Written by Dr Genevieve Ferraris, GP and Menopause Specialist, The Menopause Hub
Menopause awareness is steadily growing, and more women are seeking information from friends, healthcare practitioners and social media to learn about menopause and HRT. An increasing area of interest in menopause is the use of testosterone and the perceived benefits thereof. Women may have heard that testosterone is ‘the missing hormone’ and will come to you asking for more information and or a prescription. It is helpful to understand when testosterone should be used, and the potential benefits and risks.
Testosterone in women comes from three sources:1
1. The ovaries (25%)
2. The adrenal glands (25%)
3. Peripheral conversion of androstendione (from the ovaries and adrenal glands) into testosterone
Levels of testosterone decline gradually with age, with the greatest drop occurring in women between the ages of 20 and 40.2 By menopause, the levels have plateaued and remain mostly stable. Levels only drop abruptly after bilateral oophorectomy.3
Androgens in women are essential for development of female sexual anatomy and physiology,4 as well as modulation of sexual behaviour and desire.3
The decision of when to prescribe testosterone should be based on symptoms and not on serum levels of testosterone. Women may have low testosterone levels and remain asymptomatic –testosterone replacement in this case in not appropriate.4 Currently, the only prescribing indication for testosterone is in postmenopausal women with low libido which is causing distress (hypoactive sexual desire disorder).3
Hypoactive sexual desire disorder (HSDD) is defined as ‘persistent or recurrent deficiency or absence of sexual fantasies and desire for sexual activity with marked distress and interpersonal difficulty’.3 A biopsychosocial approach should be taken in women with low libido as it is very multifactorial. Other causes, including relationship difficulties, psychological concerns, physical symptoms, sociocultural issues and medication side effects should be assessed for and treated appropriately first.3,4
Thus far, studies to date have not demonstrated beneficial effects of testosterone in women for mood, cognition, energy and musculoskeletal health.4 There is a need for good quality studies with these health issues as primary outcomes, as some patients do report an improvement in these areas with the use of testosterone therapy.4 There is also very little data currently available on the use of testosterone in premenopausal women.4
NICE Menopause Guidelines suggest that before a woman is started on testosterone therapy she should be offered a trial of conventional HRT,4 as her symptoms may improve simply with the initiation of an appropriate HRT regime. The incidence of potential adverse side effects may also be higher in women who are on testosterone-only therapy.4
If testosterone is to be used in a patient, there are various preparations available. There are currently no licensed testosterone products available for women in Ireland and the UK. It is therefore reasonable to prescribe licensed male preparations for female patients and down-titrated to an appropriate female dose.3,4 It is important that when counselling patients on the benefits and risks of testosterone that the use of an unlicensed product is also discussed, and recorded in their notes.2 IMC guidance on the prescription of unlicensed medication should be consulted. Of note, there is a 1% testosterone cream for women licensed in Australia (AndroFeme®) but which remains unlicensed outside of Australia.
Transdermal preparations provide the most physiologic form of replacement; intramuscular injections, subcutaneous pellets and oral preparations should be avoided in case of supraphysiologic levels and side effects.3 Transdermal preparations should be dosed to maintain premenopausal physiologic ranges – in most cases this will be one tenth of the prescription male dose.3,4 One of the most commonly prescribed products for women in Ireland is Testogel® 50mg sachets. Women should apply one tenth of a sachet (ie 5mg per day) once daily to the upper outer thigh or buttock. AndroFeme® is also available and is dosed as 0.5ml daily with a dosing applicator. It is applied in the same way as Testogel.
The most common side effects with testosterone are excess hair growth (especially in areas of gel application), acne and weight gain.4 These are reversible with dose reduction or discontinuation of the product. Male pattern baldness, voice deepening and clitoromegaly are very unlikely with physiologic doses.4 Clinical trials have shown no impact on lipid metabolism, cardiometabolic makers, liver function and breast density, however there remains a lack of long term safety data.3
Patients should be monitored for clinical response to treatment, with most patients noting an improvement in sexual function between 6 weeks and 3 months of use.3,4 They should then be followed up every 6 – 12 months, noting both benefits and any side effects.4 Treatment should be discontinued after 6 months of use if there has been no clinically significant improvement in symptoms.3
The British Menopause Society recommends that, prior to initiating treatment, women have blood tests to establish baseline testosterone levels (and to ensure that levels are not actually high before starting therapy).4 Total testosterone levels should then be repeated between 6 weeks and 3 months from starting, and thereafter every 6 – 12 months.4 Levels should be maintained within a physiologic range. Total testosterone levels, rather than free androgen index, provide a more accurate representation of response to treatment.
The menopause transition can be a difficult time in a woman’s life, and she may seek any treatment that could improve her symptoms. While testosterone does have a role to play in managing some of these symptoms, the benefits may have been oversold in the general media and we should remain mindful as practitioners as to when, why and how we prescribe it. However there are good guidelines that exist as above, and in patients where it is appropriate to prescribe testosterone we should not be afraid to do so.
References available on request
