Women's Health and Medicine

A Look at Hormones, Aging and Sexual Health Pharmacology

Female sexuality is much more complicated than male sexuality with multiple factors concerning desire, including such disparate items as physiology, past sexual experiences, sexual expectations, cultural and religious beliefs, availability of a partner and of course, the individual’s hormonal status. Access and knowledge of alternative treatment options are also dictated by these factors.

Many hormones may influence female sexuality, including estrogens (female hormones), oxytocin, progesterone, androgens like testosterone and all their metabolites. Testosterone is the hormone of desire in both sexes and a deficiency impacts libido in both men and women. Estrogen deficiency is most commonly seen in the peri-menopausal and postmenopausal women and include vasomotor symptoms including hot flashes, night sweets, urogenital atrophy and often a diminution in sexual desire. Men are likewise directly impacted by both testosterone and estrogen levels present in the bloodstream. In men, the free testosterone levels are key to ensure healthy sexual function and too much estrogen causes adverse side effects.

Women experiencing hormonal imbalance have been successfully using natural or bio-identical hormone replacement therapy. During menopause there is frequently a decrease in a feeling of well being, atrophy of the vagina, anxiety, emotional instability, depression, decline in short term memory and concentration, myalgia, arthralgia, an aversion to be touched and in general these also can lead to a decrease in sexual desire. Estrogen replacement will alleviate most of these vasomotor symptoms, including vaginal atrophy, but desire and restoration of female libido may not always occur in the estrogen treated peri-menopausal and postmenopausal women.

This has lead to the theory that in postmenopausal women where desire is not elevated by estrogen replacement there may be an androgen deficiency. On the other hand, if we are to treat women with androgens in a safe and effective manner, doctors must weigh The ability of laboratory techniques to define hypoandrogenism in women is hampered by the inability of the laboratory test themselves to measure testosterone levels of the lower end of the normal female reproductive range. On the other hand, there is an entity in postmenopausal women treated adequately with estrogen therapy that not only includes low sexual libidos but decrease sexual motivation, fatigue, lack of well being and probability low levels of bioavailable free testosterone.

Before a doctor treats women with androgen replacement therapy adequate estrogen therapy must be instituted and consideration for mental health counseling or referral to a sex therapist should be made. This androgen deficiency syndrome, however, is accepted for women who have had bilateral ovariectomy or in younger women who have suffered primary or secondary ovarian failure associated with low libido and low blood androgen levels.

>What causes low levels of male hormones in women. The ovaries produce androstenedione, testosterone and dehydroepiandrosterone (DHEA). The adrenals produce androstenedione and dehydroepiandrosterone sulfate (DHEA-S). The DHEA-S can be further metabolized to testosterone or estrogens. In addition the testosterone through the enzyme of 5-alpha reductants converts the serum testosterone to dihydrotestosterone (DHT) or estradiol (E2) these are the active hormones that work within the cells.

Age in general leads to a drop in androgen levels in women and is due to the age-related drop in adrenal production of androgen and the loss of the mid-cycle surge in ovarian testosterone. Removal of the ovaries results in a reduction of 50 percent in testosterone and androstenedione. Chemical oophorectomy including chemotherapy, use of GNRH hormone inhibitors, radiation therapy, glucocorticoids and the administration of exogenous estrogens are other causes for diminution in androgens. Oral postmenopausal estrogen therapy and oral contraceptives will suppress free testosterone by increasing serum hormone binding globulins (SHBG) and suppressing pituitary luteinizing hormone (LH).

Steroids by mouth suppress pituitary secretions of adrenal corticotropic hormone and therefore adrenal androgen production as well. This probably explains the bone loss frequency in patients who are taking long-term steroids. Lastly, hypothalamic amenorrhea and hypoproaccelerinemia are usually associated with low testosterone and many women with premature ovarian failure have low testosterone levels. Therefore, the use of oral contraceptives in older women or women with amenorrhea or premature ovarian failure may actually worsen their androgen deficiency.

