Levels of testosterone in women decline between the ages of 20 and 40. By menopause the levels have plateaued out and are stable. At age 65, endogenous testosterone levels start to increase.
Testosterone is not the third component of HRT. Unlike oestrogen, there is not a 'relative deficiency' i.e. in most women levels are within the normal female range as production is not just ovarian in nature.
Managing women with hypoactive sexual desire disorder (lack of desire, change/reduction of orgasm), necessitates a biopsychosocial approach. It is important to consider contributory factors which include vulvovaginal atrophy and relationship issues.
Criteria for NHS Testosterone Treatment
Use of testosterone gel is restricted in BNSSG to the treatment of low libido causing distress in women with optimised HRT and with either early menopause (age 45 and under) or surgical menopause only. Use of testosterone gel for women outside of this cohort is non-formulary and is not currently supported.
Testosterone gel is ‘Amber 3 months’ on BNSSG formulary, which means it must be initiated by a menopause specialist. See testosterone shared care protocol (Sections A-D and H must be completed by the applicant (icb.nhs.uk)
Please ensure criteria are met before referring to the menopause clinic for consideration of testosterone treatment
If referring for testosterone replacement:
At present, within BNSSG, testosterone should not be prescribed outside of this guidance. There is on-going work to review the current guidelines, and these pages will be updated in due course.
Private Patients
If a patient is started on testosterone privately for a non-formulary indication, then this can be continued privately. NHS prescriptions should only be issued if a patient meets the referral criteria above and they have been referred into the complex menopause clinic for consideration of continuation.
See Referrals for further details
In line with the BNSSG Testosterone shared care protocol, once efficacy has been demonstrated and following their 6 month follow up with the complex menopause service, patients can be discharged back to their GP for on-going care, with support from secondary care advice and guidance platforms as required. Clear advice will be provided in their discharge letter.
The GP will be responsible for:
Available preparations include: Tostran® 2% gel and Testogel® 40.5mg/2.5g gel sachets.
At present, there is no preparation of testosterone that is licensed for use in women in the UK. All use is ‘off-license’.
Testosterone availability is not currently stable, and the dose and use of preparations are not interchangeable. Women using these medications should ensure they are taking them exactly as prescribed.
See HRT Prescribing pathway for further details
Please be aware of the following contraindications to testosterone treatment:
It should also be used with caution in patients with cardiovascular disease, liver disease, renal insufficiency.
Total testosterone level should remain under the upper limit of the normal range and should be performed
In certain circumstance SHBG can be helpful and you will be guided by a specialist if required.
Blood tests can be taken in primary care, the responsibility to review results remains with the prescribing clinician.
Adverse effects of testosterone are uncommon if levels are maintained within the female physiological range.
Side effects include the following and may not be reversible:
If side effects occur, please check dosage and how it is being used, different preparations have different dosing schedules. Consider reducing dosage or stopping.
Safety data regarding testosterone is limited to 2-3 years follow up and excluded people with cancer, and high cardiovascular risk.
Woman should have annual reviews that updates her on new evidence and states:
Given an increase in endogenous testosterone production around the age of 65, a pragmatic approach is to encourage women to reduce and stop testosterone around this age, or if testosterone levels start to increase.
Patient Resources
Some interesting and helpful books on female libido include
Resources and References
BMS Statement on Testosterone - British Menopause Society (thebms.org.uk)
Sections A-D and H must be completed by the applicant (icb.nhs.uk)
Davis SR, Bell RJ, Robinson PJ, Handelsman DJ, Gilbert T, Phung J, Desai R, Lockery JE, Woods RL, Wolfe RS, Reid CM, Nelson MR, Murray AM, McNeil JJ; ASPREE Investigator Group. Testosterone and Estrone Increase From the Age of 70 Years: Findings From the Sex Hormones in Older Women Study. J Clin Endocrinol Metab. 2019 Dec 1;104(12):6291-6300
Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.
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