For her 45th birthday, Lisa Todd* received a trip to Hawaii and a sex toy that came with seven settings and three pages of instructions.
That vibrating toy, the colour of an over-ripe tomato, saw a lot of action. As did its new owner.
"I've always loved sex and sex has always loved me back," says Todd, a university professor whose office walls are covered in framed degrees and the sort of prints beloved by dentists' waiting rooms.
"I've been with my husband for 10 years but for most of my adult life having sex two or even three times a day has been pretty standard." And real swinging-from-the-chandeliers-type sex, she adds, in the kind of voice that indicates she's neither joking nor exaggerating.
But almost a year after Todd's 45th birthday, the bright red sex toy was languishing at the back of her bedside drawer.
"One morning I woke up and cringed not only at the thought of sex but at my husband's touch, which once electrified me," says Todd who moved from Auckland to Melbourne three years ago. "I'd gone from having an incredibly high sex drive to feeling as though I never wanted to have sex ever again."
The cause of Todd's sexual indifference? The onset of menopause or, as Todd describes it, a "downhill slide of sex drive and dried-up hormones".
"It was as though someone had draped a curtain over me, thick as fog and heavy as cement, which drained my life-force. My libido completely disappeared, along with my energy and an ability to concentrate. I also fell into a deep depression."
Todd's doctor prescribed HRT, medication that replaces female hormones the body no longer makes after menopause. It helped with the night sweats, hot flushes, weight gain and lack of focus, but did little for her libido. The change deeply affected Todd and her marriage.
"It wasn't just about not having sex, menopause robbed me of a sense of being a woman, almost like a whole part of my life had been shut off. As for my poor husband, he had no idea what was going on."
At the gym one day, Todd overheard a woman talking about how testosterone, the so-called male hormone, had changed her life.
"This woman was going on about how HRT replaced vanishing estrogen and progesterone, but didn't really address the issue of testosterone, which drops for women in their 40s and 50s. She said doctors won't tell you about it, but one of testosterone's many benefits is it gives you back your sex drive and zest for life."
There was no mention of the possible side effects of testosterone supplementation, such as facial and body hair, acne, deepening of the voice and abnormal enlargement of the clitoris. Nor of possible hair loss, an increased risk of breast cancer and heart attack.
So Todd visited her GP who referred her to an endocrinologist, who handed her a tube of testosterone and a bill for $400.
It was worth every cent, she says, because within three weeks of applying the gel to her inner thigh every night, Todd had re-joined the pack.
"It's impossible to talk about it without sounding evangelical, but that little tube gave me back my life. I had more energy and no longer felt sick and tired of life. My hair was glossy and I zipped through gym sessions. But best of all, my libido came back."
A quick science lesson: testosterone is a steroid hormone made from cholesterol that in women is produced in the ovaries and adrenal glands. It may contribute to keeping bones, muscles and hair strong, can relieve joint pain, boosts the brain's neurotransmitters (messenger chemicals) that keep the brain alert and focused; and is instrumental in the production of serotonin and dopamine, which aid sex drive (it's often called the hormone of desire). Women make three times as much testosterone as estrogen and we reach peak production in our 20s. But as we age, the conveyor belt slows down, leading to the symptoms experienced by Todd.
Testosterone can be increased naturally in the body by the usual suspects: exercise (especially strength training to build lean muscles, and high-intensity interval training to jump-start the metabolism), eating whole, plant-based, organic foods, eliminating sugar and processed foods and drinking less alcohol.
Which is probably why women of a certain age in the US and UK have jumped on the testosterone supplementation bandwagon. Whack on a cream and get oodles of energy and a great sex life without having to diet and exercise? Yes, please.
Actress Jane Fonda, for example, claimed at 70 that testosterone supplementation had transformed her sex life, while 54-year-old British television presenter Trinny Woodall swore the hormone "gave her the energy of a 25-year-old".
Meg Matthews, former wife of Oasis' Noel Gallagher, credited it with "giving back her life".
"When the menopause hit me, I thought my life was over," the 51-year-old told the UK Times. "I had chronic fatigue, no libido, terrible headaches and couldn't walk to the toilet in the morning, my joints were so stiff. Now I'm doing gymnastic flips in the gym."
Dr Megan Ogilvie has heard all the stories. The Auckland endocrinologist will prescribe testosterone when HRT and even sexual counselling (more about that later) haven't worked. But Ogilvie, who's based at Remuera's Fertility Associates, isn't convinced by testosterone's status as the new wonder drug.
