For midlife women on social media last week, there was one hot topic of discussion: testosterone.
The ‘male’ sex hormone – also produced at lower levels in women – has fast become the latest buzzword in menopause care.
Drugs containing testosterone have been championed by both private clinics and campaigners such as TV presenter Davina McCall. It’s often described as the ‘missing piece of the jigsaw’, taken alongside standard HRT to restore a woman’s joie de vivre in middle age.
Facebook and Instagram accounts of self-styled menopause specialists with thousands of followers are filled with similar claims.
Topping up testosterone levels can transform a woman’s flagging libido, they say, banish brain fog, and improve energy and mood. In the longer term, advocates add, it could even stave off dementia, improve bone strength and maintain muscle mass. Such statements have thrust testosterone into the spotlight as another hormone which – like oestrogen and progesterone – should be replaced as levels decline with age.
Drugs containing testosterone have been championed by both private clinics and campaigners such as TV presenter Davina McCall (pictured)
Last week, figures revealed how powerful the so-called ‘Davina effect’ has been. NHS prescriptions for testosterone gels have rocketed ten-fold in the last seven years, with a significant uptick following the airing of Davina McCall’s documentary on the subject.
The data, from a Freedom of Information request by the Pharmaceutical Journal, revealed 4,675 women over 50 were prescribed testosterone in November 2022 alone – up from 429 in November 2015. The same pattern was true for women aged 49 and under.
But experts have pointed out these figures are only the tip of an iceberg. GPs remain cautious about prescribing the hormone – partly because there is no licensed testosterone drug specifically for women in the UK.
Far more patients are thought to get it privately, at a significant personal cost, from private doctors: the same doctors who are extolling its benefits the loudest. It means the true number of women taking it remains unknown, but it could run to more than 100,000.
Speaking to The Mail on Sunday, doctors and scientists say there is no evidence to justify most of the claims regarding testosterone.
Women are being exploited, they argue, by those who say the hormone gels are ‘the answer’ to their menopause problems.
They warn that, without appropriate supervision, patients could end up taking the hormone when they don’t need it, or taking too much – risking a wide range of side effects including acne, excess hair growth, greasy skin and even voice changes. They also warn of a condition called clitoromegaly, which causes the clitoris to become permanently enlarged.
Hormone specialist Dr Annice Mukherjee said: ‘Women are being hood winked to some extent. Testosterone is a trend, driven by social media, which promises a one-size-fits-all approach to the menopause which is simply not the reality. When the right women get it, it’s transformational. When the wrong women get it, it can cause harm.
‘Some are struggling to feed their families during a cost-of-living crisis, and are being rightly told by their GP they don’t need testosterone. Yet they feel they’re being deceived because of what they’ve heard online. Many pay hundreds of pounds a year privately for it.
‘I’ve never seen so much confusion and distress among women because they feel they can’t get hold of what they think they need. It is so wrong.’
It’s been two years since The Mail on Sunday became one of the first newspapers to question whether more women should be given testosterone during menopause.
Then, campaigners, doctors and women spoke about the profound benefits of taking the hormone, particularly if – after starting standard HRT – they were left with symptoms including low libido, low mood and brain fog.
One was Haitham Hamoda, then-chair of the British Menopause Society, who called for more women to be given access to the hormone. But Dr Mukherjee says the pendulum ‘has now swung too far in the opposite direction’ – and too many women are being led to believe they need the medication but are unlikely to benefit.
‘Some private clinics seem to be giving it to every patient,’ she says. ‘That’s a concern.’
In men, testosterone is involved in muscle and bone growth at puberty, and, in adulthood, for the development of secondary sexual characteristics such as body and facial hair and sperm production.
As women don’t produce as much, they don’t develop these ‘male’ characteristics. However, the hormone also increases levels of dopamine in the body, a chemical messenger crucial to brain health and which plays a role in pleasure, concentration and decision-making.
INFLUENCER: Davina McCall shows her 1.6million Instagram followers how she uses testosterone cream
Testosterone levels in women change throughout life, during the menstrual cycle, and even fluctuate throughout the day – but are thought to decline around the time of the menopause.
The best evidence on the role the hormone plays in menopause comes from clinical trials into testosterone drugs, which have shown the medication can improve sex drive.
That’s why guidelines from NHS watchdog the National Institute for Health and Care Excellence (NICE) recommend that if women still have a low libido after starting HRT they may benefit from a testosterone gel.
No product specifically for women is licensed in the UK, but Androfeme – an Australian product designed for women – is available privately. Doctors can also prescribe smaller doses of male products such as Testogel or Tostran.
Former president of the International Menopause Society Susan Davis, professor of women’s health at Monash University in Melbourne, carried out a review of the highest quality trials which was published in The Lancet in 2019.
‘The evidence that testosterone may improve sexual interest and reduce any distress associated with that, is irrefutable,’ she says.
