Testosterone Therapy for Women

The Hormone Nobody Talks About

When we talk about women's hormones, we almost always mean estrogen. When we talk about testosterone, we almost always mean men.

This framing is not just inaccurate — it has caused measurable harm to women's health. It has led to a systematic underrecognition of testosterone deficiency in women, the dismissal of women's hormone-related symptoms, and the near-complete absence of testosterone therapy from standard women's healthcare.^[1]

Women produce testosterone. The ovaries produce approximately 25% of circulating testosterone in premenopausal women. The adrenal glands produce additional amounts. Total testosterone in women is approximately 10% of the level in men — but that lower level is no less physiologically significant.

"Sexual health is health. And yet — we don't talk about women's testosterone. We talk about estrogen, we talk about progesterone. But the hormone that plays a critical role in women's sexual desire, energy, muscle mass, bone density, and cognitive function? That one we mostly ignore." — Dr. Rachel Rubin, MD, urologist and sexual medicine specialist

What Testosterone Does in Women's Bodies

Sexual Function and Desire

This is the most well-documented role of testosterone in women. Testosterone is the primary hormonal driver of sexual desire — in both men and women. The sharp, sustained decline in testosterone during and after the menopausal transition is a major contributor to the loss of sexual desire that affects the majority of postmenopausal women.^[4]

Energy and Vitality

Women with low testosterone consistently report decreased energy, reduced sense of well-being, and fatigue that does not improve with rest. Multiple controlled studies have demonstrated that testosterone therapy in women with low baseline levels improves energy ratings and quality-of-life measures.^[5]

Muscle Mass and Physical Function

Testosterone supports muscle protein synthesis. The decline during menopause contributes significantly to the loss of muscle mass (sarcopenia) and strength that accelerates in postmenopausal women. Resistance exercise supports muscle maintenance, but when testosterone is deficient, even aggressive strength training may not fully compensate.^[6]

Bone Health

Testosterone contributes to bone formation and helps maintain bone mineral density. While estrogen is generally considered the primary sex hormone involved in maintaining women's bone health, the role of testosterone is significant and often underappreciated.^[7]

The Clinical Evidence

NAMS 2022 Position Statement

The North American Menopause Society's 2022 position statement concluded: "The use of systemic testosterone for the treatment of hypoactive sexual desire disorder in postmenopausal women is supported by evidence."^[9]

ISSWSH Clinical Practice Guideline (2021)

The International Society for the Study of Women's Sexual Health issued a landmark guideline recognizing systemic testosterone therapy as effective for the treatment of HSDD in postmenopausal women, based on a comprehensive review of randomized controlled trial data.^[10]

The Lancet Meta-Analysis (2019)

Islam et al. published a systematic review and meta-analysis of 46 randomized controlled trials involving nearly 13,000 women. Key findings: significant improvements in sexual function with testosterone therapy, no serious adverse events at physiological doses, and no cases of virilization at physiological doses.^[11]

The Glynne Study (2025)

A retrospective cohort study of 510 women using transdermal testosterone cream for persistent low libido, cognitive symptoms, and mood changes during perimenopause and postmenopause found significant improvements across all symptom domains after 4 months of treatment.^[12]

HSDD: The Condition No One Talks About

Hypoactive Sexual Desire Disorder (HSDD) is the most common female sexual dysfunction diagnosed in clinical practice, affecting approximately 40% of postmenopausal women.^[13]

HSDD is defined as:^[13]

• Persistently or recurrently deficient or absent sexual fantasies and desire for sexual activity
• The symptoms cause marked personal distress or interpersonal difficulty
• The symptoms are not better explained by a nonsexual mental disorder, medical condition, medication effects, or severe relationship distress

The condition is not about attraction, not about relationship satisfaction, not about "just getting older." It is a recognized medical condition with measurable biological correlates and an evidence-based treatment.

How Testosterone Therapy Works for Women

The Critical Distinction: Women's Doses vs. Men's Doses

The doses used in women's testosterone therapy are approximately 1/10th of the doses used in male TRT. The goal is to restore premenopausal physiological testosterone levels — not to produce male-range androgen levels.

Transdermal Is Preferred

For women, transdermal (topical) testosterone — gel or cream applied to the skin — is the preferred delivery method because it provides steady-state hormone levels, allows for precise low-dose titration, and avoids first-pass liver metabolism.^[15]

Safety: Separating Evidence from Fear

The most common concern about testosterone therapy in women is the risk of virilization. At physiological doses — the doses used in properly prescribed women's testosterone therapy — the 2019 meta-analysis found no cases of virilization across 46 randomized controlled trials involving nearly 13,000 women.^[11]

Cardiovascular Safety

In February 2025, the FDA removed the cardiovascular black box warning from all approved testosterone products based on the TRAVERSE trial (NEJM, 2023) — which found no increased risk of adverse cardiovascular events in men using testosterone for hypogonadism. Physiological testosterone therapy in women has not been associated with increased cardiovascular risk in the available evidence. The FDA's February 2025 action reflects this evidence base.

Current evidence suggests physiological testosterone does not increase breast cancer risk and may have a protective effect in some contexts. Testosterone is not recommended as treatment for women with a history of breast cancer without specialist consultation.

The Systemic Barriers Women Face

• Medical education gaps — Most physicians receive minimal training in menopause and women's hormone health
• Regulatory gaps — There is currently no FDA-approved testosterone product labeled for women in the US — though the January 2026 FDA development pathway guidance for women's testosterone (Aviva Bio AVA-291) signals that an approved product may be achievable within the next several years
• Clinical bias — Women's symptoms have historically been attributed to psychological causes
• The WHI legacy — The 2002 Women's Health Initiative created lasting fear around hormone therapy in women. The FDA's November 2025 action formally removed the black box warnings that were based on the WHI findings, declaring them unsupported by the full evidence base. The regulatory climate is shifting — but it will take time for clinical practice to catch up.

What to Ask Your Provider

Finding the Right Provider

The most important factor in getting appropriate care is finding a provider who takes women's hormone health seriously.

• NAMS-certified Menopause Practitioners (NCMPs) — physicians who have passed the National Menopause Society certification exam
• Sexual medicine specialists — ISSWSH members, physicians with fellowship training in sexual medicine
• Endocrinologists with a focus on women's health