Testosterone enhances estradiol's effects on postmenopausal bone density and sexuality

Bone Health for Gynaecologists

Osteoporosis, the most common bone disorder, profoundly impacts women's health, especially during postmenopausal phases. Characterised by diminished bone mineral density (BMD), it increases the risk of fractures, affecting mobility, quality of life, and potentially mortality. The present review analyses the intricate interactions among physiological alterations, diseases, and medications that lead to bone mineral density reduction in women. It underscores the importance of gynaecologists in the prevention, diagnosis, and management of osteoporosis via early risk assessment, suitable hormone treatment, and lifestyle modifications. Essential considerations encompass the categorisation of osteoporosis into primary (age-related) and secondary (attributable to diseases or pharmacological treatments) types, with particular emphasis on predisposing conditions such as premature menopause, hormone deficits, and cancer therapies. The significance of diagnostic instruments such as DXA and novel methodologies like trabecular bone score and quantitative ultrasonography is emphasised for precise evaluation and surveillance. The review also addresses nutritional methods, physical exercise, and pharmaceutical interventions, including hormone replacement therapy (HRT), selective oestrogen receptor modulators (SERMs), and other anti-resorptive drugs, to preserve bone health. This review highlights the important role of gynaecologists in maintaining women's bone health, promoting a proactive strategy to avert osteoporosis-related complications and enhance long-term results.

The association between female sexual function and metabolic features of the polycystic ovary syndrome in Turkish women of reproductive age

OBJECTIVE

To investigate the association between female sexual function and metabolic features among women with polycystic ovary syndrome (PCOS) during reproductive age.

METHOD

This was a cross-sectional study in which 288 women with PCOS and 180 women without PCOS between the ages of 20 and 40 years were evaluated. All women had serum total testosterone, androstenedione, DHEA-S, fasting glucose, total cholesterol, HDL-C, LDL-C, and triglyceride levels analyzed. The McCoy Female Sexual Questionnaire (MFSQ) was applied to all studied women. Exploratory factor analysis and reliability analysis were done after data collection. The factor loadings of MFSQ domains were compared between women with PCOS and controls.

RESULTS

Average factor loadings of the MFSQ sexuality domain and MFSQ sexual partner domain were significantly lower in the PCOS group when compared to controls. There was no correlation between the two sexual function domains of the MFSQ and the PCOS features either in the PCOS group or the controls.

CONCLUSION

PCOS is a heterogeneous disease with different metabolic components, such as insulin resistance, obesity, and hyperandrogenism. Although sexual function among women with PCOS was lower than controls, no differences were found in metabolic features of the PCOS and non-PCOS groups with relation to sexual function determined by the MFSQ.

Metabolic benefits afforded by estradiol and testosterone in both sexes: clinical considerations

Testosterone (T) and 17β-estradiol (E2) are produced in male and female humans and are potent metabolic regulators in both sexes. When E2 and T production stops or decreases during aging, metabolic dysfunction develops and promotes degenerative metabolic and vascular disease. Here, we discuss the shared benefits afforded by E2 and T for metabolic function human females and males. In females, E2 is central to bone and vascular health, subcutaneous adipose tissue distribution, skeletal muscle insulin sensitivity, antiinflammatory immune function, and mitochondrial health. However, T also plays a role in female skeletal, vascular, and metabolic health. In males, T's conversion to E2 is fundamental to bone and vascular health, as well as prevention of excess visceral adiposity and the promotion of insulin sensitivity via activation of the estrogen receptors. However, T and its metabolite dihydrotestosterone also prevent excess visceral adiposity and promote skeletal muscle growth and insulin sensitivity via activation of the androgen receptor. In conclusion, T and E2 are produced in both sexes at sex-specific concentrations and provide similar and potent metabolic benefits. Optimizing levels of both hormones may be beneficial to protect patients from cardiometabolic disease and frailty during aging, which requires further study.

Sexual Desire and Pharmacologic Management

Female sexual desire is a complex interplay of neurotransmitters and hormones. Diagnosis is based on clinical features and sexual distress. Treatments that affect neurotransmitters and hormones that may be out of balance can help improve sexual desire in women with hypoactive sexual desire disorder.

New Possibilities for Hormonal Vaginal Treatment in Menopausal Women

Hormonal vaginal therapy is an effective treatment option for women who experience vaginal symptoms related to hormonal changes. Estrogen and prasterone are widely used as vaginal treatments, particularly for urogenital atrophy. These symptoms may include vaginal dryness, itching, burning, and pain during sexual intercourse, all of which can significantly affect a woman's quality of life. Previous studies have indicated that such treatment improves tissue elasticity, moisturizes the vagina, and can have a substantial impact on urine incontinence and vaginal microflora and decreases dyspareunia. Hormonal therapy is also useful and commonly used before vaginal surgical treatment. Prasterone is quite a new option for vaginal therapy in Poland and is mainly recommended for dyspareunia in menopausal women. The study related to prasterone therapy emphasizes its effectiveness and safety, making it advantageous to explore its beneficial impact. This paperwork aims to summarize the mechanism of action as well as the effects of both drugs and their beneficial action during vaginal treatment.

Testosterone for women: certainties and uncertainties

The clinical effects of testosterone in women have expanded from the field of androgen excess to consideration of testosterone action and the consequences of depletion and replacement. This article is not a comprehensive review of the vast and increasing literature in this field. Rather, it summarizes some of what is known of testosterone in women that the author elected to highlight in a plenary lecture and is hopefully informative, but not to be considered conclusive.

Association between testosterone levels and bone mineral density in females aged 40-60 years from NHANES 2011-2016

Growing evidence indicates that testosterone is a conspicuous marker for assessing male bone mineral density (BMD). However, research regarding testosterone levels and BMD is sparse and controversial for females. Hence, we aimed to investigate the association between testosterone levels and BMD among adult females aged 40–60 years in the United States. In this cross-sectional study, all participants were part of the National Health and Nutrition Examination Survey (2011–2016). A weighted general linear model was used to estimate the association between testosterone levels and lumbar BMD. Age, race, income level, education level, body mass index (BMI), blood urea nitrogen (BUN) level, serum uric acid (UA) level, serum calcium (Ca) level, serum phosphorus (P) level, the use of oral contraceptive pills, the use of hormone replacement therapy (HRT), smoking status, drinking status, and the use of corticosteroids were adjusted using a weighted multiple regression model. Subgroup analyses were performed using the same regression model. We included 2198 female participants in the study, and testosterone levels were positively associated with lumbar BMD after adjusting for all the covariates (β = 1.12, 95% CI 0.31, 1.93). In subgroup analyses, the associations in the fourth quartile of testosterone levels were stronger for the participants aged 40–50 years old (quartile 4, β = 42.92, 95% CI 7.53, 78.30 vs. quartile 1) and 50 to 60-year-old (quartile 4, β = 32.41, 95% CI 0.14, 64.69 vs. quartile 1). Similar results were found in other subgroups, including subgroups for race (Non-Hispanic Black, Other), income level (income ≤ 1.3, income > 3.5), education level (college or higher), BMI > 25 kg/m², BUN levels ≤ 20 mg/dL, UA levels ≤ 6 mg/dL, Ca levels ≤ 10.1 mg/dL, P levels ≤ 5 mg/dL, drinking status, never smoker, never taking birth control pills, and HRT user. There was no interaction among the covariates in the association between lumbar BMD and testosterone levels (P for interaction > 0.05). In US adult females aged 40–60 years, the testosterone level was a positive predictor of the lumbar BMD after adjusting for covariates.

