What is hypoactive sexual desire disorder?
Hypoactive sexual desire disorder (HSDD) presents a persistent absence or deficiency of sexual fantasies and desire, in some individuals leading to significant distress or interpersonal difficulty.1
While its aetiology encompasses various biological, psychological, and social factors, testosterone deficiency is recognised as a potential contributor. Testosterone replacement therapy (TRT) has been explored as a treatment option for individuals with HSDD during the menopause, particularly those with low testosterone levels. However, its efficacy remains debatable, with inconsistent results observed across studies.2
Additionally, testosterone supplementation carries potential risks of adverse effects including acne, increased body hair at site of application, generalised hirsutism, alopecia, mood changes, deepening of the voice, and enlarged clitoris, some of which may be irreversible.3 Therefore, the use of testosterone in treating HSDD necessitates careful consideration, individualised approaches, and close monitoring by healthcare professionals.
Why is further guidance needed on the provision of TRT in patients with HSDD?
HSDD is present in around 12.3% of woman aged 45–64 years, with an increasing number of these patients being offered a trial of TRT.4 The British Menopause Society (BMS) issued guidance to GPs and other healthcare professionals around the use of TRT in HSDD.5 The current authors conducted an audit in their own trust (Leeds, UK, 2024) on woman from primary care aged ≥40 years (n = 100) and found poor compliance with testosterone monitoring.6 The most striking findings identified were inadequate blood test monitoring and the significant number of patients who had supraphysiological testosterone levels, often without appropriate correction of dose.
Recommendations to enhance guidelines for testosterone therapy in patients with HSDD
In response to these findings, which clearly demonstrated poor compliance with the BMS guidelines, a multidisciplinary team developed local guidelines to be used in conjunction with the BMS guidance to provide greater clarity on testing. Given the lack of evidence available, these are generally pragmatic recommendations based on clinical experience, pertaining to the timing, collection, and interpretation of testosterone results; see Box 1 and Figure 1 for a summary. The most notable and alarming finding from the 2024 audit data was the considerable number of patients with testosterone levels significantly above the normal female reference range, with many remaining in the supraphysiological range even at subsequent reviews. The current authors feel that healthcare professionals should play a pivotal role in ensuring that BMS blood monitoring recommendations are followed. Although testosterone creams can have varying pharmacokinetics, the BMS guidelines do not specify when or how to collect blood samples for monitoring TRT. Indeed, collection post-dose (within 2–3 hours) is not recommended and can lead to significant variability due to peak testosterone measurements and varying pharmacokinetics of different formulations.7 Additionally, while the guidelines reference the impact of sex hormone-binding globulin (SHBG) on testosterone measurement, there is a clear lack of understanding regarding how this should be managed in practice. Current data do not support the use of SHBG and calculation of free testosterone.8 In unique cases, it is recommended to seek discussion and advice around measuring SHBG in these patients from the local duty biochemist.
| • If the patient is on oestrogen, topical rather than oral preparations must be used to mitigate artefactual (not genuine, due to oestrogen increasing SHBG) changes in total testosterone measurements. |
| • Check baseline testosterone level. Leeds, UK, measures total testosterone and in females it is by tandem mass spectrometry. |
| • Normal female physiological range testosterone ≤1.8 nmol/L (Leeds reference range). Other laboratories using different methodology may have different upper limits of normal. |
| • It is recommended that testosterone levels are checked before treatment to establish a baseline for future monitoring and to ensure levels are not in the upper range before treatment is commenced. |
| • Testosterone <1.4 nmol/L (or <75% of local reference range) →consider commencing TRT trial. |
| • Testosterone ≥1.4 nmol/L (or ≥75% of local reference range) →TRT therapy not recommended. |
• Book 3-month appointment when TRT commenced and ensure blood result available to review.
— →If demonstrable clinical improvement and levels within female physiological range, continue with TRT. — → If testosterone ≥2.0 nmol/L (or ≥110% of local reference range), reduce dose and repeat in 2–4 weeks (even if no side effects). — →If no improvement after 6 months, then discontinue TRT.
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| • Testosterone levels to be checked at 12 months and again annually thereafter. |
• Healthcare professional controls overprescription of TRT.
— At 3 months healthcare professional will not prescribe any further testosterone until a blood measurement is undertaken and result available. — At 12 months, and every 12 months subsequently, healthcare professional will not prescribe testosterone until a blood measurement undertaken and result available.
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| • Blood sample should be collected in the morning and before application. Ideally the gel should be applied below the waist; however, if it is applied to the arm, bloods should be collected from the opposite arm. |
| • If testosterone levels do not correlate with dosing or clinical picture, consider contamination from venepuncture site. A significant number are seen of artefactually elevated testosterone results secondary to contamination of the venepuncture site. |
| • Randomised clinical trials of testosterone to date have not demonstrated the beneficial effects of testosterone therapy for cognition, mood, energy, or musculoskeletal health in women. Treatment should be offered for HSDD only. |
| • Testosterone gel in a sachet/tube container can result in inaccurate dosage; using a pump delivery system is recommended. |
Box 1. Recommendations to enhance guidelines for testosterone therapy in patients with HSDD
Figure 1. Summary of testosterone-monitoring recommendations for patients with HSDD. HSDD = hypoactive sexual desire disorder. TRT = testosterone replacement therapy.
Conclusion
HSDD represents a significant challenge in clinical practice, particularly due to poor compliance with existing BMS guidelines. This non-adherence hampers effective management and treatment outcomes for the increasing number of patients affected by HSDD. The efforts of the current authors to produce further guidance aim to address these gaps by providing clearer, more actionable strategies for healthcare providers. By enhancing understanding and adherence to these updated protocols, it is anticipated that there will be improved patient outcomes and a more standardised approach to managing HSDD. Ultimately, these steps will contribute to better care for this growing patient demographic.
Notes
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
- © British Journal of General Practice 2025
