Effects of intranasal 17β-estradiol administration on serum bioactive interleukin-6 and C-reactive protein levels in healthy postmenopausal women

Use of Testosterone in Postmenopausal Women

The role of testosterone in women and its potential as a therapeutic agent continue to attract controversy. The clinical trials of testosterone therapy for women primarily have focused on treatment of female sexual dysfunction, with the largest placebo-controlled studies being of transdermal testosterone in postmenopausal women. Based on the cumulative data from these studies, loss of sexual desire with associated personal distress currently is the only agreed-on indication for judicious testosterone supplementation for postmenopausal women. This article reviews the physiology of testosterone in women, summarizes the findings from observational studies and clinical trials, and considers indications for testosterone use.

Longitudinal changes over three years in sex steroid hormone levels in women aged 70 years and over

OBJECTIVE

Sex steroid levels in women vary with increasing age from the age of 70 years (70+). Whether this reflects change within individuals with age or a survival advantage is not known. This study aimed to determine the stability of circulating sex steroids and SHBG over time in individual women aged 70+.

DESIGN

A prospective cohort study.

PARTICIPANTS

400 women, aged 70+ not using any sex steroid, anti-androgen/oestrogen or glucocorticoid therapy.

MAIN OUTCOME MEASUREMENTS

Sex steroid concentrations, measured by liquid chromatography-tandem mass spectrometry and sex hormone-binding globulin (SHBG) by immunoassay, in paired blood samples drawn 3 years apart and analysed together.

RESULTS

400 women, median (IQR) age 78.0 (8.6) years, were included in the analysis. Mean testosterone concentrations were statistically significantly higher in follow-up samples compared with baseline. The change was modest (mean change 31 pmol/L, 95% confidence interval (CI) 2.4-59.8; p = .034), and an increase was not observed in all women. There was a statistically significant decline in mean body mass index (mean change -0.4 kg/m² , 95% CI 0.6 to -0.3; p < .001) and a significant increase in the mean serum SHBG concentration (mean change 4.0 nmol/L, 95% CI 2.7-5.4; p < .001). The change observed in testosterone was not explained by the observed change in SHBG. There was no significant change in the mean oestrone or dehydroepiandrosterone concentration.

CONCLUSIONS

Testosterone concentrations in women aged 70+ were more likely to increase than decrease. Whether increasing testosterone concentrations in older women confer a survival advantage needs investigation.

Treatment of Hypoactive Sexual Desire Disorder Among Women: General Considerations and Pharmacological Options

Hypoactive sexual desire disorder (HSDD) is a persistent or recurrent absence of sexual fantasies and desire for sexual activity, causing marked personal distress or interpersonal difficulties. HSDD affects 10% of U.S. women and is associated with depression and other negative emotional states. It is imperative that psychiatrists are competent to make this diagnosis and are aware of available treatment options. A full psychiatric and medical history are necessary to identify potential causes or contributing factors that may need to be addressed first. The authors discuss the diagnostic tools available as well as general diagnostic considerations for psychiatrists. Given its importance in the understanding of the available treatments for this disorder, the pathophysiology behind HSDD is reviewed. The authors emphasize the treatment of HSDD, including general treatment considerations, treatment in the context of depression, and psychotherapy and medications that have been approved by the U.S. Food and Drug Administration.

Sexual Dysfunction in Women With Kidney Disease

Sexual health is inversely associated with estimated glomerular filtration rate and is associated with adverse cardiovascular outcomes, depression, poor self-image, and impaired quality of life. Many women with chronic kidney disease (CKD) and ESKD experience symptoms of sexual dysfunction which is underrecognized secondary to a variety of factors including physicians' discomfort in discussing sexual health, patients' reluctance to bring up sexual health, difficulty in the assessment of sexual health in comparison to men, and the overall lack of well-conducted clinical studies in women. The pathophysiology is not fully understood but likely involves changes in sex hormones throughout the hypothalamic-pituitary-ovarian axis. Proper evaluation of this axis is necessary as treatment is tailored to these findings and can improve outcomes. A comprehensive assessment of sexual dysfunction inclusive of women with varying gender identification and sexual orientation, partnered with recognition and treatment of contributing factors as well as identifying the underlying cause, is paramount. With the lack of studies, particularly in women with CKD, treatment options, in some cases, can be considered unchartered territory. In this article, we will review available evidence on the pathophysiology, clinical manifestations, and treatment for sexual dysfunction in women with CKD and ESKD.

Low-Dose Testosterone Augmentation for Antidepressant-Resistant Major Depressive Disorder in Women: An 8-Week Randomized Placebo-Controlled Study

OBJECTIVE

Low-dose testosterone has been shown to improve depression symptom severity, fatigue, and sexual function in small studies in women not formally diagnosed with major depressive disorder. The authors sought to determine whether adjunctive low-dose transdermal testosterone improves depression symptom severity, fatigue, and sexual function in women with antidepressant-resistant major depression. A functional MRI (fMRI) substudy examined effects on activity in the anterior cingulate cortex (ACC), a brain region important in mood regulation.

METHODS

The authors conducted an 8-week randomized double-blind placebo-controlled trial of adjunctive testosterone cream in 101 women, ages 21-70, with antidepressant-resistant major depression. The primary outcome measure was depression symptom severity as assessed by the Montgomery-Åsberg Depression Rating Scale (MADRS). Secondary endpoints included fatigue, sexual function, and safety measures. The primary outcome of the fMRI substudy (N=20) was change in ACC activity.

RESULTS

The participants' mean age was 47 years (SD=14) and their mean baseline MADRS score was 26.6 (SD=5.9). Eighty-seven (86%) participants completed 8 weeks of treatment. MADRS scores decreased in both study arms from baseline to week 8 (testosterone arm: from 26.8 [SD=6.3] to 15.3 [SD=9.6]; placebo arm: from 26.3 [SD=5.4] to 14.4 [SD=9.3]), with no significant difference between groups. Improvement in fatigue and sexual function did not differ between groups, nor did side effects. fMRI results showed a relationship between ACC activation and androgen levels before treatment but no difference in ACC activation with testosterone compared with placebo.

