International Society for the Study of Women's Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women

Menopause and Sexual Health: Hormones, Aging or Both?

Sexual health is multidimensional across the lifespan. At midlife, women may face challenges to sexuality, often requiring intervention. Menopause-related and age-related hormonal changes intermingle with common medical conditions and contribute to biological substrates less favorable to a healthy sexual response. Psychological, sociocultural, and relational factors modulate the impact of such changes positively or negatively, contributing to adaptation or manifestation of sexually related distress. A comprehensive diagnostic approach and multidimensional management are needed to address sexual symptoms due to both menopause and aging, individualizing non-pharmacological and pharmacological evidence-based treatment options according to personal goals and expectations in the woman/couple.

Plasma and salivary hormone responses to a 30-min exercise stress test in young, healthy, physically active females

Overreaching, a consequence of intensified training, is used by athletes to enhance performance. A blunted hormonal response to a 30-min interval exercise stress test (55/80) has been shown in males after intensified training, highlighting cortisol and testosterone as potential biomarkers of overreaching. Despite accounting for ~50% of the population, studies into hormonal responses to exercise in females are lacking. The menstrual cycle and oral contraceptives profoundly affect hormonal responses, necessitating separate investigations into the female response to the same exercise-stress test. On three separate visits, 13 females (6 oral contraceptive users, 7 eumenorrheic) completed a VO2max test, resting control trial, and 55/80 stress test. The 55/80 involves alternating between 1 min at 55% VO2max and 4 min at 80% VO2max. Blood and saliva were collected pre, post, and 30 min post-55/80, and at coinciding time points during the resting control trial. Plasma progesterone, estrogen, and plasma and salivary cortisol and testosterone were analyzed via ELISA. A significant elevation of salivary and plasma cortisol (~141% and ~87%, respectively, p < 0.001), salivary testosterone (~93%, p < 0.001), and plasma progesterone (~58%, p = 0.004) were evident from pre- to post-55/80. Plasma testosterone remained unchanged. Hormonal responses were attenuated in oral contraceptive users. The 55/80 induces hormonal elevations in females, similar in magnitude as males.

Adverse event profiles of drug-induced decreased libido: an assessment of the US food and drug administration Adverse Event Reporting System

BACKGROUND

Drug-induced decreased libido significantly affects the quality of life and relationships of patients. However, no comprehensive study has examined the relationship between drugs and libido. This study assessed drug-induced decreased libido by mining data from the US Food and Drug Administration Adverse Event Reporting System (FAERS).

RESEARCH DESIGN AND METHODS

Adverse drug event (ADE) reports from the first quarter of 2004 to the fourth quarter of 2023 in FAERS were collected and screened for reports of decreased libido and were subjected to medication signal mining by using the disproportionality analysis.

RESULTS

Overall 10,773 ADE reports were obtained. Thirty-three of the top 50 drugs with the highest frequency of ADE reports did not mention the risk of reduced libido in their instructions. Fifty-eight drugs showed potential decreased libido risk based on the disproportionality analysis, with 40 of the drugs not mentioning the risk of reduced libido in their instructions. Of these 40 drugs, drugs used in genito urinary and sex hormones and nervous system were the drug class with the greatest number of ADE reports.

CONCLUSION

A data mining exercise using FAERS for drugs that cause decreased libido has identified 40 drugs with new signals of adverse effects that should be closely monitored in medical practice.

Ovarian Insufficiency: Clinical Spectrum and Management Challenges

The term "ovarian insufficiency" describes the decline of ovarian function resulting in fertility loss and the marked decrease of ovarian steroid hormone production. From a clinical standpoint, ovarian insufficiency presents in three different settings. The first is natural menopause at midlife occurring at the average age of 51 years. The second arises after surgical oophorectomy owing to disease or elective cancer prophylaxis. Finally, primary or premature ovarian insufficiency is characterized by menopause occurring before age 40, often of undetermined etiology, but at times linked with genetic mutations, autoimmune syndromes, metabolic conditions, iatrogenic etiologies, and toxic exposures. Each clinical situation presents unique concerns and management challenges. The majority of women with intact ovaries who live to age 51 experience natural menopause, with early menopause <45 years. In the United States, surgical menopause with bilateral oophorectomy occurs in ∼600,000 women per year. The timing and specific clinical indication for oophorectomy alters management. Primary ovarian insufficiency occurs in 1% of women, although recent estimates suggest the prevalence may be increasing. Symptoms of ovarian insufficiency include hot flashes or vasomotor symptoms, mood disorders, sleep disruption, and vaginal/urinary symptoms. Health concerns include bone, cardiovascular, and cognitive health. Management of symptoms and preventive strategies varies depending upon the age, clinical situation, and specific health concerns of each individual. Treatment options for symptom relief include cognitive behavior therapy and hypnosis, nonhormonal prescription therapies, and hormone therapy. Tailoring the therapeutic approach over time in response to age, emerging medical issues, and patient desires constitutes individualized care.

