries were exposed to radiation while undergoing cancer treatment.

If you checked any of the above statements, you fit the age and ovarian status for testosterone deficiency and may have TDS. Now go on to the next questionnaire.  The second questionnaire lists the most common symptoms of TDS. Not everyone with TDS has all of these symptoms, but most women who have testosterone deficiency have at least a few of them. Place a check mark next to any statements that apply to you.

I have lost my sex drive.
I have had orgasms in the past but can no longer have an orgasm, or it is more difficult.
I have more fatigue than before I was 38.
My motivation is gone. I don’t feel like doing anything!
I have insomnia.
I wake up in the middle of the night and can’t go back to sleep.
I do not feel rested when I wake up in the morning.
I have a new diagnosis of anxiety and/or depression that I did not have before age 38.
I have developed migraine headaches since age 38.
I have gained weight, especially in my belly.
I have decreased exercise stamina.
My muscles are getting smaller, and I am not as strong.
My height has decreased.
I have osteopenia or osteoporosis.
I can’t remember the names of things, people, or places anymore.
I have difficulty solving problems and getting organized.
I have developed dry eyes that cause me to use medicine or see an eye doctor.
I have multiple joint aches, like arthritis.
My knees and hips hurt when I exercise or put any weight on them.
I have been diagnosed with an autoimmune disease (MS, rheumatoid arthritis, lupus, scleroderma) after the age of 38.
I have lost my balance.
My skin is thin and saggy.
I look old.
I have lost my joy for living. I no longer have a sense of well-being.

What are the total number of check marks on the Symptom Questionnaire?

If you answered YES to FOUR or more of the symptoms of TDS, OR yes to loss of sex drive and two other symptoms, you probably have TDS.

Sex & Testosterone

“He just wanted to have sex once a month, but I couldn’t even do that! I know it is terrible of me, but I just hate it when he touches me!”

Prior to turning 40, Wendy had a higher-than-average sex drive and had once enjoyed a very satisfying sex life with her husband. After 40, she felt betrayed by her own body.

“I don’t know what’s wrong with me! I pick on him on nights when we usually have sex just so I don’t have to do it! I love him, but I don’t want to have sex anymore. What’s wrong with me?”

Wendy, like so many women her age, found her lack of sexual desire beginning to erode her relationship with her husband, Doug. Wendy said he was hurt and confused. Doug said, “Sex is important to me and was a very important part of our marriage for the last 20 years. Then one day I came home and she told me she’s done with this part of her life. It’s over and she’s not having sex anymore! I couldn’t believe it! Bait and switch, that’s what it was. Have great sex for the first part of the marriage, and then just unilaterally decide it is over. I’m not going to be able to do this the rest of my life!”

In this chapter we look closely at the issues of aging and how loss of libido impacts our lives. This happens to all of us as we age. Over time, we lose the amount of testosterone our bodies made when we were young, and this occurs regardless of whether we are in a relationship or not. Even those of us who have celibate lifestyles will feel changes in our level of desire and in our ability to deny ourselves sexual satisfaction. Arousal and desire are original-issue equipment, and this portion of our equipment comes on line when we hit puberty. As we age, our equipment begins to deteriorate; we feel less arousal and less desire.

What happens to a relationship when the sex drive dies for one of the partners and not the other? A tremendous challenge to the survival and maintenance of the relationship arises when partners no longer cuddle, nurture physically, or have sex, and lose that avenue of intimacy.

The Big “O”

No, I’m not talking about the magazine. Orgasm is like the weather: everyone talks about it, but few know much about it. It either happens or it does not, and no one knows why. When there are problems with orgasm, no one knows what to do to “fix” them.

We are driven to participate in sex because of the pleasure it can bring. We are made this way. We want to have sex because it is fun and feels good. And one of the most “feel- good” experiences we can have sexually is the one called orgasm. The brain is the most sexual organ, but it requires peripheral stimulation to get it to deliver an orgasm. A full answer requires a look at the physiology of an orgasm and the difference between orgasm and sex.

Most simply stated, adequate levels of free testosterone are fundamental to a healthy sexual drive, a healthy sex life, and even orgasm. A happy relationship and even social cohesion depend on it. Unfortunately many women never experience it until they receive testosterone pellets. We have seen some of these women within a month of treatment return to our offices and announce loudly to the waiting room full of patients, “That is what everyone has been talking about! Thank you, thank you, thank you!”

