UK Menopause Body Updates Testosterone Prescribing Guide

Key Takeaways: The British Menopause Society (BMS) released an updated clinician tool, "Testosterone replacement in menopause," reviewed May 2026 and authored by Professor Nick Panay, forming Chapter 17 of the BMS Management of the Menopause 7th edition. It keeps the supported indication narrow -- hypoactive sexual desire disorder (HSDD) only, after a biopsychosocial assessment and a trial of conventional HRT -- and states plainly that randomized trials still do not support testosterone for cognition, mood, energy, or musculoskeletal health. It also gives concrete UK off-label starting doses (Tostran 10 mg on alternate days; Testogel approximately 5 mg/day; AndroFeme 5 mg/day), names total testosterone by mass spectrometry as the monitoring test, and explicitly tells clinicians to stop using the Free Androgen Index and free testosterone assays. A 1% testosterone cream is now licensed for women in the UK, Australia, New Zealand, and South Africa, with a UK pump-pack launch hoped for in 2026.

What the BMS Updated

The British Menopause Society is the UK's leading professional body for menopause clinicians. Its Tools for Clinicians are short, practical prescribing guides that translate the evidence into day-to-day decisions for GPs and specialists. The testosterone tool was reviewed in May 2026 and now sits inside the BMS Management of the Menopause 7th edition (2026) as Chapter 17, "The role of androgen therapy in women." The author is Professor Nick Panay, one of the architects of the 2019 Global Consensus Position Statement on testosterone in women.

The principles are not new. What is new is the precision: this version pins down the doses, names the monitoring test, tells clinicians which tests to abandon, and flags a regulatory milestone -- the arrival of a licensed testosterone cream for women in the UK.

For anyone navigating women's testosterone -- whether through the NHS, a UK private clinic, or a US telehealth platform -- this tool is one of the clearest statements of what guideline-aligned care actually looks like.

The Indication Stays Narrow: HSDD Only

The BMS position is unambiguous. Testosterone in women is supported only for hypoactive sexual desire disorder (HSDD) -- distressing low sexual desire -- and only after two gates are cleared:

1. A biopsychosocial assessment to exclude other causes of low desire, including relationship factors, psychological causes, and medication effects (SSRIs and SNRIs are named explicitly).
2. A trial of conventional HRT first. The tool cites NICE Guideline NG23 and BMS guidance that estrogen-based HRT should be optimized before testosterone is added.

A key mechanistic point the tool makes: oral estrogens, especially conjugated estrogens, raise sex hormone binding globulin (SHBG) and can blunt testosterone's effect. Simply switching a woman from oral to transdermal estrogen can raise free testosterone enough to help desire without adding any testosterone at all. This is the kind of practical lever that distinguishes evidence-aligned prescribing from reflexively reaching for a testosterone script.

The tool also insists that genitourinary symptoms be treated in parallel -- vaginal estrogen for dryness and painful intercourse -- so that a desire problem is not actually a pain-avoidance problem in disguise. See the vaginal estrogen GSM guide for how that fits alongside systemic hormone therapy.

"No Demonstrated Benefit" for Energy, Mood, Cognition, or Muscle

This is the line that will land hardest against the current wellness narrative. The BMS tool states directly:

"Randomised clinical trials of testosterone to date have not demonstrated the beneficial effects of testosterone therapy for cognition, mood, energy and musculoskeletal health."

It acknowledges that some individuals report improvement in these areas, and it calls for better-designed studies with these symptoms as primary outcome measures rather than secondary observations. It then points to the trial built to do exactly that.

The ESTEEM Trial

The BMS highlights the NIHR-funded ESTEEM trial -- "Evaluating the clinical and cost-effectiveness of Testosterone to improve Menopause-related quality of life" -- run from Cardiff University. ESTEEM is randomizing 400+ menopausal women to testosterone or placebo, with menopause-specific quality of life (MENQOL) as the primary outcome, measured at 3, 6, and 12 months. Women can self-refer or enroll through their GP. The trial runs to roughly 2028.

This matters because it is the first large randomized trial designed to test whether testosterone helps menopausal women beyond libido -- the exact claim that drives much of the direct-to-consumer market. Until ESTEEM and trials like it report, the BMS says the primary indication should remain HSDD.

