Androgen therapy in women: an Endocrine Society Clinical Practice guideline

Transdermal menopausal hormone therapy: delivery through skin changes the rules

IMPORTANCE TO THE FIELD

Transdermal hormone therapy is replacing oral estrogens and androgens as safe enhancements of life quality for postmenopausal women. Estradiol and testosterone are dosed into the microvascular circulation directly through skin so there is no first-pass hepatic transformation or deactivation of the dosed estradiol or testosterone.

AREAS COVERED IN THIS REVIEW

This review critically examines recent clinical trials describing experience with transdermal estradiol and testosterone in postmenopausal women. Transdermal estradiol is effective in the treatment of vasomotor symptoms (VMS) and can provide its benefits at higher levels of safety than have been heretofore possible with oral estrogens. Transdermal testosterone is effective in the treatment of hypoactive sexual desire disorder (HSDD) documented in multiple, well-powered randomized clinical trials with demonstrated high levels of safety.

WHAT THE READER WILL GAIN

The reader will learn that transdermal estradiol and testosterone, in properly selected postmenopausal women, significantly and safely enhance life quality, are likely to become increasingly popular, and will probably replace oral hormone therapy.

TAKE HOME MESSAGE

Transdermal delivery of native estradiol for VMS and testosterone for HSDD has significant advantages in safety and efficacy over traditional oral preparations which are now available for clinical use.

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.

Standardization of testosterone measurements in humans

Testosterone levels are used primarily for the diagnosis of hypogonadism in men and androgen excess in women. Current studies suggest that serum testosterone measurements may be indicated in a wide range of diseases and conditions. Translation of testosterone levels outside of the reference ranges into clinical treatment, appropriate cut offs for clinical guidelines and epidemiological studies with public health impact pose challenges due to the measurement variability among assays and in assay sensitivity. While introducing mass spectrometry technology can overcome some of these challenges and help to improve measurements, it faces variability issues similar to those observed with immunoassays that need to be addressed. To overcome these problems in testosterone testing, the Centers for Disease Control and Prevention, National Center for Environmental Health, Division of Laboratory Sciences (CDC/NCEH/DLS) started a steroid hormone standardization project. Their objective was to create testosterone measurement results that are traceable to one accuracy basis, thus allowing measurements to be comparable across methods, time, and location. CDC/NCEH/DLS conducts activities to standardize and improve testosterone assays and laboratory measurements by establishing metrological traceability to a higher order reference method and material. In addition, the standardization effort includes pre- and post-analytical challenges, such as test selection, interpretation, and establishing reference ranges to improve the translation of standardized results into clinical guidelines and public health assessments. CDC is conducting these standardization activities in collaboration with the clinical, laboratory, and research communities.

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.

Androgen deficiency in women; role of accurate testosterone measurements

Androgen deficiency in women has been recognized as a distinct clinical syndrome that affects thousands of women particularly women in the postmenopausal period of their life. This syndrome has been described by several names including female androgen deficiency syndrome as well as hypoactive, sexual desire disorder. A recent large survey concerning sexual problems in women also adds personal distress as a potential contributor to the low sexual desire found in some women with sexual dysfunction. Recognition of an androgen deficiency syndrome however, has been controversial and limited to a clinical diagnosis due to the lack of accurate and sensitive methods for measuring androgens in women. Up until now, available methods for measuring the sex steroids have been dependent on antibody based assays that employ a range of different detection systems including the use of isotopes such as tritium and I-125 or chemical signalling molecules that produce chemiluminescence. These assays have become increasingly more sensitive for the measurement of testosterone but are still incapable of providing the proper low-end sensitivity for analyzing testosterone in female blood specimens. Assays for testosterone performed either manually or with highly automated immunoassay instruments have been used to measure testosterone in women but with varying degrees of success. Existing immunoassay-based methods are quite adequate for measuring testosterone levels in males but lack sufficient sensitivity to accurately and reproducibly measure testosterone in females and pre-pubertal children. Recent advances with the use of ultrasensitive methods such as mass spectrometry coupled to either gas or liquid chromatography have improved the technology for measuring testosterone and other low concentration sex steroids like estradiol to the degree that mass spectrometry based methods are now capable of measuring the testosterone levels found in normal women and in women with extremely low levels of testosterone as observed in a true androgen deficiency disorder. This application of mass spectrometry for measuring testosterone should allow clinicians to better define female androgen deficiency and facilitate further investigation in the diagnosis and optimal management of androgen deficiency in women.

Hormone treatment and muscle anabolism during aging: androgens

Aging is associated with a gradual decline in circulating testosterone concentrations and decreased musculature in men. While testosterone administration is often considered when symptoms of hypogonadism are presented, the long-term effects of androgen use on muscle physiology are not yet fully understood. The definition of hypogonadism in men remains obscure but is generally indicated by total testosterone concentrations less than a threshold value of 300-500 ng/dL. Androgen replacement therapy is generally safe in men and women with low endogenous testosterone concentrations. The development of selective androgen receptor modulators (SARMs) may provide additional options in treatment of hypogonadism while lowering the potential of side effects often associated with long-term androgen use. Androgen administration, either alone or in combination with other treatments, can be successful in improving muscle mass by increasing protein anabolism and reducing protein catabolism in men and women. Further research is necessary to optimize the anabolic and anticatabolic properties of androgens for treatment and prevention of muscle loss in men and women.

