FAQ: Who is a candidate for testosterone therapy in women?

This FAQ is a summary of the discussion in the second episode of the Special Report series Testosterone in women: The evidence-practice gap in the US. In the episode, Maria Uloko, MD, a board-certified urologist specializing in comprehensive sexual health, asks Bruce Dorr, MD, FACOG, URPS, FMCP-M, a board-certified ob-gyn with subspecialty training in urogynecology, how he decides whether testosterone is appropriate for a woman with low desire, fatigue, or a loss of well-being she attributes to low testosterone.

The conversation centers on how symptoms, clinical context, and lab values each factor in, and on why Uloko argues for judging candidacy by hormone state rather than age. The answers below come from the panelists' remarks in the episode.

How does Dorr decide whether testosterone is appropriate?

Dorr described a patient-first approach. Many patients arrive with a folder of labs or ask for labs, he said, but he evaluates the person in front of him. “I'm sitting with the patient in front of me, not the testosterone number, not these labs, and low desire doesn't automatically mean testosterone deficiency,” Dorr said.

“So I've got to look at this patient in front of me comprehensively. What's her relationship like? What are these medicines that she comes on? I have so many people on so many different medicines from so many different providers. How do I bring that all together? Does she have pain? As a urogynecologist, I'm constantly looking at estrogen deficiency or certainly other contributors that may be painful going on for my patient, too. So the testosterone level does not diagnose low desire”

What role do labs play?

Dorr said a baseline lab shows where the patient is starting and helps keep her safe when prescribing a controlled substance. He avoids arbitrary targets. “I'm not going towards a number. I'm going towards a clinical response and a benefit for this patient,” Dorr said.

He also cautioned against over-treating.

“I'm going towards a clinical response and a benefit for this patient. And I certainly don't want to make her manly if she doesn't want to be manly, right? So that is a scary part for a lot of women, and certainly for a lot of practitioners out there, also.”

What about patients outside the strongest evidence?

Dorr said the strongest evidence sits with postmenopausal women with hypoactive sexual desire disorder, but his practice regularly includes premenopausal patients and women who have lost ovarian function through surgery, tumors, endometriosis, or premature ovarian insufficiency. In those patients, he said, the biologic rationale may be compelling, but the evidence is less complete.

Should hormone state, not age, guide who is treated?

Uloko said yes. Hard cut-offs for menopause can obscure patients such as those on anti-testosterone medication or with primary ovarian insufficiency, whose hormone levels may mirror a postmenopausal state regardless of age. “We actually need to stop equating testosterone levels with an age,” she said.

She drew a parallel to men. “What we're actually saying is that people with low levels of hormones need testosterone,” Uloko said, adding that in men “we don't have an age cutoff for when we start treating.”

When can hormone loss begin?

Dorr agreed with Uloko and added that perimenopause can start “a good 10 years prior” to the end of cycles. He said it is not uncommon for “women in their 30s to start experiencing hormone loss or hormone fluctuations,” which supports looking at the clinical picture rather than lab values alone.

This FAQ was developed as a summary of the Special Report series discussion. To hear the full conversation, watch the complete series, Testosterone in women: The evidence-practice gap in the US.