Testosterone implants in women: Pharmacological dosing for a physiologic effect

Inflammation dynamically regulates steroid hormone metabolism and action within macrophages in rheumatoid arthritis

RATIONALE

In inflammatory diseases such as rheumatoid arthritis (RA), steroid metabolism is a central component mediating the actions of immuno-modulatory glucocorticoids and sex steroids. However, the regulation and function of cellular steroid metabolism within key leukocyte populations such as macrophages remain poorly defined. In this study, the inflammatory regulation of global steroid metabolism was assessed in RA macrophages.

METHODS

Bulk RNA-seq data from RA synovial macrophages was used to assess transcripts encoding key enzymes in steroid metabolism and signalling. Changes in metabolism were assessed in synovial fluids, correlated to measures of disease activity and functionally validated in primary macrophage cultures.

RESULTS

RNA-seq revealed a unique pattern of differentially expressed genes, including changes in genes encoding the enzymes 11β-HSD1, SRD5A1, AKR1C2 and AKR1C3. These correlated with disease activity, favouring increased glucocorticoid and androgen levels. Synovial fluid 11β-HSD1 activity correlated with local inflammatory mediators (TNFα, IL-6, IL-17), whilst 11β-HSD1, SRD5A1 and AKR1C3 activity correlated with systemic measures of disease and patient pain (ESR, DAS28 ESR, global disease activity). Changes in enzyme activity were evident in inflammatory activated macrophages in vitro and revealed a novel androgen activating role for 11β-HSD1. Together, increased glucocorticoids and androgens were able to suppress inflammation in macrophages and fibroblast-like-synoviocytes.

CONCLUSIONS

This study underscores the significant increase in androgen and glucocorticoid activation within inflammatory polarized macrophages of the synovium, contributing to local suppression of inflammation. The diminished profile of inactive steroid precursors in postmenopausal women may contribute to disturbances in this process, leading to increased disease incidence and severity.

Androgen-based therapies in women

Androgens play a key biological role in libido and sexual arousal in women, and knowledge about their complex role in other systems remains ambiguous and incomplete. This narrative review examines the role of endogenous androgens in women's health throughout the life span before focusing on evidence surrounding the use of androgen-based therapies to treat postmenopausal women. The role of testosterone as a therapeutic agent in women continues to attract controversy as approved preparations are rare, and use of off-label and compounded formulations is widespread. Despite this androgen therapy has been used for decades in oral, injectable, and transdermal formulations. Responses to androgen therapy have been demonstrated to improve aspects of female sexual dysfunction, notably hypoactive sexual desire disorder, in a dose related manner. Substantial research has also been conducted into the role of androgens in treating aspects of the genitourinary syndrome of menopause (GSM). Evidence for benefits beyond these is mixed and more research is required regarding long-term safety. However, It remains biologically plausible that androgens will be effective in treating hypoestrogenic symptoms related to menopause, either through direct physiological effects or following aromatization to estradiol throughout the body.

Testosterone Pellet Use in Transgender Men

Purpose

We assessed the efficacy and short-term adverse effects of testosterone pellet use in transgender men to broaden therapeutic options.

Methods

We conducted a retrospective study of 30 transgender men who started testosterone pellets between 2018 and 2020.

Results

Testosterone pellets were started at dosages 675-825 mg per cycle and dose was adjusted according to testosterone levels obtained 1 to 6 months post-testosterone pellet insertion. Pharmacokinetics of testosterone pellet in transgender men was similar to those in cisgender men. Total testosterone levels reached a peak in 1 month and remained in the therapeutic range for ∼4 months in the range of 300-800 ng/dL. After switching over to testosterone pellets, 100% of patients continued to achieve amenorrhea and deepening of their voice. Most of the patients noticed increased hair growth in androgen-dependent regions (96.3%) and improved libido (70%). Adverse events were notable for a rate of polycythemia that was unexpectedly high at 46.67%. Pellet extrusion was found in 13.33% of patients. There was a low rate of pellet site hematoma (6.67%) and cellulitis (3.33%). No thromboembolic or cardiovascular events occurred in any of the patients.

Conclusion

This study reveals that testosterone pellets are a reasonable alternative to other testosterone modalities in transgender men but would use caution in patients with a history of polycythemia or higher risk for thromboembolic events.

