Reproductive hormone levels in gynecologic oncology patients undergoing surgical castration after spontaneous menopause

Sexual Health in Women Affected by Gynecologic or Breast Cancer

Sexual health problems are prevalent among women affected by gynecologic or breast cancer. It is important to understand the effects cancer treatment can have on sexual health and to have the tools necessary to identify and treat sexual health problems. This Clinical Expert Series discusses practical methods for routinely screening for sexual dysfunction and reviews sexual health treatment options for women affected by cancer. We review the limitations of the current literature in addressing sexual health problems among sexually and gender minoritized communities. Finally, we discuss appropriate timing of referrals to sexual health experts, physical therapists, and sex therapists. Multiple resources available for both patients and clinicians are included.

Role Of Ovarian Metastases In Colorectal Cancer (ROMIC): a Dutch study protocol to evaluate the effect of prophylactic salpingo-oophorectomy in postmenopausal women

Background

The mean incidence of ovarian metastases (OM) in patients with colorectal cancer (CRC) is 3.4%. The 5-year survival of these patients, even when operated with curative intent, is remarkably low. The lifetime risk of ovarian cancer is approximately 1.3%. Prophylactic salpingo-oophorectomy (PSO, or surgical removal of the ovaries and fallopian tubes) could reduce the number of CRC patients that develop OM after removal of the primary tumor, as well as preventing the occurrence of primary ovarian cancer. Recently, the care pathway for CRC has been changed in several hospitals in line with the updated Dutch guideline. The possibility of PSO is now discussed with postmenopausal CRC patients in these hospitals. The aims of the current study are firstly to estimate the incidence of OM and primary ovarian cancer in postmenopausal patients with CRC, and secondly to evaluate the effect of PSO in these patients.

Methods

An information bulletin and decision guide on this topic was implemented in several Dutch hospitals in 2020. Post-decision outcomes will be collected prospectively. The study population consists of postmenopausal (≥ 60 years of age) patients that are operated with curative intent for CRC. Based on their own preference, patients will be divided into two groups: those who choose to undergo PSO and those who do not. The main study parameters are the reduction in incidence of ovarian malignancies (metastatic or primary) following PSO, and the number needed to treat (NNT) by PSO to prevent one case of ovarian malignancy.

Discussion

This will be the first study to evaluate the effect of PSO in postmenopausal CRC patients that is facilitated by an altered CRC care pathway. The results of this study are expected to provide relevant information on whether PSO adds significant value to postmenopausal patients with CRC.

Trial registration

International Clinical Trials Registry Platform, NL7870. Registered on 2019 July 12. URL of trial registry record: https://trialsearch.who.int/Trial2.aspx?TrialID=NL7870.

Protocol version: 1.0, date 2021 June 8. 

Ovarian metastases in young women with colorectal cancer: a retrospective multicenter cohort study

BACKGROUND AND PURPOSE

Previous studies indicated that approximately 3.4% of female colorectal cancer (CRC) patients are at increased risk of developing ovarian metastases (OM). It has been suggested that young women more frequently develop this form of metastatic disease.

METHODS

This study evaluated, in 6 Dutch hospitals, the proportion of young women with CRC who developed OM.

RESULTS

In a cohort of 200 young (age ≤ 55) women with CRC, the proportion of patients diagnosed with synchronous or metachronous OM was calculated. This study revealed that 5% (n = 10) of young female CRC patients developed ovarian metastases resulting in a 5-year overall survival rate of approximately 40%. Furthermore, six patients had concurrent peritoneal metastases, five patients had bilateral ovarian metastases, and five patients had synchronous metastases, while the median time of the occurrence of metachronous metastases (n = 5) was 19 months.

CONCLUSION

This retrospective multicenter cohort study indicates that 5% of young women with CRC either present with or develop OM. This result appears to be clinically relevant and demonstrates the need for improved surveillance for young women diagnosed with CRC.

Ovarian metastases from colorectal cancer in young women: a systematic review of the literature

BACKGROUND AND PURPOSE

In female colorectal cancer patients, a mean proportion of synchronous and/or metachronous ovarian metastases of 3.4% was described. Previous literature showed that young or premenopausal women (≤ 55 years of age) may be more frequently affected. Once ovarian metastases are diagnosed, the prognosis of the patient is generally dismal, with 5-year survival varying from 12 to 27%. The present study is aimed at determining the proportion of young or premenopausal women diagnosed with colorectal cancer who presented with or developed ovarian metastases by reviewing the current literature on this topic.

METHODS

This review was performed by querying MEDLINE and EMBASE databases using a combination of terms: "colorectal neoplasms, colorectal cancer, ovarian neoplasms, Krukenberg tumor, young adult, young age, premenopause." Studies that indicated ovarian metastases, either synchronous or metachronous (or a combination of the two), in young women were retrieved and analyzed.

RESULTS

The review identified 14 studies encompassing 3379 young or premenopausal female colorectal cancer patients. In this selected group of patients, a mean proportion of ovarian metastases of 4.6% [95% CI: 4.0;5.4] was found.

CONCLUSIONS

This review showed that approximately one in twenty young female colorectal cancer patients will present with or develop ovarian metastases. Since outcome of this specific oncological pathology is often dismal, this finding is clinically relevant. It demonstrates the need to develop strategies to lower the incidence of ovarian metastases with adequate treatment and counseling of these patients.

The impact of risk reducing bilateral salpingo-oophorectomy on sexual function in BRCA1/2 mutation carriers and women with Lynch syndrome: A systematic review and meta-analysis

OBJECTIVE

In the absence of an effective screening test, women with a high genetic predisposition for ovarian cancer are recommended to undergo risk-reducing bilateral salpingo-oophorectomy (RRBSO) once childbearing is complete. This reduces the risk of ovarian cancer by up to 96%, but can result in undesirable side effects, including menopausal symptoms and sexual dysfunction. We have performed a systematic review and meta-analysis to investigate the effect of RRBSO on sexual function in women at high risk of breast/and or ovarian cancer.

METHODS

A literature search of the AMED (Allied and complementary medicine), Embase and Medline databases was performed, using search terms including sexual function, risk reducing and oophorectomy. Results were filtered according to the PRISMA protocol. Quality assessment of studies was performed using the Newcastle-Ottawa scale. Data were pooled in meta-analysis.

RESULTS

There were 21 eligible studies, 10 of which reported sufficient data for meta-analysis. Most studies were retrospective cohort or observational studies. Fifteen of the 21 studies (71%) reported a negative impact of RRBSO on sexual function. Participant numbers ranged from 37 to 1522. Meta-analysis was performed with studies including 3201 patients. This demonstrated that RRBSO has a statistically significant negative impact on sexual function (SMD -0.63, [-0.82, -0.44], p = 0.03). There was a trend towards reduced sexual pleasure and increased discomfort but this did not reach statistical significance. There was minimal change in the frequency of sex. There was a significant increase in vaginal dryness post-RRBSO (SMD 9.25, [3.66, 14.83], p < 0.00001). There was no significant difference in sexual function between pre-menopausal and post-menopausal RRBSO. Hormone replacement therapy (HRT) did not abolish this negative impact.

