Androgen Treatment for Hypoactive Sexual Desire
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Androgen Treatment for Hypoactive Sexual Desire?
George Kovalevsky, M.D.
The role of androgens in female sexual function has been investigated in many studies, often with conflicting results, and thus remains unclear. Nevertheless, it is widely accepted that androgens exert an important influence on female sexual function. In particular, androgen levels have been linked with sexual desire1,2. Despite the lack of consistency of the data, the predominance of the evidence indicates that androgen therapy is effective in improving sexual desire in women, particularly those with low androgen levels.
Evaluation and diagnosis of female sexual dysfunction (FSD) continues to be a challenging task for the practicing physician. The process is compromised by the absence of validated physiologic tests. However, recently revised guidelines for the classification of FSD are now available to help establish an appropriate diagnosis3. This classification separates the disorder into four major categories: sexual desire disorder, sexual arousal disorder, orgasmic disorder, and sexual pain disorders. Hypoactive sexual desire disorder (HSDD) is the most common type of FSD with approximately one-third of women between the ages of 18 and 59 reporting lack of desire4. HSDD is defined as persistent or recurrent deficiency (or absence) of sexual fantasies/thoughts, and/or desire for or receptivity to sexual activity, which causes personal distress3. It is important to note that in order to meet the definition, lack of desire must be persistent and result in distress. Thus, short term problems caused by adverse social situations or long term diminished desire that does not trouble the individual woman do not qualify.
If HSDD is diagnosed, it is important to attempt to identify its cause. HSDD often coexists with other types of FSD and may be secondary to the other problem. For example, it is easy to understand how dyspareunia can lead to HSDD over time. A thorough medical history and examination may help to elucidate an underlying etiology. HSDD may be due to chronic illness such as diabetes or coronary artery disease. Special attention must be paid to mental health since many conditions such as depression and anxiety disorder often result in FSD. Medications may also cause FSD. These include commonly used agents, such as oral contraceptive pills and anti-depressants. Lastly, it is imperative to look for underlying relationship and situational issues, e.g., lack of intimacy, communication difficulties with partner, fatigue, high emotional stress, and lack of free time. Androgen deficiency should be considered as only one of the possible etiologies and be evaluated on par with all of the above factors.
Female androgen deficiency has been shown to be a true clinical entity and a potential cause of FSD. Symptoms attributed to androgen deficiency include HSDD, fatigue, and diminished well-being. Androgen deficiency may be due to normal aging, ovarian failure (i.e. premature menopause, surgical oophorectomy), adrenal insufficiency, use of estrogens or antiandrogens, or hypopituitarism5. If androgen deficiency is suspected, serum androgen levels should be assessed. A significant obstacle to such investigation is the difficulty of measuring androgen levels in women6. It is important to consider the biologically active free testosterone and not just the total testosterone. Most of the testosterone is protein-bound in the blood and concentrations are affected by shifts in the levels of sex hormone-binding globulin (SHBG) and to a lesser degree by changes in albumin. Free testosterone is representative of the actual concentration of testosterone to which tissues are exposed. However, accurate free testosterone assays are not available to most clinicians, and true normal ranges have not been established for women. Therefore, in most clinical settings, measurement of total testosterone and SHBG levels provides the most useful information. Total testosterone levels in or below the lower quartile with normal or elevated SHBG levels are consistent with androgen deficiency5.
Androgen deficiency is most commonly seen in postmenopausal women; however, androgen levels begin to decline during the reproductive years. In a recent placebo-controlled randomized trial, investigators recruited healthy women in the late reproductive years (mean age 39.7±4.2 year) with low libido and low or normal testosterone levels (women with levels in or above the upper quartile were excluded). Participants self-administered 10mg of testosterone 1% cream or placebo to the thigh on a daily basis. The study showed a significant improvement in sexual function and well-being in the treatment arm as compared to placebo7. Thus, it seems plausible that healthy women in their late reproductive years may benefit from androgen therapy.
After menopause, a progressive decline in both ovarian and adrenal androgen production occurs. This effect is most dramatic in women undergoing bilateral oophorectomy. Use of estrogen replacement further decreases the amount of bioavailable androgens by increasing the levels of sex hormone binding globulin, thereby further lowering the amount of bioavailable testosterone. Thus, postmenopausal women are at high risk for developing the symptoms associated with androgen deficiency, including HSDD. Most of the evidence demonstrating efficacy of androgen therapy for HSDD comes from studies of postmenopausal women.
