Unleash the power of testosterone in menopause: an in-depth 2023 review

Our comprehensive review of testosterone for menopause answers all your questions. What benefits can you expect, are there any side effects, and how can you get it?

Is testosterone is the missing component of your menopausal hormone replacement therapy

Hormone replacement therapy (mHRT) with oestrogen and a progestogen is widely understood and accepted. mHRT can offer effective relief from menopausal symptoms like hot flashes, night sweats, mood swings and more. It can also protect against the long-term effects of menopause, like weakened bones, fractures, and even dementia. The use of testosterone for menopause, however, is still somewhat controversial.

For many, testosterone is the classic male hormone. Why on earth would a woman want to take it? As we’ll see, testosterone plays a vital role in women’s health, and testosterone replacement may be the missing piece in your menopausal hormone replacement regime.

However, there’s much confusion and misinformation around the use of testosterone for menopause. Even the average doctor is somewhat in the dark about its safety and effectiveness in menopause. We’re going to take a deep dive into all things testosterone to give you a comprehensive and evidence-based review of testosterone therapy for menopausal symptoms. We’ll explore the benefits and potential risks of testosterone therapy, explain how to determine if testosterone may be right for you, how to get it and use it, and how best to approach your doctor to discuss treatment options.

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Ten things you need to know about testosterone in menopause

Short on time to read everything? Here’s the top line:

1. The testosterone level in your body is more than ten times higher than that of oestrogen. Testosterone plays a vital role in women, maintaining muscle mass and bone strength, helping to regulate temperature, mood, sleep and coordination. It’s also crucial for your sex life. It strengthens and supports the sexual organs and supporting tissues, aiding vaginal lubrication and stimulating sexual desire.

2. Testosterone levels fall slowly from your twenties onwards, without the abrupt drop you see with oestrogen at menopause.

3. Lower testosterone levels affect some women but not others, causing vague symptoms like fatigue, a loss of energy and mood swings. Most importantly, it can lead to a lack of interest in sex.

4. Testosterone can be prescribed at menopause if you have a decreased interest in sex that’s causing you distress or harming your relationships, provided there is no other untreated cause, and your testosterone is in the lower half of the normal range.

5. For most women, treatment is with a cream or gel applied to the skin of your outer thigh or buttocks once a day.  It’s usually taken alongside standard mHRT with oestrogen and often a progestogen.

6. Because testosterone products are not licenced for women in most countries, it may be a little challenging to get it prescribed for you. You may have to pay for a private prescription or pay for it yourself rather than through your insurance.

7. In studies, testosterone replacement therapy can double or triple the level of sexual desire, the frequency of sex, and the number of orgasms and satisfying sexual events.

8. When taken as a gel or cream, studies have shown few, if any, side effects. There’s a slight increase in the number of women reporting acne (7 in 100 vs 5 in 100 on placebo), but that’s all. You’ll need occasional blood tests to ensure your blood level stays in the normal range. If it goes too high, you’ll have a greater risk of side effects.

9. There have been concerns that testosterone HRT may cause an increased risk of cardiovascular disease, breast cancer and liver disease. In studies, no increased rate of these conditions has been seen. Whilst this is reassuring, there aren’t many studies lasting more than two years, so we are less knowledgeable about long-term risks.

10. There are a few reasons why you may not be able to take testosterone. The most important reasons are if you are pregnant or breastfeeding or have a high risk of cardiovascular disease, high cholesterol, liver disease or signs of testosterone excess. If you have ever had hormone-sensitive cancer, such as breast, ovarian or uterine, you should talk to your cancer specialist before starting testosterone.

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Have specific questions? Jump straight to the information you need.

What is testosterone, and what does it do?

Falling hormone levels and the symptoms of menopause

Throughout your reproductive life, the number of eggs in your ovaries falls from between one and two million at birth to no more than ten thousand by the time you reach forty. Since much of the body’s oestrogen is produced in the ovaries by developing egg follicles, oestrogen production falls as the number of eggs reaches these low levels. As a consequence, most women experience symptoms such as hot flashes and night sweats, brain fog, mood swings, disturbed sleep, vaginal dryness, dry skin and more. But oestrogen and progesterone aren’t the only hormones produced by the ovaries; they also produce testosterone. Testosterone levels also fall in mid-life, and this, too, has consequences for your health.