Counseling in menopausal women: How to address the benefits and risks of menopause hormone therapy. A FIGO position paper

Menopause marks the end of menstrual cyclicity and, depending on individual vulnerability, has several consequences related to gonadal steroid deprivation, especially if it is premature. Menopause may be more burdensome for some women than for others. Individual factors, such as personal history, socioeconomic status, ethnicity, and current health conditions, affect symptomatology and, thereby, the menopausal experience. In addition, some menopausal symptoms, such as severe hot flashes, sleep disorders, and depression, are markers of future health risks. Counseling is a fundamental part of health care in the peri- and postmenopause periods. It must include an assessment of the patient's symptoms, needs, desires, and risk profile to address the benefits and risks of menopausal hormone therapy (MHT) on an individual basis and promote a healthy lifestyle. Indeed, healthcare practitioners can and must protect the health and lives of mid-life women by increasing awareness of menopausal symptoms and ensuring healthcare options, especially MHT. The type and duration of MHT should be tailored based on the patient's history, menopausal age, physical characteristics, and current health status so that the benefits always outweigh the risks. This FIGO position paper focuses on the benefits and risks of MHT on health domains, target organs, and systems, and on systemic and vaginal MHT regimens, to provide indications that can be used in the clinical practice for menopausal counseling. Moreover, it offers insights into what FIGO considers the mainstay for the healthcare management of women in peri- and postmenopause, worldwide.

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.

The yin and yang of GSM and low sexual desire

Numerous surveys have documented that sexuality and/or sexual activity is important to women at all stages of adulthood, including postmenopause. Genitourinary syndrome of menopause (GSM) and hypoactive sexual desire disorder (HSDD) are common disorders in postmenopausal women and may co-occur. Both are often undiagnosed due to a lack of knowledge of the disorder, health-care professional discomfort in discussing sexual problems or a lack of routine screening. It is incumbent upon health-care professionals to identify and differentiate these conditions in women through a biopsychosocial assessment, and may require a focused physical examination. Numerous treatments, both non-pharmacologic and pharmacologic, are available to address GSM and HSDD.

Hormones and Aging: An Endocrine Society Scientific Statement

Multiple changes occur across various endocrine systems as an individual ages. The understanding of the factors that cause age-related changes and how they should be managed clinically is evolving. This statement reviews the current state of research in the growth hormone, adrenal, ovarian, testicular, and thyroid axes, as well as in osteoporosis, vitamin D deficiency, type 2 diabetes, and water metabolism, with a specific focus on older individuals. Each section describes the natural history and observational data in older individuals, available therapies, clinical trial data on efficacy and safety in older individuals, key points, and scientific gaps. The goal of this statement is to inform future research that refines prevention and treatment strategies in age-associated endocrine conditions, with the goal of improving the health of older individuals.

A multicentre cross-sectional clinical study on female sexual dysfunction in postmenopausal Chinese women

OBJECTIVE

The aim of this study was to investigate the factors affecting the sex lives of postmenopausal Chinese women, especially the influence of body weight, climacteric symptoms and androgens.

METHODS

A total of 437 postmenopausal women were investigated in the Department of Gynecological Endocrinology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University and two allied medical institutions from April 2020 to March 2021. Sociodemographic data were collected. Female sexual dysfunction was evaluated using the Female Sexual Function Index (FSFI). The modified Kupperman index was used to assess climacteric symptoms. Methods based on liquid chromatography-tandem mass spectrometry were employed to measure the serum levels of total testosterone, bioavailable testosterone, free testosterone, androstenedione and dehydroepiandrosterone. Pearson's correlation coefficient and multiple linear regression analyses were performed to determine the correlation between characteristics and FSFI scores.

