Testosterone for Women: The Treatment Your Doctor Probably Isn't Offering

When most people hear "testosterone," they think of men. But women make it too: the ovaries and adrenal glands produce it throughout life, and it is one of the influences on sexual desire, muscle, bone and the brain. Levels fall gradually with age, and that has made testosterone one of the most talked-about and most oversold treatments in menopause care. Here is what it can and cannot do.

Why your doctor may not have mentioned it

• It's off-label in the US. There is no FDA-approved testosterone product for women, so any prescription is off-label. That is legal and common in medicine, but some clinicians are uncomfortable with it.
• Training gaps. Many doctors had little training in menopause care, let alone in testosterone for women.
• Its evidence-based use is narrow. Testosterone is supported for one thing, distressing low sexual desire after menopause. A clinician who declines to prescribe it for fatigue or brain fog is following the evidence.

What testosterone can and cannot do

The 2019 Global Consensus Position Statement on Testosterone Therapy for Women, endorsed by The Menopause Society, the Endocrine Society, the International Menopause Society and others, reviewed the randomized trial evidence: 36 trials involving about 8,500 women. At doses that keep levels in the normal female range:

Sexual desire and arousal: This is where the evidence is. For postmenopausal women with hypoactive sexual desire disorder (HSDD), meaning low desire that causes distress, testosterone improved desire, arousal, orgasm and satisfaction. It is the one use the consensus calls evidence-based.

Energy, mood and wellbeing: The consensus found no effect on general wellbeing and no effect on depressed mood. Some women report more energy or feeling more like themselves, and most trials were short, but trials have not confirmed these effects, so fatigue or low mood alone are not reasons to start it.

Memory and thinking: There is not enough evidence to recommend testosterone for brain fog or to prevent cognitive decline.

Muscle and body composition: No statistically significant effect on lean body mass, body fat or muscle strength was found. Resistance training and adequate protein are the better-supported tools.

Bone density: No effect on bone density at 12 months.

How testosterone is prescribed for women

Because there is no FDA-approved women's product, clinicians usually use one of two approaches:

A small dose of an approved men's product: A fraction of an approved men's transdermal gel, often about a tenth of the male starting dose. Where no female product is available, this is the approach the consensus prefers, because the product itself is regulated.

Compounded testosterone cream: A compounding pharmacy makes a cream at a female strength. It is widely used in the US, but the consensus does not recommend compounded products unless an approved equivalent is not available, because their strength and consistency are not regulated the way approved drugs are.

Not recommended: pellets and injections, which can push levels above the normal female range (and pellets cannot be removed if side effects appear), and oral testosterone, because of its effect on cholesterol.

What about side effects?

At doses that keep levels in the female range, side effects are usually mild and dose-related. They can include:

• Acne: Usually mild, and often improves with a lower dose.
• Increased facial or body hair: Usually mild at proper doses.
• Oily skin: Can occur but is usually mild.
• Voice changes and clitoral enlargement: Rare at proper doses, but they may not reverse, which is why dosing matters.

Women need roughly a tenth of a man's dose. Blood tests are used to check that levels are not high before starting and to keep treatment within the normal female range. They are not used to diagnose low desire, and the dose is not raised to chase a number.

Is testosterone safe for women?

In the randomized trials behind the consensus, no serious adverse events were recorded with non-oral testosterone at doses in the female range. But long-term safety data are limited, and current data cannot show whether testosterone affects the risk of heart attack or death.

Women who should discuss testosterone carefully with their provider include those with a history of hormone-sensitive cancers, polycystic ovary syndrome (PCOS), or liver disease.

How to find a provider who prescribes testosterone for women

Not every HRT provider prescribes testosterone. When searching for a provider, ask:

• Do you prescribe testosterone for women with low sexual desire, and how do you look at other causes first?
• Will you use an approved product at a female dose, or a compounded one, and why?
• How do you monitor levels, and how will we decide whether it is working?

In our provider directory, you can filter for providers who prescribe testosterone.

If your current provider declines, ask why. If low desire is the concern and other causes have been looked at, a second opinion from a menopause specialist is reasonable. If the concern is fatigue or brain fog, a clinician who declines testosterone is following the evidence.