Testogel is a testosterone gel licensed for men but increasingly prescribed off-label for postmenopausal women experiencing persistent low sexual desire (hypoactive sexual desire disorder) that has not improved with oestrogen-based hormone replacement therapy. Testosterone levels naturally decline during menopause, and supplementation aims to restore physiological levels within the normal premenopausal female range, thereby improving libido and reducing distress. This article explains how to use Testogel safely for menopause, including application technique, dosing considerations, potential side effects, and the importance of specialist monitoring. Off-label use requires careful counselling, individualised dosing, and regular follow-up to ensure safety and effectiveness.

What Is Testogel and How Does It Work for Menopause?

Testogel is a transdermal testosterone gel licensed in the UK for testosterone replacement in men with hypogonadism. It is increasingly prescribed off-label for postmenopausal women experiencing hypoactive sexual desire disorder (HSDD)—persistent low sexual desire causing distress—when adequate oestrogen-based hormone replacement therapy (HRT) has not fully resolved this symptom and other causes have been excluded.

Testosterone is an androgen hormone produced naturally by the ovaries and adrenal glands in women, in much smaller quantities than in men. During and after menopause, testosterone levels decline alongside oestrogen and progesterone. This reduction can contribute to low sexual desire. Testosterone supplementation aims to restore physiological levels within the normal premenopausal female range, thereby improving sexual desire and reducing associated distress.

The mechanism of action involves testosterone binding to androgen receptors in various tissues, including the brain and reproductive organs, influencing neurotransmitter activity related to libido. NICE guidance (NG23) and the British Menopause Society (BMS) recognise testosterone as a treatment option for HSDD in postmenopausal women, provided oestrogen-based HRT has been optimised, biopsychosocial causes (such as relationship issues, depression, or medication side effects) have been addressed, and the woman has been fully counselled about off-label use.

Evidence for benefits beyond sexual desire—such as improvements in energy, mood, cognition, or bone density—is currently insufficient, and testosterone should not be prescribed for these indications alone. Improvements in sexual desire typically become apparent within 6–8 weeks, though a trial of up to 6 months is recommended; if there is no meaningful benefit by then, treatment should be discontinued.

It is important to note that Testogel is not licensed for use in women, so prescribing it for menopause constitutes off-label use. Women considering testosterone therapy should have a thorough discussion with a specialist menopause clinician or endocrinologist. Transdermal oestrogen is preferred over oral oestrogen when adding testosterone, as oral oestrogen raises sex hormone-binding globulin (SHBG), which can reduce the effectiveness of testosterone therapy.

How to Apply Testogel Safely During Menopause

Applying Testogel correctly is essential to ensure effective absorption, minimise side effects, and prevent unintended transfer to others. Women require a much lower dose than men. A typical starting dose for off-label use in women is approximately 5 mg of testosterone daily (roughly one-tenth of a 50 mg Testogel 1% sachet), with careful titration based on symptoms and blood testosterone levels. Your prescribing clinician will provide precise, individualised instructions, including how to measure the dose accurately.

Product-specific considerations are important. Testogel 1% sachets (50 mg per 5 g sachet) allow for more accurate measurement of small doses and may be applied to the shoulders, upper arms, or lower abdomen. Testogel 16.2 mg/g pump delivers larger, fixed doses per actuation and is more difficult to use for the very small doses required by women; if this formulation is prescribed, application is restricted to the shoulders and upper arms only as per the Summary of Product Characteristics (SmPC). Your clinician and pharmacist will advise on the most suitable product and measuring technique.

Application technique should be followed carefully:

• Choose a clean, dry area of skin on the shoulders, upper arms, or (if using Testogel 1% sachets) lower abdomen. Avoid broken, irritated, or recently shaved skin.

• Wash and dry your hands before opening the sachet or using the pump.

• Measure and apply the prescribed amount as directed by your clinician. Spread the gel thinly and evenly over the designated area. Do not rub vigorously; gentle application is sufficient.

• Allow the gel to dry completely (usually 3–5 minutes) before dressing. The gel is flammable until dry—avoid smoking, naked flames, or other ignition sources during this time.

• Wash your hands thoroughly with soap and water immediately after application.

Timing and consistency matter. Apply Testogel at the same time each day, ideally in the morning. Avoid swimming, bathing, or heavy sweating for at least two hours after application to ensure adequate absorption.

Preventing transfer is critical, especially to children and partners. Once the gel is dry, cover the application site with clothing. Avoid direct skin-to-skin contact on the treated area for at least two hours, or wash the site with soap and water before close contact. If accidental contact occurs, the other person should wash the affected area promptly with soap and water. Do not apply Testogel to the breasts or genital area.