What is testosterone?

Testosterone is vital for women’s health, as we will see. In women, the ovaries produce about a quarter of the testosterone and other ‘male hormones’ (androgens). An equal amount is produced by the adrenal glands – fortune cookie-sized glands that sit on top of the kidneys. The remainder is made in other body tissues by converting intermediate compounds produced by the adrenal glands and ovaries [1].

How do testosterone levels differ in men and women?

Men typically have much higher levels of testosterone than women. On average, a man’s body produces ten times more testosterone than a woman’s. This difference in the balance of testosterone and oestrogen levels is the primary reason men and women develop different physical characteristics. That’s right, not only do women have testosterone, but men have oestrogen too.

You’ll likely be surprised to hear that testosterone levels in premenopausal women are around ten times higher than levels of estradiol, the primary type of oestrogen.

What happens to testosterone in menopause?

How do testosterone levels change during menopause?

How many people are affected by low testosterone?

Because there’s such an overlap between symptoms due to low oestrogen and those due to low testosterone, it’s hard to know how many women are affected.

Because a rapid fall in testosterone is more troublesome than a gradual decline, a quarter of women aged 20 to 49 who had surgical menopause caused by the removal of their ovaries suffer from HSDD [4].

Testosterone replacement therapy for menopause

What are the benefits of testosterone replacement therapy in menopause?

In 2020, experts from ten societies with expertise in women’s health reviewed all available data. They developed a global position statement to guide doctors on using testosterone replacement during menopause [4]. A further ten organisations subsequently endorsed their position. They concluded that the only compelling evidence for using testosterone is to treat low sexual desire in postmenopausal women, specifically where it is causing significant distress – known as hypoactive sexual desire disorder (HSDD), and only after other causes had been excluded.

At the moment, there is no clear evidence of any other benefits from testosterone replacement therapy for menopause

We know that testosterone is important for maintaining bone strength. We also know that women with naturally higher testosterone levels are 40% less likely to have a hip fracture [6]. So it’s possible that taking testosterone replacement therapy may reduce the risk of fractures, but so far, we don’t have any long-term clinical studies to show if this is the case.

Many women report that taking testosterone brings additional benefits, like helping them think more clearly and having more energy or zest for life. To date, there has been no convincing evidence from any clinical studies of benefits from testosterone on mental sharpness, mood, energy or musculoskeletal health. One study did show that taking testosterone was associated with fewer menopausal symptoms overall [7].

Some experimental evidence shows that testosterone may protect against brain changes that can lead to dementia. So far, we don’t have long-term studies to establish whether this happens in real life.

What are the risks of testosterone replacement therapy for menopause?

As time goes by and evidence accumulates, confidence grows that testosterone can be a safe and effective treatment for low libido in menopause. However, official bodies remain cautious about recommending or approving its use because of theoretical risks.

The three principal concerns worry experts about testosterone treatment for menopause. These are increasing the risk of heart disease and breast cancer and of so-called virilization, which can lead to the development of masculine characteristics like acne, balding, facial hair growth and enlargement of the clitoris. So how do these concerns stack up in the real world?

The only significant side effect of testosterone replacement therapy seen to date is acne

As we have seen, a meta-analysis (where the results of many studies were combined) showed how effective testosterone can be at treating low libido [5,29]. That same analysis also looked at side effects. It did show increased rates of acne. Seven percent of women treated with testosterone for menopause had acne compared to 5% of those who didn’t take testosterone. Aside from that, the studies didn’t show any cause for concern. There was no difference in the number of women noticing increased facial hair (15% vs 14%), hair loss from the scalp (4.5% vs 4.4%), or deepening of the voice (3.8% vs 3.4%) [4,8,9].

Clinical trials have not shown any increase in heart attacks

Concerns about an increased risk of cardiovascular disease arise because testosterone can increase bad cholesterol and decrease good cholesterol. This is seen if you take testosterone as tablets. However, testosterone doesn’t appear to significantly affect cholesterol levels when used through the skin as a cream or gel.

There has been no evidence from clinical trials of more heart attacks in women taking testosterone [9]. This is encouraging, and there is even evidence that testosterone may protect against cardiovascular disease [10]. That said, few studies lasted longer than two years, so we still don’t have a definitive answer.