CONCLUSION

Sexual function declines post RRBSO, independent of menopausal status. Comprehensive pre-operative counselling regarding anticipated menopausal and sexual symptoms is key to setting realistic patient expectations and minimising post-operative distress. Information and support regarding management of these side effects should be available to all patients.

The role of androgens in women's health and wellbeing

Androgens in women, as well as in men, are intrinsic to maintenance of (i) reproductive competency, (ii) cardiac health, (iii) appropriate bone remodeling and mass retention, (iii) muscle tone and mass, and (iv) brain function, in part, through their mitigation of neurodegenerative disease effects. In recognition of the pluripotency of endogenous androgens, exogenous androgens, and selected congeners, have been prescribed off-label for several decades to treat low libido and sexual dysfunction in menopausal women, as well as, to improve physical performance. However, long-term safety and efficacy of androgen administration has yet to be fully elucidated. Side effects often observed include (i) hirsutism, (ii) acne, (iii) deepening of the voice, and (iv) weight gain but are associated most frequently with supra-physiological doses. By contrast, short-term clinical trials suggest that the use of low-dose testosterone therapy in women appears to be effective, safe and economical. There are, however, few clinical studies, which have focused on effects of androgen therapy on pre- and post-menopausal women; moreover, androgen mechanisms of action have not yet been thoroughly explained in these subjects. This review considers clinical effects of androgens on women's health in order to prevent chronic diseases and reduce cancer risk in gynecological tissues.

Olfactory Exposure to β-Caryophyllene Increases Testosterone Levels in Women's Saliva

INTRODUCTION

From previous studies, we hypothesized that olfactory exposure to β-caryophyllene stimulates women's libido. However, Japan's sex culture is so closed that it is difficult to test this possibility without accumulating scientific evidence. Therefore, it is necessary to measure the concentration of sex-related hormones in saliva, an experimental technique that is relatively easy to obtain research permission, and to obtain a scientific basis to convince ethics committee reviewers.

AIM

The aim of this study is to investigate whether β-caryophyllene increases salivary testosterone concentrations associated with libido and vaginal sensation during intercourse in women.

METHODS

19 women in the follicular phase of the menstrual cycle participated in the study. The subjects then sat in front of the odor exposure device we had created. Each subject was exposed to dipropylene glycol for 20 minutes, followed by 3% β-caryophyllene for 20 minutes. Saliva was collected 4 times: before and after control exposure, and before and after β-caryophyllene exposure.

MAIN OUTCOME MEASURE

Salivary testosterone and estrogen concentrations were measured with a competition ELISA.

RESULTS

β-caryophyllene significantly increased the salivary concentration of testosterone (control vs β-caryophyllene; 0.97 ± 0.05 vs 1.13 ± 0.03, P = .00, 95% confidence interval of control: 0.84-1.09, 95% confidence interval of β-caryophyllene: 1.04-1.20) but not estrogen (control vs β-caryophyllene; 1.05 ± 0.03 vs 1.07 ± 0.04, P = .69, 95% confidence interval of control: 0.96-1.12, 95% confidence interval of β-caryophyllene: 0.98-1.15).

STRENGTHS & LIMITATIONS

The personal preferences of the subjects and the order of exposure may have affected the results.

CONCLUSION

β-caryophyllene may be a remedy with fewer side effects for women with decreased libido. We believe that β-caryophyllene may be a remedy for women with decreased libido. However, this hypothesis must be tested by further clinical studies. Wataru Tarumi, Kazuyuki Shinohara. Olfactory Exposure to β-Caryophyllene Increases Testosterone Levels in Women's Saliva. J Sex Med 2020;8:525-531.

Medical ovariectomy in menopausal breast cancer patients with high testosterone levels: a further step toward tailored therapy

Five years of adjuvant therapy with anti-estrogens reduce the incidence of disease progression by about 50% in estrogen receptor-positive breast cancer patients, but late relapse can still occur after anti-estrogens have been discontinued. In these patients, excessive androgen production may account for renewed excessive estrogen formation and increased risks of late relapse. In the 50% of patients who do not benefit with anti-estrogens, the effect of therapy is limited by de novo or acquired resistance to treatment. Androgen receptor and epidermal growth factor receptor overexpression are recognized mechanisms of endocrine resistance suggesting the involvement of androgens as activators of the androgen receptor pathway and as stimulators of epidermal growth factor synthesis and function. Data from a series of prospective studies on operable breast cancer patients, showing high serum testosterone levels are associated to increased risk of recurrence, provide further support to a role for androgens in breast cancer progression. According to the above reported evidence, we proposed to counteract excessive androgen production in the adjuvant setting of estrogen receptor-positive patients and suggested selecting postmenopausal patients with elevated levels of serum testosterone, marker of ovarian hyperandrogenemia, for adjuvant treatment with a gonadotropins-releasing hormone analogue (medical oophorectomy) in addition to standard therapy with anti-estrogens. The proposed approach provides an attempt of personalized medicine that needs to be further investigated in clinical trials.

The effect of hormone therapy on quality of life and breast cancer risk after risk-reducing salpingo-oophorectomy: a systematic review

BACKGROUND

It is unclear if the use of hormone therapy (HT) in carriers of BRCA mutations improves the quality of life (QOL) without increasing the risk of breast cancer following a risk-reducing salpingo-oophorectomy (RRSO). Our objective was to assess the effect of HT on QOL and breast cancer risk, after RRSO.

METHODS

We searched MEDLINE, EMBASE, CINHAL, and others, from inception to July 22, 2016, to identify relevant studies. Two reviewers independently screened identified records for controlled trials and observational studies that addressed the effect of HT on QOL and breast cancer risk in women with BRCA mutations, post RRSO. Two reviewers independently extracted data on populations, interventions, comparators, outcomes, and methodological quality. Studies addressing the same outcome were synthesized using written evidence summaries or tables.

RESULTS

Of the 1,059 records identified, 13 met our inclusion criteria. All studies were observational. Six studies assessed the effect on QOL. Of these, 3 showed improvement in QOL with HT use. The risk of breast cancer was evaluated in 4 studies. The mean duration of follow-up was 2.6 years (range 0.1-19.1). The risk of breast cancer did not change with HT use in all 4 studies.

CONCLUSIONS

Cumulative evidence from our review suggests that short-term HT use following RRSO improves QOL. The effect on breast cancer risk is still unclear. There are too few long-term studies to draw any strong conclusions. The need for future well-designed RCTs for more established evidence is imperative.

Risk of colorectal cancer with hysterectomy and oophorectomy: A systematic review and meta-analysis

BACKGROUND

Colorectal cancer (CRC) is the second most commonly diagnosed cancer worldwide in females. Sex hormones may play a protective effect in CRC pathogenesis. Ovarian sex steroid levels are reduced in premenopausal women after hysterectomy. Prospective studies have revealed an 80% decrease in serum oestradiol levels after bilateral oophorectomy in premenopausal women. We aimed to elucidate the relationship between hysterectomy or oophorectomy and risk of CRC.

METHODS

We estimated relative risk (RR) and 95% confidence intervals (95% CIs) with the meta-analysis. Cochran's Q test and Higgins I² statistic were used to check for heterogeneity. Subgroup and sensitivity analyses were performed as were Egger's and Begg's tests and the "trim-and-fill" method for publication bias analysis.

