Androgens in postmenopausal women TOG 2022

Question 1

How much more testosterone do women produce than oestrogen

Answer 1

3-4 x more - most quantitively most prevalent active sex hormone Hsteroid in women

Question 2

Diagram showing pre-menopausal production of androgen

Answer 2

Question 3

Explain the androgen production from the ovaries premenopause

Answer 3

The theca cells produces testosterone and androtestosterone, which either circulate or converted to oestrogens by the granulose cells.

Question 4

When during the menstrual cycle is testosterone production from the ovaries highest, and when during the day?

Answer 4

Highest mid cycle and remain high during luteal phase.
Highest in morning.

Question 5

Which precursors are most made by the adrenal glands?

Answer 5

Adrenals make DHEA-S and DHEA which are a precursory to testosterone

Question 6

Premenopausally what proportion of testosterone is made by
1) Ovary
2) Adrenal glands
3) Peripheral conversion

Answer 6

Ovary 25%
Adrenal 25%
Peripheral 50%

Question 7

What proportion of testosterone is unbound. What does it bind to?

Answer 7

Unbound 1-2%
Binds to SHGB 66% or albumin 33%

Question 8

Which drugs can increase levels of SHBG?

Answer 8

Tamoxifen
PO estrogen
PO thyroxine

Reducing free androgen index

Question 9

What factors decrease SHBG?

Answer 9

PO testosterone
Glucocorticoids
High fructose
Increased visceral adiposity
Insuline resistence

Question 10

When is testosterone first noted?

Answer 10

Maturation of zona reticularis, 1st production of DHEA and DHEA-S age 6-8
Start of adrenarche

Question 11

What age to testosterone levels peak?

Answer 11

18-24yrs
Age related atrophy of the adrenal gland, only 10% by the time menopause reached.

Question 12

At menopause where is testosterone produced

Answer 12

50% ovaries
40% peripheral conversation

Question 13

How to calculate free androgen index?

Answer 13

Total testosterone x 100/SHBG

Question 14

If considering treatment with tesoterone, what levels should be measured?

Answer 14

Before treatment total testosterone, then 2-3 months after starting treatment

Ensure within reference range

Question 15

Diagnosis of female sexual dysfunction

Answer 15

o >6 months & >75% sexual experiences

Question 16

When can testosterone be considered for female sexual dysfunction

Answer 16

• In acquired hypoactive sexual desire disorder/dysfunction – all potential modifiable biopsychological factors should be identified & addresses, only if this fails should androgen therapy be used

Question 17

When does NICE consider testosterone for low sexual desire?

Answer 17

NICE consider testosterone if oestrogen therapy alone is not effective for low sexual desire

Consider vaginal oestrogen if vaginal atrophy

Question 18

Side effects of testosterone

Answer 18

acne, excess hair growth, alopecia, virilisation - stop quickly with stopping

Question 19

Which patient should not have prescribed testosterone

Answer 19

active liver diease, competitive athletes, high testosterone levels

Question 20

Is there are specific testosterone that is licences for use by women

Answer 20

No off licence - should explain this to patient

Question 21

How should gel or cream be applied>

Answer 21

Gel/cream should be used on clean, dry skin on lower abdomen or upper thigh, avoid skin contact with others until the skin is dry & wash hand

Question 22

How long does it take to see response to testosterone?
How often should review

Answer 22

• Response usually takes 8 weeks and needs minimum 3 months, no improvement after 6 months should be stopped
• Review minimum every 6 months to assess for SE

Research mostly used for 6-12 months so after this is efficacy and safety not known