CONCLUSIONS

Adjunctive transdermal testosterone, although well tolerated, was not more effective than placebo in improving symptoms of depression, fatigue, or sexual dysfunction. Imaging in a subset of participants demonstrated that testosterone did not result in greater activation of the ACC.

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.

Testosterone therapy and other treatment modalities for female sexual dysfunction

PURPOSE OF REVIEW

Recently in October 2019 a Global Consensus Position on the use of Testosterone Therapy for Women was published. The use of testosterone and other agents for female sexual dysfunction (FSD) is an important topic for the urologist focusing on sexual health. This review describes the known causes for FSD, and discusses the role of androgens in this disorder, the evidence for using testosterone treatment, and other current and emerging therapies.

RECENT FINDINGS

A recent meta-analysis, published in The Lancet Diabetes & Endocrinology evaluated a total of 36 randomized control trials spanning 1990-2018 and includes a total of 8480 patients. The primary findings were that testosterone therapy (TTh) increased sexual function including satisfactory sexual event frequency, sexual desire, pleasure, arousal, orgasm, responsiveness, and self-image when compared with either a placebo or drug-control (e.g., estrogen ± progestogen). In addition, TTh reduced sexual concerns and distress in postmenopausal women. Side effects included an increase in weight, acne, and hair growth, but there was no increase in serious adverse events. Importantly, TTh duration was greater than 12 weeks in all randomized control trials included in this meta-analysis.

SUMMARY

TTh is effective to treat FSD in postmenopausal women. More data is required to evaluate the long-term safety data on the effects of TTh on cardiovascular health, breast health, cognitive function, and the musculoskeletal system in women.

The role of testosterone in menopausal hormone treatment. What is the evidence?

About 40% of postmenopausal women have decreased sexual desire, causing distress. Estrogen therapy attenuates vaginal complaints but has no effect on sexual desire. Although sexual function has been linked to testosterone, there is no clear relation between sexual desire and circulating levels of testosterone. Nevertheless, treatment with transdermal (patch) testosterone improved sexual function in several randomized controlled trials. Women with hypoactive sexual desire disorder who were treated with testosterone reported more satisfying sexual episodes and sexual desire compared with the placebo group. Adverse effects were mild. However, there is no testosterone drug designed for women available on the European market. Consequently, women who opt for testosterone treatment have to use preparations made for men with a high drug concentration. Adequate dosage for women is therefore challenging. A trial of 5 mg transdermal testosterone (gel or cream) daily or less has been suggested, followed by close monitoring of side effects and hormone level.

Female Sexual Dysfunction: ACOG Practice Bulletin Clinical Management Guidelines for Obstetrician-Gynecologists, Number 213

Female sexual dysfunction encompasses various conditions that are characterized by reported personal distress in one or more of the following areas: desire, arousal, orgasm, or pain (). Although female sexual dysfunction is relatively prevalent, women are unlikely to discuss it with their health care providers unless asked (), and many health care providers are uncomfortable asking for a variety of reasons, including a lack of adequate knowledge and training in diagnosis and management, inadequate clinical time to address the issue, and an underestimation of the prevalence (). The purpose of this document is to provide an overview of female sexual dysfunction, to outline updated criteria for diagnosis, and to discuss currently recommended management strategies based on the best available evidence.

Effect of Estrogen Receptor- Alpha Gene Polymorphism (IVS1-397 T>C) on Microvascular Complications of Type 1 Diabetes Mellitus

BACKGROUND

Type 1 diabetes mellitus (T1DM) is an autoimmune disease whose etiology involves genetic predisposition as well as environmental factors. Polymorphisms of some genes are among the most important genetic factors that influence autoimmunity. Gender is another important factor affecting autoimmunity. Females are more susceptible to autoimmune diseases which may be due to the effect of sex hormones on the immune system activity. The metabolic effects of estrogen are mediated through its receptor - alpha. The exact mechanism is not well understood. A number of polymorphisms have been reported in the Estrogen Receptor- alpha (ER-alpha) IVS1 397 T>C gene which may be involved in the pathogenesis of diabetes.

OBJECTIVES

To assess the influence of Estrogen Receptor- alpha gene [IVS1-397 T>C] polymorphism on vascular complications of type1 diabetes mellitus in pubertal females and on the glycemic control.

METHODS

This cross-sectional case-control study included 40 pubertal regularly menstruating girls less than 18 years with type 1 diabetes mellitus recruited from the Pediatric Diabetes Clinic, Children's Hospital, Ain-Shams University and 20 healthy age-and sex-matched controls. Estrogen receptor alpha genotypes were analyzed by Restriction Fragment Length PCR and correlated with both clinical and laboratory parameters in the studied cases. ER-alpha was chosen as it might play a role in diabetes pathogenesis.

RESULTS

The study revealed the TC genotype was the most prevalent genotype of the estrogen receptor. The TT genotype patients had a younger age of onset of T1DM. The prevalence of obesity was higher among TC and TT than in CC bearing patients. In addition, CC genotype patients had the least prevalence of microalbuminuria and had better glycemic control than other genotypes.

CONCLUSION

Our findings suggest that Estrogen receptor- alpha gene may be affecting the age of onset of Type1 diabetes mellitus in pubertal girls as well as the glycemic control of these patients, where CC bearing girls had better glycemic control than other genotypes and less incidence of microalbuminuria.

Safety and efficacy of testosterone for women: a systematic review and meta-analysis of randomised controlled trial data

BACKGROUND

The benefits and risks of testosterone treatment for women with diminished sexual wellbeing remain controversial. We did a systematic review and meta-analysis to assess potential benefits and risks of testosterone for women.

METHODS

We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science for blinded, randomised controlled trials of testosterone treatment of at least 12 weeks' duration completed between Jan 1, 1990, and Dec 10, 2018. We also searched drug registration applications to the European Medicine Agency and the US Food and Drug Administration to identify any unpublished data. Primary outcomes were the effects of testosterone on sexual function, cardiometabolic variables, cognitive measures, and musculoskeletal health. This study is registered with the International Prospective Register of Systematic Reviews (PROSPERO), number CRD42018104073.

