Testosterone Dosing for Postmenopausal Women
For postmenopausal women with hypoactive sexual desire disorder (HSDD), transdermal testosterone should be initiated at 10 mg daily, applied as a gel or cream to achieve physiological testosterone levels within the premenopausal range. 1
Recommended Starting Dose and Formulation
- Start with 10 mg of transdermal testosterone daily, applied as a 1% hydroalcoholic gel over approximately 15 cm² of skin (typically the outer thigh). 1
- This dose produces stable serum testosterone levels of approximately 3.2 nmol/L, which falls within the normal premenopausal range. 1
- Higher doses (20-30 mg) produce supraphysiological levels with minimal additional benefit and should be avoided. 1
Route of Administration Priority
Transdermal formulations are strongly preferred over other routes:
- Transdermal testosterone (patches, gels, or creams) provides physiological testosterone levels and avoids the supraphysiological peaks seen with injections. 2, 3
- Injectable testosterone and pellets are NOT recommended for postmenopausal women as they cause supraphysiological levels and increased side effects. 3
- Oral methyltestosterone may be considered only as a short-term alternative if transdermal preparations are unavailable, but this is suboptimal. 2
Clinical Indication
- The sole evidence-based indication for testosterone therapy in postmenopausal women is HSDD (hypoactive sexual desire disorder). 4
- Women with diminished libido or impaired sexual function due to low circulating testosterone levels are appropriate candidates. 5
- Testosterone therapy should be used in conjunction with adequate estrogen replacement when indicated. 2
Monitoring Protocol
Initial monitoring:
- Measure testosterone levels 2-3 months after treatment initiation or after any dose adjustment. 6
- Target mid-normal premenopausal testosterone levels (approximately 1-3 nmol/L). 6, 1
Ongoing monitoring:
- Once stable levels are achieved, monitor testosterone levels every 6-12 months. 6
- Evaluate treatment effect after 3-6 months and consider limiting therapy to 24 weeks initially until long-term safety data become available. 5, 2
Critical Safety Considerations
Duration and safety limitations:
- Long-term cardiovascular, cancer, and cognitive safety data are lacking for testosterone therapy in postmenopausal women. 3
- Current evidence supports only short-term use (up to 24 weeks) with demonstrated efficacy. 5, 2
- Women should be informed that androgen treatment is supported by limited data and long-term health effects remain unclear. 5
Monitoring for adverse effects:
- Watch for androgenic side effects (though these are rare at physiological doses). 3
- Monitor for elevated red blood cell count, which occurs more frequently with injectable formulations. 6
Special Populations
Surgically menopausal women:
- Women who have undergone bilateral oophorectomy are particularly appropriate candidates, as the ovaries normally continue producing androgens after natural menopause. 2
- These women should be adequately estrogenized before initiating testosterone therapy. 2
Women with premature ovarian insufficiency (POI):
- Progestins with anti-androgenic effects should be avoided in women with POI and low testosterone, as they may worsen hypoandrogenism. 5
Practical Implementation
No FDA-approved testosterone preparation exists specifically for women:
- Current practice involves off-label use of compounded testosterone creams or reduced dosing of male-approved therapies. 3
- Apply the gel in a thin layer to clean, dry skin (outer thigh preferred) each morning. 1
- Absorption occurs within hours, with stable levels achieved by day 3-5 of treatment. 1
Expected clinical benefits: