Can testosterone (testosterone) be given in cases of menstrual bleeding in men?

Testosterone Should NOT Be Given for Menstrual Bleeding

Testosterone therapy is contraindicated for managing menstrual bleeding and will likely worsen the clinical situation by causing breakthrough bleeding, hormonal dysregulation, and virilization without addressing the underlying cause of abnormal uterine bleeding.

Why Testosterone is Inappropriate for Menstrual Bleeding

Testosterone Causes Bleeding, Not Stops It

• Breakthrough bleeding is a common complication in patients on testosterone therapy, occurring in approximately 25% of individuals despite initial amenorrhea, with bleeding typically beginning around 24 months after testosterone initiation 1
• Even in transgender men specifically using testosterone to suppress menstruation, persistent vaginal bleeding occurs and is associated with suboptimal testosterone levels, higher BMI, and lower free androgen index 2
• When breakthrough bleeding occurs on testosterone therapy, no single management method has been found superior, and many cases (79.3%) have no identifiable cause 1

Mechanism of Testosterone-Related Bleeding

• Lower testosterone levels and inadequate androgenic effect are paradoxically associated with persistent bleeding in those on testosterone therapy 2
• Testosterone therapy interrupts normal hormonal feedback mechanisms and can create an unstable endometrial environment 3
• Adjustment of testosterone doses or addition of progestogens is often required to achieve amenorrhea, indicating testosterone alone is insufficient for menstrual control 2

Appropriate Uses of Testosterone (None Apply to Menstrual Bleeding)

Established Indications

• Testosterone is indicated only for androgen replacement therapy in men with documented testosterone deficiency (hypogonadism with total testosterone <275 ng/dL and symptoms) 3
• Testosterone therapy should not be commenced in patients trying to conceive as it interrupts spermatogenesis 3
• The goal of testosterone therapy is normalization of testosterone levels to 450-600 ng/dL in hypogonadal men, not menstrual suppression 3

Critical Contraindications Relevant to This Question

• Exogenous testosterone has inhibitory effects on reproductive function and is not designed for menstrual cycle management 3
• Testosterone therapy in women causes virilization including deepening voice, facial hair growth, clitoral enlargement, and male pattern baldness 3
• The FDA specifically warns about testosterone transfer to women and children causing virilization, precocious puberty, and hyperandrogenism 3

Clinical Pitfalls to Avoid

• Do not use testosterone as a menstrual suppressant - it is not indicated, not effective, and causes significant adverse effects including breakthrough bleeding 2, 1
• Do not confuse gender-affirming testosterone therapy protocols (which aim for amenorrhea but frequently fail) with treatment of abnormal uterine bleeding in cisgender women 2, 1
• Recognize that even in transgender men where amenorrhea is desired, breakthrough bleeding remains problematic and difficult to manage 1

What Should Be Done Instead

For menstrual bleeding management, appropriate evidence-based options include:

• Progestogens (oral or intrauterine) for endometrial stabilization
• Combined hormonal contraceptives for cycle regulation
• GnRH agonists for medical amenorrhea when indicated
• Investigation of underlying pathology (structural lesions, coagulopathy, endocrine disorders)

Testosterone has no role in managing menstrual bleeding and represents inappropriate prescribing that will likely harm the patient through virilization and paradoxically worsen bleeding patterns 3, 2, 1.