FINDINGS

Our search strategy retrieved 46 reports of 36 randomised controlled trials comprising 8480 participants. Our meta-analysis showed that, compared with placebo or a comparator (eg, oestrogen, with or without progestogen), testosterone significantly increased sexual function, including satisfactory sexual event frequency (mean difference 0·85, 95% CI 0·52 to 1·18), sexual desire (standardised mean difference 0·36, 95% CI 0·22 to 0·50), pleasure (mean difference 6·86, 95% CI 5·19 to 8·52), arousal (standardised mean difference 0·28, 95% CI 0·21 to 0·35), orgasm (standardised mean difference 0·25, 95% CI 0·18 to 0·32), responsiveness (standardised mean difference 0·28, 95% CI 0·21 to 0·35), and self-image (mean difference 5·64, 95% CI 4·03 to 7·26), and reduced sexual concerns (mean difference 8·99, 95% CI 6·90 to 11·08) and distress (standardised mean difference -0·27, 95% CI -0·36 to -0·17) in postmenopausal women. A significant rise in the amount of LDL-cholesterol, and reductions in the amounts of total cholesterol, HDL-cholesterol, and triglycerides, were seen with testosterone administered orally, but not when administered non-orally (eg, by transdermal patch or cream). An overall increase in weight was recorded with testosterone treatment. No effects of testosterone were reported for body composition, musculoskeletal variables, or cognitive measures, although the number of women who contributed data for these outcomes was small. Testosterone was associated with a significantly greater likelihood of reporting acne and hair growth, but no serious adverse events were recorded.

INTERPRETATION

Testosterone is effective for postmenopausal women with low sexual desire causing distress, with administration via non-oral routes (eg, transdermal application) preferred because of a neutral lipid profile. The effects of testosterone on individual wellbeing and musculoskeletal and cognitive health, as well as long-term safety, warrant further investigation.

FUNDING

Australian National Health and Medical Research Council.

Polycystic Ovary Syndrome (PCOS) and Sexual Dysfunctions

Objectives: Polycystic ovary syndrome (PCOS) is a very common endocrine disorder affecting 5% to 10% of women in reproductive age all over the world. Many comorbidities have been associated with PCOS including infertility, obesity, depression, anxiety, hirsutism, alopecia, and sexu al dysfunctions. In this paper, we have reviewed the available Indian and international literature regarding psychiatric and sexual comorbidities of PCOS.

Methods: PubMed, Cochrane, Google Scholar, and other databases were used to conduct the search. Research published in English was included. We searched the databases using the terms ‘polycystic ovary syndrome’, ‘PCOS’, ‘infertility and PCOS’, ‘sexual dysfunctions and PCOS’, etc.

Results: For this review, we could find about 90 papers pertaining to the subject. Most of them focused on the effect of infertility and symptoms of PCOS such as hirsutism on body image and sexual dysfunctions. Meta-analyses showed that women with PCOS had poor rates of sexual desire, orgasm, and lubrication. Body image often had a negative impact on sexual thoughts and fantasies.

Conclusion: Focus on sexual dysfunctions in PCOS has been emphasized only recently after high rates of its prevalence have been found. Hence, management of PCOS involves a multidisciplinary approach where proper assessment and management of sexual dysfunctions should be given its due importance.

Testosterone therapy for women with low sexual desire: a position statement from the Brazilian Society of Endocrinology and Metabolism

OBJECTIVE

To summarize current evidence regarding testosterone treatment for women with low sexual desire.

MATERIALS AND METHODS

The Female Endocrinology and Andrology Department of the Brazilian Society of Endocrinology and Metabolism invited nine experts to review the physiology of testosterone secretion and the use, misuse, and side effects of exogenous testosterone therapy in women, based on the available literature and guidelines and statements from international societies.

RESULTS

Low sexual desire is a common complaint in clinical practice, especially in postmenopausal women, and may negatively interfere with quality of life. Testosterone seems to exert a positive effect on sexual desire in women with sexual dysfunction, despite a small magnitude of effect, a lack of long-term safety data, and insufficient evidence to make a broad recommendation for testosterone therapy. Furthermore, there are currently no testosterone formulations approved for women by the relevant regulatory agencies in the United States, Brazil, and most other countries, and testosterone formulations approved for men are not recommended for use by women.

CONCLUSION

Therefore, testosterone therapy might be considered if other strategies fail, but the risks and benefits must be discussed with the patient before prescription. Arch Endocrinol Metab. 2019;63(3):190-8.

Female Sexual Dysfunction

Female sexual dysfunction can drastically diminish quality of life for many women. It is estimated that in the United States 40% of women have sexual complaints. These conditions are frequently underdiagnosed and undertreated. Terminology and classification systems of female sexual dysfunction can be confusing and complicated, which hampers the process of clinical diagnosis, making accurate diagnosis difficult. There are few treatment options available for female sexual dysfunctions, however, some interventions may be of benefit and are described. Additional treatments are in development. The development of clear clinical categories and diagnostic guidelines for female sexual dysfunction are of utmost importance and can be of great benefit for clinical and public health uses and disease-related research.

Impact of estrogens in males and androgens in females

Androgens and estrogens are known to be critical regulators of mammalian physiology and development. While these two classes of steroids share similar structures (in general, estrogens are derived from androgens via the enzyme aromatase), they subserve markedly different functions via their specific receptors. In the past, estrogens such as estradiol were thought to be most important in the regulation of female biology, while androgens such as testosterone and dihydrotestosterone were believed to primarily modulate development and physiology in males. However, the emergence of patients with deficiencies in androgen or estrogen hormone synthesis or actions, as well as the development of animal models that specifically target androgen- or estrogen-mediated signaling pathways, have revealed that estrogens and androgens regulate critical biological and pathological processes in both males and females. In fact, the concept of "male" and "female" hormones is an oversimplification of a complex developmental and biological network of steroid actions that directly impacts many organs. In this Review, we will discuss important roles of estrogens in males and androgens in females.