“Adipose-derived mesenchymal stem cell therapy for the management of female sexual dysfunction: Literature reviews and study design of a clinical trial”

Hormone imbalance and female sexual dysfunction immensely affect perimenopausal female health and quality of life. Hormone therapy can improve female hormone deficiency, but long-term use increases the risk of cardiovascular diseases and cancer. Therefore, it is necessary to develop a novel effective treatment to achieve long-term improvement in female general and sexual health. This study reviewed factors affecting syndromes of female sexual dysfunction and its current therapy options. Next, the authors introduced research data on mesenchymal stromal cell/mesenchymal stem cell (MSC) therapy to treat female reproductive diseases, including Asherman’s syndrome, premature ovarian failure/primary ovarian insufficiency, and vaginal atrophy. Among adult tissue-derived MSCs, adipose tissue-derived stem cells (ASCs) have emerged as the most potent therapeutic cell therapy due to their abundant presence in the stromal vascular fraction of fat, high proliferation capacity, superior immunomodulation, and strong secretion profile of regenerative factors. Potential mechanisms and side effects of ASCs for the treatment of female sexual dysfunction will be discussed. Our phase I clinical trial has demonstrated the safety of autologous ASC therapy for women and men with sexual hormone deficiency. We designed the first randomized controlled crossover phase II trial to investigate the safety and efficacy of autologous ASCs to treat female sexual dysfunction in perimenopausal women. Here, we introduce the rationale, trial design, and methodology of this clinical study. Because aging and metabolic diseases negatively impact the bioactivity of adult-derived MSCs, this study will use ASCs cultured in physiological oxygen tension (5%) to cope with these challenges. A total of 130 perimenopausal women with sexual dysfunction will receive two intravenous infusions of autologous ASCs in a crossover design. The aims of the proposed study are to evaluate 1) the safety of cell infusion based on the frequency and severity of adverse events/serious adverse events during infusion and follow-up and 2) improvements in female sexual function assessed by the Female Sexual Function Index (FSFI), the Utian Quality of Life Scale (UQOL), and the levels of follicle-stimulating hormone (FSH) and estradiol. In addition, cellular aging biomarkers, including plasminogen activator inhibitor-1 (PAI-1), p16 and p21 expression in T cells and the inflammatory cytokine profile, will also be characterized. Overall, this study will provide essential insights into the effects and potential mechanisms of ASC therapy for perimenopausal women with sexual dysfunction. It also suggests direction and design strategies for future research.

Blood testosterone levels in sickness and in health: Male chimpanzee testosterone levels decrease in face of an immune challenge

As an integral part of the immune response, testosterone secretion is inhibited when an individual is confronted with an immune challenge. Testosterone-mediated physiological, morphological, and behavioral traits are compromised at times of impaired health. Nevertheless, males of some species seem to maintain high levels of testosterone when confronted with an immune challenge, upholding competitive strength but compromising their immune response. It has been argued that this phenomenon will occur only in species living in social systems with high degrees of male-male competition over mating opportunities. Male chimpanzees contest over access to fertile females and dominants sire the majority of offspring. This male mating pattern makes chimpanzees a candidate species where we could expect males to maintain high testosterone levels, compromising their immune response, to ensure immediate reproductive success. We measured blood testosterone levels in male and female chimpanzees, who expressed clinical symptoms (symptomatic) or showed no evidence of clinical disease on assessment (asymptomatic). For females, we expected to find lower testosterone levels in symptomatic individuals than in asymptomatic subjects. In males, we would predict lower testosterone levels in symptomatic individuals than in asymptomatic males, if the immune response leads to a decrease in testosterone secretion. Alternatively, males could have equal levels of testosterone when symptomatic and asymptomatic, upholding competitive strength. Our results show that male chimpanzees exhibit lower levels of testosterone when confronted with an immune challenge than when being asymptomatic. This suggests that male testosterone secretion is suppressed as part of the immune response, which potentially increases survival and lifetime reproductive success. It will, however, negatively impact momentary competitive ability. Also, males may employ different mating strategies, some of which are less testosterone-driven (e.g., affiliative strategies). Consequently, in some individuals, the costs of maintaining high testosterone levels may not outweigh the potential gain in reproductive success.

Hypoactive Sexual Desire Disorder in Women: Physiology, Assessment, Diagnosis, and Treatment

Nearly half of women in the United States report problems with sexual function. Many health care providers do not ask about sexual concerns during routine clinical encounters because of personal discomfort, lack of familiarity with treatment, or the belief that they lack adequate time to address this complex issue. This may be especially true for hypoactive sexual desire disorder (HSDD), the most commonly identified sexual problem among women. HSDD is characterized by a deficiency of sexual thoughts, feelings, or receptiveness to sexual stimulation that has been present for at least 6 months, causes personal distress, and is not due to another medical condition. This is an up-to-date overview of HSDD for clinicians, discussing its physiology, assessment, diagnosis, and treatment strategies. Although a definitive physiology of HSDD is still unknown, multiple hormones and neurotransmitters likely participate in a dual-control model to balance excitation and inhibition of sexual desire. For assessment and diagnosis, validated screening tools are discussed, and the importance of a biopsychosocial assessment is emphasized, with guidance on how this can be implemented in clinical encounters. The 2 recently approved medications for HSDD, flibanserin and bremelanotide, are reviewed as well as off-label treatments. Overall, HSDD represents a common yet likely underrecognized disorder that midwives and other health care providers who care for women across the life span are in a unique position to address.

International Society for the Study of Women's Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women

AIM

To provide a clinical practice guideline for the use of testosterone including identification of patients, laboratory testing, dosing, post-treatment monitoring, and follow-up care in women with hypoactive sexual desire disorder (HSDD).

METHODS

The International Society for the Study of Women's Sexual Health appointed a multidisciplinary panel of experts who performed a literature review of original research, meta-analyses, review papers, and consensus guidelines regarding testosterone use in women. Consensus was reached using a modified Delphi method.

OUTCOMES

A clinically useful guideline following a biopsychosocial assessment and treatment approach for the safe and efficacious use of testosterone in women with HSDD was developed including measurement, indications, formulations, prescribing, dosing, monitoring, and follow-up.

RESULTS

Although the Global Position Statement endorses testosterone therapy for only postmenopausal women, limited data also support the use in late reproductive age premenopausal women, consistent with the International Society for the Study of Women's Sexual Health Process of Care for the Management of HSDD. Systemic transdermal testosterone is recommended for women with HSDD not primarily related to modifiable factors or comorbidities such as relationship or mental health problems. Current available research supports a moderate therapeutic benefit. Safety data show no serious adverse events with physiologic testosterone use, but long-term safety has not been established. Before initiation of therapy, clinicians should provide an informed consent. Shared decision-making involves a comprehensive discussion of off-label use, as well as benefits and risks. A total testosterone level should not be used to diagnose HSDD, but as a baseline for monitoring. Government-approved transdermal male formulations can be used cautiously with dosing appropriate for women. Patients should be assessed for signs of androgen excess and total testosterone levels monitored to maintain concentrations in the physiologic premenopausal range. Compounded products cannot be recommended because of the lack of efficacy and safety data.

