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Role of androgens underplayed

Much of the focus of treatment for post-menopausal symptoms has been on estrogen, which is certainly an important and beneficial therapy for many women; but in fact, women produce more testosterone than estrogens daily, and their bodies convert the testosterone to estrogen. In adult women, testosterone has long been known to play a key role in sexuality, in the prevention of bone loss and increased bone density. Like estrogen, testosterone production drops significantly after menopause. Yet the impact of post-menopausal testosterone decline has been far less studied than that of estrogen.

In my practice, we have used this hormone successfully to treat not only post-menopausal women but also women in their reproductive years who have experienced a loss of interest in sex. There’s a straightforward biochemical reason why some women who are on estrogen either for birth control purposes or to treat menopausal symptoms might especially need testosterone: Most of a woman's natural testosterone supply is already "bound" to a protein called sex hormone binding globulin or SHBG. Only about one percent of the body’s supply is available to act on tissues.

Estrogen given alone triggers the production of more SHBG, which then binds up more testosterone. The SHBG phenomenon explains the fatigue and loss of libido that may accompany estrogen therapy, so a woman who was not lacking in testosterone before she started hormone replacement therapy may become deficient during the course of therapy.

Who should consider taking it?
Women who have experienced a decrease in sexual interest and pleasure might want to talk with their physicians about the possibility of taking androgen supplements. There is a blood test to measure the presence of free testosterone in your body, and your physician will be able to determine if you are deficient.

In the study published in the Journal of Reproductive Medicine, our subjects were otherwise healthy post-menopausal women who rated their prior interest in sex as moderate to high. There are some women who report a lifelong low level of desire, and there may be many other factors in addition to androgen deficiency that contribute to this profile.

The benefits
Our subjects reported their experience to be like the turning off of a switch in their bodies. Their loss of libido was distressing to them and threatened their sense of well-being. After treatment with an estrogen-androgen compound, these women without exception reported "feeling like themselves" again. In addition to improving sexual desire, testosterone is a key factor in maintaining muscular strength and appetite. Some women also report improved concentration and restored feelings of well-being.

A word of caution
There are adverse effects if women receive an excess of androgens. These include skin reactions such as an increase in oiliness and acne, an increase in body and facial hair and voice changes. It’s important women be monitored by their physicians to ensure they are receiving the appropriate dose.

Choices for supplementing testosterone
Testosterone is available in a number of forms. Estratest ^®, which contains both estrogen and testosterone, has been available by prescription for decades and has a long history of clinical safety and efficacy. There is currently a testosterone patch on the market for men, and within a few years, we expect this will be available for women as well. There are also gels and creams that contain testosterone, but we are unsure of how much of the active ingredient in these creams enters the bloodstream, so I have been hesitant to prescribe any of these until we have the results of long-term studies.

Estratest is currently the standard treatment. I advise my patients to take the medication for a minimum of six weeks before deciding whether it is working effectively since it can take a while before any effect is noticed.

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Dr. Sarrel is an attending obstetrician/gynecologist at Yale-New Haven Hospital and a professor of obstetrics and gynecology at the Yale University School of Medicine.