A systematic review of randomized controlled trials investigating the efficacy and safety of testosterone therapy for female sexual dysfunction in postmenopausal women

The clinical sequelae of oestrogen deficiency during menopause are undoubted. However, the pathophysiological role of testosterone during the menopause is less clear. Several randomized, placebo-controlled clinical trials suggest that testosterone therapy improves sexual function in postmenopausal women. Some studies suggest that testosterone therapy has additional effects, which include increased bone mineral density and decreased serum high-density lipoprotein (HDL) cholesterol. Furthermore, the long-term safety profile of testosterone therapy in postmenopausal women is not clear. This article will provide a concise and critical summary of the literature, to guide clinicians treating postmenopausal women.

Effects of testosterone therapy for women: a systematic review and meta-analysis protocol

BACKGROUND

Testosterone therapy for women is in widespread use, primarily in the form of compounded preparations and off-label use of formulations for men. The benefits and risks of such therapy remain uncertain. This review will identify and evaluate studies that have examined the effects of testosterone therapy for women on a range of outcomes including sexual function, cardiovascular events, metabolic parameters, musculoskeletal health, wellbeing, cancer events, androgenic effects and withdrawal rates.

METHODS

Studies meeting our pre-determined inclusion criteria will be identified through searches in Ovid MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL) and Web of Science. Assessing a range of outcomes, we will assess the risk-of-bias of relevant studies and draw conclusions about the strength of evidence for benefits and risks of testosterone therapy for each outcome.

DISCUSSION

This comprehensive systematic review with meta-analysis will provide the foundation for the development of evidence-based clinical practice guidelines that will address benefits and risks of testosterone therapy, when treatment might be appropriate or inappropriate, areas of clinical uncertainty and the basis for assessment and monitoring of patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42018104073.

Is polycystic ovary syndrome associated with risk of female sexual dysfunction? A systematic review and meta-analysis

The aim of this study was to evaluate whether polycystic ovary syndrome (PCOS) is a risk factor for female sexual dysfunction (FSD) by conducting a systematic review and meta-analysis. The databases PubMed, EMBASE and the Cochrane Library were searched for relevant studies. The association between PCOS and risk of FSD was assessed by relative risk or standard mean differences with 95% confidence interval. The protocol for this meta-analysis is available from PROSPERO (CRD42018102247). Overall, 2626 participants (mean age 25-36 years) were included from 10 studies (five cross-sectional and five case-control studies), 1163 of whom were women with PCOS. The pooled results from eight included studies providing the number of cases revealed no significant association between PCOS and increased risk of FSD (RR = 1.09, 95% CI 0.9 to 1.32; heterogeneity: I² = 11.0%). The combined overall standard mean difference from five studies reporting Female Sexual Function Index (FSFI) scores showed that patients with PCOS had similar values in total FSFI scores compared with healthy controls (standard mean difference = -0.03, 95% CI -0.12 to 0.05; heterogeneity: I² = 0.0%). Sensitivity analyses yielded similar results. This meta-analysis suggests no direct association between PCOS and risk of FSD. Well-controlled trials with large sample sizes, however, are needed to validate this evidence.

Female Sexual Function at Midlife and Beyond

Sexual function is an important component of quality of life for women. Midlife poses several challenges to optimal sexual function and intimacy for women. In addition to anatomic factors related to estrogen deficiency, such as genitourinary syndrome of menopause, vulvovaginal atrophy, and pelvic organ prolaps, psychosocial factors, including prior sexual trauma, play an important role in sexual function in women. Several treatments have emerged for female sexual dysfunction; long-term studies and head-to-head comparisons are lacking.

Differential Effects of Estradiol and Progesterone on Cardiovascular Risk Factors in Postmenopausal Women

Context

Controlled, blinded studies of sex-hormone replacement in postmenopausal women using natural estradiol (E₂) and native progesterone (P) are few.

Objective

To delineate the effect of E₂ alone or with P on lipids and inflammatory markers.

Design

A placebo-controlled, double-masked, prospectively randomized study of 40 healthy, postmenopausal volunteers assigned to four treatment groups: placebo, intramuscular E₂, and/or micronized oral P for 23 (±2) days.

Results

Treatment with E₂ alone compared with placebo lowered total cholesterol (TC; P = 0.006), non-high-density lipoprotein cholesterol (nonHDL-C; P = 0.004), low-density lipoprotein cholesterol (LDL-C; P = 0.012), and apolipoprotein B (Apo B; P = 0.02) levels, and raised HDL-C levels (P = 0.03 vs the 3 other groups). Conversely, addition of P to E₂ reduced HDL-C levels (P = 0.015). Triglyceride concentrations manifested no effect on E₂ or P. High-sensitivity C-reactive protein (hsCRP) level was highest in women with E₂ and P replacement (P = 0.018 vs placebo). Leptin and IL-6 concentrations did not vary. P treatment decreased adiponectin levels (P = 0.019). Serum E₂ levels correlated linearly with TC, LDL-C, nonHDL-C, Apo B (all negatively), and SHBG (positively) concentrations. P level correlated negatively with TC (P = 0.029), HDL-C (P = 0.002), and adiponectin (P = 0.002) levels.

Conclusion

In this study, there were individual and interactive effects of E₂ and P on key lipids in postmenopausal individuals.

The International Society for the Study of Women's Sexual Health Process of Care for Management of Hypoactive Sexual Desire Disorder in Women

The International Society for the Study of Women's Sexual Health process of care (POC) for management of hypoactive sexual desire disorder (HSDD) algorithm was developed to provide evidence-based guidelines for diagnosis and treatment of HSDD in women by health care professionals. Affecting 10% of adult females, HSDD is associated with negative emotional and psychological states and medical conditions including depression. The algorithm was developed using a modified Delphi method to reach consensus among the 17 international panelists representing multiple disciplines. The POC starts with the health care professional asking about sexual concerns, focusing on issues related to low sexual desire/interest. Diagnosis includes distinguishing between generalized acquired HSDD and other forms of low sexual interest. Biopsychosocial assessment of potentially modifiable factors facilitates initiation of treatment with education, modification of potentially modifiable factors, and, if needed, additional therapeutic intervention: sex therapy, central nervous system agents, and hormonal therapy, guided in part by menopausal status. Sex therapy includes behavior therapy, cognitive behavior therapy, and mindfulness. The only central nervous system agent currently approved by the US Food and Drug Administration (FDA) for HSDD is flibanserin in premenopausal women; use of flibanserin in postmenopausal women with HSDD is supported by data but is not FDA approved. Hormonal therapy includes off-label use of testosterone in postmenopausal women with HSDD, which is supported by data but not FDA approved. The POC incorporates monitoring the progress of therapy. In conclusion, the International Society for the Study of Women's Sexual Health POC for the management of women with HSDD provides a rational, evidence-based guideline for health care professionals to manage patients with appropriate assessments and individualized treatments.

