Who should take testosterone in menopause

The beneficial effects are limited to the bedroom, one expert has found.

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Treating postmenopausal women with testosterone improves sexual outcomes, but there is no evidence – or not enough high-quality data – to suggest it can also be used to treat or prevent a range of other conditions.

That’s according to Professor Susan Davis, an endocrinologist and clinician researcher from Monash University.

“It doesn’t matter how you slice and dice it … There’s irrefutable evidence that if you treat postmenopausal women with low libido with testosterone, you get a benefit – and an increased number of satisfactory sexual events,” she told delegates at the International Menopause Society’s World Congress on Menopause at the weekend.

The improvements in sexual function after testosterone treatment include increased desire, arousal and orgasm frequency, as well as a reduction in sexual distress – which Professor Davis described as a pretty sound outcome.

But a deep dive into data from mechanistic and observational studies, as well as clinical trials and meta-analyses, revealed there was inconclusive evidence to support using testosterone for other conditions, including cardiovascular disease, depression, sarcopenia or osteoporosis.

One such example of this came from the Sex Hormones in Older Women (SHOW) study, which was a substudy of the NIH- and NMHRC-funded ASPREE study and involved over 5000 women over the age of 70 with no history of cognitive impairment.

Initial analyses suggested that women with low testosterone were 33% more likely to display depressive symptoms as measured by the Center for Epidemiologic Studies Depression Scale (CEDS-10), regardless of what cutoff was used to indicate depression as an outcome or whether the women were on antidepressant therapy.

“However, the point I’d like to make here is that when we put testosterone in the model with other factors like BMI, smoking, alcohol [intake] and living arrangements, it made a miniscule effect. [And] while our finding was statistically significant, it is not clinically meaningful. The impact of testosterone blood levels was very small in discriminating women with depression from [those] without,” Professor Davis highlighted.

The ability to determine whether testosterone improved cognitive function was limited by little to no methodological consistency between previous observational studies. This is demonstrated by a 2023 systematic review that found 10 studies explored 11 different domains of cognitive function using a whopping 37 different instruments.

Unsurprisingly, the findings for testosterone on cognition were inconsistent and inconclusive.

“This is not a licence to treat women and tell them that testosterone will prevent cognitive decline,” Professor Davis warned. “We always need to go back to the data.”

While there is a shortage of data on the potential benefits of testosterone beyond sexual functioning, there is no shortage of data highlighting the potential side effects of testosterone therapy.

Pooling clinical trials data reveals that acne and hair growth were the most commonly reported side effects. There was a slight tendency for some women to gain weight while using testosterone but there were no consistent associations with alopecia or voice changes.

“Although, none of these studies did voice recordings,” Professor Davis highlighted.

“So, if you can use testosterone and your patient is a professional singer, you will need to have that conversation with them that we don’t have data [on that potential risk].” 

The IMS World Congress on Menopause in Melbourne ends today.