The greatest risk for women with regards to testosterone therapy is the unregulated prescribing of male formulations and compounded testosterone, often described as “bio-identical hormone therapy.” Both treatment approaches put women at serious risk of excessive exposure. The International Menopause Society and the US Endocrine Society specifically recommend against the use of male testosterone products and compounded testosterone therapy for women.
Testosterone should only be prescribed if there is confidence in the formulation to be used. This leaves few options presently for clinicians. There is an urgent need for a formulation for women to be approved by the regulators.
In the interim, the only options include the 1% testosterone cream available in Australia, and where available, pharmaceutically manufactured, not compounded, testosterone pellets.
Before testosterone therapy is initiated, a full medical history, including sexual history, and examination should be performed. It is important to identify the duration of the problem and whether or not it is partner-specific or generalized. The patient should be asked about ability to achieve orgasm and if not, whether this has been lifelong or of new onset. If lifelong, sexual counseling is indicated.
Prior to treating a woman with FSD with testosterone, consider and treat as indicated:
Sexual health knowledge.
Individual psychological factors.
Body image and self-esteem.
Experience of sexual abuse/trauma.
Negative attitudes, inhibitions and anxieties.
Health related factors.
Medication side effects, particularly antidepressants and antipsychotics.
Although fatigue is a common complaint amongst women, if present, this may be the cause of low desire-arousal and warrants investigation. Basic investigations should include thyroid function, iron stores and fasting blood glucose.
Absolute contraindications to testosterone therapy include evidence of androgen excess, pregnancy and lactation, and a history of breast cancer.
If a woman is to be treated for desire-arousal disorder with testosterone, a baseline total testosterone level, as well as SHBG, should be measured. This is to avoid treating women with a normal testosterone level inappropriately and to guide therapy. Women with very high SHBG levels are unlikely to respond to treatment, and in the first instance an effort should be made to reduce their SHBG. For example, switching the woman from oral to transdermal estrogen therapy. If a woman has a very low SHBG level then the dose of testosterone should be lowered, as any exogenous testosterone is likely to be cleared rapidly from the circulation, increasing the risk of androgenic side effects.
Treated women should be monitored carefully as it is always possible for a woman to over-treat herself. Optimally, testosterone should be measured after a few weeks of initiating treatment, and if treatment is ongoing, then 6-monthly. A testosterone implant should never be re-inserted without checking that the testosterone levels have fallen back into the low female range. A consistent finding in studies of transdermal testosterone has been that efficacy is not observed until after 4–6 weeks of treatment. Patients need to be made aware of this. If a woman has not experienced improvements in her sexual well-being after 6 months of therapy, then treatment should cease, as an improvement after that time is not likely. Women need to be aware that treatment is a trial, as not all women will experience a benefit.