Transdermal testosterone therapy improves well-being, mood, and sexual function in premenopausal women

Low sexual desire--is it all in her head? Pathophysiology, diagnosis, and treatment of hypoactive sexual desire disorder

Hypoactive sexual desire disorder (HSDD) is thought to be the most prevalent form of female sexual dysfunction (FSD), affecting up to 1 in 10 US women. Hypoactive sexual desire disorder is defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) as persistent or recurrent deficiency or absence of sexual fantasies and thoughts, and/or desire for, or receptivity to, sexual activity, which causes personal distress or interpersonal difficulties and is not caused by a medical condition or drug. This definition has recently received criticism and recommendations for changes encompass the inclusion of duration, intensity, and frequency, and the elimination of distress as a diagnostic criterion. More recently, it has been suggested that arousal and desire be combined into one disorder for the upcoming DSM-V. Causes of low desire include chronic medical conditions, medications, surgeries, and psychosocial factors, but not necessarily increased age; both pre- and postmenopausal women can have HSDD, although the frequency appears to vary by age. Sexual function requires the complex interaction of multiple neurotransmitters and hormones, both centrally and peripherally, and sexual desire is considered the result of a complex balance between inhibitory and excitatory pathways in the brain. For example, dopamine, estrogen, progesterone, and testosterone play an excitatory role, whereas serotonin and prolactin are inhibitory. Thus, decreased sexual desire could be due to a reduced level of excitatory activity, an increased level of inhibitory activity, or both. A number of validated self-report and clinician-administered instruments are available for assessing female sexual function; however, most have been used primarily in clinical research trials. The Decreased Sexual Desire Screener (DSDS) was developed for practicing clinicians who are neither trained nor specialized in FSD to assist in making an accurate diagnosis of generalized acquired HSDD. As our understanding of the pathophysiology of HSDD increases, it may become easier for physicians to identify and treat women with low sexual desire.

Safety and tolerability of testosterone patch therapy for up to 4 years in surgically menopausal women receiving oral or transdermal oestrogen

Two clinical trials previously demonstrated the safety of 300 μg/day transdermal testosterone patch (TTP) treatment for up to 6 months in 1094 surgically menopausal women with hypoactive sexual desire disorder (HSDD). Adverse events (AE), clinical laboratory tests, vital signs, physical examinations and mammograms were evaluated in open-label extensions of these two trials for up to 4 years and are presented in this article. Nine hundred and sixty-seven patients received at least one application of the TTP resulting in 1092 patient-years of exposure. There was no increase over time in the rate of new occurrences or severity of AEs, serious AEs, or withdrawals due to AEs. The most common AEs associated with treatment were application site reactions and unwanted hair growth; however, most were mild and rarely resulted in study withdrawal. No clinically meaningful changes in serum chemistry, haematology, lipid profile, carbohydrate metabolism, renal and liver function or coagulation parameters were noted with up to 4 years of therapy. Consistent with age-appropriate expected rates, three cases of invasive breast cancer were observed. No important changes in the safety or tolerability profile of TTP were revealed with long-term use for up to 4 years in otherwise healthy oophorectomised women with HSDD on concomitant oestrogen.

Menopause and sexual desire: the role of testosterone

The present short review underlines the role of testosterone (T) in the motivational and satisfaction components of women's sexuality and critically discusses the strategies to treat hypoactive sexual desire disorder (HSDD), a condition of low desire associated with personal and/or interpersonal difficulties, which is more common in surgical menopausal women. There are multiple ways androgens target the brain regions (hypothalamic, limbic and cortical) involved in sexual function and behaviour. Even though circulating available androgens have been implicated in several domains of sexual response, they seem to be related weakly to symptoms, such as low sexual desire, poor sexual arousal, orgasm and diminished well-being in postmenopausal women. The possibilities of treating low sexual desire/HSDD are multifaceted and should include the combination of pharmacological treatments able to maximize biological signals driving the sexual response, and individualized psychosocial therapies in order to overcome personal and relational difficulties. Transdermal T has been shown to be effective at a dose of 300 µg/day both in surgically and naturally menopausal women replaced with estrogen or not, without any relevant side-effects. However, the decision to treat postmenopausal women with HSDD with T is mainly based on clinical judgement, after informed consent regarding the unknown long-term risks.

