Is testosterone therapy recommended for women with low libido?

Testosterone Therapy for Women with Low Libido

Testosterone therapy is recommended for postmenopausal women with hypoactive sexual desire disorder (HSDD) who want to improve sexual function, but is not recommended for premenopausal women except in specific clinical circumstances. 1

Indications for Testosterone Therapy in Women

• Testosterone therapy should be considered for postmenopausal women with HSDD not primarily related to modifiable factors such as relationship or mental health problems 1
• Limited data supports testosterone use in late reproductive age premenopausal women with HSDD 1
• Testosterone may benefit women with specific conditions causing androgen deficiency, including surgical menopause, premature ovarian failure, adrenal insufficiency, and hypopituitarism 2, 3
• Testosterone therapy should not be used to improve energy, vitality, physical function, or cognition in women, as these benefits have not been established 4

Clinical Assessment Before Treatment

• A comprehensive biopsychosocial assessment should be performed to rule out other causes of low sexual desire before considering testosterone therapy 1
• Baseline total testosterone level should be measured, not to diagnose HSDD, but as a reference for monitoring therapy 1
• Clinicians should assess cardiovascular risk factors before initiating testosterone therapy, as is recommended for men 5, 4
• Hemoglobin/hematocrit should be measured at baseline, as testosterone therapy can increase these values 4

Treatment Protocol

• Transdermal testosterone formulations are preferred to maintain physiologic premenopausal testosterone levels 1, 3
• Male testosterone formulations can be used cautiously with appropriate dosing adjustments for women 1
• Target testosterone levels should be maintained in the physiologic premenopausal range to minimize side effects 1, 3
• Compounded testosterone products are not recommended due to lack of efficacy and safety data 1

Monitoring and Follow-up

• Total testosterone levels should be monitored to maintain concentrations in the physiologic premenopausal range 1
• Patients should be assessed for signs of androgen excess including acne, hirsutism, and voice changes 2, 3
• Symptoms should be reevaluated within 12 months of starting therapy 4
• Treatment should be discontinued if there is no improvement in sexual function 4
• Long-term monitoring is necessary as safety data beyond short-term use is limited 1, 3

Benefits and Risks

Benefits:

• Moderate improvement in sexual function, particularly libido and sexual satisfaction 1, 5
• May improve mood and sense of well-being in selected patients 5

Risks:

• Common side effects include hirsutism and acne, which reverse with discontinuation 2
• Oral testosterone may decrease HDL cholesterol levels 5
• Long-term safety data regarding cardiovascular risk and breast cancer is lacking 3
• No serious adverse events have been reported with physiologic testosterone use in women 1

Important Considerations and Limitations

• Testosterone therapy for women is not FDA-approved in the United States, making all use off-label 1, 3
• Informed consent should include discussion of off-label use, benefits, and potential risks 1
• The diagnosis of androgen deficiency in women is hampered by lack of precise definitions and sensitive assays 6
• Many studies have used pharmacological rather than physiological testosterone levels 6

Special Populations

• Testosterone therapy should not be prescribed to women who are currently trying to conceive, as it can suppress fertility 4
• For transgender women (male-to-female), testosterone suppression is a goal of hormone therapy rather than supplementation 7
• Women with a history of hormone-sensitive cancers should avoid testosterone therapy until more safety data is available 3