Is testosterone therapy suitable for a 78-year-old woman with low testosterone levels?

Testosterone Therapy for a 78-Year-Old Woman

Testosterone therapy may be considered for a 78-year-old woman specifically if she has decreased sexual desire causing personal distress, has no other identifiable causes, and is already on estrogen therapy, though evidence in this age group is limited and FDA-approved formulations for women do not exist. 1

Clinical Context and Evidence Base

The available guidelines focus predominantly on men, with limited but relevant data for postmenopausal women. The North American Menopause Society provides the most direct guidance for this population. 1

When Testosterone May Be Appropriate

Testosterone therapy in postmenopausal women is supported only for one specific indication:

• Sexual dysfunction: Women with decreased sexual desire (libido) associated with personal distress, where no other identifiable cause exists, may be candidates for testosterone therapy. 1
• Concomitant estrogen requirement: Testosterone treatment without concomitant estrogen therapy cannot be recommended due to lack of evidence. 1
• Documented benefit: Randomized controlled trials show testosterone has positive effects on sexual desire, arousal, and orgasmic response in postmenopausal women. 1

What Testosterone Does NOT Treat

Do not prescribe testosterone for the following indications, as evidence is inadequate: 1

• Preserving or increasing bone mineral density
• Reducing hot flashes
• Increasing lean body mass
• Improving general well-being or fatigue
• Cognitive function

Critical Diagnostic Considerations

Before considering testosterone therapy, you must: 1

• Rule out non-hormonal causes: Physical factors, psychosocial factors (relationship issues, depression, anxiety), and medications that reduce libido
• Confirm physiologic cause for low testosterone: Such as bilateral oophorectomy (though natural age-related decline also occurs)
• Do NOT use testosterone levels to diagnose deficiency: Clinically available laboratory assays do not accurately detect testosterone at concentrations typically found in women, and no specific testosterone level has been linked to a clinical syndrome of testosterone insufficiency. 1

Formulation and Dosing

Preferred formulations: 1

• Transdermal patches or topical gels/creams are preferred over oral products due to first-pass hepatic effects with oral formulations
• Avoid custom-compounded products when possible, as dosing may be inconsistent
• Men's testosterone products carry risk of excessive dosing, though some clinicians use lower doses off-label (no FDA-approved testosterone product exists specifically for women)

Absolute Contraindications

Do not prescribe testosterone if the patient has: 1

• Breast cancer (current or history)
• Uterine cancer
• Cardiovascular disease
• Liver disease

Safety Profile and Monitoring

Known adverse effects: 1

• Hirsutism and acne are associated with testosterone therapy, though actual risks are not well-defined
• Unknown risks: Whether testosterone increases risk of breast cancer, cardiovascular disease, or thromboembolic events remains unclear

Monitoring requirements: 1

• Testosterone levels: Monitor only to detect supraphysiologic levels (not to diagnose deficiency)
• Subjective assessments: Sexual response, desire, and satisfaction
• Adverse effects surveillance: Androgenic effects (acne, hirsutism, voice changes)
• Duration: Administer at the lowest dose for the shortest time that meets treatment goals

Evidence Limitations

Critical gaps in the evidence base: 1

• Few data exist for testosterone therapy beyond 6 months duration
• Limited data for women not using concomitant estrogen therapy
• No long-term safety studies establish cardiovascular or breast cancer risk
• Studies have not specifically focused on women in their late 70s

Clinical Decision Algorithm

For this 78-year-old woman, proceed as follows:

1. Assess primary complaint: Is decreased sexual desire causing personal distress the primary concern?
2. Exclude other causes: Depression, medications (antihypertensives, SSRIs), relationship factors, other medical conditions
3. Verify estrogen status: Is she on estrogen therapy? (Required for testosterone use)
4. Screen for contraindications: Breast/uterine cancer history, cardiovascular disease, liver disease
5. If appropriate, initiate trial: Use transdermal formulation at lowest dose
6. Monitor at 3-6 months: Assess symptom improvement and adverse effects
7. Discontinue if no benefit: Do not continue beyond 6 months without clear improvement

Common Pitfalls

• Using testosterone for general "anti-aging" or vitality: No evidence supports this, and it exposes patients to unknown risks 1
• Prescribing without estrogen: Evidence only supports use with concomitant estrogen 1
• Using testosterone levels to diagnose deficiency: Assays are unreliable at female ranges 1
• Long-term use without reassessment: Safety beyond 6 months is not established 1

The decision requires careful patient counseling about limited evidence, potential risks, and the narrow indication for use. 1