Changes to testosterone prescribing for post menopausal women

You may think of testosterone as male hormone, but women make this hormone too. It is just one of the sex hormones that women produce, along with oestrogen and progesterone.

Levels of testosterone in your body gradually reduce throughout your reproductive years and level off in menopause. There is no sudden drop off at menopause with many women not even noticing a difference. Testosterone levels generally return to premenopausal levels later in life.
Some people are more sensitive to these natural fluctuations in levels and sometimes benefit from extra testosterone.

The current recommended reason is for persistent low sex drive (Hypoactive sexual desire disorder, HSDD) in women after all other possible factors, including taking adequate oestrogen, have been addressed. Even with this indication, it does not help everyone. There is not enough evidence at the moment to recommend its use for low energy, low mood, fatigue or brain fog.

Randomised clinical trials of testosterone to date have not demonstrated the beneficial effects of testosterone therapy for cognition, mood, energy and musculoskeletal health. Further better designed studies are required with these health issues as primary outcome measures as some individuals report improvement of these symptoms. Until these data are available, the primary indication for testosterone should therefore be for HSDD following a biopsychosocial approach.

In most women testosterone levels are often within the normal female range as production is not just from your ovaries.
Blood tests are not able to diagnose whether you need testosterone but are used as a safety check to ensure you are not getting too much on top of your own natural levels.

The NICE Menopause Guideline (NG23) and the BMS recommend that a trial of conventional HRT is given before testosterone supplementation is considered.
 Switching women with HSDD from oral to transdermal ( through the skin) oestrogen can be beneficial as this can increase the proportion of circulating free testosterone without requiring extra testosterone. It is important that any symptoms of vulvovaginal atrophy are also adequately treated if testosterone is being considered for HSDD.

NICE Guidance on menopause states that testosterone can be considered for those postmenopausal women that need it (NG23).
Testosterone can be prescribed on the NHS if the prescriber is familiar with it and is willing to prescribe it ‘off licence’. Some clinicians prefer not to prescribe unlicensed medication for safety reasons and refer to a specialist which is what we do at our surgery.

In the NHS, testosterone is usually given as a gel, which you rub into your skin. It comes as a gel in a small sachet, tube or pump dispenser and you only need to rub a pea- size amount of this gel into your skin. One 50mg sachet or tube should last around 10 days. The gel should be rubbed onto your lower abdomen, thighs or the inner aspect of your forearm. In the UK testosterone is not currently licensed for use by women, so it is said to be prescribed ‘off licence’.
Privately, you may be given a type of testosterone which is not generally available on the NHS. This product is called AndroFeme 1. It comes with a measure and is recommended to be used daily. It is only available on special order with a private prescription.
It can sometimes take a few months for the full effects of testosterone to work; a 3–6-month trial is often recommended.

If you use the recommended dose side effects are said to be very few.

The commonest side effects are excess hair growth, acne and weight gain which are usually reversible with reduction in dosage or discontinuation.
Alopecia, deepening of voice, clitoral enlargement and cardiovascular disease are rare when using at recommended dosages but are irreversible if they do occur rotate the area of skin you apply it to and do not use more than suggested. Higher doses may lead to unwanted effects
If side effects occur, please check dosage and how it is being used, different preparations have different dosing schedules. Consider reducing dosage or stopping. 

Also patients need to be aware there have been reports of skin transfer of testosterone gel and so care needs to taken as to how it is used and stored:
– Topical testosterone products are used for testosterone replacement. When using these products on your skin, you must take care that the testosterone product is not accidentally transferred onto the skin of someone else.

If the testosterone in the product is accidentally transferred to someone else through physical contact, it can lead to increased blood testosterone levels in the other person. It can cause facial and body hair growth, deepening of voice and changes in the menstrual cycle of women, or accelerated height, genital enlargement, and early puberty (including development of pubic hair) in children.

The following precautions can reduce the risk of accidentally transferring testosterone from the patient’s skin to another person:
1. After applying the product, wash your hands with soap and water
2. Once the product has dried, cover the application site with clean clothing (such as a t-shirt)
3. Before physical contact with another person (adult or child), wash the application site with soap and water after the recommended time period following application has passed

Long term safety data regarding testosterone is limited and uncertainty remains effects on cancer, cardiovascular disease, VTE and dementia risk. 

Active liver disease
History of hormone sensitive breast cancer
History of blood clots or cardiovascular disease
Sleep apnoea or heart failure
Competitive athletes – care must be taken to maintain levels well within the female physiological range
Women with upper normal or high baseline testosterone levels / FAI