Is testosterone therapy recommended for a woman in perimenopause?

Testosterone Therapy for Perimenopause

Testosterone therapy is NOT recommended for women in perimenopause, as there is insufficient evidence to support its use during this transitional phase, and current guidelines only support its consideration in carefully selected postmenopausal women with hypoactive sexual desire disorder (HSDD) who have failed other interventions. 1, 2

Evidence Base and Current Limitations

The available evidence for testosterone therapy in women is limited to postmenopausal populations, not perimenopausal women:

• No FDA-approved testosterone formulation exists for women in the United States due to lack of long-term safety data, making any use technically off-label 2
• Published randomized controlled trials demonstrate modest benefits for sexual function (primarily desire, arousal, and orgasmic response) only in postmenopausal women after spontaneous or surgical menopause 1
• Data are inadequate to support testosterone use for any indication other than HSDD, including bone density preservation, hot flash reduction, lean body mass increase, or general well-being 1
• Limited research exists specifically for women of late reproductive age (perimenopause), with insufficient evidence to recommend testosterone during this phase 2

Why Perimenopause Is Different

Perimenopausal women have fluctuating hormone levels rather than the sustained low testosterone seen in postmenopausal women:

• Endogenous testosterone levels have not been clearly linked to sexual function in women, and no testosterone level has been definitively associated with a clinical syndrome of testosterone insufficiency 1
• Clinically available laboratory assays do not accurately detect testosterone concentrations at values typically found in women, making diagnosis and monitoring problematic 1
• The hormonal instability of perimenopause makes it impossible to establish a baseline testosterone deficiency that would justify treatment

When Testosterone Might Be Considered (Postmenopausal Only)

If a woman progresses to postmenopause, testosterone therapy may be considered only under these strict conditions:

Eligibility Criteria

• Postmenopausal status (not perimenopausal) with decreased sexual desire causing personal distress 1
• No other identifiable causes ruled out, including physical factors, psychosocial factors, and medications 1
• Physiologic cause for reduced testosterone (e.g., bilateral oophorectomy) 1
• Failed non-hormonal interventions first 2

Absolute Contraindications

• Breast or uterine cancer 1
• Cardiovascular disease 1
• Liver disease 1
• Hormone-sensitive malignancies 2

Formulation and Monitoring

• Transdermal patches or topical gels/creams are strongly preferred over oral products due to first-pass hepatic effects with oral formulations 1
• Custom-compounded products should be used with extreme caution due to inconsistent dosing 1
• Testosterone products formulated for men carry risk of excessive dosing, though some clinicians use lower doses off-label 1
• Laboratory testing should monitor for supraphysiologic levels before and during therapy, not to diagnose deficiency 1
• Monitor for hirsutism and acne, though actual risks are not well defined 1

Safety Concerns

• Unknown long-term risks for breast cancer, cardiovascular disease, and thromboembolic events 1, 3
• Most consistent adverse effect is reduction in HDL cholesterol, particularly with methyltestosterone 4
• Few data exist for testosterone therapy without concomitant estrogen or for use longer than 6 months 1
• The FDA warns that testosterone therapy may increase cardiovascular complications 5

Alternative Management for Perimenopausal Symptoms

For perimenopausal women experiencing symptoms:

• Address vasomotor symptoms with standard estrogen-based hormone therapy if appropriate (see separate guidelines on HRT timing and contraindications) 6, 7
• Evaluate and treat other contributors to sexual dysfunction, including relationship factors, medications (SSRIs, antihypertensives), depression, anxiety, and medical conditions 1, 2
• Consider non-hormonal options for sexual dysfunction before any hormonal intervention 2
• Low-dose vaginal estrogen for genitourinary symptoms provides local benefit without systemic risks 6

Critical Clinical Pitfalls to Avoid

• Do not prescribe testosterone to perimenopausal women based on symptoms alone, as the evidence base does not support this practice 1, 2
• Do not use testosterone levels to diagnose "androgen deficiency" in women, as this diagnosis does not exist and assays are unreliable at female physiologic ranges 1
• Do not prescribe testosterone for non-sexual indications (bone health, energy, cognition, well-being), as data do not support these uses 1, 2
• Do not initiate testosterone without first ruling out and addressing other causes of sexual dysfunction 1
• Do not use testosterone without comprehensive counseling about lack of long-term safety data and potential cardiovascular risks 1, 3