Testosterone in Menopause: What the Evidence Supports

Someone mentioned testosterone at a dinner party, or you read about it in a magazine, or your clinician brought it up when you described a libido that has gone silent. It used to be rarely discussed in the context of menopause. Now it comes up often enough that it is worth knowing what the evidence actually supports and where the gaps are.

The plain version: testosterone levels decline gradually with age in all women, not sharply at menopause. The strongest evidence for testosterone therapy in postmenopausal women is for low sexual desire that is causing distress, after other causes have been addressed. The benefit is modest but real. Evidence for other symptoms like fatigue, mood and cognitive function is limited. No testosterone product is FDA-approved for women in the US. Guidelines recommend low doses, monitoring, and time-limited use because long-term safety data in women are sparse.

What’s going on

Testosterone is often thought of as a male hormone, but women produce it too, primarily in the ovaries and adrenal glands. It plays a role in sexual desire, bone density, muscle mass, energy and mood [6]. Unlike estrogen, which drops sharply during menopause, testosterone declines gradually from the late twenties onward. By the time someone reaches their late forties, testosterone levels are roughly half of their peak, and the decline continues after menopause [6].

The question is whether this decline causes symptoms that warrant treatment. For some people, the answer appears to be yes, particularly when it comes to sexual desire. A 2019 global consensus statement, endorsed by multiple international societies including The Menopause Society, concluded that the only evidence-based indication for testosterone therapy in postmenopausal women is hypoactive sexual desire disorder (HSDD), meaning persistently low desire that causes personal distress [1].

A meta-analysis of 36 randomized controlled trials involving over 8,400 women found that testosterone therapy was associated with a modest but statistically significant increase in satisfying sexual episodes, sexual desire and self-reported sexual function compared with placebo [2]. The absolute improvement was modest. It did not transform anyone’s experience. But for people whose distress was significant, even a moderate improvement was clinically meaningful.

Is it the change, or something else?

May respond to testosterone	Overlaps with other conditions	Needs prompt attention
Persistent low desire causing distress, after other causes addressed	Relationship issues (a common contributor to low desire)	Virilizing symptoms at any dose (deepening voice, significant hair growth)
Low desire that did not improve with estrogen therapy alone	Depression or anxiety (both affect libido)	Rapid or marked mood changes after starting testosterone
Reduced sexual arousal and satisfaction alongside low desire	Medication side effects (SSRIs, beta-blockers commonly reduce desire)	Acne or hair changes that are distressing
	Fatigue from sleep disorders, thyroid disease or anemia	Abnormal lipid changes on blood work

Low sexual desire in midlife has many potential contributors, and testosterone is not always the answer. A clinician should evaluate relationship factors, medications, mood, other hormonal changes and general health before considering testosterone therapy [5].

What helps, and how well

Testosterone therapy for low desire. The evidence supports a modest benefit for sexual desire and satisfaction in postmenopausal women when used at low doses. The global consensus statement recommends a trial of testosterone at doses that approximate premenopausal physiological levels, with monitoring of blood levels to avoid supraphysiological concentrations [1]. NICE recommends considering testosterone supplementation for menopausal women with low sexual desire if hormone replacement therapy alone has not been effective [4].

How strong is the evidence? Moderate for sexual desire specifically. The meta-analysis showed a consistent benefit, though the magnitude was modest. Evidence for other outcomes is weaker.

Testosterone for energy, mood and cognition. These are the symptoms people often hope testosterone will address, and the evidence here is less clear. The same meta-analysis found no significant effects on mood, cognition, body composition or general well-being [2]. Some individuals report improvements in energy and mood, but clinical trial data have not consistently supported these benefits. This does not mean testosterone never helps with these symptoms. It means the evidence is not strong enough to recommend it for those purposes.

Formulation and dosing. Because no testosterone product is approved for women in the US, prescribing is off-label. Options include transdermal testosterone preparations (patches, gels or creams), typically at one-tenth the male dose. Oral testosterone is not recommended because of liver metabolism and lipid effects. Compounded preparations are available but are not regulated with the same consistency as commercial products [1] [5]. Pellet implants are available but carry a risk of supraphysiological levels and are generally not recommended in guidelines.

Monitoring. Guidelines recommend checking testosterone levels before and during treatment, along with lipid profiles and liver function. Treatment should be reviewed at 3 to 6 months. If there is no benefit by 6 months, it should be stopped [1].

What does not help. DHEA supplements (a testosterone precursor) are widely marketed for menopausal symptoms. The evidence for systemic DHEA is weak, and over-the-counter formulations are not well regulated. Vaginal DHEA (prasterone) does have evidence for vaginal symptoms specifically, but that is a different use than systemic testosterone therapy.

Take this to your appointment

1. I have been experiencing low sexual desire that is distressing to me. Could testosterone therapy be appropriate, and have we ruled out other causes?
2. I am already on hormone therapy. Could adding testosterone help with desire that has not improved?
3. What formulation and dose would you recommend, and how will we monitor my levels?
4. What side effects should I watch for, and when should I report them?
5. How long should I try testosterone before we assess whether it is working?

A fictional example

This example is fictional and illustrative. Dana is not a real person.

Dana, 54, has been on estrogen-progestogen therapy for two years, which helped her hot flashes and sleep. But her sexual desire, which started declining in her late forties, has not improved. It is not that she cannot respond physically. The interest is simply absent, and it bothers her. Her clinician reviews her medications (none that typically affect libido), asks about her relationship (stable, supportive), screens for depression (negative), and discusses testosterone. They agree on a trial of a low-dose transdermal testosterone cream, with blood levels checked at baseline and at three months. At her follow-up, Dana reports a modest improvement in desire and no side effects. They continue the trial with a plan to reassess at six months.

See a clinician promptly if… you have any bleeding after 12 months without a period, very heavy or prolonged bleeding, new chest pain, a painful swollen leg or sudden shortness of breath, or low mood that won’t lift. If you are thinking about harming yourself, call or text 988 in the US, or call 911 in an emergency. This article is general education, not medical advice.

Related reading: Hormone Therapy Risks: Put the Headlines in Numbers | Bioidentical vs Conventional Hormone Therapy: What the Terms Mean