It is a truly sad thing for a woman to go through life “anorgasmic.” She feels deprived, guilty, and ashamed. These feelings are entirely unnecessarily. The principal physical cause of this condition is the lack of testosterone. If women are given an adequate amount of testosterone, they become orgasmic. Our bodies are made to work that way; when they do not, there is a reason. Obviously, anorgasmic conditions may have other causes such as sexual abuse trauma, or some medical condition or treatment may be suppressing their hormone levels. These women have a different problem to solve in order to become orgasmic. But for those who are suffering this condition as a result of low or missing testosterone, there’s a cure. I promise.

Psychological and Emotional Blocks to Orgasm

It is important to note that independent of physiology, many women need emotional safety that allows them to relax enough to be sexually receptive and let their bodies work through this “natural” experience. This receptivity is emotional and psychological. This is what we mean when we speak of being “in the mood”; our bodies work the way they were designed. But without emotional and psychological safety, a full sexual experience that includes orgasm may not be possible.

Some women report that their bodies are working well and they are building to the release of an orgasm—and then it just “goes away.” This can happen for a number of reasons:

Antidepressants, which are known to inhibit orgasm.
Distracted thinking: problem solving, worrying, or focusing on some responsibility that needs to be taken care of. This is guaranteed to interrupt “connectivity” and inhibit the orgasmic experience.
Emotional resistance to being sexually responsive can inhibit orgasm.
Past traumas such as sexual abuse or rape can cause some women to “go away” mentally, and hence not be mentally or emotionally present during sexual behaviors. The body will function and work the way it is designed, but the brain protects these women from this experience.

If a woman is not having orgasms, or has never had an orgasm, the first step is to check the levels of testosterone in her system. Second is an evaluation of medicines she may be on. Third, the physician should find out whether or not she has a history of trauma. Fourth, he or she must explore her full medical history and the functioning of her relationship. Many women find that the best answer is a multidisciplinary approach incorporating good medical treatment with good counseling.

The Science of an Orgasm

Some women who are anorgasmic tell us that they do not know for sure if they have ever had an orgasm and ask, “How would I know?” It is useful to discuss this incredible, oxytocin-making, good-feeling process from the scientific perspective of what goes on when someone has an orgasm.

Dr. Beverly Whipple has done extensive research on the brain and physiology of orgasm in women, and she reports that every portion of the brain is engaged in some way in the orgasmic experience. Looking at an MRI as a woman has an orgasm, it is easy to see why they often describe the experience as fireworks going off. Women are aroused to orgasm in three distinct parts of their bodies: the clitoris, the G-spot, and the cervix. Even though the brain is involved in each one, there are localized stimulatory and erotic areas that trigger the release called orgasm. Each of these areas “feels” different when sexual intimacy occurs.

At the surface of the skin, there are sensory nerve bundles that, when stimulated, carry messages to the brain by different “highways.” When the clitoris is stimulated, the messages from that area go to the lower levels of the spine and then are transmitted up the central nervous system to the brain. The G-spot and cervix each have their own “highway” to the brain. The sensory bundles that go from these areas approach the central nervous system at differing locations. Most women have areas where most of their orgasms originate, either because of their sexual practices or because of the nerve bundles that are peculiar to their own anatomy. Most often this is the clitoris, which can be stimulated manually, orally, or by pressure during sexual intercourse. Orgasms can be triggered at any or all of the three trigger sites, and it is possible for a woman to have an incredibly powerful orgasm that is triggered at all three locations at the same time!

Physical Causes for Orgasm Loss

Some women who have hysterectomies that include the removal of their cervix will lose one of their three orgasmic sites. If this was the primary or only site from which a woman managed to experience orgasm, she will be devastated. If she is fortunate enough to be able to experience orgasms from the other two sites, she may not even notice the loss.

Orgasms may also fail when there is not enough testosterone. The key here is that testosterone causes the release of nitric oxides. Nitric oxides cause the vascular congestion that leads to swelling of the sexual organs in order to increase the amount of area available for friction. This swollen friction is what physically leads to the release we call orgasm. This testosterone-related process is the same for women and men.

There is also, according to Dr. Whipple’s research, a specific peripheral nerve that runs from each of the orgasm sites directly to the brain to signal the release of oxytocin, the overwhelming pleasure chemical that is released in the culmination of the orgasmic experience. If there is damage to these nerves, there is loss of the powerful sense of completion that we call orgasm.

One of the ways that people “know” that they have orgasms is that they ejaculate. Both men and women can and do ejaculate. Men, especially when they are younger, tend to focus on this single event as the goal of any sexual encounter. As men age, or rather as they mature, their ability to participate in sexual intimacy becomes more about the intimacy and less about the orgasm. Ejaculation is often, but not always, part of an orgasm. It is visible and tangible, but ejaculation is not absolutely necessary for the experience of an orgasm.

