What is testosterone replacement and how is it linked with women's sexuality?

Testosterone clearly has a role in sexual desire and overall female sexual function and should be considered as part of the complex and multifaceted treatment paradigm. However, replacement of testosterone in females remains controversial, and many researchers are still unconvinced about any direct linkage between testosterone and female sexual health. The data are confusing and conflicting. Female androgen insufficiency syndrome[1] is considered a medical condition characterized by blunted or decreased motivation, persistent fatigue, and a decreased sense of personal well-being that is identified by sufficient plasma estrogen and low circulating bioavailability of testosterone as well as low sexual desire (libido). Other potential symptoms include bone loss, decreased muscle strength, and changes in cognition or memory. Bone density may also be affected.

The North American Menopause Society published a comprehensive position statement in September 2005 that reviews testosterone use in women and includes monitoring, safety, and replacement guidelines and dosages for postmenopausal women. The society suggests that testosterone replacement may be helpful for certain postmenopausal women under certain circumstances (surgically menopausal or spontaneously menopausal). The position paper recommends testosterone in combination with estrogen replacement but also outlines clear follow-up guidelines and precautions that should be discussed with prospective patients. Informed consent and discussion of insufficient long-term safety data beyond 6 months is also required. This paper is crucial because to date there is no FDA-approved testosterone product for women, and many sexual medicine clinicians and healthcare providers are prescribing this medication (often off-label) to women.

A recent publication in the New England Journal of Medicine, "Testosterone for Low Libido in Post-Menopausal Women Not Taking Estrogen," showed that women who are not receiving estrogen treatment may have a modest and meaningful improvement in sexual function when they take the 300 microgram testosterone patch. There were more cases of breast cancer in the treatment arm of this study, and the researchers state that the long-term effects of testosterone on the breast remain uncertain.

At the time of publication of this book, there is no FDA-approved androgen product available for women. The use of male products or bioidentical products is off-label and should proceed with caution. More long-term safety data are warranted. It is interesting to note that in Europe a testosterone patch has recently been approved. It is now widely used in Europe, and many women in the United States and Canada are obtaining this medication over the Internet.

On the other hand, many healthcare providers are concerned about testosterone use because women are not ruled by testosterone or any other specific hormone. Dennerstein and associates from Australia present interesting data in an article titled "The Relative Effects of Hormones and Relationship Factors on Sexual Function of Women through the Natural Menopause Transition." The study was a prospective population-based questionnaire study of more than 300 Australian women that investigated the relative effects of hormonal and relationship factors on female sexual dysfunction during the natural menopausal transition. The results are provocative because they demonstrate that prior sexual functioning and relationship issues were more important than hormonal determinants of sexual function in midlife. Again, this is another supportive research article that reiterates that female sexual health is a complex interaction of hormones, biopsychosocial factors, and past sexual experiences.

Women are not victims of their hormones, and hormones, no matter the combination, are not the simple answer to sexual complaints. If you are unhappy because of poor communication with your partner and you're not sexually excited by your partner anymore, estrogen, progesterone, and testosterone may not change this situation. Hormones are often considered the mainstay of treatment for sexual complaints in woman and often they do help; however, to take them without looking at yourself as a total woman, your relationships with your partner, the dynamics in your household, and the psychostressors that influence your day-to-day activities is to miss the sexual health boat.

Very high levels of testosterone in products may have several potential serious side effects including, but not limited to, increased facial and body hair growth (hirsutism), weight gain, abnormal enlargement of the clitoris (clitoromegaly), hair loss (alopecia), changes in lipid profiles, and liver or hematologic changes. Women who have taken testosterone supplements have also have reported emotional changes. The safety of androgen in the cancer population has not been adequately studied. There is a concern that testosterone can be converted or aromatized to estrogen, which may reactivate, promote, or stimulate tumor growth. Long-term data on breast cancer risk is forthcoming and should be monitored. The new testosterone transdermal matrix patch has proven to be promising for female desire or libido issues; further randomized controlled trials that examine long-term safety are warranted. There is no silver bullet, and testosterone is not the sole answer to a complicated medical condition.

  • [1] A constellation of symptoms attributed to low testosterone levels in women. Some of the symptoms include fatigue, decreased well-being, lack of energy or motivation, and decreased or absent sexual interest or desire.
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