Hormone Therapy: Testosterone and Its Use in Sexual Health

As we age, the body produces lower levels of essential sex hormones. In men, this is sometimes referred to as andropause or androgen decline of the ageing male (ADAM). In women, this is known as menopause. Both testosterone and estrogen reduce naturally, resulting in sexual dysfunction, urinary tract issues, muscle loss, bone density loss (osteoporosis), hair loss, and an increased risk of heart issues and type II diabetes.

Testosterone replacement therapy (TRT), also known as systemic testosterone replacement, is used to restore natural levels of testosterone in the body to the normal range in those with testosterone deficiency. This can help improve the sexual and urinary dysfunction that men and women may experience along with other age-related physiological changes. TRT may come as a transdermal solution (through the skin) via patches, gels, or pellets, or as an intramuscular injection.

Male Sexual Health

The main use of TRT is to improve men’s sexual function and is currently only approved by the U.S. Food and Drug Administration (FDA) for use with men with testosterone deficiency. Men tend to prefer intramuscular injection for TRT.

In terms of sexual dysfunction, TRT can improve sex drive (libido), erectile dysfunction (ED), lower urinary tract symptoms like urinary incontinence or frequency, and may have some effect on benign prostatic hyperplasia (BPH; enlarged prostate) – though research has also shown negative effects.

TRT may also help improve other aspects of andropause, such as muscle and bone strength, the likelihood of type II diabetes, and, in from early-stage research, heart issues. Andropause may also impact mood, energy, and overall well-being, so treating these symptoms may improve men’s quality of life.

Despite its benefits, TRT may have some less-than-satisfactory outcomes, which require consistent monitoring. For one, TRT can lower sperm count, potentially reducing fertility. Those who want to maintain fertility may want to discuss other options with their healthcare provider first.

Red blood cell count may also increase with TRT (polycythemia), which can increase the risk for stroke, heart attack, clogged arteries in the lungs (pulmonary embolism), and severe blood clots (deep vein thrombosis).

Sometimes, the testosterone does not behave properly, instead converting into estrogen. This may cause men to grow breast tissue (gynecomastia). Additionally, TRT can increase skin oil production, leading to acne. While not serious, these side effects can be irritating and should be discussed with a healthcare provider.

Recent research suggests that TRT does not increase the risk of high-grade prostate cancer. Your provider can discuss the risks and benefits with you

Female Sexual Health

Estrogen is known as the primary female sex hormone and is currently the gold-standard therapy for menopausal conditions. However, testosterone also plays an essential role in women’s sexual function. During menopause, women’s estrogen and testosterone levels experience a rapid decline, resulting in genitourinary syndrome of menopause (GSM), which includes a variety of sexual health issues:

• Low libido
• Vaginal dryness
• Sexual pain (dyspareunia)
• Vaginal pain (vaginismus)
• Mood changes
• Urinary tract issues.

With menopause, women may also experience mood changes, hot flashes, and other physical changes.

Despite its use for female sexual dysfunction for decades, a 2019 global consensus statement provides the only recommended use of TRT for women: to treat hypoactive sexual desire disorder (HSDD), a psychological condition causing low sex drive that is distressing. Because TRT is only FDA-approved in men, it may be prescribed in adjusted doses or in combination with other hormones, allowing it to last longer. Women tend to prefer the gel option.

Recently, an International Society for the Study of Women’s Sexual Health (ISSWSH) expert consensus panel review found that in adjusted doses, vaginal TRT may be beneficial for relieving GSM symptoms. However, more research is needed to confirm any side effects, and estrogen therapy remains the gold standard for treating GSM.

Key Takeaways

• Sex hormone decline (andropause and menopause) is natural as people age.
• Testosterone plays a key role in the sexual and overall health of both men and women.
• TRT restores natural testosterone levels to those of a young adult.
• This helps improve sexual function, muscle and bone strength, and reduces the risk of other health conditions associated with older age.
• TRT is currently FDA-approved for men only and is available in male doses.
• Women may treat HSDD or GSM with testosterone, so doses will need to be adjusted.
• If ageing is causing sexual health concerns, it may be beneficial to speak with a sexual health professiona

Resources:

Davis, S. R., Baber, R., Panay, N., Bitzer, J., Perez, S. C., Islam, R. M., Kaunitz, A. M., Kingsberg, S. A., Lambrinoudaki, I., Liu, J., Parish, S. J., Pinkerton, J., Rymer, J., Simon, J. A., Vignozzi, L., & Wierman, M. E. (2019). Global consensus position statement on the use of testosterone therapy for women. The Journal of Clinical Endocrinology & Metabolism, 104(10), 4660–4666. https://doi.org/10.1210/jc.2019-01603

Morley, J., Bassil, N., & Alkaade, S. (2009). The benefits and risks of testosterone replacement therapy: A Review. Therapeutics and Clinical Risk Management, 427. https://doi.org/10.2147/tcrm.s3025

Parish, S. J., Simon, J. A., Davis, S. R., Giraldi, A., Goldstein, I., Goldstein, S. W., Kim, N. N., Kingsberg, S. A., Morgentaler, A., Nappi, R. E., Park, K., Stuenkel, C. A., Traish, A. M., & Vignozzi, L. (2021). International Society for the Study of Women’s Sexual Health Clinical Practice guideline for the use of systemic testosterone for hypoactive sexual desire disorder in women. The Journal of Sexual Medicine, 18(5), 849–867. https://doi.org/10.1016/j.jsxm.2020.10.009

Ramasamy, R., Osterberg, Ec., & Bernie, A. (2014). Risks of testosterone replacement therapy in men. Indian Journal of Urology, 30(1), 2. https://doi.org/10.4103/0970-1591.124197

Simon, J. A., Goldstein, I., Kim, N. N., Davis, S. R., Kellogg-Spadt, S., Lowenstein, L., Pinkerton, J. V., Stuenkel, C. A., Traish, A. M., Archer, D. F., Bachmann, G., Goldstein, A. T., Nappi, R. E., & Vignozzi, L. (2018). The role of androgens in the treatment of genitourinary syndrome of Menopause (GSM): International Society for the Study of Women’s Sexual Health (ISSWSH) expert consensus panel review. Menopause, 25(7), 837–847. https://doi.org/10.1097/gme.0000000000001138

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Uloko, M., Rahman, F., Puri, L. I., & Rubin, R. S. (2022). The clinical management of testosterone replacement therapy in postmenopausal women with hypoactive sexual desire disorder: A Review. International Journal of Impotence Research, 34(7), 635–641. https://doi.org/10.1038/s41443-022-00613-0