Testosterone

THE USE OF TESTOSTERONE IN POST MENOPAUSAL WOMEN

Regardless of on-going controversies surrounding long-term use of estrogen and estrogen-progestogen preparations, there is little doubt that hormone replacement therapy is effective in the management of some of the symptoms that result from ovarian failure. Systemic therapy is advised for vasomotor symptoms such as flushing and sweating, whereas local topical preparations are appropriate for symptoms of vaginal dryness.

The ovary also contributes to the production of the "male" hormone, testosterone, in women; after surgical removal of the ovaries, circulating testosterone levels drop by 50%. Levels may also be reduced in women after a hysterectomy with conservation of the ovaries; this is possibly because the blood supply to conserved ovaries may be adversely affected by surgery. Less commonly other illnesses may be associated with low testosterone level, and women with premature ovarian insufficiency may have low testosterone levels.

For this reason there has been interest in the use of testosterone for some postmenopausal women. There has been interest in the use of testosterone for improved energy, mood and sense of well being, though evidence for this has not yet confirmed this effect. Furthermore, the use of testosterone can be associated with improvements in some aspects of female sexual function and is an option that some women may consider.

Currently the only recommended indication for use of testosterone for women is for persistent low sexual desire (known as hypoactive sexual desire disorder, HSDD) after all other contributory factors have been addressed. Sexual desire in women is complex and factors such as low energy, anxiety, low mood, vaginal dryness and discomfort, as part of menopausal symptoms, along with relationship issues, life stresses, should all be considered. Testosterone replacement may not be the magic answer! If all factors have been considered and it has been decided to have a trial of testosterone, the best effect is likely to be only moderate; one extra satisfying sexual episode per month. If there is no benefit after a trial of 6 months, then it should be stopped.

Previously in the UK, testosterone could be given in implant form or patch. However, the patch has now been withdrawn and the implant is only currently available in some clinics. The implant involves the insertion of a pellet every 6 months under the skin using local anaesthetic. A tablet form of HRT, tibolone, contains a combination of estrogen, progestogen and testosterone and can be taken by women who are postmenopausal. Testosterone gel can be used but is currently only licensed for use in men in the UK and would be used in a smaller dose for women only under specialist advice. A testosterone cream is available which is licensed for women, but is currently only available on private prescription.

At the moment it is usual to offer testosterone therapy only to women who are already using systemic estrogen treatment. Therefore there would be no reason to commence testosterone at the same time as commencing HRT, since controlling menopausal symptoms with the use of HRT, may also lead to improved sexual desire.

As with all treatments, the possibility of side effects requires consideration. Skin changes, slight increases in facial hair and hair at the site of application may occur. Deepening of the voice and enlargement of the clitoris are irreversible though rare; even less likely are abnormalities of liver function. These adverse effects can be minimised by monitoring the levels of testosterone in the blood.

Women who may wish to consider the use of testosterone therapy should discuss the options with their doctor.

Links for further reading

1. An article from Menopause Matters Magazine, Issue 55, Spring 2019: "Testosterone: The magic extra - or is it?"
   A specialist menopause nurse explains about this special hormone.
   » Download "Testosterone" as a PDF (2.4Mb)
   
   
2. Womens Health Concern fact sheet on testosterone: "Testosterone for women"
   » Download "Testosterone for women" as a PDF (151Kb)
3. » Sexual wellbeing, intimacy and menopause | NHS inform
4. Global Consensus Position Statement on the Use of Testosterone Therapy for Women
   » (researchgate.net) PDF