Androgens and sexual behaviour in women using oral contraceptives

Are Endogenous Androgens Linked to Female Sexual Function? A Systemic Review and Meta-Analysis

BACKGROUND

The benefits of treatment with testosterone (T) in women with loss of desire suggest that low androgens may distinguish women with sexual dysfunction (SD) from others; however, evidence on this point is lacking.

AIM

To answer the question: is there an association between endogenous levels of androgens and sexual function in women?

METHODS

An extensive search was performed in MEDLINE, Embase and PsycInfo. Four separate meta-analyses were conducted for total T, free T, Free Androgen Index (FAI), and Dehydroepiandrosterone sulphate (DHEAS). Cohort, cross-sectional, and prospective studies were included.

OUTCOMES

The main outcome was the association between endogenous androgens and sexual desire. Global sexual function was considered as a secondary outcome. The effect measure was expressed as standardized mean difference (SMD).

RESULTS

The meta-analysis on total T included 34 studies involving 3,268 women, mean age 36.5 years. In 11 studies, a significant association was found between sexual desire, measured by validated psychometric instruments, and total T (SMD = 0.59 [0.29;0.88], P < 0.0001), with a moderate effect. The association with global sexual function (n = 12 studies) was also significant (SMD = 0.44 [0.21;0.67], P <0.0001). Overall, total T was associated with a better sexual function (SMD = 0.55 [0.28;0.82)], P < 0.0001), with similar results obtained when poor quality studies were removed. Age showed a negative relationship with the overall outcome. No differences were found when stratifying the studies according to menopausal status, type of menopause, age at menopause, use of hormonal replacement therapy, relationship status, method for T measurement, phase of the menstrual cycle or use of hormonal contraception. The meta-analysis of T derivatives (free T and FAI) also showed a significant, moderate association with sexual desire. In contrast, DHEAS seems not to exert any significant influence on desire, whilst showing a positive association with global sexual function.

CLINICAL IMPLICATIONS

Endogenous androgens show a moderate association with a better sexual function in women; however, the role of psychological, relational and other hormonal factors should not be overlooked.

STRENGTHS & LIMITATIONS

This represents the first attempt at meta-analyzing data available on the topic. A significant publication bias was found for total T.

CONCLUSION

There appears to be a moderate association between total T and sexual desire/global sexual function, which is confirmed, although weak, in studies employing liquid chromatography-mass spectrometry (LC-MS). Similar results on desire were obtained for free T and FAI. DHEAS only showed a positive association with global sexual function. More research is needed. Maseroli E and Vignozzi L. Are Endogenous Androgens Linked to Female Sexual Function? A Systemic Review and Meta-Analysis. J Sex Med 2022;19:553-568.

Female Sexual Dysfunction: Review of the Disorder and Evidence for Available Treatment Alternatives

With the introduction and marketing of sildenafil, national attention has focused on sexual dysfunction in men. However, strides are being made to focus more effort on evaluation and treatment of female sexual disorder (FSD) since a 1999 national survey reported prevalence rates as high as 43% in women. Evaluation and assessment of FSD requires a comprehensive history and physical examination. Understanding of FSD requires knowledge and understanding of sexual anatomy, physiology, and pathophysiology. Nonpharmacologic treatment may include sex therapy or relationship counseling. Pharmacologic treatment of FSD has focused mainly on hormonal therapies, including estrogen and testosterone, with the majority of studies being done in postmenopausal and hysterectomized women. However, recent studies indicate a more prudent and careful use of hormonal therapies. Research is also moving toward evaluation of bupropion and sildenafil as options for women who suffer from FSD. Available evidence for treatment alternatives is scant and in some cases inconclusive.

Gestodene: a review of its pharmacology, potency and tolerability in combined contraceptive preparations

Combined progestin-estrogen pills are an established and reliable contraceptive option used by women worldwide. Combined oral contraceptives (COCs) containing the progestins--gestodene, desogestrel or norgestimate--were developed to minimize androgenic side effects and are considered an effective, well-tolerated contraceptive option. Gestodene achieves contraceptive efficacy with the lowest dose of any progestin in a COC, and has an established and favorable short- and long-term tolerability profile. In this review we present an overview of the pharmacology, potency and tolerability of gestodene.