Mood disorders and sexual functioning in women with functional hypothalamic amenorrhea

OBJECTIVE

To investigate the sexual function of women with functional hypothalamic amenorrhea (FHA) and to test the mediating effects of depression and anxiety on the sexual functioning of women with FHA.

DESIGN

In this cross-sectional study, participants completed questionnaires on sexual function, depression, and anxiety.

SETTING

Tertiary care university hospital.

PATIENT(S)

Women with (n=41) and without (n=39) FHA recruited from a gynecologic endocrinology unit.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The McCoy Female Sexuality Questionnaire assessed sexual function, and the Zung Scale measured depression and anxiety.

RESULT(S)

Women with FHA experienced more sexual function problems and significantly higher depression and anxiety compared to women without menstrual dysfunction. In addition, depression offered a significant explanation for the sexual problems experienced by women with FHA.

CONCLUSION(S)

The psychologic symptoms that contribute to the onset of FHA partially mediate the relationship between FHA and sexual dysfunction.

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?

DHEA, important source of sex steroids in men and even more in women

A major achievement from 500 million years of evolution is the establishment of a high secretion rate of dehydroepiandrosterone (DHEA) by the human adrenal glands coupled with the indroduction of menopause which stops secretion of estrogens by the ovary. Cessation of estrogen secretion at menopause eliminates the risks of endometrial hyperplasia and cancer which would result from non-opposed estrogen stimulation during the post-menopausal years. In fact, from the time of menopause, DHEA becomes the exclusive and tissue-specific source of sex steroids for all tissues except the uterus. Intracrinology, a term coined in 1988, describes the local formation, action and inactivation of sex steroids from the inactive sex steroid precursor DHEA. Over the past 25 years most, if not all, the genes encoding the human steroidogenic and steroid-inactivating enzymes have been cloned and sequenced and their enzymatic activity characterized. The problem with DHEA, however, is that its secretion decreases from the age of 30 years and is already decreased, on average, by 60% at time of menopause. In addition, there is a large variability in the circulating levels of DHEA with some post-menopausal women having barely detectable serum concentrations of the steroid while others have normal values. Since there is no feedback mechanism controlling DHEA secretion within 'normal' values, women with low DHEA will remain with such a deficit of sex steroids for their remaining lifetime. Since there is no other significant source of sex steroids after menopause, one can reasonably believe that low DHEA is involved, in association with the aging process, in a series of medical problems classically associated with post-menopause, namely osteoporosis, muscle loss, vaginal atrophy, fat accumulation, hot flashes, skin atrophy, type 2 diabetes, memory loss, cognition loss and possibly Alzheimer's disease. A recent randomized, placebo-controlled study has shown that all the signs and symptoms of vaginal atrophy, a classical problem recognized to be due to the hormone deficiency of menopause, can be rapidly improved or corrected by local administration of DHEA without systemic exposure to estrogens. In addition, the four domains of sexual dysfucntion are improved. For the other problems of menopause, although similar large scale, randomized and placebo-controlled studies usually remain to be performed, the available evidence already strongly suggests that they could be improved, corrected or even prevented by exogenous DHEA. In men, the contribution of adrenal DHEA to the total androgen pool has been measured at 40% in 65-75-year-old men. Such data stress the necessity of blocking both the testicular and adrenal sources of androgens in order to achieve optimal benefits in prostate cancer therapy. On the other hand, the comparable decrease in serum DHEA levels observed in both sexes has less consequence in men who continue to receive a practically constant supply of testicular sex steroids during their whole life. In fact, in men, the appearance of hormone-deficiency symptoms common to women is observed at a later age and with a lower degree of severity. Consequently, DHEA replacement has shown much more easily measurable beneficial effects in women. Most importantly, despite the non-scientific and unfortunate availability of DHEA as a food supplement in the United States, a situation that discourages rigorous clinical trials on the crucial physiological and therapeutic role of DHEA, no serious adverse event related to DHEA has ever been reported in the world literature (thousands of subjects exposed) or in the monitoring of adverse events by the FDA (millions of subjects exposed), thus indicating, as expected from its known physiology, the excellent safety profile of DHEA. With today's knowledge, one can reasonably suggest that DHEA offers the promise of a safe and efficient replacement therapy for the multiple problems related to hormone deficiency after menopause without the risks associated with estrogen-based or any other treatments.

Effect of sex steroid use on cardiovascular risk in transsexual individuals: a systematic review and meta-analyses

OBJECTIVE

To summarize the available evidence on the cardiovascular effects of cross-sex steroid use in transsexuals.

