If we say low testosterone, you might think of a TV ad starring a middle-aged man worried about “low T.” But even though testosterone is considered the quintessential “male” hormone, women make it too. Why? What does testosterone do for female physiology? Could a prescription for testosterone help women feel better? Some women have told us it relieves menopausal symptoms and improves their sex lives.
Why Do Women Make Testosterone?
An excellent overview titled “Testosterone in Women—the Clinical Significance” (Lancet Diabetes & Endocrinology, Dec. 2015) begins this way:
“Testosterone is a critical but enigmatic female hormone.”
The article goes on to point out that that testosterone is a “precursor for biosynthesis of estradiol.” Please hit the pause button and digest that thought. Testosterone is a building block for the primary female estrogen known as estradiol. Huh? Women need testosterone to make estrogen! That’s not something most people realize.
Actually, the whole process starts with cholesterol. It is the very first building block for a bunch of precursor compounds including androstenedione, dehydroepiandrosterone (DHEA) and dihydrotestosterone (DHT). The testosterone and DHT that are created in the ovaries, adrenal glands and other body tissues is ultimately converted to estradiol.
In postmenopausal women, estrogen is also created in bones, breast, blood vessels and brain (Endocrinology, Nov. 2001). One little hiccup. Measuring testosterone in the blood of postmenopausal women is not necessarily a good way to determine “low T.” That’s because it misses intracellular testosterone. A good endocrinologist will take into account a woman’s clinical experience, not just her blood levels of testosterone.
By now, you are probably feeling a bit overwhelmed. The bottom line appears to be that testosterone has both a direct effect on women as well as an indirect effect by helping with the formation of estrogen, the quintessential female hormone. Testosterone levels reach their maximum concentration when women are in their 30s and 40s and then start declining.
Does Testosterone Help Women, Too?
Q. After a friend told me that she had great success with testosterone cream, I asked my gynecologist about it. She prescribed a low-dose cream and I have been using it for years.
I am happy with the results. I have more energy, better mood, a high sex drive, amazing orgasms and less body fat. My husband is happy because I’m happy and our sex life is great. Why don’t more women know about this?
Another woman wrote:
“My libido had dropped to zero after menopause. A new doctor prescribed testosterone cream specially formulated by a compounding pharmacy.
“I was like a teenage boy until I found the right dose! It doesn’t take much. My bone density is excellent, and I now have an active sex life.”
A. The FDA has not approved testosterone for women. The FDA cautions that:
“prescription testosterone products are approved only for men who have low testosterone levels caused by certain medical conditions.”
The only way to get this topical medicine is with a prescription at a compounding pharmacy. Doctors are allowed to prescribe drugs “off label” if they feel the benefits outweigh the risks. The FDA does not approve of such actions, especially in the case of TRT (testosterone replacement therapy).
Testosterone Implants:
Some physicians advocate implanted testosterone pellets. This is an off-label use. The FDA does not approve of such treatment for women. It remains highly controversial. One physician wrote this in the Journal of Personalized Medicine (Aug. 2022):
“There is growing evidence to support the use of physiologic doses of testosterone for sexual function, osteoporosis prevention, brain protection, and breast protection. The safety of testosterone use in women has been evaluated for the past 80 years. A recent publication on the complications of subcutaneous hormone-pellet therapy, looking at a large cohort of patients over 7 years, demonstrated long-term safety. In addition, there have been two large long-term peer-reviewed studies showing a significant reduction in the incidence of invasive breast cancer in women on testosterone therapy. Perhaps it is time for the FDA to consider approving products that would benefit testosterone-deficient women.”
One woman shares her story:
Q. I am a woman with undetectable testosterone levels. My doctor prescribed a low-dose testosterone pellet that he inserted under my skin. It lasted for several months. This was not covered by insurance, but the results were worth it.
A. Women make testosterone as well as estrogen. Testosterone treatment for women remains controversial, however. The FDA has not approved this hormone for women. Some doctors have prescribed it for decades to ease certain menopausal symptoms, including vaginal dryness and low sex drive.
When testosterone levels are very low, women may feel depressed and have decreased sexual desire. Your doctor should monitor your testosterone levels to make sure your hormone levels remain within normal limits.
The most common side effects of testosterone pellet therapy involve acne and hair growth. Concerns have been raised that high levels of testosterone might deepen the voice and cause anger or hostility. An article titled “The Safety of Testosterone Therapy in Women” published in the Journal of Obstetrics and Gynaecology Canada, Sept. 2012 notes that: “Anger and hostility are not observed in women with serum testosterone within physiologic limits.” To read more about the benefits and risks of testosterone in women, please take a moment to read this journal article from Canada. It is quite comprehensive.
TRT (Testosterone Replacement Therapy) & Libido?
Can testosterone help women with sexual arousal and satisfaction? A review in the journal U.S. Pharmacist (Aug. 19, 2019) reports that:
“TRT has been shown to be effective for improving libido, sexual desire, arousal, sexual frequency, and sexual satisfaction in women.”