Management of hypoactive sexual desire disorder in women: current and emerging therapies

Hypoactive sexual desire disorder (HSDD) is a common multifactorial condition which is characterized by a decrease in sexual desire that causes marked personal distress and/or interpersonal difficulty. The general idea that HSDD is a sexual dysfunction difficult to treat is due to the large number of potential causes and contributing factors. Indeed, a balanced approach comprising both biological and psycho-relational factors is mandatory for accurate diagnosis and tailored management in clinical practice. There are currently no approved pharmacological treatments for premenopausal women with HSDD, while transdermal testosterone is approved in Europe for postmenopausal women who experience HSDD as a result of a bilateral oophorectomy. Even though the role of sex hormones in modulating the sexual response during the entire reproductive life span of women is crucial, a better understanding of the neurobiological basis of sexual desire supports the idea that selective psychoactive agents may be proposed as nonhormonal treatments to restore the balance between excitatory and inhibitory stimuli leading to a normal sexual response cycle. We conclude that the ideal clinical approach to HSDD remains to be established in term of efficacy and safety, and further research is needed to develop specific hormonal and nonhormonal pharmacotherapies for individualized care in women.

Testosterone therapy for reduced libido in women

Modest benefit has been shown from transdermal testosterone therapy given to postmenopausal women with reduced sexual desire. An increased frequency of satisfying sexual encounters and intensity of sexual desire and response has been shown in medically and psychiatrically healthy women able to have 2-3 satisfying sexual experiences each month before therapy commences. Women more clearly sexually dysfunctional in keeping with currently proposed definitions of sexual disorder have not been studied. Numerous factors are known to influence women's sexual desire with mood and feelings towards the partner showing the most robust associations. How to identify women whose low desire might stem from low testosterone activity remains unknown: neither serum levels of testosterone nor its metabolites correlate with desire or function. Production of androgens in the brain, sensitivity of the androgen receptors, and activity of cofactors are all potentially relevant confounds. The long-term safety of systemic testosterone with or without estrogen is unknown but necessary as women's sexual lives tend to endure as long as there is an active partner.

Androgen deficiency and therapy in women

PURPOSE OF REVIEW

This review will provide a brief overview of androgen physiology, outline the conditions associated with androgen deficiency in women, and provide data on the potential benefits and risks of testosterone therapy.

RECENT FINDINGS

This review summarizes relevant data on treatment and reviews the findings regarding safety of therapy.

SUMMARY

Testosterone is a necessary component of female physiology acting both directly and indirectly through aromatization to estrogens. Reduction in testosterone levels in women can result in deleterious effects emotionally, sexually and/or physically. Testosterone therapy resulting in serum levels in the high-normal range can provide significant improvement in these areas. The use of exogenous androgens in women with symptoms suggestive of androgen deficiency but with low-normal serum levels remains controversial.

The effect of the weak androgen oxandrolone on psychological and behavioral characteristics in growth hormone-treated girls with Turner syndrome

The weak androgen oxandrolone (Ox) increases height gain in growth-hormone (GH) treated girls with Turner syndrome (TS), but may also give rise to virilizing side effects. To assess the effect of Ox, at a conventional and low dosage, on behavior, aggression, romantic and sexual interest, mood, and gender role in GH-treated girls with TS, a randomized, placebo-controlled, double-blind study was conducted. 133 patients were treated with GH (1.33 mg/m(2)/d) from baseline, combined with placebo (Pl), Ox 0.03 mg/kg/d, or Ox 0.06 mg/kg/d from the age of eight, and with estrogens from the age of 12. The child behavior checklist (CBCL), Junior Dutch Personality Questionnaire (DPQ-J), State-subscale of the Spielberger's State-Trait Anger Scale, Romantic and Sexual Interest Questionnaire, Mood Questionnaire, and Gender Role Questionnaire were filled out before, during, and after discontinuing Ox/Pl. The changes during Ox/Pl therapy were not significantly different between the dosage groups. In untreated patients, the mean CBCL total (P=0.002) and internalizing (P=0.003) T scores, as well as the mean DPQ-J social inadequacy SD score (SDS) (P=0.004) were higher than in reference girls, but decreased during GH+Ox/Pl therapy (P<0.001, P=0.05, P<0.001, respectively). Whereas the mean total (P=0.01) and internalizing (P<0.001) T score remained relatively high, the mean social inadequacy SDS became comparable with reference values. We conclude that in GH-treated girls with TS, Ox 0.03 mg/kg/d or 0.06 mg/kg/d does not cause evident psychological virilizing side effects. Problem behavior, frequently present in untreated girls with TS, decreases during therapy, but total and internalizing problem behavior remain increased.

Should women receive androgen replacement therapy, and if so, how?

The available clinical evidence supports efficacy of testosterone therapy for the treatment of postmenopausal women with hypoactive sexual desire disorder (HSDD) who have undergone a comprehensive clinical evaluation. Although few preparations designed to deliver an appropriate dose of testosterone for women are available, use of testosterone by women for the management of HSDD is widespread. Issues that continue to simulate debate in this therapeutic area include whether HSDD is a condition that merits pharmacotherapy, how effective is such treatment and whether testosterone therapy is safe. Hence the question, should women receive androgen replacement therapy, and if so, how?

