What are the guidelines for testosterone replacement therapy in females with low libido?

Testosterone Replacement Therapy in Females with Low Libido

Testosterone therapy should be considered for postmenopausal women with hypoactive sexual desire disorder (HSDD) when other causes have been ruled out, but it is not routinely recommended for premenopausal women due to limited safety data. 1

Diagnostic Approach for Low Libido

Before considering testosterone therapy, evaluate:

1. Rule out modifiable factors:

   • Relationship problems
   • Mental health issues (depression, anxiety)
   • Medication side effects (especially SSRIs/SNRIs) 2
   • Vaginal dryness/dyspareunia requiring local estrogen treatment

2. Laboratory testing:

   • Baseline total testosterone level (not for diagnosis but for monitoring) 1
   • Consider other hormonal testing (estrogen levels, thyroid function)

Indications for Testosterone Therapy

Testosterone replacement is most appropriate for:

• Postmenopausal women (natural or surgical) with HSDD 1, 3
• Women with premature ovarian insufficiency (POI) with persistent low libido despite adequate estrogen replacement 2
• Women with hypopituitarism or adrenal insufficiency with low libido 2

Contraindications

Testosterone therapy should be avoided in:

• Women with breast cancer history 2
• Untreated vaginal dryness (address this first)
• Pregnancy or women trying to conceive
• Severe acne or hirsutism
• Undiagnosed abnormal genital bleeding
• Active liver disease

Treatment Protocol

1. Formulations:

   • Transdermal preparations are preferred (patches, gels) 1, 4
   • Male formulations can be used with appropriate dosing adjustments for women 1
   • Compounded products are not recommended due to lack of safety/efficacy data 1

2. Dosing:

   • Target physiologic premenopausal testosterone ranges 1
   • Start with low doses and titrate based on response and testosterone levels
   • Typical starting dose: 300 μg/day via transdermal application (approximately 1/10 of male dosing)

3. Monitoring:

   • Baseline and follow-up testosterone levels (maintain in physiologic premenopausal range) 1
   • Clinical assessment at 3-6 months for efficacy and side effects
   • Monitor for signs of androgen excess (acne, hirsutism, voice changes)
   • Long-term monitoring (annual visits) if therapy continues

Expected Benefits and Limitations

• Moderate therapeutic benefit for sexual desire and satisfaction 1, 4
• Effects typically seen within 3-6 months
• If no improvement after 6 months of adequate dosing, consider discontinuation
• Benefits may include improved sexual desire, arousal, and satisfaction

Safety Considerations

1. Short-term safety:

   • Mild side effects may include acne, hair growth, and mild voice changes
   • Monitor for androgenic side effects at each visit

2. Long-term safety:

   • Long-term safety data beyond 24 months is limited 1, 4
   • No clear evidence of increased cardiovascular risk with physiologic dosing
   • Theoretical concerns about breast cancer risk, though recent data suggests androgens may actually suppress proliferative effects of estrogen 4

Special Populations

1. Breast cancer survivors:

   • Testosterone therapy is not recommended 2
   • Consider non-hormonal approaches for sexual dysfunction

2. Women with POI:

   • May benefit from testosterone supplementation when estrogen replacement is already optimized 2
   • Careful monitoring required

3. Premenopausal women:

   • Limited data supports use in late reproductive age women 1
   • Recent studies show increasing prescriptions in this population despite limited evidence 5

Alternative Approaches for Low Libido

If testosterone is contraindicated or ineffective:

• Optimize estrogen replacement (if postmenopausal)
• Consider bupropion for sexual dysfunction, especially if on SSRIs 2
• Sex therapy and psychological interventions
• Address vaginal dryness with local estrogen or lubricants 2

Clinical Pearls

• Testosterone therapy is currently off-label for women in most countries
• Informed consent discussion should include off-label status and limited long-term safety data
• Treatment should be discontinued if no benefit is observed after 6 months
• Testosterone may not be effective without adequate circulating estrogen 2
• Recent data shows increasing testosterone prescriptions for HSDD, particularly in women aged 41-55 5

Remember that testosterone is just one component of managing female sexual dysfunction, and a comprehensive approach addressing psychological, relationship, and physical factors is essential for optimal outcomes.