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Testosterone is a word that often brings to mind images of big
men, big trucks and gladiator-style football. After all, testosterone is considered to be the principal male hormone, playing
an important role in the development and maintenance of typical masculine characteristics, such as facial hair, muscle mass
and a deeper voice. So why would women want testosterone? The fact is, women produce it too, and it has more positive influences
than you might think.
Carpenter, M.D., is a consultant in endocrinology and health informatics research
at Mayo Clinic, Rochester, Minn. He has practiced in endocrinology, with a special interest in hormone replacement, for 25
years. Here he addresses questions about the role of testosterone in women.
Testosterone is usually thought of as a male hormone, but women have it, too.
How much testosterone do women produce?
Testosterone production is substantially lower in women than it is in men. After
puberty, a woman begins to produce a constant, adult level of testosterone. The production is split about 50:50 between the
ovaries and the adrenal glands. In men, the testes produce testosterone. Women produce just a fraction of the amount of testosterone
each day that men do.
What does testosterone do for women?
Studies show that it helps maintain muscle and bone and contributes to sex drive,
or libido. There are also quality-of-life issues. If you give testosterone replacement to testosterone-deficient women, they
often say they feel better, but they're not specific as to how.
One of the tough things about research in this area is what has been measured
and what hasn't. Testosterone levels, muscle mass and bone strength have been measured. When testosterone levels in the blood
increase, bone density generally improves. Although a few researchers have attempted to measure changes in sex drive and overall
quality of life, these important effects are much more difficult to assess. A study in the New England Journal of Medicine
evaluated sexuality and quality of life in women with low blood levels of testosterone. After raising their blood levels of
testosterone using a medicated skin patch, health and sexuality seemed to improve.
Which women should have their testosterone levels checked?
It's a complicated answer. After menopause, testosterone production drops, but
not as sharply as estrogen does. For women who've had their ovaries removed, testosterone production drops by roughly one-half,
sometimes resulting in less-than-normal testosterone blood levels.
Generally, the women who have too little testosterone are those who may go to
their doctor with concerns like, "Ever since I had my ovaries removed, I don't feel like the same person. I'm not as strong,
I don't have as much energy and I don't have the same sex drive." Should we measure testosterone in all women who've had their
ovaries removed? I don't know. If a woman says her sex life has diminished since her hysterectomy, her doctor may check her
testosterone level. If it's low, she can consider testosterone replacement.
Another group at risk of low testosterone is women who have lost pituitary gland
function because of a medical condition or past surgery. The pituitary sends hormone messages to the adrenal glands and ovaries.
Without the pituitary signal, hormones aren't manufactured. These women require estrogen and cortisone replacement, and they're
also testosterone deficient. This isn't a common problem, however.
Why aren't more women being given testosterone replacement?
It's true that very few women are getting testosterone replacement. As I've
indicated, good studies about deficiency are sparse. Because of that, many doctors aren't yet convinced of the benefits. In
testosterone replacement studies done 15 or 20 years ago, the doses were often too high. As a result, there were side effects,
such as body hair growth and acne.
Another major problem is that we don't have good product choices to give women
because the drug companies don't manufacture many products for testosterone replacement in women. In the New England Journal
of Medicine study mentioned before, researchers tested a skin patch designed for women. Unfortunately, this patch isn't
yet available but may well be in the future. Testosterone patches are available for men, and there is a testosterone gel they
can apply to their skin. But because women would need a much smaller dose, they cannot use the patches or gels designed for
men.
Right now there's really not a good way to replace testosterone in women. We
can use injections, but most women don't want to come in for a shot every 2 or 3 weeks, and the blood levels are hard to regulate.
After an injection, testosterone levels may go up too high, then decline, like a roller coaster. There's no pure testosterone
in pill form either. Synthetic pills are available but tend to be unevenly absorbed into the body and may pose some risk to
the liver. Testosterone delivered through the skin with a patch is absorbed quite evenly and seems more natural, with less
potential for serious side effects. Using patches doesn't appear to be risky as long as the dose is regulated.
How important is it for women with low testosterone to have it replaced?
It isn't an imminent health danger per se. However, think about the older woman
with osteoporosis who has fallen and fractured her hip. If her testosterone is low, would replacement have helped prevent
her hip fracture? It's possible. Testosterone has the potential to strengthen her bones. Additionally, she might have been
able to prevent the fall if her muscle mass had been better.
