Percutaneous administration of testosterone gel in postmenopausal women--a pharmacological study

Addition of testosterone to endocrine care for transgender women: a dose-finding and feasibility trial

OBJECTIVE

Transgender women who underwent gonadectomy have lower serum testosterone concentrations than cisgender women. There is uncertainty regarding the dosing and side effects of supplementation of testosterone in transgender women. This study aimed to assess the feasibility of dosing testosterone to the cisgender female physiological range in transgender women. In addition, we explored changes in cardiovascular parameters, virilizing side effects, and clinical symptoms.

DESIGN

This is an open-label, single-arm feasibility study. Participants initially went through a dose-titration phase with 2-week intervals of 0.07-0.09-0.13 mL (277-318-403 μg bioavailable testosterone) testosterone 2% gel to establish a dose leading to serum testosterone concentrations between 1.5 and 2.5 nmol/L. This dose was then continued for 8 weeks.

METHODS

Participants applied daily transdermal testosterone 2% gel (Tostran®) at the prescribed dosage. Testosterone was measured every 2-4 weeks. Laboratory analyses, side effects, and clinical symptoms were evaluated.

RESULTS

In total, 12 participants were included. Most participants required a dose of 0.07 mL (277 μg bioavailable testosterone) or 0.09 mL (318 μg bioavailable testosterone) to reach serum testosterone concentrations of 1.5-2.5 nmol/L. Continuing this dose, testosterone concentrations remained stable throughout the study. Changes in clinical outcomes were in the desired direction, and side effects were mild.

CONCLUSIONS

The use of testosterone supplementation in transgender women seems feasible and safe in the short term. Although dosing requires personalized titration, stable testosterone levels can be established. A blinded, placebo-controlled, randomized clinical trial is needed to study the clinical benefit.

Detection of testosterone microdosing in healthy females

The ready detectability of synthetic androgens by mass spectrometry (MS)-based antidoping tests has reoriented androgen doping to using testosterone (T), which must be distinguished from its endogenous counterpart making detection of exogenous T harder. We investigated urine and serum steroid and hematological profiling individually and combined to determine the optimal detection model for T administration in women. Twelve healthy females provided six paired blood and urine samples over 2 weeks prior to treatment consisting of 12.5-mg T in a topical transdermal gel applied daily for 7 days. Paired blood and urine samples were then obtained at the end of treatment and Days 1, 2, 4, 7, and 14 days later. Compliance with treatment and sampling was high, and no adverse effects were reported. T treatment significantly increased serum and urine T, serum dihydrotestosterone (DHT), urine 5α-androstane-3α,17β-diol (5α-diol) epitestosterone (E), and urine T/E ratio with a brief window of detection (2-4 days) as well as total and immature (medium and high fluorescence) reticulocytes that remained elevated over the full 14 posttreatment days. Carbon isotope ratio MS and the OFF score and Abnormal Blood Profile score (ABPS) were not discriminatory. The optimal multivariate model to identify T exposure combined serum T, urine T/E ratio with three hematological variables (% high fluorescence reticulocytes, mean corpuscular hemoglobin, and volume) with the five variables providing 93% correct classification (4% false positive, 10% false negatives). Hence, combining select serum and urine steroid MS variables with reticulocyte measures can achieve a high but imperfect detection of T administration to healthy females.

Androgen supplementation in assisted reproduction: where are we in 2019?

PURPOSE OF REVIEW

The purpose of this review is to provide an overview of androgen supplementation in ART with the most updated evidence, from animal studies to its clinical applications in poor ovarian responders (POR) and the future studies to be published.

RECENT FINDINGS

Animal studies, has shown that testosterone supplementation, can be an option to increase the recruitable follicular pool in POR. However, the potential mechanism of action, dose, and duration of treatment is still under investigation. Early studies in humans reported promising results in favor of androgens [dehydroepiandrosterone (DHEA) or testosterone] in POR. Nevertheless, recent evidence does not appear to follow the initial results, whereas the type, dose, and duration of testosterone administration appear to be crucial for treatment effect.

SUMMARY

Testosterone seems to play an essential role in regulating ovarian function. However, it is worrisome that androgens are used off-label, despite that the available evidence is weak. Although testosterone supplementation may be beneficial in POR, published studies have used inconsistent doses and duration of administration. An ongoing trial (T-TRANSPORT trial) for the first time aims to provide conclusive evidence on whether transdermal testosterone administration can improve the reproductive outcomes in patients undergoing IVF/ICSI.

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.

