Dr Fiona MacRae specialises in integrative women’s health and bioidentical hormone balancing. She is an expert in bio-identical hormonal replenishment therapy for the Marion Gluck Clinic, which pioneered the use of bioidentical hormones to treat menopause, perimenopause, and other hormone-related issues.
Here, she discusses the role of androgens in the health of men and women
Androgens, commonly referred to as male sex steroids, play vital roles in the health and wellbeing of both men and women. These sex steroid hormones include testosterone, dihydrotestosterone (DHT), and dehydroepiandrosterone (DHEA). Though predominantly associated with male physiology, they perform critical functions across genders, influencing everything from bone density to libido. Understanding their multifaceted role and the challenges surrounding their management sheds light on the growing importance of personalised hormone therapies.
Androgens in men
In men, androgens – chiefly testosterone – are fundamental to the development and maintenance of male characteristics and reproductive health. Testosterone regulates libido, bone mass, fat distribution, muscle mass, strength, red blood cell production, and sperm generation. As men age, testosterone levels naturally decline, leading to a range of physical and psychological changes. This decline, often referred to as ‘andropause’, has prompted increasing research into its broader health impacts.
Androgens in women
Although androgen levels are lower in women than men, they are no less significant. Androgens influence libido, hair growth during puberty, and the maintenance of bone density. Primarily produced in the ovaries, adrenal glands, and peripheral tissues, these hormones are critical to overall hormonal balance. One notable use of androgens in female health is intravaginal DHEA, an FDA-approved treatment for genitourinary syndrome of menopause, highlighting their therapeutic potential.
Androgen-related health challenges
The balance of androgens is delicate, and both excess and deficiency can lead to health concerns. In men, low androgen levels, often resulting from hypogonadism, are associated with decreased libido, fatigue, muscle weakness, and weight gain. This condition can stem from primary testicular failure or secondary causes linked to pituitary or hypothalamic disorders. Conversely, excessive testosterone or heightened sensitivity to DHT can lead to conditions such as androgenic alopecia (male-pattern hair loss).
While testosterone replacement therapy (TRT) is a common treatment for low testosterone, it comes with potential risks. Hepatotoxic androgens should be avoided due to liver toxicity, and TRT can temporarily suppress spermatogenesis, posing challenges for men who wish to preserve fertility. Elevated red blood cell production from testosterone treatment may also increase the risk of blood clots, requiring careful risk-benefit analyses before initiating therapy.
In women, excess androgens often manifest as polycystic ovary syndrome (PCOS), a condition marked by irregular menstrual cycles, hirsutism, and acne. PCOS has a complex aetiology, with genetic, hormonal, and metabolic factors at play. Androgenic alopecia, another common issue, is often linked to hormonal imbalances and can be distressing for affected women.
Key challenges in diagnosing and treating androgen-related conditions
Managing androgen-related disorders requires a nuanced and individualised approach. Key challenges can include:
- Diagnostic complexity:
- Symptoms of androgen excess or deficiency can overlap with other conditions, complicating diagnosis. For instance, cortisol disruption may mimic androgen imbalance symptoms, such as weight gain and thinning bones. In men, testosterone levels naturally vary, with peak levels typically occurring in the morning (7:00–10:00 AM), making the timing of blood tests critical. This diurnal variation is less studied in women, further complicating diagnosis.
- Balancing treatments:
- Hormone therapies, such as TRT, must be carefully managed to avoid adverse effects. In men, TRT can increase prostate-specific antigen (PSA) levels, potentially feeding undiagnosed prostate cancer. Similarly, elevated testosterone can exacerbate hair loss in individuals predisposed to androgenic alopecia. For women, treatments for PCOS or other androgen-related conditions require careful monitoring to avoid exacerbating metabolic or cardiovascular risks.
- Individual variability:
- Responses to androgen therapies can vary widely among individuals. Factors such as genetic predispositions, metabolic differences, and co-existing health conditions necessitate personalised treatment strategies.
- Long-term management:
- Many androgen-related conditions, such as hypogonadism or PCOS, require ongoing treatment. This long-term approach can lead to compliance challenges and concerns about the lack of extensive safety data for certain therapies.
Advances in androgen research and treatment
Ongoing research continues to shed light on the complexities of androgen-related health issues and offers hope for more effective treatments. Notable developments include:
- Selective Androgen Receptor Modulators (SARMs):
- These novel therapies aim to provide the benefits of traditional androgen treatments with fewer side effects, offering promising alternatives for conditions like hypogonadism.
- PCOS research:
- Advances in understanding the genetic basis of PCOS and the role of lifestyle interventions in managing symptoms hold promise for more effective and targeted therapies.
- Men’s health awareness:
- Growing recognition of ‘andropause’ has spurred research into the broader impacts of ageing-related testosterone decline, with studies like the TEAAM trial highlighting the potential benefits of TRT for improving physical performance in older men.
- Biomarkers and genetics:
- Research into specific biomarkers and genetic predispositions aims to improve the accuracy of diagnoses and the personalisation of treatments for androgen-related disorders.
Overall, androgens play a critical role in the health of both men and women, influencing everything from reproductive health to bone density and metabolic function. While significant progress has been made, ongoing research continues to address treatment complexities and underlying mechanisms associated with androgen-related health issues. As our understanding of androgen-related health issues continues to evolve, so too will the strategies for effectively managing them.
