Part A. Serum Androgen Levels in Women Aged 20–49 Years with No Complaints of Sexual Dysfunction

Serum androgen levels in healthy premenopausal women with and without sexual dysfunction: Part A. Serum androgen levels in women aged 20–49 years with no complaints of sexual dysfunction

A Guay1*, R Munarriz2, J Jacobson1, L Talakoub2, A Traish2, F Quirk3, I Goldstein2 and R Spark4

1Center for Sexual Function, Lahey Clinic, Peabody, Massachusetts, USA; 2Institute for Sexual Medicine, Boston University School of Medicine, Boston, Massachusetts, USA; 3Central Research, Pfizer Ltd., Sandwich, UK; and 4Steroid Research Laboratory, Beth Israel-Deaconess Medical Center, Boston, Massachusetts, USA

Androgen insufficiency is a recognized cause of sexual dysfunction in men and women. Age-related decrements in adrenal and gonadal androgen levels also occur naturally in both sexes. At present, it is unclear if a woman’s low serum androgen level is a reflection of the expected normal age-related decline or indicative of an underlying androgen-deficient state. We studied premenopausal women with no complaints of sexual dysfunction to help define a normal female androgen profile. In all, 60 healthy, normally menstruating women, ages 20–49 y, were studied. The Abbreviated Sexual Function Questionnaire was administered along with a detailed interview. Radioimmunoassay measurements of morning serum testosterone (T), free testosterone (fT), dehydroepiandrosterone- sulfate (DHEAS), sex hormone-binding globulin (SHBG), and free androgen index (FAI) were measured during days 8–15 of the menstrual cycle. In women 20–49 y old without complaints of sexual dysfunction, serum androgen levels exhibit a progressive stepwise decline. Comparing values obtained in women age 20–29 y to those obtained in women 40–49 y, specific hormone decrements were DHEAS 195.6–140.4 lg/dl, serum T 51.5–33.7 ng/dl, fT 1.51–1.03 pg/ml. SHBG did not change significantly in women in this age group. The FAI reflected the age-related decrease in female androgen levels. The framework for the development of a female androgen profile in women with no complaints of sexual dysfunction has been established, and an age-related decrease in testosterone and its adrenal precursor, DHEAS, has been demonstrated. The FAI mirrors these decreases and its usefulness in clinical practice is confirmed. A precipitous decline in all androgens occurs after the decade of the 20s, yet SHBG does not show a significant change throughout the premenopausal years. International Journal of Impotence Research (2004) 16, 112–120. doi:10.1038/sj.ijir.3901178 Published online 4 March 2004

