When do women need testosterone replacement?

Requiring a mindful approach, testosterone replacement therapy is a complex and effective option for women to treat low testosterone levels and testosterone deficiency.

Mr Gidon Lieberman, leading consultant gynaecologist and fertility specialist, provides a comprehensive insight into testosterone replacement for women, including how testosterone is found in women and when testosterone replacement is considered.

What is testosterone?

Testosterone is a hormone which directly affects wellbeing, body shape, sex drive and the production of other hormones such as oestrogen.

It is a popular belief that testosterone is a ‘male’ hormone, only made in men and related to things like muscles, body building, an imbalance sometimes seen in polycystic ovarian syndrome (PCOS), libido and skin problems like acne. However, while all of these are true to some degree, testosterone is also found in women, secreted by the adrenal glands and the ovaries. Following menopause, testosterone production levels fall, but the hormone is still made in the ovaries.

How is testosterone found in women?

In women, the majority of testosterone is dormant due to a protein called sex hormone binding globulin (SHBG) which binds testosterone and mops it up. The only testosterone which is biologically active is unbound (free) testosterone. Thus, only the free amount of testosterone – instead of the total amount – needs analysis in a blood test for testosterone.

In particular, women with PCOS will frequently have higher levels of free testosterone. This will manifest through skin problems. To restore testosterone levels, the use of the combined oral contraceptive may be recommended, which will enhance SHBG levels. Free testosterone levels will then fall.

Testosterone levels will decrease once women reach menopause. Although some women may have pronounced symptoms, others may not recognise when testosterone levels fall. Women who have experienced an early, surgically or medically induced menopause are the most symptomatically affected, in my experience.

When is testosterone replacement considered?

Loss of libido is the main indicator for testosterone replacement, which should treat decreased sex drive if this is caused by reduced testosterone levels. Treatment will not have the same effect on all patients; some will call it a “game changer” while others will not even notice a difference. On the other hand, ordering testosterone replacement will not address loss of libido if decreased sex drive is due to relationship problems or other medical concerns.

Other conditions including loss of enjoyment in life (anhedonia), concentration and task focus can also be addressed with testosterone replacement. Oestrogen deficiency can also cause these symptoms and thus, it is worth to consider testosterone replacement in these cases - especially for women with recurrent concentration or brain fog despite oestrogen replacement.

In most cases, treatment will help women to feel better, but like with oestrogen replacement, testosterone replacement will never truly reverse the natural progression of testosterone.

What are the treatment options for testosterone replacement?

At first, testosterone replacement was administered as an implant under the skin which was placed every six months. However, removal of the implant was very difficult and the implant also left a scar on the stomach or the bum, which many patients unsurprisingly did not like.

Now, gel products are used, which are comfortable and, at the moment, easy to source. However, it is important for patients to understand that in the UK none of the gel products have an official license of use for women. For this regulatory concern, GPs will not prescribe testosterone lightly. Each prescription is done outside of official regulations and this is mostly due to the lack of clinical trials in course.

Despite this, testosterone has been safely used by women for a very long time. In other countries, testosterone is licensed for use in women and hopefully, this will be the case for the UK in the near future.

In my case, depending on the availability of the gel product and patient choice, I generally prescribe Tostran, Androfemme or Testogel, which are all equally effective. With time, I hope that there will be a surge in prescription confidence, increasing the availability of testosterone.

What are the side effects of testosterone replacement?

There are many concerns about taking testosterone and the possible side effects - and I understand that completely. Loss of head hair, skin problems and (very uncommonly) voice changes can occur. Nevertheless, in reality, it is very rare to experience problems or complications as long as testosterone is used within the recommended doses and not placed onto skin that has dark hair. Before treatment is started again, blood tests for both total and free testosterone levels should be ordered, and again after three months.

At the moment, I understand that GPs can be reticent to prescribe testosterone due to licensing regulations. However, attitude towards prescriptions is changing and I hope that soon, testosterone treatment will become easily available for everybody.

If you are considering testosterone replacement, or simply wish to know more about this treatment, make sure to visit Mr Lieberman’s Top Doctors profile today.