Testosterone Cypionate Dosing for Postmenopausal Women with HSDD
Testosterone cypionate at 100 mg intramuscularly monthly is the only published starting dose for hypoactive sexual desire disorder in postmenopausal women, though transdermal testosterone (300 mcg/day) is the better-studied and preferred formulation. 1
Critical Context: Testosterone Cypionate is Not the Recommended Formulation
Transdermal testosterone is the evidence-based formulation for HSDD in postmenopausal women, not testosterone cypionate. 2, 3 The question asks specifically about cypionate, but this represents a significant clinical pitfall—the vast majority of high-quality evidence and guideline recommendations support transdermal delivery, not injectable formulations.
Why Transdermal is Preferred Over Injectable:
Transdermal testosterone 300 mcg/day (applied as 1% testosterone gel, 5g twice weekly) is the dose supported by multiple high-quality randomized controlled trials showing clinically meaningful improvements in sexual function 2, 4, 5
Injectable formulations carry higher risk of elevated red blood cell counts compared to transdermal preparations 6
Transdermal delivery allows for more physiologic dosing that targets mid-normal premenopausal testosterone levels, whereas injectable cypionate produces supraphysiologic peaks followed by troughs 6
If Testosterone Cypionate Must Be Used
The only published evidence for testosterone cypionate specifically shows:
100 mg intramuscularly monthly for 3 months was the dose studied in a small preliminary trial that demonstrated efficacy for HSDD 1
This dose increased salivary testosterone levels above baseline and significantly improved sexual desire scores in both pre- and postmenopausal women 1
However, this represents low-quality evidence from a single small study without long-term safety data. 1
Treatment Algorithm for HSDD in Postmenopausal Women
First-Line Considerations (Not Testosterone):
- For premenopausal women, flibanserin 100 mg daily at bedtime is first-line 2
- For postmenopausal women, non-hormonal options should be considered first, including CBT, pelvic physical therapy, and vaginal moisturizers 7
When to Consider Testosterone:
Testosterone should only be considered as second- or third-line therapy in postmenopausal women after other interventions have failed 2
Absolute contraindications:
Relative considerations:
- Adequate estrogen levels may be necessary for testosterone efficacy 2
- Women should be counseled that efficacy is modest: approximately 1 additional satisfying sexual event every 2 months compared to placebo 2, 4
Monitoring Requirements
If testosterone therapy is initiated (regardless of formulation):
- Measure testosterone levels 2-3 months after initiation or dose adjustment 6
- Target mid-normal premenopausal female range (NOT male reference ranges of 500-600 ng/dL) 2
- Monitor every 3 months during the first year, then every 6-12 months once stable 2, 6
- Evaluate treatment effect after 3-6 months; consider limiting initial therapy to 24 weeks 6
- Monitor for androgenic side effects including unwanted hair growth (occurs in ~30% at 300 mcg/day transdermal) 4
Critical Safety Concerns
Long-term safety data for testosterone in women remains uncertain, particularly regarding breast cancer risk. 4 One high-quality trial found 4 cases of breast cancer in testosterone-treated women versus none in placebo over 52 weeks, though causality was unclear 4. This underscores the importance of careful patient selection and informed consent discussions. 4
The FDA has not approved any testosterone formulation for HSDD in women, making this an off-label use requiring thorough documentation and patient counseling 2.