Testosterone Cream for Low Testosterone in Women
Testosterone therapy can be considered for postmenopausal women with hypoactive sexual desire disorder (HSDD) who have adequate estrogen levels, using transdermal formulations at physiologic doses, though no testosterone preparation is currently FDA-approved for women in the United States. 1, 2
Clinical Context and Limitations
The evidence base for testosterone therapy in women comes primarily from studies in postmenopausal women with low libido, not from general "low testosterone" indications. It is critical to understand that testosterone therapy in women is entirely off-label use, as no FDA-approved testosterone product exists specifically for women. 2 The FDA label for AndroGel and similar products explicitly contraindicates use in women who are pregnant and does not include dosing recommendations for women. 3
When to Consider Testosterone Therapy
Testosterone therapy should be considered specifically for women with: 1, 2, 4
- Hypoactive sexual desire disorder (HSDD) - absent or greatly diminished sexual motivation/desire causing personal distress
- Adequate estrogen levels - this is a prerequisite, as estrogen deficiency must be addressed first
- Persistent unexplained fatigue or decreased sense of well-being
- Surgically menopausal women (post-oophorectomy) who are at highest risk for androgen deficiency 4
Formulation Selection
Transdermal testosterone is strongly preferred over oral formulations for women. 5, 2
- Transdermal preparations (patches, gels, creams) do not adversely affect lipid profiles, whereas oral testosterone decreases HDL cholesterol 5, 2
- Physiologic to slightly supraphysiologic serum free testosterone concentrations should be targeted 2
- Compounded preparations may be necessary since no FDA-approved female-specific product exists, though this introduces quality control concerns 6
Critical caveat: AndroGel is formulated for men at doses of 20.25-81 mg daily 3, which far exceeds appropriate female dosing. Women require much lower doses, typically in the range that achieves upper normal or slightly supraphysiologic female testosterone levels. 2
Safety Profile (Up to 2 Years)
Short-term studies up to 2 years demonstrate acceptable safety: 5, 1
- Mild, reversible side effects: acne and hirsutism are the most common androgenic effects 5, 2
- No increased risk of: hepatotoxicity, endometrial hyperplasia, behavioral hostility, cardiovascular events, blood pressure changes, or polycythemia 5
- Breast cancer risk: Data are mixed, with some experimental evidence suggesting testosterone may decrease estrogen-induced breast epithelial proliferation 5
Major limitation: Long-term safety data beyond 2 years are lacking. 5, 7
Monitoring Requirements
Women on testosterone therapy require: 7
- Baseline and periodic testosterone levels (targeting upper normal female range)
- Monitoring for androgenic side effects (acne, hirsutism, voice changes)
- Lipid profile monitoring if using oral formulations
- Clinical assessment of symptom improvement
Practical Pitfalls
Do not use male-dosed testosterone products like AndroGel at standard male doses in women - this will result in supraphysiologic levels and significant virilization. 3 The FDA label for these products does not provide female dosing because they are not approved for women.
Do not prescribe testosterone without ensuring adequate estrogen replacement first - testosterone is an adjunct to, not a replacement for, estrogen therapy in postmenopausal women. 1, 2
Do not use testosterone in premenopausal women without careful consideration - most evidence is in postmenopausal populations. 1
Evidence Quality
Multiple randomized, double-blind, placebo-controlled trials demonstrate that testosterone significantly improves libido, sexual desire, arousal, frequency, and satisfaction compared to placebo in postmenopausal women with HSDD. 1, 2 However, the relationship between serum testosterone concentrations and sexual desire remains conflicting. 2
The absence of FDA approval and standardized long-term safety data means this remains an off-label therapy requiring informed consent about limitations and risks. 2, 7