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Thank you for entrusting in the compounding services at MD Custom Rx to help meet the unique medication needs of your patients. We are excited to share with you our monthly newsletter and look forward to continuing to be your medication problem solvers. Please don't ever hesitate to let us know how we can be of further assistance to you and your practice.
Sincerely,
John, Dan and Monica |
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Therapy for Female Sexual Dysfunction
Female libido is multifactorial and complex. Declining estrogen levels in postmenopausal women affects vaginal function. A randomized controlled clinical trial included 80 postmenopausal women between 40 and 70 years of age evaluated female sexual function after using topical vaginal administration of estrogen, testosterone, or K-Y jelly as a placebo. The women were randomized to treatment with topical vaginal estrogen, testosterone, or oil lubricant alone, three times a week for a period of 12 weeks. The Female Sexual Function Index (FSFI) was used to assess changes in sexual response at baseline, and after 6 and 12 weeks. After 12 weeks of treatment, topical testosterone produced improvements in the FSFI domains of sexual desire, lubrication, satisfaction, reduced pain during intercourse, and total score compared with lubricant alone. Treatment with topical estrogen in comparison with lubricant alone showed an improvement in desire. The analysis over the time of the treatment showed that testosterone and estrogen improved desire and lubrication, and reduced pain. Furthermore, women who used testosterone showed improvements over time in arousal, orgasm, and satisfaction.1
In younger women, there is a correlation between the use of birth control pills and increased sexual dysfunction. Peri-menopausal and post-menopausal women often present clinically with low libido and pain with sexual activity. Properly balanced neurotransmitters, such as serotonin and dopamine, are also essential for maintenance of healthy libido and a woman's ability to achieve orgasm.2
Chronic stress is known to have negative effects on reproduction, but little is known about how it affects the sexual response cycle. A study conducted by the Department of Psychology, University of Texas at Austin, examined the relationship between chronic stress and sexual arousal and the mechanisms that mediate this relationship. They confirmed that women experiencing high levels of chronic stress show lower levels of genital arousal and dehydroepiandrosterone (DHEAS) and higher levels of cortisol and cognitive distraction compared with women with average levels of stress.3
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Low Testosterone Levels and Erectile Dysfunction
Erectile dysfunction is highly prevalent, affecting up to half of men in their 50-70s, and has been variably associated to a variety of causes including unhealthy lifestyles, such as smoking or overweight, or comorbidities such as hypertension, diabetes mellitus, and neurological disorders. General interest toward ED has exploded since the introduction of PDE5i drugs that are widely accepted as the first line treatment in patients suffering from this condition. In the last decade, the time lapse between first symptoms of sexual disorders and seeking of medical advice has greatly reduced. Unfortunately, no PDE5i has been proven curative, but rather the drug is a symptomatic treatment. Epidemiological data supports an inverse relationship between sexual health and testosterone levels, and it is well accepted that testosterone deficiency is a good marker of sexual and physical frailty. However, several other hormones, including LH, prolactin, TSH, and FT4 are involved in sexual functioning and should be investigated in a proper work-out of ED.4
Male hypogonadism, caused by intrinsic pathology of the hypothalamic-pituitary-testicular (HPT) axis, is an under-diagnosed condition. By contrast, late onset hypogonadism (LOH), due to functional suppression of the HPT axis from age-related comorbidities, may be less common than previously believed. Pathologically based hypogonadism is, after a thorough diagnostic work-up, treated with testosterone replacement therapy, unless fertility is desired. LOH with modest reductions in testosterone levels should primarily be managed by attention to lifestyle measures, especially weight loss, and optimization of comorbidities. Clear treatment goals should be identified, and efficacy and safety should be monitored according to published clinical practice guidelines.5
In contrast to women who experience a sudden drop in estradiol levels around the time that menses ceases, the age-related drop in testosterone in men is more gradual at 0.5-2.0% per year from early adulthood onwards. As levels of sex hormone binding globulin (SHBG) rise with age by 1-2% per year, the decline in free testosterone level is greater and is 2-3% per year. Most older men have testosterone levels within the reference range. However, the age-dependent decrease in testosterone levels is accelerated by accumulation of comorbidities, especially obesity. Indeed, a normal testosterone level can be considered to be a sensitive biomarker of good health.5
Many chronic diseases are associated with low testosterone levels via suppression of gonadotropin production. Testosterone levels are commonly lowered in men with metabolic syndrome, type 2 diabetes mellitus, obesity, depression, obstructive sleep apnea, chronic kidney disease or anorexia nervosa. In addition, certain medications, in particular glucocorticoids or opioids, reduce gonadotropins and testosterone levels.
Testosterone replacement is recommended for symptomatic classical androgen deficiency syndromes after excluding contraindications in the initial work up. Men with organic hypogonadism respond very well to testosterone replacement therapy and show a marked improvement in sexual function, sense of well being and energy levels, and maintenance of secondary sexual characteristics. However, testosterone therapy does not improve fertility; in fact, because of gonadotropin suppression, testosterone therapy may suppress spermatogenesis. Testosterone therapy should not be started without a thorough work-up to delineate the underlying etiology and identify associated pathologies. Older obese men with chronic comorbidities commonly present with non-specific symptoms and modestly low testosterone. In such men emphasis should be on weight loss and optimization of comorbidities. The risk-benefit ratio of testosterone therapy in such men is less favorable than in men with organic androgen deficiency.5
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Testosterone Therapy Can Reduce Male Fertility
The use of hormones for rejuvenation is increasing with the aging of the Baby Boomer population. Exogenous testosterone and anabolic androgenic steroids suppress intratesticular testosterone production, which may lead to azoospermia or severe oligozoospermia. Men desiring children at a later age may be unaware that treatment with testosterone and use of anabolic androgenic steroids have well-established detrimental effects on spermatogenesis, but sperm production may recover after therapy is stopped.6
When male fertility is a concern, the following approaches may be considered:
- Change in lifestyle to include strength training, a healthy diet, and decreased consumption of alcohol and nicotine
- Weight management
- Use of aromatase inhibitors such as anastrazole, chrysin, resveratrol and/or zinc to decrease aromatase activity and conversion of testosterone to estradiol, simultaneously affecting two potential causes of male infertility
- Use of 5-alpha-reductase inhibitors such as progesterone and/or saw palmetto to decrease 5-alpha reductase activity and conversion of testosterone to DHT
It is important to consider additional endocrine imbalances, including all hormones and cortisol, along with stress evaluation and reduction, to have a complete picture of factors contributing to sexual dysfunction.
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