Testosterone and desire: where NICE, the BMS and the global consensus sit

Testosterone is the only hormonal option with a guideline footprint for low sexual desire in women — and the one most often prescribed outside its evidence base. This page sets out where the guidance actually sits.

The one evidence-based indication

The 2019 Global Consensus Position Statement — endorsed by the International Menopause Society, the Endocrine Society, the International Society for Sexual Medicine, ISSWSH, the Royal College of Obstetricians and Gynaecologists and others — concluded that the only evidence-based indication for testosterone therapy in women is postmenopausal women with HSDD, after a full biopsychosocial assessment (Davis et al., 2019). It found insufficient evidence to support use for any other symptom or condition, including mood, cognition, bone or general wellbeing, and insufficient data in premenopausal women.

NICE

NICE NG23 advises clinicians to consider testosterone supplementation for menopausal women with low sexual desire if HRT alone is not effective. The sequence matters: HRT first, then testosterone as an addition, not a replacement.

British Menopause Society

The BMS Tool for Clinicians on testosterone replacement in menopause (reviewed May 2026) states that testosterone should only be considered in women who complain of low sexual desire after a biopsychosocial approach has excluded other causes, and notes that a female-specific 1% testosterone cream has now been licensed in the UK, alongside Australia, New Zealand and South Africa. Historically, UK prescribing relied on off-label use of products licensed for men at a fraction of the male dose; a licensed female preparation changes the prescribing conversation and the documentation required.

Before starting

• Confirm the indication: postmenopausal, distressing low desire, biopsychosocial screen completed, on adequate oestrogen replacement where indicated.
• Baseline total testosterone (and SHBG to calculate a free androgen index where your lab supports it) — to exclude a woman who is already in the upper range, not to diagnose HSDD. A low baseline does not predict response.
• Discuss expectations: the aim is physiological premenopausal concentrations; response is modest and takes weeks to months; a proportion will not respond.

Monitoring

Repeat total testosterone at around three to six weeks (or per local protocol) and at six months; the target is to keep levels within the physiological female range. If there is no clinically meaningful benefit at six months, stop. Ask about acne, hirsutism and hair changes at the application site; supraphysiological levels and virilising effects are the signals to stop or reduce.

The common errors

1. Prescribing testosterone for low desire in a woman whose antidepressant, pain or relationship is the driver.
2. Prescribing it as a first-line agent before oestrogen replacement in a symptomatic menopausal woman.
3. Treating a "low" testosterone level in a woman with no distress.
4. Continuing indefinitely without a six-month review.
5. Extrapolating to premenopausal women, where the consensus finds insufficient evidence.

Where this pathway sits

The Desire Clinic's assessment covers the full range of options — psychosexual, hormonal and, where a clinician judges it appropriate, other pharmacological routes — and applies the guidance above. Menopausal status, prior HRT and the biopsychosocial screen determine which options are relevant for an individual woman; that is a clinical decision made in the consultation.

Reflective learning

1. How does your practice document the rationale for testosterone in women, and does it capture the baseline level and six-month review?
2. What proportion of your testosterone prescriptions in women follow an HRT trial, as NG23 sequences it?
3. A 44-year-old with regular cycles asks for testosterone "for libido". What does the consensus say, and how do you explain it?

References

• Davis SR et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. J Clin Endocrinol Metab 2019;104:4660–6. doi:10.1210/jc.2019-01603
• NICE NG23. Menopause: identification and management. https://www.nice.org.uk/guidance/ng23
• British Menopause Society. Tool for Clinicians: Testosterone replacement in menopause (reviewed May 2026). https://thebms.org.uk