RESULTS

Risk of CRC was increased 30% for women undergoing oophorectomy relative to the general population and 24% with hysterectomy relative to no surgery. The risk was increased 22% with hysterectomy with bilateral salpingoo-ophorectomy as compared with simple hysterectomy. On subgroup analysis, risk of rectal cancer was increased 28% and colon cancer 19% with hysterectomy. Europeans seem to be sensitive to the risk of CRC, with 27% increased risk after hysterectomy. The risk of CRC after oophorectomy gradually increased with age at oophorectomy. The risk was greater with bilateral oophorectomy, with 36% increased risk, than unilateral oophorectomy, with 20% increased risk. Risk was increased 66% with time since oophorectomy 1-4 years as compared with 5-9 and ≥ 10 years.

CONCLUSIONS

Risk of CRC was increased for women undergoing hysterectomy or oophorectomy. Women with susceptibility genes for ovarian cancer or metrocarcinoma should choose oophorectomy or hysterectomy. For women not at high risk for these cancers, oophorectomy or hysterectomy should not be recommended for increasing the subsequent risk of CRC.

Population-based analysis of colorectal cancer risk after oophorectomy

BACKGROUND

The development of colorectal cancer is influenced by hormonal factors. Oophorectomy alters endogenous levels of sex hormones, but the effect on colorectal cancer risk is unclear. The aim of this cohort study was to examine colorectal cancer risk after oophorectomy for benign indications.

METHODS

Women who had undergone oophorectomy between 1965 and 2011 were identified from the Swedish Patient Registry. Standard incidence ratios (SIRs) and 95 per cent confidence intervals for colorectal cancer risk were calculated compared with those in the general population. Stratification was carried out for unilateral and bilateral oophorectomy, and hysterectomy without specification of whether the ovaries were removed or not. Associations between the three oophorectomy options and colorectal cancer risk in different locations were assessed by means of hazard ratios (HRs) and 95 per cent confidence intervals calculated by Cox proportional hazards regression modelling.

RESULTS

Of 195 973 women who had undergone oophorectomy, 3150 (1·6 per cent) were diagnosed with colorectal cancer at a later date (median follow-up 18 years). Colorectal cancer risk was increased after oophorectomy compared with that in the general population (SIR 1·30, 95 per cent c.i. 1·26 to 1·35). The risk was lower for younger age at oophorectomy (15-39 years: SIR 1·10, 0·97 to 1·23; 40-49 years: SIR 1·26, 1·19 to 1·33; P for trend < 0·001). The risk was highest 1-4 years after oophorectomy (SIR 1·66, 1·51 to 1·81; P < 0·001). In the multivariable analysis, women who underwent bilateral oophorectomy had a higher risk of rectal cancer than those who had only unilateral oophorectomy (HR 2·28, 95 per cent c.i. 1·33 to 3·91).

CONCLUSION

Colorectal cancer risk is increased after oophorectomy for benign indications.

Maintaining sexual health throughout gynecologic cancer survivorship: A comprehensive review and clinical guide

OBJECTIVE

The diagnosis and treatment of gynecologic cancer can cause short- and long-term negative effects on sexual health and quality of life (QoL). The aim of this article is to present a comprehensive overview of the sexual health concerns of gynecologic cancer survivors and discuss evidence-based treatment options for commonly encountered sexual health issues.

METHODS

A comprehensive literature search of English language studies on sexual health in gynecologic cancer survivors and the treatment of sexual dysfunction was conducted in MEDLINE databases. Relevant data are presented in this review. Additionally, personal and institutional practices are incorporated where relevant.

RESULTS

Sexual dysfunction is prevalent among gynecologic cancer survivors as a result of surgery, radiation, and chemotherapy-negatively impacting QoL. Many patients expect their healthcare providers to address sexual health concerns, but most have never discussed sex-related issues with their physician. Lubricants, moisturizers, and dilators are effective, simple, non-hormonal interventions that can alleviate the morbidity of vaginal atrophy, stenosis, and pain. Pelvic floor physical therapy can be an additional tool to address dyspareunia. Cognitive behavioral therapy has been shown to be beneficial to patients reporting problems with sexual interest, arousal, and orgasm.

CONCLUSION

Oncology providers can make a significant impact on the QoL of gynecologic cancer survivors by addressing sexual health concerns. Simple strategies can be implemented into clinical practice to discuss and treat many sexual issues. Referral to specialized sexual health providers may be needed to address more complex problems.

Sexual and reproductive health in cancer survivors

As patients live longer after cancer diagnosis and treatment, attention to symptoms and quality of life (QoL) are of increasing importance both during treatment and throughout survivorship. Two complications of multi-modal cancer treatment that can profoundly affect both men and women are sexual dysfunction and infertility. Survivors at highest risk for treatment-related sexual dysfunction are those with tumors that involve the sexual or pelvic organs and those whose treatment affects the hormonal systems mediating sexual function. Sexual dysfunction may not abate without appropriate intervention. Therefore, early identification and treatment strategies are essential. Likewise, multiple factors contribute to the risk of infertility from cancer treatment and many cancer patients of reproductive age would prefer to maintain their fertility, if possible. Fortunately, advances in reproductive technology have created options for young newly diagnosed patients to preserve their ability to have a biologic child. This paper will focus on the sexual and reproductive problems encountered by cancer survivors and discuss some treatment options.

The physical consequences of gynecologic cancer surgery and their impact on sexual, emotional, and quality of life issues

INTRODUCTION

Surgical management of gynecologic cancer can cause short- and long-term effects on sexuality, reproductive function, and overall quality of life (QOL) (e.g., sexual dysfunction, infertility, lymphedema). However, innovative approaches developed over the past several decades have improved oncologic outcomes and reduced treatment sequelae.

AIM

To provide an overview of the standards of care and major advancements in gynecologic cancer surgery, with a focus on their direct physical impact, as well as emotional, sexual, and QOL issues. This overview will aid researchers and clinicians in the conceptualization of future clinical care strategies and interventions to improve sexual/vaginal/reproductive health and QOL in gynecologic cancer patients.

MAIN OUTCOME MEASURES

Comprehensive overview of the literature on gynecologic oncology surgery.

METHODS

Conceptual framework for this overview follows the current standards of care and recent surgical approaches to treat gynecologic cancer, with a brief overview describing primary management objectives and the physical, sexual, and emotional impact on patients. Extensive literature support is provided.

RESULTS

The type and radicality of surgical treatment for gynecologic cancer can influence sexual function and play a significant role in QOL. Psychological, sexual, and QOL outcomes improve as surgical procedures continue to evolve. Procedures for fertility preservation, laparoscopy, sentinel lymph node mapping, and robotic and risk-reducing surgery have advanced the field while reducing treatment sequelae. Nevertheless, interventions that address sexual and vaginal health issues are limited.

CONCLUSIONS

It is imperative to consider QOL and sexuality during the treatment decision-making process. New advances in detection and treatment exist; however, psycho-educational interventions and greater patient-physician communication to address sexual and vaginal health concerns are warranted. Large, prospective clinical trials including patient-reported outcomes are needed in gynecologic oncology populations to identify subgroups at risk. Future study designs need clearly defined samples to gain insight about sexual morbidity and foster the development of targeted interventions.

