Postmenopausal Testosterone for Low Libido Only, Doctors Say

Your patients may see ads claiming that testosterone replacement therapy (TRT) offers postmenopausal women health benefits beyond restored sex drive: that TRT can improve their mood, energy, and thinking and give them stronger bones and bigger muscles.

How accurate are these claims? According to six experts who talked with Medscape Medical News, not very.

"Right now in this country and around the world, testosterone's only use in postmenopausal women is for libido," said Adrian Sandra Dobs, MD, MHS, professor of medicine and director of the Johns Hopkins Clinical Research Network at Johns Hopkins Medicine in Baltimore, Maryland.

"Treating postmenopausal women with testosterone is a rarity. Some physicians and some wellness centers make their money out of prescribing estrogen and testosterone to women in patches, gels, creams, capsules, pellets, and other forms. But when you look at the scientific data, outside of libido, it's difficult to recommend testosterone therapy," she added by phone.

"One has to be very careful about using testosterone in women," Dobs cautioned. "There's a lot of hype out there."

Low testosterone in women has not been well studied, and no testosterone treatments for this condition have been approved by the US Food and Drug Administration (FDA). Providers need to adjust male treatment data to their female patients, who require significantly lower doses than males. Contraindications and long-term side effects are poorly understood, said Mary Rosser, MD, PhD, assistant professor women's health and director of integrated women's health at Columbia University Irving Medical Center in New York City.

"Despite this preponderance of scientific evidence and recommendations, the myths about testosterone die hard, including that it improves women's muscle function, endurance, and well-being," Rosser said.

"Websites that use compounded products or pellets are not FDA-regulated; therefore, they have no responsibility to prove their claims; they can entice women into using this stuff with all kinds of promises about 'hormone balancing' and other meaningless terms. The Endocrine Society statement reviewed the clinical studies on testosterone for various indications surrounding physical endurance, well-being, and mental health — and the studies do not support its use," Rosser added.

According to the Australasian Menopause Society, women's blood testosterone levels tend to peak in their 20s, slowly decline to around 25% of peak levels at menopause, then rise again in later years.

Susan Davis, PhD, and her colleagues at Monash University in Melbourne, Australia, found in a study that TRT in postmenopausal women may improve sexual well-being and that side effects include acne and increased hair growth. But they found no benefits for cognition, bone mineral density, body composition, muscle strength, or psychological well-being, and they note that more data are needed on long-term safety.

Postmenopausal Testosterone Recommended for Libido Only

"Hypoactive sexual desire disorder (HSDD) is really the only indication for postmenopausal testosterone use," Nanette F. Santoro, MD, professor and chair of obstetrics and gynecology at the University of Colorado School of Medicine in Aurora, noted by email. "In clinical studies using androgen gel containing testosterone, testosterone treatment has resulted in a mean of one more satisfying sexual encounter per month.

"Consensus statements issued by the Endocrine Society, The International Menopause Society, and the North American Menopause Society have come to similar conclusions: The only indication for androgen therapy for women is HSDD," added Santoro, an author of the Endocrine Society statement.

"Sexual health and the sense of well-being are very much related," Sandra Ann Carson, MD, professor of obstetrics and gynecology at Yale Medicine in New Haven, Connecticut, said by phone. "So we give testosterone to increase sexual desire. Testosterone is not a treatment for decreased sense of well-being alone. Women who lose their sense of well-being due to depression or other factors need to have a mental health evaluation, not testosterone."

"Because no female product is presently approved by a national regulatory body, male formulations can be judiciously used in female doses and blood testosterone concentrations must be monitored regularly," Rosser said. "The recommendation is for considering use of compounded testosterone for hypoactive sexual desire only; it is against use for overall health and wellness.

"The real mischief occurs when women are exposed to doses that are supraphysiologic," Rosser cautioned. "At high doses that approach and sometimes exceed men's levels of testosterone, women can have deepening of the voice, adverse changes in cholesterol, and even breast atrophy. This can occur with bioidentical compounded testosterone and with testosterone pellets. The National Academies of Science, Engineering, and Medicine recommend unequivocally that such preparations not be used."

Not all postmenopausal women should take TRT, said Meredith McClure, MD, assistant professor in the Department of Obstetrics and Gynecology of UT Southwestern Medical School in Dallas, Texas, because it has only been shown in trials to help with HSDD.

She advised clinicians to avoid prescribing testosterone to patients who "can't take estrogen, including if [they] have hormone-sensitive cancer, blood clot risk, liver disease, heart attack, stroke, or undiagnosed genital bleeding."

TRT for Non-Libido Issues May Sometimes Be Appropriate

"Perhaps women with hip fracture or cancer cachexia could benefit from testosterone to build muscle mass," said Dobbs, who is involved in an ongoing study of testosterone treatment in women with hip fracture. "But as yet, we have no proof that testosterone helps."

In rare cases, Stanley G. Korenman, MD, a reproductive endocrinologist and associate dean for ethics at UCLA Health in Los Angeles, California, treats postmenopausal patients with TRT for reasons other than low libido. "I have a very specialized practice in reproductive endocrinology and internal medicine and am one of very few people in the country who do this kind of management," he told Medscape by phone. "If my postmenopausal patients have low testosterone and lack energy, I'm willing to give them low doses. If they feel more energetic, we continue, but if they don't, we stop. I don't think there's any risk whatsoever at the low level I prescribe.

"I prescribe standard gel that comes in a squirt bottle, and I suggest they take half a squirt every other day — about one eighth of a male dose — on the sole of the foot, where hair does not grow.

"I would not prescribe testosterone for bone health. We have bisphosphonates and other much better treatments for that. And I would not prescribe it to someone who is seriously emotionally disturbed or seriously depressed. This is not a treatment for depression."

"Postmenopausal testosterone is not 'the latest greatest thing,' but being very low risk, it's worth trying once in a while, in the appropriate patient, at the right dose," Korenman advised. He cautioned people to "avoid the longevity salespeople who sell all sorts of things in all sorts of doses to try to keep us alive forever."

All contributors report no relevant financial relationships.

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Credits:
Lead image: M R Fakhrurrozi | Dreamstime.com
Image 1: Johns Hopkins Medicine
Image 2: Columbia University Irving Medical Center
Image 3: University of Colorado
Image 4: Rob Lisak
Image 5: UT Southwestern Medical Center
Image 6: Stanley G. Korenman, MD

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Cite this: Postmenopausal Testosterone for Low Libido Only, Doctors Say - Medscape - Oct 25, 2023.