Testosterone reduces amygdala-orbitofrontal cortex coupling

Testosterone influences various aspects of affective behavior, which is mediated by different brain regions within the emotion circuitry. Previous neuroimaging studies have demonstrated that testosterone increases neural activity in the amygdala. To investigate whether this could be due to altered regulation of amygdala functioning which is thought to be mediated by the prefrontal cortex, we studied the effects of exogenous testosterone on the interaction between the amygdala and other brain regions. Healthy middle-aged women received a single nasal testosterone dose in a randomized, placebo-controlled, crossover manner, and performed an emotional face matching task while their brain activity was measured with functional MRI. The results show that testosterone rapidly reduced functional coupling of the amygdala with the orbitofrontal cortex, and enhanced amygdala coupling with the thalamus. This suggests that testosterone may reduce the regulatory control over the amygdala, or that testosterone shifts amygdala output away from the orbitofrontal cortex towards the thalamus. Testosterone also reduced functional coupling with the contralateral amygdala. Because interhemispheric amygdala coupling is lower in men than in women, this result suggests that circulating testosterone may contribute to this sexual dimorphism.

Androgen replacement therapy in Turner syndrome: a pilot study

CONTEXT

Women with Turner syndrome (TS) have reduced levels of androgens due to ovarian failure.

HYPOTHESES

Morbidity associated with TS, such as bone fragility, metabolic changes, obesity, neurocognitive profile, and sexual problems may partly relate to androgen insufficiency and improve on androgen replacement therapy (ART).

OBJECTIVES

The objective of the study was to determine the effect of androgens on morbidity in TS.

DESIGN

Fourteen TS women (aged 17-27 yr) participated in a randomized, double-blind, placebo-controlled crossover pilot. The study was conducted in a hospital outpatient clinic between December 2001 and July 2004.

INTERVENTION

TS patients were on estrogen/progestin replacement therapy. Subjects received oral 1.5 mg methyl testosterone (ART) or placebo for 1 yr and the alternative for another year.

MAIN OUTCOME MEASURES

The study compared body composition as a primary outcome, and physiology, biochemistry, visceral fat, cognition, and quality of life (QOL) as secondary outcomes.

RESULTS

ART as compared with placebo reduced total cholesterol, triglycerides, and high-density lipoprotein cholesterol. It improved bone mineral density, increased lean body mass, and decreased fat mass. ART improved attention, reaction time, and verbal memory and had no effect on executive functions and spatial cognition. Patients reported improved QOL, including general health, coping with stress, and sexual desire.

CONCLUSIONS

Androgen insufficiency plays a role in TS-impaired body composition, neurocognition, and QOL, and these aspects improve with ART, which was safe and effective when given for 1 yr.

Is there a neuroendocrinological rationale for testosterone as a therapeutic option in depression?

Depression is a disease of growing incidence and economic burden worldwide. In view of increasing treatment resistance, new therapeutic approaches are urgently needed. In addition to its gonadal functions, testosterone has many effects on the central nervous system. An association between testosterone levels and depressive symptoms has been proposed. Many hormones and neurotransmitters are involved in the aetiology and the course of depression including serotonin, dopamine, noradrenaline, vasopressin and cortisol. Testosterone is known to interact with them. Preclinical data suggest that testosterone has antidepressant potential. However, the data from clinical studies have been inconsistent. This review provides a critical overview on the currently available preclinical and clinical literature and concludes with clinical recommendations.

A prospective study of the association between endogenous hormones and depressive symptoms in postmenopausal women

OBJECTIVE

Across a woman's lifetime, variations in hormone levels are known to influence mood and well-being. Whether absolute or changes in hormone levels over time are associated with depression among postmenopausal women remains unclear.

METHODS

The Melbourne Women's Midlife Health Project is a longitudinal population-based study of women who were followed through the menopausal transition. This analysis is based on data collected from 138 postmenopausal women in years 11 and 13 of the study, who were assessed for the presence of depressive symptoms using the Center for Epidemiological Studies Depression Scale. Logistic regression models were developed to determine whether absolute or changes in hormone levels were associated with depression.

RESULTS

No significant associations were found between depressive symptoms and the absolute levels of sex hormone-binding globulin, testosterone, free androgen index, estradiol, free estradiol, or follicle-stimulating hormone (FSH). On the other hand, women with a decline in total serum estradiol over the 2-year period had a more than threefold increased risk of depressive symptoms (odds ratio, 3.5; 95% CI, 1.2-9.9). A large increase in FSH levels over this period was also associated with depressive symptoms (odds ratio, 2.6; 95% CI, 1.0-6.7). These associations remained even after adjustment for initial depression score, as well as a range of potential confounding factors.

