Skip to main content

Main menu

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • BJGP LIFE
  • MORE
    • About BJGP
    • Conference
    • Advertising
    • eLetters
    • Alerts
    • Video
    • Audio
    • Librarian information
    • Resilience
    • COVID-19 Clinical Solutions
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers

User menu

  • Subscriptions
  • Alerts
  • Log in

Search

  • Advanced search
British Journal of General Practice
Intended for Healthcare Professionals
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers
  • Subscriptions
  • Alerts
  • Log in
  • Follow bjgp on Twitter
  • Visit bjgp on Facebook
  • Blog
  • Listen to BJGP podcast
  • Subscribe BJGP on YouTube
Intended for Healthcare Professionals
British Journal of General Practice

Advanced Search

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • BJGP LIFE
  • MORE
    • About BJGP
    • Conference
    • Advertising
    • eLetters
    • Alerts
    • Video
    • Audio
    • Librarian information
    • Resilience
    • COVID-19 Clinical Solutions
Clinical Intelligence

Should we be prescribing testosterone to perimenopausal and menopausal women? A guide to prescribing testosterone for women in primary care

Alice Scott and Louise Newson
British Journal of General Practice 2020; 70 (693): 203-204. DOI: https://doi.org/10.3399/bjgp20X709265
Alice Scott
Essex Private Doctors, Shenfield, Essex.
BSc, MRCGP, DCH, DFSRH
Roles: Advanced Certificate Menopause Care, GP and menopause specialist
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Louise Newson
Newson Health Menopause and Wellbeing Centre, Stratford-upon-Avon, Warwickshire.
BSc(Hons), MRCP, FRCGP
Roles: Advanced Certificate Menopause Care, GP and menopause specialist
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info
  • eLetters
  • PDF
Loading

INTRODUCTION

Testosterone is one of the sex hormones that women produce, yet it is often overlooked. Women actually produce three times as much testosterone as oestrogen before the menopause. Levels of testosterone gradually decline because of increasing age or they reduce abruptly following oophorectomy.

The most commonly described symptoms of androgen insufficiency include dysphoric mood, unexplained fatigue, change in sexual function including reduced libido, changes in cognition, vasomotor symptoms, bone loss, and decreased muscle strength.1

Reduced or lack of libido is very common in menopausal women. The National Institute for Health and Care Excellence (NICE) guidelines state that testosterone supplementation can be considered for menopausal women with low sexual desire if hormone replacement therapy (HRT) alone is not effective.2 The British Menopause Society (BMS) 2016 recommendations advise that this indication could be extended to include menopausal women with low sexual desire and tiredness.3

Testosterone can be important in women for bone density and muscle mass, cognitive function, mood, sexual function, and energy.1 Adequate levels of testosterone are important for the maintenance of musculoskeletal health and possibly vascular and brain function.

EVIDENCE TO SUPPORT TESTOSTERONE USE IN WOMEN

Numerous studies have shown that adding testosterone to hormonal therapy can improve sexual function and general wellbeing among women during their menopause. A recent systematic review and meta-analysis of testosterone treatment in women has provided robust support for a trial of testosterone in women when clinically indicated. In postmenopausal women, testosterone supplementation improved several domains of sexual response, including sexual desire, pleasure, arousal, orgasm, and self-image.4

It has also been shown to have additional benefits including the improvement of urogenital, psychological, and somatic symptoms, an increase in bone density, and enhancement of cognitive performance when combined with oestrogen as part of HRT. Many women notice that taking testosterone improves their mood, concentration, motivation, and energy levels.

A significant problem with prescribing testosterone is that there are currently no available licensed preparations for women in the UK. The BMS has recently released some guidance on testosterone prescribing which suggests some of the products that can be used and their doses (Box 1).5 General Medical Council guidance on the prescription of unlicensed medication should be consulted when prescribing. It is important to ensure that women are adequately oestrogenised before adding in testosterone; this is usually the case when they are no longer experiencing vasomotor symptoms or vaginal dryness.

  • Testogel® ([Besins Healthcare UK Ltd] 1% testosterone gel in 5.0 g sachets containing 50 mg testosterone): starting dose 1/10 of a sachet/day = 5 mg/day, that is, each sachet should last 10 days.

  • Tostran® ([Kyowa Kirin Ltd] 2% testosterone gel in a canister containing 60 g): starting dose 1 metered pump of 0.5–10 mg on alternate days — each canister should last 240 days.

  • AndroFeme® ([Lawley Pharmaceuticals] 1% testosterone cream in 50 ml tubes with screw cap) (only available privately): starting dose 0.5 ml/day = 5 mg/day, that is, each tube should last 100 days.

Box 1.