If a postmenopausal woman is on hormone replacement therapy (HRT), does that
affect her need for testosterone?
Yes. Estrogen therapy — with or without progesterone — can further
suppress residual testosterone production by the ovaries. That's because hormone signals from the pituitary gland drive ovarian
hormone production. Taking estrogen partially reduces the pituitary hormone signal to the ovaries and potentially reduces
testosterone production. The pituitary senses there's enough estrogen, so it doesn't send the signal for more estrogen and
testosterone.
What are the side effects of testosterone replacement?
When given in appropriate doses, there are no negative side effects. Today we
can measure blood levels, so it's easier to monitor the dose. Excessive testosterone can cause acne, body hair growth and
scalp hair loss in women. Excessive testosterone supplementation, such as you'll find with anabolic steroids used by athletes,
also tends to drop high-density lipoprotein (HDL) cholesterol levels. That's the "good" cholesterol. Lower HDL levels increase
the risk of heart disease.
What about other androgens, such as dehydroepiandrosterone (DHEA)?
DHEA is a weak androgen or male hormone. Although it's true that DHEA levels
decline with age, very few well-designed research studies show benefit from replacement. Another New England Journal of
Medicine study says DHEA treatment improves sexual function in women who have underactive adrenal glands, but not many
people are using the supplement for that reason. In addition, many people are taking DHEA in very large quantities. Again,
excessive amounts of synthetic androgens drive down HDL cholesterol levels, which is considered a cardiovascular risk. People
who are ill often have lower-than-normal DHEA or testosterone levels. This appears to be a normal physiologic response to
illness and not the cause of the illness.
By Mayo Clinic staff
WO00019
March 31, 2003
© 1998-2004 Mayo Foundation for
Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial
personal use only. "Mayo," "Mayo Clinic," "MayoClinic.com," "Mayo Clinic Health Information," "Reliable information for a
healthier life" and the triple-shield Mayo logo are trademarks of Mayo Foundation for Medical Education and Research.
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2964
TESTOSTERONE
GEL FOR LOSS OF LIBIDO
Gabe Mirkin, M.D.
A study from Australia in the medical journal, Menopause, shows that Androgel, a gel containing
the male hormone, testosterone, improves well-being, mood, and sexual function in premenopausal women with low libido and
low testosterone. As women age, many lose interest in making love and feel insecure, even though their blood levels of the
male hormones testosterone and DHEAS are normal or low. The bodies of all heathy women produce more of the male hormone, testosterone,
than the female hormone, estrogen. Just like men, with aging women have a significant lowering of their blood testosterone
levels, and this lowering of testosterone can cause depression and loss of muscle strength and sexual desire. Healthy women
in their 40's have approximately half the testosterone level as women in their 20's.
A group of reproductive endocrinologists classified the symptoms of depression and loss of libido
and muscle strength into one syndrome which they called Female Androgen Insufficiency Syndrome. This syndrome is most common
at the menopause and in women who have had their ovaries removed, but it can occur any time in a woman's life. The commonly-prescribed
treatment of estrogen replacement to postmenopausal women and those who have had their ovaries removed often causes and worsens
this syndrome.
The brain produces a hormone called FSH that causes the ovaries to produce the female hormone,
estrogen. Estrogen circulates in the blood and goes to the brain, where it stops the brain from producing FSH. Without FSH,
the ovaries stop making the male hormone, testosterone. Many studies show that giving estrogen to menopausal women may reduce
their sex drive by lowering blood levels of testosterone. A woman's sexual desire is driven by her body's production of testosterone,
not estrogen. Women who have had their ovaries removed suffer from the same symptoms because the ovaries produce most of the
male hormones in a woman's body. So women who suffer from Androgen Deficiency Syndrome caused by taking estrogen at menopause
or by having had their ovaries removed surgically can feel much better when they take a combination of the two hormones produced
by normal ovaries: estrogen and testosterone.
The adrenal glands, located near the kidneys, also produce a male hormones, called DHEAS. Women
who have underactive adrenal glands have low blood levels of that hormone, and also suffer from Female Androgen Deficiency
Syndrome. Their symptoms can be controlled by taking DHEA supplements.
