The Case for Androgens in Menopausal Women: When and How?
A 55-year-old healthy married woman complains of reduced sexual desire and arousal for the past 10 years. She denies any dyspareunia. She underwent a hysterectomy with bilateral salpingo-oophorectomy at the age of 45 for symptomatic uterine fibroids. Afte
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Grace Huang and Shehzad Basaria
Case Presentation A 55-year-old healthy married woman complains of reduced sexual desire and arousal for the past 10 years. She denies any dyspareunia. She underwent a hysterectomy with bilateral salpingo-oophorectomy at the age of 45 for symptomatic uterine fibroids. After the surgery, she started experiencing hot flashes, vaginal dryness, and decreased sexual desire. She was prescribed with a transdermal estradiol patch which relieved her hot flashes and vaginal dryness but did not improve her sexual symptoms. Her total and free testosterone levels are low at 12 ng/dl and 1.5 pg/ml, respectively. She had a normal mammogram within the last year. She asks whether testosterone replacement is an option to treat her sexual symptoms. How should this patient be assessed and treated?
Androgen Physiology in Postmenopausal Women Similar to men, women also experience age-related decline in gonadal steroids [1]. At the time of natural menopause, there is sudden and permanent cessation of ovarian follicle formation and decline in estrogen production. Although serum androgen levels decline with age in women, much of this decline is between the ages of 20–40 years. Furthermore, there is no cessation of androgen production during natural menopause. The two major sources of androgen production in women are the ovaries and the adrenal glands [2]. In women, testosterone is produced directly by the ovaries and by peripheral conversion of androstenedione and dehydroepiandrosterone (DHEA), G. Huang, MD (*) • S. Basaria, MD Section of Men’s Health, Aging and Metabolism, Brigham and Women’s Hospital, Harvard Medical School, 221 Longwood Ave, BLI-541, Boston, MA 02115, USA e-mail: [email protected] © Springer International Publishing Switzerland 2017 L. Pal, R.A. Sayegh (eds.), Essentials of Menopause Management, DOI 10.1007/978-3-319-42451-4_10
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G. Huang and S. Basaria Testosterone
Adrenal Ovary
Postmenopausal 180 µg/24h
Premenopausal 250 µg/24h
190 µg/24h 75 %
60 µg/24h 25 %
90 µg/24h 50 %
90 µg/24h 50 %
Androstenedione
Premenopausal 3.0 mg/24h
1.5 mg/24h 50 %
1.5 mg/24h 50 %
Postmenopausal 1.5 mg/24h
1.2 mg/24h 80 %
0.3 mg/24h 20 %
Fig. 10.1 The contribution of the ovaries and the adrenals to serum androgen levels in pre- and postmenopausal women [3]
which are synthesized by the ovaries and the adrenal glands, respectively. In young premenopausal women, the ovary is responsible for approximately 25 % of the testosterone production, while 75 % is derived from the adrenal glands. However, in postmenopausal women, the ovary becomes a major source of androgens and contributes to approximately 50 % of the total testosterone production (Fig. 10.1) [3]. Although the climacteric ovary becomes atrophic and loses capacity to synthesize estradiol, it still continues to secrete substantial amount of androgens under the stimulation of gonadotropins [2]. In fact, the steepest decline in testosterone levels occurs in the early reproductive years between the ages of 20–40 with a plat
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