Commonly used testosterone replacement in menopause5

The normal range of testosterone is difficult to define as most of the available tests do not provide the accuracy or precision required when testing the low serum concentrations in women. As most testosterone is protein bound to sex hormone-binding globulin (SHBG), there is only a small circulating free fraction, which is difficult to measure reliably. The level of bioavailable testosterone can be estimated using Free Androgen Index (FAI). BMS guidance suggests that in a symptomatic woman with an FAI of <1%, a trial of testosterone supplementation could be considered.5

It can sometimes take several weeks or even months for a woman to notice the beneficial effects of testosterone. If they have not noticed an improvement after 6 months, then it is unlikely to be beneficial.

Current BMS guidance suggests that, when monitoring women who are using testosterone, the level of FAI should be maintained at <5% but that clinical improvement in symptoms is more important than aiming for a specific level on treatment (Box 2).5

  • Testosterone can be a useful adjunct to HRT care in many women.

  • Check the patient is well oestrogenised before starting (no vasomotor symptoms).

  • Calculate FAI = total testosterone/SHBG × 100 and if in the lowest quartile (<1%) consider a trial of testosterone.

  • Check FAI after starting treatment and aim to keep it <5%.

Box 2.

Practical points

An international task force of experts from leading medical societies, brought together by the International Menopause Society, has recently produced a Global Position Statement to provide clear guidance regarding the prescribing and measurement of testosterone for female testosterone therapy, as well as advice on testosterone prescribing practices that have the potential to be ineffectual or cause harm. They concluded that testosterone can be effective at improving sexual wellbeing for postmenopausal women with hypoactive sexual desire dysfunction (HSDD). Recognised benefits included improved sexual desire, arousal, orgasm, and pleasure, together with reduced concerns and distress about sex.6 They advise measuring testosterone levels at baseline and at 3–6 weeks after treatment initiation. Patients should be monitored for their clinical response to treatment and assessed for signs of androgen excess, with a serum total testosterone level every 6 months to screen for overuse. There should be cessation after 6 months if there has been no response to treatment.6

SAFETY OF TESTOSTERONE

Testosterone appears to be safe when used transdermally and in low doses. There are little long-term safety data on the use of testosterone in menopausal women beyond 2 years. What is available is reassuring in that transdermal testosterone is not associated with an increase in blood pressure and has no adverse effects on lipid profile.6 Evidence shows that there are also no changes in renal function, liver function, or blood cell indices with transdermal testosterone in women.7 There is no increased risk of breast cancer in the short term6 and it does not appear to stimulate the endometrium.8 It is currently not known how safe it is to prescribe testosterone to women who have breast cancer, and this would be a decision for a secondary care menopause service, on a case-by-case basis and after discussion with an oncologist.

Side effects can occasionally occur including acne and increased hair growth at the site of application, but increase in facial hair, alopoecia, or voice deepening does not occur if testosterone levels are kept within the female physiological range.4

There is an urgent need to ensure gender equality in effectively managing women with sexual dysfunction related to hypoandrogenic states. Having a licensed testosterone preparation available for women would certainly be a step in the right direction.

As most menopausal women can be managed in primary care, the new BMS guidance will aid GPs to feel confident to initiate testosterone, if appropriate, or to continue prescriptions that have been started in specialist clinics.

Notes

Funding

None.

Provenance

Freely submitted; externally peer reviewed.

Competing interests

Louise Newson has had financial relationships (as lecturer, writer, member of advisory boards) with various pharmaceutical companies and travel expenses and registration fees paid to attend international menopause conferences by Besins, Lawley Pharmaceuticals and Theramex. She is the director of Newson Health Ltd. Alice Scott has declared no competing interests.

Discuss this article

Contribute and read comments about this article: bjgp.org/letters

  • Received July 10, 2019.
  • Revision requested August 9, 2019.
  • Accepted September 10, 2019.
  • © British Journal of General Practice 2020