If you are a woman who has even one of the following symptoms, ask your doctor to test you for
lack of male hormones: depression, lack of motivation, loss of energy, lack of interest in making love, lack of joy in making
love, muscle weakness, osteoporosis or weak bones, or vaginal pain during intercourse. Ask your doctor to draw blood tests
for testosterone, the male hormone produced by the ovaries, and DHEAS, the male hormone produced by the adrenal glands. Even
if your blood levels of the male hormones are normal, you could still try the testosterone cream, Androgel. Too much of the
cream can cause masculinizing symptoms, but as long as you do not exceed 2.5 grams of Androgel each week, you are at low risk
for growing hair on your face and body.
1) Transdermal testosterone therapy improves well-being, mood,
and sexual function in premenopausal women. Menopause - the Journal of the North American Menopause Society, 2003, Vol 10,
Iss 5, pp 390-398. R Goldstat, E Briganti, J Tran, R Wolfe, SR Davis. Davis SR, Jean Hailes Fdn, Res Unit, 173 Carinish Rd,
Clayton, Vic 3168, AUSTRALIA.
1a) Androgen production in women. Fertility and Sterility, 2002, Vol 77, Iss 4, Suppl.
4, pp S3-S5. HG Burger.
2)Aromatization of androgens in women: current concepts and findings. Fertility and Sterility,
2002, Vol 77, Iss 4, Suppl. 4, pp S6-S10. ER Simpson.
3)Role of androgens in female genital sexual arousal: receptor
expression, structure, and function. Fertility and Sterility, 2002, Vol 77, Iss 4, Suppl. 4, pp S11-S18. AM Traish, N Kim,
K Min, R Munarriz, I Goldstein.
4) Dehydroepiandrosterone: a springboard hormone for female sexuality. Fertility and
Sterility, 2002, Vol 77, Iss 4, Suppl. 4, pp S19-S25. RF Spark.
5) Hormones, mood, sexuality, and the menopausal transition.
Fertility and Sterility, 2002, Vol 77, Iss 4, Suppl. 4, pp S42-S48. L Dennerstein, J Randolph, J Taffe, E Dudley, H Burger.
6)
Randomized clinical trials of combined estrogen-androgen preparations: effects on sexual functioning. Fertility and Sterility,
2002, Vol 77, Iss 4, Suppl. 4, pp S49-S54. BB Sherwin. 7) Sexual effects of androgens in women: some theoretical considerations.
Fertility and Sterility, 2002, Vol 77, Iss 4, Suppl. 4, pp S55-S59. J Bancroft. 8) Androgen deficiency in the oophorectomized
woman. Fertility and Sterility, 2002, Vol 77, Iss 4, Suppl. 4, pp S60-S62. JL Shifren. 9) Androgen deficiency: menopause and
estrogen-related factors. Fertility and Sterility, 2002, Vol 77, Iss 4, Suppl. 4, pp S63-S67. PM Sarrel.
10) When
to suspect androgen deficiency other than at menopause. Fertility and Sterility, 2002, Vol 77, Iss 4, Suppl. 4, pp S68-S71.
SR Davis.
11) The hypoandrogenic woman: pathophysiologic overview. Fertility and Sterility, 2002, Vol 77, Iss 4, Suppl.
4, pp S72-S76. GA Bachmann.
12) Estrogen replacement therapy: effects on the endogenous androgen milieu. Fertility
and Sterility, 2002, Vol 77, Iss 4, Suppl. 4, pp. S77-S82. JA Simon.
13) Female androgen insufficiency: the Princeton
consensus statement on definition, classification, and assessment. Fertility and Sterility, 2002, Vol 77, Iss 4, pp 660-665.
G Bachmann, J Bancroft, G Braunstein, H Burger, S Davis, L Dennerstein, I Goldstein, A Guay, S Leiblum, R Lobo, M Notelovitz,
R Rosen, P Sarrel, B Sherwin, J Simon, E Simpson, J Shifren, R Spark, A Traish.
At drmirkin.com
2292 -- 9/1/03
POSTMENOPAUSAL
TESTOSTERONE INCREASES SEXUALITY
Gabe Mirkin, M.D.
A study from Columbia Medical School shows that many postmenopausal women who take estrogen replacement
have reduced sexual interest and desire, and giving these women the male hormone, testosterone, significantly increases their
interest and desire.
