What is the best and lowest dose of testosterone to start with in women?

Testosterone Dosing for Women

For women requiring testosterone therapy, the lowest effective starting dose is 10 mg per day using a 2% gel formulation (Fortesta) applied to the skin of the front and inner thighs. 1

Formulation Options and Starting Doses

• Transdermal preparations are preferred over oral formulations due to better safety profile and avoidance of first-pass hepatic effects 2
• The lowest available doses by formulation type include:
  • Transdermal gels/solutions (preferred):
    • Fortesta 2% gel: 10 mg per actuation (lowest available dose) 1
    • Axiron 2% solution: 30 mg per actuation 1
  • Transdermal patches:
    • Androderm: 2 mg/24-hour patch 1
  • Injectable options (typically require dose adjustment for women):
    • Testosterone enanthate: Consider 50 mg weekly or lower 1, 3

Dosing Considerations for Women

• Start with the lowest possible dose to minimize side effects while achieving clinical benefit 2
• For premenopausal women with decreased sexual satisfaction, a metered-dose transdermal spray of 90 μL daily has shown efficacy 4
• For breast cancer patients on ovarian suppression, low-dose topical testosterone (3 mg/day) improved sexual function without elevating estradiol levels 5
• Non-binary individuals desiring partial masculinization may benefit from low-dose testosterone therapy for more gradual effects 1

Monitoring Recommendations

• Measure testosterone levels 2-3 months after initiating therapy or changing doses 3
• For women, target testosterone levels should be significantly lower than the male reference range 2
• Once stable levels are achieved, monitoring every 6-12 months is typically sufficient 3
• Monitor for potential adverse effects including:
  • Hirsutism and acne (most common side effects) 2
  • Virilization effects (clitoral enlargement, voice deepening) 1
  • Polycythaemia 1
  • Reduced HDL cholesterol 1

Safety Considerations

• Testosterone therapy is contraindicated in women with breast or uterine cancer (unless specifically prescribed as part of cancer treatment protocol as in 5) 2
• Cardiovascular and liver disease are contraindications for testosterone therapy 2
• Transdermal gels carry risk of transfer to partners or children through skin contact 1
• Long-term cardiovascular outcomes remain unclear, requiring careful risk-benefit assessment 1
• Counsel patients that testosterone should be administered at the lowest dose for the shortest time that meets treatment goals 2

Clinical Efficacy

• Testosterone therapy in women with low libido has demonstrated improvement in:
  • Sexual desire and arousal 6, 2
  • Frequency of satisfying sexual events 4
  • Overall sexual function 5
• Benefits typically appear within 3 months of treatment initiation 5, 4