CONCLUSIONS

Changes in estradiol and, to a lesser extent, in FSH levels are associated with an increased risk of depressive symptoms in postmenopausal women. These results further support a role for fluctuating rather than absolute hormone levels in depression in later life.

Preliminary investigation of plasma levels of sex hormones and human growth factor(s), and P300 latency as correlates to cognitive decline as a function of gender

Background

Aging is marked by declines in levels of many sex hormones and growth factors, as well as in cognitive function. The P300 event-related potential has been established as a predictor of cognitive decline. We decided to determine if this measure, as well as 2 standard tests of memory and attention, may be correlated with serum levels of sex hormones and growth factors, and if there are any generalizations that could be made based on these parameters and the aging process.

Findings

In this large clinically based preliminary study several sex-stratified associations between hormone levels and cognition were observed, including (1) for males aged 30 to 49, both IGF-1 and IGFBP-3 significantly associated negatively with prolonged P300 latency; (2) for males aged 30 to 49, the spearman correlation between prolonged P300 latency and low free testosterone was significant; (3) for males aged 60 to 69, there was a significant negative correlation between P300 latency and DHEA levels; (4) for females aged 50 to 59 IGFBP-3 significantly associated negatively with prolonged P300 latency; (5) for females at all age periods, estrogen and progesterone were uncorrelated with P300 latency; and (6) for females aged 40 to 69, there was significant negative correlation between DHEA levels and P300 latency. Moreover there were no statistically significant correlations between any hormone and Wechsler Memory Scale-III (WMS-111). However, in females, there was a significant positive correlation between estrogen levels and the number of Attention Deficit Disorder (ADD) complaints.

Conclusion

Given certain caveats including confounding factors involving psychiatric and other chronic diseases as well as medications, the results may still have important value. If these results could be confirmed in a more rigorously controlled investigation, it may have important value in the diagnosis, prevention and treatment of cognitive impairments and decline.

Testosterone and depression: systematic review and meta-analysis

BACKGROUND

Studies suggest that testosterone (TT) replacement may have an antidepressant effect in depressed patients.

OBJECTIVE

The objective of this study was to explore the effect of TT administration on depression using both a systematic review of the literature and a meta-analysis.

METHODOLOGY

A search was conducted of MEDLINE, the Clinical Trials Registry, and Cochrane Central for English-language publications concerning randomized, placebo-controlled trials involving use of TT therapy in depressed patients. We searched for additional trials in the individual reference lists of the articles identified in the search. A study was judged to be relevant for inclusion in this review and meta-analysis if it reported original data from a controlled trial comparing use of TT and placebo in patients diagnosed with a depressive disorder according to DSM criteria, and the treatment response was evaluated according to changes on the Hamilton Rating Scale for Depression (HAM-D). We extracted the following data from the identified studies: study source, total number of participants in the study and in each treatment group, participants' ages, number of participants with a diagnosis of hypogonadism or HIV/AIDS, study duration, type of intervention, and change in HAM-D scores in the groups receiving TT versus placebo. The meta-analysis evaluated the effect of TT replacement on response in depressed patients as measured by change in HAM-D scores in the available placebo-controlled, randomized clinical trails.

RESULTS

Seven studies (N=364) were identified that included a placebo-control group in a double-blind design. Eligibility criteria were clearly reported in all trials. Meta-analysis of the data from these seven studies showed a significant positive effect of TT therapy on HAM-D response in depressed patients when compared with placebo (z=4.04, P<0.0001). Subgroup analysis also showed a significant response in the subpopulations with hypogonadism (z=3.84, P=0.0001) and HIV/AIDS (z=3.33, P=0.0009) as well as in patients treated with TT gel (z=2.32, P=0.02).

CONCLUSIONS

TT may have an antidepressant effect in depressed patients, especially those with hypogonadism or HIV/AIDS and elderly subpopulations. The route by which TT is administered may play a role in treatment response.

Methodology and challenges to recruitment to a randomized, double-blind, placebo-controlled trial of oral DHEA in postmenopausal women

OBJECTIVE

To report on the issues encountered in the recruitment of healthy naturally menopausal women in the community to a randomized placebo-controlled trial of dehydroepiandrosterone (DHEA) therapy for treatment of loss of sexual desire.

METHODS

Recruitment of women was achieved by advertising and media publicity. We have reported on the method by which women initially contacted us and the reasons for nonparticipation.

RESULTS

Nine hundred and eighteen women contacted us about participating in the study; 706 of these were telephoned screened, and 93 of these (10%) women were randomized to therapy. The main determinants for nonparticipation included ineligibility on phone screening (58%), withdrawal of interest either before or after screening (55%), and preexisting pathology after attending for screening (8%).

