Testosterone Therapy For Post-Menopausal Women

Testosterone is an important hormone in women’s wellbeing, but treatment with testosterone for women’s hypoactive sexual desire disorder (HSDD) has remained controversial. Multiple publications consisting of original research, reviews, and meta-analyses supporting the “off label use” of testosterone therapy for HSDD in postmenopausal women has been published over the past 25 years.  This includes the International Global Consensus Position Statement on the Use of Testosterone Therapy for Women published simultaneously in 4 journals, with authors representing multiple organizations including sexual medicine, endocrine, obstetrics and gynecology, and menopause societies. It provided clinical guidance regarding the use of testosterone therapy in women, examining the effect on sexual function; well-being, mood, and cognition; musculoskeletal effects; cardiovascular and breast health; as well as androgenic side effects and adverse events. However, there remains a need for a consensus clinical practice guideline that provides a comprehensive management strategy for the use of systemic testosterone in women with HSDD.

We do not suggest the routine use of androgen (testosterone) therapy for postmenopausal women. However, testosterone therapy that increases serum concentrations to the upper limit or slightly above the limit of normal for postmenopausal women has been shown to improve female sexual function in selected populations of postmenopausal women. There are approved testosterone products for women in Australia, but not in the United States. Testosterone levels in adult males are approximately 10 to 15 times higher than levels in females. Thus, for postmenopausal patients, a dose of testosterone should be 10 percent or less of the standard male dose. We do not recommend testosterone treatment that increase the levels in the low male range. Even though this may significantly increase sexual desire in females, it is not advised due to potential risks and side effects.

Government agencies are aware that the treatment of HSDD in postmenopausal women is an unmet need. However, FDA approved testosterone therapy for women is not currently available in the United States, presumably because of the lack of long-term efficacy and safety data and the barriers to product development and approval. Most important is the lack of guidance as to the types of studies, end points, results, and safety data required for approval, in contrast to the clear pathway for testosterone products for men.

For postmenopausal patients with hypoactive sexual desire disorder, testosterone therapy is an option for carefully selected patients. Candidates for therapy must have no contraindications to taking androgens or estrogens (as androgens are changed to estrogens in the body). The individual must be willing to accept potential testosterone side effects, and understand that this therapy is not approved for females by the US Food and Drug Administration (FDA).  A commonly used preparation is testosterone transdermal topical gel applied daily to the skin of the arms, legs, or abdomen in appropriate doses. The dose may be started lower and adjusted by blood test periodically under the supervision of the prescriber. We do not recommend compounded products because of the lack of efficacy and safety data.

It’s crucial to emphasize that any use of testosterone in women should be under the guidance of a medical professional, and women should not purchase unregulated products online or use products designed for men. Using inappropriate or too high a dose can cause side effects, such as acne, hair loss, and increased body hair growth. Overtreatment can also lead to voice deepening, clitoral enlargement, and breast reduction in some women. Testosterone supplementation can also increase the risk of developing blood clots, stroke, and heart disease, especially in women with a history of these conditions. It can also affect cholesterol levels, leading to an increase in bad cholesterol and a decrease in good cholesterol.

Although testosterone therapy should be considered only for post-menopausal women, limited data also support the use in late reproductive age premenopausal women in selected cases when there is no potential possibility of pregnancy in the future. We do not prescribe androgen therapy for premenopausal patients with hypoactive sexual desire disorder when there is the possibility of pregnancy in the future. Androgen therapy can lead to potential adverse events (e.g., inadvertent exposure to a developing fetus if pregnancy occurs).