Testosterone Troches in Women: Clinical Use and Administration
Testosterone troches (compounded buccal formulations) cannot be recommended for women with hypoactive sexual desire disorder (HSDD) due to lack of efficacy and safety data, and should only be considered when no approved transdermal testosterone preparation is available. 1
Critical Limitation of Troches
The 2019 Global Consensus Position Statement explicitly states that compounded "bioidentical" testosterone therapy—which includes troches—lacks evidence for efficacy and safety 1. This is a crucial distinction because:
- Transdermal testosterone is the evidence-based formulation for treating HSDD in postmenopausal women 2, 3
- Compounded products have variable quality, inconsistent dosing, and no regulatory oversight
- The clinical trials demonstrating benefit used transdermal preparations, not oral/buccal compounded formulations
When Troches Might Be Considered (Last Resort Only)
If an approved transdermal product is unavailable, compounded troches may be used only if 1:
- The compounding pharmacy complies with Good Manufacturing Practice standards
- Active Pharmaceutical Ingredients meet purity requirements
- Dosing is strictly limited to achieve physiologic premenopausal testosterone concentrations (typically 20-70 ng/dL total testosterone)
Important caveat: FDA-approved buccal testosterone products (like Striant®) are explicitly contraindicated in women and designed for male dosing 4. These should never be used in women.
Proper Clinical Approach If Using Testosterone
Patient Selection
- Only indication: Postmenopausal women with HSDD after formal biopsychosocial assessment 1, 2
- HSDD must not be primarily due to relationship problems, mental health issues, or other modifiable factors 3
- Limited data support use in late reproductive age premenopausal women 2, 3
Pre-Treatment Requirements
- Obtain baseline total testosterone level (not for diagnosis, but for monitoring) 1, 2
- Provide informed consent discussing off-label use, benefits, and risks 2, 3
- Exclude contraindications: pregnancy, breast cancer, cardiovascular disease 1
Monitoring Protocol
- Initial monitoring: Repeat testosterone level 3-6 weeks after starting 1
- Ongoing monitoring: Check total testosterone every 6 months to screen for overuse 1
- Target range: Maintain concentrations in physiologic premenopausal range (20-70 ng/dL) 1, 2
- Clinical assessment: Monitor for androgenic side effects (acne, hirsutism) 1
- Efficacy assessment: If no benefit by 6 months, discontinue treatment 1
Formulations That Should Be Used Instead
Preferred approach: Use government-approved transdermal male testosterone formulations (gels, patches) at doses appropriate for women 1, 2, 3. This provides:
- Predictable absorption
- Ability to titrate dosing
- Better safety profile
- Evidence-based efficacy
Typical dosing: 5-10 mg transdermal testosterone daily, adjusted based on clinical response and testosterone levels 2, 3.
Critical Safety Considerations
- Avoid supraphysiologic formulations: Pellets and injections are not recommended as they cannot maintain physiologic levels 1
- Long-term safety unknown: Data beyond 24 months are lacking 1
- Not for prevention: No data support testosterone for preventing breast cancer, cardiovascular disease, or osteoporosis 1
- Breast cancer caution: Women with hormone-sensitive breast cancer should not receive testosterone 1
Expected Outcomes
When using appropriate transdermal testosterone (not troches), women can expect 1:
- Average of one additional satisfying sexual event per month
- Improvements in desire, arousal, orgasm, pleasure, and responsiveness
- Reduction in sexual distress
- Mild increases in acne and facial/body hair in some women
The bottom line: Troches are a suboptimal formulation that should be avoided whenever possible. If testosterone therapy is indicated for HSDD, use transdermal preparations with proper monitoring to maintain physiologic levels and assess for both efficacy and safety.