Androgen Replacement Therapy in Women

Marie Lebbe; David Hughes; Nicole Reisch; Wiebke Arlt

Expert Rev Endocrinol Metab. 2012;7(5):515-529.

Studies on Testosterone Replacement in Women

Surgical menopause by bilateral oophorectomy is typically accompanied by an abrupt 50% drop in circulating testosterone levels.^[35] Investigators have noted that approximately half of the patients undergoing bilateral oophorectomy reported decreased sexual desire after surgery,^[36] frequently matching the proposed diagnostic criteria for HSDD. Several randomized studies have focused on the effect of testosterone replacement on the sexual parameters outcome in surgically menopausal patients with HSDD. Shifren et al. treated 75 oophorectomized women on estrogen replacement with transdermal testosterone patches (TTP), delivering 150 or 300 µg/day against placebo for 12 weeks. Normalization of serum-free testosterone was associated with an improvement in sexuality and well-being. This improvement was more substantial in patients receiving 300-µg testosterone daily; however, this dose resulted in slightly supraphysiological serum levels of testosterone.^[37] These observations were further confirmed in two bigger trials with a total of 1095 surgically menopausal women suffering with HSDD and receiving 300-µg testosterone patches for 24 weeks.^[38,39]

As described above, physiological menopause is not associated with androgen deficiency per se and, therefore, does not routinely require androgen therapy.^[40] If problems with libido arise in women receiving oral postmenopausal estrogen treatment, known to increase SHBG levels and decrease free testosterone, one should consider reducing the dose of estrogen rather than initiating androgen therapy. Nevertheless, several clinical trials with testosterone treatment in naturally menopausal patients with sexual complaints have been performed. Davis et al. studied 814 naturally postmenopausal women with HSDD, without estrogen replacement, with daily 150 or 300 µg transdermal testosterone versus placebo.^[41] At 24 weeks, an increase of 2.1 satisfying sexual episodes per month was observed in the 300 µg/day TTP group. However, this so-called APHRODITE study recorded 30% androgenic skin effects, and 2.4% breast cancers were observed in the 300 µg study population.^[41] The recently published ADORE study evaluated the efficacy of a similar dosed testosterone patch in 272 naturally menopausal women with HSDD, predominantly not using hormone therapy and demonstrated significant improvements in satisfying sexual episodes at 6 months, without particular side effects after 24 weeks of treatment.^[42] Addition of 2 mg methyltestosterone daily for 12 months in addition to combined estrogen–progestin replacement in 60 postmenopausal women with onset of sexual dysfunction after menopause showed a significant increase in sexual energy.^[43]Table 1 summarizes the randomized controlled studies on testosterone replacement in postmenopausal women with regard to their outcomes, including sexual function, mood, bone density, body composition and lipids.^[44–66] The main outcome in these studies is improvement in sexual function and well-being; comparing the different studies is challenging as study populations differ and a wide range of sexual questionnaires has been used. There are inherent difficulties with sexuality questionnaires, which may be compromised by insufficient validation and also the unavoidable need for self-reporting of domains such as sexual interest and desire, satisfaction, excitement/arousal, attitude/behavior and the quality of the relationship. A variety of physiologic, medical and psychological factors can contribute to sexual dysfunction, and a review on this topic did not yield a single questionnaire universally useful for researchers or clinicians who wish to measure sexual function.^[67]

Whether women with autoimmune-origin premature ovarian failure (POF) may also benefit from androgen replacement therapy is not yet clear. As one could expect based on their younger age and as observed by Benetti-Pinto et al., serum levels of DHEA and DHEAS levels were significantly higher in women with POF compared with postmenopausal women.^[68] However, a study of ovarian biopsies in POF patients nicely demonstrated that the autoimmune process does not affect granulosa and theca cells to the same extent and consequently circulating androgen levels can be either unchanged or decreased in POF.^[69] It is warranted to check the serum levels of androgen precursors and active androgens in women with nonsurgical POF as clinical experience demonstrates significant variability, with some suffering from pronounced androgen deficiency and others demonstrating normal circulating androgen levels.

