WE TEND TO think of testosterone as a male hormone and associate it with male characteristics and building muscle, but women make this hormone too in small amounts. It is made in the ovaries and in the adrenal glands.
It is just one of the sex hormones that women produce, along with oestrogen and progesterone. Levels of testosterone in your body gradually reduce as you become older, starting to fall naturally in our 30’s, with many women not even noticing.
Others are more sensitive to the changes and sometimes benefit from extra testosterone as part of their Hormone Replacement Treatment (HRT). Young women who have surgical menopause (removal of ovaries) may notice the change in testosterone more, perhaps because they are younger, because the drop is sudden or because their sex drive is more dependent on testosterone.
The use of testosterone in women has been happening for decades. 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 the use of testosterone for low energy, low mood, fatigue or brain fog although some women report a significant improvement in these symptoms.
The prescribing of testosterone in women is “unlicensed” meaning the drug has not been awarded a specific license for its use in women, but there are several guidelines now available for its use including in the British Menopause Society’s Tools for Clinicians and a 2019 consensus statement by the International Menopause Society.
Testosterone is given topically (through the skin) 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.
Blood levels of testosterone should be checked before starting treatment and after 6-8 weeks to ensure that levels are being kept to a reasonable level. Levels should be tested every 6 months during treatment. Side effects of overuse include unwanted hair, lowering voice and male pattern baldness and acne. These tend to be reversible upon stopping treatment.
Most of the evidence regarding testosterone use in women in the literature is short-term. We know that testosterone does not seem to affect breast density however, women with a personal history of breast cancer were excluded from the studies so we do not know if it affects recurrence rates in these patients and we do not have any data to assess the effect of long-term testosterone use on breast tissue.
Similarly, we do not know the effect of testosterone on cardiovascular risk in women, however, short-term use does not seem to increase your risk of a heart attack or stroke.
Although the general consensus is that systemic HRT should be prescribed before a trial of testosterone there is trial data that in women with low or no sex drive testosterone used without oestrogen is equally safe and effective.
There is a possibility that this may cause an imbalance between oestrogen and testosterone leading to symptoms like unwanted hair and acne similar to the pattern we see in women with Polycystic Ovarian Syndrome. In my personal practice, I tend to follow the following basic rules:
Fix oestrogen first - We have the ability to change one hormone to another inside our body in a complex system of endocrine pathways. For this reason, if the oestrogen levels have not been stabilised, e.g. a patient is still suffering from menopausal flushes, it is likely that the testosterone we are giving can just be made into oestrogen inside the patient’s body. On the other hand, if flushing and other symptoms are largely resolved and low sex drive remains, a trial of testosterone use is reasonable.
Fix vaginal dryness – Vaginal atrophy is underreported by patients and patients are often not asked about it by their healthcare professional. It needs to be treated with localised oestrogen by vaginal pessaries or gel. This is because the lack of oestrogen in the vaginal and surrounding tissues causes poor blood supply to the area and therefore the hormones being taken by patch/gel or tablet are unlikely to get into the vaginal tissues. Vaginal atrophy can cause very painful intercourse and therefore should be treated before improving sex drive.
More likely to initiate in younger women – Younger women are likely to be more dependent on testosterone for many things including sex drive and are therefore more likely to require replacement.
It is important to set realistic treatment goals from the outset. Sex drive is extremely multifactorial and therefore no one element tends to improve it. It is unlikely that a patient with disturbed sleep due to flushing and night sweats, constant anxiety and agitation, crushing fatigue and vaginal discomfort is going to have a healthy sex drive.
Many women report that their mood and lack of sex drive have had a negative effect on their relationships and it takes a variable amount of time for all of these factors to improve.
Given all the issues above I probably start approximately 10% of my peri- and menopausal patients on testosterone. I give them a six-month trial and reassess at that point. In my practice, what I’ve found is that at least half have stopped using it due to no improvement or because it made them worse. For some women (but the minority in my experience), Testosterone is the “the missing ingredient” that drastically improves their quality of life.
Dr Karen Soffe is joint lead of the Complex Menopause Clinic Cork University Maternity Hospital CUMH and a GP lead with special interest in women’s mid-life health and accredited menopause specialist. She will be speaking at the upcoming National Menopause Summit Cork supported by M&S which takes place on Friday October 20th in Cork City Hall. Tickets and summit details including speaker line-up and agenda available at www.nationalmenopausesummit.com.
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