Testosterone supplementation is not recommended for women, unless they have a clinical diagnosis of hypoactive sexual desire disorder, a joint task force led by the Endocrine Society has determined.
While a number of studies have shown that testosterone supplementation helps improve sexual desire, cognition, and other outcomes, most are either too small, too short, or confounded by other factors to provide irrefutable evidence of the hormone’s benefit for any indication other than hypoactive sexual desire disorder (HSDD), Dr. Margaret E. Wierman and her colleagues wrote in the Journal of Clinical Endocrinology and Metabolism (J. Clin. Endocrinol. Metab. 2014;99:3489-510).
Dr. Margery Gass
A trial of testosterone is only appropriate for postmenopausal women with a diagnosed HSDD, wrote the task force, which also noted that libido and response improvements don’t necessarily correlate with testosterone serum levels. If there’s no clinical response after a 6-month trial, the hormone should be discontinued.
The hormone-health connection is clearly important to women, and many have already done Internet research on the topic, said Dr. Margery Gass, executive director of the North American Menopause Society. A Google query for “hormones to control aging” turned up 9.5 million results, she said.
Although NAMS was not involved in creating the new clinical guideline, the society supports it, she said in an interview.
“The Endocrine Society has published an excellent set of guidelines on the use of androgen therapy in women. These guidelines are in harmony with NAMS’ comments on the use of testosterone and dehydroepiandrosterones,” included in the group’s clinical practice guideline for the care of midlife women (Menopause 2014;21:1038-62). That paper also recommends a trial of testosterone therapy “in carefully selected postmenopausal women with female sexual interest/arousal disorder and no other etiology for their sexual problems.”
Dr. Gass continued, “I encourage clinicians to use both publications to help women understand the misinformation about testosterone and other androgens that they are seeing on the Internet.”
Dr. Wierman, chief of endocrinology at the University of Colorado, Aurora, led the task force, composed of representatives from the American Society for Reproductive Medicine, the American Congress of Obstetricians and Gynecologists, the European Society of Endocrinology, and the International Menopause Society. Together, they reviewed the extant literature and, in addition, commissioned meta-analyses to examine the issue of androgen supplementation in premenopausal and postmenopausal women – either healthy or with specific conditions. Evidence was graded as level 1 (strong) or level 2 (weak).
The group considered androgen supplementation for a number of indications: infertility; sexual dysfunction; cognition; cardiovascular, metabolic, and bone health; and general well-being. It found little strong data to support the practice in any of these except HSDD.
As a basic tenet, the task force agreed that androgen testing for most women is inaccurate, and thus virtually incapable of providing useful diagnostic information. Testosterone levels vary among women and within their different hormonal life stages, and there are no validated reference ranges.
Sexual function
A controversial issue, women’s sexual health remains somewhat of a mystery, the team noted – a complex web of physical, emotional, and psychological factors. Evidence derived from testosterone therapy in postmenopausal women shows that the hormone may influence all aspects of sexual response by improving desire, subjective arousal, and vaginal blood flow, and increasing frequency of orgasm.
However, decreasing sexuality is a common phenomenon for women, and is not dependent on physiologic testosterone levels. While response to testosterone therapy didn’t always correlate with plasma levels, most trials found that a daily dose of 300 mcg provided optimal benefit. One study found a more than 115% increase in reported orgasms, compared with a 38% increase in the placebo group, and another found 2.12 more satisfactory sexual events per month, compared with 0.73 per month with placebo.
One trial of a testosterone gel was negative, but was only available as an abstract. A large randomized trial of transdermal testosterone gel that recruited 3,565 naturally and surgically postmenopausal women, and accrued several thousand women-years of data, has yet to be published.
For postmenopausal women with properly diagnosed HSDD, the task force recommended a 3- to 6-month trial of testosterone for those who request therapy and in whom it is not contraindicated.
Testosterone levels should be measured at baseline and after 3-6 weeks of initial treatment to assess patient overuse. In cases of ongoing testosterone therapy, levels should be reviewed every 6 months to monitor for excessive use and signs of androgen excess.
Other indications
The task force noted insufficient evidence for the following indications:
• Infertility. One meta-analysis reported an overall 11% increase in live births; another found no benefit. The individual studies were marred by methodological issues, the team said.