Androgen levels can also be reduced in Turner syndrome due to failure of ovarian maturation. This can result in variable effects on body composition, neurocognition and quality of life, and these aspects have recently been shown to improve with administration of oral 1.5-mg methyltestosterone, in a small study on 12 months of treatment in 14 women.^[70]

The Endocrine Society Guidance from 2006 recommend against the general use of testosterone in postmenopausal women because the indications are ill defined, and evidence of safety in long-term studies is lacking.^[34] The presence of sexual dysfunction alone, in the context of normal circulating androgen levels, is certainly no justification for the initiation of androgen treatment, as supraphysiological androgen levels do not result in an additional improvement of sexual function over and above normal.

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Table 1. Randomized controlled studies on testosterone treatment in postmenopausal women.
Study (year)	Patients	Design	Duration	Testosterone administration	Effect of testosterone	Ref.
Barrett-Connor et al. (1999)	n = 311; surgical menopause	Double-blind	2 years	CEE, 0.625 mg/day CEE, 1.25 mg/day CEE, 0.625 mg, + MT, 1.25 mg/day CEE, 1.25, + MT 2.5 mg/day	↓ menopausal symptoms ↑ HDL and TG in CEE alone ↑ BMD in CEE + MT	[44]
Braunstein et al. (2005)	n = 447; surgical postmenopausal women on ERT; 24–70 years	Double-blind, placebo-controlled, parallel-group	24 weeks	Placebo 150 µg/day TTP 300 µg/day TTP 450 µg/day TTP	↑ sexual desire and satisfying sexual activity in 300 and 450 µg/day group	[45]
Basaria et al. (2002)	n = 40; >1 year menopause; natural and surgical; >3 m ERT; >21 years	Double-blind, parallel-group	16 weeks	1.25 mg CEE 1.25 mg CEE +2.5 mg MT ↓ TG	↓ plasma viscosity ↑ fibrogen	[46]
Buster et al. (2005)	n = 533; HSDD, surgical menopause, on RT	Double-blind, placebo-controlled	24 weeks	Placebo TTP 300 µg/day	↑ satisfying sexual activity ↑ sexual desire ↓ personal distress	[38]
Chiuve et al. (2004)	n = 40; surgical menopause on ERT	Double-blind, parallel-group	10 weeks	1.25 mg CEE 1.25 mg CEE +2.5 mg MT	↓ apoC I,II,III ↓ apoE ↓ TG, ↓ HDL	[47]
Davis et al. (1995)	n = 34; menopause natural/surgical	Single-blind	2 years	E 50 mg/3M implant E 50 mg + T 50 mg/3M implant	More ↑ in BMD, in all sites of the body More ↑ sexual energy ↓ LDL in both group ↓ total body fat-free mass	[48]
Davis et al. (2000)	n = 34; menopause natural/surgical	Single-blind	2 years	E 50 mg/3M implant E 50 mg + T 50 mg/3M implant	↓ total chol ↓ LDL ↓ total body fat-free mass ↓ fat-free mass (FM:FFM) ratio	[49]
Davis et al. (2006)	n = 61; HSDD, surgical menopause on ERT	Double-blind, placebo-controlled	24 weeks	Placebo TTP 300 µg/day	↑ sexual desire ↓ personal distress	[50]
Davis et al. (2008)	n = 814; surgical and natural menopause 20–70 years	Double-blind placebo-controlled	52 weeks	150 µg/day TTP 300 µg/day TTP Placebo	↑ sexual desire, higher in 300-µg group	[41]
Davis et al. (2009)	n = 279; surgical and natural menopause	Double-blind, placebo-controlled, parallel-group	52 weeks	150 µg/day TTP 300 µg/day TTP Placebo	No difference from placebo for total dense or nondense area on digital mammograms from baseline to week 52	[51]
De Paula et al. (2007)	n = 85; HSDD, postmenopausal, on HRT	Double-blind, placebo-controlled and crossover	16 weeks	Placebo 16 week MT 2.5 mg 16 week Placebo 8 week + MT 2.5 mg 8 week MT 2.5 mg 8 week + placebo 8 week	No change in liver enzymes and lipids ↑ sexual satisfaction ↑ sexual desire	[52]
Dobs et al. (2002)	n = 36; natural menopause	Double-blind, placebo-controlled, parallel	16 weeks	EE 1.25 mg/day EE + MT 2.5 mg/day	↑ sexual activity ↑ lean body mass ↓ % body fat ↑ body weight	[53]