In addition to physical and psychological blocks, there can be social inhibitors that we have not discussed because the social complexities that limit sexual behaviors among men and women represent an entirely different field of study. If you are interested in knowing more about this subject, you can search among both sociological and anthropological literature for references.

Nonphysical Barriers to Intimacy

Thus far, we have been talking about arousal and attraction in mating patterns. Now let’s look a little closer at some of the problems that can disrupt or inhibit the sexual expression of intimacy in an established relationship.

Sometimes sexual problems develop due to outside pressures such as money, stress, or life problems. Relationships also unwind when the partners discover that after the bloom is off the rose, they do not feel attracted to, or very much like, one another. Finally, physiological changes in either partner can lead to problems of intimacy and sexual functioning.

So which comes first: depression, or anxiety and the loss of libido? Or is the loss of testosterone the reason libido diminishes? Any or all of these can cause loss or disruption of sexual desire and responsiveness. In many cases the loss of testosterone is the initial cause of the problem. So we have learned to always look behind the symptoms of depression/anxiety to see if there is first and foremost a testosterone problem.

Areas of concern about sexual performance often arise when one of the partners is either overly anxious or overly depressed. One often masks the presence of the other. When you treat depression and there is improvement, often you discover anxiety at a level that disrupts functioning. It can happen the other way as well; you can control the anxiety and discover that the individual is also depressed.

Maybe I’m Just Nuts!

Some women with symptoms such as those we have described grow concerned that they are having psychological problems. When they consult a doctor specializing in hormone replacement therapy, they explain that they no longer feel like themselves. They say they have changed on the inside and are not the women they were before all this happened. They feel trapped in bodies that are not theirs, and they cannot find a way to do anything about it.

These women are trying to learn how to operate an unfamiliar system, and they talk about how their desire for everything that once was important to them has gone. They do not desire sex, and they do not enjoy the things they once did, such as going out to a nice restaurant or entertaining friends. They say they feel “gutted,” and that their inner self has just gone away. They naturally feel powerless to do anything about it.

They are acutely aware of the change in themselves, and they worry that they are going crazy. Many people in their lives may reinforce that idea, telling them they should be medicated or even institutionalized. Most women are reluctant to mention this to their doctors because of fear that their doctors will agree. They feel broken in a serious way, and on top of that, they feel isolated because no one seems to know why it’s happening or what to do about it. Thus, it takes a lot of courage for them to tell a third party what they are going through.

Before they find help, these women who fear loss of their sanity usually attempt to hide their symptoms and their fears. They try for a while to walk through their lives under the radar, in hiding, hoping their husbands and others won’t notice. When they gain the courage to actually tell their doctors what is going on, they are very relieved to hear that many other women have described exactly the same problems. They are heartened that there is hope for significant improvement. Yet they are also afraid to believe their problems are treatable and curable with the replacement of just a single hormone that they often did not know they even had.

When Hormones Are Replaced, Why Isn’t It All Better?

This is a question many couples ask Brett as a therapist. For some lucky couples, life is better once the hormones are replaced and the libido is rejuvenated. For many others, it is not that simple. Depending on how long their intimacy has atrophied, couples have made adjustments that separate and isolate them from each other on a connected level. They have each made accommodations that allow the marriage to exist and the family to “work,” but they have grown apart. This emotional separation is often surrounded by layers of hurt and anger, or even just numbness.

How do you get over this hurt and anger and the adaptive responses you have made to fulfill your life when your partner has not seen or noticed you for a very long time? How do you let go of the old wounds and hurts and not use them as ammunition to wound your partner or defend yourself?

Couples have to look at their relationship skills and expectations and work on their abilities to communicate. They must learn how to communicate first with themselves in an honest way. Who am I? What do I want? And then they have to take the risk to offer that information to their partner and say, “This is who and what I am and what I want—do you still want me and will you still love me?”

Each partner needs to get to the place where he or she can have this conversation within him- or herself, and then with his or her partner. This often requires the intervention of a therapist who is an expert in communication skills, possesses an understanding of how relationship patterns work, and knows how cultural influences constrict or hamper our abilities to be honest with ourselves and with each other.