The long-term effects of this off-label use, have not been well studied, though, and safe dosing guidelines are not well established.
An oral medicine, Estratest, was once prescribed to treat symptoms of menopause. This is now only found as a generic pill, esterified estrogens with methyltestosterone.
Like other estrogen replacement pills, it carries a black box warning about endometrial cancer and cardiovascular complications. That might help explain why many women haven’t considered whether they might need testosterone.
Separating estrogen from testosterone is important, though. An analysis of data from the Nurses’ Health Study from 1978 to 2002 reported that (Archives of Internal Medicine, July 24, 2006):
“Among women with a natural menopause, the risk of breast cancer was nearly 2.5-fold greater among current users of estrogen plus testosterone therapies than among never users of PMHs [postmenopausal hormones].”
Sadly, there hasn’t been nearly enough research into both the benefits and risk of testosterone for women. We find this very disappointing.
When Could Testosterone Help Women with Low Libido?
Most doctors will consider testosterone for a woman only if she has persistent difficulty with libido. However, measuring testosterone levels to make a diagnosis does not seem to be straightforward (Journal of Obstetrics and Gynaecology Canada, March 2017). Women’s sexual desire is not a simple barometer of testosterone in their systems. Psychological well-being and the state of the relationship also have strong effects on a woman’s interest in sexual activity (Journal of Sexual Medicine, March 2017).
A group of women approaching menopause reported on their libido and symptoms and provided blood for testing (Menopause, Nov. 2018). Those whose testosterone levels fluctuated most were more likely to report diminished interest in sex. Women who were depressed, those who reported vaginal dryness and those whose children were living at home were more likely to report decreased libido regardless of their testosterone levels.
Side Effects of Testosterone:
In some cases when testosterone levels are low, we expect that a cream or patch providing modest doses of this hormone might help women reclaim their libido. Excess testosterone may lead to irreversible side effects, including a deeper voice and enlarged clitoris.
Some women may experience hoarseness, acne and growth of unwanted facial hair. Women who are still menstruating may notice changes in their periods. Liver problems and blood clots are other potentially serious reactions to testosterone.
Does Testosterone Help Women Athletes?
A study in the British Journal of Sports Medicine reveals that elite female athletes who have naturally high testosterone perform better than those with normal androgen levels. The investigators analyzed data for both male and female athletes from the 2011 and 2013 track and field world championships (Bermon & Garnier, British Journal of Sports Medicine, online, July 3, 2017 ).
Male sprinters tended to have higher free testosterone levels than men in other events. On the other hand, those in throwing events averaged lower testosterone than men in other events. Testosterone levels in women didn’t appear to vary by the event.
How Does High Testosterone Affect Competition?
When women with high testosterone were compared to those with low levels of this male hormone, performance differed slightly. Nonetheless, the small differences were significant.
Although the improvements in events such as pole vault, 400 meter hurdles, 800 meter runs and the hammer-throw were modest, at this level of competition, even a small advantage can lead to a championship. The women competing in the hammer-throw did 4.53 percent better if they had elevated testosterone levels. That was the greatest difference among all the contestants.
Another Testosterone Benefit:
There is evidence that bone mineral density is affected by testosterone levels. To quote from the article titled The Safety of Testosterone Therapy in Women:
“Bone mineral density is significantly related to testosterone levels in postmenopausal women.
“Although limited, the existing evidence indicates that testosterone therapy has positive protective effects on bone health.”
To be fair, though, the relationship between testosterone and bone mineral density remains controversial. A study in Scientific Reports (March 25, 2023) reports:
“Using a highly sensitive hormone assay method, our study identified a significant association between testosterone and BMD of the hip in women over 65 years of age, suggesting that lower testosterone increases the risk of osteoporosis.
“The finding of a significant positive influence of testosterone in bone mineral density of the hip in older women should encourage further research into testosterone deficiency in elderly women, with a potential impact in the prevention and treatment of postmenopausal osteoporosis. The effects of testosterone on the bone of older postmenopausal women are not very well documented but it is known that testosterone may have direct effects on bone via the androgen receptor, or indirect effects via aromatization.”
Whether extra testosterone will prevent osteoporosis or fractures in postmenopausal women with low T remains to be determined.
We remain disappointed that there remain so many question and so few answers about testosterone replacement therapy. Here is what two researchers from Australia and Denmark say about this issue (Lancet Diabetes & Endocrinology, Dec. 2015):
“Testosterone is an essential hormone for women, with physiological actions mediated directly or via aromatisation to oestradiol throughout the body. Despite the crucial role of testosterone and the high circulating concentrations of this hormone relative to oestradiol in women, studies of its action and the effects of testosterone deficiency and replacement in women are scarce. The primary indication for the prescription of testosterone for women is loss of sexual desire, which causes affected women substantial concern. That no formulation has been approved for this purpose has not impeded the widespread use of testosterone by women—either off-label or as compounded therapy…Clinical trials suggest that exogenous testosterone enhances cognitive performance and improves musculoskeletal health in postmenopausal women.”
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