Keywords: diagnostic testing; endocrinology of sexual function

Introduction or adrenal source, causes virilism and hirsutism, symptoms demanding prompt medical attention. Inadequate androgen levels adversely impact The importance of male hormones (androgens) in women’s health, and female androgen insufficiency female health is often only apparent when a syndrome has recently been proposed.1 Progress in woman’s androgen levels are present in excess. this field has been hampered by the lack of precise Androgen hypersecretion, whether from an ovarian analytical methods and the lack of experimental models. This is further confounded by psychosocial and relationship issues as well as the changing hormonal status of women as they age. Testosterone insufficiency also shares symptoms with a variety of *Correspondence: A Guay, MD, Lahey Clinic Northshore, One Essex Center Drive, Peabody, MA 01960, USA. medical and psychological conditions, such as E-mail: [email protected] depression and chronic illness. This research was supported by a private grant from the An age-related decrease in androgen levels, includ- Ellithorpe family. ing gonadal testosterone and the adrenal androgen Received 19 March 2003; revised 2 June 2003; accepted 22 dehydroepiandrosterone-sulfate (DHEAS), has been June 2003 confirmed by many investigators, in order to Normal androgen levels in premenopausal women A Guay et al 113 differentiate women with normal age-related decre- In all, 10 women in the initial sample failed to ments in androgen levels from those who are experien- complete the survey and were therefore excluded. cing a bona fide age-defined androgen deficiency.2–7 Of the remaining 80 participants, an additional 12 Plasma androgen levels in control populations, in were screen failures, reducing the sample further to the presence or absence of normal sexual function, 68 females. Eight were dismissed due to questions have not been addressed. This is quite important, as on blood sampling, collection, and storage. The final suggested in Laumann’s study.8 His group found sample for study consisted of 60 women without that 43% of women (n ¼ 1749) between the ages of evidence of sexual dysfunction and with complete 18 and 59 y had some form of sexual dysfunction. laboratory information. A more careful dissection of these data will show that between 30 and 32% of women suffered from decreased sexual desire, and that this number Laboratory testing varied little across age, expressed in decades. Since testosterone insufficiency is one of the several Blood samples for hormone analysis were drawn in causes of decreased libido, the relationship of the morning between 0800 and 1200. Although the androgen blood test values in aging women without existence of a circadian rhythm for testosterone in sexual dysfunction must be better defined. women, as is known for men, has been debated, the Sexual problems surface in both sexes coincident evidence now points to higher levels in the fore- with the age-related decline in gonadal and adrenal noon.9,10 Blood samples were also collected during androgen levels. However, the relationship between the middle third of the menstrual cycle, between days low androgen levels and female sexual dysfunction 8 and 15, when androstenedione and testosterone remains unclear. The aim of this study was to levels are the highest.11,12 The blood samples were determine testosterone (T) and free testosterone (fT) quickly centrifuged, and stored frozen at À201 C. levels in healthy premenopausal women between the ages of 20 and 49 y with no complaints of sexual dysfunction. To this end, we screened healthy Hormone analyses premenopausal women for sexual dysfunction using selected domains of the Sexual Function Question- naire (SFQ) and evaluated androgen levels only in Serum samples were coded and maintained frozen at women who were proven not to have complaints of –201C. To avoid intra-assay variability, each hormone sexual dysfunction. was measured in a single continuous hormone assay. Hormone analyses were performed using commer- cially available radioimmunoassay kits. Materials and methods DHEAS was measured using a kit from by Diagnostic Products Corporation of Los Angeles, California, USA. Crossreactivity was 100% for Participants DHEAS and 0.121% with androstenedione, 15% with 9-hydroxyandrostenedione, 0.046% with es- trone 3 sulfate, 0.55% with androsterone sulfate, In all, 90 healthy, premenopausal volunteers, 0.5% with DHEA and negligible for all other steroids between the ages of 20 and 49 y, presented for tested. The interassay coefficient was 6.3–7.7%. evaluation to be normal controls. Interested women FT was measured using the Coat a Count Kits of responded to posters placed at the entrance to the Diagnostic Products Corporation, Los Angeles, Cali- above medical institutions in a manner acceptable to fornia, USA. Crossreactivity was 0.41% for dihydro- the respective Institutional Review Boards. These testosterone, 0.01% for androstenedione, 0.10% for included women having routine examinations, methyl testosterone and o0.01% for all other steroids family members, and interested medical personnel. tested. The interassay coefficient was 8.0–8.5%. The inclusion criteria required that subjects were in The total serum testosterone levels were measured stable, heterosexual relationships and were free with the Immunochem serum testosterone kit of ICN of acute or chronic medical and/or psychological Biomedicals Inc., Diagnostic Division of Costa Mesa, illnesses. Women were screened by structured California, USA. The crossreactivities of the anti- clinical interviews for complaints of women’s serum used in the T RIA were 7.8% for dihydro- sexual problems: irregular menstrual cycles, chronic testosterone, 2.0% for 11-oxosterone, 2.20% for 5 disease, substance abuse, anxiety, depression, and alpha androsterone 3 beta, 17 beta diol, and less medication use (especially oral contraceptives). The than 0.01% for all other steroids tested. The inter- absence of women’s sexual concerns was defined assay coefficients were 9.57–10%. through subjective reports of libido, arousal, and SHBG measurements were performed using the orgasm during an interview, as well as through double antibody method of Diagnostic Services Lab responses to a clinical survey instrument (Abbre- of Webster, Texas, USA. Crossreactivity was 100% for viated Sexual Function Questionnaire, ASFQ). SHBG and negative for TBG, IgG, albumin, and all