METHODS

We searched relevant electronic databases and sought additional references from experts. Eligible studies reported on cardiovascular events, venous thromboembolism, blood pressure and fasting serum lipids. Data were extracted in duplicate. We used the random-effects model to estimate the pooled weighted mean difference (WMD) and 95% confidence intervals (CIs).

RESULTS

We found 16 eligible studies, mostly uncontrolled cohorts of varied follow-up durations (1471 male-to-female (MF) and 651 female-to-male (FM) individuals). In the MF individuals, cross-sex hormone use was associated with a statistically significant increase in fasting serum triglycerides without changes in the other parameters (WMD = 23.39 mg/dl; 95% CI = 4.82-41.95). In the FM individuals, there was a similar increase of triglycerides (WMD = 31.35 mg/dl; 95% CI = 7.53-55.17) and a reduction of high density lipoprotein (HDL)-cholesterol (WMD = -6.09 mg/dl; 95% CI = -11.44 to -0.73). There was a statistically significant but clinically trivial increase in systolic blood pressure (WMD = 1.74 mmHg; 95% CI = 0.21-3.27). Analyses were associated with significant heterogeneity across studies. There were very few reported cardiovascular events (deaths, strokes, myocardial infarctions or venous thromboembolism), more commonly among MF individuals.

CONCLUSIONS

Very low quality evidence, downgraded due to methodological limitations of included studies, imprecision and heterogeneity, suggests that cross-sex hormone therapies increase serum triglycerides in MF and FM and have a trivial effect on HDL-cholesterol and systolic blood pressure in FM. Data about patient important outcomes are sparse and inconclusive.

Preoperative low serum testosterone levels are associated with tumor aggressiveness in radical prostatectomy treated cancer patients

: The aim of this study was to characterize the aggressiveness of prostate cancer as assessed by the Gleason score (GS), the predominant Gleason pattern (pGP), and testosterone (T) serum concentration.

: A total of 247 patients, referred to our Department (from January 2007 to December 2009) for a radical prostatectomy, underwent preoperative T and bioavailable testosterone (samplings between 07:00 and 10:00 h). Serum determinations (radioimmunoassayed in a central laboratory). GS and pGP were determined in prostate biopsies and prostate tissue specimens.

: In biopsy specimens, a GS7 was observed in 105 (43%) patients; 25 (10%) had pGP4. In prostate specimens, 163 (66%) had a GS7; 60 (24%) had pGP4. For prostate specimens, comparing the 75 patients with pGP4 (GS 4+3, 4+4 and 4+5) to the 172 with pGP3 (GS 3+3 and 3+4), T was lower (4.03 vs. 4.75 ng/mL, p=0.003) and prostrate-specific antigen (PSA) higher (11.1 vs. 7.3 ng/mL, p<0.00001). Extra prostatic extension and positive margins were observed more frequently (52% vs. 18%, p<0.000001 and 29% vs. 15%, p=0.009, respectively). The 40 patients with T <3.0 ng/mL were larger (+5 kg, body mass index: +1.7 kg/m

: Aggressiveness of the tumor cannot be properly estimated by the GS and pGP found in biopsies. The pGP in prostate specimens is of paramount importance, particularly in the case of a Gleason 7, to appreciate the outcomes and to choose the treatment. Preoperative testosterone should be added to PSA determination to improve prediction of treatment outcomes.

Contribution of androgen receptor sensitivity to the relation between testosterone and sexual desire: An exploration in male-to-female transsexuals

BACKGROUND

Low sexual desire is present in 1/3 of male-to-female transsexuals (post-operative male-to-female transsexual persons on estrogen replacement). Several studies report lower endogenous testosterone (T) levels in this group compared to community dwelling women. However, no relationship between T and sexual desire has been found in male-to-female transsexuals. Considering its role in androgen sensitivity, cytosine-adenine-guanine (CAG) trinucleotide repeat sequence in the androgen receptor (AR) might modify the relationship between T levels and sexual desire in male-to-female transsexuals.

AIM

This study aims to assess the potential contribution of the number of CAG repeats in the association between T and sexual desire in male-to-female transsexuals. MATERIAL, SUBJECTS, AND METHODS: Thirty-four post-operative male-to-female transsexuals participated in a cross-sectional study. The Sexual Desire Inventory, a questionnaire measuring sexual desire, was completed. Serum levels of total (TT) and free T (FT), DHEA-S, SHBG, and LH were measured in morning blood samples. AR gene CAG repeat length was determined by automated DNA fragment analysis of exon 1 of the AR gene.

RESULTS

The CAG repeat length ranged from 14 to 28 with a median of 21. CAG polymorphism was correlated with FT (r=0.389; p=0.023) but not with TT (r=0.191; p=0.280). The observed interaction between TT and CAG was significant only for solitary sexual desire (p=0.002). The interaction of CAG repeats and FT on sexual desire failed to reach significance.

CONCLUSIONS

We could not establish that CAG repeat length is a consistent modulating factor in the relationship between TT or FT and sexual desire in male-to-female transsexuals.

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.

