For decades, conversations about hormone therapy for women have centered primarily on estrogen and progesterone—especially for symptoms such as hot flashes, night sweats, sleep disruption, and genitourinary changes.

But another hormone is increasingly entering the conversation: testosterone.

Although testosterone is often thought of as a “male hormone,” women naturally produce testosterone throughout their lives. Androgens play roles in sexual function and may influence other aspects of health and well-being. As women age, androgen levels change, prompting growing interest in whether testosterone therapy may have a role in individualized menopause care.

The important question, however, is not simply whether testosterone can help women. It is which women may benefit, for which symptoms, and what the evidence currently supports.

Testosterone: Not Just a “Male” Hormone

Testosterone is an important sex steroid in women, produced by the ovaries and adrenal glands and through conversion of other hormones in peripheral tissues.

Androgen levels change across adulthood, but symptoms such as fatigue, brain fog, low mood, and reduced libido are complex and cannot be attributed to a testosterone level alone. Current clinical guidance does not support diagnosing a generalized “androgen deficiency syndrome” in otherwise healthy women based simply on symptoms or a low laboratory value.

That does not mean testosterone has no place in women’s health. It means treatment should be based on symptoms, clinical context, evidence, and thoughtful monitoring rather than a laboratory number alone.

What Does the Evidence Support?

The strongest evidence for testosterone therapy in women is for hypoactive sexual desire disorder (HSDD) in appropriately evaluated postmenopausal women.

The Global Consensus Position Statement on testosterone therapy for women concluded that testosterone can improve sexual desire and related sexual function in postmenopausal women with HSDD when therapy maintains concentrations within the physiologic range for women (Davis et al., 2019).

Similarly, clinical guidance from the Endocrine Society and ACOG recognizes a potential therapeutic role for testosterone in carefully selected women with sexual dysfunction while emphasizing appropriate evaluation and monitoring (American College of Obstetricians and Gynecologists, 2019; Wierman et al., 2014).

But sexual function may not be the only reason women are asking about testosterone.

What About Energy, Mood, and Brain Fog?

This is where the science becomes particularly interesting—and where we need to separate promising evidence from established evidence.

Women frequently describe fatigue, changes in motivation, mood symptoms, decreased resilience, difficulty concentrating, and a sense that they simply do not feel like themselves during the menopausal transition.

Emerging observational research has explored whether testosterone therapy may improve some of these symptoms. Some studies have reported improvements in energy, mood, cognition, sexual interest, and overall quality of life among women receiving testosterone therapy.

These findings are encouraging, but observational studies cannot prove that testosterone caused the improvement. They may be influenced by other treatments, changes in estrogen therapy, lifestyle factors, expectations, or placebo effects.

Randomized controlled evidence remains much more limited.

For example, Dichtel et al. (2020) studied low-dose testosterone augmentation in women with antidepressant-resistant major depressive disorder and did not find a significant antidepressant benefit compared with placebo.

For now, major guidelines do not recommend testosterone routinely for depression, cognition, fatigue, metabolic health, bone health, or general well-being.

That may change as the evidence develops—but we are not there yet.

Bioidentical Hormones: An Important Distinction

The term “bioidentical hormone therapy” can be confusing because it is often used to describe very different treatments.

“Bioidentical” or “body-identical” generally refers to hormones that are chemically identical to hormones produced by the human body. Estradiol and micronized progesterone are examples—and FDA-approved versions of both are available.

This is different from custom-compounded hormone therapy.

The REPLENISH trial evaluated an FDA-approved oral combination of 17β-estradiol and micronized progesterone in postmenopausal women and demonstrated significant improvement in moderate-to-severe vasomotor symptoms while providing endometrial protection (Lobo et al., 2018).

International recommendations have similarly discussed regulated body-identical hormone therapy as an evidence-based option in menopause management (Palacios et al., 2024).

ACOG recommends FDA-approved menopausal hormone therapies over custom-compounded preparations when an approved formulation can meet the patient’s needs. Compounding may have an appropriate role in selected circumstances, but compounded products do not undergo the same FDA premarket review for safety, efficacy, quality, and dosing consistency as FDA-approved medications.

In other words:

Bioidentical does not automatically mean compounded, and compounded does not automatically mean better.

What About Testosterone Formulations?

There is currently no testosterone product specifically FDA-approved for women in the United States.

International consensus guidance favors transdermal testosterone when treatment is indicated, using dosing that maintains serum concentrations within the physiologic premenopausal female range.

When a female-specific formulation is unavailable, some expert guidance supports carefully using an appropriately reduced dose of a testosterone product approved for men, with clinical and laboratory monitoring.

Formulations that result in supraphysiologic testosterone concentrations should be avoided.

This is particularly important when considering pellets or injectable preparations, because some dosing strategies may produce concentrations substantially above the physiologic female range.

