Testosterone in women: Early history of androgen therapy

Welcome back to another Contemporary OB/GYN Special Report series. In this episode, moderator Bruce Dorr, MD, FACOG, URPS, IFMCP, discusses testosterone therapy in women with Sharon J. Parish, MD.

Dorr opens the series by noting that he has practiced through remarkable changes in how clinicians understand women's hormones. Some of those changes, he says, were driven by science, some by fear, and some by assumptions that probably should have been questioned from the beginning.

Dorr points out that testosterone in women can sound like a new idea, even though women were treated with androgens nearly a century ago. Parish explains that the history of medicine can offer both reassurance and context when clinicians face controversial questions. For her, the testosterone story begins in the 1970s and 1980s with Helen Singer Kaplan, a psychiatrist at Cornell who pioneered the use of small-dose testosterone implants in research on women's desire.

According to Parish, Kaplan's work was purely research driven, because no product was approved at that time. Kaplan found a fine line between overtreatment and the benefit of turning women's brains back on. The effect was thought to act at the level of the central nervous system, with peripheral responses as well, when the dose kept women in the range they once had. Kaplan was particularly interested in women moving through perimenopause and menopause into older age.

Parish emphasizes that the barrier to testosterone therapy for women has never really been efficacy. Instead, it has always been providing adequate safety data from longer-term trials. When Dorr asks why early interest did not translate into enduring evidence, Parish points to gaps in gender-specific research, noting that women's sexual health research is still catching up. Companies pursued products and clinicians adapted products approved for men, but adequately powered trials with outcomes sufficient for approval proved difficult to achieve.

In the next episode, Dorr and Parish examine how the success of conjugated equine estrogen and an estrogen-deficiency view of menopause pushed androgens to the margins of women's health.