Women on Testosterone

Contents

• Introduction
• Differentiate the hormone deficiency
• Profound effect
• Dangerous nymphomania

Introduction

Early testosterone was given to women in the form of implants as that was the only preparation licensed for use in women. There are now gels licensed for men which can be used off-licence in a smaller dose for women and at last, a testosterone patch has recently received a licence for use in women who have had a hysterectomyThe surgical removal of the uterus (womb). and bilateralOn both sides of the body salpingo oophorectomy.

There is often a delusion amongst patients that testosterone is a male hormone. Of course it is a normal female hormone but it is not always understood that in healthy young women it is present in 10 times the level as oestradiol. Similarly there are many more Androgen receptor sites in the female brain than oestrogenA hormone involved in female sexual development, produced by the ovaries. receptors. Androgen levels begin to decline at the age of 20 and by the time of the natural menopauseThe time of a woman’s life when her ovaries stop releasing an egg (ovum) on a monthly cycle. the levels are much reduced. Everyone is aware that oestrogen levels fall with the menopauseThe time when a woman's periods permanently cease. but there is also a 50% fall of testosterone after a natural menopausalRelating to the menopause, the time of a woman’s life when her ovaries stop releasing an egg (ovum) on a monthly cycle. and a 75% fall in testosterone after bilateral oophorectomy.

Differentiate the hormone deficiency

Healthy young women produce about 100μg-200μg of testosterone each day which is about 5% of the daily testosterone production in men. Half of this is derived from the ovariesFemale reproductive organs situated one on either side of the uterus (womb). They produce egg cells (ova) and hormones in a monthly cycle. and half from the adrenal glandsA pair of small, triangular shaped glands located above each kidney, responsible for regulating the body’s response to stress and helping to control metabolism. as the hormone DHEA is converted to testosterone in the body fatOne of the three main food constituents (with carbohydrate and protein), and the main form in which energy is stored in the body.. The decline in androgenA type of steroid hormone that stimulates male development. Testosterone is an androgen. levels contribute to a decline in sexual desire, arousal and orgasm and also has effects on general well-being, energy, mood, bone physiology and decreased muscleTissue made up of cells that can contract to bring about movement. mass as well as hot flushes.

It is important to differentiateThe specialisation of cells or tissues for a specific function. the symptoms of oestrogen deficiency in post-menopausalAfter the menopause - technically only once a woman has had no menstrual period for one year. women from testosterone deficiency. The oestrogen deficient woman has typical climacteric symptoms of hot flushes, sweats, sleep disturbance, mood changes and vaginal dryness. These symptoms do, of course, overlap with many of the symptoms of testosterone deficiency known as the Female Androgen Deficiency Syndrome (FADS). There are typically five symptoms of this condition:

1. Decreased well-being and self-confidence.
2. Decreased energy.
3. Decreased sexual desire and arousal.
4. Increased depressionFeelings of sadness, hopelessness and a loss of interest in life, combined with a sense of reduced emotional well-being.
5. Headaches.

Profound effect

As gynaecologists we commonly see this symptom complex of androgen deficiency in women who have had a hysterectomy and bilateral oophorectomy and have been maintained on a low dose of oral oestrogens for several years. They have no hot flushes and sweats and have no vaginal dryness but they do not feel well. They have predictable problems with loss of energy, loss of sex drive, depression, headaches and loss of self-confidence. These symptoms which have a profound effect on quality of life respond well to the addition of small amounts of testosterone.

It is no surprise that FADS occurs commonly after bilateral salpingo-oophorectomy but we do not know its incidenceThe number of new episodes of a condition arising in a certain group of people over a specified period of time. after hysterectomy with ovarianrelating to the ovaries conservation. It is not rare. Nor is it rare in intact post-menopausal women, peri-menopausal women, or even younger women who have problems of sexual response. The diagnosisThe process of determining which condition a patient may have. should be made by taking a careful history of poor sexual response and other appropriate symptoms within a good relationship where these are also helped by a response to testosterone therapy. A pre-treatment testosterone level is not very valuable for the diagnosis as we usually measure total testosterone. Ninety five per cent of total testosterone is bound to sex hormone binding globulin (SHBG) and therefore, inactive. The free testosterone is more important for function but difficult and expensive to measure in these tiny quantities.