El-Hage et al. (2007)	n = 36; HSDD, surgical menopause	Double-blind, placebo-controlled, cross-over	12 weeks	T cream 10 mg/day	↑ sexual desire ↑ frequency of sex No change in lipids, blood pressure or weight	[54]
Flöter et al. (2005)	n = 50; surgical menopause, on ERT, 45–60 years	Double-blind, placebo-controlled, cross-over	24 weeks	(1) estradiol 2 mg + TU 40 mg (2) estradiol 2 mg + placebo	↓ IGF-I ↓ propeptide of type I procollagen ↑ total lean body mass No change in fat mass, BMI, BMD and blood pressure	[55]
Nathorst-Böös et al. (2006)	n = 53; HSDD, postmenopausal, on ERT	Double blind, crossover	24 weeks	(1) ERT + T gel 10 mg/day (2) ERT + placebo	↑ sex quality parameters No change in liver enzymes, lipids, endometrium and blood velocity	[56]
Hofling M et al. (2007)	n = 99; postmenopausal, on ERT (2 mg estradiol and 1 mg norethisterone acetate)	Prospective, double-blind, placebo-controlled	24 weeks	(1) ERT + TTP 300 µg/day (2) ERT + placebo	↑ mammographic density in 1830% of women, no differences between the two groups	[57]
Hofling M et al. (2007)	n = 99; postmenopausal, on ERT (2 mg estradiol and 1 mg norethisterone	Prospective, double-blind, placebo-controlled	24 weeks	(1) ERT + TTP 300 µg/day (2) ERT + placebo	Placebo group: fivefold ↑ (p < 0.001) in breast cell proliferation (fine needle biopsy). T group: no ↑	[58]
Panay et al. (2010)	n = 272; HSDD, natural menopause	Double-blind, placebo-controlled	24 weeks	(1) TTP 300 µg/day (2) placebo	↑ satisfying sexual episodes ↑ desire ↓ distress	[42]
Penotti et al. (2001)	n = 40; postmenopausal, on HRT since 1–5 years (E2 50 µg/day + MPA 10 mg/day for 12 days every other month)	Double-blind, placebo-controlled	32 weeks	(1) HRT + TU 40 mg/day (2) HRT + placebo	↑ pulsatility index of Doppler cerebral artery ↓ HDL ↑ sexual desire	[59]
Penteado et al. (2008)	n = 60; HSDD, postmenopausal, on HRT (CEE 0.625 mg + MPA 2.5 mg)	Double-blind, placebo-controlled	52 weeks	(1) HRT + MT 2.0 mg/day (2) HRT + placebo	↑ sexual energy No change in orgasmic capacity	[43]
Raisz et al. (1996)	n = 28; natural, menopause	Double-blind, placebo-controlled, parallel	9 weeks	(1) CEE 1.25 mg (2) CEE + MT 2.5 mg/day	↑ bone formation ↓ HDL, ↓ TG	[60]
Sherwin & Gelfand et al. (1985)	n = 53, surgical menopause	Double-blind, placebo-controlled, crossover	12 weeks	(1) EE (2) TE 150 mg (3) EE + TE 150 mg (4) placebo	↑ sexual desire, arousal, fantasies	[61,62]
Shifren et al. (2000)	n = 75, surgical menopause, on ERT (CEE 0.625 mg), 31–56 years	Double-blind, placebo-controlled	12 weeks	(1) ERT + TTP 150 µg/day (2) ERT + TTP 300 µg/day (3) ERT + placebo	↑ frequency of sexual activity, pleasure-orgasm, well-being at 300 µg/day	[37]
Shifren et al. (2006)	n = 549; HSDD, natural menopause, on ERT	Double-blind, placebo-controlled, parallel group	24 weeks	(1) 0.625 mg CEE (2) 0.625 mg CEE + TTP 300 µg/day	↑ total satisfying sexual episodes ↑ sexual desire ↓ personal distress	[63]
Simon et al. (2005)	n = 562; HSDD, surgical menopause, on ERT, 26–70 years	Double-blind, placebo-controlled	24 weeks	(1) ERT + TTP 300 µg/day (2) ERT + placebo	↑ total satisfying sexual activity ↑ sexual desire ↓ distress	[39]
Warnock et al (2005)	n = 102; HSDD, surgical menopause, on ERT (CEE 1.25 mg), 33–62 years	Double-blind	8 weeks	(1) ERT + MT 2.5mg (2) ERT + placebo	No changes in sexual desire/interest	[64]
Watts et al. (1995)	n = 66; surgical, menopause	Double-blind, placebo-controlled, parallel	24 months	(1) CEE 0.625 mg/day (2) CEE + MT 2.5 mg/day	↑ BMD (lumbar spine) ↓ HDL ↓↓ TG	[65]
Zang et al. (2006)	n = 63; natural menopause	Open, parallel group	12 weeks	(1) 40 mg TU/2 days (2) 2 mg estradiol valerate/day (3) both	(1) and (3): ↓ insulin-induced glucose disposal, ↑ lean body mass, ↓ HDL	[66]

