What is the appropriate initial testosterone dose for a 38-year-old female patient with a circulating testosterone level of 200 ng/mL?

Testosterone Therapy for a 38-Year-Old Female Patient

Testosterone therapy is not indicated for this female patient with a circulating testosterone level of 200 ng/mL, which is already significantly above the normal female reference range of 0.48-3.42 nmol/L (approximately 13.8-98.6 ng/dL).

Assessment of Current Testosterone Levels

The patient's reported testosterone level of 200 ng/mL (20,000 ng/dL) is:

• Extremely high for a female patient
• Far above the normal female reference range of 0.48-3.42 nmol/L (13.8-98.6 ng/dL) 1
• Even exceeds the normal male reference range of 300-950 ng/dL 2

Clinical Implications

Potential Health Risks

• This elevated testosterone level poses significant health risks including:
  • Virilization (development of male secondary sexual characteristics)
  • Menstrual irregularities
  • Polycythemia (increased red blood cell count)
  • Cardiovascular risks
  • Lipid abnormalities
  • Potential liver function abnormalities

Appropriate Clinical Approach

1. Investigate the cause of this extremely elevated testosterone level
2. Consider discontinuing any current testosterone supplementation
3. Evaluate for underlying conditions that could cause testosterone elevation:
   • Polycystic ovary syndrome (PCOS)
   • Adrenal disorders
   • Ovarian tumors
   • Exogenous testosterone use

Testosterone Therapy Guidelines

Testosterone therapy in women:

• Is not FDA-approved for general use in women
• Has been studied primarily in men with hypogonadism
• Carries significant risks of virilization in women 3
• When used in research settings for women, doses are typically 1/10 of male doses 3

Monitoring Recommendations

If the patient is currently on testosterone therapy:

• Immediately check complete blood count for polycythemia
• Assess liver function tests
• Evaluate cardiovascular risk factors
• Monitor for signs of virilization

Important Considerations

Normal Testosterone Ranges

• Female normal range: 0.48-3.42 nmol/L (13.8-98.6 ng/dL) 1
• Male normal range: 300-950 ng/dL 2

Therapeutic Goals

• For men requiring testosterone therapy, the American Urological Association recommends targeting levels in the middle tertile of the normal reference range (450-600 ng/dL) 3, 2
• No established therapeutic target exists for women, as testosterone therapy is not FDA-approved for general use in women

Conclusion

The proposed dose of 0.0251 weekly of 200 mg/mL testosterone (approximately 5 mg weekly) is inappropriate given the patient's already extremely elevated testosterone level. The clinical focus should be on investigating and addressing the cause of the current testosterone elevation rather than initiating additional testosterone therapy.