Concerns that testosterone might increase breast cancer rates have so far proven unfounded

People have worried that testosterone treatment might increase the risk of breast cancer. That’s because oestrogen can increase the risk of breast cancer, and testosterone can be converted to oestrogen by an enzyme called aromatase. There’s lots of aromatase in breast tissue, so some scientists worry that taking testosterone may lead to higher oestrogen levels in the breast which might increase the risk of breast cancer.

The meta-analyses that combined many studies of testosterone for menopause looked at this. The two-year follow-up period for most studies is too short to give meaningful results for a disease like breast cancer that takes a long time to develop. However, reassuringly, there were no changes in breast density, suggesting testosterone has little effect on the breast [5,29].

More reassuring was a study of 1267 women taking testosterone for ten years. These women had a 39% lower rate of breast cancer [11]. In another, women taking testosterone had a 36% lower rate of breast cancer [12]. Indeed, even women with previous breast cancer had no signs of recurrence. Because women taking testosterone had lower breast cancer rates, it is now being investigated as a potential breast cancer treatment. These results are certainly encouraging. However, we still don’t have much safety data for treatment with testosterone lasting more than two years.

No other safety concerns have been seen when testosterone is used as a cream or gel

High blood levels of testosterone, which occur when you take it as tablets, can cause abnormalities in the liver and even increase the risk of liver cancer. An early sign of these changes is raised levels of liver enzymes, easily seen in standard blood tests. Neither these liver changes nor raised liver enzymes in the blood have been seen with testosterone given through the skin [5].

Women with higher natural levels of testosterone have higher rates of depression. However, no increased rates of depression have been seen in trials of testosterone therapy [5].

Finally, studies of testosterone given through the skin as gels and creams have shown no effects on blood sugar or kidney function tests [5].

How does testosterone treatment for menopause compare with other hormone therapies?

Testosterone isn’t an alternative to conventional menopausal hormone replacement therapy (mHRT) with oestrogen plus or minus a progestogen. Oestrogen levels plummet around menopause, causing many short-term symptoms and long-term complications. Replacing oestrogen usually gives significant relief from menopausal symptoms. It also has lasting benefits – protecting bone strength and likely reducing the risk of dementia and heart attacks, so long as it’s started before age 60 and within ten years of the final menstrual period. You’ll also need a progestogen if you still have your uterus to prevent oestrogen from causing an overgrowth of the uterus lining, which increases the risk of uterine cancer.

Testosterone can’t replace these actions of standard mHRT, but it can be a helpful addition. With our current knowledge, testosterone is recommended to improve sexual desire and sexual enjoyment, where low levels lead to distress. As our understanding increases, it may find other uses.

Testosterone is usually given after standard mHRT has been taken for a while and has not adequately improved sexual desire and enjoyment. Where vaginal symptoms such as dryness or pain during intercourse are significant, vaginal oestrogen can be very effective. With regular mHRT, oestrogen levels in the vagina are typically not high enough to give much relief.

How do I get menopausal testosterone replacement therapy?

How do I know if testosterone therapy is right for me?

Testosterone is only recommended for the treatment of low sexual desire. More specifically, it can be prescribed for a condition called hypoactive sexual desire disorder (HSDD). What that mouthful means is that someone has a low level of sexual desire, AND they are distressed by it, AND there’s no other explanation. You must also have a blood testosterone level in the bottom half of the ‘normal’ range. Let’s take this step by step.

1. Do you have hypoactive sexual desire disorder (HSDD)?

The official definition says you have HSDD if, for at least six months, you have had:

a) A lack of motivation for sex, as shown by

  – Having few or no spontaneous sexual thoughts.

  – Not responding to sexual cues or stimulation or being unable to maintain interest through sexual activity.

  – Not wanting to initiate or participate in sex, including avoiding situations that could lead to sex.

AND

b) The situation is causing you distress, such as frustration, worry, grief, sorrow, sadness, or a sense of loss, or is harming your relationship.

AND

c) Your problems are not due to some other cause. Human sexual desire is very complex and easily disturbed.  There are many reasons why you may lose interest in sex, such as those listed in the table. To check for any of these conditions, your doctor will need to look into your medical history, ask about new symptoms, examine you and arrange some blood tests.

