The use of testosterone therapy in females has been addressed in the first global consensus position statement. It aimed to provide guidance on assessment and management of female sexual dysfunction and indications for testosterone therapy.
It highlighted the only evidence-based indication for testosterone therapy was treatment of hypoactive sexual dysfunction disorder (HSDD) in postmenopausal women. There are insufficient data to support the use in premenopausal women and there is no data to show benefit to cardiometabolic, musculoskeletal or cognitive health or wellbeing. Women at high risk for cardiometabolic disease and those with a history of breast cancer were excluded from the randomised controlled trials.
An Australian perspective on the global consensus statement, published in the MJA in 2020, proposed an algorithm for considering testosterone treatment in postmenopausal women, recommending menopausal hormonal therapy (MHT) be considered before initiating testosterone.
The issue of low sexual desire may not be readily volunteered and may be long-standing. A community based sample of Australian women aged 40-65 reported more than two thirds had low sexual desire and almost one third met criteria for HSDD.
There are several classifications for HSDD. Generally, it is defined as at least six months of lack of spontaneous or responsive sexual desire or behaviour change to avoid sexual activity which causes personal distress.
Clinical assessment of women with sexual problems includes medical, sexual and social history to help identify potential contributing factors. In post-menopausal women, menopausal hormonal therapy (MHT) can improve vasomotor symptoms (VMS), urogenital symptoms and mood disturbance and vaginal oestrogen formulations benefit vulvovaginal atrophy.
It would seem reasonable to see if MHT addresses potential contributing factors to sexual dysfunction prior to a trial of testosterone therapy. Of note, oral oestrogen raises sex hormone binding globulin (SHBG) reducing available free testosterone, this effect is not seen with topical preparations.
Testosterone is generally measured by immunoassay which lack precision at the lower concentrations found in women. Androgen levels decline steadily during reproductive years with a nadir in their early 60s. Measurement of testosterone is not used to diagnose HSDD, as it does not correlate with testosterone levels.
Testosterone and SHBG are measured to exclude high levels prior to starting testosterone therapy and to monitor biochemical response to treatment. In addition to baseline biochemistry, it is useful to gauge symptoms prior to starting and after commencement of treatment. Similar to what is available through the Australasian Menopause Society, information sheets for assessment of symptoms prior to and after initiation of MHT.
Reassessment of serum testosterone levels three to six weeks after initiation of testosterone therapy or dose adjustment is recommended, aiming for pre-menopausal physiological testosterone levels. If there is no symptomatic benefit after six months, treatment is discontinued.
Adverse effects of testosterone therapy, when achieving the physiological levels of pre-menopausal women, are limited to excess hair and acne and not associated with serious side effects. Ongoing monitoring of testosterone levels and for signs of androgen excess continues every six months. Safety data is limited to 24 months of treatment.
Until recently, available testosterone formulations have been the same as those designed for treatment of men, with potential risk of excessive dosing. In November 2020, the Therapeutic Goods Administration (TGA) approved a 1% transdermal testosterone cream for postmenopausal women with HSDD. Small clinical studies have shown 5-10mg daily achieved total and free testosterone levels in the pre-menopausal range.
Recommended further reading includes the MJA article with a proposed algorithm for assessment and treatment of HSDD and information sheets such as but not limited to what is available through the Australasian Menopause Society.
Key messages
- Treatment of HSDD is the only evidence-based indication for testosterone therapy in post-menopausal women
- In 2020 the TGA approved a transdermal testosterone cream for postmenopausal women with HSDD
- A trial of testosterone therapy may be appropriate for some women whose symptoms are not addressed by MHT.
– References available on request
Author competing interests – nil