Testosterone for Menopausal Women?

By Victoria Carrington, M.D.

Many women may be surprised that testosterone plays an important role in maintaining the hormonal balance in a woman’s body. Testosterone actually gets converted into estrogen in the body. Testosterone is a member of the group of hormones known as androgens, the hormones primarily responsible for the sexual characteristics of males. In females, testosterone is the second-most potent androgen and is made both in the ovaries and in the adrenal glands. Testosterone is also formed in the liver, skin, fat and muscle from other androgens. The body maintains complicated pathways of biochemical interactions that include testosterone and other androgens, cholesterol, estrogens, DHEA and cortisol. All of the components of these pathways interact with each other to finely regulate the levels of hormones circulating throughout the body.

Androgens such as testosterone are responsible for starting the process of puberty in both boys and girls and remain important throughout the life span of a woman. Women make one-seventh the amount of testosterone as men do daily and as women age, their testosterone levels decline. A woman at the age of 40 has only one-half of the testosterone as a woman of the age of 21. If a woman undergoes surgical removal of her ovaries, her testosterone levels drop very steeply. In menopause, the ovary becomes a more important source of testosterone contributing almost half of the testosterone made in the body with the adrenal glands and other tissues making up the balance.

Roles of testosterone include maintaining sexual desire, contributing to a sense of well-being, supporting cognitive function, increasing bone mass and maintaining favorable lean muscle mass ratios. Symptoms experienced by menopausal women include those that may be caused by a decrease in testosterone such as loss of sexual desire, mood changes, fatigue, concentration and memory problems, osteoporosis and increases in body fat. Because of this correlation of symptoms of menopause with those of testosterone deficiency, researchers are considering how adding testosterone to a menopausal woman’s system could help to decrease some of the troubling symptoms of menopause.

Testosterone has been F.D.A.-approved for men for various disorders for many years. More recently, scientists have begun to investigate the role of testosterone supplementation in women. Hormonal supplements containing testosterone can be administered to the body through several different routes depending on the chemical type of testosterone desired. Testosterone is available as intramuscular injections, subcutaneous (under the skin) capsules, sublingual (under the tongue) tablets, oral, transdermal (on the skin) patches, gel or emulsion. The route through which the testosterone is delivered as well as the type of testosterone administered will determine how much of the testosterone that enters the body is actually available to be used by the body. Testosterone is now being considered as a welcome addition to standard HRT.

Typical hormone replacement therapy for menopausal women involves the replacement of estrogen and progesterone. These hormones are particularly helpful for target symptoms such as hot flashes and vaginal dryness. Many women however, despite taking their estrogen/progesterone medications faithfully, still do not quite feel like they are restored to their former quality of life. Many women report an overall decrease in their quality life partly due to mood and sexual changes. These findings, combined with more research on the roles of testosterone in women, have led to some new conclusions concerning possible roles of testosterone in menopausal women.

Recent studies have addressed the role of testosterone in improving the quality of the sex life of the menopausal woman. Many menopausal women report symptoms consistent with hypoactive sexual desire disorder (HSDD). In this disorder, women report decreased libido that is causing them personal distress. A study sponsored by the makers of a testosterone patch had women with HSDD who were taking either estrogen or estrogen/progestin hormone replacement therapies wear either a testosterone patch or a placebo. The women wearing the testosterone patch reported having sex four times as much as the women wearing the placebo patch. The women wearing the testosterone patch also reported an increase in sexual desire, sexual arousal, orgasm, pleasure, responsiveness and self-image. The reported side effects included an increase in facial hair and skin irritations at the site of the patch. The overall results of the study were encouraging and should lead the way for a F.D.A.-approved testosterone patch for women with HSDD.

Some proponents of the use of testosterone therapy in menopausal women point out additional roles of testosterone in the treatment of symptoms that may be seen in menopause or with increasing age. Some studies suggest testosterone may be helpful in the treatment of the headaches and fatigue sometimes associated with menopause. Because of oral testosterone’s impact on triglycerides, it has been suggested that it can serve as a triglyceride lowering agent in those with high levels of triglycerides. Testosterone’s role in increasing bone density suggests that oral testosterone therapy may be a welcome addition to estrogen therapy in helping to protect against osteoporosis. Painful breasts may be a side effect of estrogen therapy and testosterone can reduce the painfulness of breast tissue when given with estrogen. Some researchers have begun to wonder if testosterone’s role in converting fat to lean tissue could be useful in the age-related changes of obesity and diabetes that may appear in the menopausal years.

Will testosterone therapy replace standard estrogen/progestin HRT? No. Testosterone interacts with estrogen in the body and testosterone will work with estrogen in the menopausal woman for optimal health. For instance, in hypoactive sexual desire disorder, both testosterone and estrogen are crucial for treatment. The estrogen is responsible for decreasing the vaginal dryness and pain often found in the menopausal woman. These changes are necessary for the menopausal woman to desire to have sex and then to enjoy sex. Estrogen also can play a role on how much testosterone is actually available to the body depending on the route through which the estrogen is given. It is known that the standard doses of estrogen found in standard hormone replacement therapy decreases the body’s available level of testosterone.

Are there any possible drawbacks to testosterone therapy in the woman who is menopausal? The full answer to that question is not known at this time. Right now, the F.D.A. has not approved any testosterone preparations for long-term use in women. Despite many short-term studies investigating testosterone in women using various formulations of testosterone through various routes that have shown testosterone therapy to be well-tolerated, no long-term studies have been done to thoroughly investigate issues of safety over the long-term in women. Using the lowest doses possible over the shortest time possible seems prudent when considering the use of testosterone in treating symptoms of menopause. Testosterone products should never be used in a woman who is or may be pregnant and perimenopausal women using testosterone must be careful to use appropriate contraception.

As more long-term studies are done on testosterone in women, we may find that an important component of HRT in menopause has been missing. Women may begin to reclaim the quality of life that they had prior to menopause with the addition of testosterone to standard estrogen and estrogen/progestin therapy for the treatment of the symptoms of menopause.