Menopause is a significant phase in a one's life, marked by the end of menstrual cycles and a natural decline in reproductive hormones. While estrogen and progesterone are often the focus of menopause care, testosterone also plays a crucial role in women's, and gender diverse AFAB patients', health during this transition.
Testosterone: Not Just for Men
Contrary to popular belief, testosterone is not exclusively a male hormone. Women produce testosterone too, and it's essential for various bodily functions, including sexual desire, bone density, muscle strength, and mood regulation. In fact, if you were to randomly draw a woman's blood, the level of testosterone is often higher than the level of estrogen!
The Decline of Testosterone During Menopause
As women and gender diverse AFAB folx approach menopause, their bodies produce less testosterone. This decline can lead to a range of symptoms, such as reduced libido, fatigue, and a decrease in overall well-being. It's important to note that not all females will experience these symptoms, and the need for testosterone supplementation should be evaluated on an individual basis. After surgical menopause (bilateral oophorectomy), testosterone levels decline dramatically.
When to Consider Testosterone Supplementation
According to the North American Menopause Society's Practice Pearl on testosterone use, testosterone therapy may be considered for midlife women with low libido and associated distress, known as hypoactive sexual desire disorder (HSDD). The decision to use testosterone therapy should be made after evaluating psychological, relational, and medical factors (1). Testosterone therapy is not currently recommended for low mood, low muscle mass, or osteoporosis although it has evidence of benefit in all of these areas(2, 3, 4).
The Synergy with Menopause Hormone Therapy (MHT)
For women undergoing MHT, adding testosterone can enhance the therapy's effectiveness, particularly in improving sexual function and general well-being. It's recommended to try conventional MHT first before considering testosterone supplementation (1). This stepwise approach will allow us to tease out the effects, both positive and negative, of each component of your hormone therapy.
Potential Benefits and Cautions
While some studies suggest testosterone can improve menopausal symptoms like sexual function and mood, it's essential to proceed with caution. The long-term safety of testosterone therapy is not fully established, and there can be side effects such as acne, irreversible deepening of the voice, irreversible clitoral enlargement, anger, adverse changes in lipids and liver function, and excess hair growth. Its use shouldn't be taken lightly.
A study from September 2024 found that testosterone replacement in perimenopause and menopause was associated with improved mood and cognition. All nine cognitive and mood symptoms that were studied showed improvement, with mood symptoms showing more improvement (47%) than cognitive symptoms (39%). 52% of those in the study reported an improvement in libido (4).
Unfortunately, there are no FDA-approved formulations of testosterone that are designed for women. Therefore, the recommendation is to prescribe 1/10th of the dose formulated for men. Sadly, this greatly increases the risk of inadvertent overdose and side effects. Compounded testosterone cream from a reputable compounding pharmacy may lead to better outcomes, but this approach is not yet recommended by The Menopause Society due to concerns over quality control.
Hormonal pellets containing testosterone are heavily discouraged because women often become supratherapeutic (too high) in testosterone, but the pellets can't be removed once inserted. This leads to an increased risk for irreversible side effects.
The Practice Pearl on HSDD emphasizes that while low testosterone levels do not clearly correlate with sexual function, clinical trials have shown that testosterone therapy can be effective for HSDD in postmenopausal women. It's important to disclose potential limitations and adverse effects to patients considering testosterone therapy and to institute appropriate monitoring once treatment has begun (5).
Recommended Monitoring
The Menopause Society recommends checking total testosterone, sex hormone binding globulin (SHBG), complete blood count, liver function, and lipid profile at baseline. Check total testosterone again 3 to 6 weeks after starting therapy (1,6).
Normal total testosterone (ng/dL): 20-29 years 45.5-57.5; 30-39 years 27.6-39.8; 40-49 years 27.0-38.6 (6)
If the dose is increased, total testosterone should be checked again in 3 to 6 weeks (1,6).
If the dose is decreased due to high levels of testosterone, total testosterone should be rechecked in 2 to 3 weeks (1).
If the dose remains stable, total testosterone should be checked every 4 to 6 months (1,6).
Complete blood count, liver function, and lipid profile should be checked semiannually for one year, then yearly thereafter (1).
If no improvement is seen with testosterone levels in the normal physiologic range, consider calculating free testosterone (will need total testosterone, albumin, and SHBG) and checking 5-alpha reductase. If calculated free testosterone or 5-alpha reductase levels are low, the clinician can consider treating to a higher total testosterone than the normal physiologic range (5).