Testosterone addition to estrogen therapy - effects on inflammatory markers for cardiovascular disease

OBJECTIVE

To analyze the effects of testosterone addition to estrogen therapy in comparison with estrogen alone on cardiovascular risk factors in postmenopausal women.

METHODS

Fifty surgically postmenopausal women were included in this double-blind, placebo-controlled and randomized study to receive daily oral treatment with estradiol valerate 2 mg + placebo (E/P) or estradiol valerate 2 mg + testosterone undecanoate 40 mg (E/T) for 24 weeks and then switched to the other regimen for another 24 weeks. Sex hormones, High sensitivity CRP (hsCRP), Interleukin-6 (IL-6), Tissue necrosis factor (TNF)-alpha, Insulin-like growth factor binding globulin (IGFBP-1), vascular cell adhesion molecule (VCAM)- 1, and homocysteine were analyzed at baseline and after 6 and 12 months.

RESULTS

Estradiol and androgens increased as expected during the treatments. After 6 months of E/P, increases of hsCRP and IGFBP-1 and a decline of VCAM were recorded, whereas IL-6, TNF-alpha, and homocysteine were unchanged. When testosterone was added to estrogen, the increase of IGFBP-1 and decline in VCAM was similar as with estrogen treatment alone. However, testosterone addition counteracted the estrogen-induced rise in hsCRP but had no effects on IL-6, TNF-alpha, and homocysteine.

CONCLUSION

Data suggest that testosterone addition to estrogen treatment in postmenopausal women has a modest influence on inflammatory markers and there were no apparent adverse effects. On the contrary, the estrogen-induced increase in hsCRP was suppressed.

Should the ovaries be removed or retained at the time of hysterectomy for benign disease?

BACKGROUND

Bilateral oophorectomy is commonly performed at the time of hysterectomy for benign disease. Indications for oophorectomy vary, but in most cases relatively little high-quality information is available to inform the surgeon or patient regarding the relative risks and benefits of ovarian conservation or removal. This review will address the common clinical situations when oophorectomy may be performed and will evaluate the evidence for risk and benefit in each of these circumstances. The aim of this review is to bring together the evidence regarding oophorectomy in pre- and post-menopausal women and to highlight the areas needing further study.

METHODS

We searched the published literature for studies related to outcomes following surgical menopause, risk-reducing surgery for ovarian cancer, surgical treatment for endometriosis, bilateral oophorectomy for benign disease and treatment for premenstrual syndrome/premenstrual dysphoric disorder.

RESULTS

Rates of oophorectomy at the time of hysterectomy for benign disease appear to be increasing. There is good evidence to support bilateral salpingoophorectomy (BSO) as a risk-reducing surgery for women at high risk of ovarian cancer, but relatively little evidence to support oophorectomy or BSO in other circumstances. There is growing evidence from observational studies that surgical menopause may impact negatively on future cardiovascular, psychosexual, cognitive and mental health.

CONCLUSION

Clinicians and patients should fully consider the relative risks and benefits of oophorectomy on an individual basis prior to surgery.

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.

Testosterone, sex hormone-binding globulin and free androgen index among adult women: chronological and ovarian aging

BACKGROUND

In this study, levels and rates of change in total testosterone (T), sex hormone-binding globulin (SHBG) and free androgen index (FAI) were related to chronological age and to the final menstrual period (FMP) as an indicator of ovarian aging.

METHODS

Data were annually acquired over a 15-year period in 629 women of the Michigan Bone Health and Metabolism Study cohort. Data were censored for hormone therapy use. Endogenous androgen patterns over time were described with stochastic processes and bootstrapping.

RESULTS

With ovarian aging, T levels rose from a mean of 18 ng/dl commencing 10 years prior to the FMP to 27 ng/dl at the FMP. Over the 20-year period encompassing the FMP, modeled mean SHBG levels changed from 58 to 34 nM and the FAI ratio increased from 1.6 to 2.9 in a non-linear manner. With chronological aging, total T levels increased (P < 0.0001) from 43 to 50 years, but not thereafter. SHBG declined steadily with age with a modestly greater rate of change between 49 and 54 years. The FAI increased from 1.3 to 2.5 from 34 to 58 years.

CONCLUSIONS

T increased from approximately age 40 until the FMP whereas SHBG had rate of change patterns reflecting both chronological and ovarian aging components. These data provide new insight into the endogenous androgen patterns at mid-life.

Interlaboratory comparison study of serum total testosterone [corrected] measurements performed by mass spectrometry methods

BACKGROUND

Though mass spectrometry (MS) assays are increasingly used for routine clinical measurements of serum total testosterone (TT), information about the variability of results is limited. This study assessed the variability of TT measurement results from routine MS assays.

METHODS

Twenty serum samples (12 females, 8 males) were analyzed on 2 days by seven high performance liquid chromatography (HPLC), and one gas chromatography (GC)-tandem mass spectrometry (HPLC-MS/MS, GC-MS/MS) assays. Two samples (male and female) were provided in five replicates to assess the within-run variability. Results were compared against those obtained at National Institute of Standards and Technology (NIST). The within- and between-laboratory variability was assessed for each sample. Comparisons to the NIST results were performed using bias plot and Deming regression analysis.