This is the same evidentiary line drawn by The Menopause Society's position that there is no justification beyond HSDD and by the broader women's testosterone cardiovascular safety review. Three major bodies, on three continents, converge on the same standard.

The Concrete Doses: Tostran, Testogel, AndroFeme

Because there is no widely available product designed and dosed for women in most of the world, UK clinicians down-titrate male products to roughly one-tenth of the male dose. The tool lists the commonly used options with starting doses:

Product	Formulation	Female starting dose	How long it lasts
Tostran	2% testosterone gel, 60 g canister	1 pump (0.5 g) = 10 mg on alternate days	~240 days per canister
Testogel	2.5 g sachet, 40.5 mg (new formulation)	1/8 sachet/day = ~5 mg/day	~8 days per sachet
AndroFeme	1% cream, 10 mg/ml, 50 ml tube	0.5 ml/day = 5 mg/day	~100 days per tube
Testosterone implants	100 mg pellets (imported)	--	Currently unavailable in UK (QC recall)

A few important caveats the tool attaches to these numbers:

• Oral testosterone is not recommended -- it is hard to monitor and can cause adverse lipid effects.
• Compounded bioidentical testosterone is not recommended by regulators or menopause societies.
• Tibolone is weakly androgenic and is an oral option for some, but is often not sufficiently androgenic or estrogenic, and its progestogenic effect is unnecessary (and potentially harmful) in women without a uterus.
• Application technique matters: apply gel or cream to clean, dry skin on the lower abdomen or upper thighs, let it dry before dressing, wash hands immediately, avoid skin contact with partners or children until dry, don't wash the area for 2-3 hours, and rotate the application site to avoid local hair growth.

These figures are UK off-label practice. They are useful as a reality check on what physiologic dosing looks like, but the right dose for any individual is set by a prescriber against labs and response. For a fuller route-by-route breakdown, see the women's testosterone dosage guide, testosterone cream for women, and testosterone gel for women.

Stop Using the Free Androgen Index

One of the most actionable shifts in this tool is what it tells clinicians not to measure. Many women on testosterone -- especially in the US telehealth market -- are tracked with "free T" or a calculated Free Androgen Index (FAI). The BMS pushes back:

• Total testosterone, ideally by LC-MS/MS, is the recommended monitoring test. It "provides a more accurate representation of therapeutic response than free testosterone or the calculated Free Androgen Index."
• Free testosterone assays are not recommended because their correlation with biological activity "has not been confirmed."
• The FAI may not accurately reflect the testosterone actually available to activate receptors, because some protein-bound testosterone is bioavailable and not all free testosterone is biologically active.

So how should a clinician judge a dose? Primarily clinically -- did HSDD improve, and are there androgenic side effects (acne, excess hair)? -- with total testosterone kept inside the female physiologic reference range as support.

SHBG still earns a role in two specific situations:

• High SHBG (often from oral estrogen) can explain a poor response despite a normal total testosterone -- a cue to switch to transdermal estrogen.
• Very low SHBG can explain androgenic side effects despite a normal total testosterone -- a cue to lower the dose.

This is a meaningful contrast with how testosterone is monitored in men, where free testosterone and the Vermeulen calculation are central. The female protocol is simpler on paper -- total T plus clinical response -- but demands a prescriber who knows the female reference range and isn't chasing a "free T" number.

Monitoring Schedule and Safety

The tool lays out a straightforward monitoring rhythm:

• Before starting: check total testosterone to set a baseline and rule out an already-high level. Avoid testosterone in women with upper-normal or high baseline levels.
• At 2-3 months: recheck (some guidelines say 3-6 weeks; the BMS treats that as aspirational given NHS review timelines).
• Every 6-12 months thereafter: confirm levels stay in the female physiologic range.
• Efficacy timeline: allow 3-6 months to judge whether it's working.
• Annual review: reassess ongoing use, weighing benefits and risks like any HRT.

Notably, routine FBC and lipid monitoring is not required at female doses -- a contrast with male testosterone therapy, where hematocrit surveillance is essential because of polycythemia risk.

