What is the appropriate prescription for testosterone cream for a postmenopausal woman undergoing Hormone Replacement Therapy (HRT)?

From the Guidelines

Testosterone cream can be prescribed for postmenopausal women experiencing symptoms like decreased libido, energy, and muscle mass, with a typical prescription being 1-2% testosterone cream applied daily to thin skin areas. The most recent and highest quality study, 1, found that intravaginal testosterone cream was safe and improved vaginal atrophy and sexual function in postmenopausal survivors of hormone receptor-positive breast cancer receiving aromatase inhibitor therapy. When prescribing testosterone cream, it is essential to start with the lowest effective dose and adjust as needed after 3-6 months based on symptom improvement and blood levels. The goal is to maintain testosterone levels in the upper range of normal for premenopausal women, typically 20-50 ng/dL. Some key points to consider when prescribing testosterone cream include:

• Applying the cream to thin skin areas, such as the inner thigh, upper arm, or lower abdomen, using approximately 0.5-1 gram (pea-sized amount) per application
• Monitoring for potential side effects, such as acne, hair growth, voice deepening, and clitoral enlargement, which are usually dose-dependent and reversible if caught early
• Regular blood tests every 3-6 months to check testosterone levels and potential effects on lipids and liver function
• Supervision by a healthcare provider experienced in hormone replacement therapy, as testosterone for women is typically compounded and used off-label in the United States. It is also important to note that testosterone is often prescribed alongside estrogen therapy, as the combination may provide better symptom relief than estrogen alone, as suggested by 1.

From the Research

Administration of Testosterone Cream for Postmenopausal Women

• Testosterone cream can be used for postmenopausal women with hypoactive sexual desire disorder, as it has shown short-term efficacy with few androgenic side effects 2.
• The preferred route of administration is transdermal, as it has a more neutral lipid profile compared to oral administration 3, 4.
• Custom-compounded products should be used with caution due to potential inconsistent dosing 3.
• Testosterone products formulated specifically for men have a risk of excessive dosing, although some clinicians use lower doses of these products in women 3.

Dosage and Monitoring

• The dosage of testosterone cream should be within premenopausal physiologic testosterone ranges 2.
• Laboratory testing of testosterone levels should be used only to monitor for supraphysiologic levels before and during therapy, not to diagnose testosterone insufficiency 3.
• Monitoring should also include subjective assessments of sexual response, desire, and satisfaction, as well as evaluation for potential adverse effects 3.

Safety and Efficacy

• Testosterone therapy has been shown to improve sexual function, including desire, arousal, orgasm, pleasure, and responsiveness, in postmenopausal women 5, 4.
• Common adverse effects include a decrease in high-density lipoprotein (HDL) cholesterol levels, acne, and hair growth 5, 4.
• Long-term data on cardiovascular, cancer, and cognitive safety are lacking 2.
• Testosterone therapy is contraindicated in women with breast or uterine cancer, or in those with cardiovascular or liver disease 3.