RESULTS

The multivariate linear regression analysis revealed that the modified Kupperman index score and the factor unsatisfactory marital relations had the strongest negative correlations with all FSFI domains (P < 0.05); secondary education level was negatively associated with desire, arousal and orgasm (P < 0.05). Total testosterone positively affected the score for pain (P < 0.05). There was no correlation between bioavailable testosterone, free testosterone, androstenedione and dehydroepiandrosterone and all FSFI domains (P > 0.05).

CONCLUSION

Climacteric symptoms and sociodemographic factors had a notable effect on sexual function. It is necessary to provide more attention to and intervention for their climacteric symptoms to improve the quality of life of postmenopausal women.

Female Sexual Dysfunction: An Appraisal of Canadian Clinical Practice Guidelines Using the AGREE II Instrument

Female sexual dysfunction (FSD) is a prevalent concern among Canadian women. While clinical practice guidelines (CPGs) are commonly relied upon to guide evidence-based decision making, the availability and quality of published Canadian CPGs for FSD is unknown. More broadly, there is also a paucity of literature, which has evaluated documents guiding Canadian CPG development. A search was conducted to identify Canadian documents describing CPG development processes. Eligible documents underwent full-text review to extract content pertaining to scope and target audience. A separate search was conducted to identify Canadian CPGs specific to FSD. Eligible documents underwent quality appraisal using the validated Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. Four documents outlining CPG development processes were identified. While there were similarities in the steps for CPG development, discrepancies in scope, target user, and affiliated development group across the Canadian methodologies were noted. One Canadian CPG specific to FSD was identified. Th is CPG scored highly in the domains of Scope and Purpose (79%), and Clarity of Presentation (86%), although it did not reach the same quality threshold for the remaining domains. Our results suggest the need for consistent guidelines that are implementable by Canadian CPG developers across the diverse clinical landscape, including women’s sexual health. Th is is the first study to evaluate the quality of CPGs for FSD using the AGREE II instrument. Our appraisal identifies areas of weakness that should be considered when updating this CPG in the future and in the development of new CPGs in this field.

[Efficacy and safety of testosterone in the treatment of hypoactive sexual desire in women: what does the evidence say?]

OBJECTIVE

To determine the efficacy and safety of testosterone in the treatment of hypoactive sexual desire in women.

MATERIALS AND METHODS

A systematic review of the literature was carried out in different electronic databases (CINAHL, DynaMed, EMBASE, Lilacs, Medline, Scopus, among others), between January 1990 and May 2021; through standardized search terms. The outcomes evaluated included the efficacy and safety of testosterone in increasing sexual desire, the total number of satisfactory sexual activity, the number of orgasms and the level of distress in patients with hypoactive sexual desire and the proportion of adverse reactions.

RESULTS

72 articles were included. The use of testosterone, in postmenopausal women, with hypoactive sexual desire, reports a positive effect on sexual function, with significant increases in satisfactory sexual activity, as well as improvement in all domains of sexual function (desire, arousal and orgasmic response) and a decrease in personal anguish, with an increase in the Female Sexual Function Index score. In women of childbearing age, testosterone is formulated for "off-label" use, in such a way that compounds and doses designed for treatments in men or magisterial formulas are used (which are not approved by consensus groups or endorsed by research), but has not shown any effect on sexual function. The most frequent adverse reactions are usually hirsutism and acne, although in general testosterone, at physiological doses, has a favorable safety profile.

CONCLUSIONS

Testosterone is an effective and safe therapy in the treatment of hypoactive sexual desire disorder in women after menopause. Currently there are no studies available to support the use of testosterone therapy in women of reproductive age, therefore, its use is not approved.

Pharmacologic therapeutic options for sexual dysfunction

PURPOSE OF REVIEW

Sexual problems are reported by up to 45% of individuals assigned female at birth. Although sexual function is a complex biopsychosocial construct, there are a number of pharmacologic treatment options aimed at addressing the changing vaginal hormonal milieu in postmenopausal individuals and moderating the excitatory and inhibitory aspects of the central nervous system in those with hypoactive sexual desire disorder.