But the review also found there was not enough evidence to recommend testosterone for any other reason. Studies have looked at whether it can improve cognition and bone health, reduce muscle wastage and boost mood, with several published since 2019.
‘In all cases – apart from libido – the data is unreliable and shows no benefit,’ says Prof Davis.
‘There’s enough data on general wellbeing to say there’s no benefit to mood. A trial looking at women with major depression found no evidence of benefits.’
She adds: ‘For cognitive function, bone and muscle, which we’re particularly interested in, the available data consistently shows no evidence of benefit from clinical trials or from observational studies.
‘At the moment, on this evidence base, you’d be prescribing [for these reasons] on a whim. It’s misleading to suggest there are other benefits. We have no idea.’
Yet Dr Paula Briggs, chair of the British Menopause Society, and sexual and reproductive health consultant, says ‘around half’ of the women coming to her NHS clinics do so because they want testosterone.
Many have been ‘coached’ in what to say to get a prescription.
Dr Briggs says: ‘If a woman doesn’t say her libido is poor, then going by the NICE guidelines I can’t prescribe. Women are sharing information that testosterone helps with all kinds of problems, and coaching each other to say they have low libido, even if they don’t, in order to get the medication. That’s not fair for patients who may not see the benefits they’re promised.’
One menopause campaigner illustrated this perfectly when she posted on Twitter last week: ‘Women only say they want testosterone for libido because they know their GPs won’t give it to them if they say it’s for menopause lethargy. We’re not stupid.’
Best practice means doctors should first rule out other potential causes of low libido such as depression or relationship problems. Women should then have a blood test to measure their testosterone levels. This is not to see if they are low, but to make sure they are not already high before the hormone treatment is started, as topping up high levels can lead to side effects.
‘Looking at levels in general doesn’t always correlate with symptoms,’ Dr Briggs explains. ‘You could line up ten women, with ten different results, and the ones with the lowest testosterone might have the best sex drive.
‘It’s complicated. The main thing is you don’t want to give them too much.’
She will give patients a low dose if they meet the criteria. ‘It might make things better,’ she says. ‘We do another blood test at six weeks when I’d expect testosterone to shift to the upper end of the normal range. After six months, if there’s no benefit, it should stop.’
Several doctors who spoke to the MoS said they knew GPs who had been ‘threatened’ by patients if they refused to prescribe testosterone. Dr Mukherjee said: ‘Some patients are telling GPs they’ll sue if they won’t prescribe. Some come to my clinic and complain their GPs are useless. I tell them to question social media, not their doctor.’
On Facebook forums, dozens of women claim their mood improved ‘within days’ of starting testosterone. But Prof Davis argues this is largely a placebo effect.
‘In the trials, the effects of libido start to kick in at around four weeks, and peak at three months,’ she says.
‘Anything earlier is going to be placebo. If you’ve got charismatic private doctors telling women testosterone is going to make them feel better, initially they will. And they’re paying a lot of money to feel better.’
Dr Mukherjee agrees: ‘Women will immediately feel a benefit as they feel empowered after getting the treatment. That is a powerful boost for your mental health.’
The other big concern is that patients may take too much. Public health specialist Dr Ash Paul warns women are often not properly supervised after getting their prescription, and may increase their dose if they don’t see an effect. Dr Briggs recalled one patient who confessed she’d been taking nearly a week’s worth every day.
Also on the forums, women discuss experimenting with their dosage. One described how she had turned into a ‘horny teenager’ after bumping up the prescribed amount when she failed to see a benefit after just a few days.
Another complained her GP wanted her to stop taking testosterone because her levels were too high – while a private doctor told her it was ‘fine’ to continue if she wasn’t experiencing side effects.
Experts say as long as testosterone remains within the normal range – equivalent to a normal level pre-menopause – there is nothing to worry about. But known side effects of too much include acne, greasy skin, headaches, changes in mood and excess hair.
In trials, women experiencing these issues did not generally drop out, says Prof Davis, suggesting they weren’t severe. More serious issues include male pattern baldness: losing hair from the head, but gaining it elsewhere. It can also cause the voice to become deeper and more masculine.
Dr Mukherjee describes seeing one patient – a professional singer – whose career was in jeopardy when her voice ‘became croaky’ after being prescribed testosterone by a private doctor.
‘No one was monitoring her levels, even though it was noted as high the previous year,’ she adds.
There are also questions over the effect of testosterone on the heart. It is known that men who take anabolic steroids – which include testosterone – to increase muscle mass are more likely to suffer heart disease and strokes.
Dr Briggs says: ‘If you use too much [testosterone] it’s just like taking an anabolic steroid.’
Experts agree more research is needed. Prof Davis is set to start several big studies investigating if giving testosterone in menopause can affect muscle wastage, bone strength and cognitive function.
But in the meantime, experts say there also needs to be more oversight of an industry which has spiralled out of control.
‘We have to put the brakes on,’ says Dr Briggs. ‘I’ve heard that testosterone is the missing piece of the jigsaw. But it’s not.’