RESULTS

The overall coefficient of variation of the results obtained with MS assays was <15%CV at >1.53 nmol/L and <34%CV at 0.3 nmol/L. The between-assay variability was the major contributor to the overall variability. The assay precision was the highest (<3%CV) with assays using liquid-liquid extraction for sample preparation or GC-MS/MS. The mean percent difference to the reference assay was 11%. The slopes of Deming regression analysis of the MS assays were between 0.903 and 1.138 (correlation coefficient: >0.996). TT concentrations for one assay were above the measurement range.

CONCLUSIONS

The variability of TT measurement results among MS assays is substantially smaller than that reported for immunoassays. The type of sample preparation may affect assay precision. Standardizing assays can further reduce the variability of measurement results.

Breast cancer in young women and its impact on reproductive function

BACKGROUND

Breast cancer is the most common cancer in women in developed countries, and 12% of breast cancer occurs in women 20-34 years. Survival from breast cancer has significantly improved, and the potential late effects of treatment and the impact on quality of life have become increasingly important. Young women constitute a minority of breast cancer patients, but commonly have distinct concerns and issues compared with older women, including queries regarding fertility, contraception and pregnancy. Further, they are more likely than older women to have questions regarding potential side effects of therapy and risk of relapse or a new primary. In addition, many will have symptoms associated with treatment and they present a management challenge. Reproductive medicine specialists and gynaecologists commonly see these women either shortly after initial diagnosis or following adjuvant therapy and should be aware of current management of breast cancer, the options for women at increased genetic risk, the prognosis of patients with early stage breast cancer and how adjuvant systemic treatments may impact reproductive function.

METHODS

No systematic literature search was done. The review focuses on the current management of breast cancer in young women and the impact of treatment on reproductive function and subsequent management. With reference to key studies and meta-analyses, we highlight controversies and current unanswered questions regarding patient management.

RESULTS

Chemotherapy for breast cancer is likely to negatively impact on reproductive function. A number of interventions are available which may increase the likelihood of future successful pregnancy, but the relative safety of these interventions is not well established. For those who do conceive following breast cancer, there is no good evidence that pregnancy is detrimental to survival. We review current treatment; effects on reproductive function; preservation of fertility; contraception; pregnancy; breastfeeding and management of menopausal symptoms following breast cancer.

CONCLUSION

This paper provides an update on the management of breast cancer in young women and is targeted at reproductive medicine specialists and gynaecologists.

Mammary gland and endometrial effects of testosterone in combination with oral estradiol and progesterone

OBJECTIVE

The goal of this pilot study was to evaluate the effects of testosterone (T) cotherapy on mammary gland and endometrial measures in a postmenopausal primate model.

METHODS

Twenty-five surgically postmenopausal cynomolgus monkeys were randomized by social group to receive daily treatment with (1) placebo, (2) oral micronized 17beta-estradiol (1 mg/d equivalent in women) + progesterone (200 mg/d equivalent in women) (E + P), or (3) E + P with T administered via subcutaneous pellets for 8 weeks at a high dose (15 mg) followed by 8 weeks at a low dose (1.5 mg) (E + P + T). The main outcome measures were breast and endometrial epithelial proliferation, as measured by Ki67/MIB1 immunolabeling.

RESULTS

Intralobular breast proliferation did not differ significantly among groups after 8 weeks of treatment but was marginally higher (P = 0.03) in the E + P + T group after 16 weeks of treatment. No significant increase in proliferation was seen for E + P alone. Comparable changes in mammary gland markers of estrogen-receptor activity were seen for the E + P and E + P + T groups. In the endometrium, the addition of T did not increase endometrial glandular proliferation or estrogen-receptor activity or result in any distinct histologic changes.

CONCLUSIONS

The findings of this study do not support the idea that T antagonizes the effects of combined hormone therapy on breast proliferation or markers of estrogen-receptor activity. Overall, the short-term effects of T cotherapy on the mammary gland and endometrium were minimal.

Sexually dimorphic effects of testosterone administration on brain allopregnanolone in gonadectomized rats

INTRODUCTION

Clinical and biological evidences have shown a wide range of neuroactive effects of testosterone administration.

AIM

Evaluation of the effects of 2-weeks treatment with testosterone (T), Dihydrotestosterone (DHT), and estradiol valerate (E2V) on brain and serum allopregnanolone (AP) in gonadectomized rats of both sexes.

MAIN OUTCOME MEASURES

AP levels were measured in frontal and parietal lobe, hippocampus, hypothalamus, anterior pituitary, and in serum.