CLINICAL IMPLICATIONS

This clinical practice guideline provides standards for safely prescribing testosterone to women with HSDD, including identification of appropriate patients, dosing, and monitoring.

STRENGTHS AND LIMITATIONS

This evidence-based guideline builds on a recently published comprehensive meta-analysis and the Global Position Statement endorsed by numerous societies. The limitation is that testosterone therapy is not approved for women by most regulatory agencies, thereby making prescribing and proper dosing challenging.

CONCLUSION

Despite substantial evidence regarding safety, efficacy, and clinical use, access to testosterone therapy for the treatment of HSDD in women remains a significant unmet need.

International Society for the Study of Women's Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women

BACKGROUND

The Global Consensus Position Statement on the Use of Testosterone Therapy for Women (Global Position Statement) recommended testosterone therapy for postmenopausal women with hypoactive sexual desire disorder (HSDD).

AIM

To provide a clinical practice guideline for the use of testosterone including identification of patients, laboratory testing, dosing, post-treatment monitoring, and follow-up care in women with HSDD.

METHODS

The International Society for the Study of Women's Sexual Health appointed a multidisciplinary panel of experts who performed a literature review of original research, meta-analyses, review papers, and consensus guidelines regarding testosterone use in women. Consensus was reached using a modified Delphi method.

OUTCOMES

A clinically useful guideline following a biopsychosocial assessment and treatment approach for the safe and efficacious use of testosterone in women with HSDD was developed including measurement, indications, formulations, prescribing, dosing, monitoring, and follow-up.

RESULTS

Although the Global Position Statement endorses testosterone therapy for only postmenopausal women, limited data also support the use in late reproductive age premenopausal women, consistent with the International Society for the Study of Women's Sexual Health Process of Care for the Management of HSDD. Systemic transdermal testosterone is recommended for women with HSDD not primarily related to modifiable factors or comorbidities such as relationship or mental health problems. Current available research supports a moderate therapeutic benefit. Safety data show no serious adverse events with physiologic testosterone use, but long-term safety has not been established. Before initiation of therapy, clinicians should provide an informed consent. Shared decision-making involves a comprehensive discussion of off-label use, as well as benefits and risks. A total testosterone level should not be used to diagnose HSDD, but as a baseline for monitoring. Government-approved transdermal male formulations can be used cautiously with dosing appropriate for women. Patients should be assessed for signs of androgen excess and total testosterone levels monitored to maintain concentrations in the physiologic premenopausal range. Compounded products cannot be recommended because of the lack of efficacy and safety data.

CLINICAL IMPLICATIONS

This clinical practice guideline provides standards for safely prescribing testosterone to women with HSDD, including identification of appropriate patients, dosing, and monitoring.

STRENGTHS & LIMITATIONS

This evidence-based guideline builds on a recently published comprehensive meta-analysis and the Global Position Statement endorsed by numerous societies. The limitation is that testosterone therapy is not approved for women by most regulatory agencies, thereby making prescribing and proper dosing challenging.

CONCLUSION

Despite substantial evidence regarding safety, efficacy, and clinical use, access to testosterone therapy for the treatment of HSDD in women remains a significant unmet need. Parish SJ, Simon JA, Davis SR, et al. International Society for the Study of Women's Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women. J Sex Med 2021;18:849-867.

International Society for the Study of Women's Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women

Background: The Global Consensus Position Statement on the Use of Testosterone Therapy for Women (Global Position Statement) recommended testosterone therapy for postmenopausal women with hypoactive sexual desire disorder (HSDD).

Aim: To provide a clinical practice guideline for the use of testosterone including identification of patients, laboratory testing, dosing, post-treatment monitoring, and follow-up care in women with HSDD.

Methods: The International Society for the Study of Women's Sexual Health appointed a multidisciplinary panel of experts who performed a literature review of original research, meta-analyses, review papers, and consensus guidelines regarding testosterone use in women. Consensus was reached using a modified Delphi method.

Outcomes: A clinically useful guideline following a biopsychosocial assessment and treatment approach for the safe and efficacious use of testosterone in women with HSDD was developed including measurement, indications, formulations, prescribing, dosing, monitoring, and follow-up.

Results: Although the Global Position Statement endorses testosterone therapy for only postmenopausal women, limited data also support the use in late reproductive age premenopausal women, consistent with the International Society for the Study of Women's Sexual Health Process of Care for the Management of HSDD. Systemic transdermal testosterone is recommended for women with HSDD not primarily related to modifiable factors or comorbidities such as relationship or mental health problems. Current available research supports a moderate therapeutic benefit. Safety data show no serious adverse events with physiologic testosterone use, but long-term safety has not been established. Before initiation of therapy, clinicians should provide an informed consent. Shared decision-making involves a comprehensive discussion of off-label use, as well as benefits and risks. A total testosterone level should not be used to diagnose HSDD, but as a baseline for monitoring. Government-approved transdermal male formulations can be used cautiously with dosing appropriate for women. Patients should be assessed for signs of androgen excess and total testosterone levels monitored to maintain concentrations in the physiologic premenopausal range. Compounded products cannot be recommended because of the lack of efficacy and safety data.

Clinical Implications: This clinical practice guideline provides standards for safely prescribing testosterone to women with HSDD, including identification of appropriate patients, dosing, and monitoring.

Strengths & Limitations: This evidence-based guideline builds on a recently published comprehensive meta-analysis and the Global Position Statement endorsed by numerous societies. The limitation is that testosterone therapy is not approved for women by most regulatory agencies, thereby making prescribing and proper dosing challenging.

Conclusion: Despite substantial evidence regarding safety, efficacy, and clinical use, access to testosterone therapy for the treatment of HSDD in women remains a significant unmet need.

Use of Testosterone in Postmenopausal Women

The role of testosterone in women and its potential as a therapeutic agent continue to attract controversy. The clinical trials of testosterone therapy for women primarily have focused on treatment of female sexual dysfunction, with the largest placebo-controlled studies being of transdermal testosterone in postmenopausal women. Based on the cumulative data from these studies, loss of sexual desire with associated personal distress currently is the only agreed-on indication for judicious testosterone supplementation for postmenopausal women. This article reviews the physiology of testosterone in women, summarizes the findings from observational studies and clinical trials, and considers indications for testosterone use.

Androgens in premenopausal women and women with premature ovarian insufficiency

Premature ovarian insufficiency (POI) results in both estrogen and testosterone insufficiency. Whether testosterone therapy may be of benefit for women with POI is uncertain. Presently, the only evidence-based indication for testosterone therapy for women is for the treatment of postmenopausal women with low sexual desire with associated personal distress. Consistent with this, available evidence does not support the prescription of testosterone to prevent cardiometabolic disease, bone loss, sarcopenia, or cognitive decline or to improve well-being and low mood in postmenopausal women. Data pertaining to the treatment of women with POI with testosterone are limited. This article reviews androgen physiology in premenopausal women and the impact of POI on circulating androgen concentrations, summarizes findings from observational studies and clinical trials of testosterone therapy in premenopausal women and women with POI, and concludes with recommendations regarding testosterone use in women with POI.