BMD: Bone mineral density; CEE: Combined esterifi ed estrogens; Chol: Cholesterol; ERT: Estrogen replacement therapy; HDL: High-density lipoprotein; HRT: Hormonal replacement therapy; HSDD: Hypoactive sexual desire disorder; LDL: Low-density lipoprotein; MPA: Medroxyprogesterone acetate; MT: Methyltestosterone; T: Testosterone; TE: Testosterone enanthate; TG: Triglycerides; TTP: Transdermal testosterone patch; TU: Testosterone undecanoate.

Table 2. Randomized controlled trials on dehydroepiandrosterone replacement in women with adrenal insufficiency.
Study (year)	Patients	Design	Dose/duration	Effect of DHEA	Ref.
Arlt et al. (1999), Callies et al. (2001)	Primary (n = 14) and secondary adrenal insufficiency (n = 10; 23–59 years)	Double-blind, placebo-controlled, crossover	DHEA 50 mg/day versus placebo for 4 months	↑ well-being and mood ↓ anxiety and depression ↑ sexual interest and satisfaction ↓ HDL	[74,75]
Bilger et al. (2005)	Secondary adrenal insufficiency (n = 5; (15–23 years)	Double-blind, placebo-controlled, crossover	DHEA 50 mg/day versus placebo for 12 months	↑ psychological function	[76]
Brooke et al. (2006)	Secondary adrenal insufficiency (n = 26)	Double-blind, placebo-controlled, crossover	DHEA 50 mg/day versus placebo for 12 months	↓ dose growth hormone replacement	[77]
Hunt et al. (2000)	Primary adrenal insufficiency (n = 24; 26–59 years)	Double-blind, placebo-controlled, crossover	DHEA 50 mg/day versus placebo for 3 months	↑ self-esteem ↑ mood ↓ fatigue no change in sexual function; in BMD or in HDL	[78]
Johannsson et al. (2002)	Secondary adrenal insufficiency due to hypopituitarism (n = 38; 25–65 years)	Double-blind, placebo-controlled, crossover	DHEA 20–30 mg/day versus placebo for 6 months	↑ alertness ↑ sexual relations no change in BMD ↓ HDL	[79]
Libe et al. (2004)	Primary and secondary adrenal insufficiency (n = 7)	Double-blind, placebo-controlled	DHEA 50 mg/day versus placebo for 4 months	↓ LDL in Addison ↓ fat mass No change in sexuality and well-being, no change in glucose-metabolism	[80]
Lovas et al. (2003)	Primary adrenal insufficiency (n = 39)	Doubleblind, placebo-controlled, parallel	DHEA 25 mg/day versus placebo for 9 months	No change in subjective health status, fatigue and sexuality; ↑ sweat odor ↑ scalp itching	[81]
Dhatariya et al. (2005)	Adrenal insufficiency (n = 28)	Double-blind, placebo-controlled, crossover	DHEA 50 mg/day versus placebo for 12 weeks	↑ insulin sensitivity ↓ HDL ↓ LDL ↓ TG	[82]
Dhatariya et al. (2008)	Adrenal insufficiency (n = 28)	Double-blind, placebo-controlled, crossover	DHEA 50 mg/day versus placebo for 12 weeks	No effect on physical performance, body composition, protein metabolism	[83]
Gurnell et al. (2008)	Primary adrenal insufficiency (n = 106)	Double-blind, placebo-controlled	DHEA 50 mg/day versus placebo for 12 months	↑ BMD at femoral neck ↑ total body lean mass, no change in fat mass No benefit on fatigue, cognitive or sexual function	[84]
Van Thiel et al. (2005)	Secondary adrenal and somatotropic insufficiency (n = 16; 61 ± 2 years)	Double-blind, placebo-controlled, crossover	DHEA 50 mg/day versus placebo for 16 weeks	No substantial benefit on quality-of-life parameters	[85]

BMD: Bone mineral density; DHEA: Dehydroepiandrosterone; HDL: High-density lipoprotein; LDL: Low-density lipoprotein; TG: Triglycerides.

