Testosterone as part of hormone replacement therapy in menopausal women – what do we know so far? A Narrative Review

Abstract Testosterone is an essential endogenous hormone in women, exerting physiological actions in reproductive and non-reproductive tissues. Despite the increased demand for the use of testosterone for an array of menopausal symptoms beyond sexual functions, there is a lack of robust evidence on its impact on cardiovascular and musculoskeletal health and cognition. The aim of this review is to provide an overview of evidence-based indications of testosterone as part of menopausal hormone replacement therapy (HRT) in women, highlight the uncertainties, evidence gaps and future research priorities. This narrative review synthesised current evidence on the physiological role of testosterone; indications for testosterone as part of HRT; clinical efficacy; formulation and prescribing; and safety profile. Testosterone declines across the adult female lifespan until the late sixth decade, and the menopausal transition itself has no meaningful independent impact on testosterone concentrations. Transdermal preparations maintaining testosterone levels in the physiological range are generally safe, with potential side effects of acne and hair growth. The existing high-quality evidence, including national and international guidelines recommend that hypoactive sexual desire disorder (HSDD) in postmenopausal women is the only evidence-based indication for use; the evidence does not support use for any other symptom, nor for disease prevention. Lay Summary Testosterone, widely known as the male hormone, is also produced naturally in women and plays an important role throughout their lifespan. There has been a growing use of testosterone for a range of symptoms in menopausal women, including low sexual desire, low mood, fatigue, poor memory, and heart and bone health. This review brings together the current evidence and guidelines on testosterone as part of hormone replacement therapy (HRT) in menopausal women, including its impact on reproductive and non-reproductive tissues; when it is indicated to be prescribed and in what forms; safety and gaps in existing evidence. We found that there is high-quality evidence to support the use of testosterone for low sexual desire where conventional HRT has not helped. Transdermal preparations are recommended with no serious side effects at testosterone levels normally found in women. There is insufficient evidence to support its use for brain, heart and bone health. This represents an area of focus for future research.