Appendix 1. GGC Prescribing Advice: Testosterone in Menopause

Testosterone preparations are not currently licensed for any menopausal symptoms.  All testosterone preparations need regular monitoring.  Once you have read the guidance, if you wish to discuss prescribing or require further advice, please email the support service based at Sandyford: ggc.menopausesupport@nhs.scot

If you refer to a specialist, the most common result is likely to be a letter of advice.  Where testosterone is recommended by the specialist, it remains your clinical decision to prescribe

Clinical Indications

• Testosterone supplementation should only be considered in women who complain of low sexual desire after a biopsychosocial approach has excluded other causes such as relationship, psychological and medication related Hypoactive Sexual Desire Disorder (HSDD) e.g. SSRIs/SNRIs.
• Although studies have shown that testosterone can be beneficial in women not using concomitant oestrogen containing hormone therapy, the incidence of adverse androgenic effects is higher, therefore this strategy is not usually recommended in routine clinical practice
• Randomised clinical trials of testosterone to date have not demonstrated the beneficial effects of testosterone therapy for cognition, mood, energy and musculoskeletal health

Management prior to considering testosterone

• Oral oestrogens, especially conjugated oestrogens, can reduce the effectiveness of testosterone by increasing sex hormone binding globulin levels. Switching individuals with HSDD from oral to transdermal oestrogen can be beneficial as this can increase the proportion of circulating free testosterone without requiring exogenous testosterone
• It is important that any symptoms of vulvovaginal atrophy are also adequately treated if testosterone is being considered for HSDD.
• Individuals should ideally be well oestrogenised on standard systemic HRT (and, if appropriate, local vaginal oestrogen) before considering use of testosterone.

Side effects

• Can include acne, hirsutism, alopecia, hair growth at the application site, irritability and rarely clitoromegaly and voice deepening
• Evidence about long-term safety of testosterone for this indication is limited.

Prescribing and monitoring

As testosterone for low libido associated with menopause is 'off-label’ it is out-with the remit of the GGC Formulary. If being considered, prescribers should refer to NHSGGC Unlicensed Medicines Policy and Off-label or unlicensed use of medicines for further information on prescribing ‘off label’ medicines

Transdermal testosterone is used off-label, at the following maximum doses:

• If testosterone is to be prescribed, we recommend trialling testosterone for a 3-month period and then assessing whether it has been effective.
• It is helpful to measure total testosterone prior to commencing treatment and after 3 months to ensure levels are not supraphysiological.
• If there is no sustained benefit after 6 months, it should be discontinued.
• If remaining on treatment, annual assessment along with standard HRT is recommended, including a measurement of total testosterone level to ensure within physiological range.

Caution: Accidental exposure to topical testosterone: risk of harm to children              Premature puberty and genital enlargement have been reported in children who were in close physical contact with an adult using topical testosterone and who were repeatedly accidentally exposed to this medicine.

Further information:

Testosterone replacement in menopause - British Menopause Society (thebms.org.uk)

Patient information leaflet

Drug Safety Update: Topical Testosterone