Testosterone HRT in Surgical Menopause
Although testosterone is considered a male sex hormone, females produce testosterone in their ovaries and adrenal glands (with about half coming from each). Together with the female sex hormone estrogen, testosterone plays a role in the growth and maintenance of female reproductive tissue and bone mass. There is also some evidence that testosterone is involved in sexual function among women in surgical menopause; the use of testosterone therapy has been found to increase sexual satisfaction for many in surgical menopause.
Testosterone levels naturally decline throughout a female’s lifespan. Loss of testosterone is particularly profound after surgical and medical menopause when testosterone production decreases by more than 50%.
The use of testosterone therapy has been found to increase sexual satisfaction for many (but not all!) in surgical menopause.
It is worth noting that testosterone is not readily available to many people and can be difficult to obtain, even from specialists. There is a lack of consistency globally in prescribing testosterone HRT - causing much frustration for patients.
How does surgical menopause influence testosterone levels?
What are the benefits of taking testosterone in surgical menopause?
What are the potential side effects of using testosterone in surgical menopause?
What are the risks of taking testosterone in surgical menopause?
What different versions does testosterone come in for surgical menopause?
When should I start testosterone in surgical menopause?
How much testosterone do I need?
Why is it so hard to get prescribed testosterone as a woman/AFAB individual in surgical menopause?
How does surgical menopause influence testosterone levels?
After bilateral oophorectomy (surgical menopause) you will experience about a 50% reduction in the amount of testosterone in your body. Unfortunately, research in this area is limited relative to research on the role of depleted estrogen levels; therefore, many unanswered questions remain about the role of testosterone changes in wellbeing among those in surgical menopause.
"Many people think of it as the “male” hormone which is correct, but women produce testosterone too. In fact, women produce three times as much testosterone as estrogen before menopause. Testosterone is made in your ovaries and also your adrenal glands, which are small glands near your kidneys. Levels of testosterone in your body gradually reduce as you become older" - Dr. Louise Newson, My Menopause Doctor, and IAPMD SMAC member.
What are the benefits of taking testosterone in surgical menopause?
For those in surgical menopause who develop low libido and arousal, testosterone may help with these symptoms. Improvements have been noted in the number of satisfying sexual episodes, frequency of sexual activity, libido, orgasm, arousal, pleasure or enjoyment of sex, sexual responsiveness, sexual self-image, and sexual or relationship satisfaction.
Some existing studies suggest that testosterone therapy does not have any impact on hot flashes, bone density, weight, BMI, anxiety, or depression, although better-controlled studies are needed to examine these possible outcomes. The limited research we do have does suggest further benefits to mood and headaches, and this ties in with what is often observed in clinical practice by some members of our Surgical Menopause Advisory Committee, but more data via carefully controlled studies is needed to give definitive answers.
So far, in clinical trials testosterone has been found to improve sexual function in women more than a placebo. So if you are in surgical menopause and have a reduced libido - testosterone may be helpful to you.
‘No one told me that it can take months and months to start feeling the benefits of testosterone - At about 6 months I noticed a difference in libido, but I would not say I have felt a difference in mood or energy. Maybe I need to speak to my consultant about upping my dose?!” - Patient
What are the potential side effects of using testosterone in surgical menopause?
There are usually no side effects with testosterone treatment as it is given to replace the testosterone that you are otherwise lacking. Very occasionally adverse effects are reported and these are shown below; if thought to be linked, the dosage should be reduced or treatment stopped.
Increased body hair where you apply the gel (occasional problem) – In this case, you should spread the gel more thinly, vary the site of where you are applying the gel, and consider reducing the dosage.
Generalised Hirsutism - excessive growth of dark or coarse hair in a male-like pattern — face, chest and back (uncommon)
Alopecia, male pattern hair loss (uncommon)
Acne and greasy skin (uncommon)
Deepening of voice (rare)
Enlarged clitoris (rare)
Randomised controlled trials and meta analyses have not shown an increased risk of cardiovascular disease or breast cancer although longer term trials would be desirable.