An update on the pharmacological management of female sexual dysfunction

INTRODUCTION

Female sexual dysfunction (FSD) is a global health issue, with as many as 12% of women over 18 years old reporting sexual difficulties associated with distress. It is a multifaceted problem with psychological and biological causes. Affected women tend to have an impaired quality of life, a decreased level of well-being and relationship issues. Hence there is a need for management options for affected women.

AREAS COVERED

This paper focuses on current pharmacological options for the treatment of FSD, particularly estrogens and androgens, which have been extensively studied. Some investigational drugs are also described, including the centrally acting agents such as flibanserin and bupropion, and intravaginal DHEA and testosterone, which may be useful as an alternative for women with specific conditions, such as breast cancer survivors.

EXPERT OPINION

Although approval for the use of testosterone for treatment of FSD is limited to some European countries and restricted to surgically menopausal women, there is extensive off-label use for this purpose. No other product has yet achieved regulatory approval for treatment of FSD. Completion of studies of nonhormonal FSD therapies and safety studies of testosterone may result in regulatory approval of such products for the treatment of FSD in the near future.

The impact of prophylactic salpingo-oophorectomy on menopausal symptoms and sexual function in women who carry a BRCA mutation

OBJECTIVE

Prophylactic salpingo-oophorectomy is recommended to women who carry a BRCA1 or BRCA2 mutation to reduce the risks of breast, ovarian and fallopian tube cancer. We measured the impact of prophylactic salpingo-oophorectomy on menopausal symptoms and sexual functioning in women with a BRCA mutation.

METHODS

Women who underwent prophylactic salpingo-oophorectomy between October 1, 2002 and June 26, 2008 for a known BRCA1 or BRCA2 mutation were invited to participate. Participants completed questionnaires before prophylactic surgery and again one year after surgery. Measures of sexual functioning and menopausal symptoms before and after surgery were compared. Satisfaction with the decision to undergo prophylactic salpingo-oophorectomy was evaluated.

RESULTS

114 women who underwent prophylactic surgery completed questionnaires before and one year after surgery. Subjects who were premenopausal at the time of surgery (n=75) experienced a significant worsening of vasomotor symptoms (hot flashes, night sweats and sweating) and a decline in sexual functioning (desire, pleasure, discomfort and habit). The increase in vasomotor symptoms and the decline in sexual functioning were mitigated by HRT, but symptoms did not return to pre-surgical levels. HRT decreased vaginal dryness and dyspareunia; however, the decrease in sexual pleasure was not alleviated by HRT. Satisfaction with the decision to undergo prophylactic salpingo-oophorectomy remained high regardless of increased vasomotor symptoms and decreased sexual function.

CONCLUSIONS

Women who undergo prophylactic salpingo-oophorectomy prior to menopause experience an increase in vasomotor symptoms and a decrease in sexual functioning. These symptoms are improved by HRT, but not to pre-surgical levels.

Aging of the human ovary and testis

Aging is associated with structural and functional alterations in all organs of the human body. The aging of gonads represents in this respect a special case, because these organs are not functional for the whole lifespan of an individual and their normal function is not indispensable for functions of the rest of the body. Ovarian function lasts for the reproductive life of a woman, i.e., from menarche until menopause. The testicular endocrine function, in contrast, begins already in utero, is interrupted between neonatal life and puberty, and continues thereafter along with spermatogenesis, with only slight decline, until old age. The aging processes of the ovary and testis are therefore very different. We describe in this review the structural and functional alterations in the human ovary and testis upon aging. Special emphasis will be given to clinically significant alterations, which in women concern the causes and consequences of the individual variability of fertility during the latter part of the reproductive age. The clinically important aspect of testicular aging entails the decline of androgen production in aging men.

Androgen replacement therapy in androgen-deficient women with hypopituitarism

Hypopituitarism is a rare disorder, but its prevalence has increased as a result of an increase in secondary causes of hypopituitarism such as traumatic brain injury and cranial irradiation. Estrogen with or without progestogen (progestin) treatment is conventional therapy in women with hypopituitarism. Recent data demonstrate that women with hypopituitarism may experience marked androgen deficiency as a consequence of secondary loss of function of the adrenal cortex and/or ovaries. This deficiency is not always considered and therefore androgen therapy is not routinely prescribed. Recent clinical trials indicate that testosterone supplementation in physiological doses for androgen-deficient women with hypopituitarism may improve psychological well-being and sexual function, and increase bone mineral density and lean body mass. Dehydroepiandrosterone (DHEA; prasterone) supplementation may be an option for women with hypopituitarism who have secondary adrenal insufficiency and low levels of DHEA and DHEA sulfate. While short-term treatment with testosterone or DHEA appears to be safe, long-term safety data are lacking. Androgenic adverse effects limit the acceptability of treatment for some women. Further studies to establish the efficacy and safety of androgen treatment for long-term intervention in a larger group of hypopituitary androgen-deficient women are needed.

Long-term effects of bilateral oophorectomy on brain aging: unanswered questions from the Mayo Clinic Cohort Study of Oophorectomy and Aging

In the Mayo Clinic Cohort Study of Oophorectomy and Aging, women who had both ovaries removed before reaching natural menopause experienced a long-term increased risk of parkinsonism, cognitive impairment or dementia, and depressive and anxiety symptoms. Here, we discuss five possible mechanistic interpretations of the observed associations; first, the associations may be non-causal because they result from the confounding effect of genetic variants or of other risk factors; second, the associations may be mediated by an abrupt reduction in levels of circulating estrogen; third, the associations may be mediated by an abrupt reduction in levels of circulating progesterone or testosterone; fourth, the associations may be mediated by an increased release of gonadotropins by the pituitary gland; and fifth, genetic variants may modify the hormonal effects of bilateral oophorectomy through simple or more complex interactions. Results from other studies are cited as evidence for or against each possible mechanism. These putative causal mechanisms are probably intertwined, and their clarification is a research priority.

Androgen insufficiency in women

Androgens are directly secreted by the ovaries and adrenals in women, and androgen precursors from these glands are converted in a variety of peripheral tissues into androgens. The major androgen in women is testosterone, and its action in target tissues can be mediated through the androgen receptor or through the estrogen receptor after aromatization to estradiol. Low sexual desire that causes personal distress (or hypoactive sexual desire disorder [HSDD]) is the most common form of female sexual dysfunction, and androgen insufficiency is one cause of this problem. In addition to a low libido, the clinical construct of the female androgen insufficiency syndrome includes the presence of persistent, unexplained fatigue and a decreased sense of well-being. Although there is conflicting information about the relationship between serum testosterone concentrations and sexual desire, multiple randomized, double-blind, placebo-controlled treatment trials have demonstrated that testosterone improves libido significantly more than placebo. Doses that provide physiologic to slightly supraphysiologic serum free or bioavailable testosterone concentrations are safe and associated with only mild androgenic side effects of acne and hirsutism. Oral, but not parenteral or transdermal, testosterone may decrease high-density lipoprotein cholesterol. At present, no testosterone preparation has been approved by the FDA for the treatment of low sexual desire (HSDD), so all such therapy is considered to be off-label use at this time.

Evidence against a role for ovarian hormones in the regulation of blood flow

OBJECTIVE

To determine the effect of ovarian hormone deficiency on peripheral vascular function.

