What are the options for Testosterone Replacement Therapy (TRT) in women?

Testosterone Replacement Therapy Options for Women

Testosterone therapy for women should be considered primarily for those with hypoactive sexual desire disorder (HSDD), using transdermal formulations at doses appropriate for women, with careful monitoring of testosterone levels to maintain them within the physiologic premenopausal range. 1

Indications for Testosterone Therapy in Women

• Testosterone therapy is recommended for postmenopausal women with hypoactive sexual desire disorder (HSDD) not primarily related to modifiable factors or comorbidities 1
• Limited data supports use in late reproductive age premenopausal women with HSDD 1
• Testosterone therapy may be considered for women with premature ovarian insufficiency (POI) due to medical treatments like chemotherapy or radiation 2
• Common symptoms of androgen insufficiency include absent or diminished sexual motivation/desire (libido), unexplainable fatigue, and lack of sense of well-being 3

Available Formulations and Administration

First-Line Options:

• Transdermal testosterone preparations (patches, gels) are the preferred route of administration 1
  • These formulations have less impact on coagulation and lipid profiles compared to oral formulations 4
  • Government-approved transdermal male formulations can be used cautiously with dosing appropriate for women 1

Administration Considerations:

• Dosing must be significantly lower than male dosing to maintain testosterone levels in the physiologic premenopausal range 1
• For women with an intact uterus requiring hormone therapy, guidelines typically recommend estrogen plus progestin rather than estrogen plus androgen combinations 5

Second-Line Options:

• Oral testosterone preparations are less preferred due to potential adverse effects on lipid profiles 4
• Compounded testosterone products are not recommended due to lack of efficacy and safety data 1

Monitoring and Safety

• Before initiation, baseline total testosterone levels should be measured (not for diagnosis but for monitoring) 1
• Regular monitoring of testosterone levels is essential to maintain concentrations in the physiologic premenopausal range 1
• Monitor for signs of androgen excess (acne, hirsutism) 4
• Short-term studies (up to 2 years) have shown that testosterone therapy at appropriate doses does not increase risk of:
  • Hepatotoxicity
  • Endometrial hyperplasia
  • Behavioral hostility
  • Adverse cardiovascular effects 4

Important Considerations and Cautions

• Testosterone therapy is not FDA-approved specifically for women, making prescribing and proper dosing challenging 1
• Testosterone should not be used for primary prevention of chronic conditions 5, 2
• Women with hormone-sensitive cancers should avoid systemic hormone therapy 2
• The long-term safety of testosterone therapy in women has not been fully established 4
• Informed consent should include discussion of off-label use, benefits, and risks 1

Special Populations

• For women with premature ovarian insufficiency (POI), 17β-estradiol (17βE) is the preferred estrogen component of HRT, which can be combined with appropriate progestins 6
• In cancer survivors with POI, testosterone therapy decisions should be made in consultation with specialists 7

Common Misconceptions About Testosterone in Women

• Contrary to common belief, testosterone at appropriate doses:
  • Is not masculinizing
  • Does not cause hoarseness
  • May increase scalp hair growth
  • Has mood-stabilizing effects and does not increase aggression 8

Testosterone therapy offers moderate therapeutic benefit for women with HSDD, but must be carefully prescribed and monitored to maintain physiologic levels and minimize potential adverse effects 1, 4.