The effect of combined oral contraception on testosterone levels in healthy women: a systematic review and meta-analysis

BACKGROUND; Combined oral contraceptives (COCs) reduce levels of androgen, especially testosterone (T), by inhibiting ovarian and adrenal androgen synthesis and by increasing levels of sex hormone-binding globulin (SHBG). Although this suppressive effect has been investigated by numerous studies over many years, to our knowledge no systematic review concerning this issue had been performed. This systematic review and meta-analysis was performed to evaluate the effect of COCs on concentrations of total T, free T and SHBG in healthy women and to evaluate differences between the various types of COCs (e.g. estrogen dose, type of progestin) and the assays used to assess total T and free T.

METHODS

A review of the literature was performed using database searches (MEDLINE, EMBASE and the Cochrane Central Register of Clinical Trials) and all publications (from inception date until July 2012) investigating the effect of COCs on androgen levels in healthy women were considered eligible for selection. Three reviewers were involved in study selection, data extraction and critical appraisal. For the meta-analysis, data on total T, free T and SHBG were extracted and combined using random effects analysis. Additional subgroup analyses were performed to evaluate differences between the various types of COCs (e.g. estrogen dose, type of progestin) and the assays used to assess total T or free T.

RESULTS

A total of 151 records were identified by systematic review and 42 studies with a total of 1495 healthy young women (age range: 18-40 years) were included in the meta-analysis. All included studies were experimental studies and 21 were non-comparative. Pooling of the results derived from all the included papers showed that total T levels significantly decreased during COC use [mean difference (MD) (95% confidence interval, CI) -0.49 nmol/l (-0.55, -0.42); P < 0.001]. Significantly lower levels of free T were also found [relative change (95% CI) 0.39 (0.35, 0.43); P < 0.001], with a mean decrease of 61%. On the contrary, SHBG concentrations significantly increased during all types of COC use [MD (95% CI) 99.08 nmol/l (86.43, 111.73); P < 0.001]. Subgroup analyses revealed that COCs containing 20-25 µg EE had similar effects on total and free T compared with COCs with 30-35 µg EE. In addition, suppressive effects on T levels were not different when comparing different types of progestins. However, subgroup analyses for the estrogen dose and the progestin type in relation to changes in SHBG levels did show significant differences: COCs containing second generation progestins and/or the lower estrogen doses (20-25 µg EE) were found to have less impact on SHBG concentrations.

CONCLUSIONS

The current literature review and meta-analysis demonstrates that COCs decrease circulating levels of total T and free T and increase SBHG concentrations. Due to the SHBG increase, free T levels decrease twice as much as total T. The estrogen dose and progestin type of the COC do not influence the decline of total and free T, but both affect SHBG. The clinical implications of suppressed androgen levels during COC use remain to be elucidated.

The influence of combined oral contraceptives on female sexual desire: a systematic review

OBJECTIVES

To determine the relationship between the use of combined oral contraceptives (COCs) and sexual desire based on a systematic review of the literature.

METHODS

MEDLINE Complete, Google Scholar and the Cochrane Library were searched for articles published between 1975 and 2011, reporting the effects of oral contraceptives on sexual desire. Reports fully meeting all the predefined criteria were analysed and included in a final reference list. In addition, a review of the reference list of selected articles was carried out.

RESULTS

We evaluated 36 studies (1978-2011; 13,673 women). Of the COC users (n = 8,422), 85% reported an increase (n = 1,826) or no change (n = 5,358) in libido and 15% reported a decrease (n = 1,238). We found no significant difference in sexual desire in the case of COCs with 20-35 μg ethinylestradiol; libido decreased only with pills containing 15 μg ethinylestradiol.

CONCLUSIONS

The majority of COC users report no significant change in libido although in most studies a decline in plasma levels of free testosterone and an increase in those of sex hormone binding globulin were observed.

