Androgens ovary and adrenals 5050 Deficiency common after BSO Testosterone by 50 in post menopausal Premature Ovarian Insufficiency 23 have low sex drive After menopause imbalance of hormones very low E relative high T therefore due to imbalance women can have slig ID: 930280
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Slide1
Where does Testosterone come from ?
Androgens : ovary and adrenals ( 50:50)
Deficiency common
after BSO (Testosterone ↓ by 50%)
in post menopausal
Premature Ovarian Insufficiency (*2/3 have low sex drive)
After menopause : imbalance of hormones , very low E , relative high T, therefore due to imbalance women can have slight
hirsuitism
Slide2Testosterone Assays
Assays not sensitive : Immunoassay and Mass spectrophotometry
Blood levels not equal to tissue levels, assays imprecise at low levels and cross react with with NET
Correlation of levels with Symptoms is poor, offers no diagnostic valueBioavailable testosterone : free Testosterone , not bound to SHBG , and intracranial Testosterone in CNS may play a role too Free test , Free Androgen Index (FAI) is importantFAI= Total Testosterone x100 SHBG Interpretation of assaysBaseline tests – Serum Test < 1.7 nmol/L, ( post menopause) and in POI <7%( <40urs )Androfeme 1 cream 0.5 ml daily . At 3 months FAI ↑ to 3, Test = 1 nmol/L Davis, Baber , Panay et al . Climacteric ,Maturitas. J Sex Med , JCEM 2/9/19
Slide3Cases with Reduced sex Drive
Josie, Age 55 , works in Public Health
TAH with BSO at 50 for heavy periods
Happily married x 30 yrs Has low sex drive –is affecting her relationship for few years No VVA, hot flushes have settled Not depressed , no stressful contributing factors, no medications, sex once in 3 months TFTS – nad , Serum Test =0.2 nmol/l , FAI ( cannot be calculated) , SHBG =35 Rosie, Age 55 , NHS Manager Periods stopped at 53
On HRT x 2 years , hot flushes better
Happily married x 30
yrs
Main problem is low sex drive Affecting her relationship Not depressed , no stressful contributing factors, no medications, sex once in 3 months TFTs – nad , Serum Test = 0.5 nmol/L , FAI cannot be calculated , SHBG = 56
Will you consider Testosterone ?
Slide4Testosterone: Global Consensus Position statement on Use of Testosterone therapy for women
Where an appropriate approved female testosterone preparation is not available, off label, prescribing of an approved male formulation is reasonable, provided hormone concentrations are maintained in the physiologic female range.
No recommendations for use in premenopausal women , lack of data
Evidence based Indications recommended by IMS ( Task Force) HSDD – Hypoactive sexual desire disorder FAD – Female arousal disorder FOD – Female Orgasmic disorder Dose recommended in post menopause with or without HRT equal to premenopausal concentration - Post menopausal- BSO ( Surgical menopause) TestosteronePremature Ovarian Insufficiency (POI) Insufficient evidence to support use for cognitive function, mood , bone mineral density, well being, sarcopenia , energy levels , headaches Safety : Only data on Short term transdermal T therapy : no impact on breast cancer, lipid profile, CVS, bone, AND long term insufficient data
www.imsociety.org
,
Davis et al. Global Consensus Position Statement on the use of Testosterone Therapy for Women.
Maturitas. 2019;128:89-93.
Slide5Role of Testosterone
Testosterone : 100-400mcg/day (
usedto
be available in patch form discontinued) EMAS approved use of Testosterone patches , Testosterone Implant for women with BSO who are on E2 replacement only NICE Guidance : Trial of Systemic HRT before Testosterone RX Baseline tests – Serum Test <1.7 nmol/L, FAI low usually <1Preparations available (5 mg/day)Unlicensed , off label use Testogel ™1 sachet x 10 days ( 0.5 ml=5 mg /day) off label Tostran gel ™(2%) 1 measure on alternate days (off label ) Androfeme 1 cream™ – 0.5 ml daily ( unlicensed use-imported) Testosterone Implant 100 mg yearly ( unlicensed, in pts with TAH with BSO)Tibolone does help sex drive , less E side effects, breast less dense, less breast cancer risk cf combined HRT, higher risk of stroke over 60s
Repeat Testosterone levels
at ideally 3-6 weeks and every 6 months
but BMS guidance: repeat at 3 months , followed by once a year
( FAI < 5) If no response in 3-6 months , discontinue Rx. Androfeme 1 cream ™by Lawley Pharma www.independentpharmacy.co.ukAn Endocrine Society Cl Practice Guideline . Wierman et al. JCEM2014, Climacteric, Maturitus
2/9/19
Slide6Adverse effects of Testosterone
Occasional : increased hair growth at site
Uncommon :
hirsuitism, acne , alopecia Rare : deepening of voice , enlarged clitoris Contra-indication 1. Breast cancer , other E-hormone dependent cancers 2. Active liver disease 3. High baseline and Free Androgen Index