DESIGN

Randomized, single-blind, placebo-controlled.

SETTING

General clinical research center.

PATIENT(S)

Twelve healthy, lean, premenopausal women with regular menstrual cycles.

INTERVENTION(S)

Measurements were made during the early to midfollicular and midluteal phases of the menstrual cycle. Patients were then randomized to an 8-week course of gonadotropin-releasing hormone agonist (GnRHa) (n = 6) or placebo (n = 6) and retested. On each occasion, blood flow was assessed in the basal postabsorptive state and under euglycemic-hyperinsulinemic-hyperaminoacidemic conditions.

MAIN OUTCOME MEASURE(S)

Calf blood flow by venous occlusion plethysmography.

RESULT(S)

No differences in calf blood flow under postabsorptive (1.65 +/- 0.09 vs. 1.73 +/- 0.16 mL/100 g tissue per minute) or insulin-stimulated conditions (2.24 +/- 0.20 vs. 2.30 +/- 0.18 mL/100 g tissue per minute) were found between the follicular and luteal phases of the menstrual cycle, respectively; therefore, pretreatment data were averaged. Ovarian hormone suppression did not alter postabsorptive calf blood flow (GnRHa: 1.68 +/- 0.13 to 1.69 +/- 0.15; placebo: 1.69 +/- 0.21 to 1.64 +/- 0.14 mL/100 g tissue per minute) or the blood flow response to insulin infusion (GnRHa: 2.40 +/- 0.21 to 2.37 +/- 0.29; placebo: 2.10 +/- 0.28 to 2.19 +/- 0.35 mL/100 g tissue per minute).

CONCLUSION(S)

Variation in ovarian hormones associated with the menstrual cycle or short-term ovarian hormone deficiency induced by GnRHa do not affect calf blood flow under postabsorptive conditions or the response to hyperinsulinemia.

Androgen levels in adult females: changes with age, menopause, and oophorectomy

CONTEXT

Changes in androgen levels across the adult female life span and the effects of natural menopause and oophorectomy have not been clearly established.

OBJECTIVE

The objective of this study was to document the effects of age on androgen levels in healthy women and to explore the effects of natural and surgical menopause.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study was conducted of 1423 non-healthcare-seeking women, aged 18-75 yr, randomly recruited from the community over 15 months.

MAIN OUTCOME MEASURES

Serum levels by age of total testosterone (T), calculated free T, dehydroepiandrosterone sulfate, and androstenedione in a reference group of women free of confounding factors. Women in the reference group had no usage of exogenous steroid therapy; no history of tubal ligation, hysterectomy, or bilateral oophorectomy; and no hyperprolactinemia or polycystic ovarian syndrome. The effects of natural and surgical menopause on sex steroid levels were also examined.

RESULTS

In the reference population (n = 595), total T, calculated free T, dehydroepiandrosterone sulfate, and androstenedione declined steeply with age (P < 0.001), with the decline of each being greater in the earlier than the later decades. Examination of serum androgen levels by year in women aged 45-54 yr showed no independent effect of menopausal status on androgen levels. In women aged 55 yr or older, those who reported bilateral oophorectomy and were not on exogenous steroids had significantly lower total T and free T levels than women 55 yr or older in the reference group.

CONCLUSIONS

We report that serum androgen levels decline steeply in the early reproductive years and do not vary because a consequence of natural menopause and that the postmenopausal ovary appears to be an ongoing site of testosterone production. These significant variations in androgens with age must be taken into account when normal ranges are reported and in studies of the role of androgens in women.

Testosterone therapy in women: a review

Female sexual dysfunction is a complex problem with multiple overlapping etiologies. Androgens play an important role in healthy female sexual function, especially in stimulating sexual interest and in maintaining desire. There are a multitude of reasons why women can have low androgen levels with the most common reasons being age, oophorectomy and the use of oral estrogens. Symptoms of androgen insufficiency include absent or greatly diminished sexual motivation and/or desire, that is, libido, persistent unexplainable fatigue or lack of energy, and a lack of sense of well being. Although there is no androgen preparation that has been specifically approved by the FDA for the treatment of Women's Sexual Interest/Desire Disorder or for the treatment of androgen insufficiency in women, androgen therapy has been used off-label to treat low libido and sexual dysfunction in women for over 40 y. Most clinical trials in postmenopausal women with loss of libido have demonstrated that the addition of testosterone to estrogen significantly improved multiple facets of sexual functioning including libido and sexual desire, arousal, frequency and satisfaction. In controlled clinical trials of up to 2 y duration of testosterone therapy, women receiving androgen therapy tolerated androgen administration well and demonstrated no serious side effects. The results of these trials suggest that testosterone therapy in the low-dose regimens is efficacious for the treatment of Women's Sexual Interest and Desire Disorder in postmenopausal women who are adequately estrogenized. Based on the evidence of current studies, it is reasonable to consider testosterone therapy for a symptomatic androgen-deficient woman with Women's Sexual Interest and Desire Disorder.

Postmenopausal bilateral oophorectomy is not associated with increased fracture risk in older women

We studied whether oophorectomy performed after menopause is associated with an increased risk of hip or vertebral fractures in 6295 Study of Osteoporotic Fractures participants. There was no association between postmenopausal oophorectomy and the risk of hip or vertebral fractures.

INTRODUCTION

Bilateral oophorectomy after natural menopause has been associated with an increased risk of osteoporotic fractures, potentially because of a decline in serum estradiol and testosterone levels after the oophorectomy. We prospectively tested this hypothesis in the Study of Osteoporotic Fractures (SOF).

MATERIALS AND METHODS

We studied 6295 white women 65 years of age participating in the SOF who were not taking estrogen therapy at baseline. Hip fracture analyses included 708 hip fractures; vertebral fracture analyses included 267 incident vertebral fractures. Baseline serum estradiol and free testosterone values were available in a small subset of participants.

RESULTS AND CONCLUSION

There were no significant differences in age, weight, or BMD between the women who underwent postmenopausal oophorectomy (n = 583) and those who did not (n = 5712). Free testosterone levels were significantly lower among women who had a postmenopausal oophorectomy. A history of postmenopausal oophorectomy was not associated with an increased risk of hip (hazard ratio [HR] = 1.1; 95% CI = 0.9-1.5) or vertebral fracture (HR = 0.7; 95% CI = 0.5-1.2). The relationship between oophorectomy and hip fracture was not altered by adding serum estradiol level (HR = 1.3; 95% CI = 0.5-3.2) or serum free testosterone level (HR = 1.7; 95% CI = 0.8-3.7) to the model. In summary, postmenopausal oophorectomy was not associated with an increased risk of hip or vertebral fracture in this cohort. These results are in contrast to previous findings, suggesting that the relationship between postmenopausal oophorectomy and fractures is not fully elucidated and that incidental oophorectomy after menopause should still be considered carefully in each potential patient.

Androgen replacement therapy in women

OBJECTIVE

Review of literature with regard to androgen replacement therapy in women.

DESIGN

Review of the MEDLINE database and references from articles.

