Androgens in Health and Disease.pdf - E Library

274 Bancroft
4. Studies using placebo control typically show a substantial placebo effect in improving
well-being and sexual interest. Placebo control is, therefore, important.
With these caveats, what can we learn from studies of HRT in the natural or surgical
menopause?
Natural Menopause. A number of studies, particularly earlier ones, included women
with both natural menopause and surgical menopause, sometimes without even indicating
the numbers of each. Where a study has a substantial majority of natural menopause
subjects, it will be considered in this subsection. In those which have a substantial
majority of surgical menopausal subjects, they will be considered in the next subsection.
Burger et al. (97) reported on 20 postmenopausal women whose lack of libido had
persisted on “adequate oral estrogen replacement,” but whose “other main symptoms,
such as hot flushes and vaginal dryness,” had been relieved. Fourteen of these women
had gone through natural menopause. They were randomly assigned to either estrogen
implant or estrogen plus testosterone implant. On average, the combined-implant group
showed improvement in libido and sexual enjoyment within the first 6 wk, whereas the
“estrogen-only” group did not. The latter group were, therefore, given an additional T
implant and proceeded to show the same improvement as the combined group. It is
noteworthy that no other symptoms were reported, and no indication was given of
whether these women were suffering from tiredness, lack of concentration, or depression
before starting the implants.
Myers et al. (98) studied 40 naturally postmenopausal women who were randomly
assigned to 4 groups of 10 subjects each: P (Premarin only), PP (Premarin plus Provera),
PT (Premarin plus methyltestosterone), and PL (placebo); they were assessed over a 10wk
period. Subjects were assessed with both self-ratings and laboratory measurement of
vaginal pulse amplitude (VPA) response to erotic stimuli, a measure of genital response.
There were no group differences in treatment effects on any of the sexuality variables,
including VPA, except for masturbation. This showed a trend toward higher frequency
and a significant increase in enjoyment of masturbation in the PT group. There was a
trend (p = 0.06) toward group differences in mood, but, unfortunately, no further details
were given of this measure. This study illustrates well the complex effects of exogenous
hormone administration; in particular, an increase in SHBG in the P and PP groups and
a significantly lower level of SHBG in the PT group. Given that the three treatment
groups did not differ in their plasma E 2 levels, this demonstrates the likely increase of
free E 2 as well as T in the PT group.
Davis et al. (99) studied 34 women, 2 of whom had had their ovaries removed. All had
shown intolerance of or inadequate response to oral HRT. They were randomly assigned
to either E implant or E+T implants, administered three times monthly for 2 yr. Women
with specific complaints of low sexual desire were excluded. (It was considered unethical
to randomly assign them to E only!). This exclusion is important and will be discussed
further below. Women in both groups showed significant improvement in sexuality
measures, and for most of the variables, the E+T group improved significantly more than
the E group, except that toward the end of the 2-yr study period, there was a decline in
the measures of sexuality that was attributed to a reduced frequency of implants because
of continuing supraphysiological levels of T. This is a potentially interesting phenomenon
that, as we will see, recurs in other studies using supraphysiological doses. This
study is limited by having no measures of mood or well-being and behavioral measures
only relating to sex.