Testosterone Replacement Therapy in Postmenopausal Women with HSDD

Overview of Testosterone Replacement Therapy (TRT) in Postmenopausal Women with HSDD

• Androgen Decline in Women

  • Decrease in androgen levels due to ovarian and adrenal function decline during menopause.
  • Leads to Female Sexual Dysfunction (FSD) which includes issues with arousal, desire, orgasm, and pain.
  • A prevalent form is Hypoactive Sexual Desire Disorder (HSDD), marked by lack of sexual thoughts or desire.

• Importance of Testosterone in Women

  • Androgens play a crucial role in sexual motivation and function.
  • Reduction in testosterone levels is hypothesized to correlate with HSDD.
  • On average, testosterone production in women is 1000 times greater than estradiol.

• TRT as a Treatment for HSDD

  • 2019 Global Consensus endorsed TRT for postmenopausal women with HSDD.
  • The International Society for the Study of Women’s Sexual Health published guidelines endorsing TRT use.
  • TRT is considered effective in restoring sexual health and function in affected women.

Evaluation and Diagnosis of HSDD

• Classification of FSD

  • Defined in DSM-IV, including disorders like HSDD, Female Arousal Disorder, and others.
  • DSM-V controversially merges HSDD and Female Arousal Disorder into Female Sexual Interest/Arousal Disorder (FSIAD).

• Diagnostic Approach

  • Biopsychosocial approach recommended, involving comprehensive evaluation (medical, surgical, social, sexual history).
  • Utilize validated questionnaires such as FSFI and the Sexual Interest and Desire Inventory for assessment.
  • Physical exams should assess signs of hypogonadism and hormonal panels (total testosterone, free testosterone, estradiol, SHBG).

Evidence for TRT Efficacy in HSDD

• Clinical Studies
  • Evidence suggests testosterone therapy improves libido and sexual function:
  • Buster et al. (2005): Increased satisfying sexual activity in testosterone vs. placebo.
  • Davis et al. (2008): Higher doses of transdermal testosterone significantly improved sexual events and desire compared to placebo.
  • ADORE study: Significant improvements in libido and sexual events from testosterone patches.
• Combination Therapies
  • Studies indicate that combining testosterone with estrogen enhances sexual function beyond estrogen alone.
  • Evidence points toward dose-dependent improvements in sexual function when using TRT.

Types of Testosterone Formulations

• Approved for Treatment of HSDD

  • No FDA approval specifically for HSDD in women; use is off-label.
  • Common formulations include transdermal options (patch, gel) due to better administration and titration.
  • Available options like oral testosterone and IM injections pose risks due to level fluctuations.

• Counseling for Patients

  • Discussing off-label use benefits and risks, informed consent is crucial.
  • Advice on minimizing transference in transdermal applications is necessary for safety.

Monitoring and Management of Treatment

• Monitoring Protocols
  • Regular monitoring necessary to assess testosterone levels and adjust dosing appropriately.
  • Baseline assessments before starting TRT include liver function and lipid panels.
  • Monitoring total testosterone levels 3–6 weeks after initiation and adjusting dosage as needed.
  • Aim for maximal therapeutic effect typically seen in 6-12 weeks; review progress using self-reported instruments.

Future Research Directions

• Need for Comprehensive Studies
  • More randomized controlled trials needed for TRT efficacy in premenopausal women.
  • Investigate standardized methods for measuring testosterone levels to improve research outcomes.
  • Future studies should focus on patient-centered outcomes like relief of distress and improved relationships, alongside sexual desire.

Conclusions

• HSDD is a widespread condition among women, particularly postmenopausal, affecting their quality of life.
• TRT presents a viable option for improving sexual function and health, though more research is essential for broader applications and safety assessments.
• Addressing the long-term effects of TRT and establishing standards for treatment are priorities for ongoing research in women's sexual health management.