Policy on the prescribing of testosterone in perimenopausal and menopausal women

Along with oestrogen, the menopause can cause levels of testosterone to fall. This can cause a low sex drive (libido).

Testosterone is not currently licensed to treat symptoms of menopause, but a specialist doctor may be able to prescribe it for you if HRT has not helped. Your specialist will arrange any investigations you require and will provide ongoing monitoring and prescriptions for the duration of your treatment. We will not be able to prescribe the treatment from the practice or offer monitoring tests.

We can however offer assessment and support to exclude other causes that can contribute to poor libido and we would encourage an ongoing dialogue with us as your GP regarding your menopause. 

Background

NICE menopause guidelines state that testosterone gels can be considered as a supplement to topical HRT in women with ongoing low sexual desire where oestrogen has been fully optimised. The British menopause society (BMS) also support this where HRT alone is not effective. It should only be prescribed in combination with topical HRT as oral oestrogens increase levels of SHBG and thereby reduce the efficacy of testosterone replacement. There is evidence that oestrogen replacement alone can increase clitoral and vaginal sensitivity and increase libido and given that oestrogen is a licensed treatment for menopause this should be optimised first.

Where this has been done and the clinician has made a full assessment to exclude other medical, social and psychological factors it may be appropriate to consider testosterone. However, there are currently no licensed products in the UK for this purpose. The guidelines also state that when discussing treatment with patients it should be noted there is no safety data available beyond 2 years of use.

Where testosterone supplementation is prescribed, the patient should have baseline tests for testosterone, SHBG, lipids, LFTs and an FBC. Baseline testosterone and SHBG are to ensure levels are not high pre-treatment. Lipids have been shown to increase with oral testosterone treatment and there is a dose dependent stimulation of erythropoiesis which increases with patient age. Liver failure is a contraindication.

Women should be reviewed at 3-6 weeks with repeat blood tests and then have annual review including testosterone, lipids and an FBC.

Treatment is contraindicated in active liver disease, hormone sensitive breast cancer, competitive athletes and women with high normal or raised baseline total testosterone levels.

Prescribing unlicensed medications

GMC guidance states that in order to prescribe an unlicensed medication; we as doctors must be satisfied there is sufficient evidence to demonstrate safety and efficacy. We must also take responsibility for prescribing the medication, overseeing patient care, monitoring and follow up treatment or ensure another suitable doctor is in place to do so. This must also be documented in a clear and accurate record as to the reasoning for prescribing an unlicensed medication.

Patients must be given sufficient information about the medication to allow them to make an informed decision about treatment.

Wickham Surgery Policy

After much discussion, the GP partners at Wickham Surgery do not feel the GMC specifications to prescribe off license testosterone therapy have been met based on a lack of safety data beyond two years. We accept that patients may well seek this treatment from specialists with more experience prescribing testosterone off license in this manner however we will not accept shared care prescribing agreements as this infers ongoing liability and responsibility on us in primary care.

Patients receiving prescribed testosterone therapy for menopause/perimenopause will need to remain under the care of a suitable specialist in order to receive ongoing monitoring and prescriptions from their specialist. The GMC are clear that it is the responsibility of the prescriber to arrange appropriate monitoring and this does not form part of the normal remit of primary care.

This policy will be reviewed in the event of new evidence for long-term safety in women prescribed transdermal testosterone supplementation.