How much testosterone should a woman take during menopause?

Before menopause, a woman's body produces three to four times more testosterone than estrogen. While testosterone levels decline gradually with age, supplementation is sometimes considered for postmenopausal women to address specific symptoms like low libido. Understanding how much testosterone should a woman take during menopause requires careful consideration of dosing, formulations, and expert medical guidance to ensure safety and effectiveness.

Quick Summary

A woman's testosterone dosage during menopause is highly individualized, typically starting at a low, daily dose of a transdermal gel or cream. The therapy is primarily for addressing hypoactive sexual desire disorder and must be carefully managed by a healthcare provider. Doses aim to mimic premenopausal levels to minimize side effects, with regular monitoring of blood tests and symptoms.

Key Points

• Start Low and Monitor: The initial dose for transdermal gels or creams is determined by a healthcare provider and adjusted based on clinical response and blood levels, aiming for a physiologic range.

• Primary Indication is HSDD: The main evidence-based reason for testosterone therapy in menopausal women is to address hypoactive sexual desire disorder (HSDD) after other options, like estrogen therapy, have been tried.

• Avoid Pellets and Injections: Pellets and injections are not recommended for menopausal women due to the risk of uncontrolled, supraphysiologic hormone spikes that can cause irreversible side effects.

• Monitor Carefully for Side Effects: A healthcare provider must monitor testosterone levels and watch for androgenic side effects like acne, excess hair growth, or voice deepening. Some of these effects are irreversible if levels remain too high.

• Consider Alternatives: Lifestyle changes, addressing vaginal dryness with local estrogen, and sex therapy are effective alternatives or adjuncts to testosterone for sexual health and well-being.

• Physiologic Levels are Key: The goal of therapy is to raise testosterone to the normal premenopausal range, not to achieve male-level hormone concentrations.

• Safety Data is Limited Long-Term: While short-term studies have shown safety, long-term data on cardiovascular and breast cancer risks are still limited for testosterone therapy in women.

Why Testosterone Therapy is Considered for Menopausal Women

Testosterone is a vital hormone for women's health, influencing sexual desire, mood, energy, and musculoskeletal strength. As menopause approaches, testosterone levels decline, though not as sharply as estrogen, which can contribute to various symptoms. The primary evidence-based use of testosterone therapy in postmenopausal women is for treating hypoactive sexual desire disorder (HSDD), a condition characterized by a distressing lack of sexual desire. Some women also report benefits beyond libido, including improved energy, mood, and mental clarity, though these are not consistently supported by robust evidence and are not the formal indication.

• Impact on Libido: The most documented effect of testosterone therapy is the improvement of sexual function, including desire, arousal, and orgasm frequency, particularly in women with HSDD.
• Potential for Broader Benefits: Anecdotal evidence suggests improvements in mood, motivation, energy levels, and bone density for some women, especially when combined with standard hormone replacement therapy (HRT).
• Importance of Estrogen Replacement: It is recommended that women are adequately estrogenized, typically through HRT, before considering adding testosterone. In many cases, addressing estrogen deficiency can resolve some symptoms that may be incorrectly attributed to low testosterone.

Recommended Dosages and Formulations

There are currently no FDA-approved testosterone products specifically for women in the United States, meaning any prescription is considered an off-label use. Consequently, doctors typically prescribe a reduced dose of a male-strength product or a compounded cream. The goal is to restore testosterone levels to the normal premenopausal range without causing adverse androgenic effects.

Topical Gels and Creams

Transdermal gels and creams are the most common and safest method of delivery, as they allow for flexible and adjustable dosing.

• Dosage: A healthcare provider will determine the appropriate dose for an individual, aiming to restore testosterone levels to a physiological range.
• Application: The cream should be applied daily to clean, dry skin on the upper outer thigh, buttock, or upper arms. Patients must take precautions to prevent transference to others, such as washing hands and covering the area with clothing.
• Adjustment: The dose can be adjusted, if necessary, based on symptom improvement and blood testosterone levels, under medical supervision.