On safety, the tool calls adverse effects "uncommon if levels are maintained within the female physiological range." The most common are excess hair growth, acne, and weight gain -- usually reversible with dose reduction. Voice deepening, scalp hair loss, and clitoral enlargement are described as rare at physiologic doses. Longer-term cardiovascular and breast-cancer data remain limited, but short-term randomized and meta-analysis data are described as reassuring. Testosterone should be avoided or used with caution in pregnancy or breastfeeding, active liver disease, a history of hormone-sensitive breast cancer, and competitive athletes.

The Licensing Milestone

For decades the central problem in women's testosterone has been the absence of a product designed, dosed, and licensed for women. The BMS tool flags a real shift: 1% testosterone cream is now licensed for women in Australia, New Zealand, South Africa, and the UK. AndroFeme has been imported to the UK under special MHRA license, and full UK marketing authorization was made contingent on the product becoming available as a pump pack -- hoped for in 2026.

The BMS frames this as an encouraging precedent and hopes regulators elsewhere follow, noting the large body of efficacy and safety data that already exists. It is candid that part of the licensing gap reflects "the reluctance of the pharmaceutical industry thus far to finance further clinical studies."

In the US, there is still no FDA-approved testosterone product for women, but the regulatory picture is moving: a Phase 3 metered-dose transdermal product for HSDD is advancing, the FDA has signaled a development pathway for testosterone in women, and the removal of HRT black-box warnings has shifted the broader environment.

What This Means If You're Considering Testosterone

The BMS tool is a useful checklist for evaluating any prescriber, NHS or private, UK or US telehealth:

1. Is the indication HSDD -- distressing low desire -- or is the clinic selling testosterone for fatigue and brain fog? The evidence supports the first; the second is exploratory at best.
2. Did they optimize estrogen first? Switching oral to transdermal estrogen can fix desire without testosterone at all.
3. Are they monitoring total testosterone (ideally LC-MS/MS), not chasing a "free T" or FAI number?
4. Is the dose physiologic -- in the range of Tostran 10 mg alternate days, Testogel ~5 mg/day, or AndroFeme 5 mg/day -- and titrated to keep total T in the female range?
5. Is there a baseline lab, a 2-3 month recheck, and an annual review -- with a willingness to stop if there's no benefit at 3-6 months?

A clinic that handles these well is practicing guideline-aligned care. One that prescribes fixed-dose testosterone for nonspecific symptoms without baseline labs or follow-up is operating ahead of the evidence.

Compare HRT and TRT Clinics

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Related Reading

• Menopause Society: No Testosterone Justification Beyond HSDD -- the US counterpart position the BMS tool echoes
• Acrux Female Testosterone Phase 3 HSDD Trial -- the regulatory pathway toward a US-approved women's product
• Testosterone for Women Complete Guide -- the broader clinical picture
• Women's Testosterone Dosage Guide -- route-by-route dosing detail
• Testosterone Cream for Women -- the formulation closest to AndroFeme
• Vaginal Estrogen and GSM Guide -- the companion treatment the BMS insists on for genitourinary symptoms
• Best Online HRT Clinic for Women -- clinics that match the standards the evidence requires

References

1. British Menopause Society. "Testosterone replacement in menopause." Tool for Clinicians. Reviewed May 2026. Author: Professor Nick Panay in collaboration with the BMS Medical Advisory Council. Part of BMS Management of the Menopause 7th edition (2026), Chapter 17.
2. Islam RM, Bell RJ, Green S, Page MJ, Davis SR. "Safety and efficacy of testosterone for women: a systematic review and meta-analysis of randomised controlled trial data." Lancet Diabetes Endocrinology 2019;7(10):754-766.
3. Davis SR, Baber R, Panay N, et al. "Global Consensus Position Statement on the Use of Testosterone Therapy for Women." Journal of Clinical Endocrinology & Metabolism 2019;104(10):4660-4666.
4. NICE Guideline NG23. "Menopause: identification and management." Last updated 7 November 2024.
5. Cardiff University Centre for Trials Research. ESTEEM trial -- "Evaluating the clinical and cost-effectiveness of Testosterone to improve Menopause-related quality of life." NIHR-funded; primary outcome MENQOL in 400+ women.