You should expect your doctor to ask about your general physical health, other medical conditions, relationship difficulties, and other psychological causes of stress and to enquire about cultural or religious values which may influence how you think about sex [4].

You shouldn’t expect testosterone to be a Band-Aid for other medical or psychological issues. However, neither are they a reason why you cannot use testosterone. It may be appropriate to use testosterone replacement at the same time as other issues are being addressed.

Have you had little interest in sex for at least six months?  YES [ ]   NO [ ]

Does your lack of interest in sex cause you distress?   YES [ ]   NO [ ]

Have all the conditions or issues listed in the table been excluded or appropriately addressed?   YES [ ]   NO [ ]

If you can answer yes to these three questions, you meet the HSDD criteria. You and your doctor should consider whether testosterone might be right for you.

2. Is your testosterone in the bottom half of the ‘normal’ range?

Testosterone blood tests are a little more complicated than other blood tests you might be used to. That means that interpreting testosterone levels isn’t always straightforward. You can find out more about understanding your testosterone levels here.

Blood levels of testosterone vary throughout the day. You should have your blood taken in the morning when levels are highest. They also vary with your periods, peaking mid-cycle.

The ‘normal’ ranges for blood tests can vary from one laboratory to another, depending on the method they use. The normal range for a lab will be shown on the lab report along with your result. A typical normal range for total testosterone might be 27 – 40 ng/dL (0.94 – 1.39 nmol/L) [13].

This means that in this example, your testosterone would be in the bottom half of the normal range if it is less than 33.5 ng/dL or 1.16 nmol/L.

Calculating if your testosterone is in the bottom half

You can work out the middle of the range by adding the figures for the top and bottom of the range and then dividing by two. In our example, 27 + 40 = 67, then 67/2 = 33.5.

Your lab will likely have a different normal range and may give the results in different units. You may want to ask your doctor for help interpreting the result.

Because your testosterone levels can vary, your doctor may want to check your level more than once before deciding to prescribe testosterone.

Is your testosterone level lower than the mid-point of the lab’s normal range?   YES [ ]   NO [ ]

Your doctor can prescribe testosterone if your blood testosterone is in the bottom half of the normal range for your age.

3. Is there a reason why you should not take testosterone?

There are a few situations in which most doctors would not prescribe testosterone. The key reasons are:

4. You are at a high risk of fatal cardiovascular disease (> 5%) [10]. This risk can be calculated using factors such as your weight, smoking, and exercise and measurements such as your blood pressure and cholesterol levels. There are online tools to calculate your risk, such as the one at the American College of Cardiology.

5. You have high cholesterol.

6. You have signs of excess testosterone, such as acne, excessive facial hair growth, and balding. All of these can be features of menopause, so it’s a question of degree.

7. You have liver disease.

8. You are taking testosterone-blocking medication such as spironolactone, finasteride or dutasteride. These are sometimes used by women to reduce excessive hair growth or other signs of testosterone excess.

9. You are a competitive athlete. It may be okay to take testosterone, but you would need to keep your testosterone levels well within the normal range. You should check with an expert in this area.

Is there a reason why you would not be able to take testosterone?   YES [ ]   NO [ ]

Your doctor can prescribe testosterone provided there are no reasons why it may not be safe for you.

4. Have you already tried standard menopausal hormone replacement therapy?

Regular mHRT with oestrogen plus or minus a progestogen often does improve sexual desire. It can also help with vaginal symptoms such as dryness or pain during sex. However, vaginal oestrogen is much more effective for that. For this reason, testosterone is not usually recommended until you’ve given mHRT a trial for a few months.

Taking oestrogen HRT by mouth lowers your testosterone. So you should take oestrogen through the skin as a patch, gel or spray rather than by tablet.

Have you taken mHRT (through the skin) for several months but found it didn’t improve your sexual desire and enjoyment enough?   YES [ ]   NO [ ]

Since standard mHRT may improve your symptoms, you should try it for several months before adding in testosterone.

I’m ready to try testosterone replacement therapy. What happens next?