Other Formulations

• Testosterone Patches: Patches have been used in some studies, but they are not widely available.
• Testosterone Injections and Pellets: Many medical organizations, including the British Menopause Society, do not recommend injections or pellets for women in menopause. These delivery methods can cause inconsistent and supraphysiologic (above normal) levels, which increases the risk of side effects and is often irreversible once administered.

Monitoring and Potential Risks

Close monitoring is crucial during testosterone therapy to ensure a woman's levels remain within the safe, premenopausal range. Excessive testosterone levels can lead to unwanted androgenic side effects, some of which may be permanent.

Monitoring Guidelines

• Baseline Testing: Before starting therapy, a baseline measurement of total testosterone and Sex Hormone Binding Globulin (SHBG) should be taken.
• Follow-up Testing: Repeat blood tests are recommended periodically after starting treatment and thereafter to check for appropriate levels.
• Symptom Assessment: Clinical response should be the primary indicator of efficacy. If there is no improvement in sexual function after a reasonable trial period determined by a healthcare provider, treatment should be discontinued.

Feature	Transdermal Cream/Gel	Testosterone Pellets/Implants
Dosing Control	Highly adjustable; dose can be easily changed or stopped.	Irreversible for 3-6 months once implanted; dosage cannot be changed.
Hormone Levels	Delivers relatively stable, physiologic levels when dosed correctly.	Can cause supraphysiologic spikes, leading to potential side effects.
Risks	Lower risk of androgenic side effects with proper dosing.	Higher risk of severe and potentially irreversible side effects.
Application	Daily self-application to the skin; risk of transference if not careful.	Requires minor in-office surgical procedure every few months.
FDA Status (US)	Compounded or off-label use of male products.	Off-label use; unregulated and discouraged by medical societies.
Cost & Coverage	Often requires out-of-pocket payment; not covered by most insurance.	Typically out-of-pocket; can be costly.

Alternatives to Testosterone Therapy

For menopausal women, addressing sexual dysfunction and other symptoms does not always require testosterone. Several alternatives and lifestyle adjustments can be effective.

• Vaginal Estrogen: For women experiencing vaginal dryness and painful intercourse (part of Genitourinary Syndrome of Menopause, or GSM), local vaginal estrogen therapy can be highly effective at low doses.
• Lifestyle Adjustments: Improving sleep quality, regular exercise, stress reduction techniques like mindfulness or yoga, and maintaining a healthy diet can positively impact energy, mood, and overall well-being.
• Cognitive Behavioral Therapy (CBT): Therapy that focuses on coping skills and thought patterns has been shown to improve sexual functioning and body image in peri- and postmenopausal women.
• Other Medications: For some women, particularly those for whom testosterone is not appropriate, other non-hormonal medications or lifestyle interventions may be considered. These could include certain antidepressants or DHEA, though the evidence for efficacy and safety varies.

Conclusion

For postmenopausal women experiencing distressing low sexual desire that has not improved with standard HRT, low-dose testosterone therapy may be an option under close medical supervision. The starting dosage is typically determined by a healthcare provider using a transdermal cream or gel, with adjustments made based on symptom response and blood level monitoring to remain within the physiologic premenopausal range. Formulations like pellets and injections are generally not recommended due to safety concerns related to supraphysiologic hormone spikes. Given that testosterone for women is off-label in many countries, a comprehensive discussion with a knowledgeable healthcare provider is essential to weigh the potential benefits against the risks and to explore all available alternatives. Patients should never self-prescribe or use high doses of male products due to the high risk of irreversible side effects.

Potential Side Effects of Testosterone Therapy

While low-dose testosterone is generally safe, higher doses or individual sensitivities can cause side effects:

• Acne and oily skin: Stimulated oil production can lead to breakouts.
• Excess hair growth (hirsutism): Particularly on the face and body, though it is usually reversible with dose reduction.
• Head hair loss (alopecia): A male-pattern thinning of the hair on the scalp is possible at higher doses.
• Voice deepening: A potentially irreversible effect of excessive testosterone.
• Clitoral enlargement: Another possible irreversible effect of supraphysiologic levels.
• Mood changes: Irritability or aggression can occur, especially with higher dosages.
• Changes in lipid profile: Some studies have noted changes in cholesterol, though the long-term impact is not yet fully understood.

