Testosterone…the not so “male hormone”
What’s the deal with testosterone anyway?
Testosterone is often thought of as the "male hormone," but in reality, it plays a crucial role in both men and women.
In the female body, testosterone contributes to libido, mood, energy, cognitive function, and muscle strength.
While estrogen and progesterone are the primary hormones governing female physiology, testosterone is essential for overall well-being.
Fun fact: Testosterone is the most abundant biologically active hormone in women.
Whoa! Didn’t see that one coming, right?!?
The Science of Testosterone in Women
Testosterone is produced in the ovaries, adrenal glands, and peripheral tissues. Although women produce significantly lower amounts of testosterone compared to men (about 1/10th the amount), this hormone is vital for maintaining bone density, muscle mass, cognitive function, and sexual health.
Testosterone levels naturally decline with age, particularly during perimenopause, starting around the 30s, leading to potential symptoms such as decreased libido, fatigue, brain fog, and reduced muscle strength.
Testosterone Therapy in Women
While testosterone therapy is FDA-approved for men with low testosterone, its use in women remains off-label. However, clinical evidence supports the role of testosterone therapy in specific conditions, particularly Hypoactive Sexual Desire Disorder (HSDD).
Women with HSDD experience a persistent lack of sexual desire, distressing enough to affect their quality of life.
Testosterone therapy has been shown to improve sexual function and satisfaction in these individuals.
Hypoactive Sexual Desire Disorder (HSDD) is a medical condition characterized by a persistent or recurrent lack of sexual desire that causes significant distress or interpersonal difficulty. It is the most common female sexual dysfunction and can be influenced by hormonal changes, psychological factors, medical conditions, and medications. Women with HSDD may experience frustration, decreased intimacy, and an overall reduction in quality of life. Testosterone therapy has been shown to be an effective treatment for HSDD by improving sexual desire, arousal, and overall sexual satisfaction.
Beyond HSDD, many women seek testosterone therapy for benefits such as:
Mood and Mental Clarity: Research suggests that testosterone may improve mood, reduce depression and anxiety, and enhance cognitive function, including reducing brain fog (1).
Physical Performance: Some studies indicate that testosterone can improve muscle strength, exercise capacity, and recovery, although data on this specific to women using testosterone in physiologic doses is lacking.
Energy and Motivation: Many women report feeling more energetic and motivated after starting testosterone therapy, particularly those experiencing profound fatigue associated with perimenopause and menopause.
Why Is There No FDA-Approved Testosterone Product for Women?
Despite growing evidence supporting the benefits of testosterone therapy for women, no FDA-approved testosterone product exists for female patients in the United States. One major reason is the historical focus on testosterone as a "male hormone," leading to limited research and regulatory approval pathways for female-specific formulations.
Additionally, clinical trials on testosterone therapy in women have been inconsistent in dosing, delivery methods, and outcome measures, making it difficult for regulatory bodies to establish standardized guidelines for approval.
The FDA has expressed concerns over the long-term safety of testosterone therapy in women, particularly regarding cardiovascular risks, effects on breast health, and metabolic implications. Without large-scale, long-term studies, the FDA remains cautious about approving testosterone products for women. As a result, women seeking testosterone therapy have to rely on compounded formulations or off-label prescriptions of male-specific testosterone products at reduced doses.
Methods of Testosterone Administration and Dosing
Testosterone therapy can be administered in several forms, each with its own benefits and drawbacks:
Testim gel is a male-formulated FDA-approved commercially available form of testosterone gel.
Creams and Gels: Applied to the skin and absorbed transdermally, these allow for adjustable dosing but may require a careful application to prevent the transfer to others and take care more time to build up treatment-effective levels of testosterone in the bloodstream.
Injections: Typically given intramuscularly or subcutaneously, injections provide steady absorption but can lead to peaks and troughs in hormone levels.
Pellets: Implanted under the skin, these offer long-lasting testosterone release but require a minor procedure and cannot be easily adjusted.
Troches: Dissolvable lozenges that provide sublingual absorption, though absorption rates can be inconsistent.
Potential Side Effects of Testosterone Therapy
Like any hormone therapy, testosterone comes with potential risks and side effects.
The most common side effects include:
Acne and oily skin
Increased facial or body hair growth (hirsutism)
Irritability
Changes in body odor
Increased sexual desire, intrusive sexual thoughts
Scalp hair thinning
Deepening of the voice (rare but irreversible at higher doses)
Clitoromegaly (irreversible enlargement in clitoris)
Changes in cholesterol levels
Possible impact on liver function (rare with transdermal or low-dose therapy)
To minimize risks, testosterone therapy should be carefully monitored with regular blood tests to ensure appropriate dosing and avoid excessive levels.
Physiologic vs. Supraphysiologic Dosing
Testosterone therapy should aim for physiologic dosing, which restores testosterone to levels typically found in premenopausal women.
Supraphysiologic dosing, which vastly exceeds natural levels (>150 ng/dL), can lead to increased potential for adverse effects such as excessive hair growth, voice deepening, and changes in cholesterol.
Proper monitoring ensures optimal dosing to maximize benefits while minimizing risks.
Getting started on testosterone therapy
Prior to starting on testosterone therapy, lab work should be done.
This typically consists of:
Lipid Panel
Comprehensive Metabolic Panel (CMP)
Complete Blood Count (CBC)
Thyroid Levels
Testosterone Levels
Once lab work comes back, it will be reviewed with you and should be repeated at least every 6 months while on therapy to ensure optimal levels.
The best form of testosterone delivery will be decided upon, and you can start therapy when you feel comfortable.
Final Thoughts
Testosterone is an essential hormone for both men and women, and its decline can contribute to a range of symptoms. While not FDA-approved for women, testosterone therapy is a well-researched option for improving sexual function, mood, mental clarity, and physical performance in select individuals.
If you’re considering testosterone therapy, let me know so we can determine if it’s right for you.
In Health,
Jackie Piasta, WHNP-BC, MSCP
Women’s Health Nurse Practitioner and Menopause Society Certified Practitioner
References
Glynne S, Kamal A, Kamel AM, Reisel D, Newson L. Effect of transdermal testosterone therapy on mood and cognitive symptoms in peri- and postmenopausal women: a pilot study. Arch Womens Ment Health. Published online September 16, 2024. doi:10.1007/s00737-024-01513-6
Davis SR, Baber R, Panay N, et al. Global consensus position statement on the use of testosterone therapy for women. Climacteric. 2019;22(5):429-434. doi:10.1080/13697137.2019.1637077
Islam RM, Bell RJ, Green S, et al. Safety and efficacy of testosterone for women: a systematic review and meta-analysis of randomized controlled trials. Lancet Diabetes Endocrinol. 2019;7(10):754-766. doi:10.1016/S2213-8587(19)30267-7
Parish SJ, Simon JA, Davis SR, et al. International Society for the Study of Women's Sexual Health clinical practice guideline for the use of systemic testosterone for hypoactive sexual desire disorder in women. J Sex Med. 2021;18(5):849-867. doi:10.1016/j.jsxm.2021.02.008
Davison SL, Bell RJ, Donath S, et al. Androgen levels in women who have and who do not have sexual dysfunction: a population-based study. Lancet. 2005;366(9481):896-902. doi:10.1016/S0140-6736(05)67224-2
Reed BG, Bou Nemer L, Carr BR. Has testosterone therapy been shown to improve quality of life in women? Transl Androl Urol. 2016;5(4):434-439. doi:10.21037/tau.2016.06.05