Your doctor will want to go through the same process we have here:

• Talk to you to see if your symptoms fit with a diagnosis of hypoactive sexual desire disorder.
• Assess if any physical or psychological issues need to be addressed first or at the same time. This will likely involve discussing sensitive topics, an examination and blood tests.
• Ensure your blood testosterone level is in the bottom half of the normal range.
• Be sure there is no reason why you should not use testosterone

That means you likely won’t get a testosterone prescription immediately. You’ll need to see your doctor again once all the results are back.

Once you decide to try testosterone, you should be on oestrogen HRT through the skin as a patch, gel or spray rather than by tablet. That’s because taking oestrogen by mouth lowers your testosterone, which would defeat the purpose of using it.

Your doctor will most likely prescribe testosterone as a cream or gel. After using it for a couple of months, your doctor will want to see you to ask if you are starting to see benefits, but more importantly, to ensure you aren’t getting too high of a dose.

How is testosterone supplied, and how do I use it?

A big challenge with testosterone for women is that Australia is the only country that has licenced a product made specifically for women. As we’ve seen, testosterone levels in men are ten times higher than in women, which means the testosterone preparations for men are ten times too strong for women. More accurately, the individual doses are ten times too large.

AndroFeme 1: The only testosterone product designed for women

If you’re not in Australia, your doctor can still get AndroFeme 1 and have it delivered directly to you. Ask your doctor to contact the manufacturer, Lawley Pharmaceuticals, at www.doctordirect.com.au.

Outside of Australia, Japan, South Africa, the United Kingdom and Ireland, Lawley has partnered with Tanner Pharma Group. Your doctor can email them at androfeme@tannerpharma.com to get details.

In March 2023, Lawley applied for licensing of AndroFeme in the UK. It will likely take some months before a decision is made. If it is licenced, it is likely to become available through a regular NHS prescription.

Using testosterone products designed for men

If you don’t use AndroFeme 1, you will most likely use a cream or gel made for men. Typically the starting dose for men is 50mg/day, while for women, it is 5mg/day. That means you’ll need to use one-tenth of the dose recommended for men.

As you’ll see from the table below, getting the correct dose from a pump can be tricky. How do you measure a quarter or a fifth of a pump? If you have a 1% gel, the amount required for 5mg testosterone (a typical starting dose) is 0.5 ml, an amount of gel slightly larger than a pea and around the size of an edamame or baked bean, as you can see in the videos below.

You can use a syringe to measure any testosterone gel accurately

While AndroFeme 1 receives a lot of praise for being the only product designed for women, it contains 1% testosterone, just like most of the products for men. It is supplied with a small syringe which you use to measure the 0.5ml dose, as explained in the videos below. There’s nothing special about the syringe other than being pink, so you can get a syringe and use it for gels made for men. Be sure to rinse it out after each use.

How do I apply the gel or cream?

You should apply the required amount of gel or cream to the clean, dry skin of your outer thigh or buttock, rubbing it in until it has been absorbed. You should not apply elsewhere, particularly not to broken or inflamed skin or around the vulva or vagina or nearby skin. Once it’s dried, you should cover the treated area with clothes to avoid contact with other people.

As soon as you have applied the cream or gel, you should wash your hands thoroughly with soap and water. This is important to prevent transferring testosterone to other areas of your body or other people.

It’s best to apply it at the same time each day. Testosterone levels are naturally higher in the mornings, so that may be a good time to use it if you can make it fit your schedule.

Why it’s a bad idea to apply testosterone to your genitals

In online forums, some women suggest applying the cream or gel to the vulva, clitoris or nearby areas, suggesting that this improves sexual enjoyment. This is not a good idea. With higher doses of testosterone, for example, with testosterone tablets, one of the side effects sometimes seen is significant enlargement of the clitoris. In the womb, it’s testosterone that causes the genitals of the young foetus to develop into a penis or remain small as a clitoris. They both have the same origin.  Enlargement of the clitoris hasn’t been seen with testosterone used as a cream or gel when used as recommended because levels in the clitoris are low. However, if you apply it to the genital area, levels of testosterone in the clitoris will be a lot higher, and this could lead to clitoral enlargement.

Why is it so important to wash my hands after use and cover the treated area with clothes?