It is important to have regular blood monitoring to reduce the risk of any side effects occurring.
Note: AndroFeme®1 contains almond oil so should not be used if you have an allergy to almonds.
What are the risks of taking testosterone in surgical menopause?
Testosterone therapy for postmenopausal women and AFAB individuals, in doses that your body would naturally produce before surgical menopause, is associated with mild increases in acne and body/facial hair growth in some.
There is very little long-term safety data available for testosterone use in women/AFAB individuals and more work is needed to determine the long-term safety of testosterone therapy.
Available data suggest that short-term transdermal testosterone therapy does not impact breast cancer risk. However, the data from studies are insufficient to determine the long-term breast cancer risk with testosterone use. Caution is recommended for testosterone use in women with hormone-sensitive breast cancer (Expert Opinion).
Testosterone should not be used in the following situations:
During pregnancy or breastfeeding
Active liver disease
History of hormone sensitive breast cancer – off label exceptions to this may be agreed in fully informed women with intractable symptoms not responding to alternatives
Competitive athletes – care must be taken to maintain levels well within the female physiological range
Women with upper normal or high baseline testosterone levels / FAI.
What different versions does testosterone come in for surgical menopause?
Here are the different versions in which testosterone is available. Is it important to note that other than AndroFem 1, these products are not licensed for use in females. This means it may be difficult to obtain/be prescribed unless you are under the care of a provider who is trained and confident to prescribe it ‘off license’.
Testosterone Implants
These are also known as ‘pellets’. A hormone implant is a small crystalline slow release pellet which usually contains 50mg or 100mg testosterone. Implants are inserted under the skin, usually in the abdomen (stomach) or in the buttock. With a local anaesthetic, a small 5mm incision (cut) is made in the skin. Using an ‘introducer’ the implant is inserted under the skin into the fatty layer. The wound is covered with ‘steristrips’ and a sterile dressing. This should remain in place for 48 hours and the wound kept dry. Occasionally a soluble stitch is used if the wound continues to bleed. This usually dissolves and falls out in 7-10 days, but if not it should be removed by a healthcare practitioner.
AndroFeme 1 - Cream
AndroFeme 1 is a 1% testosterone cream that comes in 50ml tubes with a screw cap. Starting dose is 0.5ml/day = 5mg /day. Each tube should last 100 days. AndroFeme 1 should be applied daily to the outer thigh or lower torso. If those places are not suitable then please ask your doctor for advice. The cream should be applied to a large area of skin. You should speak to your provider about availability and access to AndroFem 1 in your country. AndroFem 1 is manufactured in Australia and may or may not be imported (and therefore available) where you live. AndroFem1 is soon to be licensed for use in the UK.
Testogel & Tostran - Gel
Testogel is a 1% testosterone gel which comes in 5.0g sachets containing 50mg testosterone. The starting dose 1/10 of a sachet/day = 5mg/day i.e. each sachet should last 10 days. It comes as a gel in a small sachet and you only need to rub a pea- size amount of this gel into your skin. One 50mg sachet should last around 10 days. It should be rubbed onto your lower abdomen or your thighs. After use you should roll the top of the sachet down and seal with a clip between uses.
Tostran is a 2% testosterone gel which comes in a canister containing 60g testosterone. The starting dose is 1 metered pump of 0.5g = 10mg on alternate days – each canister should last 240 days. The typical starting strategy is one measure applied every other day to the thigh. This delivers an average 5mg/day.
Again, availability and access to these products will vary and you need to speak to your doctor to see if they are a possibility for you.
It can sometimes take a few months for the full effects of testosterone to work - a 3-6 month trial is often recommended. The testosterone gel/cream should be applied to clean dry skin (lower abdomen/upper thighs) and allowed to dry before dressing. Skin contact with partners or children should be avoided until dry and hands should be washed immediately after application. The area of application should not be washed for 2-3 hours after application.
Note: Compounded bioidentical testosterone preparations are not recommended by the regulatory authorities or the menopause societies.