Long-Term Safety Concerns

Limited long-term data for women on testosterone therapy means uncertainty persists regarding risks such as cardiovascular and breast cancer outcomes, though short-term studies and limited long-term data for physiologic doses have been somewhat reassuring. Medical guidelines emphasize that testosterone is not recommended for conditions beyond HSDD due to insufficient evidence for other benefits and the lack of long-term safety data.

Starting Testosterone Therapy: A Step-by-Step Guide

1. Consult a Healthcare Provider: Discuss your symptoms with a doctor experienced in menopause and hormone therapy. They will rule out other causes of low libido, such as relationship issues, medication side effects, or depression.
2. Blood Testing: Establish a baseline with blood tests for total testosterone and Sex Hormone Binding Globulin (SHBG), preferably using a sensitive LC/MS assay.
3. Ensure Adequate Estrogen: Confirm that systemic HRT has sufficiently addressed other menopausal symptoms before adding testosterone.
4. Prescription and Formulation: Receive a prescription for a low-dose transdermal cream or gel, or a formulation licensed for women where available (e.g., AndroFeme in Australia).
5. Start Treatment: Begin with the dose recommended by your healthcare provider and apply it to a rotating site on the skin.
6. Monitor and Adjust: Follow up with your doctor and get blood work done after starting to check levels. The dose may be adjusted based on symptom response and laboratory results.
7. Assess Efficacy: If there is no improvement in sexual desire and associated distress after a duration recommended by your healthcare provider, consider discontinuing therapy.

Patient and Provider Expectations

• Subtle Changes: Unlike dramatic results advertised online, the benefits of safe, physiologic-dose testosterone are often subtle and gradual, especially for improvements in libido.
• Regular Monitoring: Continuous follow-up is necessary to monitor for potential side effects and ensure hormone levels remain safe. Regular blood tests and symptom checks are standard.
• Not a Universal Solution: Testosterone is not a panacea for all menopausal symptoms. It primarily addresses HSDD and should be considered as one part of a comprehensive management strategy.

Final Considerations for Testosterone Use

Women should be fully informed about the off-label nature of testosterone prescriptions and the potential for side effects, some of which may be irreversible. Engaging in a thorough discussion with a knowledgeable healthcare provider is the most critical step in determining if and how to proceed safely with testosterone therapy during menopause.

The British Menopause Society's guide to testosterone replacement provides further guidance on dosage and monitoring.

Frequently Asked Questions

What is a typical starting dose of testosterone cream for women in menopause?

A healthcare provider will determine the appropriate starting dose of transdermal testosterone cream or gel, which is typically a low amount to start.

What are the primary benefits of testosterone therapy for menopausal women?

The main proven benefit is the improvement of low sexual desire (HSDD) and overall sexual function. Some women may also experience better energy, mood, and muscle mass, but evidence for these broader benefits is less conclusive.

What are the risks of taking too much testosterone?

Excessive testosterone can cause androgenic side effects such as acne, increased facial and body hair (hirsutism), head hair loss, deepening of the voice, and clitoral enlargement. Some of these effects may be irreversible.

Are testosterone pellets a safe option for menopausal women?

No, many medical societies advise against using testosterone pellets in women. They deliver unpredictable, high hormone levels that increase the risk of severe and potentially irreversible side effects.

How long does it take for testosterone therapy to work for women?

Significant improvement in sexual function can often be seen within several weeks, with effects evaluated over a few months. If no improvement occurs after a duration recommended by a healthcare provider, treatment should be discontinued.

Do I need to take estrogen replacement with testosterone?

Testosterone therapy is typically added after ensuring adequate estrogenization has been achieved with standard HRT. Testosterone alone is not recommended for treating common menopausal symptoms like hot flashes.

How are testosterone levels monitored during therapy?

Blood tests, using a sensitive LC/MS assay, are conducted at baseline and again periodically after starting treatment to check levels. Ongoing monitoring is recommended, along with tracking symptom response, all under medical guidance.