Testosterone for Postmenopausal Women

Testosterone for Postmenopausal Women

Testosterone gel for postmenopausal women with Hypoactive Sexual Desire Disorder

What is testosterone?

Testosterone is a sex hormone produced naturally in the ovaries and adrenal glands. It is generally considered to be a male hormone, and does not need replacing in all women. Testosterone levels naturally decline between the ages of 20 and 40 years, and by menopause the levels have plateaued and are stable.  Some women do not notice this change where as others are very sensitive to it and require additional testosterone replacement treatment.

You may benefit from a trial of testosterone if you suffer with a low sex drive and have a low testosterone level in your blood.

Testosterone replacement at present should only be prescribed for postmenopausal women as per the British Menopause Society (BMS) recommendation. There is minimal data for testosterone replacement in premenopausal women which remains a controversial area requiring more research. In Hereford and Worcester testosterone is only on the prescribing formulary for postmenopausal women.

What are the benefits of testosterone?

Testosterone is used to treat symptoms of Hypoactive Sexual Desire Disorder (HSDD).  This is a female androgen insufficiency affecting 9-15% of postmenopausal women. The symptoms include: low sex drive (libido), decreased receptivity and pleasure, decreased orgasms and vaginal dryness. Low testosterone levels can also lead to: decreased wellbeing and blunted motivation, persistent and unexplained fatigue, decreased bone mineral density and muscular strength and changes in cognition and memory with brain fog.

However, desire and libido are multifactorial, so a biopsychosocial approach should be taken, to first exclude other potential causes:

• Relationship
• Psychological
• Medication related: SSRIs and SNRIs
• Vulvovaginal atrophy (ensure this are treated prior to testosterone).

Unfortunately, testosterone replacement does not help everyone.

How is testosterone treatment given?

In the UK, testosterone is prescribed ‘off label’ as it is not licenced for women. This means that the manufacturer of the medicine no longer specifies that it can be used for women in this way. Although testosterone is licenced for men, the licence for women was removed in 2012 for commercial reasons, despite many studies showing its benefit and safety. In the NHS we prescribe testosterone that is licenced for men, ‘off label’ at the normal female dose. NICE and The British Menopause Society both recommend considering a trial of testosterone treatment for women suffering with decreased libido despite adequate oestrogen replacement. Please ensure you use the dose specified and not that on the packet (as that is the male dose regimen).

Testosterone dose regimens for women:

Testosterone gel (Tostran@ 2%) comes in a canister. Use 1 pump (10mg) a pea sized amount, every other day.

Testosterone gel (Testogel@ 40.5mg) comes in a 2.5g sachet. Apply 40.5mg over an 8-day period, the contents of a 2.5g sachet to be divided for daily dosing. One sachet should last 8 days.

Testosterone should be rubbed into clean, dry, non-hairy area most commonly the lower abdomen or upper thighs. It is important to rotate the area to avoid hair growth and to spread it thinly. You need to allow the area to dry prior to dressing and do not wash for 2-3 hours after applying. Also ensure the area does not come into contact with your partner, children or pregnant women and wash your hands well after application. Please see drug safety update below for further information. Do not use the amount stated on the packet as this is the dose for men.

Are there any side effects?

There can be some side effects but these are minimised by the small amount that is used and rotating the area of skin.

Uncommon risks include: increased body hair at the site of application, hirsutism, weight gain, acne and male pattern hair loss.

Rare risks include: deepening of the voice, alopecia and enlarged clitoris.

There is a lack of long term data in using testosterone in women, but data up to five years shows no adverse effect in healthy women after menopause.

Evidence from 2 year follow-up shows a lower risk of cardiovascular disease and no obvious adverse effects on: blood pressure, lipid profile, breast cancer risk, or the endometrium (lining of the womb).

Before commencing Testosterone

Prior to starting testosterone, it is important to ensure you first have enough oestrogen. This can be topped up with ‘HRT’ hormone replacement therapy. The safest route to give oestrogen is topically through the skin via a patch or gel. If you have a uterus, you will also need to take a form of progesterone; either locally (Mirena^@), orally (utrogestan^@ tablets) or as a combined patch. If you have any symptoms of vaginal dryness it is also recommended to start topical oestrogen cream or pessaries before commencing testosterone.