METHODS

Eight groups of Wistar female and eight groups of Wistar male rats were included. For each sex, one group of fertile and one group of gonadectomized rats were employed as control receiving placebo. The others groups received subcutaneous T at the dose of 10 microg/kg/day and 100 microg/kg/day for female rats, and 1 mg/kg/day and 5 mg/kg/day for male rats, or DHT at the doses of 1 microg/kg/day, 10 microg/kg/day, and 100 microg/kg/day for females, and 0, 1 microg/kg/day, 1 mg/kg/day and 5 mg/kg/day for males, or E2V (0.05 mg/Kg/day).

RESULTS

Ovariectomy (OVX) and orchidectomy (OCX) induced a significant decrease in AP in all brain areas analyzed, as well as in serum. In OVX rats, T replacement, as well as E2V, significantly increased AP content in all brain areas and in plasma. In OCX, T and E2V did not actively result in influencing AP concentration in frontal and parietal lobe, while it produced a significant rise in AP levels in the hippocampus, hypothalamus, anterior pituitary, and serum. Conversely, DHT replacement had no affect on AP levels anywhere or at any administered dose, either in males or in female rats.

CONCLUSIONS

Gender difference and T therapy affect brain AP synthesis/release during the reproductive aging. This effect becomes particularly evident in the brain of ovariectomized animals, where the content of this specific neurosteroid is much more responsive than male animals to testosterone replacement.

Traceability in laboratory medicine

BACKGROUND

In patient and population samples, generation of analytical results that are comparable and independent of the measurement system, time, and location is essential for the utility of laboratory information supplied in healthcare. Obtaining analytical measurement results with such characteristics is the aim of traceability in laboratory medicine. As awareness of the benefits of having traceable measurement results has increased, associated efforts have been directed toward making traceability a regulatory requirement and developing approaches to enable and facilitate the implementation of traceability. Although traceability has been a main focus of many laboratory standardization activities in the past, discussions are still ongoing with regard to traceability and its implementation.

CONTENT

This review provides information about the traceability concept and what needs can be fulfilled and benefits achieved by the availability of traceable measurement results. Special emphasis is given to the new metrological terminology introduced with this concept. The review addresses and describes approaches for technical implementation of traceable methods as well as the associated challenges. Traceability is also discussed in the context of other activities to improve the overall measurement process.

SUMMARY

Establishing metrological traceability of measurement results satisfies basic clinical and public health needs, thus improving patient care and disease control and prevention. Large advances have been made to facilitate the implementation of traceability. However, details in the implementation process, such as lack of available commutable reference materials and insufficient resources to develop new reference measurement systems continue to challenge the laboratory medicine community.

Androgen synthesis in adrenarche

The enzymes and pathways of steroidogenesis are central to an understanding of adrenarche. The quantitative regulation of steroidogenesis occurs at the first step, the conversion of cholesterol to pregnenolone. Chronic quantitative regulation is principally at the level of transcription of the CYP11A1 gene encoding P450scc, which is the enzymatically rate-limiting step. Acute regulation is mediated by the steroidogenic acute regulatory protein (StAR), which facilitates the rapid influx of cholesterol into mitochondria, where P450scc resides. Qualitative regulation, which determines the type of steroid produced in a cell, is principally at the level of P450c17 (CYP17). In the absence of P450c17 in the zona glomerulosa, C21 deoxy steroids are produced, leading to the mineralocorticoid, aldosterone. In the presence of the 17alpha-hydroxylase but not the 17,20 lyase activity of P450c17 in the zona fasciculata, C21, 17-hydroxy steroids are produced, leading to the glucocorticoid, cortisol. When both the 17alpha-hydroxylase and 17,20 lyase activities of P450c17 are present in the zona reticularis, the androgen precursor DHEA is produced. The discrimination between 17alpha-hydroxylase and 17,20 lyase activities is regulated by two post-translational events, the serine phosphorylation of P450c17 and the allosteric action of cytochrome b5, both of which act to optimize the interaction of P450c17 with its obligatory electron donor, P450 oxidoreductase. In the adrenal zona reticularis, the abundant expression of P450 oxidoreductase and cytochrome b5, and the low expression of 3beta-hydroxysteroid dehydrogenase (HSD3B2) result in the production of the large amounts of DHEA that characterize adrenarche.

Effect of testosterone and a nutritional supplement, alone and in combination, on hospital admissions in undernourished older men and women

BACKGROUND

In older people, undernutrition is associated with increased hospitalization rates and mortality. Because weight loss in older people often reflects a disproportionate reduction of skeletal muscle, anabolic treatments may be beneficial.

OBJECTIVE

Our aim was to evaluate the hypothesis that testosterone treatment and a nutritional supplement have additive benefits.

DESIGN

Oral testosterone undecanoate (40 mg daily for women, 80 mg twice daily for men) and an oral nutritional supplement (475 kcal/d) were administered, alone or combined, for 1 y to 49 community-dwelling, undernourished people [Mini Nutritional Assessment score <24 and low body weight (body mass index, in kg/m(2): <22) or recent weight loss (>7.5% over 3 mo)] aged >65 y (mean age: 77 y; 26 women and 23 men). Hospital admissions and other variables were assessed.

