What is the appropriate testosterone injection dosage, titration, and monitoring protocol for a post‑menopausal woman with hypoactive sexual desire disorder?

Testosterone Injection Dosing for Postmenopausal Women with HSDD

Testosterone injections are not recommended for women with hypoactive sexual desire disorder; instead, transdermal testosterone at 300 mcg/day is the evidence-based formulation, applied as approximately 5 grams of 1% testosterone gel twice weekly to achieve physiologic premenopausal serum levels. 1, 2, 3

Why Transdermal—Not Injectable—Testosterone

• Injectable testosterone formulations designed for men produce supraphysiologic peaks and troughs that cannot be safely titrated to maintain female physiologic ranges, making transdermal delivery the only guideline-endorsed route. 2, 3
• The International Society for the Study of Women's Sexual Health explicitly states that government-approved transdermal male formulations can be used cautiously with dosing appropriate for women, but does not endorse injectable preparations. 2, 3
• Compounded testosterone products, including injectables, cannot be recommended due to lack of efficacy and safety data. 2, 3

Transdermal Testosterone Dosing Protocol

Initial Dosing

• Start with 300 mcg/day of transdermal testosterone, which translates to approximately 5 grams of 1% testosterone gel applied twice weekly (every 3–4 days). 1, 2
• Apply to dry, intact skin of the abdomen, back, upper thighs, or upper arms, rotating application sites. 1
• The target is to achieve testosterone levels in the mid-normal premenopausal female range—not male reference ranges of 500–600 ng/dL. 1

Monitoring Schedule

• Measure baseline total testosterone before initiating therapy (level is not used to diagnose HSDD, only for monitoring). 2, 3
• Check total testosterone at any time of day during treatment, as peak levels occur 6–8 hours after gel application but timing is not critical for monitoring. 1
• Monitor every 3 months during the first year, then less frequently if stable. 1, 2
• Assess for signs of androgen excess (acne, hirsutism, voice deepening, clitoromegaly) at each visit. 2, 3

Efficacy Assessment and Duration

• Reassess clinical response after 3–6 months; discontinue if no improvement in sexual desire or distress. 1
• Limit therapy to a maximum of 24 months due to lack of long-term safety data beyond this timeframe. 1
• Women who experience meaningful benefit report approximately one additional satisfying sexual event every 2 months compared to baseline, with desire scores moving from "seldom" to "sometimes" feeling sexual desire. 1, 4

Patient Selection and Contraindications

Absolute Contraindications

• Current or history of breast cancer or other hormone-dependent malignancies. 1
• Pregnancy, breastfeeding, or women attempting conception. 1
• Current breast cancer treatment with aromatase inhibitors (testosterone may reduce efficacy). 1

Clinical Context Requirements

• Testosterone should only be prescribed after a biopsychosocial assessment confirms HSDD is not primarily due to modifiable factors such as relationship problems, untreated depression, or inadequate estrogen levels. 2, 3
• Adequate circulating estrogen is necessary for testosterone efficacy; consider concurrent estrogen therapy in women with severe hypoestrogenism. 1
• Obtain informed consent discussing off-label use, modest efficacy (approximately 52% report meaningful benefit vs. 31% with placebo), and unknown long-term safety. 2, 3, 4

Treatment Algorithm

First-Line (Premenopausal Women)

• Flibanserin 100 mg orally at bedtime daily is FDA-approved for premenopausal HSDD. 1

Second-Line (Premenopausal)

• Bupropion or buspirone may be considered, though data are limited. 1

Third-Line (Postmenopausal Women)

• Transdermal testosterone 300 mcg/day for postmenopausal women without hormone-dependent cancer history, after failure of psychosocial interventions. 1, 2
• This represents the only evidence-based hormonal indication for testosterone in women. 2, 5

Common Pitfalls to Avoid

• Do not use total testosterone levels to diagnose HSDD—low testosterone does not equal HSDD, and normal levels do not exclude it. 2, 3
• Do not prescribe compounded testosterone preparations—these lack standardized dosing, quality control, and safety data. 2, 3
• Do not target male testosterone ranges—this causes virilization and does not improve outcomes. 1
• Do not continue therapy beyond 6 months without documented clinical benefit—the modest effect size means many women will not respond. 1, 4
• Do not prescribe testosterone as monotherapy for vaginal atrophy or dyspareunia—these symptoms require local estrogen or other targeted treatments. 1, 6

Adjunctive Therapies

• Cognitive-behavioral therapy and pelvic floor physical therapy improve sexual pain, arousal, and satisfaction and should be offered alongside or before testosterone. 1, 6
• Vaginal moisturizers (3–5 times weekly) and lubricants address coexisting vaginal atrophy that may contribute to sexual dysfunction. 1, 6