My non-medical opinion.
Sub-Q TC IMO is the best approach for HRT (T) in women. Inexpensive, very effective, easy to administer and control dosing. I have about 12 female clients on prescribed T (creams, pellets and sc inj), and there are a number of others at the gym where I train clients. Dosing should be based on the desired response balanced with side effects and tolerance for side effects. The response (effects and side effects) vary widely with any given dose. You can’t dose based on blood levels, dose based on response and sides. Normal range for women is meaningless and if you treat to simply restore “normal’ it is unlikely you’ll see anything positive changes in libido, energy, mental clarity, menopausal Sx, body comp, etc. You really need supraphysiological to achieve results and that doesn’t mean the patient will end up with a beard as some suggest. Reference Dr Rebecca Glaser’s work, she has numerous publications on the subject esp with pellets and in women that are at risk for or have been treated for breast cancer.
My perspective on various treatments are that pellets are expensive, once inserted should sides develop one has to wait until the pellet is metabolized and that takes 10 – 12 weeks. It may take several rounds to find the optimal dose and that could take a year to figure out. Pellets also yield higher blood levels for the first several weeks and sometimes less than optimal the last several weeks. Metabolism of the pellet also varies. Creams work but absorption varies, intravaginal is the best way to administer. SC inj (27 g ½” insulin) syringe is simple and painless. Steady state is achieved in 6 weeks and dosing can be adjusted quickly if needed.
Testosterone overall is safe in otherwise healthy women, study the FTM trans lit. Decades of use of high doses has not resulted in increased morbidity or mortality from heart disease, stroke or cancer. In fact it may be preventative for breast cancer (see Glaser’s 10 yr study).
The positive effects are increased libido, energy, metabolism, BMD and lean mass, sense of well being and increased confidence/self-esteem, and resolution of menopausal Sx without the need for estrogen. In fact, Sx may be resolved even in women on an aromatase inhibitor that have had BCa. The most common side effects are acne, hair growth, clitoral enlargement and balding and the extent is very individualized. Some women develop sides with very low dosing, others can tolerate blood levels up to 500 ng/dl with few sides. Tolerance to sides is also very individual. Some women love the way they feel on T and are willing to accept some level of virilizing sides, others have one extra hair on their face and they freak out. Acne tends to resolve with time and continuing treatment, this has been observed in the FTM lit. Most other sides, voice change and clitoral enlargement stabilize with time as does hair growth. For some women in a male dominated business environment, the deeper voice sounds more authoritative and works to their benefit. The clitoral enlargement/increased sensitivity (within reason) is generally feared until it happens and then the nuclear orgasms that accompany are game changers for their sex life. Women shave just about every place on their bodies but to have to shave a few hairs off their face it suddenly turns into a crisis. Again depends on tolerance. For some, no big deal, shave or laser it off, for others it is intolerable. The only side that is really bothersome is the hair loss. Depends on genetics, some have issues even at very low doses, others do not at higher doses. For some T results in scalp hair growth (Glaser). All forms of non-methylated testosterone (esters, pellets, cream and oral micronized) should have minimal if any effects on blood lipids, maybe a slight decrease in HDL and not clinically relevant. The remaining labs (LFTs) should be unremarkable.
One female at the gym is on TC 50 mg/5 days (prescribed). Total blood T is about 670 ng/dl and fT about 23, this was 4 days after an inj and 6 months of treatment and 3 years on cream prior to that. Slight change in voice and a little more blond body hair, that’s it. No acne, hair loss, etc. Her physique is impressive for a 25 yr old pro figure competitor let alone at 54 yr old female. Hard as nails, lean and very muscular. BMD 3x normal for a young female. No other sides, labs are fine.
Based on years of observation and the lit that is out there, a good place to start with SC TC is 10 mg twice a week, give it 6 weeks and check blood T and fT using MS/MS/LC. See how the patient feels and watch for sides. I don’t think there is any need to go past a total of 40 – 50 mg/wk total even in women that seem immune to sides. Micro dose so the dosing is split up to avoid spikes in blood conc.
Make sure the patient knows exactly what they are getting into. If they are really fearful of any cosmetic sides, I wouldn’t treat them, not worth the risk.
Regarding sides, 2.5 mg of finasteride is helpful for acne and hair loss to some degree and will not mitigate the positive effects of T, but only in women past child bearing age, no risk of pregnancy, in fact no female that is trying to conceive should be given T. In addition, if erythrocytosis is an issue, make sure the patient is off the finasteride for 4 weeks before donating blood. It happens in women as it does men. Do not use spironolactone for sides, it blocks androgen receptors everywhere and blunts the positive effects of T and has its own set of sides as a diuretic. The rebound coming off SP can last for weeks and is unpleasant.
Bottom line, the response to T in women is very individualized, treat that way. Lastly, I have not seen one issue regarding negative behavioral issues with women on T. If she’s a bitch to begin with, she may be a bigger bitch on T, then again if she feels much better it could go the other way as well.
