Testosterone and The Menopause
Testosterone Replacement & Female Androgen Deficiency
Testosterone is a androgen hormone. We commonly think of it as a male hormone but it has an important role in normal female development, behavior and health; it is important for sexual function and interest, vaginal health, cognition, energy levels and bone strength and health. Half of a woman’s testosterone comes from the ovaries and half from the adrenal glands; testosterone acts on cells and tissues directly but is also converted into oestogens, particularly in fat cells. Some of the actions of testosterone are actually the effects of oestrogens.
What happens at the Menopause?
The production of testosterone declines in women from the mid-thirties onwards, thought as the menopause progresses there is no sudden drop in testosterone.
This is quite different if there is a surgical menopause – when the ovaries are removed – where there is a precipitous drop in testosterone.
After the menopause the level of oestrogen falls but the remaining small quantities of testosterone can cause some women to have male type symptoms such as excess hair growth (hirsutism) and sometimes even male pattern hair loss.
Female Androgen Deficiency Syndrome (FAD) & Hypoactive Sexual Desire Disorder (HSDD)
The lack of testosterone can cause tiredness, lack of energy, difficulty concentrating and a low libido. Together this can be Female Andogen Deficiency Syndrome (FAD), and the loss of libido can be termed Hypoactive Sexual Desire Disorder (HSDD).
How is FAD or HSDD diagnosed?
Usually the patient’s story is enough to make the diagnosis, a blood test is not always necessary, though sometimes one might be done if there is any uncertainty.
Indication and License for Use of Testosterone - why is this important?
Normally drugs have a license to be used in a specific situation. No testosterone therapy has a license for use in women for FAD or HSDD. This is despite our National Institute for Health and Care Excellence (NICE) recommending doctors ‘Consider testosterone supplementation for menopausal women with low sexual desire if HRT alone is not effective.’ – from NICE guideline [NG23] published November 2015 (accessed 3/1/18).
The lack of license is not a safety issue, it is merely for commercial reasons. Doctors prescribe many treatments off their labeled indication and license.
Testosterone therapy in this circumstance might not be the usual experience of a GP; not every person treating menopause will have experience considering it and this can explain why some women have difficultly getting help and advice.
Testosterone - how can it be given?
The most common way to prescribe and give testosterone is currently with transdermal gels. The products change regularly for commercial reasons (and this is written with thanks to the British Menopause Society), and for the most up to date advice one must speak to a doctor with experience of managing the menopause. There is excellent patient advice at Womens Health Concern.
Testogel [Besins Healthcare UK] (1% testosterone gel in 5.0g sachets containing 50mg testosterone): Starting dose 1/10 of a sachet/day = 5mg/day i.e. each sachet should last 10 days.
Tostran [Kyowa Kirin Ltd] (2% testosterone gel in a canister containing 60g ) : Starting dose 1 metered pump of 0.5g = 10mg on alternate days – each canister should last 240 days.
AndroFeme*[Lawley Pharma] (1% testosterone cream in 50ml tubes with screw cap): Starting dose 0.5ml/day = 5mg /day i.e. each tube should last 100 days.
Testosterone Implants** [Smartway Pharma] (100mg implanted pellets) Unlicensed – imported from USA
* AndroFeme is not currently available in the NHS and is being imported from Western Australia by special license from the MHRA. Designed for female usage.
** Testosterone implants are currently unlicensed in the UK and can only be used privately or through agreement of the local formulary committee with appropriate monitoring of hormone levels and adverse effects. Designed for female usage.
Some patients prefer testosterone by injection, though this is more difficult in women and usually need very specific consideration from someone familiar with both the menopause, the indications for the testosterone, testosterone injections and monitoring the treatment
How to apply the Testosterone Gel
Testosterone gel is applied to clean dry skin, rub it in and allow to dry before getting dressed. It can be applied on the wrists, arms, thighs, abdomen or shoulders; wash your hands immediately after applying but do not wash the application area for 2 – 3 hours afterwards. Do not allow skin contact with partners or children and keep the medication out of reach of children.
Expected effects
The symptoms of fatigue, lethargy, poor cognition and loss of libido should improve.
Monitoring
Blood tests are not obligatory, it is the response to therapy that is important. However it is usual to check the testosterone, full blood count, renal and liver function every six months and lipids yearly, alongside routine health monitoring.
Common side effects
Hirsutism, increased facial or body hair is common.
Alopeia – male pattern hair loss is less common, as are acne and greasy skin.
Rarely can the voice deepen and the clitoris enlarge.
Who cannot use testosterone gel or replacement?
Do not use testosterone if you are pregnant or breastfeeding, if you have a history of hormone sensitive breast cancer or if you are a competitive athlete and anabolic steroids are banned.
Every effort is made to ensure that this health and medication advice is accurate and up to date. It is for information only and supports your consultation it does not obviate the need for that consultation and should not replace a visit to your doctor or health care professional.
The written advice is general in nature and in is not specific to individual patients and LondonSwissMedical Ltd or Dr Philip Kelly cannot accept any liability for actions arising from its use nor can they be held responsible for the content of any pages contained in any external link. Dr Philip Kelly normally manages the menopause in the context of pituitary and/or hypothalamic disease or the management of osteoporosis. If your case is complex, particularly if a patient needs advice on HRT in the context of hormone sensitive breast cancer, Dr Kelly may recommend you see a colleague who is a specific menopause specialist registered with the British Menopause Society though this is not necessary for every patient.
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