Testosterone and libido in surgically and naturally menopausal women

The assessment and then treatment of a change in libido, or a change in the desire to partake in sexual activity, during the menopausal transition and beyond has been a challenging and elusive area of clinical research. This is partly due to the multidimensional nature of female sexuality, the difficulties of measuring testosterone in women in a reliable and accurate manner, and the complexity of the neurobiology and neurobehavior of female sexual desire. In addition, there is a lack of evidence for diagnostic specificity of low free testosterone levels for the symptom of low libido in women for whom there are no confounding interpersonal or psychological factors; although, in the symptomatic population of surgically or naturally menopausal women, a low level of free testosterone often accompanies a complaint of reduced desire/libido. The randomized clinical trial research on testosterone replacement for naturally and/or surgically menopausal women with sexual dysfunction has been criticized for a high placebo response rate, supraphysiological replacement levels of testosterone, the perception of modest clinical outcome when measuring objective data such as the frequency of sexual intercourse relative to placebo, and the unknown safety of long-term testosterone replacement in the estrogen-replete surgically or naturally menopausal woman. A careful review of current evidence from randomized, controlled trials lends support to the value of the replacement of testosterone in the estrogen-replete menopausal woman for whom libido and desire has declined. The issue of long-term safety remains to be answered.

Androgen replacement therapy in women

Female androgens are derived from either the adrenal and peripheral conversion of the adrenal sex steroid precursor, dehydroepiandrosterone, or from direct ovarian production. Adrenal insufficiency or bilateral oophorectomy (surgical menopause) result in severe androgen deficiency, which can be clinically associated with impaired libido, drive and energy. Physiological menopause does not necessarily lead to androgen deficiency. The previously suggested definition of female androgen deficiency syndrome, as the concurrent presence of low androgen levels and low libido, is not precise enough and may lead to overdiagnosis. Current replacement options include transdermal testosterone or oral dehydroepiandrosterone treatment, both of which have been shown to result in significant improvements, in particular in libido and mood, while long-term effects on body composition, cardiovascular and cancer risk are less documented. Owing to these concerns, androgen replacement should be reserved for women with severe androgen deficiency due to an established cause and matching clinical symptoms.

Sexuality and the menopause

Sexuality is innate within all women to a greater or lesser extent, and is affected by a number of extrinsic factors that occur in the menopausal transition. Assessing hormone status is difficult as evidence exists that sex hormones may differ between ethnic groups, and that bio-assays may be insensitive at lower testosterone levels. Data are available on the prevalence of female sexual dysfunction, but results from cross-sectional studies differ from those of longitudinal studies. The original traditional models of human sexual response have been challenged, and new models have been defined which show more complex interaction between intrinsic and extrinsic factors. Definitions of sexual dysfunction have been redefined. There are a limited number of randomized, placebo-controlled trials of drugs to improve sexual function. These include sildenafil citrate, tibolone and hormone replacement therapy. Randomized controlled trials on testosterone replacement in naturally and/or surgically menopausal patients with female sexual dysfunction have been criticized for a high placebo response rate and short duration. This chapter seeks to put sexuality into perspective and to define both function and dysfunction.

Current Management Strategies of the Postmenopausal Patient with Sexual Health Problems

INTRODUCTION

Sexual health concerns of menopausal women include decreases in sexual interest, arousal, lubrication, and orgasm, and increases in sexual pain, all of which may be associated with distress.

AIM

To review a step-care progression of sexual healthcare management: identification of the sexual health problem; education of the patient and the partner; modification of reversible causes; first-line therapies consisting of devices and medications; and second-line therapies with more invasive treatments including surgery.

METHODS

The healthcare provider is presented with a clinical diagnosis and treatment paradigm that engages mind, body, and relationship issues proceeding step-wise in a rational and cost-effective fashion.

MAIN OUTCOME MEASURE

Literature review in women's sexual health.

RESULTS

Women's health, including sexual health, is a fundamental human right. Supported by evidence-based data, a step-care approach to diagnosis and management of women with sexual health problems is advised. Multidisciplinary interventions should be considered as needed. Identification of sexual health concerns engages diagnostic components of psychologic consultation, history, physical examination, and laboratory testing as appropriate. Key to clinical assessment is the detailed sexual, medical, and psychosocial history. No agreement exists on necessary laboratory tests. Patient (and partner) education improves understanding of treatment options and expectations, and promotes a trusting patient-physician partnership. Modification of reversible causes includes sex therapy, lubricants, altering medications, modifying lifestyle and physical therapy for pelvic floor disorders. First-line therapies should be administered based upon diagnosis, needs, expectations, risks, benefits, and cost, and include medical devices and drugs such as hormones, vasoactive agents, dopamine agonists, topical steroids, anti-infectious agents, and analgesic agents. Second-line therapies, such as surgery, are initiated upon failure, insufficient response, or adverse side effects associated with one or more of the first-line therapies or patient preference.