CONCLUSIONS

Despite ongoing interest by women to participate in research for therapies to treat low libido, concerns about the use of any hormonal treatment and the time poverty experienced by many women at midlife present new barriers to recruitment and need to be considered in assessing the feasibility of studies in this field.

Testosterone increases amygdala reactivity in middle-aged women to a young adulthood level

Testosterone modulates mood and sexual function in women. However, androgen levels decline with age, which may relate to the age-associated change in sexual functioning and the prevalence of mood and anxiety disorders. These effects of testosterone are potentially mediated by the amygdala. In the present study, we investigated whether the age-related decline in androgen levels is associated with reduced amygdala activity, and whether exogenous testosterone can restore amygdala activity. Healthy young and middle-aged women participated during the early follicular phase of the menstrual cycle, and amygdala responses to biologically salient stimuli were measured with functional magnetic resonance imaging (fMRI). Androgen levels were lower in middle-aged than young women, which was associated with decreased amygdala reactivity. Endogenous testosterone levels correlated positively with amygdala reactivity across the young and middle-aged women. The middle-aged women received a single nasal dose of testosterone in a double-blind, placebo-controlled, crossover manner, which rapidly increased amygdala reactivity to a level comparable to the young women. The enhanced testosterone levels correlated positively with superior frontal cortex responses and negatively with orbitofrontal cortex responses across individuals, which may reflect testosterone-induced changes in amygdala regulation. These results show that testosterone modulates amygdala reactivity in women, and suggest that the age-related decline in androgen levels contribute to the decrease in amygdala reactivity.

Androgen replacement therapy in androgen-deficient women with hypopituitarism

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

Testosterone replacement therapy in the climacteric: benefits beyond sexuality

Testosterone therapy during menopause has a wide range of benefits that reach beyond the realm of human sexuality. This is a consequence not only of the widespread distribution of androgen receptors in various extragonadal tissues but also of the conversion of androgens to estrogens in the tissues in which aromatase expression is present. For this reason, testosterone therapy during the climacteric years will not only supply androgens but will also stimulate estrogen production in tissues that express aromatase. Furthermore, the bioavailability of androgens to the tissues depends not only on the rate of their production by the postmenopausal ovaries and adrenals but also on the circulating levels of sex hormone-binding globulin (SHBG). Tibolone inhibits SHBG production in the liver, thus increasing free testosterone levels. The association of tibolone with testosterone as a form of androgen replacement therapy during the climacteric is discussed, as is the use of low-dose testosterone, tibolone or the association of both in perimenopausal patients with signs of androgen deficiency. Testosterone treatment has a boosting effect not only on human sexuality but also on the sensation of well-being, a stimulatory effect conferred by the increase in beta-endorphins.

Comparative bioavailability of metoprolol tartrate after oral and transdermal administration in healthy male volunteers

BACKGROUND AND OBJECTIVE

Transdermal drug delivery systems (TDDSs) of metoprolol tartrate have been previously prepared and evaluated in vitro and in vivo in an animal model. This study compares the bioavailability of metoprolol tartrate from a TDDS with that from a conventional marketed tablet in healthy human volunteers.

METHODS

This was an open-label, balanced randomised, two-treatment, two-period crossover study with a washout period of 1 week. Volunteers were randomised (by means of a SAS software-generated randomisation schedule) to have a TDDS applied to their chest for 48 hours or to receive a 100 mg conventional marketed tablet of metoprolol tartrate in period I. In period II, the volunteers received the other dosage form. Blood samples were collected through an indwelling cannula placed in the forearm vein of each subject. Metoprolol tartrate concentrations were quantified in plasma samples by a validated high-performance liquid chromatography method.

RESULTS

A 3-fold improvement in bioavailability was observed with the TDDS form over oral therapy as shown by the extent of absorption indicated by the mean area under the concentration-time curve from time zero to time t values for tablets (451.98 ng x h/mL) and TDDS (1552.66 ng x h/mL). Although the maximum plasma concentration was higher for the tablet form than the TDDS (77.67 +/- 23.33 vs 51.16 +/- 16.61 ng/mL), the variable absorption profile, which is a characteristic feature of oral therapy, was quite evident. Plasma metoprolol tartrate concentrations plummeted to therapeutically ineffective concentrations as early as 8 hours following oral administration.

CONCLUSION

The TDDS developed in our laboratory produced therapeutically effective plasma concentrations for up to 48 hours, with a minimum of 26.09 ng/mL and a maximum of 76.70 ng/mL, which is in good agreement with the therapeutic range (20-100 ng/mL) of metoprolol tartrate. It could be concluded that the TDDS meets the intended goal of 2-day management of hypertension with application of a single patch, obviating the inconvenience of frequent administration and thus improving patient compliance.