Masculinizing hormones are far more effective than feminizing hormones in increasing a woman's
interest and desire in lovemaking. The brains of normal women produce hormones called FSH and LH that stimulate the ovaries
to produce both male and female hormones. When male and female hormones rise too high, they prevent the brain from producing
the hormones that stimulate the ovaries. So giving postmenopausal women the female hormone, estrogen, can stop their brains
from making FSH which stimulates the ovaries to make masculinizing hormones. Giving these women both estrogen and testosterone
pills markedly elevated their blood levels of masculinizing hormones, and increased their interest in making love.
0.625 mg of esterified estrogens and 1.25 mg of methyltestosterone
testosterone and suppressed SHBG. Scores measuring sexual interest or desire and frequency of desire increased from baseline
with combination treatment and were significantly greater than those achieved with esterified estrogens alone. Title Comparative
effects of oral esterified estrogens with and without methyllestosterone on endocrine profiles and dimensions of sexual function
in postmenopausal women with hypoactive sexual desire. Fertility and Sterility, 2003, Vol 79, Iss 6, pp 1341-1352. RA Lobo,
RC Rosen, HM Yang, B Block, RG VanderHoop. Lobo RA, Columbia Univ Coll Phys & Surg, Dept Obstet & Gynecol, 622 W 168th
St, New York,NY 10032 USA
1237 -- 9/3/02
FEMALE
SEXUAL DYSFUNCTION
Gabe Mirkin, M.D.
According to several research papers, more than 90 percent of middle-aged women suffer from decreased
desire to make love, not being aroused by sexual stimuli, or inability to climax. An article in the Mayo Clinic Proceedings
summarizes the accepted treatment plan for this condition, called Female Sexual Dysfunction.
Lack of desire is associated with poor health, overwork, lack of privacy, or failure to be in
a caring relationship. It is also associated with depression, certain medications and drugs, and low blood levels of the male
hormone, testosterone. According to the study, 87 percent of married women claim that they have decreased desire, 83 percent
find it very difficult to climax, 74 percent lubricate poorly, and 71 percent have discomfort on making love.
Every woman who feels that she has Female Sexual Dysfunction should realize that hundreds of
different medications can prevent a woman from having desire or being able to climax: antihistamines, blood pressure medications,
antibiotics, cancer drugs, stomach and intestinal medications, contraceptives, sleeping pills, antidepressants, alcohol, recreational
drugs, and all the antiestrogens such as tamoxifen and Lupron. It is very common for women to lose interest in making love
after they have had their ovaries removed because a woman's ovaries continue to produce large amounts of male hormones for
her entire life. Many women who have had their ovaries removed require testosterone to increase their sexual desire.
Many products on the market today are sold to increase sexual desire; they often have some variation
of Viagra in their names. Many products claim that they contain yohimbine that increases sexual desire. Several studies show
that yohimbine is not more effective than a placebo, so nobody should waste money buying products that claim that they contain
yohimbine to improve sexual desire or performance.
There is no evidence whatever that Viagra increases sexual desire in women or in men. Viagra
helps a man achieve an erection by increasing blood flow to the penis. It fills a woman's pelvic organs with blood. Since
vaginal secretions come from the bloodstream, Viagra will increase vaginal secretions, even though it does not increase desire.
The common cold medicine called ephedrine also increases vaginal secretions and can be used to increase lubrication. Prescriptions
containing phentolamine can markedly increase vaginal lubrication.
The most common cause of a dry vagina after stimulation is a vaginal infection that should be
treated with the appropriate medication to kill the offending germ, whether it is herpes, chlamydia, mycoplasma, ureaplasma,
gonorrhea, the wart virus, yeast, or intestinal bacteria.
Every women who suffers from decreased sexual desire, decreased arousal or lack of orgasms should
get blood tests for testosterone and DHEAS. Testosterone is the male hormone produce by the ovaries, and DHEAS is the male
hormone produced by the adrenal glands. Testosterone can increase sexual desire, even in women who have normal or high levels
of that hormone.
The majority of women over age 50, and many under 50, cannot climax with penile-vaginal lovemaking
because the vagina is not the source of an orgasm, the clitoris is. It takes continual and prolonged stimulation of the clitoris
for most older women to achieve an orgasm. A vibrator can provide this stimulation if other techniques are not effective.
Recently, the Food and Drug Administration of the United States approved a hand-held, battery-operated,
device with a small plastic cup that applies a very gently vacuum to the clitoris. It has been shown to make the clitoris
larger temporarily by filling the clitoris with blood. It also increases vaginal secretions and improves a woman's ability
to climax.
Mayo Clin Proc July,2002.
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