Commentary by Martha K. Richardson, MD
For those of us who prescribe or recommend androgen therapy or who just address regular inquiries from midlife women about their waning libido, these guidelines by Wierman and colleagues provide us with a review of the state of the evidence—or perhaps one should say the absence of conclusive evidence to clarify the implications of varying androgen levels in women across their lifespans or indications for supplementation of the same.
It is enlightening to reread the 2006 predecessor to this document. At that time, there were no generally available, reliable measures of testosterone for women, and although there were some studies looking at many correlates of various androgen levels and/or supplementation, the cohorts were often small and the results contradictory. The 2006 guideline concluded that there were no indications for androgen treatment of women.
Circa 2014, the assays for testosterone are improved. There are more data on the physiologic and pathologic implications of androgen levels in women, but these are still limited and often inconsistent. The current guideline supports the use of testosterone to treat “properly diagnosed” hypoactive sexual desire disorder in women who request therapy and even gives us some parameters to monitor this intervention. They sidestep the fact that there is no approved androgen product for women but do tell us not to use those formulated for men.
Although I commend this guideline to my colleagues, the knowledge gap remains large. I guess I can continue to prescribe testosterone with some ambivalence—still wondering whether the women who report therapeutic success are experiencing a placebo effect, not knowing how long testosterone is safe, and hoping for more good science about the issues midlife women face.
The North American Menopause Society (NAMS) © 2014 The North American Menopause Society