Testosterone Replacement Therapy in Women
The majority of female patients with testosterone deficiency exhibit reduced sexual drive and/or unexplained lethargy and fatigue and/or altered mood.
Management requires a multidisciplinary, integrated approach. This should be coordinated by a suitably trained medical practitioner.
Specific medical conditions such as iron deficiency, abnormal bleeding, diabetes, depression and thyroid disease require addressing before considering hormonal therapies.
Lifestyle changes such as exercise, smoking, alcohol intake and weight loss need to be reviewed.
Vaginal lubricants provide symptomatic relief for vaginal dryness and dyspareunia (difficult or painful sexual intercourse). Localized estrogen pessaries, vaginal tablets, creams and gels can also assist.
Pelvic floor physiotherapy will improve vaginal muscle tone and muscle associated with orgasm, and in managing incontinence.
Alteration of prescribed medications which may interfere with sexual function if appropriate. Especially oral hormone replacement therapy (HRT), oral contraceptives (OC's) and antidepressants.
To see a listing of which medications may interfere with sexual desire, please click here.
- Supplementation with the bioidentical hormone testosterone if testosterone deficiency is established.
A medical practitioner's assessment of a patient must include:
Medical History, Including Sexual History
It is very important that a doctor be skilled in discussing, understanding and managing problems associated with sexual matters. In terms of a sexual history it is vital that the practitioner knows his or her limits. If the doctor has little or no training in sexual counselling a referral to a trained sex counsellor is recommended.
A doctor should:
- not be judgmental due to his or her own sexual prejudices or "hang-ups"
- ensure that the patient understands the issue of doctor-patient confidentiality
- be sensitive and optimistic when dealing with relationship issues
- encourage consultation with partner present
- allow extended time for consultations
- understand that problems may not be revealed without specific enquiry
- understand that sensitive and embarrassing issues may not be readily volunteered
It is important that a general "good female health" check be undertaken by your doctor.
Routine screening should include: mammogram, Pap smear, cardiovascular parameters, fasting blood glucose, serum thyroid stimulating hormone (TSH), full blood examination and iron studies.
Further specific investigations of specific medical disorders such as abnormal bleeding, breast lump(s), incontinence and osteoporosis are essential before any consideration of testosterone treatment.
Psychological evaluation of mood, well-being and sexual function may need to be conducted.
Hormone Blood Testing
The measurement of testosterone levels in the blood provides a snapshot of what the testosterone status of the person is at the time of taking blood.
Testosterone secretion follows a diurnal rhythm in females. That is, it rises and falls over a 24 hour period. Testosterone production occurs during the night and early morning with levels highest on waking. Serum testosterone levels slowly decrease during the day and are lowest in the late afternoon and early evening.
Therefore blood samples should preferably be taken in the morning, when hormones levels are at their highest. Individual variations in serum testosterone levels can occur due to time of day, medication usage, stress, illness or recent surgery.
The ovaries and adrenal glands do not store testosterone. Once produced testosterone is secreted into the blood stream where it is rapidly adhered to by the protein sex hormone binding globulin (SHBG).
SHBG is a transporter protein found in the blood. It acts as a carrier to move hormones around the body. Up to 99% of testosterone produced is bound to SHBG. Testosterone to which SHBG does not attach is the biologically available testosterone that is free to act on and enter into cells throughout the body. This "bio-available" testosterone is crucial in determining how well testosterone can work in the body.
Some doctors will measure only testosterone levels (called total testosterone) and not take into account the SHBG levels. While not technically wrong, total testosterone measurement alone is not the most accurate representation of how much testosterone is free to act in the body. As a consequence the total testosterone reference ranges commonly adopted by pathology laboratories for determination of "normal" and "low" testosterone are potentially misleading, because the results do not take into account the effects of SHBG.
SHBG is elevated with ageing, smoking, high alcohol intake, insulin, oral estrogens and some medications.
In order to establish an accurate diagnosis for a patient it is essential to measure the "free androgen index" or FAI. This is calculated by the total testosterone level in the blood divided by the SHBG level multiplied by 100. Pathology labs will automatically do this calculation and the result will be the FAI reading.
Generally, a FAI reading of 2 or less is a strong indication that testosterone supplementation is warranted. Other factors such as pre-existing illnesses, physical, hormonal, psychological and mental health must be taken into account before using testosterone.
Testosterone and SHBG levels are essential in the assessment of androgen insufficiency as a cause of loss of libido, mood and well-being. These measures are important regardless of menopausal status, age or ethnic background.
Testosterone Treatment Options
The majority of patients with low testosterone levels exhibit reduced sexual drive, altered mood and unexplained lethargy and fatigue.
As discussed earlier, injections of testosterone and testosterone implants have largely been superseded by products designed for delivering physiological doses of testosterone appropriate for use in women. These products are:
Intrinsa® Transdermal Testosterone Patch (Procter and Gamble, USA)
AndroFeme® 1% Testosterone Cream (Lawley Pharmaceuticals, Australia)
AndroFeme® 1% Testosterone Cream has been available in Australia since 1998 and is currently the only available approved testosterone product available for delivering testosterone safely and effectively to women. AndroFeme® is applied topically to the inner thighs, arms or lower abdomen once daily. The dose is titratable and the usual dose is 1-2cm (5-10mg testosterone) daily (measurer included). Cost is USD$50 for a 6-12 weeks supply.
To order AndroFeme® click here.
For AndroFeme® Product Information details click here. (PDF)
For AndroFeme® Consumer Medication Information click here. (PDF)
Intrinsa®Testosterone Patch (Procter and Gamble, USA).
The testosterone patch is yet to be approved by the USA Food and Drug Administration (FDA) or the Australian Therapeutic Goods Administration (TGA). Intrinsa®. has been approved by the European Agency for the Evaluation of Medicinal Products (EMEA), but is yet to be released onto the USA or Australian market. Cost in the UK is around €100 (USD$170) for a 1 month supply.