The varied nature of women's sexuality: unresolved issues and a theoretical approach

During the 20th century there were clear indications that the socio-cultural suppression of women's sexuality had lessened, revealing a marked variability of women's sexual expression. In this article we review the recent literature to explore explanations for this variability. It is clear that we know little about the nature of sexual desire, and in particular, what it is that is desired. There is also now substantial evidence that vaginal response, as measured by vaginal pulse amplitude, is a relatively automatic response to perception of sexual stimuli, regardless of whether these stimuli are perceived positively or result in subjective arousal. This is considered as a possible mechanism that allows vaginal intercourse without pain, even when the woman is not sexually aroused. The roles of androgens and estrogen in women's sexuality remain uncertain. The evidence is, however, consistent with there being a testosterone-dependent component of women's sexuality that is more important for some women than others. Finally, a new theoretical model is presented that aims to resolve these uncertainties and that proposes different types of women's sexuality. Once we have a better understanding of "normal" female sexuality, in its various forms, our ability to develop effective treatments for women's sexual problems should improve.

Pharmacologically induced hypogonadism and sexual function in healthy young women and men

Studies fail to find uniform effects of age-related or induced hypogonadism on human sexual function. We examined the effects of induced hypogonadism on sexual function in healthy men and women and attempted to identify predictors of the sexual response to induced hypogonadism or hormone addback. The study design used was a double-blind, controlled, crossover (self-as-own control). The study setting was an ambulatory care clinic in a research hospital, and the participants were 20 men (average+/-SD age=28.5+/-6.2 years) and 20 women (average+/-SD age=33.5+/-8.7 years), all healthy and with no history of psychiatric illness. A multidimensional scale assessing several domains of sexual function was the main outcome measure. Participants of the study received depot leuprolide acetate (Lupron) every 4 weeks for 3 months (men) or 5 months (women). After the first month of Lupron alone, men received (in addition to Lupron) testosterone enanthate (200 mg intramuscularly) or placebo every 2 weeks for 1 month each. Women received Lupron alone for 2 months, and then, in addition to Lupron, they received estradiol and progesterone for 5 weeks each. The results of the study: in women, hypogonadism resulted in a significant decrease in global measures of sexual functioning, principally reflecting a significant decrease in the reported quality of orgasm. In men, hypogonadism resulted in significant reductions in all measured domains of sexual function. Testosterone restored sexual functioning scores in men to those seen at baseline, whereas neither estradiol nor progesterone significantly improved the reduced sexual functioning associated with hypogonadism in women. Induced hypogonadism decreased sexual function in a similar number of men and women. No predictors of response were identified except for levels of sexual function at baseline. In conclusion, our data do not support a simple deficiency model for the role of gonadal steroids in human sexual function; moreover, while variable, the role of testosterone in sexual function in men is more apparent than that of estradiol or progesterone in women.

Does oral contraceptive-induced reduction in free testosterone adversely affect the sexuality or mood of women?

The aim of this study was to examine whether changes in plasma androgen levels (total testosterone (T), free testosterone (FT), and dehydro-epiandrosterone-sulfate (DHEA-S)) induced by oral contraceptive (OC) use were related to changes in sexual interest or response or in mood. Sixty-one women provided blood samples and were assessed, using interviews and standardized questionnaires, prior to starting, and after 3 months on OCs (Ortho-Tricyclen, Ortho-Tricyclen-Lo, or Ortho-Cyclen, all containing the same progestagen, norgestimate). Significant decreases in T, FT, and DHEA-S were found after 3 months, although the extent of reduction was variable across women. There was some support for a relationship between the degree of reduction in total T and FT and the frequency of sexual thoughts after 3 months on OCs. However, some women had no loss of sexual interest in spite of substantial reduction in FT, and there was overall no evidence that reduction in FT affected enjoyment of sexual activity with a partner. The findings are consistent with the idea that some women may be more sensitive to changes in T than others. No relationship was found between negative mood, as assessed by the Beck Depression Inventory, and changes in T, FT, or DHEA-S.

Pharmacological effects on sexual function

Many drugs may have effects on sexual function. Sexual function is complex and psychological and relationship issues are likely to have greater impacts on sexual function in women than drugs. Although it is important to understand the effects of drugs on sexual function, physicians should use caution in "medicalization" of sexual function in women [106].

Disorders of Sexual Desire and Arousal

Desire and arousal disorders are very common. These disorders can cause significant distress to a patient. A successful approach depends on an accurate diagnosis, which is dependent on history. Laboratory evaluation is usually not helpful, whereas psychosexual therapy is helpful in many cases. Although there is some evidence that drug therapy is helpful in some cases, no drug has been approved for the treatment of these disorders.