Testosterone use in postmenopausal women

The physiological, clinical and therapeutic aspects of testosterone in women's health are still a matter of controversy and debate. Quality evidence data of clinical trials favors the use of transdermal testosterone in postmenopausal women with female sexual dysfunction causing distress. Doses of testosterone should approximate physiological testosterone levels found in premenopausal women, avoiding supraphysiological concentrations that expose women to adverse events. Short-term treatment periods have been shown to be effective and safe in postmenopausal women with hypoactive sexual desire disorder/dysfunction. However, long-term safety of testosterone use must be determined.

Measurement of Fecal Testosterone Metabolites in Mice: Replacement of Invasive Techniques

Testosterone is the main reproductive hormone in male vertebrates and conventional methods to measure testosterone rely on invasive blood sampling procedures. Here, we aimed to establish a non-invasive alternative by assessing testosterone metabolites (TMs) in fecal and urinary samples in mice. We performed a radiometabolism study to determine the effects of daytime and sex on the metabolism and excretion pattern of radiolabeled TMs. We performed physiological and biological validations of the applied EIA to measure TMs and assessed diurnal fluctuations in TM excretions in male and female mice and across strains. We found that males excreted significantly more radiolabeled TMs via the feces (59%) compared to females (49.5%). TM excretion patterns differed significantly between urinary and fecal samples and were affected by the daytime of ³H-testosterone injection. Overall, TM excretion occurred faster in urinary than fecal samples. Peak excretion of fecal TMs occurred after 8 h when animals received the ³H-testosterone in the morning, or after 4 h when they received the ³H-testosterone injection in the evening. Daytime had no effect on the formed TMs; however, males and females formed different types of TMs. As expected, males showed higher fecal TM levels than females. Males also showed diurnal fluctuations in their TM levels but we found no differences in the TM levels of C57BL/6J and B6D2F1 hybrid males. Finally, we successfully validated our applied EIA (measuring 17β-hydroxyandrostane) by showing that hCG (human chorionic gonadotropin) administration increased TM levels, whereas castration reduced them. In conclusion, our EIA proved suitable for measuring fecal TMs in mice. Our non-invasive method to assess fecal TMs can be widely used in various research disciplines like animal behavior, reproduction, animal welfare, ecology, conservation, and biomedicine.

Safety and efficacy of testosterone for women: a systematic review and meta-analysis of randomised controlled trial data

BACKGROUND

The benefits and risks of testosterone treatment for women with diminished sexual wellbeing remain controversial. We did a systematic review and meta-analysis to assess potential benefits and risks of testosterone for women.

METHODS

We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science for blinded, randomised controlled trials of testosterone treatment of at least 12 weeks' duration completed between Jan 1, 1990, and Dec 10, 2018. We also searched drug registration applications to the European Medicine Agency and the US Food and Drug Administration to identify any unpublished data. Primary outcomes were the effects of testosterone on sexual function, cardiometabolic variables, cognitive measures, and musculoskeletal health. This study is registered with the International Prospective Register of Systematic Reviews (PROSPERO), number CRD42018104073.

FINDINGS

Our search strategy retrieved 46 reports of 36 randomised controlled trials comprising 8480 participants. Our meta-analysis showed that, compared with placebo or a comparator (eg, oestrogen, with or without progestogen), testosterone significantly increased sexual function, including satisfactory sexual event frequency (mean difference 0·85, 95% CI 0·52 to 1·18), sexual desire (standardised mean difference 0·36, 95% CI 0·22 to 0·50), pleasure (mean difference 6·86, 95% CI 5·19 to 8·52), arousal (standardised mean difference 0·28, 95% CI 0·21 to 0·35), orgasm (standardised mean difference 0·25, 95% CI 0·18 to 0·32), responsiveness (standardised mean difference 0·28, 95% CI 0·21 to 0·35), and self-image (mean difference 5·64, 95% CI 4·03 to 7·26), and reduced sexual concerns (mean difference 8·99, 95% CI 6·90 to 11·08) and distress (standardised mean difference -0·27, 95% CI -0·36 to -0·17) in postmenopausal women. A significant rise in the amount of LDL-cholesterol, and reductions in the amounts of total cholesterol, HDL-cholesterol, and triglycerides, were seen with testosterone administered orally, but not when administered non-orally (eg, by transdermal patch or cream). An overall increase in weight was recorded with testosterone treatment. No effects of testosterone were reported for body composition, musculoskeletal variables, or cognitive measures, although the number of women who contributed data for these outcomes was small. Testosterone was associated with a significantly greater likelihood of reporting acne and hair growth, but no serious adverse events were recorded.

INTERPRETATION

Testosterone is effective for postmenopausal women with low sexual desire causing distress, with administration via non-oral routes (eg, transdermal application) preferred because of a neutral lipid profile. The effects of testosterone on individual wellbeing and musculoskeletal and cognitive health, as well as long-term safety, warrant further investigation.

FUNDING

Australian National Health and Medical Research Council.

A systematic review of randomized controlled trials investigating the efficacy and safety of testosterone therapy for female sexual dysfunction in postmenopausal women

The clinical sequelae of oestrogen deficiency during menopause are undoubted. However, the pathophysiological role of testosterone during the menopause is less clear. Several randomized, placebo-controlled clinical trials suggest that testosterone therapy improves sexual function in postmenopausal women. Some studies suggest that testosterone therapy has additional effects, which include increased bone mineral density and decreased serum high-density lipoprotein (HDL) cholesterol. Furthermore, the long-term safety profile of testosterone therapy in postmenopausal women is not clear. This article will provide a concise and critical summary of the literature, to guide clinicians treating postmenopausal women.

Predictors of decreased libido in women during the late reproductive years

OBJECTIVE

To identify risk factors for decreased libido among women in the late reproductive years.

DESIGN

Prospective cohort. Women aged 35 to 47 years identified through random digit dialing were prospectively followed for 4 years with serial hormone assays and standardized questionnaires. Mean hormone values, hormone trends over 4 years, and fluctuation in hormone levels were compared among women with and without a decrease in libido at the last assessment period. Total testosterone, dihydroepiandrosterone sulfate, estradiol, follicle-stimulating hormone, luteinizing hormone, body mass index, psychosocial, and socioeconomic variables were evaluated using multivariable logistic regression.

RESULTS

Of 326 women, 87 (27%) reported a decreased libido, whereas 239 (73%) did not. Participant-specific means for all hormone levels over the study period were similar among both groups. However, total testosterone fluctuation over the study was significantly different between groups. Women whose testosterone levels fluctuated from 3.8 to 21.5 ng/dL around a mean value of 9 ng/dL were four times more likely to report decreased libido compared with women with little fluctuation in testosterone [odds ratio (OR) 4.0; 95% CI, 1.6-10.0]. Depression (OR 3.4; 95%CI, 1.9-6.1), vaginal dryness (OR 3.5; 95%CI, 1.8-6.6), and children living at home (OR 1.4; 95%CI, 1.1-1.7) were also independently associated with decreased libido.