Clearly, it’s essential not to expose anyone else to your testosterone or other hormone replacement therapy. They should be stored out of reach of children and pets, and empty packaging should be disposed of carefully. You should wash your hands thoroughly with soap and water after handling testosterone or HRT, then cover patches or treated skin with clothes and keep children and pets away from these areas. Before allowing treated skin to come in contact with others, you should wash it thoroughly with soap and water.

Are there other forms of testosterone apart from gels and creams?

Testosterone is also available as tablets, long-acting injections, patches and implants.

Avoid testosterone tablets and injections

Three of these you shouldn’t be considering. Absorption of testosterone tablets isn’t very predictable, and blood levels can go too high. Taking testosterone by mouth can raise your cholesterol and seriously affect your liver. Long-acting testosterone injections also lead to blood levels that are too high, putting you at a higher risk of side effects.

Don’t use men’s patches. A patch for women is in development

The patches are well-designed and release testosterone gradually, just like oestrogen patches. The problem is that they were developed for men, so the dose is far too high for women. Because of the way they are designed, you can’t cut them into tenths and expect the same gradual release.

A British company, Medherant, is developing a testosterone patch for women, with clinical studies expected to start later in 2023.

Testosterone implants and pellets are not recommended by menopause experts

That leaves implants. These can be non-absorbable silicone implants or absorbable pellets, which gradually release testosterone. Supporters say they offer more consistent blood levels and the convenience of being long-lasting. Some implants can last for 38 to 48 weeks.

However, when experts from around the world agreed on their global position statement, they decided not to recommend the use of testosterone implants. They argued that the release of testosterone from implants can be erratic and result in blood levels above the normal range. If this happens and you develop side effects, it can be difficult to locate and remove the implants or pellets [4].

The only commercial implant for women was withdrawn from the market, so now they must be made by compounding pharmacies. Unlike pharmaceutical companies, manufacturing processes at compounding pharmacies are less well-regulated, which means less confidence regarding quality, dose and safety. Also, their implants have not been tested in clinical trials. You really can’t be sure what you’re getting.

What this means is that there are not currently any safe and effective alternatives to testosterone creams and gels.

Are compounded products better than commercial testosterone products?

If you search for testosterone online, it won’t be long before you come across clinics and pharmacies offering what they describe as bioidentical testosterone that can be tailored precisely to your needs. They may also suggest their products are more effective, low in allergens or have fewer side effects. They might even be cheaper.

What that means for you is that you cannot be certain of the quality of the ingredients you will receive or the dose. The product won’t have been tested in clinical trials, and the quality control will be down to the individual pharmacy rather than government regulators. Getting drugs to be absorbed through the skin can be a complex process. The composition of the gel or cream can be critical to how much testosterone is absorbed through the skin and how fast. Even though you may be supplied with a product with the correct testosterone concentration, you can’t be sure if you will absorb too much or too little. Typically only 10% of the testosterone applied is absorbed. This leaves lots of room for error with an imperfectly formulated product.

As a result of these variables and the lack of confidence that comes with them, experts do not recommend using compounded products [15].

Generic manufacturers are not the same as compounding pharmacies

It’s worth explaining that a generic manufacturer is quite different from a compounding pharmacy. Big pharmaceutical companies such as GSK, Abbott or Bristol Myers Squibb typically develop new medicines. In return for shouldering the enormous development costs, they are given a period of time when they are the only company allowed to market the new medicine. Once that time is over, other companies can manufacture the product; these are often generic brands.

Because the generic company didn’t have to pay for the development, they can sell it cheaper. Although they don’t have to run the large clinical trials needed to licence a new product, they do have to run small studies to show that the dose you get from their product is the same as that from the large pharmaceutical company’s product. These are known as bioequivalence studies. They are also subject to full regulation of their sourcing and manufacturing processes.

When can I expect to start seeing the effects of testosterone replacement therapy?

The results of testosterone treatment are not instant. You may start noticing results in four to six weeks. It may take up to a year for you to see the full benefits. If you’ve seen no improvement after six months, it’s time to review the dose and consider other factors that might be contributing to it not working for you – see below.

How will my treatment be monitored?

The general principle for monitoring testosterone treatment is to assess how much you feel it is helping while keeping an eye out for side effects and checking blood levels to ensure they haven’t gone too high. There isn’t a target blood testosterone level to aim for.