Salivary testosterone is related to both handedness and degree of linguistic lateralization in normal women

The aim of this study was to test the hypothesis that individual differences in testosterone (T) are associated with different patterns of linguistic lateralization and hand preference. Twenty left-handed (LH) and 19 right-handed (RH) women filled in a handedness questionnaire and performed a consonant-vowel dichotic listening test (DL-CV). Salivary T was measured by radioimmunoassay (RIA). LH women showed significantly lower mean salivary T than RH women. T levels were negatively correlated with the absolute value of the DL laterality index. Subjects with right ear advantage (REA) were classified into strongly and weakly lateralized following Wexler et al. method (Brain Lang. 13 (1981) 13). When taking into account hand preference, a pattern emerged in that RH-strongly lateralized and LH-weakly lateralized women showed similar T levels. The lowest level appeared for LH-strongly lateralized women and the highest for RH-weakly lateralized women, being significantly different from each other. The results are discussed in terms of several theories that have proposed a link between testosterone and cerebral lateralization.

Sexual effects of androgens in women: some theoretical considerations

OBJECTIVE

To consider explanations for the inconsistent evidence concerning behavioral effects of androgens in women. The following possible explanatory mechanisms are explored: [1] Women vary in their behavioral responsiveness to T. [2] Some reported effects of exogenous T may be induced by increasing bioavailable estrogen. [3] Sexual effects of T may be secondary to direct effects on mood. [4] The relationship between T and sexuality is readily obscured by psychological mechanisms. [5] Stress-induced increases in adrenal androgens may further confuse the picture. [6] Women who respond to T respond to levels that are ineffective in men. There is no evidence of a threshold in women above which further increases in T have no additional effect.

CONCLUSION(S)

A theoretical model, involving desensitization of the central nervous system to T during early development in the male, is presented as a possible explanation for some of these relevant differences between men and women and for much of the conflicting evidence in the literature on women.

Controlled studies on women presenting with sexual drive disorder: I. Endocrine status

A single mid-cycle blood sample was obtained from 15 premenopausal female patients presenting with lifelong absence of sexual drive and from a control group of women with intact sexual drive. Serum levels of testosterone, 5-dihydrotestosterone (5-DHT), 17 beta oestradiol, sex hormone binding globulin, and prolactin were measured and indices of free testosterone and 5-DHT were derived. During the menstrual cycle in which the blood samples were obtained, the study subjects kept a diary of their sexual desire and activities. The only endocrine parameter that is significantly different between the two groups is free testosterone, which is lower in the patients than in the control women. Associations between endocrine parameters and indices of sexual behavior were examined. In the control group, average daily sexual thoughts correlates positively with total testosterone, free testosterone index, and free 5-DHT. Feeling of "need for sex" correlates positively with free 5-DHT index and free testosterone index. Experience of sexual thoughts correlates with need for sex, and average frequency of masturbation correlates negatively with age. In both groups, average coital frequency correlates with free testosterone index.

Hormone receptors and sexuality in the human female

There is only inferential evidence based on observational studies and deductive reasoning that allows us to suppose there are hormone receptors in the human brain that are associated with libido. Data indicate that sexually active pubescent women have higher testosterone levels than matched controls. However, any number of nonhormonal events in puberty could be related to these changes. Another circuitous way to look at hormone libido receptors in the brain is by evaluating patients on birth control pills, in whom sexual activity paradoxically decreases. Sex hormone-binding globulin (SHBG) levels are increased, and, therefore, free testosterone levels seem to be affected by the use of birth control pills. In addition, the progestins in the pill are 19-nortestosterone derivatives, which may have some androgenic effect in their own right. Women on estrogen replacement therapy with the addition of testosterone seem to report increased libido, and there is subjective information that there is an increase in psychological sense of well-being. It has been well documented that females with adrenogenital syndrome are masculinized in utero, indicating imprinting on behavior. Because of the nature of the end point (e.g., increased libido), it is difficult to draw concrete conclusions on the presence of libido receptors in the human brain. Because the outcomes and end points are so soft, it is difficult to come to a consensus, and in fact this topic polarizes opinions of the pure scientist (objective) against the clinician (subjective).

Future change in sexual behaviour?