RECENT FINDINGS

The last decade has seen an increase in the number and type of pharmacologic treatment options for dysfunction primarily associated with menopause and hypoactive sexual desire disorder. Recent publications and systematic reviews have strengthened the safety data of existing FDA-approved medications as well as off-label therapies.

SUMMARY

Pharmacologic treatment with local estrogen and testosterone replacement in postmenopausal individuals and with centrally-acting therapies such as flibanserin, bremelanotide, and testosterone in premenopausal individuals assigned female at birth are safe and can be used to improve sexual desire and sexual satisfaction.

The Roles of Androgens in Humans: Biology, Metabolic Regulation and Health

Androgens are an important and diverse group of steroid hormone molecular species. They play varied functional roles, such as the control of metabolic energy fate and partition, the maintenance of skeletal and body protein and integrity and the development of brain capabilities and behavioral setup (including those factors defining maleness). In addition, androgens are the precursors of estrogens, with which they share an extensive control of the reproductive mechanisms (in both sexes). In this review, the types of androgens, their functions and signaling are tabulated and described, including some less-known functions. The close interrelationship between corticosteroids and androgens is also analyzed, centered in the adrenal cortex, together with the main feedback control systems of the hypothalamic-hypophysis-gonads axis, and its modulation by the metabolic environment, sex, age and health. Testosterone (T) is singled out because of its high synthesis rate and turnover, but also because age-related hypogonadism is a key signal for the biologically planned early obsolescence of men, and the delayed onset of a faster rate of functional losses in women after menopause. The close collaboration of T with estradiol (E2) active in the maintenance of body metabolic systems is also presented Their parallel insufficiency has been directly related to the ravages of senescence and the metabolic syndrome constellation of disorders. The clinical use of T to correct hypoandrogenism helps maintain the functionality of core metabolism, limiting excess fat deposition, sarcopenia and cognoscitive frailty (part of these effects are due to the E2 generated from T). The effectiveness of using lipophilic T esters for T replacement treatments is analyzed in depth, and the main problems derived from their application are discussed.

Clinical management of hypoactive sexual desire disorder in postmenopausal women

Approximately 10% to 12% of women meet the criteria for hypoactive sexual desire disorder, with the highest prevalence in midlife women, ranging from 14.5% to 33%. Despite the negative effect on health and quality of life, most women are reluctant to discuss sexual concerns with healthcare professionals. Although healthcare professionals have the best opportunities to address these problems, most of them have limited awareness, education, and comfort about addressing sexual concerns, resulting in a conspiracy of silence. The purpose of this Practice Pearl is to improve the understanding of hypoactive sexual desire disorder, including symptoms, etiology, diagnosis, and treatment.

Multidisciplinary Management of Menopause: Symposium Proceedings

This proceeding summarizes a symposium on multidisciplinary management of menopause held on July 30, 2021 as part of the Health of Women 2021 conference. The workshop featured presentations by national experts who provided insights into multidisciplinary approaches to the management of menopause, vasomotor symptoms and genitourinary syndrome of menopause, bone health (including osteoporosis, muscular strength, and mobility), as well as sexual and psychological health during menopause. In this study, we highlight the major points of each presentation and the resultant discussion.

Dehydroepiandrosterone exacerbates nigericin-induced abnormal autophagy and pyroptosis via GPER activation in LPS-primed macrophages

