Testosterone for Women

Testosterone isn't just a "male hormone." Women make it too, in the ovaries and adrenal glands, and levels fall gradually with age. That has led to a lot of claims that replacing it will restore energy, focus, mood and muscle. Here is what testosterone does in women, what treatment is and is not proven to help, and how it is prescribed safely.

What testosterone does in women

Before menopause, a woman's body produces roughly 0.2-0.25 mg of testosterone a day, a small fraction of a man's production: about half comes from the ovaries and adrenal glands, and the rest from conversion of other hormones in body tissues. It acts on many tissues, including those involved in:

• Sexual desire and arousal. Testosterone is one of several influences on desire, alongside relationship quality, stress, body image, sleep, pain and other hormones.
• Muscle and bone. It is one of the hormones that act on muscle and bone.
• The brain. Testosterone receptors are found throughout the brain.

That is the body's own hormone at its normal levels. Whether adding testosterone as a treatment improves each of these is a separate question, and the trials below answer it.

What happens to testosterone with age

Unlike estrogen, which falls sharply around menopause, testosterone declines gradually over decades, starting in a woman's twenties or thirties. Natural menopause does not cause a sudden drop. Removing both ovaries (surgical menopause) causes a larger, abrupt fall.

Oral estrogen raises sex hormone-binding globulin (SHBG), a protein that binds testosterone, so it can lower free testosterone. Transdermal estrogen (patches or gel) has much less of this effect.

Is there a "low testosterone" syndrome in women?

Not a validated one. Fatigue, brain fog, low motivation, weight gain and low mood are common in midlife and have many causes, including falling estrogen, poor sleep, thyroid problems, iron deficiency, depression and stress. The Global Consensus states that a blood testosterone level should not be used to diagnose low sexual desire, and there is no cut-off that identifies which women will benefit from treatment. Blood tests are still useful to check that levels are not high before starting, and to keep treatment within the normal female range.

What the research says

The main reference is the 2019 Global Consensus Position Statement on Testosterone Therapy for Women, endorsed by The Menopause Society, the Endocrine Society, the International Menopause Society and other societies. It is based on a meta-analysis of 36 randomized trials involving about 8,500 women, published in The Lancet Diabetes & Endocrinology.

The strongest evidence is for hypoactive sexual desire disorder (HSDD): low sexual desire that causes distress. For postmenopausal women with HSDD, testosterone improved desire, arousal, orgasm and satisfaction, and this is the one use the consensus calls evidence-based. It also recommends:

• Dosing to approximate normal premenopausal levels
• Assessing the effect at 3-6 months, and stopping if there is no benefit
• Monitoring blood levels to avoid going above the female range

For other outcomes, at the physiological doses used for women, the consensus found:

• General wellbeing: no effect
• Mood: no effect on depressed mood shown
• Memory and thinking: not enough evidence to recommend it
• Muscle, body fat and strength: no statistically significant effect
• Bone density: no effect at 12 months

Some women report more energy, better mood or clearer thinking on testosterone, and most trials were short, so "not shown" is not the same as "proven not to work". But trials at safe doses have not confirmed those effects, so they are not reasons on their own to start treatment.

Why there's no FDA-approved testosterone for women

There is no FDA-approved testosterone product for women in the United States. Approved products are made and dosed for men; a woman's dose is roughly a tenth of a man's.

A testosterone gel for women, LibiGel, did not show enough benefit over placebo in its Phase III trials and was never approved. Australia has approved a testosterone cream for women (AndroFeme), but it is not an approved product in the US.

How testosterone is prescribed for women

In the US, clinicians typically 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, applied to the skin. Where no female product is available, this is the approach the Global Consensus prefers, because the product itself is regulated.

Compounded testosterone cream

A compounding pharmacy makes a cream at a strength for women, usually applied daily to the skin. 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.

Forms to avoid or approach with caution

• Pellets and injections: not recommended by the consensus, because they can push levels above the normal female range, and pellets cannot be removed if side effects appear.
• Oral testosterone: not recommended, because of its effect on cholesterol.
• Troches (lozenges): absorption is more variable than with skin products, and some providers avoid them for that reason.

Dosing: less is more

The goal is to keep testosterone within the normal premenopausal range, not above it. Signs that a dose may be too high include:

• Acne (especially along the jawline)
• Oily skin
• Facial hair growth (hirsutism)
• Hair thinning on the scalp
• Deepening of the voice
• Clitoral enlargement
• Irritability or aggression

Some of these effects, particularly voice and clitoral changes, may not be fully reversible. That is why a knowledgeable provider starts low, checks total testosterone at baseline, again 3 to 6 weeks after starting or changing the dose, and every 6 months after that, and stops if desire has not improved after 3-6 months. Short-term studies of physiological doses are reassuring, but long-term safety data are limited.

Finding a provider who prescribes testosterone for women

Many OB/GYNs and primary care doctors do not prescribe testosterone for women because it is off-label or unfamiliar. Options include:

• Menopause specialists - providers certified by The Menopause Society (MSCP) are more likely to be current on testosterone guidance
• Endocrinologists with experience in female hormone management
• Telehealth menopause clinics - some national platforms prescribe testosterone for women with evaluation and monitoring; check before you book, because many do not
• Integrative or functional medicine providers - some prescribe it often; be cautious of pellets, high target levels, or testosterone offered for energy or weight

Questions to ask your provider

• Is low sexual desire my main concern, and have other causes been looked at?
• Will you use an approved product at a female dose, or a compounded one, and why?
• What level do you aim for? (Look for the normal premenopausal range, not above it.)
• How often will you check my blood levels?
• How will we judge whether it is working, and when would we stop?

The bottom line

Testosterone has a real, evidence-based role for women: distressing low sexual desire after menopause, assessed by a clinician and treated at a dose made for women. For energy, mood, memory, muscle and weight, trials at safe doses have not shown a benefit, so those are not reasons on their own to start it.

If low desire is the problem, you are not asking for too much by raising it. Find a provider who will look at the whole picture, prescribe a dose made for women, and monitor it.

This article is for educational purposes only and is not medical advice. Testosterone therapy decisions should be made with a qualified healthcare provider who can evaluate your individual health history, risk factors, and symptoms. The information here is based on the 2019 Global Consensus Position Statement on Testosterone Therapy for Women and published research; medicine evolves, so always consult your provider for the most current recommendations.