How testosterone therapy affects female sexuality is a clinically known factor. The male hormones work directly on androgen receptors and a precursor for additional estrogen production in tissue such as fat, bone, brain, blood vessels or possibly by lowering serum hormone binding globulins (SHBG) and therefore causing an increase in the levels of bioactive steroids such as androgen.

There is no doubt that the administration of testosterone to older women with sexual desire problems improves the intensity of sexual desire, arousal, frequency of sexual fantasies, satisfaction, pleasure and relevancy and importance of sex to daily life. And therefore, postmenopausal women who are probably treated with estrogen therapy should be offered androgen replacement to improve this symptom complex.

A more difficult question deals with the pre-menopausal women who complains of decreased sexual drive and libido and who have low bioavailable testosterone. Proper hormonal ratios appear to play a role in desire and where the psychosocial and sexual history indicates hormonal problem as being the basic ideology of their libido decrease.

The administration of testosterone has been formulated and fairly much determined for men but androgen replacement therapy in women now has similar guidelines and is now offered by age management physicians, naturopaths and anti-aging doctors. for the use of androgens in women. Oral methylated testosterone is available in the United States but oral testosterone should be carefully evaluated to protect the liver. It is usually administered in combination with esterified estrogens (E.E.) 1.25 milligrams of methyltestosterone with 0.625 milligrams of E.E. or 2.5 milligrams of methyltestosterone with 1.25 milligrams of E.E. Patients obviously have to be warned about androgen side affects including increase in high density lipoproteins, cholesterol and low density lipoproteins, adverse liver affects including chemical hepatitis and possibly a higher incidence of liver cancer. More commonly, however, too much testosterone will lead to masculinizing tendencies which should be monitored by the patient and her physician should be informed if such occurs.

Oral testosterone undecenoate has not been studied in women and doses as low as 20 milligrams appear to cause undesirable side effects and therefore is not recommended at this time.

Subcutaneous implants of hormone pellets including estrogen and testosterone are available in the United States at this time, and have found to be quite effective for up to six months. Doses of 50 to 100 milligrams appeared to affectively raise the levels of estrogen and testosterone for up to six months to adequate levels to treat sexual desire problems. In the United States compounding pharmacists are able to manufacture a subcutaneous testosterone pellet which could easily be implanted by your physician.

Injectable depo-testosterone in the form of testosterone esters appears to be the safest and most commonly tried form of androgen replacement for men and women in the United States. The most common administration is 50 to 100 milligrams administered every four to six weeks intramuscular. However, many physicians use 20 milligrams every three weeks. For women masculinization with increased acne and occasional clitoral myoglia may occur with too high a dose of this therapy.

Transdermal testosterone patches have been manufactured and approved for use by men and newer technology is developing androgen replacement patches for women. Patches that increase testosterone levels greater than 25 nanograms per DL for women appear to produce significant masculinization and side affects that they should not be used.

Transdermotesosterone as a cream or a gel or testosterone using a transvaginal testosterone impregnated cream is available in the United States by specific prescriptions or through compounding pharmacists.

Contraindications to testosterone treatment include: acne, hirsutism, alopecia, and circumstances in which enhancing libido would be undesirable. Absolute contraindications include pregnancy and lactation as well as known or suspected androgen dependent neoplasia. Side effects from excessive testosterone include virilization, fluid retention and an adverse lipoprotein profile which more likely occur with the oral administration of the drug. Afenteral administration raising levels of testosterone to within physiologic ranges does not appear to have any undesirable metabolic effects. It is not known whether additional androgen will affect breast cancer since more than 50 percent of breast cancers have androgen receptors and these are associated with a longer survival in women.

In conclusion, androgen deficiency in women causing various symptoms including poor sexual desire is an entity that exists both in the menopausal and probably pre-menopausal female. In the peri or postmenopausal female the patient should be adequately treated with estrogen therapy before using androgen replacement. And the pre-menopausal woman who appears to have low bioactive levels of testosterone, androgen replacement should be used with closer monitoring.

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