International Journal of Impotence Research Normal androgen levels in premenopausal women A Guay et al 114 other proteins tested. The assays for serum pregne- provided in Appendix B. The validation of this four nolone and 17-hydroxypregnenolone were performed domain, 15-item version of the SFQ is discussed in by Quest Laboratory in Tarzana, California, USA. Results section below.

Statistical analyses Free Androgen Index (FAI)1,13

Cronbach’s alpha and Gutman split-half reliabilities The calculation of the FAI was carried out using the were calculated to determine the internal consistency following formula: of the abbreviated SFQ. Principal components ana- Total testosterone ng=dl Â 0:0347 lysis with varimax rotation was used to determine the Â 100 ¼ FAI SHBG nmol=l survey’s factor structure and ultimately, the number of domains that comprised selected survey items. Individual patient responses were scored and Abbreviated Sexual Function Questionnaire (ASFQ) summed for each unobserved factor (or domain), thereby creating scores for multiple dimensions of As some women may be unaware of what constitu- sexual function. Descriptive statistics (ie means and tes ‘normal’ sexual functioning, or may seek to standard errors) were calculated for the entire provide socially appropriate answers during clinical population. The mean survey responses were then interview, the ASFQ was used to provide a more compared against the criteria for defining normal objective measure of FSD. The SFQ comprises 34 function per domain, based on guidelines provided questions that assess desire, lubrication, pain/ in the original instrument.14 discomfort with intercourse, emotional stress, plea- Labdataforthe60womenwerealsoseparatedinto sure, satisfaction, and ability to achieve orgasm.14 three age groups: women aged 20–29 y, women aged Respondents were asked to indicate the frequency 30–39 y, and women aged 40–49 y. Means and standard of sexual activity over the past 4 weeks using a seven- errors were computed for hormonal assays collected in point ordinal response scale in which ‘0’ indicated no each subgroup (ie DHEAS, SHBG, T, fT, and the FAI). activity and ‘6’ indicated very frequent activity (416 The small sample size of each of the three groups pre- sexual encounters during the past month). Respon- cluded the creation of Gaussian curves by decade, as dents were also asked to indicate how frequently they the limited number of women in each resulted in large experienced genital warmth and sensation, as well as standard deviations. Thus, standard error of the mean intimacy and enjoyment, anxiety, orgasm, and vaginal was used to create lab ranges for each cohort instead. lubrication or tingling. For these questions, a ‘0’ indi- Multiple range (Bonferroni) t-tests were conducted cated that the respondent had not been sexually to determine significant differences in the mean active, whereas a ‘5’ indicated a very frequent, intense, hormone values among the three cohorts. In addition, or pleasurable occurrence of the event. Finally, for Pearson’s product moment correlations were used to questions about desire, anxiety, perceived importance assess bivariate, linear associations between increasing of sexual behavior, and initiation of sexual activity, a age (in years) and hormone levels for all participants. five-point ordinal scale was used. A ‘1’ indicated no Finally, the relationship between age, adrenal, desire, worry, concern, or initiation, and a ‘5’ indi- and C-19 steroids (DHEAS and total testosterone) cated very frequent desire, worry, concern, or initiation. was compared to that reported previously in the Factor analysis of the original instrument revealed clinical literature. As these few studies were seven domains: Desire, physical Arousal-sensation, composed of very heterogeneous populations, we physical Arousal-lubrication, Enjoyment, Orgasm, could not perform meta-analysis of the associations Pain, and Partner Relationship, which demonstrated between age and hormones. Confidence intervals moderate to high internal consistency (ranging from (95%) were used to evaluate all pairwise compar- 0.65 to 0.91). isons of means. All P-levels reported are two-tailed. Questions concerning fear of pain, perceived Analyses for this study were conducted using SPSS emotional intimacy and relationship-centered anxi- Statistical Software for Windows, Version 10.0 ety, which constitute the domains of Enjoyment, (Chicago, Illinois, USA, 2002). Pain, and Partner, were eliminated from screening questionnaires to maintain a focus on the physiolo- gical sexual response in this study. The remaining Results domains of Desire, Arousal-lubrication, Arousal- sensation, and Orgasm were called the Abbreviated Patient population Sexual Function Questionnaire (ASFQ). These 15 questions, along with response options and scoring, are highlighted in Appendices A and B respectively. A total of 60 women meeting the inclusion criteria The criteria for determining normal function based were selected. The mean age of the 60 patients was on the sum of questions comprising each domain are 35.0 y (77.3; range: 22–48 y).