Virtual sex is not a substitute for normal sexual intercourse, lacking emotional interaction between couples and the intimacy and reinforcement of a loving relationship.

Sex steroids and libido

The effects of steroidal hormones on sexual desire and motivation are a question still under debate. This paper reviews up-to-date knowledge regarding physiological imprinting and activation by endogenous hormones of central nervous system areas involved in libido during intrauterine life and puberty. The endocrine environment probably continues to play a role during fertile life and the postmenopausal period, but this effect is often overridden by psychological and social factors. The impairment of sexual interest during estrogen-progestin treatment is an infrequent but relevant side-effect whose possible underlying mechanisms are discussed. Both endocrine and psychorelational elements may interact. From the biological point of view, androgen and oxytocin level modification and loss of estrogen fluctuations have been considered, but also the history of hormone-related mood changes could be a risk factor. On the psychological side, both the profound repercussions of the contraceptive choice and consequent responsibility, as well as the high value attributed to sexual experience are probably facilitating elements in the loss of libido under treatment.

Testosterone predicts initiation of coitus in adolescent females

OBJECTIVE

The purposes of this study were to demonstrate, using longitudinal data, that the pubertal rise in testosterone (T) is associated with subsequent increases in female sexual interest and activity, and to examine these relationships within the context of a social control variable.

METHODS

Using data from a 2-year panel study of approximately 200 black and white postmenarcheal adolescent females, the relationships among semiannual measures of T, sex hormone binding globulin (SHBG), pubertal development, and self-reports of coital and noncoital sexual activity were assessed.

RESULTS

Testosterone and changes in T were significantly related to the timing of subsequent transition to first coitus for blacks and whites. Frequency of attendance at religious services operated as a social control variable among white females, and was found to moderate T effects on sexual transition for this group.

CONCLUSIONS

These results are consistent with a biosocial model proposing T as a causal factor in female sexual activity, and suggest that biological effects are moderated by relevant social variables.

Salivary testosterone levels in left- and right-handed adults

It has been proposed that prenatal testosterone (T) may contribute to the development of hand preference and cerebral functional asymmetry in humans. To investigate any persisting association between T and asymmetry in adulthood, left-handed (LH) and right-handed (RH) men and women were administered a hand preference questionnaire and the Fused Dichotic Words Test. Testosterone was measured in samples of saliva. Results showed that LH subjects of both sexes had lower salivary T concentrations than their RH counterparts. Among LH males, subjects with a right-ear advantage in dichotic listening tended to have lower T concentrations than subjects with a left-ear advantage. These results are consistent with the notion that T may be involved in the development of hand preference and cerebral functional asymmetry.

The effects of steroidal contraceptives on the well-being and sexuality of women: a double-blind, placebo-controlled, two-centre study of combined and progestogen-only methods

A placebo-controlled, double-blind study was carried out to assess the direct hormonal effects of combined and progestogen-only oral contraceptives on well-being and sexuality of women in two contrasting cultures. One-hundred-fifty women, who had been sterilised or whose partners had been vasectomised, were recruited from two centres-Manila, Philippines, and Edinburgh, Scotland. After one month pretreatment assessment, women were randomly assigned to one of three treatments (combined oral contraceptive (COC), progestogen-only pill (POP), or placebo; 50 within each treatment group, 25 per centre) and continued on treatment for four months. Assessment was by daily ratings, questionnaires and interviews. The COC adversely affected sexuality in the Edinburgh women, with 12 of the 25 women in this group also reporting the side effect of reduced sexual interest. There were modest negative effects of the combined pill on mood, more noticeable in the Edinburgh women. The POP was associated with no adverse effects on sexuality and some improvement in well-being in both centres. Possible explanations for the apparent lack of adverse effects in the Manila women are discussed. The negative effects reported may be less evident in women using the COC for contraceptive purposes but may lead to discontinuation in some women and warrant further investigation.

