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Prescribing information for testosterone

Until recently, many doctors were unaware of the use of testosterone supplementation in women. However the NICE guidelines do indicate that some women may benefit from adding in testosterone if their libido is still low despite being well established on a suitable dose of HRT. There are many factors that contribute to sex drive so testosterone is not always the answer, but many women understandably want to try it for themselves. Although the current evidence is only for the improvement in libido, some women also find an improvement in their sleep, mood, motivation, concentration, cognition and energy levels. It is also good for muscle and bone strength. Testosterone replacement is particularly important in younger women who have had their ovaries removed.

Before considering if testosterone is needed, oestrogen needs to be transdermal and at a reasonable dose. If you are on oral oestrogen, please talk to your HCP about changing to transdermal oestrogen and try this for at least 3 months before being referred to the service. If you are on a low dose of transdermal oestrogen and still getting lots of symptoms, this needs to be increased before considering testosterone.

Useful advice about testosterone for HCPs can be found on the British Menopause Society website and the Primary Care Women’s Health Forum. For patients there is the Women’s Health Concern and balance-menopause websites.

Detailed prescribing information is also on the Somerset CCG Prescribing Formulary. Testosterone is now green on the formulary but HCPs do need to do some extra training to become familiar with how to prescribe it to women safely. As this not something that has been discussed until recently, not all HCPs will feel confident to prescribe testosterone. Hopefully in the future there will be at least one HCP in each practice who will be able to offer this. In the meantime, patients can be referred to this service.

Prescribing information for GPs:

First line option:

Testim (1% testosterone gel) 5g tube containing 50mg testosterone. Apply one tenth of a tube (5mg daily dose) once daily to lower abdomen, buttock, or outer thigh, rotating the site of application. Replace screw top between uses. Each tube should last 10 days.

Second line option:

Tostran pump (2% testosterone gel) in 60g metered dose pump. Apply one metered dose (10mg) three times a week or on alternate days to lower abdomen, buttock, or outer thigh.

Third line option (until new sachet size is in all pharmacies as at present is likely to cause confusion, will then be second line option again):

Testogel sachets (testosterone gel)

The current 5g sachets contain 50mg testosterone and each sachet should last 10 days, giving a 5mg daily dose of testosterone.

New 2.5g sachets are coming in Spring 2022 which contain a total of 40.5mg of a more concentrated testosterone gel. Each of the new sachets should last 8 days. Sachets should be sealed with a clip between uses.

With the Testim gel and Testogel sachets it can take a while for the patient to work out how much to apply each day – suggest starting with a pea-sized amount and then they can adjust up or down depending on how long the first tube/sachet lasts.

The gel should be applied to clean, dry skin and allowed to dry before dressing. Skin contact with partners and children should be avoided until dry and hands should be washed immediately after application. The area should not be washed for 3 hours after application.

Please warn the patients that the patient information leaflet only relates to male use and give them the British Menopause Society information leaflet.

Do not prescribe the pump version of Testogel or the Testavan pump as both not suitable for women.

Tips for HCPs for prescribing testosterone:

  1. The patient should be on transdermal oestrogen at sufficient dose to relieve most symptoms before considering if testosterone supplementation is needed.
  2. Blood tests for oestradiol, testosterone and sex hormone binding globulin (SHBG) levels can be useful beforehand eg. if you are worried she already has a high level of testosterone (past history of PCOS) or you are not sure if she is absorbing her oestrogen HRT despite being on a good dose. However not all women need to have this done before initiation.
  3. Blood tests are essential after about 2 to 3 months of treatment to make sure the levels are still within the female physiological range. The free androgen index (FAI) needs to stay below 5%.

Free Androgen Index = testosterone x 100 divided by the SHBG

If the FAI is below 1% after 3 months of supplementation and the patient has not noticed any            improvement, the dose can be increased slightly eg. one Testim tube lasting 7 days instead of 10.

Blood tests are needed 2 – 3 months after any dose change and then at least annually once stable.

4.  It can take at least 3 months to notice any difference in symptoms, if no improvement after 6      months of use then we would suggest stopping it.

5. Common side-effects when starting testosterone are greasier hair and skin and an increase in spots. Some women feel more angry. If these symptoms don’t settle they can reduce the dose slightly (but they must never increase the dose without discussion).

6. Serious and possibly irreversible side-effects can happen if the dose is too high and the FAI over 5%. These include male pattern hair loss, a deepening of the voice, increased body and facial hair and an enlarged clitoris.