CONCLUSIONS

Decreased libido in the late reproductive years is associated with a pronounced fluctuation in total testosterone over time. Other independent risk factors for decreased libido include vaginal dryness, depression, and living with children. Sexual dysfunction is a complex disorder, related to physiological and psychosocial factors, requiring further investigation.

Onset of the Menopause Transition: The Earliest Signs and Symptoms

Although more than 80% of women experience some degree of psychological or physical symptoms around menopause, both women and clinicians have misconceptions about how hormonal changes relate to menopausal symptoms and psychological conditions. Recently, several large-scale, longitudinal studies have been conducted to better characterize symptoms and changes that occur around menopause. This article offers current evidence for symptoms that occur in the early menopause transition, including vasomotor symptoms, mood changes, sleep problems, and changes in sexual functioning.

Androgens in postmenopausal women: a review

There is significant interest in the use of androgen therapy for postmenopausal women. This review provides background on endogenous androgens in women, describes factors that affect circulating androgen concentrations, and examines the relationship between low levels of androgens and sexual problems. Possible effects of androgens in postmenopausal women beyond sexual function also are discussed. Clinical trials of androgen therapy for the treatment of hypoactive sexual desire disorder are reviewed, with a discussion of potential risks. A practical approach to using androgens to treat low sexual desire with associated distress is presented, accompanied by an illustrative case.

A sex-specific dose-response curve for testosterone: could excessive testosterone limit sexual interaction in women?

Testosterone treatment increases sexual desire and well-being in women with hypoactive sexual desire disorder; however, many studies have shown only modest benefits limited to moderate doses. Unlike men, available data indicate women show a bell-shaped dose-response curve for testosterone, wherein a threshold dosage of testosterone leads to desirable sexual function effects, but exceeding this threshold results in a lack of further positive sexual effects or may have a negative impact. Emotional and physical side-effects of excess testosterone, including aggression and virilization, may counteract the modest benefits on sexual interaction, providing a possible explanation for a threshold dose of testosterone in women. In this commentary, we will review and critically analyze data supporting a curvilinear dose-response relationship between testosterone treatment and sexual activity in women with low libido, and also explore possible explanations for this observed relationship. Understanding optimal dosing of testosterone unique to women may bring us one step closer to overcoming regulatory barriers in treating female sexual dysfunction.

Sexual Function after Surgery for Prostate or Bladder Cancer

Background

Compromised sexual function is often a side effect for patients following radical surgical procedures for bladder or prostate cancer.

Methods

The authors review the classification and physiology of sexual function and dysfunction. Moreover, they explain the possible pathophysiology directly resulting from surgery, and they discuss several approaches available to address these problems.

Results

Options for male sexual dysfunction, primarily erectile dysfunction resulting from radical prostatectomy or surgery for bladder cancer, range from patient education to penile prosthesis implantation. Female sexual dysfunction caused by surgical intervention for bladder cancer includes problems with libido, arousal, orgasm, and dyspareunia. Treatment options for women can include sex therapy, hormonal therapy, and preventive strategies. However, no consensus has been established on the most effective agents and time points to treat male or female sexual dysfunction following radical cystectomies or prostatectomies. The chronic intermittent treatment of erectile dysfunction following radical prostatectomy has been commonly referred to as penile rehabilitation.

Conclusions

Additional research is needed to obtain further data concerning sexual dysfunction in both men and women following radical pelvic surgeries. Modification of surgical techniques, the use of various treatment modalities for sexual dysfunction, and the development of new agents will help to successfully minimize or prevent damage and restore normal sexual function after local surgical therapy for prostate or bladder cancer in the future.

Sexual function in infertile women with polycystic ovary syndrome and unexplained infertility

BACKGROUND

While female sexual dysfunction is a frequent occurrence, characteristics in infertile women are not well delineated. Furthermore, the impact of infertility etiology on the characteristics in women with differing androgen levels observed in women with polycystic ovary syndrome and unexplained infertility has not been assessed.

OBJECTIVE

The objective of the study was to determine the characteristics of sexual dysfunction in women with polycystic ovary syndrome and unexplained infertility.

STUDY DESIGN

A secondary data analysis was performed on 2 of Eunice Kennedy Shriver National Institute of Child Health and Human Development Cooperative Reproductive Medicine Networks clinical trials: Pregnancy in Polycystic Ovary Syndrome Study II and Assessment of Multiple Intrauterine Gestations From Ovarian Stimulation. Both protocols assessed female sexual function using the Female Sexual Function Inventory and the Female Sexual Distress Scale.

RESULTS

Women with polycystic ovary syndrome had higher weight and body mass index than women with unexplained infertility (each P < .001), greater phenotypic (Ferriman-Gallwey hirsutism score, sebum score, and acne score; each P < .001), and hormonal (testosterone, free testosterone, and dehydroepiandrosterone; each P < .001) evidence of androgen excess. Sexual function scores, as assessed by the Female Sexual Function Inventory, were nearly identical. The Female Sexual Distress Scale total score was higher in women with polycystic ovary syndrome. The mean Female Sexual Function Inventory total score increased slightly as the free androgen index increased, mainly as a result of the desire subscore. This association was more pronounced in the women with unexplained infertility.

CONCLUSION

Reproductive-age women with infertility associated with polycystic ovary syndrome and unexplained infertility, despite phenotypic and biochemical differences in androgenic manifestations, do not manifest clinically significant differences in sexual function.

Testosterona, desejo sexual e conflito de interesse: periódicos biomédicos como espaços privilegiados de expansão do mercado de medicamentos

Resumo Este artigo focaliza a articulação entre pesquisa biomédica e indústria farmacêutica com base nos estudos da tecnociência. Abordamos o caso do medicamento Intrinsa – adesivo de testosterona, cujo propósito é o aumento do desejo sexual em mulheres – examinando artigos que relatam resultados de ensaios clínicos, publicados em periódicos científicos. Buscamos demonstrar como a população visada pelos ensaios clínicos foi paulatinamente expandida de modo a englobar um número cada vez maior de mulheres, o que pressupôs rearranjos na maneira de definir as disfunções para as quais o medicamento seria indicado e as possíveis causas subjacentes. Foi possível identificar três caminhos de ampliação do mercado para o Intrinsa: o primeiro baseou-se na alteração do status de menopausa. A terapia com testosterona passou a ser vinculada também ao envelhecimento (incluindo, portanto, a pré-menopausa e a menopausa “natural”) e não mais exclusivamente à menopausa cirúrgica; o segundo focalizou a dissociação entre o uso do Intrinsa e a terapia com estrógenos; o terceiro buscou vincular o medicamento ao aumento de “bem-estar”.