Effect Size in Efficacy Trials of Women With Decreased Sexual Desire

BACKGROUND

Regarding hypoactive sexual desire disorder (HSDD) in women, some reviewers judge the effect size small for medications vs placebo, but substantial for cognitive behavior therapy (CBT) or mindfulness meditation training (MMT) vs wait list. However, we lack comparisons of the effect sizes for the active intervention itself, for the control treatment, and for the differential between the two.

AIM

For efficacy trials of HSDD in women, compare effect sizes for medications (testosterone/testosterone transdermal system, flibanserin, and bremelanotide) and placebo vs effect sizes for psychotherapy and wait-list control.

METHODS

We conducted a literature search for mean changes and SD on main measures of sexual desire and associated distress in trials of medications, CBT, or MMT. Effect size was used as it measures the magnitude of the intervention without confounding by sample size.

OUTCOMES

Cohen d was used to determine effect sizes.

RESULTS

For medications, mean (SD) effect size was 1.0 (0.34); for CBT and MMT, 1.0 (0.36); for placebo, 0.55 (0.16); and for wait list, 0.05 (0.26).

CLINICAL TRANSLATION

Recommendations of psychotherapy over medication for treatment of HSDD are premature and not supported by data on effect sizes. Active participation in treatment conveys considerable non-specific benefits. Caregivers should attend to biological and psychosocial elements, and patient preference, to optimize response.

CONCLUSIONS

Few clinical trials of psychotherapies were substantial in size or utilized adequate control paradigms. Medications and psychotherapies had similar, large effect sizes. Effect size of placebo was moderate. Effect size of wait-list control was very small, about one quarter that of placebo. Thus, a substantial non-specific therapeutic effect is associated with receiving placebo plus active care and evaluation. The difference in effect size between placebo and wait-list controls distorts the value of the subtraction of effect of the control paradigms to estimate intervention effectiveness. Pyke RE, Clayton AH. Effect Size in Efficacy Trials of Women With Decreased Sexual Desire. Sex Med Rev 2018;6:358-366.

Evaluation and Management of Hypoactive Sexual Desire Disorder

INTRODUCTION

Hypoactive sexual desire disorder (HSDD) often has a negative impact on the health and quality of life of women; however, many women do not mention-let alone discuss-this issue with their physicians. Providers of gynecologic services have the opportunity to address this subject with their patients.

AIM

To review the diagnosis and evidence-based treatment of low sexual desire in women with a focus on strategies that can be used efficiently and effectively in the clinic.

METHODS

The Medline database was searched for clinically relevant publications on the diagnosis and management of HSDD.

RESULTS

HSDD screening can be accomplished during an office visit with a few brief questions to determine whether further evaluation is warranted. Because women's sexual desire encompasses biological, psychological, social, and contextual components, a biopsychosocial approach to evaluating and treating patients with HSDD is recommended. Although individualized treatment plan development for patients requires independent medical judgment, a simple algorithm can assist in the screening, diagnosis, and management of HSDD. Once a diagnosis of HSDD has been made, interventions can begin with office-based counseling and progress to psychotherapy and/or pharmacotherapy. Flibanserin, a postsynaptic 5-hydroxytryptamine 1A agonist and 2A antagonist that decreases serotonin levels and increases dopamine and norepinephrine levels, is indicated for acquired, generalized HSDD in premenopausal women and is the only agent approved in the United States for the treatment of HSDD in women. Other strategies to treat HSDD include using medications indicated for other conditions (eg, transdermal testosterone, bupropion). Bremelanotide, a melanocortin receptor agonist, is in late-stage clinical development.

CONCLUSIONS

Providers of gynecologic care are uniquely positioned to screen, counsel, and refer patients with HSDD. Options for pharmacotherapy of HSDD are currently limited to flibanserin, approved by the US Food and Drug Administration, and off-label use of other agents. Clayton AH, Kingsberg SA, Goldstein I. Evaluation and Management of Hypoactive Sexual Desire Disorder. Sex Med 2018;6:59-74.

Ignorance Is Not Bliss: If We Don't Understand Hypoactive Sexual Desire Disorder, How Can Flibanserin Treat It? Commentary

BACKGROUND

Female sexual dysfunction (FSD) affects as many as 1 in every 3 women, with a significant portion of these with hypoactive sexual desire disorder (HSDD). These figures alone present significant psychological and pharmacologic challenges. Partly in response to this situation, in 2015 the US Food and Drug Administration approved flibanserin for the treatment of HSDD. This approval has drawn criticism on the grounds of efficacy and necessity.

AIM

To better inform potential consumers about FSD, flibanserin and other interventions for the treatment of HSDD, the importance of understanding the mechanism of FSD, and the efficacy of flibanserin and to review existing relevant knowledge.

METHODS

A literature review of extant clinic studies and theoretical discussion articles was performed.

OUTCOMES

Efficacy of flibanserin for addressing symptoms associated with HSDD in premenopausal women.

RESULTS

Extant literature and empirical evidence suggest that the efficacy of flibanserin for the treatment of HSDD in premenopausal women is at least questionable.

CLINICAL TRANSLATION

Clinicians considering the prescription of flibanserin would be well advised to appreciate some of the controversies concerning the efficacy of the drug.

