What about using transdermal testosterone for treating menopausal symptoms?

Transdermal Testosterone for Menopausal Symptoms

Transdermal testosterone is not recommended as a first-line treatment for menopausal symptoms due to limited safety data in women with a history of hormone-dependent cancers and lack of FDA approval for this indication. 1

Evidence on Transdermal Testosterone for Menopausal Symptoms

Efficacy

• Transdermal testosterone has shown modest benefits for hypoactive sexual desire disorder (HSDD) in postmenopausal women, primarily improving:
  • Sexual desire and function
  • Adding approximately one satisfying sexual event per month
  • Reducing sexual distress 2, 3, 4

Safety Concerns

• No testosterone preparation is currently FDA-approved for women 2
• Safety data for testosterone use in survivors of hormonally mediated cancers are limited 1
• Current guidelines contraindicate testosterone therapy after breast cancer 1
• Long-term data on cardiovascular, cancer, and cognitive safety are lacking 2

Recommended Alternatives for Menopausal Symptoms

First-Line Options

1. Non-hormonal therapies:

   • SSRIs/SNRIs (venlafaxine, paroxetine) for vasomotor symptoms 1
   • Gabapentin for hot flashes 1
   • Vaginal moisturizers and lubricants for vaginal dryness 1

2. For vaginal symptoms:

   • Vaginal moisturizers and lubricants 1
   • Pelvic floor physical therapy for associated pelvic floor dysfunction 1
   • Vaginal dilators for pain during sexual activity 1

Second-Line Options (with caution)

1. For women without history of hormone-dependent cancers:

   • Ospemifene (SERM) for dyspareunia 1
   • Vaginal DHEA (prasterone) for vaginal dryness and dyspareunia 1
   • Flibanserin for premenopausal women with HSDD 1

2. For women with severe symptoms and no contraindications:

   • Low-dose vaginal estrogen (pills, rings, or creams) 1
   • Transdermal estradiol (preferred over oral formulations) with cyclic progesterone if uterus is intact 5

Special Considerations

For Breast Cancer Survivors

• Testosterone therapy is not recommended after breast cancer 1
• Current guidelines advise avoiding estrogen and tibolone due to potential increased risk of breast cancer recurrence 1
• Consider non-hormonal options like SSRIs/SNRIs, gabapentin, and vaginal moisturizers 1

Monitoring if Testosterone is Used

• Regular monitoring for androgenic side effects:
  • Acne and oily skin
  • Increased body hair
  • Voice changes
  • Clitoral enlargement 1
• Follow-up visits at 1-2 months after initiation, then every 3-6 months 1

Clinical Pitfalls to Avoid

1. Using supraphysiological doses - injections or pellets cause excessive testosterone levels and are not recommended 2
2. Using compounded testosterone creams without proper monitoring - these have variable potency and safety profiles 2
3. Failing to recognize that transdermal testosterone may cause skin reactions in up to 66% of users with patches and 5% with gels 1
4. Overlooking the potential for testosterone transfer to others (especially children) with transdermal preparations 1

In conclusion, while transdermal testosterone shows some benefit for sexual dysfunction in menopausal women, its use should be limited due to safety concerns and lack of FDA approval. Non-hormonal options should be prioritized, especially for women with a history of hormone-dependent cancers.