Testosterone is an important female hormone. Women produce more testosterone than oestrogen physiologically. Approximately half of endogenous testosterone and precursors are derived from the ovaries and half from the adrenal glands. Testosterone levels naturally decline throughout a woman’s lifespan. Loss of testosterone is particularly profound after iatrogenic i.e. surgical and medical menopause and premature ovarian insufficiency when testosterone production decreases by more than 50%.
Testosterone contributes to libido, sexual arousal and orgasm by increasing dopamine levels in the central nervous system. Testosterone also maintains normal metabolic function, muscle and bone strength, urogenital health, mood and cognitive function.
Indication: The only evidence based clinical indication is for acquired, generalised Female Sexual Interest/Arousal Disorder (formerly HSDD) in postmenopausal women.
Testosterone deficiency in women can lead to a number of distressing sexual symptoms such as low sexual desire, arousal and orgasm. Other contributory factors which should be taken into account when assessing women with these symptoms include psychosexual, physical, iatrogenic and environmental. The patient should be in a good healthy relationship, is not experiencing sexual pain, body (including vulva and vagina) is oestrogenised and have had medication side effects, external stressors and mental health issues addressed prior to considering testosterone for low libido.
Testosterone deficiency can also contribute to a reduction in general quality of life, tiredness, depression, headaches, cognitive problems, osteoporosis and sarcopenia. However, there is insufficient research data about the effectiveness of testosterone for these indications. Clinically, many women will see an improvement in these symptoms.
Menopausal women should be prescribed HRT in the first instance (Menopause & HRT prescribing guidance). Switching to transdermal oestrogen may be more beneficial for symptom control including for low sexual desire. For those women whose oestrogen deficiency symptoms are well controlled (systemically and genitally) but continue to be distressed by low libido and low mood, insomnia, fatigue and low energy levels, or cognitive issues (brain fog, difficulty in concentrating), a trial of testosterone would be indicated.
Serum Oestradiol levels do not need to be monitored. If oestrogen deficiency symptoms are poorly controlled, refer patient to HSH Menopause Clinic or seek advice via Clinical Dialogue.
Private Menopause Specialists: There are some private providers who have been advocating testosterone for all menopausal women, commencing testosterone at the same time as commencing HRT and without monitoring. This is out with British Menopause Society and International Menopause Society recommendations.