What is the recommended approach to testosterone therapy for a female patient experiencing perimenopause and menopause symptoms?

Testosterone Therapy for Perimenopause and Menopause Symptoms

Testosterone therapy is NOT recommended as a standard treatment for general perimenopausal or menopausal symptoms—it should only be considered for postmenopausal women with hypoactive sexual desire disorder (HSDD) who have failed standard hormone therapy and have no other identifiable causes for their sexual dysfunction. 1

Primary Treatment Approach: Estrogen-Based HRT First

For perimenopausal and menopausal symptoms (hot flashes, night sweats, mood changes, fatigue), the evidence-based first-line treatment is estrogen-based hormone replacement therapy, not testosterone 2, 3:

• Transdermal estradiol 50 μg patches (applied twice weekly) plus micronized progesterone 200 mg nightly is the preferred regimen for women under 60 or within 10 years of menopause onset with an intact uterus 2, 3
• This regimen reduces vasomotor symptoms by approximately 75%, prevents bone loss, and has the most favorable risk-benefit profile 2, 4
• Estrogen-alone therapy is appropriate only for women who have had a hysterectomy 2

When Testosterone May Be Considered

Testosterone therapy has a very narrow, specific indication in menopausal women 1:

Specific Criteria Required:

• Postmenopausal status (not perimenopausal—must have completed menopause) 1
• Hypoactive sexual desire disorder causing personal distress 1
• Failure of standard estrogen-based HRT to address sexual dysfunction 5, 1
• No other identifiable causes including physical factors, psychosocial factors, relationship issues, or medications 1
• Physiologic cause for reduced testosterone (such as bilateral oophorectomy) 1

Evidence of Efficacy:

• Testosterone therapy produces approximately one additional satisfying sexual episode per month in postmenopausal women with HSDD 6
• Improvements occur in desire, arousal, orgasm, pleasure, and responsiveness, with reduction in distress 6
• The strongest evidence exists for women after surgical menopause (oophorectomy) 5, 1

Critical Limitations and Safety Concerns

Lack of Approved Products:

• No FDA-approved testosterone preparation exists for women in the United States 6, 1
• All use represents off-label prescribing of male-approved products at reduced doses or custom-compounded formulations 6, 1
• Custom-compounded products have inconsistent dosing and should be used with extreme caution 1

Safety Data Gaps:

• Long-term data on cardiovascular, cancer, and cognitive safety are completely lacking 6
• Most trials have evaluated only 6 months of use—safety beyond this duration is unknown 1
• Data are inadequate for testosterone use without concomitant estrogen therapy 1

Known Adverse Effects:

• Hirsutism and acne are common but reversible upon discontinuation 5, 1
• Injections and pellets cause supraphysiological testosterone levels and are NOT recommended 6

Contraindications to Testosterone Therapy

Testosterone is contraindicated in women with 1:

• Breast or uterine cancer
• Cardiovascular disease
• Liver disease
• History of thromboembolic events

Monitoring Requirements

If testosterone therapy is initiated for HSDD 1:

• Monitor testosterone levels to ensure they remain within premenopausal physiologic ranges—not to diagnose deficiency, but to prevent supraphysiologic levels 6, 1
• Assess subjective improvements in sexual desire, arousal, and satisfaction 1
• Evaluate for androgenic side effects (hirsutism, acne, voice changes) 1
• Use the lowest dose for the shortest time that meets treatment goals 1

Preferred Formulations (If Used)

• Transdermal patches or topical gels/creams are preferred over oral products because they avoid hepatic first-pass metabolism 5, 1
• Oral testosterone formulations have documented adverse hepatic effects and should be avoided 1
• Male-approved testosterone products carry risk of excessive dosing, though some clinicians use reduced doses off-label 1

Common Pitfalls to Avoid

• Do not prescribe testosterone for general menopausal symptoms (fatigue, mood changes, hot flashes, bone health)—evidence does not support these indications 1
• Do not use testosterone as first-line therapy—optimize estrogen-based HRT first 5, 1
• Do not assume low testosterone levels correlate with symptoms—endogenous testosterone levels have not been clearly linked to sexual function in postmenopausal women 1
• Do not use testosterone to preserve bone density, reduce hot flashes, increase lean body mass, or improve general well-being—data are inadequate for these indications 1
• Never use injections or pellets—they produce supraphysiologic levels 6

Algorithm for Decision-Making

1. Confirm menopausal status (not perimenopausal) 1
2. Initiate standard estrogen-based HRT for vasomotor and other menopausal symptoms 2, 3
3. If sexual dysfunction persists, rule out non-hormonal causes (relationship issues, medications, psychosocial factors) 1
4. Confirm diagnosis of HSDD causing personal distress 1
5. Screen for contraindications (breast/uterine cancer, cardiovascular disease, liver disease) 1
6. Only then consider testosterone as adjunctive therapy to estrogen, using transdermal formulations at the lowest effective dose 5, 1
7. Reassess at 3-6 months—discontinue if no benefit or if adverse effects develop 1