"We need to look past the headlines to statements that can't always be backed up by research," says Ogilvie. "Testosterone does work for some women but there aren't enough long-term studies to prove its safety and effectiveness for long-term use."
There are a number of reasons for this but particularly because assays (blood tests) that measure testosterone aren't very accurate at detecting the small amount of testosterone women have. Plus there isn't a widely available product that delivers a consistent dose of testosterone each day, which makes it hard to study.
It's also a challenge to qualify low libido effectively because there are so many reasons for a lagging sex drive — from hormones and stress to poor body image and negative past sexual experiences. Every woman is different, says Ogilvie, so to expect one hormonal cream to address these various causes is a big ask.
In her book Hormonal: How Hormones Drive Desire, Shape Relationships And Make Us Wiser, UCLA Professor of Psychology Martie Haselton points the finger at sexism for the lack of research into testosterone and its close cousins, estrogen and progesterone.
"Hormones elicit stereotypes and people from the academic world are concerned their research will lead to women being confined to girlish stereotypes," says Haselton. Or, to put it more bluntly, as Todd does, "If menopause was a male problem, there would be research and medications up the wazoo."
Ogilvie agrees that could be a factor but, on the rainy Wednesday we chat, she'd rather focus on what there is instead of what there isn't. And HRT, she believes, is the answer. The estrogen and progesterone patches and pills are slowly climbing back into favour after bad press in the early noughties linked them to an increased risk of breast cancer, heart disease, stroke and blood clots.
"New Zealand is behind the rest of the world in accepting that long-term research has since shown HRT to be an effective, safe and affordable treatment. A lot of women still haven't got that message, so we're effectively under-treating menopausal women in this country, women who are putting up with hot flashes and night sweats that could be managed."
For patients who suffer from a persistently low libido, Ogilvie will prescribe AndroFeme testosterone cream. But it's her last port of call — after HRT and sexual psychologists.
"We need to look at the various reasons for low libido and sometimes that can include talking to a professional about how changes in your long-term sexual relationship can help."
AndroFeme isn't licensed for use by Medsafe, or publicly funded by Pharmac, New Zealand's medical regulatory and funding bodies, but Ogilvie's clinic has been importing it from Western Australia for 10 years. It costs patients $100 a tube (on top of the $450-plus hour-long consultation with Ogilvie) and lasts a few months. It takes around four weeks to have a clinical effect and patients are required to have a blood test every two months to ensure testosterone levels (as well as liver, lipid and red blood cell levels) remain normal.
"Around 60 per cent of my patients have a good response rate to testosterone cream, while the other 40 per cent say it didn't help. But unlike HRT, which patients can take for 5-10 years, I wouldn't prescribe testosterone for longer than a few years because we don't really know the long-term effects."
Bronwyn Ellis* was desperate that the $150 testosterone cream she bought over the internet would help revive her missing-in-action libido. It did, just not in the way she expected.
"I'd read the accounts of people having crazy, wild sex for hours after applying testosterone, but sadly that didn't happen to me," says the 52-year-old.
"I used to have a pretty normal sex life with my husband of 20 years, but once the menopause hit, I went off the idea completely." So when Ellis read about testosterone cream, she thought it was the answer to her prayers.
"I applied it every night and waited for my libido to come roaring back, which it didn't. What it did do, though, was make me feel less exhausted and over it, which means I'm more interested in having sex, even initiating it. So I do have testosterone to thank for kick-starting my sex life, just not how I thought it would."
*Names have been changed.
What about bio-identical hormones?
Some menopausal women swear by bio-identical hormones — hormones marketed to be identical in molecular structure to hormones made naturally in the body. Except bio-identical hormones aren't found in this form in nature but are made, or synthesised, from a plant chemical extracted from yams and soy.
Ogilvie isn't a fan of bio-identical hormones, believing HRT is a more effective, safe form of medication.
"Not enough is known about bio-identical hormones or its effects, and I can't be clear to my patients about the risks and benefits if I don't know what they are," she says.
The main issue seems to be that because bio-identical hormones are mixed by compounding pharmacists, there's a lack of dosage consistency.
"Studies have shown inconsistent concentrations of the product across a month's prescription. Also, bio-identical hormones can sometimes be contaminated with other hormones. We have FDA and Medsafe-approved HRT, which is funded and well researched — this is what we should be using to keep women healthy and safe."