How to prescribe testosterone therapy to a female patient using testosterone cream?

Prescribing Testosterone Therapy to Female Patients Using Testosterone Cream

Testosterone therapy for females should be prescribed using commercially manufactured testosterone creams at lower doses than those used for males, with careful monitoring of serum testosterone levels to maintain them within the physiologic female range while minimizing androgenic side effects. 1

Indications and Patient Selection

When considering testosterone therapy for female patients, carefully evaluate:

• Primary indication: Hypoactive sexual desire disorder (HSDD) with personal distress 2
• Secondary indications (less evidence):
  • Low libido
  • Decreased arousal and orgasmic response
  • Sexual dysfunction after natural or surgical menopause

Important considerations before prescribing:

• Rule out other causes of sexual dysfunction (physical, psychosocial factors, medications)
• Ensure physiologic cause for reduced testosterone (e.g., bilateral oophorectomy)
• Verify patient has no contraindications:
  • Breast or uterine cancer
  • Cardiovascular disease
  • Liver disease 2

Dosing and Administration

Initial Dosing

• Start with significantly lower doses than used for males
  • For AndroForte 5% cream: Initial median dose of 50 mg daily (range 50-100 mg) 3
  • This is lower than the 100 mg starting dose recommended for hypogonadal men 3

Application Method

1. Apply to clean, dry, intact skin
2. Use only commercially manufactured products when possible (avoid compounded formulations due to inconsistent potency) 4
3. Apply to areas that will be covered by clothing to prevent transfer to others
4. Wash hands thoroughly with soap and water immediately after application 5
5. Cover application site with clothing after the gel has dried 5

Monitoring and Dose Adjustment

1. Measure baseline testosterone levels before starting therapy

2. Check serum total testosterone levels 2-3 months after treatment initiation

3. Target testosterone levels in the mid-normal female physiologic range

4. Adjust dose based on:

   • Serum testosterone levels
   • Clinical response (improvement in sexual function)
   • Presence of side effects

5. Continue monitoring testosterone levels every 6-12 months while on therapy 4

Safety Considerations and Side Effects

Potential Side Effects

• Androgenic effects: hirsutism, acne, voice deepening
• Polycythemia (reported in 7% of transgender individuals using testosterone cream) 3
• Potential cardiovascular effects
• Virilization (with excessive dosing)

Risk Mitigation

1. Use transdermal preparations (creams/gels) rather than oral formulations to avoid first-pass hepatic effects 2
2. Use the lowest effective dose for the shortest time needed to meet treatment goals
3. Monitor for androgenic side effects at each follow-up visit
4. Discontinue therapy if significant adverse effects occur
5. Counsel patients on proper application to prevent transfer to others, especially women and children 5

Special Considerations

Concomitant Estrogen Therapy

• Consider using testosterone with concomitant estrogen therapy in postmenopausal women
• Testosterone treatment without concomitant estrogen therapy has limited evidence 2

Non-Binary and Transgender Patients

• For transgender/non-binary patients seeking masculinization:
  • AndroForte 5% cream can be used at lower starting doses (50 mg daily) for those seeking slower masculinization 3
  • Higher doses may be used for more rapid masculinization effects

Clinical Pearls and Pitfalls

Common Pitfalls

1. Using laboratory assays that don't accurately detect testosterone at female ranges
2. Prescribing male-formulated products without appropriate dose adjustment
3. Inadequate monitoring for adverse effects
4. Failing to counsel patients about potential risks and benefits

Important Reminders

• No testosterone preparation is FDA-approved specifically for women
• Compounded testosterone creams have inconsistent potency and quality 4
• Long-term data on cardiovascular, cancer, and cognitive safety are lacking 1
• Injections or pellets cause supraphysiological testosterone levels and are not recommended for women 1

By following these guidelines, clinicians can safely prescribe testosterone therapy to female patients while minimizing risks and maximizing potential benefits for sexual function and quality of life.