Why Testosterone Matters for Women: Hormone Therapy, Menopause, Libido, and Modern Women's Health

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What does testosterone do in a woman's body?

Testosterone is not a male-only hormone. In premenopausal women the ovaries supply about half the circulating testosterone [8], and much of the rest is made in peripheral tissues from adrenal precursors such as DHEA and DHEA-S [9]. A 2015 review describes its actions as mediated directly or through conversion to estradiol [2].

Levels drift down with age. In 33 healthy cycling women aged 21 to 51, 24-hour mean total testosterone was about 1.3 nmol/L at age 21 and an expected 0.61 nmol/L at 40 [10]. Adrenal precursors fall steeply: in women aged 50 to 60, serum DHEA was 70% below the peak seen at 20 to 30 [9].

Removing the ovaries matters more than age. In the Rancho Bernardo study of 684 postmenopausal women aged 50 to 89 who were not using estrogen, total and bioavailable testosterone were more than 40% lower in women who had a hysterectomy with both ovaries removed than in women with intact ovaries, after adjustment for age and body mass index [11]. Among women with intact ovaries, total (but not bioavailable) testosterone increased with age, reaching premenopausal levels in the 70-to-79 decade [11].

Does testosterone improve low sexual desire?

This is where the evidence is strongest. The diagnosis studied is hypoactive sexual desire disorder (HSDD): low sexual desire that causes distress. It is not rare. In a US survey of women by reproductive stage, HSDD prevalence ranged from 9% in naturally postmenopausal women to 26% in surgically postmenopausal women aged 20 to 49 [12].

One 52-week trial randomized 814 postmenopausal women with HSDD who were not taking estrogen to a patch delivering 150 mcg or 300 mcg of testosterone a day, or placebo, with efficacy measured to week 24 [1]. At 24 weeks, satisfying sexual episodes rose by 2.1 per four weeks on 300 mcg a day against 0.7 on placebo (P<0.001). The 150 mcg dose did not separate from placebo on that endpoint (1.2 episodes, P=0.11), though both doses increased desire and reduced distress [1].

A second trial, Intimate SM 1, enrolled 283 women on a 300 mcg/day patch and 279 on placebo, all with HSDD after removal of both ovaries and all taking estrogen, for 24 weeks. Satisfying sexual activity rose by 2.10 episodes per four weeks against 0.98 on placebo (P=0.0003) [5].

Earlier, a crossover trial in 75 women who had undergone oophorectomy and hysterectomy and were taking conjugated equine estrogens compared placebo with 150 and 300 mcg/day patches, 12 weeks each. At the higher dose, scores for frequency of sexual activity and pleasure-orgasm improved (P=0.03 for both), as did the positive well-being, depressed-mood and composite scores of the Psychological General Well-Being Index [8].

Before menopause the data are thinner. One crossover trial gave premenopausal women with low libido 10 mg/day testosterone cream; 31 women provided complete data, and the Psychological General Well-Being Index rose 12.9 points and a sexual self-rating scale 15.7 points against placebo [13].

The Endocrine Society found evidence of short-term benefit for postmenopausal women with HSDD, but recommends against testosterone for other forms of sexual dysfunction and for general well-being [4].

Does testosterone help mood, energy, thinking or bones?

Not as a guideline-supported use. The Endocrine Society guideline recommends against prescribing testosterone for cognitive, cardiovascular, metabolic or bone health, or for general well-being [4].

The DHEA trial that gets quoted is not a testosterone trial. Twenty-four women with adrenal insufficiency, who have a deficiency of adrenal androgens, took 50 mg of DHEA daily for four months and placebo for four months in random order; well-being, depression, anxiety and several measures of sexual interest improved on DHEA [14]. That was a specific deficiency, and DHEA is a different hormone from testosterone.

For bone, the human data are associations, not treatment results. In 231 women aged 32 to 77 followed for two to eight years, bone loss was associated with lower androgen concentrations in premenopausal women, and with lower estrogens and androgens in peri- and postmenopausal women [15]. A 2015 review notes that clinical trials suggest exogenous testosterone enhances cognitive performance and improves musculoskeletal health in postmenopausal women, while listing approved formulations and better data as unmet needs [2].

Where does testosterone fit in menopause hormone therapy?

Trials of testosterone in women have measured sexual function, such as satisfying sexual episodes, in postmenopausal women with distressing low desire [1][5]. The FDA-approved menopausal hormone therapy products are estrogens, estrogen-plus-progestogen combinations, progestogens for endometrial protection, and conjugated estrogens/bazedoxifene [16][17][18][19]. The Menopause Society's 2022 position statement calls hormone therapy the most effective treatment for vasomotor symptoms and genitourinary syndrome of menopause, and notes that it prevents bone loss and fracture [20].

Other menopause symptoms have their own approved options: fezolinetant, elinzanetant and paroxetine 7.5 mg for hot flashes, and ospemifene or a vaginal prasterone insert for painful intercourse due to menopause [21][22][23][24][25].

Compounded hormones sit outside all of this. FDA says it has no evidence that compounded bioidentical hormones are safe and effective and recommends FDA-approved hormone therapy [26], and ACOG's 2023 clinical consensus says compounded bioidentical menopausal hormone therapy should not be prescribed routinely when FDA-approved formulations exist [27].

What are the risks, and is any of this approved?

Depo-Testosterone is labeled for replacement therapy in males with hypogonadism [7]. A generic testosterone enanthate injection also lists delayed puberty in carefully selected boys and, secondarily, metastatic breast cancer in postmenopausal women [3]. The Depo-Testosterone label lists women who are pregnant as contraindicated and says testosterone is known to cause virilization of the female fetus [7].

The abuse section of that label lists the reactions reported in women who abuse anabolic androgenic steroids: hirsutism, virilization, deepening of voice, clitoral enlargement, breast atrophy, male-pattern baldness and menstrual irregularities [7].

In the 814-woman trial, androgenic adverse events, mostly unwanted hair growth, occurred in 30.0% of women on 300 mcg/day against 23.1% on placebo. Breast cancer was diagnosed in four women on testosterone and none on placebo, and the investigators wrote that long-term effects, including effects on the breast, remain uncertain [1]. A 2015 review found that adverse cardiovascular effects have not been seen in studies of transdermal testosterone in women, while associations between a woman's own testosterone level and cardiovascular disease or death remain unestablished [2].

Testosterone is a Schedule III controlled substance in the US [6][7].