Risks of menopausal androgen supplementation

There is increasing interest in the use of menopausal androgen replacement therapy (MART) in symptomatic women undergoing natural or surgical menopause. However, the efficacy of MART in alleviating these symptoms compared to traditional estrogen/progestin hormone replacement therapy remains a subject of debate. Accordingly, attention must be focused on the side-effects of the various MART preparations. The dose, alkylation, and route of administration of these compounds influences the development of side effects. While all androgens are potential virilizing agents, alkylated compounds have an additional risk of inducing severe hepatic consequences, regardless of their route of administration. Fortunately, the lower doses administered to women compared to men has not resulted in significant hepatic events. Generation of an adverse lipoprotein profile is possible but is not addressed in this article. Thus, virilizing and cutaneous side effects remain the primary concern. While some observational studies indicate acne and/or hirsutism are evident in tip to 38% and 36% of oral methyltestosterone-treated patients, respectively, other studies performed in a prospective fashion suggest a much lower incidence of approximately 5%. Other reported virilizing effects include deepening of the voice and clitoromegaly. Additional concerns are related to risks of developing endometrial hyperplasia when MART is used in conjunction with estrogens. Fortunately, concomitant progestin administration is protective. Finally, there is a theoretical concern that MART may increase the risk of developing breast cancer but this has not been demonstrated in clinical practice. Overall, the safety profile of MART appears to be acceptable when dosing avoids supraphysiologic testosterone levels.