International Journal of Impotence Research Normal androgen levels in premenopausal women A Guay et al 115 Instrument validation the last 4 weeks, in general, how much pulsating (tingling) in your vagina/genital area did you notice when you took part in sexual activity? Reliability analysis of the 15 SFQ questions revealed The third domain, entitled ‘Arousal-lubrication’, a strong internal consistency, with a Cronbach’s consisted of questions concerning vaginal wetness, alpha coefficient of 0.96 and Gutman’s split-half specifically: (11) over the last 4 weeks, how often reliabilities of 0.89 and 0.98, respectively. Interitem did you notice vaginal wetness/lubrication when correlations also ranged from moderate to high you took part in sexual activity? and (12) over the (0.47–0.87), consistent with the analysis of the last 4 weeks, in general, how much vaginal wetness/ 14 original instrument. lubrication did you notice when you took part in The results of the principal components analysis sexual activity? confirmed the four domains of sexual function The fourth and final domain of ‘Orgasm’ asked generated in the original analysis; these are depicted about the frequency, pleasure, and ease of orgasmic in Figure 1. Domain 1, the latent variable termed response: (24) over the last 4 weeks, how often did ‘Desire’, comprised the following questions: (1) over you have an orgasm when you took part in sexual the last 4 weeks, how often have you had pleasur- activity (maybe with or without a partner); (25) over able thoughts and feelings about sexual activity? (2) the last 4 weeks, in general, how pleasurable were the over the last 4 weeks, how often have you wanted to orgasms that you had? and (26) over the last 4 weeks, be sensually touched and caressed by your partner?; in general, how easy was it for you to reach orgasm? (3) over the last 4 weeks, how often have you wanted Factor loadings of questions across all four to take part in sexual activity?; (4) over the last 4 domains were positive and high, ranging from 0.74 weeks, how often have you initiated sexual activity to 0.91, with no crossfactor loadings. with your partner?; (15) over the last 4 weeks, how often did you take part in sexual activity with penetration (e.g. vaginal penetration and intercourse)?; and (28) thinking about your sexual life Questionnaire response over the last 4 weeks, how often did you look forward to sexual activity? Domain 2, referred to as ‘Arousal-sensation’, Figure 2 shows mean responses (7s.e.m.) to each of comprised the following questions pertaining to the four domains of the abbreviated SFQ. Using the genital stimulation: (7) over the last 4 weeks, how criterion from Quirk et al,14 (Appendix B), we often did you have a feeling of warmth in your determined that a score greater than 23 was needed vagina/genital area when you took part in sexual to exhibit normal sexual desire. The 60 women activity?; (8) over the last 4 weeks, in general, how surveyed had a mean score of 27.1 for desire. much warmth did you feel in your vagina/genital Similarly, a score greater than 14 defined normal area when you took part in sexual activity; (9) over arousal sensation, whereas a score of nine or higher the last 4 weeks, how often did you have a sensation determined normal arousal lubrication. Our sample of pulsating (tingling) in your vagina/genital area had a mean score of 19.7 for the Arousal-sensation when you took part in sexual activity? and (10) over domain, and a mean score of 11.2 on the Arousal- lubrication domain. Finally, women without sexual dysfunction were required to score 12 or better on the Orgasm domain; the 60 respondents scored an average of 14.9. Having established, that the 60