An early uncontrolled study showed that oestrogens improved dyspareuniaPain experienced by a woman during sexual intercourse. and vaginal dryness and libidoSexual drive. in 80% of this group. The addition of testosterone improved libido in 12 out of the remaining 15 patients who had not responded to oestradiol. Subsequently there have been a few better randomised controlled studies showing the benefits of testosterone therapy and latterly, the effects of transdermal testosterone patch on sexual desire, sexual activity, orgasm, pleasure, responsiveness and self image with a corresponding decrease in sexual distress. The patch Intrinsa™ is recommended in a dose of 300μg and applied twice weekly.

The value of testosterone over oestrogen and placebo was shown in trials 20 years ago by Sherwin and Gelfand with implants of hormones after hysterectomy and bilateral salpingo oophorectomy. The clear result in this study was that the addition of testosterone improved sexuality, decreased depression and improved general health scores. We have reported a prospective study of 200 women having implants of oestradiol and testosterone after hysterectomy and oophorectomy showing the long term improvement over many years of libido orgasms depression anxiety and energy. In spite of this, the vast majority of women who have lost their ovariestwo small organs that are part of the female reproductive system where eggs mature at surgery are not offered testosterone for reasons which are very hard to understand.

Although there is a tendency to equate testosterone therapy with a sexual response with increased sexual episodes, libido and easier orgasms it is important to realise that there is a non-sexual component in these benefits. Women speak of greater self confidence, greater mental acuity, less depression and they even speak about greater efficiency and communication within their work. They are also aware of increased self worth and yet they behave like “wanted women rather than neglected ones”. These non-sexual components, although important, are more difficult to assess in trials and therefore, alas have not been done.

Dangerous nymphomania 

This information does leave the question about who should be treated. Clearly, nearly all women who have had a bilateral oophorectomy should have appropriate hormone replacement therapyThe administration of female hormones in cases where they are not sufficiently produced by the body. Abbreviated to HRT. which should consist of oestradiol and testosterone. Now that testosterone is available on licence for women it is hard to justify oophorectomy in pre-menopausal women without replacement of testosterone. Although there is no licence for non-hysterectomised women to receive testosterone there is no doubt that good, well-experienced doctors will prescribe testosterone for the appropriate symptoms in women who have an intact uterusThe womb, where embryo implantation occurs and the growing foetus is nourished. and ovaries, and even in those that are pre-menopausal with the appropriate symptoms. Prescribing “off-licence” is controversial but that does not mean that it should be forbidden.

Historically, it is most interesting that whilst modern society and medicine are concerned that women should have a satisfying sex life, it was not always so. This is far removed from the attitudes in the last half of the 19th Century when nymphomania and masturbation were thought to be serious diseases which led to paralysis, coma and death. There were tens of thousands of women who underwent removal or irradiation of the clitoris to remove their sexual desires although in earlier centuries female sexuality was respected, as we can see from Titian’s Venus of Urbino in 1583. It is clear from her interned fingers and the position of her left hand and the look on her beautiful face that the position is not a matter of modesty. She is clearly enjoying herself, probably teasing her lover, the Duke of Urbino. A famous, furious comment, on this picture was Titian’s Venus of Urbino in 1583 made by Mark Twain protesting that artists can paint but writers can not write about such sexual events. This can be obtained by “Googling” Venus, Titian and Mark Twain. It is worth a few minutes of your time.

However while enjoying the “foulest, the vilest, the obscenest picture the world possesses” remember that many of your female patients are deficient in testosterone and now with patches and gels it is easy and safe to administer.

There is no longer any excuse not to do so.

This article first appeared in Capital Doctor.