RESULTS

In subjects receiving combined testosterone and nutritional supplements (n = 11), there were no hospital admissions, whereas there were 9 admissions (2 elective) in 13 subjects in the no-treatment group, 4 in the testosterone-treated group (n = 12), and 5 in the supplement-treated group (n = 13); P = 0.06 with no-treatment compared with combined treatment. When compared with the no-treatment group, the combined-treatment group had significantly fewer subjects admitted to hospital (0 compared with 5, P = 0.03), fewer days in hospital (0 compared with 74, P = 0.041), and a longer time to hospital admission (P = 0.017).

CONCLUSIONS

In undernourished older people, combined treatment with testosterone and nutritional supplementation reduced the number of people hospitalized and the duration of hospital admissions, which are important endpoints in this group. Larger, confirmatory studies are now needed. This trial was registered before commencement at clinical trials.gov as NCT00117000.

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.

Androgen deficiency: effects on body composition

Published data on the effects of androgen deficiency and testosterone administration on body composition in men and women are reviewed. In experimental paradigms, androgen deprivation decreases lean body mass and increases fat mass in men, and physiologic replacement reverses these abnormalities. The anabolic effects of testosterone administration on muscle in men are well-established, and current understanding of the underlying mechanisms are discussed. Randomized, placebo-controlled studies have been performed to investigate the effects of testosterone administration on body composition in a number of male hypogonadal states, including HIV-associated weight loss, supraphysiologic glucocorticoid administration, aging and obesity, with variable outcomes, and the results are reviewed. There are few data investigating the effects of hypoandrogenemia or androgen replacement on body composition in women, in whom endogenous testosterone levels are a fraction of those in men. A recent randomized, placebo-controlled study of physiologic testosterone replacement therapy in women with profound hypoandrogenemia due to hypopituitarism demonstrated an increase in skeletal muscle mass but no change in body fat. Further research is needed to establish the effects of endogenous androgens on the regulation of body composition in women.

Long-term effects of bilateral oophorectomy on brain aging: unanswered questions from the Mayo Clinic Cohort Study of Oophorectomy and Aging

In the Mayo Clinic Cohort Study of Oophorectomy and Aging, women who had both ovaries removed before reaching natural menopause experienced a long-term increased risk of parkinsonism, cognitive impairment or dementia, and depressive and anxiety symptoms. Here, we discuss five possible mechanistic interpretations of the observed associations; first, the associations may be non-causal because they result from the confounding effect of genetic variants or of other risk factors; second, the associations may be mediated by an abrupt reduction in levels of circulating estrogen; third, the associations may be mediated by an abrupt reduction in levels of circulating progesterone or testosterone; fourth, the associations may be mediated by an increased release of gonadotropins by the pituitary gland; and fifth, genetic variants may modify the hormonal effects of bilateral oophorectomy through simple or more complex interactions. Results from other studies are cited as evidence for or against each possible mechanism. These putative causal mechanisms are probably intertwined, and their clarification is a research priority.

The impact of assay quality and reference ranges on clinical decision making in the diagnosis of androgen disorders

The Endocrine Society guideline on Androgen Deficiency in Men emphasized that accurate measurement of testosterone (T) levels is central to the diagnosis of androgen deficiency. Similarly, accurate measurements of testosterone levels are important in the diagnosis of androgen disorders in women and children. However, the accuracy of direct radioimmunoassays for the measurement of total T levels has been questioned, especially in the low range prevalent in women, children, and androgen deficient men. Furthermore, reference limits for total and free T levels generated in a population-based sample of community-dwelling men, women, and children are not available. In the absence of standardized reference limits, the partitioning of total and free T levels into normal, low, or high values is fraught with substantial risk of misclassification. The recommendations for partitioning of individuals into those with low, normal, or high levels should be based on considerations of statistical distribution of total and free T values and the association of outcomes with varying degree of deviations from the reference limits. Ongoing efforts to generate population-based reference ranges for total and free testosterone levels in men and women will provide a framework for the interpretation of serum T levels and enhance the comprehensibility of circulating T values to practicing clinicians. These steps will facilitate the development of rational criteria for the diagnosis of androgen disorders in men, women, and children.

CDC project on standardizing steroid hormone measurements

Estradiol and testosterone measurements are widely used to assess steroid hormone status and to monitor stimulative, suppressive, or replacement therapy among children and adults of both sexes. Despite their common application, these measurements - particularly at low concentrations - show only limited comparability among assays, such as those observed for testosterone among women or for estradiol among postmenopausal women. This shortcoming hampers progress in research and in research translation. To overcome this, the Centers for Disease Control and Prevention, National Center for Environmental Health, Division of Laboratory Sciences (CDC/NCEH/DLS) initiated a project to standardize and to improve steroid hormone measurements. The project is a collaborative effort between institutions, organizations, and groups involved in estradiol and testosterone testing, test interpretation, and use. Specific activities are scheduled based on needs assessments conducted with the clinical, research, and public health communities. The initial focus of this standardization project is to improve analytical measurements through reference laboratory activities. As part of the project's translational activities, CDC/NCEH/DLS will work further with professional societies and organizations to improve pre- and postanalytical issues that affect results from these measurements and their interpretation.

