PAD Refills

Transdermal testosterone for hypoactive sexual desire disorder (HSDD)

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The BC Provincial Academic Detailing (PAD) service’s topic Medications for menopause-associated vasomotor and genitourinary symptoms delivers evidence and practical drug information for the most commonly prescribed estrogen and progestogen products (oral, transdermal, vaginal).¹ Visit www.bcpad.ca to book a session with an academic detailing pharmacist in your area. We received this question during PAD sessions: What is the role of transdermal testosterone in menopause?

Basics^2-4

HSDD is a persistent or recurrent deficiency or absence of sexual fantasies and desire for sexual activity with marked personal distress or interpersonal difficulty not otherwise accounted for by a general medical or psychiatric condition (DSM IV-TR). Canadian menopause guidelines identify off-label use of transdermal testosterone gel as an option for postmenopausal women who are distressed by decreased sexual desire where the evidence supports a small benefit on average in this population.

Evidence and role for transdermal testosterone for HSDD^4-8

Trials using a transdermal patch contribute most of the evidence. Applicability of the evidence to testosterone gel is unclear.

Current evidence does not support its use for improving body composition, reducing fracture risk, improving cognitive functioning or mood. Menopause alone is not an indication for testosterone replacement therapy and there is no established androgen deficiency associated with menopause.

Contraindications include the following: pregnancy (effective contraception recommended if prescribed to someone with child-bearing potential), severe acne, hirsutism, androgenic alopecia, high baseline testosterone levels. At the doses studied for HSDD, androgenic adverse events include acne ~8% of participants and increased hair growth in ~9% of participants. There is an absence of published long-term safety trials.

Off-label dosing and monitoring recommendations^3,6,7,10-12

Current off-label dosing recommendations vary. They are largely informed by expert opinion and extrapolated from a testosterone 1% cream, approved in Australia. It is not clear if the testosterone 1% gel available in Canada is bioequivalent to the cream.

Initial dose		How to measure using 10 mg/mL (1%) gel		Max dose
2.5 mg	once a day*	0.25 mL	Transfer gel from sachet or pump to a measuring syringe	10 mg
5 mg		0.5 mL		10 mg
6.25 mg		½ pump using Androgel metered-dose pump		6.25 mg
*Application sites: back of calf, upper outer thigh or buttock; not for vulvovaginal use

Laboratory monitoring is recommended to assess for potential overtreatment:^3,5,6

• Baseline total testosterone and sex hormone binding globulin (SHBG)
• Follow-up 3-6 weeks after initiating and every 6 months thereafter (total testosterone should not exceed 2.8 nmol/L)
• Decrease dose if signs of androgen excess or if total testosterone elevated
• Discontinue after 6 months if no therapeutic benefit

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¹BC PAD Service Medications for Menopause-Associated Vasomotor and Genitourinary Symptoms (May 2025); ²American Psychiatric Association DSM-IV; ³Society of Obstetricians and Gynaecologists of Canada JOGC 2021 (PMID:34649681); ⁴Islam Lancet Diabetes Endocrinol 2019 (PMID:31353194); ⁵Wang E Bio Medicine 2025 (PMID:41106025); ⁶Parish J Sex Med 2021 (PMID:33814355); ⁷Davis J Clin Endocrinol Metab 2019 (PMID:31498871); ⁸Menopause Society Sep 2024; ⁹Shames Int J Impot Res 2007 (PMID:16728969); ¹⁰Veterans Affairs Clinical Guidance Mar 2025; ¹¹Therapeutic Goods Administration (Australia) Prescribing Information AndroFeme 1^®; ¹²Gunter The Vajenda Oct 2025