Androgens and sexuality

A review of the literature reveals that the endocrine determinants of female sexuality are complex and difficult to characterize. In adolescent males, free testosterone directly affects sexual motivation, with social factors exerting little or no effect. In adolescent girls, by contrast, societal and peer pressure play a pivotal role in the appearance of certain sexual behaviors. Throughout a woman's life, hormonal and psychosocial factors are critical influences. It is possible that cyclic patterns of testosterone are less important for female sexual behavior than the "tonic" effect of overall testosterone levels. Although the estrogen dependence of the vaginal epithelium--important for postmenopausal women--has been clearly established, the role of other hormonal factors and treatments, particularly those involving androgens, in human female sexual behavior remains enigmatic. The search for an understanding of these relationships is not merely an interesting academic exercise but is necessary to determine what role, if any, androgens may play in the treatment of sexual dysfunction during the female reproductive years.

Low sexual desire in women: the role of reproductive hormones

The role of reproductive hormones in mediating sexual desire in healthy women is still unclear. Elucidation was sought in this study by comparing the hormonal milieu of two groups of subjects with markedly different levels of sexual desire. Seventeen women ages 27-39 who met DSM III-R criteria for severe, persistent, and generalized loss of desire (hypoactive sexual desire disorder, HSD), but had no other current psychological or medical problem, were compared to 13 healthy, sexually active women. All subjects and spouses were interviewed extensively to determine the women's sexual desire and responsiveness. Blood samples were drawn every 3 to 4 days for one menstrual cycle and were analyzed by RIA for testosterone, SHBG, estradiol, progesterone, prolactin, and luteinizing hormone. Results indicated that the HSD women's gonadal hormones fluctuated normally over the menstrual cycle, were within normal limits for each cycle phase, and were never significantly different from those of controls. Neither testosterone, non-SHBG bound testosterone, nor prolactin differentiated between the HSD women with the most and least severe HSD parameters (e.g., frequency of fantasy, masturbation, or female-initiated coitus), nor between women with lifelong and acquired HSD. The present findings did not provide evidence that reproductive hormones are important determinants of individual differences in the sexual desire of these eugonadal women.

Salivary androgens in hirsutism: are they of use in routine evaluation?

In the biochemical evaluation of hirsutism, 50% or less of patients have an elevated total serum testosterone. Recent work has suggested that measuring salivary testosterone or a derived serum 'free testosterone index' may be of use in the evaluation of hyperandrogenism. We have measured serum total, derived serum free indices and salivary concentrations of testosterone and 5 alpha-dihydrotestosterone in an unselected group of hirsute patients in order to assess their value in the routine evaluation of hirsutism. The assays were performed using a novel oxidation procedure to overcome the need for chromatographic separation. The 'free testosterone index' gave the best discrimination. Salivary androgen concentrations were comparatively poor and cannot be recommended for routine use.

Hormones and human sexual behavior

The role of sex hormones in the sexuality of men is now becoming clearer. Androgens are necessary for normal sexual appetite and for ejaculation. Erectile mechanisms, providing that appropriate erotic stimuli are available, are probably not androgen dependent. How much testosterone is required to obtain maximum sexual effect is not yet clear but it probably varies from individual to individual and may be well within the normal range in some men. Androgens may therefore be beneficial in treating loss of sexual appetite in men but are unlikely to improve erectile dysfunction unless it is secondary to loss of sexual appetite. In women the picture is much less clear. Apart from the estrogen dependence of the vaginal epithelium, important for the postmenopausal woman, female sexuality shows a very unpredictable relationship with reproductive hormones. Possible reasons for this variable picture are discussed, in particular a greater genetic variability and behavioral sensitivity to hormones in women than in men.

Attendance at a breast screening clinic: a problem of administration or attitudes

In a study of why a sample of women, aged 45-64 and registered with a group practice in Edinburgh, attended or did not attend the Edinburgh Breast Screening Clinic demographic, aetiological, social, and perceptual characteristics of attenders and non-attenders were compared. Similar proportions of attenders and non-attenders knew the chance of a breast lump being cancer and were aware of the benefits of early diagnosis and treatment. The study, however, suggests that non-attenders saw the screening clinic as a place of risk while the attenders saw screening in a positive light: 79% of non-attenders as compared with 36% of attenders said that they were afraid of cancer being found, and most women attended either to reassure themselves that they had not got breast cancer or to receive early treatment if they had. Furthermore, 72% of non-attenders as compared with 13% of attenders were anxious that their lives would be disrupted if cancer were found at the screening clinic. There may well be an important irreducible element to non-attendance due to attitudinal factors; the ethical implications of attempting to eliminate this require careful consideration.