A number of clinical trials have investigated the effect of various preparations and routes of administration of androgen replacement on female sexual function. Sherwin et al. conducted the first controlled trial of androgen administration. Their population consisted of 53 women undergoing hysterectomy and bilateral oophorectomy. Preoperatively, subjects received an intramuscular injection and were randomly assigned to either estrogen plus androgen, estrogen alone, androgen alone (200mg testosterone enanthate), or placebo. After 3 months, subjects received one month of placebo and then were crossed over to another treatment. The study demonstrated that androgen administration enhanced sexual desire, but did not have any effect on physiologic responses or orgasm.1
Other investigations have also produced evidence indicating an important role for androgens in female sexual functioning. Sarrel et al. recruited 20 postmenopausal women using estrogen replacement, with or without a progestin, who were dissatisfied with the results. They were randomized to either 1.25mg of esterified estrogens daily alone or in combination with 2.5mg of methyltestosterone. The study found that after 4 and 8 weeks of product use, women receiving the combination therapy reported significantly improved sexual sensation and desire in comparison with women receiving estrogen alone.8
Shifren et al. recruited 75 women who had undergone hysterectomy and bilateral oophorectomy, were using conjugated equine estrogens at a dose of 0.625mg per day or higher, and reported having impaired sexual function. Each subject received 3 treatments administered in random order: placebo, 150(g, and 300(g of testosterone per day transdermally for 12 weeks each. The authors found that despite a strong placebo response, treatment with the higher dose of transdermal testosterone resulted in a significant improvement in sexual function. A statistically significant difference from placebo was present only in the domains of frequency of sexual activity and sexual pleasure-orgasm.9
Most recently, Lobo et al. conducted a multicenter randomized trial using postmenopausal women on estrogen replacement who reported hypoactive sexual desire with the onset of menopause. Two hundred twenty-one subjects were randomized to receive daily either 0.625mg of esterified estrogens and 1.25mg of methyltestosterone or 0.625mg of esterified estrogens alone for 16 weeks. The authors reported that addition of methyltestosterone resulted in significant increases in level of sexual desire, frequency of desire, and responsiveness. The study also showed that the androgen treatment was well tolerated with no significant changes in acne or hirsutism, but a 17.5% decrease in HDL cholesterol was observed. This well-designed trial was also the largest and had the longest follow-up period of any such effort.2
In the studies discussed above, the serum levels of free testosterone achieved with therapy that resulted in a significant change were in the high normal to supraphysiologic range. On the other hand, lower doses that restored the subjects to an average level of testosterone, did not demonstrate a significant benefit.9 These observations have brought into question the definition of normal sexual functioning for women at “normal” testosterone levels. Some investigators have suggested that variation in testosterone levels rather than the absolute values is a more important predictor of sexual function.10
Dehydroepiandrosterone (DHEA) is a weak androgen that has received much publicity and is available in the United States without a prescription. DHEA production by both the adrenal gland and the ovary decreases with age. In postmenopausal women, peripheral conversion of DHEA and DHEAS, the sulfated form, produced by the adrenals is the major source of serum testosterone.11 Although controlled trials in postmenopausal women are lacking, preliminary evidence suggests that DHEA therapy may be beneficial in treatment of FSD. Arlt et al. performed a randomized, placebo-controlled, crossover study of 50mg daily administration of DHEA for 4 months in 24 women with adrenal insufficiency. They found that treatment resulted in a significant improvement in sexual interest, frequency of sexual thoughts, and sexual satisfaction.12 Conversely, Barnhart et al. conducted a randomized, placebo-controlled trial of 60 perimenopausal women with complaints of diminished well-being, mood, or libido. Subjects received 50mg of DHEA daily or placebo for 3 months. The authors reported a significant increase in serum DHEA, DHEAS, and testosterone, but a significant change in libido or well-being was not seen.13 However, these were perimenopausal women without evidence of androgen deficiency.
In summary, clinical trials of women with HSDD have consistently demonstrated that testosterone therapy results in a significant improvement of sexual function. Since sexual function is complex and influenced by multiple variables, not all women will benefit from androgen supplementation. Thus, a thorough evaluation is imperative for women presenting with diminished sexual desire. Those with clear androgen deficiency are most likely to experience an improvement. The incidence of adverse side effects appears acceptable, but larger studies with long-term follow up are necessary to fully assess the risks of such therapy.
1. Sherwin BB, Gelfand MM, Brender W. Androgen enhances sexual motivation in females: a prospective, crossover study of sex steroid administration in the surgical menopause. Psychosom Med 1985; 47:339-51.
2. Lobo RA, Rosen RC, Yang HM, Block B, Van Der Hoop RG. Comparative effects of oral esterified estrogens with and without methyltestosterone on endocrine profiles and dimensions of sexual function in postmenopausal women with hypoactive sexual desire. Fertil Steril 2003; 79:1341-52.
3. Basson R, Berman J, Burnett A, et al. Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. J Urol 2000; 163:888-93.
4. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. Jama 1999; 281:537-44.
5. Davis SR. When to suspect androgen deficiency other than at menopause. Fertil Steril 2002; 77 Suppl 4:S68-71.
6. Guay AT. Screening for androgen deficiency in women: methodological and interpretive issues. Fertil Steril 2002; 77 Suppl 4:S83-8.
7. Goldstat R, Briganti E, Tran J, Wolfe R, Davis SR. Transdermal testosterone therapy improves well-being, mood, and sexual function in premenopausal women. Menopause 2003; 10:390-8.
8. Sarrel P, Dobay B, Wiita B. Estrogen and estrogen-androgen replacement in postmenopausal women dissatisfied with estrogen-only therapy. Sexual behavior and neuroendocrine responses. J Reprod Med 1998; 43:847-56.
9. Shifren JL, Braunstein GD, Simon JA, et al. Transdermal testosterone treatment in women with impaired sexual function after oophorectomy. N Engl J Med 2000; 343:682-8.
10. Gracia C, Sammel M, Liu L, Hollander L, Freeman E. Decreased libido in women in the late reproductive years. Fertil Steril 2002; 78:S99.
11. Spark RF. Dehydroepiandrosterone: a springboard hormone for female sexuality. Fertil Steril 2002; 77 Suppl 4:S19-25.
12. Arlt W, Callies F, van Vlijmen JC, et al. Dehydroepiandrosterone replacement in women with adrenal insufficiency. N Engl J Med 1999; 341:1013-20.
13. Barnhart KT, Freeman E, Grisso JA, et al. The effect of dehydroepiandrosterone supplementation to symptomatic perimenopausal women on serum endocrine profiles, lipid parameters, and health-related quality of life. J Clin Endocrinol Metab 1999; 84:3896-902.
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