STRENGTHS AND LIMITATIONS

The prohibitive usage guidelines, tenuous risk-benefit profile, and considerable cost of use of flibanserin are each worthy of consideration. Flibanserin thus far has been trialed in only a narrow patient range: premenopausal women in long-term relationships with acquired or generalized HSDD.

CONCLUSIONS

Although we acknowledge that the discovery and use of flibanserin constitute a compelling narrative, we conclude by questioning the specific efficacy and necessity of flibanserin in providing a treatment for HSDD in women. Anderson R, Moffatt CE. Ignorance Is Not Bliss: If We Don't Understand Hypoactive Sexual Desire Disorder, How Can Flibanserin Treat It?

COMMENTARY

J Sex Med 2018;15:273-283.

Female Sexual Dysfunction-Medical and Psychological Treatments, Committee 14

INTRODUCTION

Since the millennium we have witnessed significant strides in the science and treatment of female sexual dysfunction (FSD). This forward progress has included (i) the development of new theoretical models to describe healthy and dysfunctional sexual responses in women; (ii) alternative classification strategies of female sexual disorders; (iii) major advances in brain, hormonal, psychological, and interpersonal research focusing on etiologic factors and treatment approaches; (iv) strong and effective public advocacy for FSD; and (v) greater educational awareness of the impact of FSD on the woman and her partner.

AIMS

To review the literature and describe the best practices for assessing and treating women with hypoactive sexual desire disorder, female sexual arousal disorder, and female orgasmic disorders.

METHODS

The committee undertook a comprehensive review of the literature and discussion among themselves to determine the best assessment and treatment methods.

RESULTS

Using a biopsychosocial lens, the committee presents recommendations (with levels of evidence) for assessment and treatment of hypoactive sexual desire disorder, female sexual arousal disorder, and female orgasmic disorders.

CONCLUSION

The numerous significant strides in FSD that have occurred since the previous International Consultation of Sexual Medicine publications are reviewed in this article. Although evidence supports an integrated biopsychosocial approach to assessment and treatment of these disorders, the biological and psychological factors are artificially separated for review purposes. We recognize that best outcomes are achieved when all relevant factors are identified and addressed by the clinician and patient working together in concert (the sum is greater than the whole of its parts). Kingsberg SA, Althof S, Simon JA, et al. Female Sexual Dysfunction-Medical and Psychological Treatments, Committee 14. J Sex Med 2017;14:1463-1491.

Sexual Function Post-Breast Cancer

The consequences of estrogen deprivation and therapeutic interventions such as radiation, chemotherapy and surgery have a significant negative impact on libido, sexual arousal, orgasmic function and the ability to have pleasurable intercourse. Evaluation and treatment of female sexual dysfunction is a significant unmet need in the breast cancer survivor in spite of the availability of safe and effective treatments.

Estrogen receptor α gene polymorphism and vascular complications in girls with type 1 diabetes mellitus

The effect of estrogens is mediated by activation of estrogen receptors (ERs). Because ER-α gene polymorphisms may exert different effects in childhood, we analyzed the associations between the IVS1 −397T>C (PvuII) polymorphism and systemic inflammatory state, proangiogenic factors, frequency of monocyte subsets, lipid profile, blood pressure, and vascular complications in girls with type 1 diabetes mellitus (DM1). We examined 180 young girls with DM1 and 120 healthy age-matched controls. The analysis concerned PvuII polymorphism of the ER-α gene as well as the levels of serum inflammatory markers (CRP, IL-6, TNF-α), proangiogenic factors (VEGF, angiogenin), 17β-estradiol, values of monocyte subsets (CD14⁺⁺CD16⁻ and CD14⁺CD16⁺), lipid profile, and blood pressure. In our study, girls with CC genotype had lower level of inflammatory and angiogenic factors and lower frequencies of CD14⁺CD16⁺ monocytes in comparison to CT or TT carriers. Simultaneously, the CC carriers had a greater population of CD14⁺⁺CD16⁻ monocytes, increased blood pressure, and serum levels of: estrogen, total cholesterol, triglycerides, and low-density lipoprotein cholesterol than girls bearing CT or TT genotype. Our study suggests a pleiotropic effect of PvuII polymorphic CC variant on diabetic vasculopathies. Although the CC genotype carriers demonstrate less inflammatory and angiogenic activity, they seem to display less favorable cardiometabolic features. Based on our study, we cannot distinguish PvuII ER-α genotype that could be useful in identification of DM1 girls that are more prone to develop of late vascular complications, before the occurrence of first clinical symptoms.

Becoming a sexual being: The 'elephant in the room' of adolescent brain development

The onset of adolescence is a time of profound changes in motivation, cognition, behavior, and social relationships. Existing neurodevelopmental models have integrated our current understanding of adolescent brain development; however, there has been surprisingly little focus on the importance of adolescence as a sensitive period for romantic and sexual development. As young people enter adolescence, one of their primary tasks is to gain knowledge and experience that will allow them to take on the social roles of adults, including engaging in romantic and sexual relationships. By reviewing the relevant human and animal neurodevelopmental literature, this paper highlights how we should move beyond thinking of puberty as simply a set of somatic changes that are critical for physical reproductive maturation. Rather, puberty also involves a set of neurobiological changes that are critical for the social, emotional, and cognitive maturation necessary for reproductive success. The primary goal of this paper is to broaden the research base and dialogue about adolescent romantic and sexual development, in hopes of advancing understanding of sex and romance as important developmental dimensions of health and well-being in adolescence.

Female Sexual Dysfunction

Female sexual dysfunction can drastically diminish quality of life for many women. It is estimated that in the United States 40% of women have sexual complaints. These conditions are frequently underdiagnosed and undertreated. Terminology and classification systems of female sexual dysfunction can be confusing and complicated, which hampers the process of clinical diagnosis, making accurate diagnosis difficult. There are few treatment options available for female sexual dysfunctions, however, some interventions may be of benefit and are described. Additional treatments are in development. The development of clear clinical categories and diagnostic guidelines for female sexual dysfunction are of utmost importance and can be of great benefit for clinical and public health uses and disease-related research.