While on testosterone, you should have your blood total testosterone measured every four to six months to ensure it stays within the normal female range. You should also have your cholesterol and liver function tests checked annually [4].

How long should I take testosterone replacement for menopause?

This is a question without a clear answer. The standard advice has been to take it for as short a time as needed. The advice is driven by concerns that testosterone might increase the risk of heart disease or breast cancer. There may also be other risks we’re unaware of since there isn’t much experience with long-term treatment. As we gain more experience in long-term treatment, doctors are likely to become more confident in its use.

Many factors affect sexual desire. Once your sex life returns to a level you’re happy with, it may stay that way even without continuing testosterone. For this reason, your doctor may suggest taking a ‘drug holiday’ from testosterone after six to twelve months to see if you still need it.

If you find you still need testosterone, it will be down to a discussion between you and your doctor, taking into account your personal risk factors and weighing those against the benefits of continuing to use it, then reviewing that decision at least annually.

What if it’s not working?

If you have not seen any benefits after three to six months, your doctor will want to check your blood testosterone levels. If they are within the normal female range, your dose can be increased to 10mg daily, i.e. up to double the starting dose. You will need your blood testosterone levels checked after six to eight weeks to ensure the higher dose hasn’t pushed your blood level outside the normal range.

If you still don’t see any benefits, it’s likely time to give up on testosterone. Increasing the dose until your blood level is above the normal female range is not advisable. You will likely start to get side effects with little likelihood of getting the desired increase in libido.

Ask your doctor about your SHBG levels

Your doctor may check your blood levels of sex hormone binding globulin (SHBG). High levels of SHBG may mop up the testosterone you are using and stop it from working. You can read more about SHBG here and see what conditions can increase your SHBG. It may be possible to increase the effectiveness of testosterone by treating a condition that is raising your SHBG.

Oestrogen taken by mouth can increase your SHBG and lower your testosterone. Therefore, you should take mHRT through the skin as a patch, gel, or spray rather than by tablets if you are also using testosterone.

Suppose you are taking mHRT as a patch or gel and still have a high SHBG level and an inadequate response to testosterone. In that case, switching from standard mHRT with oestrogen +/- a progestogen to tibolone is an option. Tibolone is an mHRT alternative that can halve SHBG levels and increase testosterone’s effect [4]. Tibolone is not available in the US.

High doses of isoflavones have been shown to lower testosterone levels [16]. Isoflavones are one of a group of chemicals known as phytoestrogens. These are plant-derived chemicals that can mimic the effects of oestrogen in the body. Phytoestrogens, including isoflavones, are widely available in over-the-counter medicines for menopausal symptoms. If you find testosterone isn’t working for you, it is worth checking the contents of any over-the-counter medication you might be taking.

Should I take testosterone HRT if my blood level is low but I don’t have any symptoms?

Currently, experts don’t see any reason to take testosterone if you don’t have symptoms just because your levels are low. As we’ve seen, testosterone levels don’t correlate well with sexual desire, so your level might be perfectly fine for you.

In the future, it might become apparent that taking testosterone has other benefits, such as preventing cardiovascular disease or dementia. Equally, long-term testosterone might have unexpected risks we don’t know about yet. For now, it is only recommended if you fit the criteria described above.

I don’t have a lowered sexual desire. Can I try testosterone anyway to boost my energy and vitality?

You may have heard women say that taking testosterone boosted their energy levels or gave back the zest for life they had been missing. You may be wondering if it could do the same for you.

Even a brief look at online forums will reveal women who believe testosterone therapy significantly improved their well-being and others who feel it did nothing. Most doctors practice evidence-based medicine. They want evidence from well-conducted clinical trials showing a treatment is effective before prescribing it. The Hippocratic Oath requires doctors to ‘do no harm or injustice’ to their patients. Giving a medicine without evidence that it will do any good risks side effects (harm) without benefit.

This concern is even greater when a medicine is prescribed ‘off-label’, as testosterone is for women. In such cases, doctors have a greater responsibility to determine for themselves the balance of risks and benefits for their patients rather than relying on the guidance of drug manufacturers and regulators.

Clinical trials have not shown any evidence that testosterone improves mood, well-being, anxiety or depression [30]. For this reason, you may have difficulty persuading your doctor to prescribe testosterone unless you have symptoms of hypoactive sexual desire disorder, the only condition for which testosterone has been shown to be helpful.