CONCLUSIONS

For postmenopausal women with sexual dysfunction, a rational clinical management strategy begins with treatment options that are most reversible and least invasive and costly.

Treatment with percutanous testosterone gel in postmenopausal women with decreased libido – effects on sexuality and psychological general well-being

OBJECTIVES

To elucidate if percutanous treatment with 10mg testosterone per day could enhance sexuality and psychological well-being in postmenopausal women presenting problems with low libido. Secondary to study the influence on blood lipids, hemoglobin and erythropoietin levels.

METHODS

Fifty-three postmenopausal women participated. As a complement to their already on-going HRT, 10mg of a testosterone gel (Testogel, Besins-Iscovesco) or placebo was administered. Treatment continued for three plus three months in a double blind, randomized, crossover design.

RESULTS

The scores concerning "frequency of sexual activity, orgasm and intercourse", "sexual arousal, fantasies and enjoyment", "satisfaction with orgasms", and "interest in sex" were all significally improved for testosterone addition as compared to placebo both before and after crossover. Testosterone levels increased more than 10-fold during treatment while DHT-levels were more than doubled. Estrogen levels were not affected during the addition of testosterone. Liver enzymes, total cholesterol, triglycerides, HDL and LDL revealed no significant differences between any of the periods or groups. Endometrial thickness did not change significantly during treatment. Hemoglobin and erythropoietin remained unchanged. No significant differences in the number of experienced side effects were found.

CONCLUSION

Testosterone gel of 10mg had positive effects on several aspects of sexual life such as frequency of sexual activity, orgasm, arousal, fantasies and sexual interest in postmenopausal women on HRT. Several psychological variables were positively influenced. The given dose resulted in too high serum levels. Even if no negative effects were observed, monitoring of serum levels and a decreased dose should be considered in future studies.

Testosterone for peri- and postmenopausal women

BACKGROUND

: The value of adding testosterone to hormone therapy (HT) for the management of peri- and postmenopausal women is controversial and has not been systematically reviewed.

OBJECTIVES

: To determine the benefits and risks of testosterone therapy for peri- and postmenopausal women taking hormone therapy.

SEARCH STRATEGY

: We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (1st November 2003), The Cochrane Library (Issue 2, 2003), MEDLINE (1966 to 1st November 2003), EMBASE (1980 to 1st November 2003), Biological Abstracts (1969 to 2002), PsycINFO (1972 to 1st November 2003), CINAHL (1982 to 1st November 2003), and reference lists of articles. We also contacted pharmaceutical companies and researchers in the field.

SELECTION CRITERIA

: Studies that were randomized comparisons of testosterone plus hormone therapy versus hormone therapy alone in peri- or postmenopausal women.

DATA COLLECTION AND ANALYSIS

: Two review authors assessed the quality of the trials and extracted data independently. Where it was necessary, the corresponding authors of eligible trials were contacted for additional information. For dichotomous outcomes Peto odds ratios and 95% confidence intervals were calculated. For continuous outcomes non-skewed data from valid scales were synthesized using a weighted mean difference or standardized mean difference. If statistical heterogeneity was found, a random-effects model was used and reasons for the heterogeneity were explored and discussed.

MAIN RESULTS

: Twenty-three trials with 1957 participants were included in the review. The median study duration was 6 months (range 1.5 to 24 months). Most of the trials were of adequate quality with regard to randomization and concealment of allocation sequence. The major methodological limitations were attrition bias and lack of a washout period in the cross-over studies. The pooled estimate from the studies suggested that the addition of testosterone to HT regimens improved sexual function scores for postmenopausal women. A significant adverse effect was a decrease in high-density lipoprotein (HDL) cholesterol levels. The discontinuation rate was not significantly greater with testosterone therapy (Peto odds ratio 1.01, 95% confidence interval 0.76 to 1.33) than with HT alone. There was insufficient evidence of a treatment effect for perimenopausal women or for other outcomes.

AUTHORS' CONCLUSIONS

: Only a limited number of studies could be pooled in the meta-analyses. This limited the power of the meta-analysis to provide conclusions about efficacy and safety. However, there is evidence that adding testosterone to HT has a beneficial effect on sexual function in postmenopausal women. There was a reduction in HDL cholesterol associated with the addition of testosterone to the HT regimens. The meta-analysis combined studies using different testosterone regimens. It is, therefore, difficult to estimate the effect of testosterone on sexual function in association with any individual hormone treatment regimen.