Testosterone therapy for menopausal women

It has been suggested that there is a link between low circulating concentrations of testosterone and reduced sexual functioning in postmenopausal women,¹ and it has been more than 60 years since the effects of testosterone therapy for the management of menopausal symptoms were first reported.² Since then, testosterone supplementation has received growing attention for its potential role in maintaining sexual function in menopausal women. The National Institute for Health and Care Excellence guideline on the diagnosis and management of menopause recommends considering testosterone supplementation for women with low sexual desire if hormone replacement therapy (HRT) alone has been ineffective.³ However, in the UK no testosterone products are licensed for such use. A testosterone patch authorised by the European Medicines Agency in 2006 for use in women with surgical menopause was withdrawn from the market in 2012 for commercial reasons.⁴ Here, we provide an update on the evidence of the effectiveness and safety of testosterone supplementation in menopausal women.

Testosterona, desejo sexual e conflito de interesse: periódicos biomédicos como espaços privilegiados de expansão do mercado de medicamentos

Resumo Este artigo focaliza a articulação entre pesquisa biomédica e indústria farmacêutica com base nos estudos da tecnociência. Abordamos o caso do medicamento Intrinsa – adesivo de testosterona, cujo propósito é o aumento do desejo sexual em mulheres – examinando artigos que relatam resultados de ensaios clínicos, publicados em periódicos científicos. Buscamos demonstrar como a população visada pelos ensaios clínicos foi paulatinamente expandida de modo a englobar um número cada vez maior de mulheres, o que pressupôs rearranjos na maneira de definir as disfunções para as quais o medicamento seria indicado e as possíveis causas subjacentes. Foi possível identificar três caminhos de ampliação do mercado para o Intrinsa: o primeiro baseou-se na alteração do status de menopausa. A terapia com testosterona passou a ser vinculada também ao envelhecimento (incluindo, portanto, a pré-menopausa e a menopausa “natural”) e não mais exclusivamente à menopausa cirúrgica; o segundo focalizou a dissociação entre o uso do Intrinsa e a terapia com estrógenos; o terceiro buscou vincular o medicamento ao aumento de “bem-estar”.

Sexual dysfunction in premenopausal women could be related to hormonal profile

Female sexual dysfunction (FSD) is a public health problem that affects women's quality of life. Although the relationship between some hormones and the FSD has been described, it is not well established for all hormones. Therefore, the aim of our study was to evaluate the association between hormonal dysfunction and sexual dysfunction in premenopausal women. We performed a cross-sectional study with 60 patients with regular menstrual cycles, with age ranging from 18 to 44 years, with previous diagnosis of FSD. All patients were evaluated using the female sexual function index (FSFI) questionnaire and had the levels of total testosterone, prolactin (PRL), thyroid-releasing hormone and free testosterone index measured. Among the 60 patients, 43 (71.7%) were diagnosed with hypoactive sexual desire disorder (HSDD), 9 (15%) had anorgasmy and 8 (3.3%) had sexual pain dysfunction. Hormonal evaluation, demonstrated that 79.1% of patients with HSDD, 78.4% of patients with anorgasmy and 50% of patients with sexual pain dysfunction had female androgen insensitivity. We can conclude that there is an important association between low levels of total and free testosterone and FSD. This finding offers a new alternative for diagnosis and treatment of HSDD. Moreover, given the potential role of androgens in sexual function, randomized controlled trials with adequate long-term follow-up are essential to confirm its possible effect.

Flibanserin for hypoactive sexual desire disorder: place in therapy

The pathophysiology, diagnosis and treatment of female sexual interest in pre- and post-menopausal women present a complex arena for patients and physicians to navigate. Flibanserin was the first pharmacologic treatment, approved by the United States Food and Drug Administration in August 2015, for hypoactive sexual desire disorder (HSDD) in premenopausal women. Side effects, contraindications and lack of approval in postmenopausal women are all limitations, as are issues surrounding patient and physician knowledge and access. Testosterone, buspirone, sildenafil, bupropion, bremelanotide, as well as herbal medications (Herbal vX or Tribulus terrestris) have demonstrated some clinical benefit in women with sexual dysfunction disorders however, trials have significant design, dosing or generalizability limitations. Nonpharmaceutical cognitive behavioral therapy, mindfulness meditation, pelvic floor therapy, and clitoral stimulators are also interventions women may pursue. This manuscript will explore the clinical data regarding these therapeutic modalities so as to bring attention to this issue of female HSDD, to offer an overview of current research, and to incite providers to initiate discussion among themselves and their patients.

Efficacy and safety of transdermal testosterone in postmenopausal women with hypoactive sexual desire disorder: a systematic review and meta-analysis

OBJECTIVE

To systematically review and summarize the existing evidence related to the efficacy and safety of transdermal T in postmenopausal women for the treatment of hypoactive sexual desire disorder (HSDD).

DESIGN

Systematic reviews and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Seven randomized controlled trials enrolled 3,035 participants; 1,350 women were randomized to treatment with T patch, and 1,379 women were randomized to placebo.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Primary outcome: satisfying sexual episodes.

SECONDARY OUTCOMES

sexual activity, orgasm, Profile of Female Sexual Function domains (desire), personal distress score, adverse events, acne, increased hair growth, facial hair, alopecia, voice deepening, urinary symptoms, breast pain, headache, site reaction, total adverse events, serious adverse events, withdrawal from study, and follow-up rate.

RESULT(S)

The T group had significantly more satisfying sexual episodes, sexual activity, orgasms, desire, significant change in Personal Distress Scale score, androgenic adverse events, acne, and hair growth compared with the placebo group. There was no significant difference between the two groups in increase in facial hair, alopecia, voice deepening, urinary symptoms, breast pain, headache, site reaction to the patch, total adverse events, serious adverse events, reasons for withdrawal from the study, and the number of women who completed the study.

CONCLUSION(S)

The short-term efficacy in terms of improvement of sexual function and safety of transdermal T in naturally and surgically menopausal women affected by HSDD either on or not on estrogen progestin hormone therapy is evident from this systematic review. The use of transdermal T is associated with increase in androgenic adverse events such as acne but is not associated with any serious adverse events.

