Testosterone treatment in menopause

Testosterone advice and treatment is one of the most common reasons for women to book a consultation with Rethink. In this blog, I’ll help you understand what testosterone can help with, what to expect if you’re considering a trial of treatment, aswell was the situation with regards to who can prescribe it for you.

The role of testosterone

Described by Maisie Hill as the Serena Williams of our hormones, with testosterone on board we feel ambitious, competitive, and active.

Not just for men, testosterone is produced by the ovaries and adrenal glands, and usually declines from our 30s, although in a more gradual way than oestrogen and progesterone. The effects are more pronounced for women with POI (premature ovarian insufficiency) and those who have had their ovaries removed surgically. Interestingly testosterone levels increase again at around age 65, it’s not yet known why or how. 

Thanks to Davina, testosterone is known for its effect on libido. The other effects though are still being debated. Women using testosterone as part of their HRT often report improvements in mood, memory, concentration and energy levels, aswell as strength and vulvovaginal health. These effects have not yet been proven in studies, but the studies done to date have not been of very high quality, so more research is needed. Observational studies have shown improvements in metabolic function, with positive effects on blood pressure, glucose and lipids. For some women adding testosterone certainly seems to significantly improve their quality of life.

Indications for testosterone HRT

Both the National Institute Clinical Excellence (NICE) and the British Menopause Society (BMS) agree that testosterone can be considered at menopause for women with low libido after a biopsychosocial approach has excluded other causes of a low libido, for example antidepressant medication.

If testosterone treatment is being considered, firstly, it is important to ensure that HRT is optimised – for example if oral oestrogen is being used, this would be changed to transdermal oestrogen as a patch/gel/spray, to increase the amount of circulating testosterone. Blood tests to look at the level of oestrogen being absorbed from the HRT are important, aswell as blood tests to assess the testosterone levels.

Although much is said about the potential benefits of testosterone, the BMS state “randomised clinical trials to date have not demonstrated beneficial effects of testosterone therapy for cognition, mood, energy and musculoskeletal health.” The National Institute Health Research (NIHR) recently announced a planned trial of testosterone vs placebo to look into other potential benefits in more detail.

Women who have experienced an earlier menopause, and women who have experienced a surgical menopause seem to show particular beneficial effects in research studies. Testosterone use is not advised unless testosterone levels are low on blood tests.

Testosterone treatment is not recommended 

  • If you are/could be pregnant  
  • If you are breast-feeding  
  • If you have had hormone-sensitive breast cancer  
  • if you have active liver disease
  • If you are a competitive athlete

Testosterone is an unlicensed medication

Currently in the UK there are no testosterone preparations specifically licensed for use in menopause care, so its use is described as “off licence”. This does not mean there are concerns about the safety or effectiveness of the treatment.

Other medicines are also used outside of their licence. Prescribing must meet criteria set by the General Medical Council (GMC) and the Medicines and Healthcare products Regulatory Agency (MHRA). 

Off licence means that the manufacturer cannot advertise or make any recommendations about using the gel for women. When using a medicine off licence it does not mean that you are part of a clinical trial. Testosterone gel for women has been shown to be effective, and use is supported by expert groups.

Previously available licensed preparations were discontinued for commercial (not medical) reasons. The safety and effectiveness of testosterone replacement in women has been demonstrated in randomised studies which have followed women for up to 12 months and reported significant improvements in sexual function. Due to the lack of availability of licensed female testosterone preparations, products which are manufactured and licensed for use in men have been used outside their product licence. The use is therefore “unlicensed”, which means that the manufacturer of the medicine has not specified it can be used in this way. 

The testosterone leaflet

As the treatments are licensed for use in men, the leaflet is written to support this use, in men. The dosing instructions on the leaflet inside the box do not apply to testosterone use in women.

How to use testosterone HRT

“Male preparations in female doses” 

The female equivalent dose is 1/10 the male dose, usually 5mg/day, so a sachet used daily for men is used over 10 days for women.

Testogel testosterone treatment

Testogel® comes as a gel in a sachet. One 40.5mg Testogel® sachet should last around 8 days. You roll the top and seal it with a clip between uses, storing it in the fridge between uses. 3 months treatment on a private prescription costs around £14.

Tostran testosterone treatment

Tostran® 2% gel, in a pump dispenser, given as one     measured pump (10 mg testosterone) usually used three times a week or alternate days. Each canister should last 240 days (4 months). It is currently unavailable in the UK

Testim testosterone treatment

Testim® comes as a gel in a small tube with a screw cap. One 50mg tube should last around 10 days. The tube should be kept in the fridge between uses. 3 months treatment on a private prescription costs around £14.


AndroFeme testosterone treatment

AndroFeme® is licensed in Australia for women. It comes with a measure for female dosing and is recommended to be used daily. It is only available on private prescription in   the UK, 3 months treatment costs around £95.

Whichever preparation is used, it should be rubbed onto clean dry skin on the lower abdomen or thighs or inner forearm and allowed to dry before you get dressed. You should not have contact with any other person while it is drying (approximately 10 minutes), and wash your hands immediately after the gel has been applied. The area that it is applied to should not be washed for three hours after application to allow the gel to be absorbed. 

How long will it take to work?

It can sometimes take a few months for the full effects of testosterone to work, so a 3-6 month trial is recommended. Treatment helps around two thirds of women.

What if I forget to use it?

If you miss a dose, take it as soon as you remember. If it is close to the time your next dose is due (within a day) do not take the missed dose and continue with your normal dosing. It is important not to take two dosages of the gel to make up for missing one.

Do I need more blood tests?

Blood tests are taken before starting treatment, repeated after 3-6 months on treatment, and then usually every 12 months. Blood tests are best taken between 8 and 10am. Testosterone should not be used on the morning of a blood test.

Can my GP take over the testosterone prescription on the NHS?

The situation is different throughout the UK, according to the local prescribing formularies.

In Bristol, North Somerset and South Glos testosterone is classified as an amber drug on the prescribing formulary for treatment of low libido causing distress in women with optimised HRT and with either early menopause (age 45 and under) or surgical menopause. So to qualify for NHS prescribing, women need to meet these criteria, be referred to a specialist for initiation of testosterone, and then after the first 3 months the prescription can be continued by the GP, if the GP agrees.

What about side-effects?

Usually, there are no side-effects of treatment.

Some extra hair growth can sometimes be seen where the gel is applied. To minimise this, it is recommended to vary the site of application and spread the gel thinly.

Weight gain is seen in some women. There can be some acne, and effects on hair growth patterns.

A deepening of the voice and enlargement of the clitoris can be seen if high doses are used, which push blood test levels above usual women’s range. It is very important not to increase the dose of testosterone without discussion with your clinician and blood test monitoring.

There is less information on any long-term effects of testosterone treatment than other forms of HRT. Currently data is limited to around 5 years of use.

Looking after your medicine 

The instructions on how you should store your treatment will be on the pharmacy label. Keep it out of the sight and reach of children. Do not use after the expiry date stated on the packaging. 

Resources with more information