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Do you have low libido and want to improve sexual desire? In this guide to using testosterone for menopause you can find out if using testosterone gel or cream may be an additional helpful form of HRT for you.
Sexual pleasure for women, and especially older women has been typically been neglected as an important aspect of health. Our holistic approach to health recognises sexual pleasure and relational intimacy both contribute to a woman's wellbeing and support treatment that addresses this.
What is Testosterone?
Testosterone is a hormone made by the ovaries and to a lesser extent the adrenal glands. As ovarian function declines, estrogen, progesterone and testosterone production declines.
Symptoms of Low Testosterone in Women During Menopause
As ovarian function declines through perimenopause, testosterone levels also reduce. Low testosterone in women can contribute to menopausal changes to body and brain including:
reduced muscle and bone mass and strength,
changes in hair growth,
reduced sexual desire/libido,
altered metabolism,
low mood
fatigue or low energy and metabolism.
What is Testosterone Hormone Therapy in Menopause?
Testosterone come in multiple different forms including oral capsules, skin implants, gels and creams.
Many formulations of testosterone are in male physiological doses, not female physiological doses.
Transdermal options such as gel or cream in female physiological doses are safer for use in women. These are applied to and absorbed into the skin.
Testosterone gel or cream is designed to increase and restore testosterone levels into the female physiological range for menopausal women.
Androgen therapy has been used in sexual health for over 35 years. Testosterone use appears to improve:
energy,
mood,
well-being and
self-perception,
all of which contribute towards sexual desire. It also appears to directly improve measures of sexuality including:
libido or sexual desire
sexual activity,
sexual arousal,
sexual excitability and
sexual pleasure and satisfaction (Testosterone in Menopause 2023).
Testosterone Hormone Therapy in Menopause in New Zealand
Testosterone can be used to raise testosterone levels which drop to low levels after menopause, It is a significant hormone for women's health and brain function in the premenopausal years.
It is important to know that although estrogen and progesterone cycles get all the attention when thinking about the menstrual cycle, testosterone is the highest sex steroid in the female body.
It peaks in the 20s and declines from there. Lower levels of testosterone especially around menopause can contribute to reduced sexual desire, changes in pelvic tissue and organ function, loss of muscle and bone mass and impacts negatively on mood, cognition, and energy levels.
Currently in New Zealand the approved and funded forms of testosterone are in the male physiological range. One product Androfeme, that is licenced in Australia, is designed for use in menopausal women.
Any prescribing of testosterone for women therefore has to be prescribed off-label (section-29 prescription). For a further explanation of what this entails read about unapproved medicines.
Testosterone Gel
Testosterone gel is absorbed via the skin and is used daily. From 1 April 2024, Testogel - a version of testosterone used typically for male testosterone replacement is funded by PHARMAC and available in New Zealand. It can be prescribed off-label for menopausal women.
While this is excellent news for menopausal women who may benefit from adding testosterone gel to their menopause hormone therapy: estrogen and progesterone, it requires careful monitoring because the dose that is needed in menopausal women is significantly lower than the amount designated to be used by men.
The version of Testogel that is funded by PHARMAC comes as a gel pump:
Testogel® 1.6% (20.25 mg/1.25 g per actuation)
The dose of testosterone in the female physiological range of 5mg is approximately 1/4 of an actuation. This may need to be adjusted down if the level is too high (above the desired female phsyiological range) or if women experience acne, unwanted body hair, mood changes.
Testosterone Cream for Women
There is a low-dose testosterone cream (Androfeme) that is absorbed via the skin helps maintain optimal testosterone levels and keep it in the female physiological range while avoiding potential side effects associated with sudden large doses.
This version of tesoterone has been validated for safety and effectiveness in menopausal women. It is registered for use in Australia.
We recognise the current funding situation in New Zealand is not ideal.
It creates both an equity gap and gender gap in accessibility to appropriate testosterone for women.
Women either have to pay an excessive amount out of pocket to pay for Androfeme to use a version of testosterone that is formulated in a safe dose for women or navigate the difficulty of trying to maintain adequate dosing using testogel, or in the majority of cases, simply do without.
What are the benefits of using Testosterone for low sexual desire in menopause?
