Low Testosterone in Women Many may be surprised that women can have testosterone! Women need testosterone to function but need it much less than men. Let us visually examine what testosterone does for women. Androgen physiology in women Androgens are essentially prohormones for other steroids in women including estrogens.
The building block for androgens is cholesterol, which is obtained in the diet. Androgens influence not only men, but women as well in their development. Androgens influence sexual desire, bone density, muscle vigor and mass, mood, energy and psychological salubrity. Androgens in women are engendered in the ovaries as well as the adrenals. Approximately 25% of androgen biosynthesis takes place in the ovaries, 25% by the adrenal glands and 50% by peripheral tissues.1 Androgens in women include testosterone, DHEA, DHEAS, androstenedione and 5 ά-dihydrotestsoterone (DHT). Of the androgenic steroids, testosterone and DHT have the most biological activity. Circulating testosterone is converted to DHT as well as estradiol (E2). On the other hand, DHEAS is engendered mainly in the adrenals and are converted to DHEA by steroid sulphatase. DHEA is engendered by both the adrenals and the ovaries. Luteinizing hormone (LH) stimulates androgen secretion by the ovaries. On the other hand, androgen secretion by the adrenals is controlled by adrenocorticotrophin (ACTH). Androgens work on multiple organ systems and receptors in women. It can influence the hypothalamus and limbic system and hence influence mood and recollection.2 In additament, androgens can influence sweat glands thus causing acne as well as in other areas in the bone, muscle, genitals and the cardiovascular system. Some of the effects of androgens are direct, whereas some are the result of conversion to E2 or DHT. Effects of low testosterone in women Different terminologies have been offered for low testosterone in women, including “Female Androgen Paucity Syndrome- FAIS” and “Hypoactive Sexual Disorder- HSDD” This syndrome or disorder can present with the following i. Decreased libido, sexual receptivity & pleasure
ii. Low energy and sedulous, unexplained fatigue
iii. Dysphoric changes
iv. Diminished psychological well being
v. Blunted motivation
vi. Bone density changes
vii. Muscle mass & vigor changes
viii. Fat redistribution
ix. Sexual hair changes
x. Cognitive and recollection changes
In a sense, this is very kindred to the Androgen Deficiency Androgen Males (ADAM) syndrome. However, unlike in males, testosterone in women is considered to be low if they are less than 20ng/dl, and conventionally lower than 10ng/dl after oophorectomy. The low testosterone levels subsist in the presence of mundane estrogen levels. Another caveat to be noted is that women taking oral estrogen incline to have higher calibers of testosterone. As such, in women on estrogen, it is preferable to quantify free or bioavailable testosterone levels. In general, women engender about 10% of the testosterone that men engender. One of the main sources of androgens in women emanates from the adrenals; and is in the form of DHEA with more minuscule amounts of testosterone emanating from the ovaries. DHEA is not stable in the blood, and it is much more facile to quantify DHEAS. A challenging area in medicine is the definition of normality. Typically, two standard deviations from mundane has been defined as mundane. Lamentably, receptor affinity cannot be quantified and the concept of relative hypogonadism has been discussed. Difficulties with Diagnosis As in the ADAM, there are consequential challenges in making a diagnosis of the FAI syndrome or HSSD. Symptoms can be very non-categorical as exemplified in the first case. Many clinical conditions can overlap or present with such symptomatology. Among the prevalent conditions, the following have to be omitted:
- Clinical melancholy
- Hypothyroidism or hyperthyroidism
- Major metabolic or alimental disorders e.g. anemia
- Chronic fatigue syndrome
- Immunologic diseases e.g. rheumatoid arthritis, systemic lupus erythematosus and HIV-AVAILS
- Major life stress or relationship quandaries have to be omitted
- Many medications can suppress levels of testosterone levels in women including antiandrogens (e.g. Lupron), corticosteroids, oral contraceptives or oral estrogen supersession therapies. In considering the etiological of low testosterone, the Princeton Consensus Verbalization has suggested that there be 5 categories:
i. Is it of ovarian inception? Patients could have had chemotherapy or radiation therapy, both of which can ravage ovarian cells. Alternatively, a surgical operation such as an oophorectomy can abstract the source of androgens.
ii. Is it of adrenal inchoation? As mentioned above, an immensely colossal source of androgens in women emanate from the adrenals, and an adrenalectomy or adrenal paucity can result in low amounts of androgens. Adrenal paucity can result from Addison’s disease or a cognate immunologic disorder.
iii. Is it of a hypothalamic-pituitary inchoation? Any vilification to the hypothalamic pituitary axis can result in a hypoandrogenic state. Revilements could be vascular or tumors, and these have to be omitted.
iv. Could it be secondary to drugs? These include antiandrogens, corticosteroids, oral contraceptives or oral estrogen supersession therapies. v. Idiopathic- no cause could be identified. If you have such issues, please contact us at Opal Medical Clinic and our web site is www.opalmendical.com.