Testosterone Therapy in Women: Current Insights

Testosterone is a hormone naturally produced in the female body (mainly by the ovaries, adrenal glands, and through peripheral conversion in tissues such as fat and skin). It plays roles in sexual health, energy, muscle strength, and more. However, its use as a therapy is limited and requires careful evaluation. Below are key points compiled from evidence-based medical guidelines.

Testosterone and Androgen Production in Women

In women, androgens (including testosterone) originate from multiple sources: approximately 25% from the ovaries, 25% from the adrenal glands, and about 50% from peripheral tissues (fat and skin) through the conversion of precursor hormones such as DHEAS and androstenedione. Adrenal glands primarily secrete weaker androgens (DHEA, DHEAS), which are then converted to testosterone in peripheral tissues.

Women produce only about one-tenth the amount of testosterone that men do, peaking mid-cycle due to ovarian activity. Surgical removal of the ovaries (oophorectomy) leads to a more dramatic decline. About 66% of circulating testosterone in women is bound to sex hormone–binding globulin (SHBG) — higher than in men. Both estrogen and thyroid hormone increase SHBG, thus reducing the amount of free (bioavailable) testosterone.

What Is Aromatization?

Aromatization is the process through which androgens (e.g., testosterone) are converted into estrogens (e.g., estradiol) via the enzyme aromatase. This occurs in various tissues such as fat, brain, and bone and helps maintain hormonal balance. In women, especially postmenopausal ones, this pathway becomes a major source of estrogen production.

Natural Course of Testosterone: Age and Menstrual Cycle

In women, testosterone levels peak in their 20s and gradually decline with age, decreasing to about 50% by menopause. Unlike estrogen, this decline is gradual and age-related, not abrupt. Levels vary among individuals and should be evaluated through blood testing.

In premenopausal women, testosterone fluctuates during the menstrual cycle, peaking around ovulation (days 12–14). This mid-cycle surge may increase libido and energy. After menopause, these cyclical variations disappear due to the loss of ovarian activity.

While gradual decline is normal, some women experience testosterone deficiency due to medical or surgical causes such as:

• Oophorectomy
• Menopause (natural, surgical, or premature)
• Adrenal insufficiency
• Chronic illness or medications (e.g., corticosteroids, oral contraceptives)
• HPA axis dysfunction
• Genetic or congenital disorders

When to Measure Testosterone

Testosterone has a diurnal rhythm, being highest in the morning. Testing should ideally be done around 10 a.m. For women on therapy, timing may depend on whether a peak or trough level is needed. In premenopausal women, testing is best done during the early follicular phase (days 3–5). Because blood testosterone does not perfectly reflect brain activity and assays in women require high sensitivity, mass spectrometry testing is preferred for accuracy.

Indications (Approved Uses)

The only evidence-based, guideline-supported indication for testosterone therapy in women is the treatment of hypoactive sexual desire disorder (HSDD) in postmenopausal women. HSDD is defined as a persistent reduction in sexual desire causing distress, after ruling out other causes (relationship issues, medications, mood disorders). Therapy can improve desire, arousal, orgasm, and satisfaction, typically adding about one extra satisfying sexual experience per month. It is usually considered after estrogen-based hormone replacement therapy (HRT) has been tried.

Most countries (e.g., the U.S.) have no testosterone product specifically approved for women; use is therefore off-label. In Australia, AndroFeme® 1% cream is approved for this indication.

Off-Label Uses

In menopause, testosterone may sometimes be prescribed for low energy, mood issues, muscle weakness, or bone health. Deficiency can cause fatigue, cognitive decline, low mood, reduced strength, poor sleep, and joint pain.

Potential cardiovascular benefits include:

• Increased coronary blood flow and vasodilation
• Reduced atherosclerosis
• Improved capillary density and tissue perfusion

The T.O.S.C.A. registry found that about one-third of women with heart failure (HFrEF) had testosterone deficiency, which correlated with worse outcomes and higher mortality.

Dosage and Administration

Target: maintain total testosterone within the premenopausal range (15–57 ng/dL).

Starting dose: 2–5 mg/day transdermal (through the skin). When using male products (e.g., Testim® or AndroGel® 1%), about 1/10 of the male dose is used (0.5 g gel = 5 mg).

Monitoring: Check serum levels after 3–6 weeks; adjust if necessary. Once stable, reassess every 6 months.

Duration: 3–6 month trial; discontinue if no benefit. Long-term safety beyond 24 months is unknown.

Avoid: Oral forms (liver/lipid effects), injections, or pellets (risk of supraphysiologic levels).

Topical Applications

Transdermal gels and creams are preferred as they maintain stable, physiologic levels and minimize side effects. Apply to clean, dry skin (outer thigh, buttocks, or abdomen). Wash hands afterward and avoid skin contact until dry.

Example: 1% cream (0.5 mL = 5 mg). Avoid use in pregnancy or potential pregnancy. Rotate application sites to prevent irritation.

Genital DHEA Cream

Vaginal DHEA cream alleviates postmenopausal symptoms such as dryness, burning, and pain during intercourse. It acts locally, converting to estrogens and androgens to improve tissue thickness, elasticity, and moisture without significantly raising systemic hormone levels.

Typically applied nightly for 2–3 months, then 3–4 times per week. Avoid in women with hormone-sensitive cancers or unexplained vaginal bleeding.

Use with Estrogen

Testosterone is often combined with estrogen therapy in postmenopausal women. Guidelines recommend at least 3 months of estrogen therapy before adding testosterone. Estrogen enhances androgen receptor sensitivity but oral estrogen increases SHBG, reducing free testosterone.

In women on aromatase inhibitors (e.g., breast cancer treatment), testosterone may help vaginal symptoms without converting to estrogen.

Potential Benefits

• Improved sexual desire and function (HSDD)
• Possible support for energy, mood, and muscle health (limited evidence)
• Enhanced cognitive sharpness and memory; low levels linked to cognitive decline and Alzheimer’s risk

Potential Side Effects / Risks

• Mild acne, facial hair growth, oily skin (reversible with dose adjustment)
• Rare: voice deepening, clitoromegaly, scalp hair loss, mood changes
• Minimal short-term effects on lipids, blood pressure, or glucose; long-term risks unknown

Contraindications

• Pregnancy or breastfeeding
• Hormone-sensitive cancers (e.g., breast, endometrial)
• Severe heart, liver, or kidney disease
• High baseline testosterone or untreated PCOS
• Premenopausal women (except under specialist supervision)

Menopausal Jawline Acne: Why?

Menopausal acne typically appears around the chin and jawline due to hormonal imbalance. As estrogen drops, the relative effect of androgens (e.g., testosterone) increases, stimulating oil production and clogging pores. Stress, genetics, and diet can worsen it. Acne during testosterone therapy may indicate that the dose needs adjustment.

References

• Jones RD. Clin Sci (Lond). 2004;107(2):149–58.
• Kaczmarek A, et al. Int J Cardiol. 2003;87(1):53–7.
• Cardinale DA. Front Physiol. 2020;11:596913.
• Barrett et al. Testosterone deficiency predicts mortality in women with HFrEF. T.O.S.C.A. Registry. 2022. DOI:10.1002/EHF2.14117