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Editorial JUNE
2008
Testosterone:
Fact or Fiction? Friend or Foe?
Michael L. Krychman, MD
It is estimated that 43% of women of all ages have some form of sexual complaint,1 the most prevalent being low desire and painful intercourse. It is thought
that a majority of female cancer survivors have sexual problems sufficient
to cause personal distress, and women with any chronic medical illness (eg,
hypertension, diabetes, and other endocrinopathies) may also experience sexual
dysfunction. Sexual intimacy is an integral part of the human experience,
and for many women, sexual problems undoubtedly affect their overall quality
of life and happiness.
However, although such sexual problems are prevalent, there is a gap in medical
knowledge and expertise in this specialty. There is a medical necessity for
information concerning diagnosis, assessment, and effective treatment in sexual
medicine. Testosterone supplementation has often been heralded as the “cure-all” for
female sexual complaints, but its use remains an emotionally charged issue
on both sides of the battle lines. The data on efficacy and side effects are
conflicting, and testosterone therapy has emerged as one of the most hotly
debated topics in gynecology.
Over the past decade, it has been my experience in the field of sexual medicine
that testosterone is often overused and inappropriately prescribed. Patients
are poorly informed, rarely subject to follow-up, and are often unaware of
potential side effects and associations with other diseases. Recently, I treated
a woman with anorgasmia who was using depot testosterone, testosterone cream,
and oral estrogen and testosterone. She was dissatisfied because the “cure” promised
by the prescribing physician—ie, testosterone—was ineffective. In addition,
her serum testosterone level was 300% higher than normal. In my opinion, many
women are erroneously given testosterone without a comprehensive and dynamic
evaluation, and are also not informed of the potential risks. Sexual complaints
are typically complex, and warrant specialized evaluation and treatment; there
will never be a “quick fix” for female sexual dysfunction.
Clearly, many experts feel that testosterone is the key to improving sensuality
and desire, citing female androgen insensitivity—which is characterized
by low motivation and libido, persistent fatigue, decreased well-being, normal
plasma estrogen values, and subnormal levels of circulating bioavailable testosterone.2 Other
symptoms may include bone loss, decreased muscle strength, and changes in cognition
or memory. Treatment commonly comprises products that are bioidentical
and/or approved for men; even the North American Menopause Society (NAMS) has
published clinical guidelines on testosterone use in selected postmenopausal
women.3 However, the NAMS
paper also advises using testosterone with estrogen, and gives concise recommendations
for follow-up and patient counseling. Protocols
for monitoring, safety, dosages, and informed consent are outlined, as well
as the lack of long-term safety data beyond 6 months and the possible negative
impact on cardiovascular and breast health. Any woman using testosterone off-label
for sexual problems should be under the care of a sexual medicine specialist,
and should have her serum levels monitored closely. Blood, lipid, and liver
profiles should also be checked, and any side effects reported immediately.
Many sexual health experts agree that testosterone has been adopted erroneously
by health care providers as a panacea for all female sexual complaints, and
a number of researchers remain unconvinced about any direct link between testosterone
and female sexual health. Generally, relationship and partner issues are paramount,
not hormonal milieu. Opponents of testosterone use cite lack of long-term safety
data, risk of breast cancer and cardiovascular events, and potential side effects
(eg, clitoromegaly, excess body hair growth, loss of scalp hair, masculinization,
voice changes). Indeed, many women with low libido are not helped by testosterone
supplementation, and there is a documented placebo effect. Notably, the Endocrine
Society opposes testosterone use in women for desire issues, claiming poor
serum measurement techniques, absence of a clinically defined androgen deficiency
syndrome, and lack of a defined mechanism of action for testosterone on sexual
function.4
Risk of breast cancer is also a consideration; many breast cancers have androgen
receptors, and androgens (including testosterone) are converted to estradiol,
which is thought to facilitate and/or stimulate breast cancer cells.5 In addition,
the safety of androgens in cancer survivors has not been adequately studied,
and some researchers claim that testosterone may be aromatized to estrogen,
which may reactivate, promote, or stimulate tumor growth.
I prefer an intermediate position: a tempered approach to female sexuality is
the best approach. I am not overzealous about hormonal manipulation, as female
sensuality is a dynamic process not solely influenced by hormones, but rather
by many interacting sociologic, cultural, and relationship factors. Hormones
may indeed be important, but the extent of their influence on the various aspects
of female sensuality and sexuality remains to be clarified.
This passionate debate will continue until further scientific information is
available, but the more significant issue here involves patient autonomy and
the need to base health care decisions on individual risk and life situation.
I feel that every woman should be provided with the somewhat confusing and
emerging data on testosterone, and be allowed to make an educated decision
based on the best medical evidence available. Health care providers who treat
sexual problems must separate personal belief from professional responsibility
and obtain adequate informed consent. Nothing we do as health care professionals
is without risk. Any therapeutic decisions must be mutual between physician
and patient, an individualized choice based on risk assessment, history, physical
findings, and the best available data. Alternative treatments, counseling,
and cognitive behavioral techniques should be discussed as well. Nonhormonal
alternatives may soon be available that show excellent promise for treating
hypoactive sexual desire disorder.
Finally, there is a desperate need to standardize the emerging field of sexual
medicine. Residency training programs and clinical fellowships are warranted
to properly train the physicians of the future.
A trial of hormonal treatment for sexual dysfunction is a personal journey that
encompasses not only individual risk, but also the extent of the “disease” and
its impact on quality of life. Sexual function is complicated and essential,
and deserves a dynamic treatment plan that includes all of its medical, psychological,
biologic, and social components.
At a recent meeting, a health care professional jokingly commented that there
are only two types of women—those who enjoy sex and those who don't, and for
those who don't, testosterone is clearly the answer. As I stood there in shocked
silence, I recognized that, in the 5 minutes before the session started, it was
not possible to win the battle against ignorance, paternalism, sexism, and antiquated
medical views. I can only hope that professionalism will prevail, and that the
field of sexual medicine will continue to gain credibility for its understanding
of female sexual response and biologic mechanisms and its commitment to education.
A respected mentor of mine once said that arrogance and ignorance are a deadly
combination for any health care provider. While I continue to grow as a sexual
medicine specialist, I remember her wise counsel.
back to top
Michael L. Krychman, MD, Associate Editor
REFERENCES
- Laumann EO, Paik A, Rosen RD. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;281(6): 537-544.
- Traish A, Guay AT, Spark RF; Testosterone
Therapy in Women Study Group. Are the Endocrine Society’s
Clinical Practice Guidelines on Androgen Therapy Misguided?
A Commentary. J Sex Med. 2007;4(5):1223-1235.
- North American Menopause Society.
The role of testosterone therapy in postmenopausal women: position
statement of the North American Menopause Society. Menopause.
2005; 12(5):497-511.
- Wierman ME, Basson R, Davis SR,
et al. Androgen therapy in women: an Endocrine Society Clinical
Practice Guideline. J Clin Endocrinol Metab. 2006; 91(10):3697-3710.
- Schover LR. Androgen therapy for loss
of desire in women: is the benefit worth the breast cancer
risk? [published online ahead of print November 17, 2007] Fertil
Steril. doi:10. 1016/
j. fertnstert. 2007. 05. 057.
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