IMS Menopause Live

Effects of testosterone treatment on clitoral haemodynamics in women with sexual dysfunction

28 February 2022

Summary

Cipriani et al. [1] published the results of an observational - retrospective analysis that aimed at exploring the effects of testosterone treatment over clitoral color Doppler ultrasound (CDU) parameters in pre- and postmenopausal women with sexual dysfunction (n=81) after 6 months. For this, authors analyzed four groups of women: those that had received transdermal 2% testosterone alone (n=23, T), combined with vaginal estrogens (n=9, T+E), local vaginal estrogen (n=12, E), or vaginal moisturizers (n=37, M). Women underwent physical, laboratory, and genital CDU examinations at both visits (baseline and after 6 months) and completed different validated questionnaires, including the Female Sexual Function Index (FSFI). The main finding was that there was a significant increase in the clitoral artery’s blood flow. After six months, T therapy significantly increased clitoral artery peak systolic velocity (PSV) when compared to both M and E groups. In addition, as compared to baseline, T treatment was related with significantly higher FSFI scores (total and desire, pain, arousal, lubrication, orgasm domain scores) at 6 months. Similar findings were observed in the T + E group. No significant differences in the variations of total and high-density lipoprotein-cholesterol, triglycerides, fasting glycemia, insulin and glycated hemoglobin levels were found among the four groups and no adverse events were observed. The authors concluded that in women with sexual dysfunction, systemic T administration, either alone or combined with local estrogens, was associated with a positive effect on clitoral blood flow and a clinical improvement in sexual function, showing a good safety profile.

Commentary

Transdermal testosterone is prescribed for the management of postmenopausal hypoactive sexual desire disorder [2]. On a physiological level, testosterone appears to activate areas of the brain in the limbic system, involved with desire and female arousal [3]. Comparatively, hormone replacement therapy with testosterone in men has shown benefits in the erectile response, activating the central and peripheral nervous system through mechanisms of penile vasodilation [4]. It seems that in women there is a similar effect, since clitoral vasodilation is essential for arousal [5]. Androgens decrease progressively during the reproductive years of women, reaching the lowest concentrations at approximately 60 years of age [3]. The peripheral response to androgens is facilitated by a higher density of receptors in the external genitalia [6], increasing androgen receptor gene expression, local vasodilatation, mucification of the epithelium, and in consequence greater vaginal lubrication, blood flow in the clitoris, vulva, labia, vagina and proliferation of vaginal epithelial cells. Similarly, androgens also modulate adrenergic and nitric oxide signals [2,7]. The significant improvement of sexual function, as determined with FSFI a validated tool, and clitoral haemodynamics after the administration of testosterone alone and in combination with vaginal estrogen observed in this study is consistent with current evidence [2]. Despite being a small sampled retrospective analysis, this is the first pilot study to show the positive effect of testosterone (alone or combined) on hemodynamic parameters of the clitoris, demonstrating a peripheral benefit, which opens the field of research to possible local or systemic treatments with testosterone to improve the local arousal response in women with sexual dysfunction and associated symptoms.

We agree with the authors that the topic of T treatment in women needs other more in-depth research and the need of specifically designed randomized trials to confirm their original findings. However, these data points may be encouraging in advance of further knowledge and findings regarding the role of testosterone in the central nervous system and in the clitoris, thus providing more evidence regarding its impact on female sexuality.

Camilo Rueda-Beltz, MD
Universidad de la Sabana, Chía, Colombia
Clínica del Country-La Colina
Bogotá, Colombia

Isabella Dávila-Neri
Universidad de la Sabana, Clínica Universidad de La Sabana
Chía, Colombia

References

1. Cipriani S, Maseroli E, Di Stasi V, et al. Effects of testosterone treatment on clitoral haemodynamics in women with sexual dysfunction. J Endocrinol Invest. 2021;44(12):2765-2776.
https://pubmed.ncbi.nlm.nih.gov/34118018/
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https://pubmed.ncbi.nlm.nih.gov/31498871/
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https://pubmed.ncbi.nlm.nih.gov/29575969/
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https://pubmed.ncbi.nlm.nih.gov/9138056/
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https://pubmed.ncbi.nlm.nih.gov/32852449/
7. Parish SJ, Simon JA, Davis SR, et al. International Society for the Study of Women's Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women. J Sex Med. 2021;18(5):849-867.
https://pubmed.ncbi.nlm.nih.gov/33814355/