Prescribing testosterone to middle-aged women ‘excessive’

Prescribing testosterone to middle-aged women is ‘excessive’ and could have long-term consequences for their health, experts warn.

They worry that “testosterone evangelists” on social media – including some celebrities and GPs – are giving women the impression that the hormone reduces fatigue and improves their energy levels, as well as protecting their hearts, brains, muscles and bones. But experts say the evidence only supports its use in postmenopausal women with low libido, when psychosocial causes have been ruled out.

“I really think testosterone prescribing in the UK has gotten completely out of control,” said Dr Paula Briggs, a consultant in sexual and reproductive health at Liverpool Women’s Hospital and chair of the British Menopause Society.

“People are told they have to have this. But we have no idea what long-term testosterone supplementation does to women.”

Despite its reputation as a male hormone, testosterone is also produced in the ovaries and female adrenal glands, and plays a vital role in the development and maintenance of female sexual anatomy, physiology, and sexual response. Levels typically peak in a woman’s 20s and 30s, and then begin to decline gradually—likely due to declining production by the ovaries and adrenal glands, although stress, surgical removal of the ovaries, and certain medications or cancer treatments can also suppress production.

In the United Kingdom, the National Institute for Health and Care Excellence (NICE) guidelines for the diagnosis and treatment of menopause say doctors may consider testosterone supplements for menopausal women with low sexual desire if conventional hormone replacement therapy based on estrogen and progesterone alone is not effective.

According to British Menopause Society GuidelinesThis should only be considered if other causes, such as psychological or relationship problems, or medication, have been ruled out. However, some private doctors are believed to prescribe it as a first-line treatment for libido problems and other symptoms.

For example, Dr Louise Newson, a GP who runs a network of private menopause practices in the UK, argued in a recent Instagram live that it is “barbaric and wrong that women don’t have access to their own hormone” and that testosterone can improve mood, energy, concentration and stamina, as well as bone density and the way our muscles and cardiovascular systems work.

While many clinicians start HRT first and then add testosterone, “I’m increasingly seeing women who are in perimenopause, their periods are still regular and most of their symptoms seem to be related to testosterone deficiency (rather than estrogen deficiency), Newson said. “For those women, I might start them on a very low dose of HRT and start testosterone at the first consultation.”

Newson said: “Testosterone has a significant impact on brain processes and functions, so clinicians should stop viewing it purely as a hormone to enhance libido.”

Prof Susan Davis, head of the Monash University Women’s Health Research Programme in Melbourne, Australia, and past president of the Australasian Menopause Society and the International Menopause Society, disputes this suggestion.

She said: “The data clearly support a trial of therapy in postmenopausal women with low sexual function that is bothering them. But we’ve looked at the evidence inside and out, looked at all the published literature and published all our own data. The evidence that testosterone will improve fatigue, well-being, cognition or whatever you want to name is just not there.”

Briggs’ biggest concern is that women may accidentally end up with extremely high or “supra-physiological” levels of testosterone in their bodies because their hormone levels are not closely monitored.

“I’ve heard doctors say it doesn’t matter if they’re out of the normal range if the patient doesn’t have any side effects, but we don’t know what’s going on in their arterial system or even their heart,” Briggs says. “Men who take high doses of testosterone (to build muscle) in gyms get cardiomyopathy — where the muscle in the heart becomes weak and can’t pump — and some of them die, so it’s not nothing.”

Prof Annice Mukherjee, a consultant endocrinologist at Spire Manchester Hospital and a media ambassador for the Society for Endocrinology, said she had seen patients with unpleasant side effects after being prescribed testosterone. “Women come to me and say, ‘My hair is falling out’ or ‘My voice has deepened and I have new acne or hair growth on my body, what’s going on?’ So I measure their testosterone and it’s sometimes the same as a man’s level,” she said.

One of her patients was a professional singer who had been prescribed testosterone by a private clinic. “Her doctor had said, ‘You need HRT, and by the way, you need testosterone.’ She came to me because she was having problems with her voice. When I tested her testosterone levels, they were more than double the normal level for a woman,” Mukherjee said.

“If we give women too much testosterone, it can affect their vocal cords. If you don’t mind your voice getting a little bit deeper, that’s fine, but if you’re a singer, it can change your pitch.”

Briggs and Dr Stephanie Faubion, medical director of the North American Menopause Society and director of the Women’s Health Research Center at the Mayo Clinic in the US, are also concerned about the lack of data on the long-term safety of testosterone use in women.

“There’s a reason we have to worry about long-term safety, and that’s because we don’t have data to say it’s safe,” Faubion said. “We also don’t have data to say it’s unsafe. But the lack of data to show safety is a real problem.”

Newson said long-term use of safely prescribed testosterone replacement is unlikely to be associated with adverse health risks, “because it is a natural hormone.”

She added: “Testosterone should be prescribed in the right dose and type to women who are likely to benefit, with appropriate monitoring. More healthcare professionals need to receive appropriate training and education on how to prescribe testosterone safely to help more women.”