Testosterone Therapy for Postmenopausal HSDD: No Target Level Exists
There is no established goal testosterone level when treating postmenopausal hypoactive sexual desire disorder with topical testosterone—treatment should be guided by clinical response (symptom improvement) rather than laboratory values. 1, 2
Why No Target Level Has Been Established
The available evidence from multiple large randomized controlled trials demonstrates efficacy based on clinical outcomes rather than achieving specific testosterone thresholds:
Clinical trials used fixed dosing regimens (300 μg/day transdermal patches or 10 mg daily cream) without titrating to specific testosterone levels, yet showed significant improvements in sexual desire and satisfying sexual activity 3, 4
The INTIMATE studies (the largest phase III trials) demonstrated 51-74% increases in total satisfying sexual activity using standardized dosing, not individualized testosterone targets 3
Treatment response occurs independently of achieving specific serum levels—women showed significant improvements in validated measures (Sexual Activity Log, Profile of Female Sexual Function) with the same fixed dose regardless of resulting testosterone concentrations 3, 4
The Evidence-Based Approach: Treat to Symptom Response
Starting Regimen
Begin with transdermal testosterone 300 μg twice weekly (patch formulation) or 10 mg daily (cream formulation) in postmenopausal women already receiving adequate estrogen therapy 5, 3, 4
Adequate circulating estrogen is required for testosterone to be effective—testosterone may not work without sufficient estrogen levels 6, 2
Monitoring Strategy
Assess clinical response at 12 weeks using validated instruments measuring sexual desire, frequency of satisfying sexual activity, and personal distress 3, 4
Monitor for androgenic side effects (acne, increased hair growth, application site reactions) rather than targeting specific testosterone levels 7, 4
Baseline and periodic testosterone measurements can confirm absorption and ensure levels remain within physiologic postmenopausal ranges, but these values should not drive dosing decisions 7
Critical Safety Considerations
Current Regulatory Status
No testosterone product is FDA-approved for female HSDD in the United States, though transdermal formulations have demonstrated efficacy and favorable short-term safety profiles in multiple trials 7
Off-label testosterone use is widespread despite lack of approval, making evidence-based guidance particularly important 7
Contraindications and Cautions
Testosterone therapy has not been established as safe or effective after breast cancer—it cannot be recommended in this population 6, 2
Avoid in women with hormone-dependent cancers, undiagnosed abnormal vaginal bleeding, active liver disease, or recent thromboembolic events 1
Long-term safety data remain limited—interim data from ongoing trials show low rates of cardiovascular events and breast cancer, but definitive long-term safety has not been established 7
Common Clinical Pitfalls
Attempting to achieve premenopausal testosterone levels is inappropriate—postmenopausal women naturally have lower testosterone, and supraphysiologic dosing increases side effect risk without proven additional benefit 7
Using testosterone without adequate estrogen leads to treatment failure—ensure women are on stable estrogen therapy before initiating testosterone 6, 2, 3
Expecting immediate results—clinical trials showed peak benefits at 12-24 weeks, not within days or weeks 3, 4
Prescribing testosterone for vaginal dryness alone—testosterone has not been shown effective for this indication; vaginal estrogen or DHEA are appropriate alternatives 1, 2
Alternative Evidence-Based Options
If testosterone is unavailable, contraindicated, or ineffective:
Flibanserin is FDA-approved for acquired, generalized HSDD in premenopausal women, resulting in approximately 1 additional satisfying sexual event every 2 months 6, 1
Bremelanotide is FDA-approved for low sexual desire in premenopausal women 1
Address contributing factors including SSRI/SNRI use (which can reduce libido and cause anorgasmia), relationship issues, and inadequate estrogen replacement 6