Testosterone and the breast

Although women have been treated with testosterone (T) for female sexual dysfunction since the 1950s, the role of T in normal female physiology is not yet fully defined. One of the major safety concerns of androgen therapy is whether androgens have a stimulatory effect on the breast that could lead to breast carcinomas. The proposed mechanisms for such stimulation include local estrogen production from the aromatase enzyme complex present in the breast tissue or by the direct stimulation of the androgen receptor. Predominant data from in vitro studies have shown that androgens actually have apoptotic and antiproliferative effects and not stimulatory effects. Animal models have shown similar results to in vitro studies, finding that androgens inhibit breast cancer growth. Prospective and retrospective epidemiological analyses have shown mixed outcomes, with no clear consensus regarding androgen use and breast cancer risk. Hyperandrogenism in patients with polycystic ovarian syndrome with elevated levels of endogenous T is not associated with an increased risk of breast cancer and may, in fact, be protective. Another human model with excess of T is female-to-male transgenderism, in which genotypic women are treated with large doses of exogenous T with no increased risk. High-dose androgen therapy also has been effective in treating patients with advanced breast cancer. Thus, the preponderance of data suggests that T use in females is not associated with an increased risk of breast carcinoma.

Testosterone for low libido in postmenopausal women not taking estrogen

BACKGROUND

The efficacy and safety of testosterone treatment for hypoactive sexual desire disorder in postmenopausal women not receiving estrogen therapy are unknown.

METHODS

We conducted a double-blind, placebo-controlled, 52-week trial in which 814 women with hypoactive sexual desire disorder were randomly assigned to receive a patch delivering 150 or 300 microg of testosterone per day or placebo. Efficacy was measured to week 24; safety was evaluated over a period of 52 weeks, with a subgroup of participants followed for an additional year. The primary end point was the change from baseline to week 24 in the 4-week frequency of satisfying sexual episodes.

RESULTS

At 24 weeks, the increase in the 4-week frequency of satisfying sexual episodes was significantly greater in the group receiving 300 microg of testosterone per day than in the placebo group (an increase of 2.1 episodes vs. 0.7, P<0.001) but not in the group receiving 150 microg per day (1.2 episodes, P=0.11). As compared with placebo, both doses of testosterone were associated with significant increases in desire (300 microg per day, P<0.001; 150 microg per day, P=0.04) and decreases in distress (300 microg per day, P<0.001; 150 microg per day, P=0.04). The rate of androgenic adverse events - primarily unwanted hair growth - was higher in the group receiving 300 microg of testosterone per day than in the placebo group (30.0% vs. 23.1%). Breast cancer was diagnosed in four women who received testosterone (as compared with none who received placebo); one of the four received the diagnosis in the first 4 months of the study period, and one, in retrospect, had symptoms before undergoing randomization.

CONCLUSIONS

In postmenopausal women not receiving estrogen therapy, treatment with a patch delivering 300 microg of testosterone per day resulted in a modest but meaningful improvement in sexual function. The long-term effects of testosterone, including effects on the breast, remain uncertain. (ClinicalTrials.gov number, NCT00131495.)

Supraphysiological testosterone enanthate administration prevents bone loss and augments bone strength in gonadectomized male and female rats

High-dose testosterone enanthate (TE) may prevent hypogonadism-induced osteopenia. For this study, 3-mo-old male and female Fisher SAS rats underwent sham surgery, gonadectomy (GX), or GX plus 28 days TE administration (7.0 mg/wk). GX reduced serum sex hormones (i.e., testosterone, dihydrotestosterone, and estradiol) (P < 0.05) in both sexes and bone concentrations of testosterone (males only), and estradiol (females only). GX also elevated urine deoxypyridinoline/creatinine in both sexes and serum osteocalcin (females only), findings that are consistent with high-turnover osteopenia. GX reduced cancellous bone volume (CBV) and increased osteoid surfaces in tibia of both sexes. GX males also experienced reduced trabecular number and width and increased trabecular separation, whereas GX females experienced increased osteoblast and osteoid surfaces. Bone biomechanical characteristics remained unaffected by GX, except that femoral stiffness was reduced in females. In contrast, TE administration to GX rats elevated serum and bone androgens to supraphysiological concentrations in both sexes but altered neither serum nor bone estradiol in males. Additionally, TE did not prevent GX-induced reductions in serum or bone estradiol in females. TE also reduced markers of high-turnover osteopenia in both sexes. In males, TE prevented GX-induced changes in trabecular number and separation, CBV, and osteoid surfaces while diminishing osteoblast and osteoclast surfaces; however, these changes were not fully prevented in females. In both sexes, TE increased femoral length and femoral maximal strength to above that of Sham and GX animals while preventing the loss of femoral stiffness in females. In conclusion, TE administration appears protective of cancellous bone in male rats and augments cortical bone strength in both sexes.