The Effects of Intensive Weight Reduction on Body Composition and Serum Hormones in Female Fitness Competitors

Worries about the potential negative consequences of popular fat loss regimens for aesthetic purposes in normal weight females have been surfacing in the media. However, longitudinal studies investigating these kinds of diets are lacking. The purpose of the present study was to investigate the effects of a 4-month fat-loss diet in normal weight females competing in fitness-sport. In total 50 participants finished the study with 27 females (27.2 ± 4.1 years) dieting for a competition and 23 (27.7 ± 3.7 years) acting as weight-stable controls. The energy deficit of the diet group was achieved by reducing carbohydrate intake and increasing aerobic exercise while maintaining a high level of protein intake and resistance training in addition to moderate fat intake. The diet led to a ~12% decrease in body weight (P < 0.001) and a ~35-50% decrease in fat mass (DXA, bioimpedance, skinfolds, P < 0.001) whereas the control group maintained their body and fat mass (diet × group interaction P < 0.001). A small decrease in lean mass (bioimpedance and skinfolds) and in vastus lateralis muscle cross-sectional area (ultrasound) were observed in diet (P < 0.05), whereas other results were unaltered (DXA: lean mass, ultrasound: triceps brachii thickness). The hormonal system was altered during the diet with decreased serum concentrations of leptin, triiodothyronine (T3), testosterone (P < 0.001), and estradiol (P < 0.01) coinciding with an increased incidence of menstrual irregularities (P < 0.05). Body weight and all hormones except T3 and testosterone returned to baseline during a 3-4 month recovery period including increased energy intake and decreased levels aerobic exercise. This study shows for the first time that most of the hormonal changes after a 35-50% decrease in body fat in previously normal-weight females can recover within 3-4 months of increased energy intake.

Estrogens and Androgens in Skeletal Physiology and Pathophysiology

Estrogens and androgens influence the growth and maintenance of the mammalian skeleton and are responsible for its sexual dimorphism. Estrogen deficiency at menopause or loss of both estrogens and androgens in elderly men contribute to the development of osteoporosis, one of the most common and impactful metabolic diseases of old age. In the last 20 years, basic and clinical research advances, genetic insights from humans and rodents, and newer imaging technologies have changed considerably the landscape of our understanding of bone biology as well as the relationship between sex steroids and the physiology and pathophysiology of bone metabolism. Together with the appreciation of the side effects of estrogen-related therapies on breast cancer and cardiovascular diseases, these advances have also drastically altered the treatment of osteoporosis. In this article, we provide a comprehensive review of the molecular and cellular mechanisms of action of estrogens and androgens on bone, their influences on skeletal homeostasis during growth and adulthood, the pathogenetic mechanisms of the adverse effects of their deficiency on the female and male skeleton, as well as the role of natural and synthetic estrogenic or androgenic compounds in the pharmacotherapy of osteoporosis. We highlight latest advances on the crosstalk between hormonal and mechanical signals, the relevance of the antioxidant properties of estrogens and androgens, the difference of their cellular targets in different bone envelopes, the role of estrogen deficiency in male osteoporosis, and the contribution of estrogen or androgen deficiency to the monomorphic effects of aging on skeletal involution.

Is There a Gender Difference in Strength of Sex Drive? Theoretical Views, Conceptual Distinctions, and a Review of Relevant Evidence

The sex drive refers to the strength of sexual motivation. Across many different studies and measures, men have been shown to have more frequent and more intense sexual desires than women, as reflected in spontaneous thoughts about sex, frequency and variety of sexual fantasies, desired frequency of intercourse, desired number of partners, masturbation, liking for various sexual practices, willingness to forego sex, initiating versus refusing sex, making sacrifices for sex, and other measures. No contrary findings (indicating stronger sexual motivation among women) were found. Hence we conclude that the male sex drive is stronger than the female sex drive. The gender difference in sex drive should not be generalized to other constructs such as sexual or orgasmic capacity, enjoyment of sex, or extrinsically motivated sex.

Effect of intravaginal dehydroepiandrosterone (DHEA) on the female sexual function in postmenopausal women: ERC-230 open-label study

OBJECTIVE

Intravaginal DHEA (dehydroepiandrosterone, prasterone), the exclusive precursor of androgens and estrogens in postmenopausal women, has previously been shown to improve all the domains of sexual function by a strictly local action in the vagina. The well recognized female sexual function index (FSFI) questionnaire was used in the present study.

DESIGN

The long-term effect of 52-week treatment with daily intravaginal 0.50% (6.5 mg) DHEA was evaluated on the various domains of female sexual function using the FSFI questionnaire at baseline, Week 26 and Week 52.

SUBJECTS

One hundred and fifty-four postmenopausal women with at least one mild to severe symptom of vulvovaginal atrophy (VVA) and who have completed the FSFI questionnaire at baseline and at least one post-baseline timepoint were included in the analysis.

RESULTS

The FSFI domains desire, arousal, lubrication, orgasm, satisfaction and pain were increased by 28%, 49%, 115%, 51%, 41% and 108%, respectively (p<0.0001 for all parameters) at 52 weeks vs. baseline, while the total score was increased from 13.4±0.62 at baseline to 21.5±0.82 (+60%, p<0.0001) at 52 weeks.

CONCLUSION

As the serum levels of DHEA and all its metabolites, including estradiol and testosterone, show no meaningful change, the present clinical data indicate a stimulatory effect of intravaginal DHEA through a strictly local action in agreement with the preclinical data showing that the androgens made locally from DHEA in the vagina induce an increase in local nerve density.

Efficacy and safety of transdermal testosterone in postmenopausal women with hypoactive sexual desire disorder: a systematic review and meta-analysis

OBJECTIVE

To systematically review and summarize the existing evidence related to the efficacy and safety of transdermal T in postmenopausal women for the treatment of hypoactive sexual desire disorder (HSDD).

DESIGN

Systematic reviews and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Seven randomized controlled trials enrolled 3,035 participants; 1,350 women were randomized to treatment with T patch, and 1,379 women were randomized to placebo.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Primary outcome: satisfying sexual episodes.

SECONDARY OUTCOMES

sexual activity, orgasm, Profile of Female Sexual Function domains (desire), personal distress score, adverse events, acne, increased hair growth, facial hair, alopecia, voice deepening, urinary symptoms, breast pain, headache, site reaction, total adverse events, serious adverse events, withdrawal from study, and follow-up rate.

RESULT(S)

The T group had significantly more satisfying sexual episodes, sexual activity, orgasms, desire, significant change in Personal Distress Scale score, androgenic adverse events, acne, and hair growth compared with the placebo group. There was no significant difference between the two groups in increase in facial hair, alopecia, voice deepening, urinary symptoms, breast pain, headache, site reaction to the patch, total adverse events, serious adverse events, reasons for withdrawal from the study, and the number of women who completed the study.

CONCLUSION(S)

The short-term efficacy in terms of improvement of sexual function and safety of transdermal T in naturally and surgically menopausal women affected by HSDD either on or not on estrogen progestin hormone therapy is evident from this systematic review. The use of transdermal T is associated with increase in androgenic adverse events such as acne but is not associated with any serious adverse events.

Sexual function and hormonal profiles in women with and without polycystic ovary syndrome: a population-based study

There is no consensus regarding the impact of polycystic ovary syndrome (PCOS) and its hormonal profile on sexual function of affected women; majority of data documented are not population based and there is a lack of studies investigating the association between hormonal profiles with sexual function in women with PCOS. We aimed to compare the sexual function of PCOS women with controls in a population-based study based on their hormonal profiles. In this cross-sectional study, sexual function (using the Female Sexual Function Index (FSFI) questionnaire) and hormonal profiles were determined in 63 PCOS subjects and 216 healthy women (controls); aged 18-45 years. A comparison of PCOS women and controls showed no statistically significant difference in total FSFI and each of its specific domain scores. There were significant positive correlations between dehydroepiandrosterone sulfate and total FSFI, orgasm and satisfaction domains in controls (r=0.156, r=0.206, r=0.275, respectively). No significant correlations between hormonal profiles and FSFI scores were found in the PCOS group, except for prolactin and orgasm (r=-0.250). In conclusion, sexual function did not differ between PCOS women and controls. High levels of androgens in women with PCOS were not associated with an improvement in sexual function.