Testosterone is primarily used to treat female sexual dysfunction in postmenopausal women such as hypoactive sexual desire disorder - the medical term for low sexual desire or low libido.
Low sexual desire encompasses a lot besides hormone levels. It includes how you feel about;
yourself,
your body,
your sexuality,
your relationships, initmacy and connectivity with partner/s,
your zest for life and
your experience of pleasure in general.
The Global Consensus Position Statement on the Use of Testosterone Therapy for Women recommends testosterone cream use in doses equivalent to your pre-menopausal testosterone level for sexual dysfunction in menopausal women.
The UK NICE Guidelines for Menopause Diagnosis and Management recommends testosterone for low sexual desire where HRT alone is not effective.
It is important to know that low testosterone is only one contributing factor to low sexual desire or low libido in women. Female sexual dysfunction at all phases of life are usually multifactorial and can include:
hormonal issues
neuroendocrine imbalance,
medications,
psychological factors,
relationship dynamics and
cultural factors. such as religious, or moral views of sexuality and
history of sexual trauma.
For this reason it is beneficial to see a clinician who treats difficulties with sexual desire from a biopsychosocial perspective.
Read more about Female Libido or Sexual Desire here.
Clinical trials have shown that for menopausal women, testosterone use results in:
increased sexual desire,
increased satisfying sexual experiences and
reduced personal distress regarding sexual experiences. (Testosterone for low libido in postmenopausal women)
Are there other benefits of using Testosterone?
Testosterone is important for vulva skin health and integrity. It helps maintain skin thickness and elasticity, and helps prevent vaginal dryness. It supports bladder and pelvic floor function. For this reason DHEA which converts to testosterone can be used for vulva-vaginal or urinary symptoms in menopause.
Testosterone also helps increase bone density in postmenopausal women.
Testosterone stimulates osteoblasts which are the cells that produce new bone .
Postmenopausal women are at greater risk of developing osteoporosis due to estrogen deficiency combined with age-related bone loss. Testosterone supports the maintenance of both muscle mass and strength.
As testosterone is important for muscle mass maintenance, Monash university are studying testosterone supplementation of muscle mass in post-menopausal women.
Testosterone is important for brain function including memory, executive function and visuospatial planning. It is also important for energy levels.
No studies have been conducted on long term benefits on bone health, muscle health and brain health in post-menopausal women, although testosterone is known to play a physiological role in maintaining these tissues and organs.
We need more research into the benefits of testosterone on muscles, bones, mood, memory and metabolism of women as they transition through perimenopause to post-menopause, as well as safety data for using it long-term.
What are the side effects of using Testosterone?
Common side effects of testosterone include:
acne and oily skin;
increased body hair at the site of application (to reduce this, vary site, spread thinly or reduce dose);
minor weight gain (average 0.5kg - from clinical trials)
thinning of head hair/ male pattern balding
headache;
abdominal symptoms such as bloating or constipation.
increased cholesterol - this only occured when females used oral testosterone and not transdermal testosterone( ie. delivered through the skin) .
Rare side effects: include deepening of voice and enlargement of clitoris. These are rare when using physiological doses of testosterone.
Always check with your doctor if you have any side effects from testosterone gel use.
Who should not use Testosterone?
People with the following conditions should get medical advice before using testosterone gel or any other form of testosterone replacement therapy:
breast cancers or other cancer that are stimulated by androgens/testosterone,
kidney disease known as nephrotic syndrome,
high calcium levels in the blood,
pregnant or breast feeding women.
How to use Testosterone?
Most women use a low dose of testosterone cream daily.
It is applied to clean dry skin on lower abdomen or upper thighs.
You need to wash your hands after application to avoid transfer of the hormone to other people
Avoid washing the area of application for 2-3 hours after application.
Testosterone use is monitored by testing the testosterone levels via a blood test every 3 months.
It can take up to 6-12 months to have effect, however studies have shown increase in satisfying sexual experiences after only 4 weeks use.
If the free androgen index is within the female physiologic range (2-5%) but there is no effect after 6 months it can be discontinued.
When should testosterone levels get checked?
