What is the recommended starting dose and titration plan for testosterone cream in adult women, including application site, monitoring schedule, and contraindications?

Testosterone Cream Dosing for Women

For adult women requiring testosterone therapy, start with 5 mg of testosterone cream applied daily to the upper arm, with serum testosterone monitoring at 2-3 months to guide dose titration up to 10 mg if needed. 1

Starting Dose and Application

• Begin with 5 mg testosterone cream applied once daily to dry, intact skin of the upper arm or torso 2, 1
• The 5 mg dose restores total testosterone and free testosterone levels to within or above the premenopausal reference range 1
• Apply to clean, dry skin and wash hands thoroughly after application to prevent unintended transfer to partners or children 2

Dose Titration

• If symptoms persist after 3 months on 5 mg, increase to 10 mg daily 1
• Note that doubling the dose from 5 mg to 10 mg produces only a 30-31% increase in testosterone levels, not a proportional doubling 1
• Evaluate treatment effect after 3-6 months and consider limiting therapy duration to 24 months given limited long-term safety data 3

Monitoring Schedule

• Check serum testosterone levels 2-3 months after initiating therapy or after any dose change 2
• Once stable therapeutic levels are confirmed, monitor every 6-12 months 2
• Testosterone concentrations can vary substantially with cream formulations, making monitoring essential to ensure appropriate levels 2
• Annual clinical review is recommended, with particular attention to treatment compliance 3

Application Site Considerations

• Primary application site: upper arms or shoulders 2, 1
• Alternative sites include chest or abdomen if needed, though absorption may vary by anatomical location 4
• Avoid application to areas with high risk of transfer (e.g., breasts, genitals) 2

Formulation Guidance

• Prescribe commercially manufactured testosterone products rather than compounded preparations when possible, as compounded products may have considerable variation in potency and quality 2
• Transdermal preparations offer the advantage of relatively stable day-to-day testosterone levels 2

Contraindications and Precautions

• Absolute contraindication: breast cancer survivors (HRT is generally contraindicated) 3
• Women with BRCA1/2 mutations without personal history of breast cancer may use testosterone therapy after prophylactic bilateral salpingo-oophorectomy 3
• Counsel patients about potential for skin-to-skin transfer to partners or children through direct contact 2
• Avoid progestins with anti-androgenic effects in women with iatrogenic premature ovarian insufficiency, as these may worsen hypoandrogenism and sexual dysfunction 3

Common Pitfalls

• Inadequate monitoring: Failing to check testosterone levels at 2-3 months can result in under- or over-dosing 2
• Assuming dose proportionality: Doubling the dose does not double testosterone levels; expect only 30% increases 1
• Transfer risk: Patients must understand proper hygiene measures to prevent unintended exposure to household contacts 2
• Using compounded products: These have unpredictable potency and should be avoided when commercial products are available 2