What is the appropriate starting dose and titration schedule for intramuscular testosterone enanthate or cypionate in adult women?

Testosterone Injection Dosing for Women

Testosterone injection therapy is not FDA-approved for women, and current evidence-based guidelines do not establish standard intramuscular dosing regimens for testosterone enanthate or cypionate in adult women. 1

Critical Context and Limitations

The available evidence for injectable testosterone in women is extremely limited:

• No guideline-recommended IM dosing exists for testosterone enanthate or cypionate specifically in cisgender women 1
• The North American Menopause Society position statement addresses testosterone therapy for postmenopausal women but does not provide specific injectable dosing protocols 1
• Transdermal formulations (creams/gels) are the preferred route when testosterone therapy is indicated in women, as they avoid first-pass hepatic effects and provide more stable levels 2, 1

When Testosterone Therapy May Be Considered

Testosterone therapy in postmenopausal women should only be considered for:

• Decreased sexual desire with personal distress that has no other identifiable cause (physical, psychosocial, or medication-related) 1
• Physiologic cause for reduced testosterone (e.g., bilateral oophorectomy) 1
• Concomitant estrogen therapy is required—testosterone without estrogen cannot be recommended due to lack of evidence 1

Preferred Formulation: Transdermal Testosterone

If testosterone therapy is indicated, transdermal preparations (creams/gels) should be used rather than injections:

• Starting dose: 10 mg daily of testosterone gel/cream applied to dry, intact skin of the torso 3
• Doses up to 20-30 mg daily have been studied, though 10 mg achieves adequate serum levels in most women 3
• Monitor serum testosterone at 2-3 months after initiation or dose changes, then every 6-12 months once stable 2
• Commercially manufactured products are preferred over compounded formulations due to quality and potency consistency 2

Absolute Contraindications

Testosterone therapy must not be prescribed to women with:

• Breast cancer (current or history) 2
• Uterine cancer 1
• Cardiovascular disease 1
• Liver disease 1

Monitoring and Safety Parameters

• Limit therapy duration to maximum 24 months due to insufficient long-term safety data 2
• Monitor for hirsutism and acne, which are associated with therapy 1
• Measure testosterone levels only to detect supraphysiologic levels, not to diagnose deficiency, as available assays are inaccurate at female physiologic ranges 1
• Conduct annual clinical review focusing on treatment adherence, subjective sexual response, and adverse effects 2, 1

Critical Pitfalls to Avoid

• Do not use testosterone products formulated for men in women—these carry significant risk of excessive dosing 1
• Do not prescribe testosterone alone without concomitant estrogen therapy in postmenopausal women 1
• Do not use laboratory testosterone levels to diagnose "testosterone deficiency" in women—no validated threshold exists 1
• Avoid compounded products when possible due to inconsistent dosing 1
• Counsel patients about potential transfer risk to partners or children with transdermal preparations 2