35 Mean Domain Scores: Normal Women (n=60) 30 Minimum Score Required for Normal Function per Domain 27.1

25 23.0 19.7 20

15 14.0 14.0 12.0

10 8.5 8.0

0 Desire Arousal-Sensation Arousal-Lubrication Orgasm *Criterion for "normal" sexual function are as follows: Desire: > 23; Arousal-Sensation: >14; Arousal-Lubrication: >8, and Orgasm: >12 (Quirk, et. al. 2002) Figure 1 Rotated factor solution confirming four-factor structure Figure 2 Mean domain scores (7s.e.m.) for 60 women respond- of the 15 items selected from the SFQ. ing to the ASFQ.

International Journal of Impotence Research Normal androgen levels in premenopausal women A Guay et al 116 women were free of sexual dysfunction, we pro- 30–39 y (P ¼ 0.001) and the mean value of 32.8 ng/dl ceeded to examine their laboratory data from blood observed in women aged 40–49 y (P ¼ 0.03). Be- analyses. tween-group differences were less dramatic with respect to the fT. Mean values were highest, again, for the youngest cohort (women 20–29 y: 1.51 pg/ml; Hormone levels and age women 30–39 y: 1.10 pg/ml (P ¼ 0.04); women aged 40–49 y: 1.02 pg/ml; mean values significantly different between youngest and oldest women where Table 1 shows descriptive statistics for each of the P ¼ 0.04). five hormone assays according to age in decades. Table 2 briefly summarizes the bivariate correla- With respect to adrenal hormones, DHEAS was tions observed between age (in years) and each highest in women aged 20–29 y, at a mean of hormone for the entire sample of 60 women. Only 195.6 mg/dl. This was significantly higher than the SHBG did not exhibit a significant correlation with mean DHEAS score for women 30–39 y (154.9 mg/dl; age (r ¼ 0.10; P ¼ 0.67). However, significant, mod- P ¼ 0.001) and for women aged 40–49 y (140.4 mg/dl; erate, and negative correlations were observed Po0.001). Women in their 30s were also slightly between age and the four remaining hormones. but significantly higher on DHEAS than their The strongest correlation was between fT and age middle-aged counterparts (P ¼ 0.046). (r ¼À0.46; Po0.001), followed by FAI (r ¼À0.35; SHBG values were similar among all three P ¼ 0.006) and DHEAS, respectively (r ¼À0.35; cohorts, showing no significant difference between P ¼ 0.009). The weakest significant correlation was groups. A mean of 51.1 nmol/l was reported for the observed between T and age in years (r ¼À0.30; 20–29 y cohort, while a mean of 48.5 nmol/l was P ¼ 0.02). observed among those aged 30–39 y. In addition, a mean of 52.7 nmol/l was reported for women aged 40 y and older (all P-values40.65). The FAI, however, was almost twice as high for women aged Discussion 20–29 y (mean: 4.34), compared to women in their 30s (mean 2.50; Po0.001) or 40s (mean: 2.46; Po0.001). Since SHBG does not change, total Our data indicate that serum levels of androgens testosterone, therefore, reflects that of free decrease with age in women as reported for men. It testosterone. is generally accepted that a decrease in the adrenal The highest mean T level was observed among the androgen precursor, DHEAS, takes place in women, youngest women, aged 20–29 (mean ¼ 51.5 ng/dl). as well as in men, as they age. However, the decrease This value was significantly higher than the mean in testosterone with age is not well documented. value of 33.7 ng/dl observed among women aged Figure 3 provides a comparison of DHEAS levels

