The buzz around hormone therapy for cisgender women is undeniable, with a surge of interest in testosterone. Big shoutout to Emilie, one of our astute RAP listeners, for spotlighting this topic! (Psst, you can also listen to us unpack this further on Primary Care RAP’s April episode).
The When and Why of Testosterone Therapy
Testosterone therapy only has one clear, evidence-backed role in cisgender women: boosting low sex drive post-menopause.
The International Society for the Study of Women’s Sexual Health released guidelines in 2021 for using testosterone to treat Hypoactive Sexual Desire Disorder (HSDD). This disorder isn’t just about lacking desire – it’s also about the stress it causes, and it’s often just referred to by patients as having a “low sex drive.”
These guidelines endorse using transdermal testosterone for women grappling with HSDD. A quick heads-up: no testosterone products for women have snagged FDA approval yet, so this treatment is entirely off-label.
What You Need to Know: Benefits vs Risks
Improved sex drive is the only proven benefit of testosterone therapy in cisgender women. Don’t expect miracles beyond that: studies have not shown that testosterone improves bone density, cognition, or body composition in women.
As for risks, short-term use appears relatively safe. Increased acne and hair growth are common side effects, but worries about voice deepening or clitoromegaly at typical doses are unfounded. There is no effect on cholesterol with transdermal preparations and no effect on breast cancer risk in short-term studies.
However, long-term safety has not been established. Furthermore, we don’t know about the risks of DVT or cardiovascular disease because in the few studies evaluating this, women were taking estrogen at the same time.
How To Prescribe Testosterone Therapy for Women
Considering starting testosterone therapy for a patient? First, ensure they fit the criteria for HSDD. You don’t need check testosterone levels, as they don’t directly tie to HSDD’s presence or severity.
Without any FDA-approved women-specific testosterone products, the recommended way to treat women with HSDD is to prescribe an FDA-approved transdermal testosterone product at a fraction of the dose recommended for men.
Oral formulations should be avoided because they have a higher risk of dyslipidemia, and IM and pellet forms of testosterone have resulted in supraphysiologic levels in women. Compounded formulations are not recommended because of a lack of efficacy and safety data. Tread carefully due to lack of efficacy and safety data, and always vet your compounded pharmacy thoroughly for compliance with industry standards for quality and safety.
Frequently Asked Questions About Testosterone Therapy
Q: What are the indications for testosterone therapy in cisgender women?
A: There is only one indication for testosterone treatment in postmenopausal women: hypoactive sexual desire disorder.
Q: Is testosterone therapy in cisgender women safe?
A: There are risks and benefits to giving postmenopausal women testosterone, but short-term therapy with transdermal testosterone has been shown to be pretty safe.
Q: How should I prescribe testosterone therapy to women with hypoactive sexual desire disorder?
A: There are no FDA-approved products on the market, so you are stuck with either low doses of transdermal products designed for men or compounded products. Compounded products are not recommended due to concerns about efficacy and safety.
For more information on prescribing testosterone therapy for cisgender women, check out "Testosterone Therapy in Cisgender Women" on April's episode of Primary Care Reviews and Perspectives!
References:
Davis SR, Baber R, Panay N, et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. J Clin Endocrinol Metab. 2019;104(10):4660-4666. PMID: 31498871
Parish SJ, Simon JA, Davis SR, et al. International Society for the Study of Women's Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women. J Sex Med. 2021;18(5):849-867. PMID: 33814355