Testosterone therapy in women in the menopause

• testosterone is an important endogenous female androgen; production drops gradually with age and by over 50% following surgical menopause or premature ovarian insufficiency (1, 2)
• NICE guidelines recommend considering testosterone supplementation for postmenopausal women presenting with low sexual desire (hypoactive sexual desire disorder [HSDD]) when systemic hormone replacement therapy (HRT) alone is ineffective (1, 4)
• all testosterone formulations used for women in the UK are prescribed off-label (e.g., Testogel 40.5 mg sachets, Tostran 2% gel), with the exception of specialist-imported licensed female products (e.g., AndroFeme 1% cream) (1, 3)

Physiological Role and Indications

Biological Function

• synthesis and origin: young females produce approximately 100 to 400 mcg daily (3 to 4 times the daily mass of oestrogen); derived equally from ovarian and adrenal precursors (e.g., androstenedione, DHEA) (2)
• physiological actions: acts directly or via peripheral conversion to oestrogen by aromatase; modulates central dopamine pathways to support libido, sexual arousal, orgasm, and sexual pleasure (2, 3)
• non-sexual symptoms: while androgen deficiency contributes to fatigue and reduced quality of life, current British Menopause Society (BMS) and global guidance state there is insufficient evidence to recommend testosterone for cognitive decline, mood disorders, bone density preservation, or general menopausal symptoms (2, 4)

Criteria for Initiation

• prerequisite oestrogenization: ensure systemic HRT is optimized (with local vaginal oestrogen where indicated) for at least 3 to 6 months before introducing testosterone (1, 4)
• switching routes: switching from oral to transdermal oestrogen lowers sex hormone-binding globulin (SHBG) and increases free circulating testosterone, which may resolve low libido without requiring exogenous androgen therapy (4)

Prescribing and Administration

Standard UK Off-Label Dosing Regimens

• Testogel 40.5 mg / 2.5 g sachet (1.62% gel) (3): 1/8 sachet daily (~5 mg/day; 1 sachet lasts 8 days)
• Tostran 2% gel (3): 1 metered pump (10 mg) applied every alternate day (0.5 g gel)
• AndroFeme 1% cream (specialist import / private prescription) (3): 0.5 ml daily (5 mg/day; 50 ml tube lasts 100 days)
• administration advice: apply to clean, dry skin on the lower abdomen or outer thigh; rotate sites to reduce local hair growth (3)

Contraindications and Precautions

• absolute contraindications: active liver disease, pregnancy, breastfeeding, and untreated upper-normal baseline testosterone / Free Androgen Index (FAI) (4)
• hormone-sensitive breast cancer: contra-indicated standardly; off-label specialist prescribing requires secondary care menopause service oversight and oncologist consultation (2, 4)

Investigation, Monitoring, and Adverse Effects

Baseline and Follow-Up Testing

• laboratory estimation: measure baseline total testosterone and SHBG to calculate FAI: FAI = (Total Testosterone / SHBG) * 100 (2, 5)
• target parameters: maintain FAI and total testosterone strictly within the normal female physiological range (typically FAI < 5%) to minimize androgenic side effects (2, 5)
• repeat testing: check serum levels at 2 to 3 months post-initiation and every 6 to 12 months thereafter (2, 5)
• trial length: evaluate clinical response at 3 to 6 months; discontinue therapy if no improvement in sexual wellbeing occurs by 6 months (2, 3)

Safety Profile and Side Effects

• adverse effects: localized hypertrichosis at application site, mild acne, or alopecia; voice deepening and clitoromegaly are rare and require immediate dose reduction or cessation (2)
• systemic safety: transdermal low-dose female testosterone does not adversely alter lipid profile, blood pressure, hepatic function, or short-term breast cancer risk (2, 3)

Reference:

1. National Institute for Health and Care Excellence (NICE). Menopause: identification and management. NICE Guideline [NG23]. Published November 2015; updated November 2024.
2. British Menopause Society (BMS). Testosterone Replacement in Menopause. BMS Menopause Practice Guideline. Published February 2020.
3. Scott A, Newson L. Should we be prescribing testosterone to perimenopausal and menopausal women? A guide to prescribing testosterone for women in primary care. Br J Gen Pract. 2020;70(693):203-204. DOI: 10.3399/bjgp20X709241.
4. British Menopause Society (BMS), Royal College of Obstetricians and Gynaecologists (RCOG), Society for Endocrinology. Joint position statement on best practice recommendations for the care of women experiencing the menopause. Post Reproductive Health. 2022;28(3):123-126. DOI: 10.1177/20533691221104868.
5. Chakrabarti R, Chakrabarti R. Prescribing hormone replacement therapy: key considerations for primary care physicians. Br J Gen Pract. 2023;73(732):330-332. DOI: 10.3399/bjgp23X733473.