As a therapist, Brett finds that many people are not able to talk to their partner about what they like, want, or even fantasize. He often suggests to these couples that they begin by writing fantasy journals, to keep private from each other and then bring it to the sessions. Then he has each of them read just two paragraphs from their journal out loud, and talk about what they have said. He asks them to share how it feels to take this risk and reveal some of what they want, and what their feelings are about what they have heard. Would they would be willing to “test” or experiment with what they heard?

Finally, he asks if they have any strong adverse reactions to what they have heard. If so, he asks them to stay with those feelings for a little while so together they can explore where they came from and what they mean. These issues can stem from a variety of sources. One of the partners may have a shame-based orientation to sex, a duty-based orientation, or religious limitations that are different from or disappointing to the other partner. People come to sexual encounters with various expectations, understandings of “satisfaction,” time cycles, and levels of availability for intimacy, as well as different focal points regarding orgasm and frequency. It can be complex, painful, and frightening when partners are out of sync or on different pages.

A person who has been out of hormonal balance for a period of time may now find herself in a relationship that can be colored by dissatisfaction or lack of desire. During the period she has been distant, the couple may have developed psychological ruts that are difficult to overcome. When they receive hormonal treatment and balance is restored, the status of the relationship will likely change. Long-standing habits and expectations may have changed for one partner but not the other. It is then Brett’s job to clarify each partner’s expectations and help them see patterns that prevent them from moving forward and reengaging in the relationship.

Here is a simplistic example of not looking to see whether habits may have changed. When Brett was very young and newly married, he did not like pizza and would not eat it. Many years later, he and his wife were having a conversation about what to order for dinner. She mentioned that she would like to order pizza but that it was not a good choice since he did not like it. He laughed because he had been eating pizza for years, but she had not noticed! She had already labeled him as a non–pizza eater. She had not examined that label carefully for some time, or noticed that some of his likes and dislikes had changed.

Eating pizza is an insignificant matter but is illustrative of an important point. Once we have been in a relationship for an extended period of time, our habituation allows us to make pretty accurate assumptions about what our partner thinks, wants, or will say and do. We have become so rhythmically attuned to them that we can make social plans, make decisions about dinner, and know whom to invite and whom to ignore for social plans. We know each other so well that we can complete thoughts, sentences, and jokes for one another. That can be a good and happiness-making confluence in a fulfilling relationship.

There can be problems here, though. Once we have imprinted our perceptions of our partner in our memory, we often stop noticing the changes in their preferences. We assume that they are the same person we married and don’t look for changes in their behavior. What if this lack of awareness about changes in our partner’s preferences is not restricted to pizza, but involves preferences in what they want or like emotionally or sexually? How can we possibly please our loved one if we do not look for or discuss changes in their desires?

A satisfying sex life requires conversation between both partners about the changes in their desires and their goals in sex and pleasure. There is nothing more satisfying than to please your loved one exactly as they desire. On the other hand, our partners cannot read our minds about what we want, so actually saying what we want is often necessary!

For an example of how talking cuts to the chase in relation to squabbles over bedroom preferences, let’s consider Pam and Mike’s relationship. Pam waited years to tell Mike that her preference was to wake up on Saturday mornings and have sex when she was relaxed, before the day started. Her husband was astounded that she had never told him that before! Mike had been chasing her around the kitchen trying to get her interested Sunday through Friday, and he was just wasting his time! Now he finally realized that it wasn’t him she was rejecting, and why she never . . . not once, ever . . . picked up his cue and responded, except on Saturday mornings. If Pam had just discussed her preferences, they could have avoided all of the negative emotions and negotiated a compromise plan.

This is the kind of emotional conundrum that can intensify when habits form over years in order to compensate for hurt, fear, or anxiety. The longer a couple is out of sync sexually, the longer it takes to heal. When we regain the sex drive of our youth, often our partner’s old accommodations will need to be challenged and changed. To challenge or change them requires that both individuals become aware of them. That takes courage and a willingness to communicate.

Remember, the longer the sexual dissynchrony has gone on, the longer it takes to heal. There are associated issues that grow like weeds around the primary problem of lack of libido: feelings of rejection, anger, and animosity develop and must be addressed. This often requires the help of a licensed counselor trained in resolving these issues. Recovery takes the willingness, time, and effort of both partners to reinvest in the part of the relationship that had been lost.

Brett’s patients find it helpful to set aside dedicated, uninterrupted time with their spouses, opportunities to be alone and both discuss their feelings and act on them if they choose. Setting up appointments such as these is a homework assignment many therapists use. William Masters and Virginia Johnson, the pioneering sex experts who established the Masters and Johnsons Institute, conducted a compelling study in which they instructed couples to relearn about their partners’ physical desires. Their homework was to go home and explore their partners’ erotic zones, but not have sex. At first the couples were limited to touching nonsexual areas of each other’s bodies. More erotic areas were added the following week. Finally, intercourse was allowed. This process forced the couple to find ways to please each other. Inevitably, couples would come back to discuss their “homework” and admit that they could not help having sex . . . and it was great! Success!