CONCLUSIONS

Androgens affect sexual function, bone health, muscle mass, body composition, mood, energy, and the sense of well-being. Androgen insufficiency clearly has been demonstrated in patients with hypopituitarism, adrenalectomy, oophorectomy, and in some women placed on oral estrogen therapy which increases sex hormone-binding globulin (SHBG) levels and lowers the free and bioavailable forms of T. Symptoms of androgen insufficiency in women may include a diminished sense of well-being, low mood, fatigue, and hypoactive sexual desire disorder with decreased libido, or decreased sexual receptivity and pleasure that causes a great deal of personal distress. The preponderance of evidence from clinical trials supports the correlation of decreased endogenous androgen levels with these symptoms and alleviation of many of the symptoms with the administration of T or, in some cases, DHEA. There are no Food and Drug Administration-approved androgen preparations on the market for treating androgen insufficiency in women. The safety profile of androgens in doses used for the treatment of hypoactive sexual desire disorder has been excellent with only mild acne and hirsutism being noted in a minority of patients.

FSH and LH responses to GnRH after ovariectomy in postmenopausal women

OBJECTIVE

Whether the postmenopausal ovary is still playing a role in the control of gonadotrophin secretion in response to GnRH has not been investigated. The aim of the present study was to test this hypothesis by examining changes in basal and GnRH-induced gonadotrophin secretion in postmenopausal women after bilateral ovariectomy.

DESIGN

The responses of LH and FSH to GnRH [10 microg intravenously (i.v.)] were investigated in postmenopausal women from 2 days before to 8 days after total abdominal hysterectomy plus bilateral ovariectomy.

PATIENTS

Nine postmenopausal women aged 52-67 years and between 5 and 15 years after menopause. In all cases the ovaries were histologically normal.

MEASUREMENTS

Pituitary responses to GnRH were calculated every 12-24 h as the net increases in LH (DeltaLH) and FSH (DeltaFSH) at 30 min above the basal values. Basal values of oestradiol (E2) and testosterone were also measured.

RESULTS

Basal values of FSH showed a significant decrease on postoperative days 2 (P < 0.01) and 8 (P = 0.03) as compared to day 0, while at the same time points after the operation LH values were marginally lower than on day 2 (P = 0.05). Serum E2 values showed a gradual increase up to postoperative day 1 (P = 0.04) and a gradual decline thereafter. Basal testosterone concentrations decreased gradually and significantly after ovariectomy and were significantly lower on day 8 than on day 0 (P < 0.01). DeltaFSH and DeltaLH responses to GnRH did not change significantly with time. A temporary increase at 12 h after the operation was not significant.

CONCLUSIONS

These results demonstrate for the first time that the removal of the ovaries in postmenopausal women does not affect GnRH-induced gonadotrophin secretion in the short term. It is suggested that the postmenopausal ovary is not a dominant regulator of hypothalamic-pituitary interactions.

Background to and management of treatment-related bone loss in prostate cancer

Prostate cancer is a common disease among older men. Androgen suppression by either orchiectomy or administration of luteinising hormone-releasing hormone (LHRH) analogues is the mainstay of treatment. Since the use of prostate-specific antigen (PSA) serum testing has become widespread, however, the timing of endocrine therapy has expanded considerably to include patients with limited involvement of extraprostatic sites and patients presenting an isolated elevation of PSA after radical treatments. These patients are expected to be treated for a long time, since they have a rather low risk of disease progression and there is no recommended time limit for LHRH analogue therapy. The long-term adverse effects of androgen deprivation therapy, therefore, deserve more attention than they have received in the past. Osteoporosis represents a special concern for men with prostate cancer receiving androgen deprivation therapy. The rate of bone loss in these men seems to markedly exceed that associated with menopause in women, and fractures occur more frequently than in the healthy elderly male population. Serial bone mineral density (BMD) evaluation could allow the detection of patients with prostate cancer who are at greater risk of osteoporosis and adverse skeletal events after androgen deprivation therapy, such as patients already osteopenic or osteoporotic at baseline and men with rapid bone loss during treatment. BMD evaluated during treatment could also be a potential surrogate parameter of antiosteoporotic therapeutic efficacy. Treatment of bone loss induced by androgen deprivation comprises general prevention measures, antiosteoporotic drugs and the use of alternative endocrine therapies. Optimising lifestyle and diet is important, although it cannot completely prevent bone loss. Patients with nonsevere bone disease may benefit from calcium and vitamin D supplements. Men who are osteoporotic before androgen deprivation or men becoming osteoporotic during treatment and/or experiencing adverse skeletal events may also require bisphosphonates. The effectiveness of these drugs in preventing fractures has been shown in a single randomised study involving patients with osteoporosis, but it has not yet been established in a prostatic cancer population without bone metastases given androgen deprivation therapy. Different forms of endocrine therapy such as low-dose estrogens, antiandrogens and intermittent androgen ablation are under investigation. They could offer the advantage of avoiding (or limiting) treatment-related bone loss. In our opinion, however, the data available so far are not robust enough to recommend these alternative endocrine therapies instead of standard androgen deprivation in routine clinical practice.

Fracture risk after bilateral oophorectomy in elderly women

Elderly women with the lowest serum estrogen levels are at the greatest risk of bone loss and fractures, but it is controversial whether the ovaries contribute to estrogen production after menopause, and therefore, whether bilateral oophorectomy in postmenopausal women might have adverse skeletal effects. To address this potential problem, we estimated long-term fracture risk among 340 postmenopausal Olmsted County, MN, women who underwent bilateral oophorectomy for a benign ovarian condition in 1950-1987. In over 5632 person-years of follow-up (median, 16 years per subject), 194 women experienced 516 fractures (72% from moderate trauma). Compared with expected rates, there was a significant increase in the risk of any osteoporotic fracture (moderate trauma fractures of the hip, spine, or distal forearm; standardized incidence ratio [SIR], 1.54; 95% CI, 1.29-1.82) but almost as large an increase in fractures at other sites (SIR, 1.35; 95% CI, 1.13-1.59). In multivariate analyses, the independent predictors of overall fracture risk were age, anticonvulsant or anticoagulant use for > or = 6 months, and a history of alcoholism or prior osteoporotic fracture; obesity was protective. Estrogen replacement therapy was associated with a 10% reduction in overall fracture risk (hazard ratio [HR], 0.90; 95% CI, 0.64-1.28) and a 20% reduction in osteoporotic fractures (HR, 0.80; 95% CI, 0.52-1.23), but neither was statistically significant. The increase in fracture risk among women who underwent bilateral oophorectomy after natural menopause is consistent with the hypothesis that androgens produced by the postmenopausal ovary are important for endogenous estrogen production that protects against fractures.

The effects of tibolone on mood and libido

OBJECTIVE

To review published data pertaining to the effects of tibolone on sexual parameters, mood, and cognitive function in postmenopausal women.

DESIGN

A review of all relevant published, peer-reviewed studies.

