What is the recommended dose of testosterone (T) for postmenopausal women when used in conjunction with estrogen (E) and progesterone (P) therapy?

Testosterone Dosing in Postmenopausal Hormone Therapy

For postmenopausal women using combined estrogen and progesterone therapy, testosterone should be administered at a dose of 300 μg/24 hours via transdermal patch as the preferred option, which has been shown to provide benefits without increasing breast cancer risk. 1

Recommended Testosterone Dosing

When adding testosterone to standard hormone therapy regimens for postmenopausal women:

• Transdermal testosterone patch: 300 μg/24 hours 1
• Alternative options:
  • Testosterone gel/cream formulations (custom-compounded products should be used with caution due to inconsistent dosing) 2
  • Oral testosterone undecanoate: 40 mg every 2 days (when used with estradiol valerate) 3

Standard Hormone Therapy Components

According to the North American Menopause Society guidelines, standard hormone therapy typically includes:

• Estrogen options:

  • Oral estradiol: 1-2 mg daily
  • Transdermal estradiol: 0.025-0.0375 mg/day patch 4

• Progesterone options (mandatory for women with intact uterus):

  • Oral micronized progesterone: 200 mg daily for 12-14 days per month (preferred option due to lower cardiovascular and breast cancer risk) 4
  • Medroxyprogesterone acetate: 2.5 mg/day (alternative) 4

Evidence for Testosterone Addition

Adding testosterone to standard hormone therapy has shown several benefits:

• Breast tissue effects: Testosterone counteracts estrogen/progestogen-induced breast cell proliferation, potentially reducing breast cancer risk 1

  • In a 6-month study, women receiving estrogen/progestogen without testosterone showed a fivefold increase in breast cell proliferation (1.1% to 6.2%)
  • Women receiving additional testosterone showed no significant increase (1.6% to 2.0%) 1

• Breast cancer risk: Addition of testosterone to conventional hormone therapy may reduce hormone therapy-associated breast cancer risk 5

  • Incidence rate with testosterone addition: 293 per 100,000 woman-years
  • Compared to estrogen/progestin alone: 380-521 per 100,000 woman-years 5

• Sexual function: Testosterone has positive effects on sexual desire, arousal, and orgasmic response in postmenopausal women 2

Important Considerations and Monitoring

• Indications: Testosterone therapy is primarily indicated for decreased sexual desire associated with personal distress in postmenopausal women 2

• Contraindications:

  • Breast or uterine cancer
  • Cardiovascular disease
  • Liver disease 2

• Monitoring:

  • Laboratory testing should be used to monitor for supraphysiologic testosterone levels, not to diagnose testosterone insufficiency 2
  • Monitor for adverse effects including hirsutism and acne 2
  • Assess sexual response, desire, and satisfaction subjectively 2

• Administration route: Transdermal patches and topical gels/creams are preferred over oral products due to first-pass hepatic effects 2

Cautions

• The U.S. Preventive Services Task Force recommends against using hormone therapy for primary prevention of chronic conditions (Grade D recommendation) 6, 4

• Testosterone products formulated specifically for men carry risk of excessive dosing 2

• Limited data exists regarding safety and efficacy of testosterone therapy:

  • In women not using concomitant estrogen therapy
  • For use longer than 6 months 2

• Potential endometrial effects: Testosterone with estrogen may alter sex hormone receptor expression in the endometrium 3

• Risk of inflammatory disease: Animal studies suggest testosterone with estrogen may induce metaplasia of genital epithelium, potentially reducing mucosal defense mechanisms 7