Testosterone blood tests should be completed just prior to your next application. This will check if your testosterone levels are adequate during it's lowest point.
Testosterone levels are usually also checked with your sex hormone binding globulin to calculate the amount of free testosterone.
Testosterone is usually checked 6-12 weeks after initiation and once stable 3 monthly.
FAQs about Testosterone in menopause
Where can I buy Testosterone in NZ?
Testosterone is a prescription medicine. It must be prescribed by a doctor in New Zealand. From 1 April 2024 Testogel will be available on presctiption from your GP or specialist for those who may benefit from it.
Is it safe to use Testosterone long-term?
There is no safety data for use of testosterone in post-menopausal women beyond 24 months, because there are no studies longer than 24 months.
Testosterone used long-term in men with low testosterone maintains bone strength (Behre 1997). There is no data as to whether it has the same effect in women.
The available data is reassuring that transdermal testosterone is not associated with higher blood pressure. cholesterol levels, kidney function, liver function, or blood cell counts in women.
There is no increased risk of breast cancer in the short term and it does not appear to stimulate the endometrium.
What is the recommended dosage for Testosterone?
The recommend dose of testosterone is a dose that keeps the free androgen index in the female physiological range.
It is usually used as an additional menopausal hormone therapy, once you are on optimised estradiol and progesterone and continue to have menopause symptoms.
How is Testosterone different from other hormone therapies?
Testosterone is usually used in conjunction with other menopause hormone replacement therapies such as estrogen and progesterone. Estrogen and progesterone are usually optimised first as it is our clinical experience that around 80 percent of women will have an improvement in libido with optimised estrogen, and fewer disruptive peri/menopausal symptoms.
What is the cost of Testosterone in NZ?
Testosterone gel in New Zealand is subsidised by Pharmac and is between $0-$15 depending on who prescribes GP/Specialist.
Testosterone cream (Androfeme) is not subsidised yet, so requires out of pocket expense and is available via Bays Health Pharmacy Auckland.
Find out more about HRT funding in New Zealand here.
Can you use testosterone if you have had a blood clot or a family history of blood clots?
Transdermal tesosterone is absorbed through the skin. It is used in low dose in women and levels are measured periodically to ensure the level stays within the female physiological range. In this range there is no increased risk of blood clot.
Does testosterone cause weight gain in women?
High levels of testosterone can cause weight gain in women. This occurs in conditions like polycystic ovarian syndrome where high levels of androgens (testosterones) are associated with increased insulin resistance and weight gain - particularly abdominal weight gain.
In menopause we are aiming to increase testosterone levels to normal female physiological levels. In this case, if your estrogen is in the ideal range, adding testosterone is unlikely to cause increases in visceral fat. There has been some minor weight gain seen in some women in clinical trails (average 0.5kg).
If you experience weight gain or unexpected changes in your body composition, talk to your health provider.
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As a menopause doctor, Dr Deb Brunt @ Ōtepoti Integrative Health would love to support you through the perimenopause and menopausal stages of life, supporting all aspects of your health and wellbeing.
Dr Deb Brunt is a menopause doctor in Dunedin, New Zealand and also provides menopause health coaching internationally to support optimal health habits for aging well so you can live your best life.
References
Behre H, et al. Long-Term Effect of Testosterone Therapy on Bone Mineral Density in Hypogonadal Men, The Journal of Clinical Endocrinology & Metabolism, Volume 82, Issue 8, 1 August 1997, Pages 2386–2390
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.
Hammes SR, Levin ER. Impact of estrogens in males and androgens in females. J Clin Invest. 2019 May 1;129(5):1818-1826.
Scott A, Newson L. Should we be prescribing testosterone to perimenopausal and menopausal women? A guide to prescribing testosterone for women in primary care. Br J Gen Pract. 2020 Mar 26;70(693):203-204.
Davis S, et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women, The Journal of Clinical Endocrinology & Metabolism, Volume 104, Issue 10, October 2019, Pages 4660–4666
Heald A, Ghaffari P, Naseem A, Zaidi N. Testogel Application in the Menopause: Making a Difference to the Lives of Women. BJPsych Open. 2023 Jul 7;9(Suppl 1):S191.