RESULTS

Tibolone is a compound that can be selectively metabolized by individual tissues to its estrogenic, progestogenic, or androgenic metabolites and hence exhibits tissue-specific hormonal effects. Tibolone also lowers sex hormone binding globulin, thus increasing free estradiol and testosterone levels. Tibolone alleviates climacteric vasomotor symptoms and displays a dominant progestogenic effect on the endometrium. Tibolone normalizes the vaginal karyopyknotic and maturation indexes and alleviates symptomatic atrophic vaginitis. Women treated with tibolone report significant reductions in vaginal dryness and dyspareunia, effects that may be secondary to both estrogenic and androgenic actions. Randomized studies indicate tibolone has positive effects on mood compared with placebo and alleviates several adverse mood parameters to a similar extent as conventional hormone replacement therapy. Improved mood is associated with increased plasma beta-endorphin. With respect to cognition, tibolone seems to improve semantic memory but does not significantly improve recognition memory. Tibolone is associated with improvements in sexual function that seem to be greater than those achieved with standard hormone replacement therapy.

CONCLUSION

Published studies indicate beneficial effects of tibolone on both libido and mood, which otherwise significantly compromise physical, psychological, and social well-being. Hence, tibolone provides another option for menopausal women experiencing loss of libido as part of their symptomatology or who have persistent low libido despite adequate estrogen/progestin replacement therapy.

Androgen insufficiency in women: summary of critical issues

Critical issues concerning the role of androgens in the physical, sexual, and emotional health of women include the following:1. Which androgens best reflect the androgen status of women? 2. What form of T should be measured and how? 3. Do T levels fall after menopause? 4. What effect does oophorectomy have on T levels? 5. What is the relationship between T and sexual dysfunction? 6. What constitutes androgen insufficiency syndrome? 7. What conditions are associated with androgen insufficiency? 8. How should a patient with suspected androgen insufficiency be evaluated? 9. Does androgen replacement therapy improve sexual dysfunction? 10. Do androgens enhance the quality of life? 11. Is estrogen and androgen therapy superior to estrogen therapy alone for low bone mineral density? 12. What are the indications for androgen replacement therapy? 13. What is the best means for delivery of androgen therapy? 14. How should androgen replacement therapy be monitored? Based on our current knowledge, it is clear that some women develop symptomatic androgen insufficiency and that androgen replacement therapy has a beneficial effect on libido, sexual satisfaction, quality of life, and bone mineralization. Androgen replacement therapy should be given the same consideration that we give estrogen replacement therapy.

Pharmacokinetics of testosterone after percutaneous gel or buccal administration

OBJECTIVE

To determine the pharmacokinetics of testosterone following its administration using transdermal gel or buccal lozenges.

DESIGN

Pilot study.

SETTING

University-based hospital.

PATIENT(S)

Ten bilaterally oophorectomized women.

INTERVENTION(S)

Daily micronized testosterone gel (1 mg) and testosterone propionate lozenge (1 mg).

MAIN OUTCOME MEASURE(S)

Total testosterone, androstenedione, dihydrotestosterone, 3alpha-androstanediol glucuronide, and sex hormone-binding globulin were measured in serum by specific radioimmunoassays; free testosterone levels were also calculated.

RESULT(S)

Before treatment, serum testosterone levels in the groups using the lozenge and gel were 16 +/- 4.0 and 20 +/- 6.0 ng/dL, respectively. Mean maximum testosterone levels obtained with the lozenge occurred 1 hour after administration on days 1 (692 +/- 236 ng/dL) and 14 (836 +/- 309 ng/dL) of treatment and fell precipitously thereafter. In contrast, testosterone levels obtained with the gel showed a prolonged rise reaching maximal levels of 97 +/- 78 and 100 +/- 60 ng/dL after 18 hours. The serum level patterns of free testosterone, dihydrotestosterone, and 3alpha-androstanediol glucuronide were similar to the corresponding total testosterone levels.

CONCLUSION(S)

Administration of testosterone lozenge by buccal absorption produced a rapid and brief elevation of testosterone levels, with levels reaching upper limits of the male range. In contrast, transdermal testosterone gel absorption resulted in a prolonged elevation of testosterone levels, which were in the hyperandrogenic female range but resembled steady state pharmacokinetics.

Potential side-effects of endocrine treatment of long duration in prostate cancer

Endocrine treatment of prostate cancer has been established for more than 5 decades. Focusing on immediate or short-term side effects, bilateral orchidectomy may cause psychological trauma, treatment with oral estrogens is combined with a high risk of severe cardiovascular complications, and the use of LH-RH agonists and antiandrogens as monotherapies or in combination may result in tumor flare, hot flashes, and gynecomastia. In recent years an increasing number of reports on anemia and/or osteoporosis related to endocrine treatment have been published. These side effects are regular and persistent after orchidectomy, or during treatment with LH-RH agonists, and are most often expressed with maximum androgen blockade. In contrast, anemia and/or osteoporosis are not reported with estrogen treatment or the use of nonsteroidal antiandrogens as a monotherapy regimen. Since many prostate cancer patients are treated hormonally for many years, control of Hb levels and bone mineral density before and after initiation of treatment at regular intervals is highly recommended as a standard of care.

Testosterone supplemental therapy after hysterectomy with or without concomitant oophorectomy: estrogen alone is not enough

Hysterectomy has the potential for generating serious consequences in terms of health, including two to seven times greater incidence and prevalence of cardiovascular disease, and quality of life, including loss of sexual libido and pleasure. More than a half-million American women undergo hysterectomy every year. Both in premenopausal women and in postmenopausal women, the ovaries are a critical source not only of estrogen but also of testosterone. Even in instances where ovaries have been spared on removal of the uterus, their function may be compromised. Today, women for whom estrogen replacement therapy is not contraindicated are routinely given supplemental estrogen following hysterectomy/oophorectomy. Many women develop and suffer symptoms of testosterone deficiency that go unrecognized and untreated. Testosterone supplemental therapy for women following hysterectomy not only can improve the quality of their lives in terms of sexual libido, sexual pleasure, and sense of well-being but also can--as does supplementary estrogen--contribute to the prevention of osteoporosis. Most importantly, an increasing body of evidence suggests that testosterone may be cardiovascular protective. As testosterone, the most potent anabolic steroid, has some anabolic effect on virtually every tissue in the body, it is likely that supplementing testosterone to physiological levels contributes to health maintenance in as yet undefined ways and that testosterone deficiency in women may be costing more in morbidity and mortality than we know at present.

Transdermal testosterone treatment in women with impaired sexual function after oophorectomy

BACKGROUND

The ovaries provide approximately half the circulating testosterone in premenopausal women. After bilateral oophorectomy, many women report impaired sexual functioning despite estrogen replacement. We evaluated the effects of transdermal testosterone in women who had impaired sexual function after surgically induced menopause.

METHODS

Seventy-five women, 31 to 56 years old, who had undergone oophorectomy and hysterectomy received conjugated equine estrogens (at least 0.625 mg per day orally) and, in random order, placebo, 150 microg of testosterone, and 300 microg of testosterone per day transdermally for 12 weeks each. Outcome measures included scores on the Brief Index of Sexual Functioning for Women, the Psychological General Well-Being Index, and a sexual-function diary completed over the telephone.

