What is the role of testosterone therapy in managing symptoms of perimenopause?

Testosterone Therapy in Perimenopause

Testosterone therapy is not recommended as a standard treatment for perimenopausal symptoms due to limited evidence supporting its efficacy and safety in this population. 1, 2

Understanding Perimenopause and Hormonal Changes

Perimenopause represents a transitional period before menopause characterized by:

• Vasomotor symptoms (hot flashes, night sweats)
• Vaginal dryness
• Sexual dysfunction
• Sleep disturbances
• Mood changes
• Cognitive dysfunction
• Arthralgias/myalgias
• Fatigue
• Changes in menstrual patterns 3, 1

These symptoms can significantly impact quality of life for many women.

Evidence on Testosterone in Perimenopause

The evidence regarding testosterone therapy specifically for perimenopausal women is limited:

• According to the North American Menopause Society position statement, endogenous testosterone levels have not been clearly linked to sexual function in postmenopausal women 2
• Most studies on testosterone therapy have focused on postmenopausal women or those who have undergone surgical menopause, with very limited data on perimenopausal women 4
• Available evidence indicates that testosterone may have a positive effect primarily on sexual function (desire, arousal, and orgasmic response) in women after menopause, but data for perimenopausal women is insufficient 2
• There is inadequate evidence to support testosterone use for other symptoms such as:
  • Preserving/increasing bone mineral density
  • Reducing hot flashes
  • Increasing lean body mass
  • Improving general well-being 2

Potential Risks and Concerns

Testosterone therapy carries several potential risks:

• Hirsutism and acne are common side effects 2, 4
• Unknown long-term risks regarding breast cancer, cardiovascular disease, and thromboembolic events 2
• Laboratory assays commonly used do not accurately detect testosterone at levels typically found in women 2
• No specific testosterone level has been clearly linked to a clinical syndrome of testosterone insufficiency 2

Current Recommended Approaches for Perimenopausal Symptom Management

For managing perimenopausal symptoms, the following evidence-based approaches are recommended:

1. Non-hormonal pharmacologic treatments for vasomotor symptoms:

   • Antidepressants (SSRIs/SNRIs)
   • Anticonvulsants (gabapentin)
   • Neuronal inhibitors
   • Certain antihypertensives (clonidine) 3, 1

2. For vaginal symptoms:

   • Vaginal moisturizers
   • Lubricants for sexual activity
   • Low-dose local estrogen preparations (rings, suppositories, creams) for vaginal dryness or atrophy 3, 1

3. Menopausal hormone therapy (MHT) for appropriate candidates:

   • Most effective therapy for vasomotor symptoms 3
   • Combination estrogen and progestins for women with an intact uterus
   • Estrogen alone for women without a uterus 3
   • Should be used at the lowest effective dose for the shortest time needed 5

When Testosterone Might Be Considered

Testosterone therapy might only be considered in very specific circumstances:

• Postmenopausal women with decreased sexual desire associated with personal distress
• When no other identifiable cause is present
• When there is a physiologic cause for reduced testosterone levels (e.g., bilateral oophorectomy)
• Only with concomitant estrogen therapy (based on available evidence) 2

Important Contraindications and Monitoring

Testosterone therapy is contraindicated in women with:

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

If testosterone is used (in appropriate candidates only), monitoring should include:

• Laboratory testing to monitor for supraphysiologic levels
• Subjective assessments of sexual response, desire, and satisfaction
• Evaluation for potential adverse effects 2

Clinical Pitfalls to Avoid

• Avoid using custom-compounded testosterone products due to inconsistent dosing 2
• Do not use testosterone products formulated for men without careful dose adjustment 2
• Do not rely on laboratory testing to diagnose "testosterone insufficiency" as no clear threshold exists 2
• Do not recommend testosterone for indications other than sexual dysfunction, as evidence is lacking 2
• Remember that the USPSTF recommends against using hormone therapy for primary prevention of chronic conditions in postmenopausal women 6