Management of female sexual dysfunction in postmenopausal women by testosterone administration: safety issues and controversies

INTRODUCTION

A Food and Drug Administration advisory group has questioned the long-term safety of testosterone administration to postmenopausal women. Although only short-term data exist on safety from the double-blind, placebo-controlled trials, testosterone has been used for more than 50 years. Therefore, some data concerning the long-term safety issues must exist in the literature.

AIM

To review the published data concerning the safety of administration of testosterone to women.

METHODS

Review of published articles identified by a search of the Ovid databases and bibliographies from articles identified as dealing with the topics of testosterone or androgen treatment of women.

RESULTS

The major adverse reactions to exogenous androgens are the expected androgenic side effects of hirsutism and acne. High-density lipoprotein levels may be decreased with oral androgens. There are insufficient long-term safety data regarding breast, endometrium, or heart safety to draw strong conclusions, although the data available to date are reassuring.

CONCLUSIONS

Testosterone administration to postmenopausal women that result in physiological to slightly supraphysiological serum-free testosterone levels is safe for at least 2 years.

Recognition and management of treatment-related side effects for breast cancer patients receiving adjuvant endocrine therapy

In postmenopausal women with hormone receptor-positive early-stage breast cancer, the use of aromatase inhibitors (AIs) to suppress estrogen is associated with improved clinical outcomes compared with tamoxifen therapy. Women receiving such endocrine therapy may experience treatment-related side effects that negatively affect health-related quality of life (QoL) and adherence to therapy. In published clinical trials and in clinical practice, adverse events (AEs) constitute the main reason for nonadherence to endocrine treatment. Serious AEs are sometimes resolved by switching to a different agent, whereas other side effects can often be managed to allow patients to remain on therapy without sacrificing QoL. Across all adjuvant endocrine trials, regardless of the treatment received, vasomotor symptoms such as hot flashes are the most common side effects. Other frequently reported side effects, such as vaginal discharge, vaginal dryness, dyspareunia, and arthralgia, vary in prevalence between tamoxifen and AIs. Here we provide an overview of reported AEs of adjuvant endocrine therapy, focusing on those that are amenable to pharmacologic or nonpharmacologic management without treatment discontinuation. Also highlighted are specific management strategies that may improve patient QoL and thereby optimize adherence to therapy, which in turn might improve patient outcomes.

Testosterone therapy in women: its role in the management of hypoactive sexual desire disorder

Disorders of sexual dysfunction occur in nearly half of women during their life, and hypoactive sexual desire disorder accounts for most of those complaints. Although the relationship between low endogenous testosterone levels and sexual desire disorders in women has not been empirically established, clinical trials have shown that exogenous testosterone therapy improves arousability, sexual desire and fantasy, frequency of sexual activity and orgasm, and satisfaction and pleasure from the sexual act. Its therapeutic role in bone mineral density, fatigue, well-being and hot flashes requires more study before specific recommendations can be made. Potential adverse effects of testosterone therapy include hirsutism, acne and deepening of the voice along with changes in lipid profiles. While less well understood, concern after increased risks for breast cancer and cardiovascular events has been raised about this therapy. Testosterone therapy is available in various formulations; the most commonly used are oral and transdermal, including patches, gels, creams and ointments.

Randomized controlled trial to evaluate transdermal testosterone in female cancer survivors with decreased libido; North Central Cancer Treatment Group protocol N02C3

BACKGROUND

Decreased libido is one of several changes in sexual function that are often experienced by female cancer patients. Transdermal testosterone therapy has been associated with increased libido among estrogen-replete women who report low libido.

METHODS

In a phase III randomized, placebo-controlled crossover clinical trial, we evaluated whether transdermal testosterone would increase sexual desire in female cancer survivors. Postmenopausal women with a history of cancer and no current evidence of disease were eligible if they reported a decrease in sexual desire and had a sexual partner. Eligible women were randomly assigned to receive 2% testosterone in Vanicream for a testosterone dose of 10 mg daily or placebo Vanicream for 4 weeks and were then crossed over to the opposite treatment for an additional 4 weeks. The primary endpoint was sexual desire or libido, as measured using the desire subscales of the Changes in Sexual Functioning Questionnaire, as assessed at baseline and at the end of 4 and 8 weeks of treatment. Serum levels of bioavailable testosterone were measured at the same times. All statistical tests were two-sided.

RESULTS

We enrolled 150 women. Women who were on active testosterone cream had higher serum levels of bioavailable testosterone than women on placebo (mean change from baseline, testosterone versus placebo, week 4, 11.57% versus 0%, difference = 11.57%, 95% confidence interval [CI] = 8.49% to 14.65%; week 8, 10.21% versus 0.28%, difference = 9.92%, 95% CI = 5.42% to 14.42%; P<.001 for all). However, the average intrapatient libido change from baseline to weeks 4 and 8 was similar on both arms.

