What is the recommended testosterone replacement therapy dose for a 55-year-old female with low testosterone (hypogonadism)?

Testosterone Therapy for 55-Year-Old Female with Testosterone <3 ng/dL

Direct Recommendation

The evidence does not support routine testosterone replacement therapy for women with low testosterone levels alone. The 2014 Endocrine Society guideline explicitly recommends against making a diagnosis of "androgen deficiency syndrome" in women and against prescribing testosterone for low androgen levels in the absence of specific, well-defined sexual dysfunction 1.

Clinical Context and Evidence

Why Low Testosterone Alone Is Not an Indication

• No established syndrome exists: There is no well-defined androgen deficiency syndrome in women, and data correlating androgen levels with specific signs or symptoms are unavailable 1.

• Testosterone levels do not predict symptoms: Importantly, even in the one condition where testosterone therapy shows benefit (hypoactive sexual desire disorder in postmenopausal women), endogenous testosterone levels did not predict response to therapy 1.

• Normal ranges are poorly defined: Current androgen assays have not adequately defined normal ranges across the female lifespan, making interpretation of "low" levels problematic 1.

The Single Evidence-Based Indication

Testosterone therapy is recommended ONLY for postmenopausal women with sexual dysfunction specifically due to hypoactive sexual desire disorder (HSDD). 1

• This is the sole indication supported by short-term efficacy and safety data 1.
• The diagnosis requires distressing, persistent absence of sexual desire that is not better explained by relationship issues, psychiatric conditions, or medications 1.
• Treatment should use high physiological doses of testosterone 1.

What NOT to Treat

The Endocrine Society explicitly recommends against testosterone therapy for 1:

• General well-being or fatigue
• Cognitive function
• Cardiovascular health
• Metabolic health
• Bone health
• Infertility
• Sexual dysfunction other than HSDD

Dosing Recommendations (If HSDD Is Present)

Transdermal Testosterone Gel

• Start with 10 mg daily of 1% testosterone gel applied to the outer thigh over approximately 15 cm² 2.
• This dose achieves mean serum testosterone levels of approximately 3.2 nmol/L (92 ng/dL) in postmenopausal women 2.
• If inadequate response, increase to 20 mg daily, which achieves mean levels of 7.2 nmol/L (207 ng/dL) 2.
• Doses above 20 mg show minimal additional benefit 2.

Transdermal Patches

• Alternative: 50-100 μg patches changed twice weekly or weekly depending on formulation 3.
• These are designed for female physiology and provide more consistent dosing than male formulations 3.

Critical Monitoring Requirements

All women receiving testosterone must be monitored for signs and symptoms of androgen excess 1:

• Acne
• Hirsutism
• Voice deepening
• Clitoromegaly
• Male-pattern hair loss

Major Caveats and Pitfalls

Formulation Issues

• Physiological testosterone preparations specifically for women are not available in the United States 1.
• Using male formulations requires careful dose adjustment and carries higher risk of supraphysiologic dosing 1.

Long-Term Safety Unknown

• No long-term safety data exist for testosterone therapy in women 1.
• Short-term studies show acceptable safety profiles, but cardiovascular, breast cancer, and other long-term risks remain undefined 1.

Contraindications

• Breast cancer (current or history)
• Cardiovascular disease
• Liver disease
• Pregnancy or breastfeeding

Clinical Algorithm

1. Assess for HSDD: Does the patient have persistent, distressing loss of sexual desire not explained by relationship problems, depression, medications, or other medical conditions? 1

   • If NO: Do not prescribe testosterone 1
   • If YES: Proceed to step 2

2. Confirm postmenopausal status: Is the patient postmenopausal? 1

   • If NO: Do not prescribe testosterone 1
   • If YES: Proceed to step 3

3. Rule out contraindications: Screen for breast cancer history, cardiovascular disease, liver disease 1

   • If present: Do not prescribe testosterone
   • If absent: Proceed to step 4

4. Initiate trial therapy: Start transdermal testosterone 10 mg daily 2

5. Reassess at 3-6 months: Evaluate symptom improvement and signs of androgen excess 1

   • If no improvement: Consider increasing to 20 mg daily or discontinuing 2
   • If improved with no adverse effects: Continue at current dose
   • If signs of androgen excess: Reduce dose or discontinue 1

Bottom Line for This Patient

For a 55-year-old woman with testosterone <3 ng/dL but no mention of HSDD, testosterone therapy is not recommended. The low testosterone level alone does not constitute an indication for treatment 1. If she has distressing loss of sexual desire meeting criteria for HSDD, then a trial of transdermal testosterone 10 mg daily would be appropriate, with close monitoring for efficacy and adverse effects 2, 1.