Testosterone is produced in the ovaries and adrenal glands throughout a woman's reproductive life. Levels begin declining gradually from the mid-30s onward, independent of menopause, and by the postmenopausal years circulating testosterone is typically 50% lower than in young adulthood.

Despite this, testosterone therapy for women receives far less clinical attention than estrogen therapy, partly because no regulatory body has approved a female-specific testosterone formulation in most countries. Women who receive it are using male products off-label at much lower doses. This regulatory gap has contributed to significant inconsistency in prescribing and monitoring.

The evidence base is now substantial enough that multiple major international societies have issued formal guidance supporting testosterone use for a specific indication: hypoactive sexual desire disorder (HSDD) in postmenopausal women.

The Evidence Base

In 2021 the International Society for the Study of Women's Sexual Health (ISSWSH) published the first formal clinical practice guideline for testosterone use in women.[1] This guideline drew on a systematic review of 36 randomised controlled trials covering more than 8,000 women, and its conclusions were endorsed by the British Menopause Society, the International Menopause Society, and the Endocrine Society.

The recommendation: transdermal testosterone at physiological female doses (targeting a serum testosterone in the premenopausal female range, roughly 150–300 micrograms per day) for postmenopausal women with HSDD.[1]

HSDD is defined as persistent or recurrent deficiency of sexual desire accompanied by personal distress. The distress component matters: many women have lower desire in midlife without finding it distressing, and treatment is appropriate for those who do.

The Davis et al. randomised trial (the largest single trial in this area, with 814 postmenopausal women) found that transdermal testosterone at 300 mcg/day produced significant improvements in sexual dysfunction and reductions in personal distress compared to placebo, in women not receiving concurrent estrogen therapy.[2]

What Testosterone Improves

The evidence is strongest for four specific outcomes:[1][2]

Sexual desire increases in most women who achieve physiological testosterone levels. This is the primary evidence base and the reason HSDD is the established indication.

Sexual arousal and response improve alongside desire. Many women report not just greater frequency of wanting sex but easier arousal and more reliable orgasm response.

Satisfaction with sexual activity and reduction in the distress associated with the desire deficit are the outcomes measured in trials, and both show consistent improvement.

Genitourinary sensitivity may improve, though this is less well studied and is partly addressed by local estrogen for GSM separately.

Claims That Outrun the Evidence

Energy and fatigue: The idea that testosterone restores energy in postmenopausal women is widespread and plausible given testosterone's role in male physiology, but clinical trial evidence is not strong enough to support prescribing for fatigue as a primary indication. Some women report more energy as a secondary effect, but controlled trial data are limited.

Cognitive function: There are mechanistic reasons to expect testosterone might support cognition, and some observational data are promising, but high-quality RCT evidence for cognitive outcomes in postmenopausal women is insufficient to make confident claims.

Mood: There is a general association between testosterone levels and mood in some studies, and women on testosterone occasionally report mood improvements. The data do not support testosterone as a treatment for mood disorders in women.

These reflect the honest state of the evidence, not a dismissal of reported benefits.

Prescribing and Monitoring

Because no female-specific formulation is approved in most countries, prescribers use male testosterone gel or cream at doses adjusted downward to produce female-physiological blood levels.

Target blood level: serum total testosterone in the upper premenopausal female range, well below the male reference range. Prescribing beyond this target increases androgenic side effect risk without evidence of additional benefit.

Monitoring should include testosterone levels at baseline and at three to six months after starting, to confirm the dose is producing appropriate rather than supraphysiological levels.

The transdermal route (gel or cream applied to the inner thigh or abdomen) is preferred over injection, which produces unstable and often supraphysiological peaks.

Side Effects at Appropriate Doses

Virilisation, voice change, and clitoral enlargement are associated with supraphysiological doses (male-range blood levels). At female-physiological doses, the reported incidence of androgenic side effects is below 5%.[1]

The most common side effects at appropriate doses are: - Acne or oily skin, typically mild - Increased facial or body hair (hirsutism), mild and reversible on stopping

Both are dose-dependent. Keeping testosterone in the premenopausal female range significantly reduces their likelihood.

Long-Term Unknowns

Long-term data on cardiovascular outcomes, breast cancer risk, and bone health for women using testosterone are limited. The trials conducted to date have not been large enough or long enough to detect small differences in rare outcomes.

The ISSWSH guideline notes there is no evidence of harm at physiological doses based on available data, while acknowledging this is not the same as established long-term safety.[1] Women considering testosterone should understand that it is supported by a meaningful RCT evidence base for sexual function, that no specific safety signals have emerged, and that long-term safety data beyond five years are sparse.

Who Should Consider It

Testosterone therapy is most clearly indicated for postmenopausal women with significantly reduced sexual desire that causes personal distress, who have already had other relevant factors evaluated: relationship dynamics, genitourinary symptoms, medications affecting libido, mood, and sleep.

HSDD is underdiagnosed because many women do not raise it with clinicians. Reduced sexual desire causing significant distress is a clinically recognised condition with an evidence-based treatment. Raising it directly with a prescriber is appropriate.

References

[1] Parish, S. J., Simon, J. A., Davis, S. R., et al. (2021). 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. Journal of Sexual Medicine, 18(5), 849-867. https://pubmed.ncbi.nlm.nih.gov/33797277/

[2] Davis, S. R., Moreau, M., Kroll, R., et al. (2008). Testosterone for low libido in postmenopausal women not taking estrogen. New England Journal of Medicine, 359(19), 2005-2017. Cited in: Clinical management of testosterone replacement therapy review. https://pmc.ncbi.nlm.nih.gov/articles/PMC9674516/