Note: Female testosterone patch – As the majority of controlled data on the efficacy and safety of testosterone therapy for postmenopausal women with female sexual interest/arousal disorder were obtained using a testosterone transdermal patch (Intrinsa 300 mcg), these patches would be the preferred product for women electing testosterone therapy but are no longer available, even in Europe. In the United States, no androgen therapies for female sexual dysfunction are approved by the FDA, which declined approval of a testosterone patch for women pending additional long-term safety data. We hope that this changes in the future with further research.
When should I start testosterone in surgical menopause?
Options and availability will vary from country to country. There is no set rule within surgical menopause as it will depend on the individuals needs and personal choice. In some experts’ clinical practice, patients are given the choice soon after surgery. That is, they are offered the option of starting testosterone immediately, or waiting to add Testosterone into their HRT regimen at a later date. Some choose to start straight away, and others decide to wait for a while.
You should work with your provider in terms of how long you continue to take testosterone. If you do not see benefits to sexual health within six months of using testosterone, we would usually advise you discontinue the treatment.
How long does testosterone take to work? How long should I try out a certain dose before making a change?
Very little research is available to inform this answer, so your individual experience may differ. Anecdotally, in clinical practise we observe that it can take several months to show full benefit.
Testosterone won’t provide benefits to sexual function for everyone - however, negative side effects are generally low, and so it is worth trying it for a few months if you are experiencing low sexual satisfaction. It is recommended that you trial testosterone for a minimum of 3 months, and if you see no improvements by the end of 6 months, then cease the treatment.
How much testosterone do I need?
Finding the right dosages can be difficult and results are unclear from existing studies, because the doses have varied so much between different trials.
With all methods, doctors are trying to achieve ‘female physiological levels’ (which is the level your body would be producing naturally if you still had ovarian function). This is commonly achieved with 5mg of Testosterone per day. Therefore, a 5mg daily dose is a good starting point.
Your doctor should regularly measure the ‘free testosterone level’ or ‘free androgen index’ (total testosterone/sex hormone binding globulin) if you are using testosterone therapy as this can be used to monitor safety, with the idea of keeping your levels within the normal range for reproductive-aged women (as provided by the lab).
Why is it so hard to get prescribed testosterone as a woman/AFAB individual in surgical menopause?
Globally, there is only currently one testosterone treatment which is licenced for use in women: AndroFeme®1. This can be hard to get prescribed but may be available via private prescription in the UK. This may be changing in 2021. See here for an update.
Other than AndroFeme®1, testosterone is prescribed ‘off licence’ for women as it is actually designed and licensed for use by men. However, it is prescribed by many menopause experts as it has proven benefits in numerous clinical trials. It is also very safe when it is used in the way that it has been prescribed for you.
Extrapolation of research data it is deemed acceptable for products licensed in men (mainly gels) to be prescribed off label in female doses. This remains to be an area that needs investigation to make testosterone available to those in natural and surgical menopause.
What can I show my doctor to educate them about the importance of testosterone therapy for surgical menopause?
It is worth noting that testosterone is not readily available to many people and can be difficult to obtain, even from specialists. There is a lack of consistency globally in prescribing testosterone HRT - causing much frustration for patients. Self advocacy is important and taking evidence based information to your providers who perhaps are not confident (yet!) in prescribing testosterone to women and AFAB individuals.
We recommend downloading and printing this Global Consensus Position Statement on the Use of Testosterone Therapy for Women, which was published in 2019 by the International Menopause Society and other leading worldwide experts:
This is also a handy tool for clinicians which was prepared and published by the British Menopause Society:
For those in the UK - here is a guide for your GP from the Primary Care Women’s Health Forum (PCWHF) to aid your doctor in being confident in prescribing testosterone. They may not be comfortable doing this and may still need you to be referred to a specialist. AndroFeme is not currently available from the NHS and is being imported from Western Australia by special license from the MHRA. Designed for female usage.
This project was financially assisted by The Patty Brisben Foundation for Women’s Sexual Health. The views expressed herein do not necessarily represent those of The Patty Brisben Foundation for Women's Sexual Health.