RESULTS

The mean (+/-SD) serum free testosterone concentration increased from 1.2+/-0.8 pg per milliliter (4.2+/-2.8 pmol per liter) during placebo treatment to 3.9+/-2.4 pg per milliliter (13.5+/-8.3 pmol per liter) and 5.9+/-4.8 pg per milliliter (20.5+/-16.6 pmol per liter) during treatment with 150 and 300 microg of testosterone per day, respectively (normal range, 1.3 to 6.8 pg per milliliter [4.5 to 23.6 pmol per liter]). Despite an appreciable placebo response, the higher testosterone dose resulted in further increases in scores for frequency of sexual activity and pleasure-orgasm in the Brief index of Sexual Functioning for Women (P=0.03 for both comparisons with placebo). At the higher dose the percentages of women who had sexual fantasies, masturbated, or engaged in sexual intercourse at least once a week increased two to three times from base line. The positive-well-being, depressed-mood, and composite scores of the Psychological General Well-Being Index also improved at the higher dose (P=0.04, P=0.03, and P=0.04, respectively, for the comparison with placebo), but the scores on the telephone-based diary did not increase significantly.

CONCLUSIONS

In women who have undergone oophorectomy and hysterectomy, transdermal testosterone improves sexual function and psychological well-being.

Menopause and post-menopause

From the endocrine point of view, menopause is considered a deficiency state and oestrogen therapy regarded as restoring the pre-menopausal endocrine milieu. Oestrogen therapy alleviates acute climacteric symptoms and also reduces the risk of cardiovascular disease, osteoporosis and Alzheimer's disease. Cardiovascular protection seems to be the major benefit of oestrogen replacement: it reduces morbidity and mortality from coronary heart disease by approximately 50%. The mechanisms are complex and not fully under-stood. In this review we discuss currently available data on the effects of hormone replacement therapy on serum lipids and lipoproteins, the vessel wall (endothelium dependent and endothelium independent), blood flow, cardiac function, blood pressure, haemostasis, insulin sensitivity and direct anti-atherosclerotic effect as possible mechanisms of cardioprotection. Oestrogen therapy reduces the rate of post-menopausal bone loss, increases bone mineral density (BMD) and decreases fracture rate. Recent evidence suggests that initiation of oestrogen therapy in older women produces larger increases in BMD which might provide a significant protective effect at the time when fracture is common. The incidence of Alzheimer's disease is reduced by 50% in post-menopausal women taking oestrogen replacement. Limited clinical trials of oestrogen treatment in women with this disease have documented beneficial effects on cognitive function. The results of epidemiological studies of the effects of oestrogens on breast cancer risk are conflicting but recent evidence suggests that the risk is increased in current users after 5 years of use and among older women. In contrast, increase in the risk of venous thromboembolism is most significant within the first 12 months of therapy, strongly suggesting the importance of individual susceptibility.

Possible bone-preserving capacity of high-dose intramuscular depot estrogen as compared to orchidectomy in the treatment of patients with prostatic carcinoma

BACKGROUND

Treatment of prostatic disease with GnRH agonists or by orchidectomy affects bone mass negatively. Estrogen treatment has beneficial effects on bone mass in women and might hypothetically have a bone preserving capacity also in patients with prostatic cancer.

METHODS

We followed serum markers for bone and collagen metabolism and sex steroids for 18 months in patients with prostatic cancer treated by orchidectomy (N = 13) or by single-drug parenteral polyestradiol phosphate (240 mg intramuscularly every second week for the first two months, and then every fourth week; N = 17).

RESULTS

Total and free testosterone reached castration levels within 1.5 months of estrogen treatment. Four patients developing progressive disease and/or signs of metastasis were excluded from the analysis. In the remaining patients, serum osteocalcin, procollagen IIIP (PIIINP), procollagen (PICP), and the crosslinked carboxyterminal telopeptide of type I collagen (ICTP) increased significantly over time following orchidectomy (N = 11). Serum osteocalcin and PICP decreased significantly over time during estrogen treatment (N = 15). Treatment values of all four markers were significantly lower in estrogen-treated than in orchidectomized patients.

CONCLUSIONS

The changes in serum bone and collagen markers indicate an increased bone turnover in orchidectomized subjects. The opposite pattern was found in the estrogen-treated patients, indicating a reduced turnover. Estrogens may also have a bone mass-preserving capacity in elderly males with prostatic cancer.

The endocrinology of the menopause

Changes in the endocrinology of the pituitary-ovarian axis first become manifest at about the age of 40, a selective rise in serum follicle stimulating hormone (FSH) levels occurring at about the same time as a marked acceleration in the loss of primordial follicles from the ovary. FSH levels gradually increase with increasing age in women who continue to cycle regularly. During the menopausal transition, initiated when changes in cycle frequency or in menstrual flow are first observed, both gonadotrophins, oestradiol and inhibin show a marked degree of variability with abrupt changes from typical post-menopausal patterns to those characteristic of the reproductive age group. Within 1-2 years after the final menstrual period or menopause, FSH levels are markedly elevated, luteinizing hormone (LH) levels moderately so, while oestradiol and inhibin levels are low or undetectable. Post-menopausally, adrenal androstenedione is the major source of oestrogen and serum testosterone levels fall moderately, with oophorectomy leading to a further significant fall. Serum sex hormone binding globulin levels fall to a small degree post-menopausally. Areas of persisting controversy include the question of whether oestradiol levels fall with increasing age prior to the onset of the menopausal transition, the relative roles of oestradiol and inhibin in the selective rise of serum FSH and the role of serum androgens post-menopausally.

Bone mineral density in patients with prostatic cancer treated with orchidectomy and with estrogens

Bone mineral density (BMD) and bone mineral content (BMC) were measured in the femoral neck area, trochanteric area and Wards triangle, and in the distal radius of the left forearm before and after 1 year of endocrine treatment in 27 patients with prostatic cancer. Eleven of the patients were treated with orchidectomy and 16 with combined oral and intramuscular estrogens. The patients were free from metastases during the entire observation period. In the orchidectomized patients, BMD and BMC of the distal radius decreased significantly following treatment, whereas no changes were observed in the estrogen-treated patients. These preliminary results demonstrate that estrogens may protect bone in male subjects also and may merit further investigations on larger groups of patients.

Elective ovarian removal and estrogen replacement therapy--effects on sexual life, psychological well-being and androgen status

Conflicting data have been reported on the psychosexual impact of hysterectomy combined with bilateral oophorectomy. Three age-matched, hysterectomized groups of women were investigated: Group A (n = 33): oophorectomized, not receiving estrogen replacement therapy (ERT); Group B (n = 33): oophorectomized, receiving ERT; and Group C (n = 35): ovaries preserved and not receiving ERT. The McCoy Sexual Rating Scale and the Psychological General Well-Being Index as well as a semi-structured interview were used to assess postoperative experience with respect to libido, vaginal lubrication, ability of getting pleasure from intercourse, and ability to achieve orgasm. Serum concentrations of total and free testosterone, insulin-like growth factor I (IGF-I), sex hormone binding globulin, dehydroepiandrosterone sulfate and 4-androstene-3,17-dione were determined. In oophorectomized women sexual life was impaired as compared to those with intact ovaries and these women complained about less pleasure from coitus, impaired libido and lubrication. Regardless of whether estrogens were administered or not a similar pattern was found, indicating that estrogens are of little value in treating these specific sexual dysfunctions. Oophorectomized women receiving ERT reported less anxiety and depression and more well-being similar to women whose ovaries had been preserved. No correlation was found between psychosexual variables and biochemical androgen markers. However, the IGF-I levels were strongly correlated to sexual activity and responsiveness.