A successful process for regaining a fulfilling sex life is different for every couple. The basic idea of communicating desires and needs to one’s loved one is difficult, but it is a basic premise for all sexual therapy.

Behavior Patterns

We develop stereotypes for many reasons, not the least of which is that they save us time. We habituate for the same reason. Remember when you were a child and you were trying to learn to tie your shoes? You had to concentrate so hard, and it was a very difficult lesson to learn. You got very frustrated as you tried to master it. But now you can tie your shoes, eat breakfast, watch television, and have a phone conversation all at the same time. The reason you can do this is that you have habituated these behaviors. They are now automatic and reflexive.

We do the same thing in relationships. Have you ever had a phone conversation with your mother and realized that you were not paying any attention at all? You know the rhythms of her speech and of her life. You can talk to her on the phone while you fix dinner, and you can interject an “Oh, my” or a laugh or a “What did he say then?” without much thought. If you actually need to attend to her in some thoughtful and present way, she will signal you by behaving differently from the way she normally does. That change is what gets you to focus. Otherwise you can finish the conversation and hang up without remembering anything she said.

When we move a relationship into commitment or marriage, we automate a pattern of behaving in the relationship. We learn over time to habituate to the pattern we have created and let our awareness of our partner fade into the background. It becomes easy to label the person in our minds: “He doesn’t like pizza or white wine. He wants this, that, or the other in the bedroom.” We slap on these labels, and we need to remind ourselves that our partner’s likes and dislikes evolve and change—just as ours do.

The point here is that we do this with our partners much more than we realize. For example, Brett may start to ask a question and his wife will answer it before he finishes the sentence. She can do this because their lives are quite habituated. Depending on the time, the location, and the topic, she knows the two or three possible things he might say. She even knows all his jokes and can laugh at the punch lines without paying any attention at all. These are good things that help relationships function . . . until all of a sudden they are not good things and they do not function. When people habituate responses to sexual cueing and requests for intimacy, they are really not attending but simply acting out of habit or responding reflexively. People even reach the point of having sex without paying particular attention to each other. The result: wham, bam, thank you ma’am, and good night! There is no real communication or intimacy.

TDS Raises the Stakes

Habituation at some level is common to every marriage, but when it leads to labeling and assumptions, it can result in very empty, unhappy relationships. If this pattern is compounded by issues of aging, things become more difficult to endure and resolve.

The loss of testosterone and estrogen in particular can compound your feelings of emptiness and unhappiness. When you receive the regenerating effects of bio-identical hormone replacement pellets from your doctor, your physiology will be restored. You will have energy, alertness, and desire. You will be better able to lose weight, increase your stamina, and become sexually interested, which may increase intimacy, or at least the desire for and the expectation of intimacy. The capacity you felt early in your relationship is, or can be, restored.

For some, this is enough. Their bodies work, they rediscover themselves, and life becomes exponentially better and more satisfying. Their sex lives are stimulating and satisfying once again. But for other clients, those who had preexisting patterns of unhappiness and mis- or disconnectedness, these issues will remain. Those couples that had distance in their marriages will still function the same way in their relationship.

In these cases, their choices tend to fall into one of these three options:

Get therapy to try to learn new ways to connect and new ways to function with one another . . . in essence, learn to have a new relationship with an old partner.
Have their potential and capacity restored, but still not be interested in or responsive to one another.
Look for new partners with whom to create “new” relationships. (They need to be aware of their tendency to seek the same kind of partner!)

The clients who choose option one or three have behaviors that tend to fall in patterns. The following case studies illustrate how some clients have worked through these issues and changed their behavior patterns. These client situations represent descriptive patterns and clusters of symptoms; hence the descriptions represent groups of similar clients, not any single individual or couple.

As you read through these examples, you may recognize some aspect of yourself or your partner. This is to be expected. The lines between categories are often fluid. As you read, try to see which pattern fits you most of the time. You may see yourself in elements of the other patterns, but you should be able to recognize the predominant one.

Also, it is worth noting that when people look for these patterns, it is often easier for them to identify their partner’s strategy or pattern than their own. This is known as denial. If you want to change, you must learn to give up your denial. Then a different future will open for you.