Androgens, Endometriosis and Pain

The intriguing relationship between androgens, endometriosis and chronic pain continues to unfold. Determining this relationship is of crucial importance to gynecologists managing people with these conditions, as common treatments dramatically alter her hormonal profiles, with both intended and unintended consequences. Although they may be present in the same individual, there is a recognized disconnect between pain or pain-related symptoms, and the presence or extent of endometriosis lesions. Reduced androgen levels provide a potential mechanism to link the development of endometriosis lesions and the presence of chronic pain. This research paper expands the presentation of our research at the World Endometriosis Congress in 2021, subsequently published in the Journal of Pain Research which demonstrated a strong inverse relationship between androgen levels and days per month of pelvic and period pain. Here we extend and further explore the evidence for a role for androgens in the etiology and management of dysmenorrhea and pelvic pain in women, both with and without endometriosis. We explore the potential for inflammation to induce low androgen levels and consider ways in which clinicians can optimize levels of androgens when treating women with these conditions. This article prompts the question: Is it estrogens that predispose people to a life of pain, or androgens that are protective?

Breast Cancer Incidence Reduction in Women Treated with Subcutaneous Testosterone: Testosterone Therapy and Breast Cancer Incidence Study

Objective

Testosterone (T) therapy has been shown to be breast protective in both pre- and post-menopausal patients. Additionally, estradiol (E) does not cause breast cancer (BC) in the majority of the world's literatures. This study aimed to investigate the incidence of invasive BC (IBC) in pre- and postmenopausal women treated with T therapy and T in combination with E (T/E).

Materials and Methods

Since January 2010, a total of 2,377 pre- and post-menopausal women were treated with T or T/E implants. IBC rates were reported based on newly diagnosed IBC cases in the total study. Total cases divided by the total sample size and years in study was expressed as an incidence per 100,000 person-years (P-Ys). The BC incidence was compared with age-specific Surveillance Epidemiology and End Results (SEER) incidence rates.

Results

As of October 2020, 14 cases diagnosed with IBC have been found in 9,746 P-Y of follow up for an incidence of 144 cases per 100,000 P-Y, substantially less than the age-specific SEER incidence rates (223/100,000), placebo arm of Women's Health Initiative Study (330/100,000), and never users of hormone therapy from the Million Women Study (312/100,000).

Conclusion

T and/or T/E pellet implants significantly reduced the incidence of BC in pre- and post-menopausal women. The addition of E did not increase the incidence over using T alone. This is the second multi-year long-term study demonstrating the benefits of T therapy in reducing the incidence of IBC.

Associations between androgens and sexual function in premenopausal women: a cross-sectional study

BACKGROUND

Although clinicians often measure the serum concentration of androgens in premenopausal women presenting with sexual dysfunction, with some women given testosterone or dehydroepiandrosterone as treatment if their concentrations are low, whether androgens are determinants of sexual function in women of reproductive age is uncertain. We aimed to clarify the associations between androgens and sexual function in a community-based sample of non-health-care-seeking women.

METHODS

This is a substudy of the Grollo-Ruzzene cross-sectional study, which recruited women aged 18-39 years from eastern states in Australia (QLD, NSW, VIC). After providing consent, women completed an online survey that included the Profile of Female Secual Function (PFSF) questionnaire, and those who were who were not pregnant, breastfeeding, or using systemic steroids were asked to provide a blood sample. At sampling, women were asked the dates of their last menstrual bleed. Serum androgens was measured by liquid chromatography and tandem mass spectrometry and sex hormone binding globulin (SHBG) by immunoassay. Associations between androgens and domains of sexual function, assessed by the PFSF, were examined in participants with regular menstrual cycles. After univariable linear regression (model 1), age, BMI, stage of menstrual cycle, and smoking status were added to the model (model 2), and then parity, partner status, and psychotropic medication use (model 3).

FINDINGS

Of 6986 women who completed the online survey (surveys completed between Nov 11, 2016, and July 21, 2017), 3698 were eligible and 761 (20·6%) provided blood samples by Sept 30, 2017. Of those who provided a blood sample, 588 (77·3%) had regular menstrual cycles and were included in the analysis. Adjusting for age, BMI, cycle stage, smoking, parity, partner status, and psychoactive medication, sexual desire was positively associated with serum dehydroepiandrosterone (β-coefficient 3·39, 95% CI 0·65 to 6·03) and androstenedione (4·81, 0·16 to 9·12), and negatively with SHBG (-5.74, -9.54 to -1·90), each model explaining less than 4% of the variation in desire. Testosterone (6·00, 1·29 to 10·94) and androstenedione (6·05, 0·70 to 11·51) were significantly associated with orgasm, with the final models explaining less than 1% of the variation in orgasm. Significant associations were found between androstenedione (7·32, 0·93 to 13·08) and dehydroepiandrosterone (4·44, 0·86 to 7·95) and pleasure, and between testosterone and sexual self-image 5·87 (1·27 to 10·61), with inclusion of parity, partners status, and psychotropic drug use increasing the proportion of variation explained by each model to approximately 10%. There were no statistically significant associations between 11-oxygenated steroids and any PFSF domain, or between arousal or responsiveness and any hormone. No associations were seen between 11-oxygenated steroids and any sexual domain, or between arousal or responsiveness and any hormone.