CONCLUSION

Increased testosterone level did not translate into improved libido, possibly because women on this study were estrogen depleted.

Acute and chronic dosing of Lepidium meyenii (Maca) on male rat sexual behavior

INTRODUCTION

The use of natural remedies for the treatment of sexual disorders is under current investigation. For generations people of the rural community in Peru have used Lepidium meyenii Walpers (Maca), because of their belief that it improves fertility and sexual desire.

AIM

To determine the acute and chronic effects of Maca on male sexual behavior and to examine chronic administration of Maca on anxiety.

MAIN OUTCOME MEASURES

Ejaculatory and mounting behavior and postejaculatory interval. Anxiety tests using an elevated plus maze, locomotion, and social interaction with another male.

METHODS

Maca (25 and 100 mg/kg) was orally administered to male rats for 30 days. Male sexual behavior was monitored after acute, 7 and 21 days of treatment. Anxiety behavior and locomotion were measured at 28-29 days using the elevated plus maze and social interaction tests.

RESULTS

Maca treatment did not produce large changes in male sexual behavior. However, an increase in ejaculation latency and postejaculatory interval was observed after both acute and 7 days of treatment. After 21 days of treatment Maca had no effect on sexual behavior. Chronic administration of Maca did not increase locomotion or anxiety.

CONCLUSION

Acute and short-term administration of Maca produced a small effect of rat male sexual behavior and long-term administration did not increase anxiety.

Might DHEA be considered a beneficial replacement therapy in the elderly?

Dehydroepiandrosterone (DHEA) [prasterone] is typically secreted by the adrenal glands and its secretory rate changes throughout the human lifespan. When human development is completed and adulthood is reached, DHEA and DHEA sulphate (DHEAS) [PB-008] levels start to decline so that at 70-80 years of age, peak DHEAS concentrations are only 10-20% of those in young adults. This age-associated decrease has been termed 'adrenopause', and since many age-related disturbances have been reported to begin with the decline of DHEA/DHEAS levels, this provides a potential opportunity for use of DHEA as replacement therapy. For these reasons, use of DHEA as a replacement therapy in aging men and women has been proposed and this paper outlines the reported beneficial effects of such treatment in humans. Many interesting results have been obtained in experimental animals suggesting that DHEA positively modulates most age-related disturbances. However, renewed interest in DHEA has arisen as a result of recent studies suggesting that DHEA appears to be beneficial in hypoandrogenic men as well as in postmenopausal and aging women. Menopause is the event in a woman's life that induces a dramatic change in the steroid milieu, and use of DHEA as 'replacement treatment' has been reported to restore both the androgenic and estrogenic environment and reduce most of the symptoms of this change. As menopause is the beginning of the biological transition of women towards senescence, it is of great interest to better understand how DHEA might help to solve and/or overcome the problems of this complex stage of life. In men with adrenal insufficiency and hypogonadism without androgen replacement, DHEA administration results in a significant increase in circulating androgens. Though most data are suggestive for use of DHEA as hormonal replacement treatment, more defined and specific clinical trials are needed to uncover all of the 'secrets' and features of this steroid before it can be used as a standard treatment. Furthermore, DHEA is perceived differently around the world, being considered only a 'dietary supplement' in the US, while in many European countries it is considered a 'true hormone' that has not been approved for use as a hormonal treatment by the European health authorities. This overview offers some points of view on use of DHEA as an experimental hormonal replacement therapy.

Safety of testosterone treatment in postmenopausal women

OBJECTIVE

To critically examine the safety of T therapy given to postmenopausal women.

DESIGN

MEDLINE literature review, cross-reference of published data, and review of Food and Drug Administration transcripts.

RESULT(S)

Although some retrospective and observational studies provide some long-term safety data, most prospective studies have had a duration of 2 years or less. In addition, with the exception of the female-to-male transsexuals, T was administered in conjunction with estrogens or estrogens and progestins, which confound the interpretation of some of the studies. The major adverse reactions are the androgenic side effects of hirsutism and acne. There does not appear to be an increase in cardiovascular risk factors, with the exception of a lowering of high-density lipoprotein with oral T. There are little data on endometrial safety, and most of the experimental data support a neutral or beneficial effect in regards to breast cancer. There does not appear to be an increased risk of hepatotoxicity, neurobehavioral abnormalities, sleep apnea, or fetal virilization (in premenopausal women) with the physiologic treatment doses of T.

CONCLUSION(S)

Except for hirsutism and acne, the therapeutic administration of T in physiologic doses is safe for up to several years. However, prospectively collected long-term safety studies are needed to provide a greater degree of assurance.