Table 1 Mean hormone levels ( þ s.e.m.) in 60 normal controls, by age (in decades)

Age 20–29 y (n ¼ 17) Age 30–39 y (n ¼ 23) Age 40–49 y (n ¼ 20)

Mean (7s.e.m.) s.e.m. range Mean (7s.e.m.) s.e.m. range Mean (7s.e.m.) s.e.m. range

Hormone DHEA (mg/dl) 195.6 ( þ 18.7) 176.9–214.3 154.9 ( þ 15.9) 139.0–170.8 140.4 ( þ 15.7) 124.7–156.1 SHBG (nmol/l) 51.1 ( þ 7.5) 43.6–58.6 48.5 ( þ 3.9) 44.6–52.4 52.7 ( þ 5.7) 47.0–58.4 Total testosterone (ng/dl) 51.5 ( þ 6.0) 45.5–57.5 33.7 ( þ 6.1) 27.6–39.8 32.8 ( þ 5.8) 27.0–38.6 A Free testosterone (pg/ml) 1.51 ( þ 0.12) 1.39–1.63 1.10 ( þ 0.08) 1.02–1.18 1.02 ( þ 0.12) 0.90–1.14 FAI 4.34 ( þ 0.62) 3.72–4.96 2.50 ( þ 0.6) 2.04–2.96 2.46 ( þ 0.48) 1.98–2.94

Hormones Groups P-values for significant differences*,** 95%CI for mean difference Significant Differences: DHEA-S (mg/dl) Age 20–29 y vs Age 30–39 y 0.001 (À19.4, 100.8) DHEA-S (mg/dl) Age 20–29 y vs Age 40–49 y o0.001 (À6.6, 117.1) DHEA-S (mg/dl) Age 30–39 y vs Age 40–49 y 0.046 (À40.8, 69.8) Total testosterone (ng/dl) Age 20–29 y vs Age 30–39 y 0.001 (À3.5, 40.0) Total testosterone (ng/dl) Age 20–29 y vs Age 40–49 y 0.031 (3.2, 40.7) A Free testosterone (pg/ml) Age 20–29 y vs Age 30–39 y 0.04 (0.06, 0.76) A Free testosterone (pg/ml) Age 20–29 y vs Age 40–49 y 0.04 (0.05, 0.77) FAI Age 20–29 y vs Age 30–39 y o0.001 (0.02, 0.2.2) FAI Age 20–29 y vs Age 40–49 y o0.001 (0.2, 2.1)

*Significant difference where Pr0.05. **Bonferroni t-tests used for all pairwise comparisons.

