HRT Article

Clinical Management of Testosterone Replacement Therapy (TRT) in Postmenopausal Women with Hypoactive Sexual Desire Disorder (HSDD)

Introduction

• Androgens decrease in production during menopause due to decline in ovarian and adrenal function.

• They play a crucial role in sexual motivation for women.

• Resulting Female Sexual Dysfunction (FSD) can include issues like sexual arousal and desire.

• HSDD: characterized by absence of sexual fantasies and desire, causing distress for at least 6 months.

• TRT shows promise for treating HSDD in postmenopausal women, although data on premenopausal women remains limited.

Importance of Androgens

• Vital for regulating vulvovaginal complex, pelvic floor, and sexual function including vaginal lubrication.

• Testosterone levels in women are about 1000 times more than estradiol, primarily produced by ovaries and adrenal glands.

• Only testosterone and dihydrotestosterone (DHT) bind to androgen receptors (AR).

• Inverse relationship between SHBG levels and free testosterone (higher SHBG means lower bioavailable testosterone).

• Age-related androgen decline leads to symptoms of HSDD, especially pronounced in women undergoing surgical menopause.

Epidemiology

• Nearly 50% of menopausal/postmenopausal women in the U.S. report some FSD; HSDD is the most common form.

• Projections: by 2030, 1.2 billion women will reach menopause, potentially increasing HSDD cases.

Evaluation and Diagnosis

• A biopsychosocial approach is essential for diagnosis, involving comprehensive patient history and verified questionnaires.

• Tools like the Female Sexual Function Index (FSFI) and the Sexual Interest and Desire Inventory are useful in assessment.

• Physical exams to assess signs of hypogonadism and hormonal imbalance follow; must include total testosterone, free testosterone, SHBG, and estradiol assessments.

Evidence for Testosterone in HSDD

• Studies indicate TRT improves libido and sexual satisfaction in postmenopausal women.

• Buster et al. (2005) showed significant increases in satisfying sexual activity with testosterone compared to placebo.

• Combination therapy with estrogen tends to yield greater improvements in sexual function.

• Draw attention to studies indicating specific dosages and administration techniques (e.g., transdermal patches).

Types of Testosterone Formulations

• TRT has not been FDA-approved for HSDD in women; informed consent is necessary due to off-label use.

• Various administration routes include intramuscular, subcutaneous, transdermal, etc., with transdermal being preferred for ease of use and consistent dosing.

• Discuss risks of transference of testosterone and adjustments required for female dosing.

Monitoring

• Essential to monitor testosterone levels and adjust dosages to avoid adverse effects and ensure therapy effectiveness.

• Baseline assessments required prior to TRT initiation, with follow-ups on testosterone levels, liver function, and symptoms of improvement or side effects.

• Recommendations for monitoring follow a regimen of repeat labs 3-6 weeks after starting treatment.

Conclusion

• HSDD significantly impacts many women, particularly postmenopausal.

• TRT presents as an effective treatment, but further research is needed to evaluate long-term effects and establish comprehensive guidelines for premenopausal women.

Future Research Areas

• Mixed data on TRT efficacy for premenopausal women suggests a need for more robust studies.

• Need for standardized measurement techniques and patient-centered outcome measures in clinical trials to assess TRT and its effects on sexual health.