If you are on oral HRT, we would recommend changing this to transdermal, as this alone can increase your bodies circulating testosterone. NICE and BMS both recommend HRT (oestrogen and progesterone) is given before testosterone is considered. This is due to the reduced safety data, but also the incidence of androgenic effects (acne, excessive hair growth) is higher in ladies not on oestrogen.

Lifestyle must be optimised, as symptoms of low testosterone can be multifactorial. Symptoms can be helped by reducing alcohol intake, increasing daily exercise, improving diet and stopping smoking, increasing sleep and relaxation, and also cognitive behavioural therapy (CBT).

Testosterone should not be given in the following cases:

1. Pregnant or breast feeding
2. Active liver disease
3. History of hormone sensitive breast cancer
4. Competitive athletes
5. Upper normal or high baseline testosterone
6. ER positive breast cancer: avoid or use very cautiously due to the potential conversion of testosterone to oestrogen in the body. Testosterone should be prescribed on an individual basis after full counselling of the possible risk of breast cancer recurrence or progression. There is limited evidence to quantify this risk.

Starting treatment

The doctor will first confirm that you are well oestrogenised on HRT, rule out other causes of HSDD (as above), and that your testosterone level is low. They will also check your kidney and liver function; as these can be affected by testosterone.

Blood tests: oestradiol, total testosterone, U&Es and LFTs (prior to starting and for monitoring purposes).

Follow-up once testosterone has been started

You will need your blood tests monitored about every 3months for the first 12months. You should be seen at 3-6months to review: your symptom control and assess for any signs of androgen excess and side effects.  Full benefit can sometimes take up to 6 months. Prior to your appointment we will ask you to repeat your blood tests so that we can ensure your testosterone remains in the normal female range.

If at 6 months you have found no benefit, testosterone will be stopped, as low libido has many other causes.

If your symptoms have improved and you wish to continue, your GP will then follow you up with 12monthly reviews and bloods.

Further information and references:

www.womens-health-concern.org

The British Menopause Society https://thebms.org.uk

Primary Care Womens Health forum www.pcwhf.co.uk

NICE Guideline [NG23] Menopause: diagnosis and management

Drug safety update –

https://www.gov.uk/drug-safety-update/topical-testosterone-testogel-risk-of-harm-to-children-following-accidental-exposure

Topical testosterone (Testogel): risk of harm to children following accidental exposure

Premature puberty and genital enlargement have been reported in children who were in close physical contact with an adult using topical testosterone and who were repeatedly accidentally exposed to this medicine. To reduce these risks, advise patients to wash their hands after application of topical testosterone, cover the application site with clothing once the product has dried, and wash the application site before physical contact with another adult or child.

If your symptoms or condition worsens, or if you are concerned about anything, please call your GP, 111, or 999.

Patient Experience

We know that being admitted to hospital can be a difficult and unsettling time for you and your loved ones. If you have any questions or concerns, please do speak with a member of staff on the ward or in the relevant department who will do their best to answer your questions and reassure you. 

Feedback

Feedback is really important and useful to us – it can tell us where we are working well and where improvements can be made. There are lots of ways you can share your experience with us including completing our Friends and Family Test – cards are available and can be posted on all wards, departments and clinics at our hospitals. We value your comments and feedback and thank you for taking the time to share this with us.

Patient Advice and Liaison Service (PALS)

If you have any concerns or questions about your care, we advise you to talk with the nurse in charge or the department manager in the first instance as they are best placed to answer any questions or resolve concerns quickly. If the relevant member of staff is unable to help resolve your concern, you can contact the PALS Team. We offer informal help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf, if you feel unable to do so, to resolve your problems and where appropriate refer to outside help.

If you are still unhappy you can contact the Complaints Department, who can investigate your concerns. You can make a complaint orally, electronically or in writing and we can advise and guide you through the complaints procedure.

How to contact PALS:

Telephone Patient Services: 0300 123 1732 or via email at: [email protected]

Opening times:

The PALS telephone lines are open Monday to Friday from 8.30am to 4.00pm. Please be aware that you may need to leave a voicemail message, but we aim to return your call within one working day.

If you are unable to understand this leaflet, please communicate with a member of staff.

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