Table 3. Randomized controlled trials on dehydroepiandrosterone treatment in women with normal adrenal function.
Study (year)	Patients	Design	Dose/duration	Effect of DHEA	Ref.
Labrie et al. (1997)	Postmenopausal, 60–70 year (n = 14)	Placebo-controlled, crossover	12 months; 10% DHEA cream	↑ vaginal epithelium maturation, no effect on endometrium, ↑ hip BMD	[86]
Panjari et al. (2009)	Postmenopausal (n = 93)	Randomized, double-blind, placebo-controlled	52 weeks; oral DHEA, 50 mg/day	No effect on endometrium nor blood lipids nor insulin resistance	[87]
Morales et al. (1995)	40–70 years (n = 17)	Randomized, double-blind, placebo-controlled	6 months; oral DHEA, 50 mg/day	↑ circulating androgen levels, = estrogen/SHBG, ↓ HDL, = insulin sensitivity, ↑ IGF-1, ↑ well-being	[90]
Baulieu et al. (2000)	60–79 year (n = 140)	Double-blind, placebo-controlled	12 months; oral DHEA, 50 mg/day	↑ circulating testosterone and estradiol, ↑ BMD, ↑ libido, ↑ skin hydratation	[92]
Nair et al. (2006)	>60 year (n = 57)	Randomized, double-blind, placebo-controlled	2 years; oral DHEA, 50 mg/day	No effect on body composition, physical performance, insulin sensitivity or quality of life	[93]
Wiser et al. (2010)	Low ovarian reserve (n = 33)	Randomized, placebo-controlled	4–5 months; oral DHEA, 75 mg/day	↑ embryo quality, ↑ live birth rate	[100]

DHEA: Dehydroepiandrosterone.

Sidebar

Key Issues

The definition of female androgen deficiency syndrome, as provided by the Princeton consensus statement in 2002, has been criticized because of its broad interpretation and the lack of routinely available sensitive and specific testosterone assays. The diagnosis of hypoactive sexual desire disorder is unspecific and does not automatically lead to justification of androgen replacement.
Physiological menopause is not associated with a sudden loss of androgen synthesis, and therefore, postmenopausal women do not routinely require androgen replacement.
The physiological, age-associated decline in androgen production does not represent an indication for androgen replacement.
In established cases of severe androgen deficiency, including surgical menopause and adrenal insufficiency, and concomitant symptoms of impaired mood and libido, the use of testosterone replacement appears feasible with probable beneficial effects on health-related quality of life and sexuality. The use of dehydroepiandrosterone as an androgen replacement tool is recommended in case of adrenal insufficiency, where it has shown similar significant benefits. However, we do not recommend dehydroepiandrosterone supplementation in women with normal adrenal function with the aim of restoring sexual function and impaired mood.
Minimal androgenic side effects have been recorded, but evidence of metabolic, cardiovascular and oncologic safety in long-term studies are lacking.
Current direct immunoassay methods are unable to accurately measure testosterone levels in women and tandem mass spectrometry represents the emerging state-of-the-art method.
Current guidelines advise against widespread use of androgen therapy, highlighting the need for caution. Although transdermal testosterone is licensed for use in Europe, the US FDA still refuses approval of female androgen replacement therapy.
In the meantime, the physiological role of androgens in women needs to be further elucidated in order to clarify the definition of androgen deficiency. Standardized normative data on serum androgen levels throughout a women's lifespan are required. Further cohort studies into the long-term potential beneficial and adverse effects of androgen replacement are urgently needed.
While it is recognized that more research is needed, we should not forget that the last decade has seen significant progress being made in the field of androgen research in women, providing us with new and reassuring information on androgen physiology and treatment in women.