Like many middle-aged women, I often feel tired, unable to concentrate, and suffer from low libido. Conventional hormone replacement therapy (HRT) has helped a bit, but according to friends in the know and social media, there’s something else that could help: testosterone.
Advocates claim that as well as boosting libido – the only thing it is recommended for – testosterone replacement can improve an array of menopausal complaints, from low mood, poor concentration and memory, to sleep problems, stamina and motivation. It may even protect women’s bones, muscles and brains, it is claimed.
If that sounds too good to be true, it’s because it possibly is: medical guidelines stress that the only evidence-based indication for testosterone use in women is for low sexual desire, and there are insufficient data to support its use for other symptoms or disease prevention. Because of this, few GPs are willing to prescribe it.
Yet women are getting hold of it through private or – as I discovered for myself – online clinics.
I managed to buy three sachets of Testogel – equivalent to a month’s supply – from Superdrug Online Doctor after filling in a short questionnaire about my sex drive and medical history, and submitting blood test results showing levels of testosterone in my body. Using the same prescription, I was then able to order a further 30 sachets from a different online pharmacy.
According to Prof Annice Mukherjee, a consultant endocrinologist at Spire Manchester hospital, I am not alone. “Testosterone evangelists on social media are saying it’s the missing hormone, and if you don’t feel great on HRT it’s because you’re missing testosterone – which is causing a lot of women to feel desperate for it,” she said. “They know that the NHS or private practitioners won’t give it unless they can identify that they’ve got low libido, so they’re learning what they need to say. If you know what boxes to tick, you can get it.”
Mukherjee and other experts are concerned that women aren’t necessarily being fully counselled about potential risks and side-effects, or how to apply testosterone safely. This is a particular issue in the UK because, unlike in Australia where a female-specific formulation has been approved, British women are usually prescribed the male formulation. Men with low testosterone should use one sachet of Testogel per day, but women must divide each sachet over 10 days, which is tricky to estimate.
Prof Susan Davis, the head of the Monash University women’s health research programme in Melbourne, Australia, said: “Even just a tiny amount more can lead to excessive amounts – so the chance of doing harm is much greater.”
Dr Paula Briggs, a consultant in sexual and reproductive health at Liverpool Women’s hospital, said she had seen a patient who had had ordered some Testogel from Superdrug and was distressed that she could only get three sachets at a time. “It should last 30 days, but she’d been using too much,” Briggs said. “There are leaflets that have been designed to explain how to use it, but people either don’t understand or they’re accessing information elsewhere that says it’s OK to use more.”
Different women respond differently to the same amount of testosterone gel, another reason why regular blood tests are needed. Mukherjee said: “If women are not being properly counselled and monitored and checked, they may end up taking what we call a supra-physiological dose, meaning that their testosterone will rise above the female reference range.
“Basically, they’re using it as an anabolic steroid, like it is used for doping in sport. It increases performance, and may lead to increased energy and wellbeing, but it can also have some pretty awful side-effects in some people, and it has longer-term risks, which is one reason why it is banned as a performance-enhancing substance in athletes.”
Dr Stephanie Faubion, a medical director for the North American Menopause Society, said: “The fact that you can get it with really no input from a provider at all is frightening. The bigger concern is that nobody is really looking at the big picture for these women. Women may be looking at testosterone to solve something that it will never solve, when it could be addressed in a different way by a medical professional seeing them in person.”
A spokesperson for Superdrug Online Doctor said its testosterone service was aimed at peri- and post-menopausal women with distressing low libido or sexual interest/arousal disorder who have not responded to oestrogen-based HRT, and all its doctors were trained in providing remote online consultations and prescriptions. They said: “We are able to verify the diagnosis by asking a series of specific questions about sexual interest and arousal … in the same way that any clinician seeing a patient face to face would do.
“We provide detailed advice to our patients to support accurate and correct dosing regimens of this medication and provide a testosterone blood test service for additional monitoring if they are unable to get this done elsewhere. Blood tests are required before starting treatment, and at regular intervals during treatment.”
Superdrug added that patients must confirm the truthfulness of the medical information they submit. “Misrepresentation of health information to obtain treatment is not only a breach of our terms but it can result in harm,” they said.
Not everyone thinks the availability of testosterone from online clinics is a bad thing. Dr Nighat Arif, a GP with a specialist interest in women’s health who has posted a variety of content on social media discussing the wider benefits of testosterone, said: “At the end of the day, you are using some hormone to replace what you feel is necessary to have replaced back to you.
“If you’ve done a blood test and you try it for six months to a year, it’s not the end of the world. If it works and you’ve spent some money privately, that’s fine – just make sure that you’re seeing a clinician or dealing with clinician who is getting your blood monitoring done.”
Arif prescribes testosterone to female patients in accordance with National Institute for Health and Care Excellence guidance, which says it can be considered for menopausal women with low sexual desire if conventional oestrogen and progesterone-based hormone replacement therapy alone is not effective.
Not all her patients report an improvement. “I’d say about 20% come back and say ‘I haven’t noticed any difference whatsoever’; about 30 to 40% say ‘I’ve noticed some difference but the days that I missed it I didn’t really notice much’; and the rest say ‘it was the bit that I needed; I got my energy levels back and I managed to get my sexual drive back as well’.”
But Davis, who has been studying the effects of testosterone in women for several decades, cautioned that perceived improvements in energy levels could be a placebo effect. She said: “I used to believe that testosterone improved wellbeing and energy, because my patients would come in and say ‘I feel great’, but when we did placebo-controlled trials we didn’t see it. Women would report feeling more energetic and that their fatigue was better, but the placebo was just as good. The placebo effect is huge, but it doesn’t last.”
Even for libido, the impact is usually not dramatic, she said.
What almost everyone agrees on is that more research is needed into the impact of testosterone on the female body – including whether it can help protect muscle and bone health or cognitive function, as some claim. Here, the data is “just all over the shop”, Davis said.
She is involved in studies to establish whether testosterone benefits bone health and sexual function in younger postmenopausal women (under 55), improves muscle strength in older women, or protects heart health in women at high risk of heart disease.
Davis is also working to understand what “normal” testosterone levels in midlife women look like, and whether this significantly changes at menopause – two other great unknowns.