Androgens and Female Sexual Function and Dysfunction--Findings From the Fourth International Consultation of Sexual Medicine

INTRODUCTION

Androgens have been implicated as important for female sexual function and dysfunction.

AIM

To review the role of androgens in the physiology and pathophysiology of female sexual functioning and the evidence for efficacy of androgen therapy for female sexual dysfunction (FSD).

METHODS

We searched the literature using online databases for studies pertaining to androgens and female sexual function. Major reviews were included and their findings were summarized to avoid replicating their content.

MAIN OUTCOME MEASURES

Quality of data published in the literature and recommendations were based on the GRADES system.

RESULTS

The literature supports an important role for androgens in female sexual function. There is no blood androgen level below which women can be classified as having androgen deficiency. Clinical trials have consistently demonstrated that transdermal testosterone (T) therapy improves sexual function and sexual satisfaction in women who have been assessed as having hypoactive sexual desire disorder. The use of T therapy is limited by the lack of approved formulations for women and long-term safety data. Most studies do not support the use of systemic dehydroepiandrosterone therapy for the treatment of FSD in women with normally functioning adrenals or adrenal insufficiency. Studies evaluating the efficacy and safety of vaginal testosterone and dehydroepiandrosterone for the treatment of vulvovaginal atrophy are ongoing.

CONCLUSION

Available data support an important role of androgens in female sexual function and dysfunction and efficacy of transdermal T therapy for the treatment of some women with FSD. Approved T formulations for women are generally unavailable. In consequence, the prescribing of T mostly involves off-label use of T products formulated for men and individually compounded T formulations. Long-term studies to determine the safety of T therapy for women and possible benefits beyond that of sexual function are greatly needed.

Physicians' attitudes towards androgen replacement therapy for male and female sexual dysfunction

Androgen deficiency syndrome is a commonly diagnosed condition. The aim of this study was to investigate common clinical practices of specialists in the field of sexual medicine regarding androgen replacement treatment for men and women. Attendees of the 16th Annual Congress of the European Society of Sexual Medicine held in January 2014 in Istanbul, Turkey, were asked to participate in a survey during the congress days. A 24-item self-report, closed-question questionnaire was distributed. Three sections were accessed: sociodemographic data, professional background and personal practice patterns regarding androgen substitution in men and women. A total of 133 physicians (mean age 47 years; range 25-79) completed the survey. Responses were inconsistent regarding the lab tests used for primary evaluation of male androgen deficiency. The majority of participants (62%) recommended testosterone replacement therapy for symptomatic men with testosterone levels <8 nmol l(-1) (231 ng dl(-1)). Similarly, most physicians (88%) recognized a correlation between libido and testosterone levels in women. Only 42% and 53% reported they would prescribe testosterone to women with low libido, premenopausal and postmenopausal, respectively. This survey showed discrepancies among physicians regarding testosterone replacement therapy for men and women.

Hypoactive Sexual Desire Disorder: A Review of Epidemiology, Biopsychology, Diagnosis, and Treatment

INTRODUCTION

Hypoactive Sexual Desire Disorder (HSDD) is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised (DSM-IV-TR) as persistent deficient sexual fantasies and desire for sexual activity that causes marked distress or interpersonal difficulty. In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), HSDD has been subsumed by Female Sexual Interest/Arousal Disorder. However, decades of research based on DSM-IV-TR HSDD criteria form the foundation of our understanding of the essential symptom of distressing low sexual desire, its epidemiology, clinical management, and treatment.

AIM

This publication reviews the state of knowledge about HSDD.

METHODS

A literature search was performed using terms HSDD and female sexual dysfunction (FSD).

MAIN OUTCOME MEASURES

Physicians acknowledge that FSD is common and distressing; however, they infrequently address it, citing low confidence, time constraints, and lack of treatment as barriers.

RESULTS

HSDD is present in 8.9% of women ages 18 to 44, 12.3% ages 45 to 64, and 7.4% over 65. Although low sexual desire increases with age, distress decreases; so prevalence of HSDD remains relatively constant across age. HSDD is associated with lower health-related quality of life; lower general happiness and satisfaction with partners; and more frequent negative emotional states. HSDD is underdetected and undertreated. Less than half of patients with sexual problems seek help from or initiate discussions with physicians. Patients are inhibited by fear of embarrassing physicians and believe that physicians should initiate discussions. The Decreased Sexual Desire Screener, a tool for detecting and diagnosing HSDD, is validated for use in general practice.

CONCLUSION

Women can benefit from intervention in primary care, behavioral health and sexual medicine settings. Psychotherapeutic and pharmacological interventions aim to enhance sexual excitatory process and decrease inhibitory processes. Flibanserin, the first centrally acting daily medication for HSDD, was recently approved in the US for premenopausal women.

Effectiveness of a low dose testosterone undecanoate to improve sexual function in postmenopausal women

BACKGROUND

Adding testosterone to hormonal therapy could improve sexual function and general well-being among women during climacteric. We evaluated the effectiveness of testosterone undecanoate on sexual function in postmenopausal women utilizing the standardized questionnaire FSFI score.

METHODS

Postmenopausal women with sexual complaints and Female Sexual Function Index (FSFI) ≤ 26.5 were enrolled in to this randomized, double-blinded, placebo-controlled trial. Participants were randomly assigned to 8-week treatment with either oral testosterone undecanoate 40 mg or placebo twice weekly with daily oral estrogen. The FSFI scores before and after treatment were compared to assess any improvement of sexual function.

RESULTS

Seventy women were recruited of which each group had 35 participants. The baseline characteristics and baseline FSFI scores were comparable between both groups. After 8 weeks of treatment, the FSFI scores significantly improved in both groups when compared to the baseline but the FSFI scores from the testosterone group were significantly higher than in the placebo group post-treatment (28.6 ± 3.6, 25.3 ± 6.7, respectively, p = 0.04). There was no difference in adverse effect between the two groups

CONCLUSIONS

The twice weekly addition of testosterone undecanoate to daily oral estrogen was associated with a significant improvement in sexual function among postmenopausal women than the use of the estrogen alone.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT01724658 (February 17, 2012).