Androgen replacement therapy in women

A 62-year-old woman came to see me for management of type 2 diabetes. I was struck by her facial and body hirsutism, it was more than I would expect in polycystic ovarian syndrome and raised concerns about possible serious underlying pathology.

However, on history I learned that she received estrogen/testosterone implants every four months from a gynecologist in another state. They had been initiated years earlier after she had had a total hysterectomy for endometriosis and polycystic ovarian syndrome. She said that they made her feel great and she could never go without them. She had been placed on spironolactone 50 mg twice a day in an attempt to manage the side effects.

It had been four months since her last implant. She was about to travel to have another one placed but I convinced her to permit us to test her levels prior to getting another implant. Her total testosterone was 194 ng/dL. The normal range for pre-menopausal women is 8-60 ng/dL and for men it is 240-950 ng/dL. Her testosterone is closer to that of a man than a woman! I wonder what her testosterone would have been had we measured it closer to after receiving an implant?

Androgen replacement therapy in women is an extremely controversial issue. Some have suggested that this may be appropriate in women who are post oophorectomy and post-menopausal and who have primary adrenal insufficiency. Reportedly, androgen therapy in this population may increase libido, improve mood and decrease fatigue. Potential negative side effects include adult acne, hirsutism and virilization.

Studies have been inconclusive and there is no FDA-approved testosterone replacement therapy for women. A handful of times, I have prescribed transdermal testosterone in women who have requested such therapy. Our goal was a testosterone in the mid to upper female premenopausal range. Unfortunately, my experience has been less than favorable. Despite reaching supposed optimal levels, more women have complained about continued symptoms of low libido, depressed mood and chronic fatigue than have reported resolution of their symptoms.

I have not formed my final opinion about androgen replacement therapy in women. I remain open minded and listen to the opinions of those who believe in androgen therapy in women. It is an intriguing concept and I agree that androgens play an important role in women. However, I need more data and positive experience before I will be convinced. I worry about the potential negative consequences of androgen replacement therapy being offered without monitoring or by a clinician inexperienced in the side effects.

Perhaps there will be a day when androgen therapy in women is better understood and becomes accepted as standard practice? Until then, I remain skeptical.

What is your opinion about androgen therapy in women? What has been your clinical experience? I look forward to reading your comments.