Expanding the Horizons of Menopausal Hormone Therapy: A Narrative Review of Progestogen-Only and Testosterone-Only Strategies for Tailored Management

Estrogen-progestogen therapy remains the clinical gold standard for managing menopausal symptoms; however, the growing emphasis on precision medicine underscores the need for individualized strategies for females with specific contraindications or distinct clinical profiles. This narrative review examines the physiological mechanisms, clinical efficacy, and safety profiles of progestogen-only and testosterone-only therapies. Evidence suggests that progestogen-only therapy, particularly oral micronized progesterone (oP4), offers a robust alternative for alleviating vasomotor symptoms and sleep disturbances through its action on GABAergic neurosteroid pathways. Notably, observational data from large cohort studies, including the Etude Epidémiologique auprès de femmes de la Mutuelle Générale de l'Education Nationale study, suggest that oP4 and dydrogesterone are associated with a more favorable risk profile for venous thromboembolism and breast cancer than synthetic progestins used in combined hormone therapy. Testosterone therapy is specifically indicated for hypoactive sexual desire disorder, with transdermal delivery preferred to bypass hepatic first-pass metabolism. In the absence of approved female-specific testosterone products in South Korea, cautious off-label dosing and rigorous monitoring remain essential. Overall, monotherapy with progestogens or testosterone constitutes a vital component of tailored menopause management, if clinicians adhere to evidence-based protocols and remain aware of the current limitations in long-term safety data.