Effects of intra-nasally administered testosterone on sexual proceptive behavior in female capuchin monkeys (Cebus apella)

Sexual dysfunction in the female has been associated with a decrease in androgen levels, which can be reversed by testosterone treatment, however, bearing the risk of adverse side effects. Nasally administered testosterone could be an effective method for androgenic treatment avoiding the first-pass intestinal and hepatic metabolism and side effects. Here we examined the effects of chronic intranasal administration of testosterone on sexual behavior in female capuchin monkeys (Cebus apella) that lived with male cohorts. During 8 days of baseline 10 females were observed for their sexual and non-sexual behavior without drug. They then received daily intranasal testosterone (0.24 mg per nostril, n=5 per group) or placebo gel for 5 days, followed by 5 days of wash out, followed by 5 days of daily intranasal application, whereby the animals that had received testosterone before, now received placebo and vice versa. Diverse sexual and non-sexual behaviors were scored. Blood samples were collected and analyzed for testosterone, estradiol, dihydrotestosterone and progesterone using EIAs. The results revealed an increase in sexual behavior (eyebrow raising, chest rubbing, courtship behavior, masturbation) in the females during testosterone treatment, which seemed to be prolonged even when testosterone treatment was discontinued. These behavioral results were accompanied by an increase in plasma testosterone levels. This study demonstrates the efficacy of testosterone in enhancing sexual behavior in female capuchin monkeys by means of intranasal application, which may be a useful alternative compared to other forms of administration.

Prolonged effects of intra-nasally administered testosterone on proceptive behavior in female capuchin monkeys (Cebus apella)

Sexual dysfunction in the female has been associated with a decrease in androgen levels, which can be reversed by testosterone treatment, however, bearing the risk of adverse side effects. Previously we found that intranasal application of testosterone led to an increase in proceptive behavior in female capuchin monkeys, which was still enhanced beyond treatment pointing to prolonged effects. Here, we sought to replicate our previous findings and to further examine possible prolonged effects of such treatment. During 5 days of baseline females were observed for their sexual and non-sexual behavior without drug. They then received daily intranasal testosterone (0.24 mg per nostril) for 7 days, followed by 15 days of intranasal testosterone application every third day or were left undisturbed (n=5 per group). Diverse sexual and non-sexual behaviors were scored. Blood samples were collected and analyzed for testosterone, estradiol, and progesterone using immunoenzymatic chemiluminescent immunoassay. In accord with our previous results an increase in sexual proceptive behavior was revealed during testosterone treatment, which persisted about 2 weeks beyond treatment in the group receiving testosterone every third day as well as in the group that no longer received any treatment. These behavioral results were accompanied by an increase in plasma testosterone levels. This study demonstrates the efficacy of testosterone in enhancing sexual behavior in female capuchin monkeys by means of intranasal application, and provided evidence that daily substance application is not necessary to maintain beneficial effects on sexual behavior. These findings render the intranasal application procedure to be a useful alternative compared to other forms of administration.

Well-being, health-related quality of life and cardiovascular disease risk profile in women with subclinical thyroid disease - a community-based study

OBJECTIVES

The aim of this study was to evaluate whether subclinical thyroid disease is associated with impaired health-related quality of life and a more adverse cardiovascular disease risk profile.

DESIGN

A community-based cross-sectional study.

SETTING AND PARTICIPANTS

A total of 1423 non-healthcare-seeking women, aged 18-75 years were randomly recruited from the community via the electoral roll from April 2002 to August 2003.

MAIN OUTCOME MEASURES

These were the scores for the Short-Form 36 (SF-36), the Psychological General Well-being Index (PGWI), thyroid hormone levels, serum lipids and high sensitivity C-reactive protein (hsCRP). Subclinical hypothyroidism (SCH) and subclinical hyperthyroidism (SCHyper) were defined as serum TSH > 4.0 mIU/l and < 0.5 mIU/l, respectively, with a normal free thyroxine (free T4) level.

RESULTS

Evaluable data were available for all participants. 10.7% of all women had an abnormal TSH value. The prevalence of a low TSH level by age group ranged from 1.2% to 6.4%, whereas the prevalence of an elevated TSH level ranged from 2.8% to 9.2% and increased with age (P = 0.002). There were no significant differences between women with SCH or SCHyper and age-matched controls for the total PGWI score or the Mental and Physical Component Scores of the SF-36. Women with SCH were no different from controls for serum lipids or hsCRP. Using linear regression, SCH vs. euthyroidism did not make an independent contribution to variation in either total cholesterol or triglycerides, with or without adjustment for age +/- age(2) +/- BMI.

CONCLUSIONS

Our data indicate that subclinical thyroid disease in women in the community is not associated with lower well-being or impaired health-related quality of life and SCH is not associated with increased serum markers of CVD risk.

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.