Androgens in Health and Disease.pdf - E Library

Chapter 14/Androgens and Sexual Function 277
implicated for the mood changes and T for the sexual changes. There was also no
attempt, in either this study or the earlier one, to examine possible relationships between
sexuality and mood. A striking finding in the second study was the decline in behavioral
response in the presence of continuing supraphysiological levels of T. Although the
three groups in the Sherwin and Gelfand (109) study were selected to be comparable in
terms of mental health and unproblematic sexual relationships, no explanation was
given for why these three regimes had been selected for these particular women in the
first place, and without such explanation, the question of whether there were relevant
pretreatment differences between the groups remains.
Castelo-Branco et al. (111), in an open comparative study of hormone replacement in
surgically menopausal women, assessed sexual functioning before HRT and after 12 mo
on HRT. They compared estrogen alone (E), a combination of estrogen and a “weak”
androgen (described as dihydroandrosterone enanthate, which is presumably meant to
be dehydroepiandrosterone enanthate) (E+A), tibolone (Tb), a synthetic steroid with
both estrogenic and androgenic properties, and no treatment (NT). All three treatments
were associated with significant improvement in sexual functioning at the end of 1 yr.
However, the E+A and Tb regimes produced more marked improvement than E alone.
Shifren et al. (112), making use of new developments in transdermal T administration,
reported on 65 women who had undergone surgical menopause from 1 to 10 yr previously.
Their average age was 47 yr (range: 31–56). All had impaired sexual function and
all had been on Premarin, at least 0.625 mg daily for at least 2 mo when recruited for the
study. All subjects continued on the same dose of oral estrogen through the study. After
a 4-wk baseline assessment, they were all given daily transdermal patches with placebo
(P), 150 µg T or 300 µg T as the daily dose, each for 12 wk with the order of presentation
randomized. The principal methods of evaluation were the Brief Index of Sexual Functioning
for Women (BISFW), expressed as percentage of mean score for “normal”
women aged 20–55, and the Psychological General Well-Being Index (PGWI). These
were administered at baseline and at the end of each of the 12-wk treatment periods.
There was a substantial placebo response; however, taking the composite BISFW score,
there was significantly more improvement with the high T dose than with placebo.
Looking at the subscales, this effect was only significant for frequency of sexual activity
and pleasure/orgasm, not for sexual desire or arousal [the opposite pattern reported by
Sherwin et al. (106)]. For mood, there was a significantly greater improvement with the
high dose for the composite score, and also for the depression and “positive well-being”
subscales. The placebo response was more marked in the younger women; for those
under 48 yr, there was no difference between placebo and active treatment on any
variable; the overall significant effects depended on the older women. The explanation
for this age effect is not clear. It may reflect that for younger women, loss of sexual
interest or enjoyment is more problematic and, hence, the expectation of or need for
improvement greater. It seems unlikely that T would be more effective in the older
women, given that they had all had their ovaries removed. This study was also unusual
in reporting levels of free T as well as total T, and these showed that whereas the total
T levels were somewhat higher than normal on the higher T dose, the free T levels were
closer to the upper part of the normal range. The transdermal route appears to have the
advantage of delivering more physiological doses of T.
In a somewhat different type of study, Kaplan and Owett (113) reported on women
who had been referred to them for sexual problems and who had either undergone