International Journal of Impotence Research Normal androgen levels in premenopausal women A Guay et al 117 Table 2 Bivariate correlations between age (in years) and DHEA-S vs Age Author hormone levels for 60 normal women 300 Labrie 250 Maccario Hormone Correlation coefficient P-value Sulcova 200 Orentreich DHEA-S (mg/dl) À0.35 0.009* 150 Lasley SHBG (nmol/l) þ .10 0.671 100 Total testosterone (ng/dl) À.30 0.022* * DHEA-S (ug/dL) A free testosterone (pg/ml) À.46 o0.001 50 FAI À.35 0.006* 0 10 15 20 25 30 35 40 45 50 55 60 65 70 75 *Statistically significant where Pr0.05. Age (yrs) Figure 3 Relationship between the decrease in DHEAS and the increase in age: a comparison of our data with the literature reported at various ages in the present study and in (adapted from Labrie et al,2 Maccario et al,3 Sulcova et al,4 five previously published works.2–6 Our data are Orentreich et al5 and Lasley et al 6). consistent with those in the literature concerning the decrease of DHEAS with age in women who were accepted as healthy controls. This is attributed Total Testosterone vs Age to the fact that assays for DHEAS are fairly similar 60 and easy to perform, so that the results do not vary 50 as much from laboratory to laboratory. Alternatively, 40 AUTHOR DHEAS is not bound to SHBG and therefore not 30 ZUMOFF prone to changes when SHBG varies with different (ng/dL) 20 clinical conditions, and also that DHEAS does not 10 Total Testosterone vary during the menstrual cycle. 0 Our data on testosterone also show that there is a 25 35 45 decrease in this hormone, irrespective of whether it Age (years) was determined by T, fT, or by calculating the FAI. Figure 4 Relationship of total testosterone with increasing age: Figure 4 compares the total testosterone levels by Author (2002) vs Zumoff (1995) (adapted from Zumoff et al7). age in the present study of normal women to a similar study of 33 women with normal sexual function by Zumoff.7 Zumoff and co-workers first assay is a trade secret and cannot be evaluated reported a linear decline of T with age. The mean T properly and independently. Wilke, and others, was recorded at approximately 28.0 ng/dl for women have suggested that the analog-free testosterone is in their 20s, 25.0 ng/dl for women in their 30s, and not affected by the level of SHBG, that is, that there 20.0 ng/dl for women over 30 y old. We report a is not a good negative correlation as there should larger decline in T for women in their 30s, with be.16 He found an r ¼À0.09, while Winters found mean values dropping from approximately 52 ng/dl a decent relationship with an r ¼À0.30.17 We have in the 20–29 y cohort to approximately 34 ng/dl also shown a good relationship, using larger and 33 ng/dl in the 30–39- and 40–49-year-old numbers of samples evaluated, with r ¼À0.31.13 groups, respectively. The larger sample size and A critical finding of our work is the marked use of a clinical assessment tool to screen women for decrease in androgens observed among women in sexual dysfunction may explain the higher their 30s. There is a smaller drop in testosterone T values observed herein. The possible impli- levels during the 40s. This observation is consistent cation is that we have excluded (by the ASFQues- with previous reports.2,4 Even the decrease in tionnaire) some women who had lower T levels, DHEAS is greatest after the 20s, but there is a which may have been manifested by a decrease in more consistent decrease that continues in the 30s sexual desire. and 40s. The measurement of fT by the analog method also SHBG was not significantly changed between the showed a decrease with age. Again, the largest ages of 20 and 49 y (ie the premenopausal period). decrease was observed among young women in their As SHBG is an integral part of the calculation of the 30s. The range is not as wide using the fT, as with FAI, the fact that SHBG does not change with age the other androgen measurements, but showed the indicates that the FAI decrease with age is related best correlation with decreasing age.15 Vermeulen, to a decrease in total, free, or bioavailable testoster- however, suggests that the results of the analog-free one and not due to protein binding. This would lend methods correlate highly with the results of the free credence to the recommendation of the Consensus testosterone by equilibrium dialysis (r ¼ 0.937), an Conference on Female Androgen Deficiency to use assay considered to be the gold standard, albeit the FAI in screening women for testosterone difficult for many laboratories to perform. A major deficiency.1 Although studies have been conducted concern is that the analog substance used in the during the perimenopausal transition and the

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International Journal of Impotence Research Normal androgen levels in premenopausal women A Guay et al 119 Appendix A. Abbreviated Sexual Function Questionnaire (ASFQ)

Desire Domain

1. Over the last 4 weeks, how often have you had 2. Over the last 4 weeks, how often have you wanted to be pleasurable thoughts and feelings about your activity? sexually touched and caressed by your partner?

{} Not at all (1) {} Not at all (1) {} Rarely (2) {} Rarely (2) {} Sometimes (3) {} Sometimes (3) {} Often (4) {} Often (4) {} Very often (5) {} Very often (5)

3. Over the past 4 weeks, how often have you wanted to 4. Over the last 4 weeks, how often have you initiated sexual take part in sexual activity? activity with your partner?

