What are the options for testosterone replacement therapy in women?

Testosterone Replacement Therapy Options for Women

Transdermal patches and topical gels or creams are the preferred testosterone replacement therapy options for women with decreased sexual desire associated with personal distress, as they avoid the first-pass hepatic effects seen with oral formulations. 1

Indications for Testosterone Therapy in Women

• Testosterone therapy should only be considered for postmenopausal women with decreased sexual desire associated with personal distress and with no other identifiable cause 1
• Current evidence supports testosterone therapy primarily for improving sexual function, including desire, arousal, and orgasmic response in women after spontaneous or surgically induced menopause 1
• Testosterone therapy is not recommended for other indications such as preserving bone mineral density, reducing hot flashes, increasing lean body mass, or improving general well-being due to inadequate supporting data 1

Available Formulations

• Transdermal patches and topical gels/creams: These are the preferred formulations for women as they avoid first-pass hepatic effects documented with oral formulations 1
• Oral formulations: Not recommended due to first-pass hepatic effects 1
• Custom-compounded products: Should be used with caution due to potentially inconsistent dosing compared to government-approved products 1
• Men's testosterone products: These carry a risk of excessive dosing in women, though some clinicians use lower doses of these products 1

Monitoring and Safety Considerations

• Laboratory testing should be used only to monitor for supraphysiologic testosterone levels before and during therapy, not to diagnose testosterone insufficiency 1
• Monitoring should include subjective assessments of sexual response, desire, and satisfaction as well as evaluation for potential adverse effects 1
• Common side effects include hirsutism and acne, though the actual risks are not well defined 1
• Long-term safety data regarding breast cancer, cardiovascular disease, or thromboembolic events risk is lacking 1
• Testosterone therapy without concomitant estrogen therapy is not recommended due to lack of evidence 1

Contraindications

• Testosterone therapy is contraindicated in women with:
  • Breast or uterine cancer 1
  • Cardiovascular disease 1
  • Liver disease 1

Pre-Treatment Evaluation

• Before initiating testosterone therapy, clinicians should:
  • Rule out causes not related to testosterone levels (physical and psychosocial factors, medications) 1
  • Ensure there is a physiologic cause for reduced testosterone levels (e.g., bilateral oophorectomy) 1
  • Counsel patients regarding potential risks and benefits 1

Treatment Approach

• Testosterone should be administered at the lowest dose for the shortest time that meets treatment goals 1
• Healthy young women produce approximately 300 micrograms of testosterone daily, with about half derived from the ovaries and half from the adrenal glands 2
• Clinical trials have demonstrated that the addition of testosterone to estrogen significantly improved multiple facets of sexual functioning including libido and sexual desire, arousal, frequency, and satisfaction 3

Common Pitfalls and Caveats

• Clinically available laboratory assays do not accurately detect testosterone concentrations at values typically found in women 1
• No specific testosterone level has been clearly linked to a clinical syndrome of hypoandrogenism or testosterone insufficiency 1
• The Endocrine Society recommends against making a diagnosis of androgen deficiency in women due to the lack of a well-defined clinical syndrome and normative data on testosterone levels across the lifespan 4
• Despite evidence for short-term efficacy in selected populations like surgically menopausal women, generalized use of testosterone is not recommended due to inadequate indications and lack of long-term safety data 4