How should I talk to my doctor about testosterone therapy for menopause?

In general, you’ll be able to have a better discussion with your doctor and have a higher chance of getting the best treatment if you understand enough to have an informed conversation, so it’s worth reading up about testosterone treatment first. If you’ve read this article, you probably already know more than most doctors!

If it’s not your regular doctor, they’ll want to know about any other medical conditions you have and what medicines or supplements you are taking.

What should I do if my doctor doesn’t seem willing to consider prescribing testosterone for me?

Firstly, you should consider the possibility that your doctor might be correct. Read through this article and see if there are reasons why testosterone is not recommended for someone in your situation.

Your personal circumstances are unique to you, so there may be other reasons why your doctor feels testosterone would not be suitable for you. Ask them to explain why they think testosterone isn’t the best solution to your issues. It may be that your doctor wants to exclude other problems or give sufficient time to assess other treatments, like regular mHRT. Perhaps they feel there are psychological or cultural factors that should be addressed first.

If you can’t see any reasons why testosterone therapy shouldn’t be tried, it may be worth making another appointment to see your doctor and bringing up the subject again. Reading this article or something similar should put you in an excellent position to explain why you think a trial of testosterone treatment would be worthwhile.

Off-label prescribing can lead doctors to be cautious about prescribing testosterone

Testosterone treatment for women isn’t especially widespread yet, so many doctors won’t be familiar with it. That may make them more cautious. Another important factor is that in most countries, testosterone for women is prescribed ‘off-label.’ That means it is being used for a situation not covered by the medicine’s licence in that country – for example, prescribing a men’s testosterone for a woman, or prescribing AndroFeme 1 in countries where it’s not licenced. Prescribing in this way comes with extra responsibilities for the doctor. If your doctor doesn’t feel they know enough about the use of a medicine in this way, they may not be willing to prescribe it. This isn’t a bad thing. We wouldn’t want doctors prescribing medicines when they don’t know how useful or safe they are.

Ask to see a specialist

If that doesn’t work, or if you’d rather see someone different, ask to see another doctor at the practice. There may be someone who specialises in menopause or women’s health.

The next option is to find a doctor knowledgeable and experienced in prescribing testosterone for women. This could be someone at a specialist government or private menopause clinic or a reproductive endocrinologist or gynaecologist. You can ask your doctor for a referral, or you may be able to make your own appointment.

Your doctor will be familiar with the services and specialists in your area and can refer you to an appropriate person. You can also find a specialist through online directories.

UK: The British Menopause Society website allows you to find an NHS or private specialist or menopause clinic near you.

Find a Menopause Specialist

US & Canada: The North American Menopause Society allows you to find doctors and nurse practitioners certified with the North American Menopause Society near you. They also list accredited members in other countries.

Australia & New Zealand: The Australasian Menopause Society website allows you to find a menopause specialist in Australia and New Zealand.

Ireland: There are specialist menopause clinics at the National Maternity, Coombe and Rotunda Hospitals in Dublin, Cork University Maternity Hospital, Nenagh Hospital in Tipperary, and Galway University Hospital.

Are there ways to boost my natural testosterone without taking testosterone replacement?

There are several natural methods and alternative remedies that may help to increase testosterone levels in women. However, it’s important to note that these methods have not been extensively studied, and their effectiveness is not well established. Talking to a healthcare professional before trying alternative remedies or supplements is always best.

Here are some complementary and alternative methods that have been suggested to increase testosterone levels:

Be aware that most supplements are not subject to meaningful regulations regarding quality, purity, contaminants, effectiveness or safety. These can all vary between manufacturers and even between batches. If you decide to try supplements, look for a reputable manufacturer.

Remember that while some of these remedies may have potential benefits for your health, they should not be used as a substitute for medical treatment. You should talk with your healthcare provider before taking any supplements or making significant changes to your diet or lifestyle. It’s also important to note that every woman’s experience of menopause is unique, and what works for one person may not work for another.

Comments

What has been your experience with testosterone? Did it bring additional benefits, like boosting your energy levels? How easy was it to get your doctor to prescribe testosterone for you? Do you have any tips that may help other people? Leave a comment below.