{} Not at all (1) {} Not at all (1) {} Rarely (2) {} Rarely (2) {} Sometimes (3) {} Sometimes (3) {} Often (4) {} Often (4) {} Very often (5) {} Very often (5)

13. {15} Over the last 4 weeks, how often did you take part 28. Thinking about your sexual life over the last 4 weeks, how in sexual activity with penetration (eg, vaginal penetration often did you look forward to sexual activity? and intercourse)?

{} I did not take part in sexual activity (0) {} Not at all (0) {} Once/twice (1) {} Rarely (1) {} 3–4 times (2) {} Sometimes (2) {} 5–8 times (3) {} Often (3) {} 9–12 times (4) {} Very often (4) {} 13–16 times (5) {} 416 times (6)

Arousal-Sensation Domain 7. Over the last 4 weeks, how often did you have a feeling 8. Over the last 4 weeks, in general, how much ‘‘warmth’’ did of ‘‘warmth’’ in your vaginal/genital area when you took you feel in your vaginal/genital area when you took part in part in sexual activity? sexual activity?

{} I did not take part in sexual activity (0) {} I did not take part in sexual activity (0) {} Not at all (1) {} None (1) {} Sometimes (2) {} Slightly warm (2) {} Often (3) {} Moderately warm (3) {} Very often (4) {} Very warm (4) {} Every time (5) {} Extremely warm (5)

9. Over the last 4 weeks, how often did you have a 10. Over the past 4 weeks, in general, how much ‘‘pulsating’’ sensation of ‘‘pulsating’’ (‘‘tingling’’ in your vaginal/genital (‘‘tingling’’) in your vaginal/genital area did you notice when area when you took part in sexual activity? you took part in sexual activity?

{} I did not take part in sexual activity (0) {} I did not take part in sexual activity (0) {} Not at all (1) {} No sensation (1) {} Sometimes (2) {} A mild sensation (2) {} Often (3) {} A moderate sensation (3) {} Very often (4) {} A strong sensation (4) {} Every time (5) {} A very strong sensation (5)

Lubrication-Arousal Domain 11. Over the last 4 weeks, how often did you notice vaginal 12. Over the last 4 weeks, in general, how much vaginal wetness/lubrication when you took part in sexual activity? wetness/lubrication did you notice when you took part in sexual activity?

{} I did not take part in sexual activity (0) {} I did not take part in sexual activity (0) {} Not at all (1) {} No wetness/lubrication (1) {} Sometimes (2) {} Slightly wet/lubricated (2) {} Often (3) {} Moderately wet/lubricated (3) {} Very often (4) {} Very wet/lubricated (4) {} Every time (5) {} Extremely wet/lubricated (5)

International Journal of Impotence Research Normal androgen levels in premenopausal women A Guay et al 120 Appendix A (Continued)

Orgasm Domain

22. (24) Over the last 4 weeks, how often did you have how 23. (25) Over the last 4 weeks, in general, how pleasurable an orgasm when you took part in sexual activity (may be were the orgasms you had? with or without a partner)?

{} I did not take part in sexual activity (0) {} I did not have any orgasms (0) {} Not at all (1) {} Not pleasurable (1) {} Sometimes (2) {} Slightly pleasurable (2) {} Often (3) {} Moderately pleasurable (3) {} Very often (4) {} Very pleasurable (4) {} Every time (5) {} Extremely pleasurable (5)

24. (26) Over the last 4 weeks, in general, how easy was it for you to reach orgasm?

{} I did not have any orgasms (0) {} Not pleasurable (1) {} Slightly pleasurable (2) {} Moderately pleasurable (3) {} Very pleasurable (4) {} Extremely pleasurable (5)

Appendix B

Criterion for determining normal sexual function can be summarized in Table B1 for the 15-item version of the SFQ

Table B1

Domain (factor) Questions Normal (non-FSD FSD score score)

Desire 1–4, 15, 28 Z23 o17 Arousal-sensation 7–10 Z14 o11 Arousal-lubrication 11, 12 Z8 o6 Orgasm 24–26 Z12 o9

International Journal of Impotence Research