Pharmacologic Treatment Options for Hypoactive Sexual Desire Disorder

Hypoactive sexual desire disorder is the most common cause of sexual dysfunction in women. According to a national survey, approximately a third of all women experience low sexual desire. The etiology of the disorder is often multifactorial. Research in treatment options for hypoactive sexual desire disorder is limited. In this article, treatment options including sex therapy, hormone therapy (estrogen, testosterone, dehydroepiandrosterone, tibolone), non-hormonal medical therapies (buproprion, buspirone, phosphodiesterase-5 inhibitors, amantadine and apomorphine) and herbal therapies (Avlimil®, Arginmax®, Zestra®, yohimbine and Ginkgo biloba) are reviewed.

Vitamin D3 deficiency is associated with female sexual dysfunction in premenopausal women

PURPOSE

To assess female sexual functions in women who were affected by vitamin D₃ deficiency.

METHODS

A total of 50 women with FSD and 58 healthy women controls were included in the study, according to the Female Sexual Function Index (FSFI) questionnaire using a 26.55 cutoff value. Detailed medical histories were obtained from all sexual active women, and all women were evaluated in terms of possible presence of depression with the Beck Depression Inventory (BDI). Serum 25-hydroxyvitamin D₃, follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, total and free testosterone, estradiol, dehydroepiandrosterone-SO₄ (DHEA-SO₄), sex hormone-binding globulin (SHBG), free thyroxine (fT4), and thyroid-stimulating hormone (TSH) levels were measured.

RESULTS

Mean age of premenopausal women was 34.9 ± 6.3 years. The level of serum 25-hydroxyvitamin D₃ was significantly lower in women with FSD compared with the controls (15.9 ± 8.4 and 26.3 ± 11.7 nmol/L, respectively). Desire (p = 0.0001), arousal (p = 0.0001), lubrication (p = 0.002), orgasm (p = 0.0001), satisfaction (p = 0.018), and pain (p = 0.010) domain scores were also correlated with the levels of serum 25-hydroxyvitamin D₃. The BDI score showed a significant negative correlation with the total FSFI score (r = -0.492, p = 0.0001). The FSFI score not showed a significant correlation with the hormones (p > 0.05).

CONCLUSION

There is a relationship with FSD and deficiency of vitamin D₃. Also, increased depressive symptoms were associated with FSD.

Non-ovarian aromatization is required to activate female sexual motivation in testosterone-treated ovariectomized quail

Although aromatase is expressed in both male and female brains, its functional significance in females remains poorly understood. In female quail, sexual receptivity is activated by estrogens. However it is not known whether sexual motivation is similarly estrogen-dependent and whether estrogens locally produced in the brain contribute to these behavioral responses. Four main experiments were designed to address these questions. In Experiment 1 chronic treatment of females with the anti-estrogen tamoxifen decreased their receptivity, confirming that this response is under the control of estrogens. In Experiment 2 chronic treatment with tamoxifen significantly decreased sexual motivation as treated females no longer approached a sexual partner. In Experiment 3 (a) ovariectomy (OVX) induced a significant decrease of time spent near the male and a significantly decreased receptivity compared to gonadally intact females, (b) treatment with testosterone (OVX+T) partially restored these responses and (c) this effect of T was prevented when estradiol synthesis was inhibited by the potent aromatase inhibitor Vorozole (OVX+T+VOR). Serum estradiol concentration was significantly higher in OVX+T than in OVX or OVX+T+VOR females. Together these data demonstrate that treatment of OVX females with T increases sexual motivation and that these effects are mediated at least in part by non-gonadal aromatization of the androgen. Finally, assays of aromatase activity on brain and peripheral tissues (Experiment 4) strongly suggest that brain aromatization contributes to behavioral effects observed here following T treatment but alternative sources of estrogens (e.g. liver) should also be considered.

Increasing women's sexual desire: The comparative effectiveness of estrogens and androgens

Both estradiol and testosterone have been implicated as the steroid critical for modulating women's sexual desire. By contrast, in all other female mammals only estradiol has been shown to be critical for female sexual motivation and behavior. Pharmaceutical companies have invested heavily in the development of androgen therapies for female sexual desire disorders, but today there are still no FDA approved androgen therapies for women. Nonetheless, testosterone is currently, and frequently, prescribed off-label for the treatment of low sexual desire in women, and the idea of testosterone as a possible cure-all for female sexual dysfunction remains popular. This paper places the ongoing debate concerning the hormonal modulation of women's sexual desire within a historical context, and reviews controlled trials of estrogen and/or androgen therapies for low sexual desire in postmenopausal women. These studies demonstrate that estrogen-only therapies that produce periovulatory levels of circulating estradiol increase sexual desire in postmenopausal women. Testosterone at supraphysiological, but not at physiological, levels enhances the effectiveness of low-dose estrogen therapies at increasing women's sexual desire; however, the mechanism by which supraphysiological testosterone increases women's sexual desire in combination with an estrogen remains unknown. Because effective therapies require supraphysiological amounts of testosterone, it remains unclear whether endogenous testosterone contributes to the modulation of women's sexual desire. The likelihood that an androgen-only clinical treatment will meaningfully increase women's sexual desire is minimal, and the focus of pharmaceutical companies on the development of androgen therapies for the treatment of female sexual desire disorders is likely misplaced.

Testosterone in women--the clinical significance

Testosterone is an essential hormone for women, with physiological actions mediated directly or via aromatisation to oestradiol throughout the body. Despite the crucial role of testosterone and the high circulating concentrations of this hormone relative to oestradiol in women, studies of its action and the effects of testosterone deficiency and replacement in women are scarce. The primary indication for the prescription of testosterone for women is loss of sexual desire, which causes affected women substantial concern. That no formulation has been approved for this purpose has not impeded the widespread use of testosterone by women--either off-label or as compounded therapy. Observational studies indicate that testosterone has favourable cardiovascular effects measured by surrogate outcomes; however, associations between endogenous testosterone and the risk of cardiovascular disease and total mortality, particularly in older women, are yet to be established. Adverse cardiovascular effects have not been seen in studies of transdermal testosterone therapy in women. Clinical trials suggest that exogenous testosterone enhances cognitive performance and improves musculoskeletal health in postmenopausal women. Unmet needs include the availability of approved testosterone formulations for women and studies to elucidate the contribution of testosterone to cardiovascular, cognitive, and musculoskeletal health and the risk of cancer.

Effect of Intravaginal Prasterone on Sexual Dysfunction in Postmenopausal Women with Vulvovaginal Atrophy

INTRODUCTION

Previous data have shown that intravaginal dehydroepiandrosterone (DHEA, prasterone) improved all the domains of sexual function, an effect most likely related to the local formation of androgens from DHEA.