INTERPRETATION

Associations between androgens and sexual function in premenopausal women are small, and their measurement offers no diagnostic use in this context. Further research to determine whether 11-ketoandrostenedione or 11-ketotestosterone are of clinical significance is warranted.

FUNDING

The Grollo-Ruzzene Foundation.

Voice Change Following Testosterone Supplementation in Women: A Multi-Institutional Case Series

OBJECTIVES

To describe voice changes as a result of the off-label use of androgen supplementation in women.

METHODS

A multi-institutional retrospective consecutive case series identified women taking androgen supplementation who presented to voice clinics at two institutions with a chief complaint of voice change between 2014 and 2019. Age, occupation, hormone therapy, indication, Voice Handicap Index-10, fundamental frequency, semitone pitch range, testosterone blood level, treatment undertaken, and long-term outcome were collected.

RESULTS

Nine women presented with voice change after initiation of androgen hormone supplementation. The mean age was 55 and three patients were performers. All patients underwent hormone therapy with testosterone supplementation, most commonly subcutaneous testosterone pellets. Six patients (67%) were being treated for menopause symptoms, one patient for decreased libido, one patient for breast cancer, and one patient who desired additional muscle gain. Time of symptom onset after hormone therapy initiation was highly variable, ranging from 0 to 48 months with a mean of 15 months. Mean Voice Handicap Index-10 was 21, mean fundamental frequency at comfortable speaking level was 155 Hz and mean semitone pitch range was 22 semitones. Two patients had markedly elevated serum total testosterone levels. Hormone therapy discontinuation and voice therapy were recommended in six (67%) patients each. Five patients returned for follow-up after treatment and noted some subjective benefit.

CONCLUSIONS

Female patients treated with androgen supplementation may experience unintended voice changes, most prominently reduction in fundamental frequency. Although some benefit may be obtained from voice therapy and cessation of hormone therapy, voice changes may be permanent. Caution should be exercised when prescribing these medications to women.

Incidence of invasive breast cancer in women treated with testosterone implants: a prospective 10-year cohort study

BACKGROUND

Testosterone implants have been used for over eighty years to treat symptoms of hormone deficiency in pre and postmenopausal women. Evidence supports that androgens are breast protective. However, there is a lack of data on the long-term effect of testosterone therapy on the incidence of invasive breast cancer (IBC). This study was specifically designed to investigate the incidence of IBC in pre and postmenopausal women (presenting with symptoms of androgen deficiency) treated with subcutaneous testosterone implants or testosterone implants combined with anastrozole.

METHODS

The 10-year prospective cohort study was approved in March 2008 at which time recruitment was initiated. Recruitment was closed March 2013. Pre and postmenopausal women receiving at least two pellet insertions were eligible for analysis (N = 1267). Breast cancer incidence rates were reported as an unadjusted, un-weighted value of newly diagnosed cases divided by the sum of 'person-time of observation' for the at-risk population. Incidence rates on testosterone therapy were compared to age-specific Surveillance Epidemiology and End Results (SEER) incidence rates and historical controls. Bootstrap sampling distributions were constructed to verify comparisons and tests of significance that existed between our results and SEER data.

RESULTS

As of March 2018, a total of 11 (versus 18 expected) cases of IBC were diagnosed in patients within 240-days following their last testosterone insertion equating to an incidence rate of 165/100000 p-y, which is significantly less than the age-matched SEER expected incidence rate of 271/100000 p-y (p < 0.001) and historical controls.

CONCLUSION

Long term therapy with subcutaneous testosterone, or testosterone combined with anastrozole, did not increase the incidence of IBC. Testosterone should be further investigated for hormone therapy and breast cancer prevention.

Subcutaneous testosterone-letrozole therapy before and concurrent with neoadjuvant breast chemotherapy: clinical response and therapeutic implications

OBJECTIVE

Hormone receptor-positive breast cancers respond favorably to subcutaneous testosterone combined with an aromatase inhibitor. However, the effect of testosterone combined with an aromatase inhibitor on tumor response to chemotherapy was unknown. This study investigated the effect of testosterone-letrozole implants on breast cancer tumor response before and during neoadjuvant chemotherapy.

METHODS

A 51-year-old woman on testosterone replacement therapy was diagnosed with hormone receptor-positive invasive breast cancer. Six weeks before starting neoadjuvant chemotherapy, the patient was treated with subcutaneous testosterone-letrozole implants and instructed to follow a low-glycemic diet. Clinical status was followed. Tumor response to "testosterone-letrozole" and subsequently, "testosterone-letrozole with chemotherapy" was monitored using serial ultrasounds and calculating tumor volume. Response to therapy was determined by change in tumor volume. Cost of therapy was evaluated.