For perimenopausal women, effective contraception is essential, as testosterone is harmful to a developing baby and pregnancy is an absolute contraindication.

Potential Side Effects and Risks of Testogel in Menopause

While many women tolerate testosterone therapy well at appropriate doses, it is important to be aware of potential side effects and risks. Common adverse effects include:

• Skin reactions at the application site, such as redness, itching, or irritation

• Acne or oily skin, particularly on the face, chest, or back

• Increased body or facial hair growth (hirsutism), which may be distressing

• Voice deepening, though rare at low doses; this change may be irreversible if it occurs

• Mood changes, including irritability, though some women report improved mood

These effects are generally dose-dependent. Irreversible virilisation (development of male characteristics, such as voice deepening or clitoral enlargement) is a concern if testosterone levels become excessively elevated, underscoring the importance of careful dosing and monitoring. If you develop signs of virilisation, stop using Testogel and contact your clinician promptly, as these changes may not reverse.

Cardiovascular and metabolic risks remain an area of ongoing research. Short-term data at physiological female doses do not show increased cardiovascular events, but long-term safety data in women remain limited. Caution is advised in those with pre-existing heart disease, hypertension, or dyslipidaemia. Testosterone may influence lipid profiles, so monitoring is prudent based on individual cardiovascular risk.

Liver function should be assessed if clinically indicated, as testosterone is metabolised by the liver. Women with liver disease should use testosterone with caution. There is no conclusive evidence linking testosterone therapy at physiological doses to breast or endometrial cancer, but long-term data are limited.

Contraindications include pregnancy (testosterone is teratogenic), breastfeeding, hormone-sensitive cancers (unless under specialist guidance), and severe liver or kidney disease. Women should inform their GP or specialist of any new symptoms, particularly signs of virilisation, chest pain, severe headache, visual disturbances, or unexplained leg swelling. If you experience chest pain, severe headache, visual disturbances, or leg swelling, seek urgent medical attention, as these may indicate serious complications.

If side effects are troublesome or concerning, contact your prescribing clinician for advice on dose adjustment or discontinuation. You can report suspected side effects via the MHRA Yellow Card scheme at yellowcard.mhra.gov.uk or through the Yellow Card app.

Monitoring and Follow-Up Care When Using Testogel

Regular monitoring is essential to ensure testosterone therapy remains safe and effective. Baseline assessments before starting Testogel should include:

• Serum total testosterone level, ideally measured in the morning

• Sex hormone-binding globulin (SHBG) and calculation of the free androgen index (FAI) may be considered if clinically indicated

• Blood pressure and cardiovascular risk assessment

Additional tests such as full blood count, lipid profile, and liver function tests may be arranged based on individual clinical indications or comorbidities, but are not routinely required for all women starting low-dose transdermal testosterone. Your clinician may also assess symptoms using validated questionnaires to establish a baseline for sexual desire and distress.

Laboratory considerations: Testosterone assays can be unreliable at low female levels. Where available, liquid chromatography-tandem mass spectrometry (LC-MS/MS) is preferred for accuracy. Use the same laboratory for consistency throughout monitoring.

Follow-up appointments are typically scheduled at 3–6 weeks after starting treatment or after any dose change, then every 6–12 months once stable, depending on individual response and risk factors. At each visit, your clinician will:

• Review symptoms and assess treatment efficacy—improvements in sexual desire and reduction in distress should be evident within 6–8 weeks, with a full trial of up to 6 months

• Measure serum total testosterone levels to ensure they remain within the normal premenopausal female reference range for your laboratory, without exceeding the upper limit of normal

• Check for signs of virilisation, such as voice changes, excessive hair growth, or clitoral enlargement

• Repeat blood tests (if clinically indicated) to detect any adverse metabolic or haematological changes

• Monitor blood pressure and cardiovascular health based on individual risk

Dose adjustments may be necessary based on symptom response and testosterone levels. If levels exceed the upper limit of the normal female range, the dose should be reduced to minimise virilisation risk. Conversely, if symptoms persist and levels are suboptimal, a cautious dose increase may be considered. If there is no meaningful improvement in sexual desire or distress by 6 months, testosterone therapy should be discontinued.

Patient self-monitoring is also important. Women should report any new or worsening symptoms promptly, including signs of virilisation, mood disturbances, skin changes, or signs of fluid retention.

Testosterone therapy is not suitable for everyone, and ongoing assessment ensures it remains appropriate. If you are taking oral oestrogen, be aware that it raises SHBG and may reduce the effectiveness of testosterone; switching to transdermal oestrogen may be considered. Shared decision-making and open communication with your healthcare team are key to optimising outcomes and maintaining safety throughout treatment.

Frequently Asked Questions