AIMS

To confirm in a placebo-controlled, prospective, double-blind and randomized study the benefits of daily intravaginal DHEA for 12 weeks on sexual function using the Female Sexual Function Index (FSFI) questionnaire.

METHODS

Placebo was administered daily to 157 women while 325 women received 0.50% (6.5 mg) DHEA daily for 12 weeks. All women were postmenopausal meeting the criteria of vulvovaginal atrophy (VVA), namely moderate to severe dyspareunia as their most bothersome symptom of VVA in addition to having ≤5% of vaginal superficial cells and vaginal pH > 5.0. The FSFI questionnaire was filled at baseline (screening and day 1), 6 weeks and 12 weeks. Comparison between DHEA and placebo of the changes from baseline to 12 weeks was made using the analysis of covariance test, with treatment group as the main factor and baseline value as the covariate.

MAIN OUTCOME MEASURES

The six domains and total score of the FSFI questionnaire were evaluated.

RESULTS

The FSFI domain desire increased over placebo by 0.24 unit (+49.0%, P = 0.0105), arousal by 0.42 unit (+56.8%, P = 0.0022), lubrication by 0.57 unit (+36.1%, P = 0.0005), orgasm by 0.32 unit (+33.0%, P = 0.047), satisfaction by 0.44 unit (+48.3%, P = 0.0012), and pain at sexual activity by 0.62 unit (+39.2%, P = 0.001). The total FSFI score, on the other hand, has shown a superiority of 2.59 units in the DHEA group over placebo or a 41.3% greater change than placebo (P = 0.0006 over placebo).

CONCLUSION

The present data show that all the six domains of the FSFI are improved over placebo (from P = 0.047 to 0.0005), thus confirming the previously observed benefits of intravaginal DHEA on female sexual dysfunction by an action exerted exclusively at the level of the vagina, in the absence of biologically significant changes of serum steroids levels.

Role of androgens in modulating male and female sexual function

Advancement in basic and clinical research has provided considerable evidence suggesting a key role of androgens in the physiology and pathophysiology of sexual function. Evidence from clinical studies in men and women with androgen deficiency support a role of androgens in maintaining sexual function in men and women and are integral in maintaining sexual health. Preclinical studies utilizing male animal models demonstrated a role of androgens in maintenance of: (i) penile tissue structural integrity, (ii) penile trabecular smooth muscle growth and function, (iii) integrity of penile nerve fiber network, (iv) signaling pathways in the corpora cavernosa, (v) myogenic and adipogenic differentiation in the corpora cavernosa, (vi) physiological penile response to stimuli, and (vii) facilitating corporeal hemodynamics. These findings strongly suggest a role for androgen in the physiology of penile erection. In addition, clinical studies in hypogonadal men with erectile dysfunction treated with testosterone provided invaluable information on restoring erectile function and improving ejaculatory function. Similarly, clinical studies in surgically or naturally postmenopausal women with androgen deficiency suggested that androgens are important for maintaining sexual desire and testosterone treatment was shown to improve sexual desire, arousal and orgasm. Furthermore, studies in female animal models demonstrated that androgens maintain the integrity of vaginal nerve fiber network, muscularis volume, and enhance genital blood flow and mucification. Based on the biochemical, physiological and clinical findings from human and animal studies, we suggest that androgens are integral for maintaining sexual function and play a critical role in maintaining sexual health in men and women.

Testosterone dose-response relationships in hysterectomized women with or without oophorectomy: effects on sexual function, body composition, muscle performance and physical function in a randomized trial

OBJECTIVE

This study aims to determine the dose-dependent effects of testosterone on sexual function, body composition, muscle performance, and physical function in hysterectomized women with or without oophorectomy.

METHODS

Seventy-one postmenopausal women who previously underwent hysterectomy with or without oophorectomy and had total testosterone levels less than 31 ng/dL or free testosterone levels less than 3.5 pg/mL received a standardized transdermal estradiol regimen during the 12-week run-in period and were randomized to receive weekly intramuscular injections of placebo or 3, 6.25, 12.5, or 25 mg of testosterone enanthate for 24 weeks. Total and free testosterone levels were measured by liquid chromatography-tandem mass spectrometry and equilibrium dialysis, respectively. The primary outcome was change in sexual function measured by the Brief Index of Sexual Functioning for Women. Secondary outcomes included changes in sexual activity, sexual distress, Derogatis Interview for Sexual Functioning, lean body mass, fat mass, muscle strength and power, and physical function.

RESULTS

Seventy-one women were randomized; five groups were similar at baseline. Sixty-two women with analyzable data for the primary outcome were included in the final analysis. The mean on-treatment total testosterone concentrations were 19, 78, 102, 128, and 210 ng/dL in the placebo, 3-mg, 6.25-mg, 12.5-mg, and 25-mg groups, respectively. Changes in composite Brief Index of Sexual Functioning for Women scores, thoughts/desire, arousal, frequency of sexual activity, lean body mass, chest-press power, and loaded stair-climb power were significantly related to increases in free testosterone concentrations; compared with placebo, changes were significantly greater in women assigned to the 25-mg group, but not in women in the lower-dose groups. Sexual activity increased by 2.7 encounters per week in the 25-mg group. The frequency of androgenic adverse events was low.

CONCLUSIONS

Testosterone administration in hysterectomized women with or without oophorectomy for 24 weeks was associated with dose and concentration-dependent gains in several domains of sexual function, lean body mass, chest-press power, and loaded stair-climb power. Long-term trials are needed to weigh improvements in these outcomes against potential long-term adverse effects.

Hormone therapy for reproductive depression in women

An email survey of patients attending a PMS and Menopause Centre produced 238 patients whose principal presenting symptom was depression. Seventy-seven percent claimed to have had severe or moderate depression, 17% had had at least one psychotic episode and 14% had attempted suicide. Fifty-eight percent had seen a psychiatrist. Seventy-one percent had received antidepressants and 17% had received mood stabilising drugs. Twelve percent had been admitted to a psychiatric hospital and 3.8% had received electroconvulsive therapy. Sixty-eight percent had premenstrual syndrome as a teenager and 145 women (89%) out of 165 women who had been pregnant had no depression during pregnancy but 110 (66%) developed postnatal depression. Ninety-seven women (58%) who had been pregnant had suffered both premenstrual depression and postnatal depression. All were treated with transdermal estrogens and 93% also had transdermal testosterone. One hundred and seventy-one patients had a uterus and received cyclical progestogen to protect the endometrium and 63% of these developed the premenstrual syndrome-type symptoms of progesterone intolerance during the progestogen days. Thirty-five percent of patients claimed to be cured and 55% had a considerable improvement with estrogen therapy. Only 3.7% reported that there was no improvement. For 94%, the hormone therapy was a life-changing event for the better. None were worse. Forty patients had hysterectomy and bilateral oophorectomy for progesterone intolerance or heavy uterine bleeding and 38 replied that it was life changing for the better with less or no depression. It is concluded that premenstrual and postnatal depressions appear in the same vulnerable women. These women are typically well during pregnancy and are a sub group of reproductive depression which also develops climacteric depression in the transition phase. These types of depression are the product of hormonal changes and respond well to transdermal hormone therapy.