To Testosterone or Not to Testosterone?
There seems to be a lot of controversy around testosterone replacement. It is billed as the solution for low sex drive, building muscle, and improving mood. Yet, not all women notice a difference when they supplement and the guidelines are specific that it’s only indicated for hypoactive sexual desire disorder (HSDD).
In fact, the Global Consensus Position Statement on the Use of Testosterone Therapy for Women states “Testosterone therapy, in doses that approximate physiological testosterone concentrations for premenopausal women, exerts a beneficial effect on sexual function including increases, above the effects of placebo/comparator therapy, of an average of one satisfying sexual event per month, and increases in the subdomains of sexual desire, arousal, orgasmic function, pleasure, and sexual responsiveness, together with a reduction in sexual concerns including sexual distress.”
What a mouthful!
They don’t define a satisfying sexual event - but I suppose getting one of those per month is a win! <I always smirk at the way these task force groups word things.>
Regardless, in layman’s terms they say using testosterone therapy at doses that would restore your levels to your younger years should have sexual benefits for you over placebo.
They go on to say that using testosterone has not been shown to improve your well-being. It also needs to be studied more regarding muscle or bone loss.
I would argue with both as clinically, I’ve seen testosterone therapy improve well-being and muscle growth in women as a whole. My former neighbor used to say that testosterone was her battery pack as she really noticed a difference!
I do realize that not all women feel this way.
When it comes to evaluating libido, I always ask my patients these questions.
Who is concerned about your sexual desire? Is it you? Is it your partner? Both? I would ask this as some women felt their libido was just fine but didn’t match that of their partner. While others felt they had zero libido which concerned them.
If you don’t have desire, can you get aroused? Meaning, maybe you don’t initiate, but once things start happening, can you get in the mood?
Can you orgasm? Has this changed? As women move through the menopausal transition, the clitoris can shrink and become less receptive to stimulus.
Is sex painful? If yes, for how long has it been painful? Has anything changed sexually? This helps me determine if painful sex is a new thing, perhaps due to vaginal dryness, or if it’s a long-standing concern that needs further evaluation. It also clues me in to a new sexual partner(s) or new practices that might be causing pain.
Evaluating Testosterone Levels:
Please keep in mind, libido is complex and involves more than just testosterone. It’s even more complex when you account for testosterone lab testing. It turns out, there is no lab level of testosterone that indicates when or if you’ll have a libido, arousal, or orgasm issue.
Testosterone does not typically plummet like progesterone and estradiol do through perimenopause. However, it can decline slowly over time starting in your 30’s.
Besides age, there are other reasons for low or declining testosterone levels such as certain medications, ovarian or adrenal gland issues as it’s made there, and chronic stress.
Laboratory testing can be done for total and free testosterone however it must be taken into account with symptoms. Liver markers in a metabolic panel are often done at the same time.
If someone is having side effects even at lower doses, lab testing for Dihydrotestosterone (DHT) is helpful. Testosterone can turn into DHT and DHT is the most potent. If it’s elevated, is likely the cause of the side effects.
It is suggested by the task force to test testosterone prior to starting therapy, then re-evaluate in 3-6 weeks both by lab and symptom evaluation. However, it can take 12 weeks to notice a difference. They state if zero improvement is noted in 6 months of use, stop the testosterone.
Types of Testosterone Therapy:
Sadly, there are no FDA approved testosterone therapies for women. Ugh! I know. Right now, it’s considered off-label use of the men’s FDA approved testosterone. They, understandably, have much higher amounts in their preparations so dosing has to be done carefully for women.
Men’s testosterone cream, such as Androgel, is probably the most commonly used.
Weekly injections are an option although not as common.
Testosterone pellets can be inserted into the hip area and last on average 3-4 months. I don’t love testosterone pellets unless it’s done by a very trained physician. I often saw the most side effects from excessive testosterone pellet dosing.
Testosterone can also be compounded. Many societies and task force groups don’t recommend compounding options unless absolutely necessary. I understand their concerns due to the inability to safely regulate the testosterone concentration within by the FDA however I have over 20 years of extremely positive experiences with compounding pharmacies and don’t hesitate to use them.
Testosterone Dosing:
Women need about 1/10th the dose of the men’s version which means 5mg/day that can go up to 10mg/day depending on labs and symptoms.
I do have women who are very sensitive to testosterone and need a much smaller starting dose such as 1mg/day or even 5mg every few days.
The key is not to get into a higher than physiological range known as supraphysiological.
Side Effects:
The most common side effects include:
Acne
Hair loss
Hirsutism (hair growth in places you don’t want, like the chin or nipple area)
Anger/irritation
Again, keeping doses such that they are in the typical female range and evaluating for the more potent DHT can help reduce the risk of side effects.
Do I Start With Testosterone?
My answer is not usually and it depends. While testosterone could do a lot of good, it’s important to evaluate other hormones such as estradiol as well. There is some research that shows an androgen (or testosterone) dominant woman relative to her estradiol could increase her risk of metabolic syndrome and visceral fat gain.
This means, adding in testosterone therapy when estradiol is low without addressing the estradiol levels could cause some problems.
In Summary:
Testosterone is not 100% straight forward however if you’re feeling hypoactive in the sexual desire area, talk with your practitioner about getting evaluated for testosterone therapy! It may even help your well-being and your muscles.
Additional Citation:
Uloko M, Rahman F, Puri LI, Rubin RS. The clinical management of testosterone replacement therapy in postmenopausal women with hypoactive sexual desire disorder: a review. International Journal of Impotence Research. 2022;34(7):635-641. doi:https://doi.org/10.1038/s41443-022-00613-0