As a widely acknowledged FDA-approved dietary supplement or over-the-counter medicines, dehydroepiandrosterone (DHEA) exerts anti-inflammatory and immunomodulatory function. Pyroptosis is an important form of programmed cell death (PCD), and which acts a key role in the body's anti-infection and inflammatory responses. But the effects and mechanisms of DHEA on pyroptosis remain unclear. Here, we found that DHEA inhibited the NLRP3 inflammasome components expression by blocking inflammatory signals in lipopolysaccharide (LPS)-primed macrophages, and prevented the bacterial toxin nigericin (Nig)-induced NLRP3 inflammasome assembly. However, DHEA exacerbated NLRP3-independent cell death in Nig-treated inflammatory macrophages. During this process, DHEA induced the abnormal autophagy, which reflected as the blocking of autophagic flux and the accumulation of autophagy receptor p62 (SQSTM1) protein. In addition, DHEA caused a burst of reactive oxygen species (ROS) and activated extracellular signal-regulated kinase (ERK) phosphorylation in LPS plus Nig-stimulated macrophages but not in LPS-treated macrophages. Mechanistically, the present study certified that the activation of G protein-coupled estrogen receptor (GPER) signal mediated the cell death induced by DHEA in Nig-stimulated inflammatory macrophages, as GPER specific inhibitor G15 alleviated the abnormal autophagy and ultimately prevented the gasdermin D (GSDMD)-mediated pyroptosis induced by DHEA. Collectively, DHEA can exacerbate Nig-induced abnormal autophagy and pyroptosis via activation of GPER in LPS-primed macrophages, which prompts us the potential application value of DHEA in anti-infection or anti-tumor immunity.

Approach to the Patient With New-Onset Secondary Amenorrhea: Is This Primary Ovarian Insufficiency?

Menstrual cyclicity is a marker of health for reproductively mature women. Absent menses, or amenorrhea, is often the initial sign of pregnancy-an indication that the system is functioning appropriately and capable of generating the intended evolutionary outcome. Perturbations of menstrual regularity in the absence of pregnancy provide a marker for physiological or pathological disruption of this well-orchestrated process. New-onset amenorrhea with duration of 3 to 6 months should be promptly evaluated. Secondary amenorrhea can reflect structural or functional disturbances occurring from higher centers in the hypothalamus to the pituitary, the ovary, and finally, the uterus. Amenorrhea can also be a manifestation of systemic disorders resulting in compensatory inhibition of reproduction. Identifying the point of the breakdown is essential to restoring reproductive homeostasis to maintain future fertility and reestablish reproductive hormonal integrity. Among the most challenging disorders contributing to secondary amenorrhea is primary ovarian insufficiency (POI). This diagnosis stems from a number of possible etiologies, including autoimmune, genetic, metabolic, toxic, iatrogenic, and idiopathic, each with associated conditions and attendant medical concerns. The dual assaults of unanticipated compromised fertility concurrently with depletion of the normal reproductive hormonal milieu yield multiple management challenges. Fertility restoration is an area of active research, while optimal management of estrogen deficiency symptoms and the anticipated preventive benefits of hormone replacement for bone, cardiovascular, and neurocognitive health remain understudied. The state of the evidence for an optimal, individualized, clinical management approach to women with POI is discussed along with priorities for additional research in this population.

Menopause and female sexual dysfunctions (FSDs)

Biological and psycho-relational factors contribute equally to the development of sexual symptoms and associated distress, a key element to diagnose female sexual dysfunctions (FSDs) in menopausal women. Consultation at midlife represents an optimal time to discuss sexual life, and healthcare providers (HCPs) have to be proactive in rising the conversation, as patients may not report their sexual concerns spontaneously. An accurate sexual history is essential to characterize the primary symptom, determine the impact on patient's quality of life and identify risk and precipitating factors. Among FSDs, hypoactive sexual desire disorder (HSDD) is very frequent at midlife together with genitourinary syndrome of menopause (GSM), a chronic condition negatively affecting the full sexual response. A multidimensional approach targeted to the patient's characteristics, goals and expectations is mandatory and should start from educative counselling and correction of modifiable risk factors. When specific treatments are required, they should include non-pharmacological and pharmacological options, often prescribed in combination to address concomitantly the biological and psychosocial components of FSDs.

Sexuality, pelvic floor/vaginal health and contraception at menopause

A multitude of biopsychosocial factors influences sexual health at midlife, a common concern in daily practice along with vaginal and pelvic health. Health-care providers (HCPs) need to be proactive in dealing with possible symptoms because in most cases early management prevents distress and improves quality of life. Female sexual dysfunctions (FSDs) may have a complex etiology but sexual history is not difficult implementing basic knowledge of risk factors and some skills helping women to cope with hormonal and age-related changes. This work summarizes key points to approach sexual symptoms in midlife women, providing principles to diagnose and manage hypoactive sexual desire disorder (HSDD) and genitourinary syndrome of menopause (GSM)/vulvovaginal atrophy (VVA), as well as manage contraceptive needs.