If, however, you don't get what you're looking for from estrogen, then it is time to look into supplementing this other important ovarian hormone.
At this point in previous versions of this article, we would suggest that supplementing progesterone before testosterone provides a safer overall hormonal profile of risks. Now that we know more about progestogen risks, especially their links to cancer, we feel that picture is much less clear. Still, all we can do is point out the dangers: it's up to you to weigh what you hope to accomplish and how you choose to get there. If you're thinking about using testosterone to boost libido, we'd like to point out that there are other areas to evaluate in the libido troubleshooting decision tree before you get to that; you might find it useful to have a look at the Sexuality and surgical menopause article to review those steps.
Okay, disclaimers about risk and benefit aside, let's look more closely at supplementing testosterone.
Testosterone supplementation for women is fairly new. Only a decade or two ago, researchers were trumpeting the astonishing news that women produced and had receptors for testosterone. Predictably, a few books were written that claimed everything a woman had wrong with her could be cured with a little testosterone, and if a little was good, a lot was better. Our stance is a lot less glamorous, but may be more survivable.
We feel that since our ovaries averaged an output of around 0.3 mg a day of testosterone, that's probably all we need of the stuff. Guys, obviously, have a lot more. Because a lot of testosterone supplements were designed for them and the experience of doctors and pharmacists is primarily with them, you may need to rein in the dose enthusiasm of the professionals. Doctors seem fairly willing to write prescriptions for testosterone, but you may need to convince them that you only want a smidgeon. For this reason, even though there is a tendency to write prescriptions for 2% or even 10% creams, a 1% or even 0.5% preparation makes a more reasonably-measureable strength for a prudent woman's dose range.
A lot of women come home from the pharmacy with their new tube of testosterone cream only to find the directions say "take as directed" and their doctor's office says something like "measure out an inch a day" when they call and ask them how they're directed to take it. The right way to approach this situation if the label doesn't show the cream strength is to call the pharmacy, speak to a pharmacist, and ask what is the strength of your cream in milligrams/unit volume and how many miligrams is in each prescribed volume dose.
Why do the numbers matter? All other things being equal, a good place to start is replacing what your body made normally: roughly 0.2-0.5 mg/day. Or even less if you are also using progesterone. By working around a normative amount, you can be both consistent and reasonable. If you need to add more later, fine—but at least you aren't going to start out at disaster level. And if you only need a very small volume every day, ask your pharmacist for a small, needle-less syringe so you can measure accurately. Your body will appreciate consistent dosing.
It not unheard of to need to adjust the other hormone doses to accommodate the addition of testosterone. Some testosterone is converted to estradiol, so it's important to understand that may act as an estrogen supplement if you're not fully meeting your estrogen needs on your estrogen hrt. According to some manufacturers, men using testosterone see a 10% or more increase in their estrogen levels when beginning testosterone supplementation. This has important implications for both typical hrt balance as well as for those who cannot or choose not to supplement their estrogen levels, since as a priority, estrogen needs will be met with the testosterone before our bodies use any leftover testosterone as itself.
If you have been on testosterone a month and don't feel that you are terribly thrilled with the results, you might also explore whether you need every bit of the estrogen you are taking. Remember, estrogen in excess tends to suppress arousal and orgasm, so in that respect it counteracts testosterone; it also raises the level of a protein that inactivates testosterone.
If this seems like a confusing situation, it is. Or at least, it is from the standpoint of our trying to drive what our body does with the supplements we give it. In fact, our body prioritizes hormone needs and scalps from everything lower down on the priority list to meet higher-priority needs. Estrogen will always trump progesterone or testosterone. Which, coming full circle, is exactly why the Endocrinologists' guidelines specify estrogen adequacy as the starting point for other hormone supplementation.
The other caution that we'd like to urge on women beginning testosterone supplementation is to be sure of their cardiovascular heath beforehand. The male profile of CV risk is higher than a woman's, and much of that is conveyed through the actions of testosterone. Many careful doctors today check a woman's lipid levels (cholesterol, HDL, LDL) and blood pressure before she starts taking it, so that if they are elevated or become elevated after she has been on testosterone awhile, other interventions can be put into place to control them. Since our risks of CV disease are elevated by menopause anyway, we think that's such a sound measure that we'd urge women whose doctors haven't thought of this to request it themselves. We think sex is just swell, but for all that taking testosterone might improve it, having a stroke surely won't.