What is the prescription protocol for testosterone (hormone replacement therapy) cream in a female patient?

From the Guidelines

Testosterone cream for women is not a standard treatment and should be approached with caution, considering the potential risks and benefits, and typically requires a prescription from a healthcare provider who specializes in hormone therapy, with a recommended dose not explicitly stated in the provided evidence, but generally, estrogen replacement therapy is the primary focus, and testosterone levels should be monitored and treated if necessary, with a goal of alleviating symptoms such as diminished libido or impaired sexual function, while minimizing potential side effects. When considering hormone replacement therapy for women, particularly those with premature ovarian insufficiency (POI), the primary focus is on estrogen replacement, with options including transdermal patches, vaginal gel, or oral estrogen 1. However, some women may experience diminished libido or impaired sexual function due to low circulating testosterone levels, and in these cases, testosterone therapy may be considered.

• The standard starting dose of testosterone cream is not explicitly stated in the provided evidence, but common formulations include AndroGel (1% or 1.62%), Testim, or compounded testosterone creams at concentrations of 0.5-2%.
• Treatment duration varies based on symptoms and response, with regular monitoring of testosterone levels (aiming for the upper range of normal female levels, typically 20-70 ng/dL) and potential side effects, such as acne, hair growth, voice deepening, and clitoral enlargement 1.
• Women may be prescribed testosterone for symptoms of low libido, fatigue, or decreased well-being, particularly after menopause or oophorectomy, and regular follow-up appointments every 3-6 months are necessary to monitor effectiveness and adjust dosing as needed.
• It is essential to note that testosterone therapy in women is often considered off-label use in many countries, as few testosterone products are specifically approved for women, and the decision to prescribe testosterone should be made on a case-by-case basis, taking into account the individual patient's needs and medical history 1.

From the Research

Testosterone Cream for Women

• The use of testosterone cream for women is supported by the International Society for the Study of Women's Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women 2.
• Systemic transdermal testosterone is recommended for women with hypoactive sexual desire disorder (HSDD) not primarily related to modifiable factors or comorbidities such as relationship or mental health problems.
• Government-approved transdermal male formulations can be used cautiously with dosing appropriate for women, and patients should be assessed for signs of androgen excess and total testosterone levels monitored to maintain concentrations in the physiologic premenopausal range 2.

Administration and Monitoring

• The aim of testosterone replacement therapy is to improve symptoms and signs of testosterone deficiency, including decreased libido, by increasing serum testosterone levels to the physiologic range 3.
• Transdermal application of testosterone gels are a commonly used route of testosterone administration, and can be used to treat hypogonadism in men 4, 5, 6.
• Patients should be monitored for signs of androgen excess and total testosterone levels should be monitored to maintain concentrations in the physiologic premenopausal range 2.
• Significant improvements in sexual function and quality of life can be noted with the use of testosterone gel 6.

Safety and Efficacy

• Safety data show no serious adverse events with physiologic testosterone use, but long-term safety has not been established 2.
• Testosterone replacement therapy is associated with multiple benefits, but the recommendations given in different guidelines are based on data from a limited number of randomized controlled trials 3.
• The use of testosterone gel has been shown to be efficacious with an acceptable safety profile, but further optimization of titration schema to reduce maximum testosterone concentration is warranted 6.