REFERENCES

  1. 1.↵
    1. Bachmann G,
    2. Bancroft J,
    3. Braunstein G,
    4. et al.
    Female androgen insufficiency: the Princeton consensus statement on definition, classification, and assessmentFertil Steril2002774660665
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. National Institute for Health and Care Excellence
    Menopause: diagnosis and management NG232015www.nice.org.uk/guidance/NG23 (accessed 21 Feb 2020).
  3. 3.↵
    1. Hamoda H,
    2. Panay N,
    3. Arya R,
    4. Savvas M
    The British Menopause Society & Women’s Health Concern 2016 recommendations on hormone replacement therapy in menopausal womenPost Reprod Health2016224165183
    OpenUrlCrossRef
  4. 4.↵
    1. Islam RM,
    2. Bell RJ,
    3. Green S,
    4. et al.
    Safety and efficacy of testosterone for women: a systematic review and meta-analysis of randomised controlled trial data.Lancet Diabetes Endocrinol2019doi:10.1016/S2213-8587(19)30189-5Epub 2019 Jul 25.
    OpenUrlCrossRef
  5. 5.↵
    1. Panay N
    Testosterone replacement in menopause2019https://thebms.org.uk/publications/tools-for-clinicians/testosterone-replacement-in-menopause/ (accessed 21 Feb 2020).
  6. 6.↵
    1. Davis SR,
    2. Baber R,
    3. Panay N,
    4. et al.
    Global consensus position statement on the use of testosterone therapy for women.Climacteric2019doi:10.1080/13697137.2019.1637079Epub 2019 Sep 2.
    OpenUrlCrossRef
  7. 7.↵
    1. Achilli C,
    2. Pundir J,
    3. Ramanathan P,
    4. et al.
    Efficacy and safety of transdermal testosterone in postmenopausal women with hypoactive sexual desire disorder: a systematic review and meta-analysisFertil Steril20171072475482
    OpenUrl
  8. 8.↵
    1. Nachtigall L,
    2. Casson P,
    3. Lucas J,
    4. et al.
    Safety and tolerability of testosterone patch therapy for up to 4 years in surgically menopausal women receiving oral or transdermal oestrogenGynecol Endocrinol20112713948
    OpenUrlCrossRefPubMed
Back to top
Previous ArticleNext Article

In this issue

British Journal of General Practice: 70 (693)
British Journal of General Practice
Vol. 70, Issue 693
April 2020
  • Table of Contents
  • Index by author
Download PDF
Email Article

Thank you for recommending British Journal of General Practice.

NOTE: We only request your email address so that the person to whom you are recommending the page knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Should we be prescribing testosterone to perimenopausal and menopausal women? A guide to prescribing testosterone for women in primary care
(Your Name) has forwarded a page to you from British Journal of General Practice
(Your Name) thought you would like to see this page from British Journal of General Practice.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Should we be prescribing testosterone to perimenopausal and menopausal women? A guide to prescribing testosterone for women in primary care
Alice Scott, Louise Newson
British Journal of General Practice 2020; 70 (693): 203-204. DOI: 10.3399/bjgp20X709265

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Should we be prescribing testosterone to perimenopausal and menopausal women? A guide to prescribing testosterone for women in primary care
Alice Scott, Louise Newson
British Journal of General Practice 2020; 70 (693): 203-204. DOI: 10.3399/bjgp20X709265
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One
  • Mendeley logo Mendeley

Jump to section

  • Top
  • Article
    • INTRODUCTION
    • EVIDENCE TO SUPPORT TESTOSTERONE USE IN WOMEN
    • SAFETY OF TESTOSTERONE
    • Notes
    • REFERENCES
  • Figures & Data
  • Info
  • eLetters
  • PDF

More in this TOC Section

  • How to manage low testosterone level in men: a guide for primary care
  • Hyperparathyroidism (primary) NICE guideline: diagnosis, assessment, and initial management
  • The atypical presentation of COVID-19 as gastrointestinal disease: key points for primary care
Show more Clinical Intelligence

Related Articles

Cited By...

Intended for Healthcare Professionals

BJGP Life

BJGP Open

 

Tweets by @BJGPjournal

 
 

British Journal of General Practice

NAVIGATE

  • Home
  • Current Issue
  • All Issues
  • Online First
  • Authors & reviewers

RCGP

  • BJGP for RCGP members
  • BJGP Open
  • RCGP eLearning
  • InnovAiT Journal
  • Jobs and careers

MY ACCOUNT

  • RCGP members' login
  • Subscriber login
  • Activate subscription
  • Terms and conditions

NEWS AND UPDATES

  • About BJGP
  • Alerts
  • RSS feeds
  • Facebook
  • Twitter

AUTHORS & REVIEWERS

  • Submit an article
  • Writing for BJGP: research
  • Writing for BJGP: other sections
  • BJGP editorial process & policies
  • BJGP ethical guidelines
  • Peer review for BJGP

CUSTOMER SERVICES

  • Advertising
  • Contact subscription agent
  • Copyright
  • Librarian information

CONTRIBUTE

  • BJGP Life
  • eLetters
  • Feedback

CONTACT US

BJGP Journal Office
RCGP
30 Euston Square
London NW1 2FB
Tel: +44 (0)20 3188 7400
Email: journal@rcgp.org.uk

British Journal of General Practice is an editorially-independent publication of the Royal College of General Practitioners
© 2023 British Journal of General Practice

Print ISSN: 0960-1643
Online ISSN: 1478-5242