The Forgotten Hormone
Testosterone isn’t just a male hormone. I want you to know that women make it their entire lives, and when levels drop, the effects on bone strength, muscle, motivation, and mood can be just as real as what men experience. It’s time we talked about it.
Testosterone Biology: What You Need to Know
I think testosterone might be the most misunderstood hormone in women's health. Most people, including many doctors, think of it as a male hormone. But your body makes it, your body needs it, and understanding the basics will help you have better conversations with your provider.
What the Evidence Shows
HSDD, or low sexual desire that causes you distress, is the only condition where testosterone has been studied extensively in women. I want you to understand that evidence, but I also want you to see the bigger picture. Testosterone does the same things in women that it does in men: it supports bone strength, muscle mass, motivation, and mood. The fact that we only study it for one narrow use case doesn’t mean that’s all it does.
The HSDD Evidence
StrongMultiple large trials (APHRODITE, INTIMATE, Shifren) show testosterone improves desire, arousal, orgasm, and satisfaction in postmenopausal women with HSDD.
The effect size is about 1–2 additional satisfying sexual events per month compared to placebo. That might not sound dramatic, but for women who went from zero, it’s meaningful.
The APHRODITE trial showed testosterone works even without concurrent estrogen therapy, which matters because not every woman can or wants to take estrogen.
In 2019, a Global Consensus Position Statement endorsed testosterone for postmenopausal women with HSDD. This is the closest thing we have to an official green light.
A Cochrane review of 36 randomized trials, covering over 8,480 women, confirmed the benefit for sexual function.
“But here’s what I find ironic: HSDD is defined as low desire that causes distress, and much of that ‘distress’ is measured by its effect on the relationship. The only time we officially recognize that women need testosterone is when its absence affects her partner.”
Beyond HSDD
Emerging but RealBone Health
Androgen receptors sit directly on bone cells. Testosterone helps build and maintain cortical bone, the dense outer shell that resists fractures.
We don’t have fracture trial data specifically in women on testosterone, so I can’t tell you it prevents hip fractures. But the biology is clear: androgen signaling matters for bone, and losing it weakens the skeleton.
Muscle Strength
Meta-analyses show testosterone produces about 1–2 kg of lean mass gain in women. That’s not bodybuilder territory; it’s modest.
But for a 60-year-old woman losing muscle every year, gaining a couple of pounds of lean mass can mean the difference between independence and fragility. It also improves strength, which matters for fall prevention.
Mood & Motivation
Testosterone modulates dopamine pathways, the same circuits that drive motivation, reward, and the feeling that you want to do things. When these pathways are underactive, the result is apathy, not sadness.
The trial data on mood is mixed, but many women report feeling more like themselves. The APHRODITE trial showed improved overall well-being, not just sexual function. That’s a signal we shouldn’t ignore.
Brain & Cognition
Androgen receptors exist throughout the female brain. Observational studies link higher androgen levels to lower Alzheimer’s risk in women.
But the largest randomized trial, the ADEPT trial, found no cognitive benefit from testosterone in older women. So while the biology is interesting, I can’t tell you testosterone protects your brain. We simply don’t know yet.
Energy
This is the most common reason women come to me asking about testosterone: “I’m exhausted and nothing helps.” I hear it every day.
There’s no strong randomized trial showing testosterone fixes fatigue. But fatigue is notoriously hard to study because it has so many causes: sleep, thyroid, iron, stress, depression. The absence of trial evidence doesn’t mean testosterone doesn’t help; it means we haven’t designed the right study yet.
I believe women deserve options for a hormone that helps with bone strength, muscle strength, motivation, and mood, all the same things we readily prescribe it for in men.
How Testosterone Is Given to Women
Here’s an important fact: there is no FDA-approved testosterone product for women in the United States. Not one. Every prescription a doctor writes for testosterone in a woman is“off-label,” meaning we’re adapting products made for men or using compounding pharmacies. This regulatory gap has been called a failure of women’s health.
No FDA-approved option exists
Unlike estrogen and progesterone, there is not a single FDA-approved testosterone product designed for women. Every approach below is either off-label, compounded, or available only outside the US. This is the reality we work within.
Transdermal Cream or Gel (Compounded)
A custom-made testosterone cream from a compounding pharmacy, usually 0.5–1 mg per day, applied to the inner thigh or another thin-skinned area. Another option I use is Testim gel: the woman draws it into a syringe and applies 0.5 mL per day, which gives reliable dosing from a commercially available product.
- Recommended approach by the 2019 Global Consensus Statement
- Dose can be fine-tuned to each patient
- Best method for reaching and staying within the normal female testosterone range
Oral Testosterone (Kyzatrex)
Kyzatrex is an oral testosterone capsule approved for men but sometimes used off-label for women at lower doses. The trick: you freeze the 100 mg gel cap, then use a pill splitter to cut it into smaller pieces. The freezing keeps the gel from making a mess, though the taste of the gel inside is not great. It works, but it takes a little effort.
- Freeze the gel cap first, then split it with a pill splitter for a fraction of the male dose
- Kyzatrex is currently developing lower-dose options that could make this easier in the future
- Oral route means it goes through the liver (first-pass metabolism), which is why transdermal is generally preferred
- A practical option for women who prefer a pill over a cream or gel
The Patch (Historical)
Intrinsa was a 300 μg/day testosterone patch, and it was the most rigorously studied female testosterone product ever made. It was approved in Europe in 2006 for women who had their ovaries removed and were experiencing low sexual desire (HSDD). But in 2004, the FDA voted 14 to 3 against approval, saying they needed more long-term safety data. It was later withdrawn from Europe due to low sales.
- The only properly tested, correctly dosed testosterone product for women was never available in the US and is no longer available anywhere
- A cautionary tale about how the post-WHI fear of hormones affected women
- Despite strong efficacy data, regulatory caution left women without a properly formulated option
The result: the only properly tested, correctly dosed testosterone product for women was never available in the US and is no longer available anywhere.
Subcutaneous Pellets
Compressed testosterone crystals (50–150 mg) implanted under the skin every 3–6 months. These are aggressively marketed by cash-pay clinics promising energy, libido, and body composition improvements. But there are serious concerns.
- Almost always produce supraphysiologic levels, often 2 to 4 times the normal female range, sometimes reaching low-normal male range
- Cannot be removed once implanted
- No randomized controlled trial evidence. The positive trials all used patches or creams at physiologic doses
- The 2019 Global Consensus explicitly recommended against pellets
DHEA
DHEA is a precursor hormone that your body can convert into testosterone (and estrogen). It’s not testosterone itself; it’s a building block your body may or may not convert the way you’d expect.
- Vaginal DHEA (Intrarosa/prasterone) is FDA-approved for vaginal dryness, and it works locally, not throughout the body
- Oral DHEA is available over the counter, but the conversion to testosterone is unpredictable and varies widely between women
- The 2019 Global Consensus did not recommend DHEA as a substitute for testosterone for treating HSDD
My approach
When I prescribe testosterone for a woman, I talk through the options and figure out together what works best for her. I typically use one of three approaches: a compounded transdermal cream, Testim gel drawn into a syringe at 0.5 mL per day, or a frozen and split Kyzatrex capsule. Each has trade-offs, and the right choice depends on the patient. I always aim for levels within the normal premenopausal female range and monitor closely. I do not use pellets. The doses are too high, the evidence is not there, and once they are in, you cannot take them out.
Safety, Risks, and Monitoring
The safety of testosterone in women depends almost entirely on one thing: the dose. At physiologic doses, meaning levels that match what your body made naturally before menopause, the short-term safety profile is good. The problems start when doses push you above that normal range.