It may take 8-12 weeks to see maximal results. If no improvement is seen in 6 months despite adjustments, discontinue treatment (6).
Consider a drug holiday after 6-12 months of treatment to see if treatment is still required (6).
Prescribing Restrictions
It is worth noting that testosterone is a controlled substance, which impacts who can prescribe it and when. Receiving your menopausal care through telehealth may affect your ability to receive testosterone.
Vanessa Weiland, Nurse Practitioner and owner of Phases Clinic, is able to prescribe testosterone for residents of Washington State but may be required to see her patients on testosterone in person on a regular basis, depending on how telehealth laws change in the future.
Future Directions
Interestingly, the tissues of the vagina, vestibule (entry to the vagina), urethra, bladder, pelvic floor, and clitoris have been found to have dense androgen receptors, meaning that they are sensitive to testosterone (6). These tissues undergo a downregulation of androgen receptors after menopause, at the same time when many people notice a loss of sensation and increased difficulty reaching orgasm (7).
This is one reason that Intrarosa (prasterone), a vaginal DHEA, was developed. DHEA, an androgen, is a precursor to both testosterone and estrogen, so this single product can deliver both of these hormones to the genital tissues. A study comparing intravaginal prasterone versus placebo found a statistically significant improvement in desire, arousal, lubrication, orgasm, sexual satisfaction, and pain during sexual activity (8). However, there have not been conclusive head-to-head studies of vaginal prasterone versus vaginal estrogen for sexual function, and there is also not adequate research on the effects of topical testosterone applied to the genitals, although it is generally discouraged at this time due to the risk for unwanted clitoral enlargement.
The Bottom Line
Testosterone plays a vital role in women's and AFAB folx' health, especially during menopause. If you're experiencing symptoms that you believe may be related to low testosterone, it's important to discuss them with your healthcare provider. Together, you can determine the best approach to managing your menopause care, ensuring your treatment is tailored to your unique needs.
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Phases Clinic is dedicated to providing comprehensive menopause care, understanding the importance of all hormones, including testosterone, in ensuring a smooth transition during this phase of life. For more information or to schedule a consultation, please reach out.
Sources
(1) NAMS Practice Pearl (2023). Testosterone Use for Hypoactive Sexual Desire Disorder in Postmenopausal Women
(2) Kamal et al. (2023) For women established on HRT, how effective is the addition of transdermal testosterone in improving symptoms beyond those related to sexual function?
(3) Aktoz et al. (2023) What is the Role of Testosterone Therapy in Postmenopausal Women: A SWOT Analysis. https://www.researchgate.net/publication/372925101_What_is_the_Role_of_Testosterone_Therapy_in_Postmenopausal_Women_A_SWOT_Analysis
(4) Glynne, S., Kamal, A., Kamel, A.M. et al. Effect of transdermal testosterone therapy on mood and cognitive symptoms in peri- and postmenopausal women: a pilot study. Arch Womens Ment Health (2024). https://doi.org/10.1007/s00737-024-01513-6
(5) NAMS Practice Pearl - North American Menopause Society. https://www.menopause.org/docs/default-source/professional/practice-pearl-kingsberg-and-faubion-management-of-hsdd.pdf.
(6) Uloko M, Rahman F, Puri LI, Rubin RS. The clinical management of testosterone replacement therapy in postmenopausal women with hypoactive sexual desire disorder: a review. Int J Impot Res. 2022 Nov;34(7):635-641. doi: 10.1038/s41443-022-00613-0. Epub 2022 Oct 5. PMID: 36198811; PMCID: PMC9674516.
(7) Traish AM, Vignozzi L, Simon JA, Goldstein I, Kim NN. Role of Androgens in Female Genitourinary Tissue Structure and Function: Implications in the Genitourinary Syndrome of Menopause. Sex Med Rev. 2018 Oct;6(4):558-571. doi: 10.1016/j.sxmr.2018.03.005. Epub 2018 Apr 7. PMID: 29631981.
(8) Tomczyk K, Chmaj-Wierzchowska K, Wszołek K, Wilczak M. New Possibilities for Hormonal Vaginal Treatment in Menopausal Women. J Clin Med. 2023 Jul 18;12(14):4740. doi: 10.3390/jcm12144740. PMID: 37510854; PMCID: PMC10380877.
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