Testosterone is an important but enigmatic female hormone. It acts directly as an androgen, as well as being an obligate precursor of estradiol biosynthesis. The control of testosterone production in women is not well known because no feedback mechanism has been described to regulate its production. Testosterone exerts physiological effects on female reproductive and non-reproductive tissues. Hormone concentrations are positively associated with sexual function, and many randomized, placebo-controlled studies have shown that it can be an effective treatment for female sexual dysfunction.
Physiology of androgens
During the reproductive years, in women testosterone is produced by the ovaries and by the peripheral conversion of androstenedione and dehydroepiandrosterone sulphate (SSDHEA), which are preandrogens synthesized by the ovaries and adrenal glands. In premenopausal women, preandrogens contribute approximately 50% of circulating testosterone.
First, testosterone concentrations begin to increase in girls between 6 and 8 years old, when the maturation of the adrenal reticular is zone leads to the highest production of SDHEA, announcing the beginning of adrenarche. The cyclic production of testosterone by the ovaries begins with the appearance of ovulation; the concentrations reach a maximum peak in the middle of the cycle and remain high during the lacteal phase.
A diurnal variation, characterized by higher concentrations in the morning, has also been documented. Maximum testosterone concentrations occur in the third and fourth decades of life, followed by a steady decline in both testosterone and its precursors, as age advances.
The physiological decrease of testosterone with age is not related to natural menopause. The reason for this decline is unknown but it is most likely due to the lower production resulting from the hypo function of the ovaries and adrenal glands.
Relationship between testosterone and female sexual function
The multi factorial nature of women’s sexual function, the range of approaches used to measure female sexual dysfunction and the drawbacks to measuring testosterone, its precursors and its metabolites have complicated this specialty. Despite these limitations, large cross-sectional and longitudinal studies have found consistent associations between androgens and female sexual function.
Importantly, sexual function is not related to changes in circulating levels of androgens in menopause or early post menopause, since blood levels of androgens do not change during the menopausal transition; In contrast, there are associations between specific androgens and self-reported measures of sexual function, both in premenopausal and postmenopausal women.
Testosterone and vaginal health
Traditionally, vulvovaginal atrophy is treated with low doses of estrogen vaginally, a highly effective and safe treatment. As for some women vaginal estrogens therapy is contraindicated (eg, women with breast cancer treated with aromatase inhibitors), the use of intravaginal testosterone has been proposed.
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Several studies have investigated the use of intravaginal testosterone in postmenopausal women without breast cancer. It has been shown that intramuscular testosterone propionate induces proliferation of vaginal epithelium in postmenopausal women.