RESULTS

There was a 43% reduction in tumor volume 41 days after the insertion of testosterone-letrozole implants, before starting chemotherapy. After the initiation of concurrent chemotherapy, the tumor responded at an increased rate, resulting in a complete pathologic response. Chemotherapy was tolerated. Blood counts and weight remained stable. There were no neurologic or cardiac complications from the chemotherapy. Cost of therapy is reported.

CONCLUSIONS

Subcutaneous testosterone-letrozole was an effective treatment for this patient's breast cancer and did not interfere with chemotherapy. This novel combination implant has the potential to prevent side effects from chemotherapy, improve quality of life, and warrants further investigation.

Effect of testosterone therapy on the female voice

OBJECTIVES

This prospective study was designed to investigate the effect of testosterone, delivered by subcutaneous implants, on the female voice.

METHODS

Ten women who had opted for testosterone therapy were recruited for voice analysis. Voices were recorded prior to treatment and at 3 months, 6 months, and 12 months while on testosterone therapy. Acoustic samples were collected with subjects reading a sentence, reading a paragraph, and participating in a conversation. Significant changes in the voice over time were investigated using a repeated-measures analysis of variance with the fundamental frequency (F0) as a response variable. Demographic variables associated with characteristics of the voice were assessed.

RESULTS

There were no significant differences in average F0 related to smoking history, menopausal status, weight, or body mass index. There was no difference in average fundamental speaking frequency (sentence, paragraph, conversation) between the pre-treatment group and any post-treatment group at 3 and 12 months. There was an increase in sentence speech F0 at 6 months. Two of three patients with lower than expected F0 at baseline improved on testosterone therapy.

CONCLUSION

Therapeutic levels of testosterone, delivered by subcutaneous implant, had no adverse affect on the female voice including lowering or deepening of the voice.

Rapid response of breast cancer to neoadjuvant intramammary testosterone-anastrozole therapy: neoadjuvant hormone therapy in breast cancer

Objective

Experimental and clinical data support the inhibitory effect of testosterone on breast tissue and breast cancer. However, testosterone is aromatized to estradiol, which exerts the opposite effect. The aim of this study was to determine the effect of testosterone, combined with the aromatase inhibitor anastrozole, on a hormone receptor positive, infiltrating ductal carcinoma in the neoadjuvant setting.

Methods

To determine clinical response, we obtained serial ultrasonic measurements and mammograms before and after therapy. Three combination implants—each containing 60 mg of testosterone and 4 mg of anastrozole—were placed anterior, superior, and inferior to a 2.4-cm tumor in the left breast. Three additional testosterone-anastrozole implants were again placed peritumorally 48 days later.

Results

By day 46, there was a sevenfold reduction in tumor volume, as measured on ultrasound. By week 13, we documented a 12-fold reduction in tumor volume, demonstrating a rapid logarithmic response to intramammary testosterone-anastrozole implant therapy, equating to a daily response rate of 2.78% and a tumor half-life of 23 days. Therapeutic systemic levels of testosterone were achieved without elevation of estradiol, further demonstrating the efficacy of anastrozole combined with testosterone.

Conclusions

This novel therapy, delivered in the neoadjuvant setting, has the potential to identify early responders and to evaluate the effectiveness of therapy in vivo. This may prove to be a new approach to both local and systemic therapies for breast cancer in subgroups of patients. In addition, it can be used to reduce tumor volume, allowing for less surgical intervention and better cosmetic oncoplastic results.

Thrombosis in Three Postmenopausal Women Receiving Testosterone Therapy for Low Libido

Our hypothesis was that thrombosis occurring in postmenopausal women given testosterone (T) or testosterone–estradiol (TE) to improve libido was associated with a prothrombotic interaction between T or TE with underlying inherited procoagulants. In three previously healthy, postmenopausal, Caucasian women with no antecedent thrombosis and previously undiagnosed G20210A prothrombin gene heterozygosity, hyperhomocysteinemia and 4G4G homozygosity of the PAI-1 gene, we describe central retinal vein thrombosis and osteonecrosis that developed at 16 days, 2 months and 11 months in the three cases, respectively, after T or TE therapy was started. Exogenous T or TE in postmenopausal women may be associated with thrombosis, speculatively when it is superimposed on underlying procoagulants. This small observational case series can serve as a starting point for a larger observational study with greater detail on patient history, serum T and estradiol levels, and detailed PCR and serologic assessment of thrombophilia and hypofibrinolysis.