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As testosterone supplementation for women is widely discussed on social media, I am regularly asked whether it could help menopausal women. The important word here is ‘could’. For some women, testosterone can make a great deal of difference to their general wellbeing, but this doesn’t happen with all women.

This article was included in issue 90 ( Autumn 2021) of The Menopause Exchange newsletter.

What is testosterone?
Testosterone is seen as the male hormone, but women make it in greater quantities than oestrogen, although at much lower levels than in men. It’s made by both the adrenal glands (above your kidneys) and the ovarian stroma, which is the substance in the middle of your ovary and not the eggs. When your eggs run out at the menopause, your testosterone production keeps going, although it’s at a gently dwindling level. It doesn’t drop suddenly for most women unless something dramatic happens to the ovaries. This could include them being removed, getting infected or caught up in radiotherapy.

Testosterone deficiency
Testosterone deficiency in women can cause several symptoms, such as muscle aches, loss of energy, and mood symptoms such as anxiety, loss of confidence and motivation and a lack of sexual interest. Clearly all of these have multiple other influences and, when it comes to sex, oestrogen is the main important hormone to feel female and enable the genital tissues to be comfortable and responsive.

If women are deficient in testosterone, testosterone replacement should help. NICE guidance on the menopause, in 2015, commented that testosterone can help where a lack of sexual interest is an issue. The advice of the International Menopause Society is that the only area for which there’s evidence of testosterone’s benefit is with sexual interest and function. It’s the lack of trials that leads to the lack of evidence, rather than the lack of effect. Testosterone can help a range of symptoms but identifying when it may be appropriate is a clinical skill and requires experience and training. You therefore need to talk to an expert.

Testosterone in the UK
There are no testosterone products in the UK with a licence for use in women, so all prescribing is outside of a licence. This means that whoever signs the prescription takes responsibility for it. Therefore, only those healthcare professionals who can make an appropriate judgement and understand the limitations of testosterone and the implications of using it should be providing prescriptions.

When considering testosterone for an individual woman, I start by listening to her story. Does she have enough oestrogen? Have her basic symptoms cleared up and, if yes, what are we left with? If she still has problems with a lack of sexual interest, lack of energy, lack of motivation and aching, I may be suspicious. Having had both ovaries surgically removed makes this more likely. I would look for scientific support for prescribing testosterone outside its licence. I would usually check her testosterone (androgen) levels and testosterone activity. To do this, I would measure her levels of both testosterone and a protein called sex hormone binding globulin (SHBG). This combines with the testosterone and stops it working. High levels of SHBG may be the reason for relatively low testosterone activity.

There are broadly three available options of testosterone for prescribing:
Testim and Testogel are 1% testosterone gel in tubes or sachets that contain 50 mg – a typical replacement requirement in a man. Women use the tube over 10 days to deliver the average daily dose of 5 mg. The tube or sachet must be sealed properly between uses. Both products come in packs of 30 and can last for months.

Tostran is a 2% testosterone gel delivered by a pump, which will deliver a 10 mg dose. This is twice as much as women would need daily, so it’s usually used on alternate days. The pump will provide 120 doses and lasts for 240 days.

Androfeme 1 is a 1% testosterone cream. This comes with a measuring syringe, and 0.5ml will provide the 5 mg dose used daily. It’s produced and licensed in Western Australia for women but has no UK licence and can only be provided on a private prescription. The 50 ml tube will last for 100 days.

The gels have a UK licence for men, so could potentially be prescribed within the NHS by a practitioner who’s able to take responsibility and understands the regulations. Whichever product is used, the aim is to deliver 5 mg of testosterone on average per day. This is usually applied to the upper inner thigh. There are two reasons for this. Firstly, the area of skin to which it’s applied may become a little hairier with time, and this area is easier to shave than many others. Secondly, testosterone is fat soluble, so it moves through the skin to collect in the fat layer, and there are very few women without a fat layer in this area.

Changes are slow and usually subtle. Some improvement is typically felt at one to two weeks, but it takes eight weeks or more to be significant. My practice is to review at three months, with more tests. I aim to get androgen levels that are midrange for normal women, which is 2% to 3%. I change the dose based on symptom relief supported by blood levels. If it’s too high, there may be skin changes such as acne. This is body equivalent testosterone. For some women, this makes a big difference. But in others, achieving a midrange androgen level makes little difference, as the cause of their problem may be relationship or other issues that need to be addressed separately, and sometimes this needs to be recognised.

In my local area, NHS prescribing of testosterone has long been regarded as a secondary care-initiated option. This means it needs to be started by someone with a certain degree of expertise in this area. Once the androgen levels have stabilised, and testosterone is shown to be effective and safe, prescribing can be picked up by primary care if the prescriber feels able to do so. Practices may differ in their approach. This may be frustrating for patients, but until licencing changes this is simply the situation.

About the author

Dr Sarah Gray is a GP who specialises in women’s health. She runs private clinics at St Erme Medical in Truro, Cornwall.

Created Autumn 2021
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