What is the recommended dose of testosterone (testosterone) for postmenopausal women?

Testosterone Dosing for Postmenopausal Women

For postmenopausal women with hypoactive sexual desire disorder (HSDD), testosterone therapy should be initiated at 300 mcg/day via transdermal patch or equivalent low-dose formulation (approximately 5-10 mg/day of topical gel), titrated to the lowest effective dose that improves sexual function without causing supraphysiologic levels. 1, 2, 3

Clinical Context and Indications

Testosterone therapy in postmenopausal women has a single evidence-based indication: treatment of HSDD in adequately estrogenized postmenopausal women where other physical and psychosocial contributors have been addressed. 2, 3 The use of testosterone for any other indication—including bone density preservation, hot flash reduction, or general well-being—lacks sufficient evidence and should not be pursued. 3

Specific Dosing Recommendations

Transdermal Formulations (Preferred)

• Transdermal patches are the first-line choice, delivering 300 mcg/day of testosterone, as they avoid first-pass hepatic metabolism and provide more consistent dosing than oral formulations. 4, 3

• Topical gels or creams can be used at doses of 5-10 mg/day applied to non-genital skin, though custom-compounded products should be used cautiously due to inconsistent dosing. 3

• Testosterone products formulated for men carry risk of excessive dosing and should be avoided or used only at fractional doses under close monitoring. 3

Oral Formulations (Not Recommended)

Oral testosterone, particularly methyltestosterone, consistently reduces HDL cholesterol and has first-pass hepatic effects that make it less favorable than transdermal routes. 4, 3 If oral therapy is considered, it should be reserved for situations where transdermal administration is not feasible.

Monitoring Requirements

Laboratory Monitoring

• Measure serum testosterone levels before initiating therapy and periodically during treatment to ensure levels remain within the physiologic range for premenopausal women (not supraphysiologic). 3

• Note that clinically available assays do not accurately detect testosterone at concentrations typical for women, so monitoring is primarily to detect excessive levels rather than to diagnose deficiency. 3

• Monitor HDL cholesterol closely, as reduction is the most consistent adverse effect, particularly with methyltestosterone. 4

Clinical Monitoring

• Assess sexual desire, arousal, orgasmic response, and overall satisfaction at regular intervals (typically every 3-6 months). 1, 3

• Evaluate for hirsutism, acne, and other androgenic side effects at each visit. 1, 3

Duration and Titration Strategy

Use the lowest effective dose for the shortest duration that meets treatment goals. 3 Most randomized controlled trials demonstrating efficacy have been limited to 6 months to 2 years of treatment. 5, 4 Long-term safety data beyond 2 years are not available, particularly regarding cardiovascular risk and breast cancer incidence. 1, 4

Start at the lower end of the dosing range and titrate upward only if symptoms persist and testosterone levels remain in the physiologic range. 3

Critical Contraindications

Testosterone therapy is absolutely contraindicated in women with:

• Breast or uterine cancer 3
• Cardiovascular disease 3
• Active liver disease 3

Essential Caveats

Estrogen Co-Administration

Testosterone should not be used as monotherapy in postmenopausal women—concomitant estrogen therapy is required, as evidence for testosterone alone is insufficient. 3 This aligns with the principle that women must be "adequately estrogenized" before considering testosterone for HSDD. 5, 2

FDA Approval Status

No testosterone preparation has been approved by the FDA specifically for use in women, so all use is off-label despite 40+ years of clinical experience. 1, 5 Patients require thorough counseling about this limitation and the lack of long-term safety data. 1

Diagnostic Approach

Before initiating testosterone:

• Rule out relationship issues, depression, medications (especially SSRIs), and other medical conditions affecting sexual function 3
• Confirm a physiologic cause for low testosterone (bilateral oophorectomy, premature ovarian insufficiency) 3
• Do not use testosterone levels to diagnose "androgen insufficiency," as no specific threshold has been validated for clinical diagnosis 3

Practical Algorithm

1. Confirm HSDD diagnosis: Persistent absent/diminished sexual desire causing personal distress 2, 3
2. Exclude other causes: Psychosocial factors, medications, relationship issues, inadequate estrogen 3
3. Verify physiologic basis: Oophorectomy, age-related decline, or other documented cause 3
4. Initiate transdermal testosterone: 300 mcg/day patch or 5 mg/day gel 3
5. Monitor at 3-6 months: Check testosterone level (avoid supraphysiologic), assess sexual function, evaluate for side effects 1, 3
6. Titrate or discontinue: If no benefit after 6 months, discontinue; if partial benefit, consider modest dose increase while monitoring levels 3