The goal of therapy should not be to chase a high testosterone number. It should be to address an appropriate clinical indication while maintaining physiologic exposure and monitoring response and adverse effects.

Monitoring Matters

Testosterone therapy should not be started and forgotten.

Consensus recommendations include obtaining a baseline total testosterone level before treatment and repeating testosterone after initiation to ensure concentrations remain within the physiologic female range.

Patients should also be monitored clinically for signs of androgen excess, including:

• Acne
• Increased facial or body hair
• Scalp hair changes
• Voice changes
• Other signs of excessive androgen exposure

Laboratory monitoring should continue periodically during therapy, along with assessment of symptoms, clinical benefit, and adverse effects.

When accurate measurement is important, liquid chromatography–tandem mass spectrometry (LC-MS/MS) is preferred because many routine testosterone immunoassays have limited accuracy at the low concentrations typically found in women.

What Do We Know About Safety?

Safety depends on the formulation, dose, duration of therapy, and the individual patient.

At physiologic doses, randomized trials of nonoral testosterone have generally found mild androgenic effects such as acne or increased facial or body hair in some women. More significant virilizing effects are uncommon when testosterone remains within the physiologic female range.

Oral testosterone is generally not recommended because of unfavorable effects on lipid profiles.

Short-term studies of physiologic-dose, nonoral testosterone have not demonstrated significant adverse effects on blood pressure, glucose, HbA1c, or lipid profiles.

However, long-term cardiovascular safety remains uncertain.

Observational database studies have produced differing findings. One claims-based analysis found no increased cardiovascular or breast cancer risk among women receiving testosterone therapy (Agrawal et al., 2024), while another large database study identified associations between testosterone therapy and increased cardiovascular outcomes in cisgender women (Lopez et al., 2023).

These studies cannot establish cause and effect, but the conflicting findings reinforce an important point:

We need better long-term safety data in women.

Women at higher cardiovascular or thromboembolic risk were also underrepresented or excluded from many randomized trials, so existing safety findings should not automatically be generalized to every patient.

What About Breast Cancer?

Available short-term evidence has not demonstrated an increase in mammographic breast density or established an increased breast cancer risk with physiologic transdermal testosterone therapy.

However, long-term data remain insufficient.

Women with a history of hormone-sensitive breast cancer require individualized assessment and collaboration with the appropriate specialists. The absence of evidence demonstrating long-term harm is not the same as evidence proving long-term safety.

Individualized Care Matters

Hormone symptoms rarely exist in isolation.

Fatigue, low libido, poor sleep, brain fog, mood changes, weight changes, and decreased resilience can have many contributors—including menopause, thyroid dysfunction, iron or nutrient abnormalities, metabolic health, sleep disorders, medications, chronic stress, mental health conditions, relationship factors, and other medical concerns.

That is why good hormone care should involve more than simply checking a testosterone level and prescribing a hormone.

A comprehensive evaluation considers symptoms, medical history, medications, reproductive and menopausal status, laboratory findings when appropriate, cardiovascular and breast health, lifestyle, sleep, mental health, sexual health, and the patient’s individual goals.

The Bottom Line

The conversation around women’s hormones is changing—and that is a good thing.

We have strong evidence supporting appropriately selected menopausal hormone therapy for many women experiencing bothersome menopausal symptoms. We also have evidence supporting testosterone therapy for a specific population of postmenopausal women with HSDD.

Beyond sexual function, emerging research examining testosterone for energy, mood, cognition, and overall quality of life is intriguing, but it should be described for what it is: promising, not yet definitive.

Women deserve more research, better education, and thoughtful conversations about all of their hormones—not assumptions that every symptom is “just menopause,” but also not promises that hormone optimization will solve every symptom.

The future of hormone care should not be about chasing numbers or using the highest dose possible.

It should be about individualized, evidence-informed care that considers the whole person.

This article is for educational purposes only and is not intended to diagnose, treat, cure, or prevent any condition and does not constitute individualized medical advice. Hormone therapy has potential risks and benefits and should be considered in consultation with a qualified healthcare professional based on individual symptoms, medical history, risk factors, and treatment goals.

References

Agrawal, P., Singh, S. M., Hsueh, J., Grutman, A., An, C., Able, C., Choi, U., Kohn, J., Clifton, M., & Kohn, T. P. (2024). Testosterone therapy in females is not associated with increased cardiovascular or breast cancer risk: A claims database analysis. The Journal of Sexual Medicine, 21(5), 414–419. https://doi.org/10.1093/jsxmed/qdae032

American College of Obstetricians and Gynecologists. (2019). Female sexual dysfunction: ACOG Practice Bulletin No. 213. Obstetrics & Gynecology, 134(1), e1–e18.

American College of Obstetricians and Gynecologists. (2023). Compounded bioidentical menopausal hormone therapy: ACOG Clinical Consensus No. 6. Obstetrics & Gynecology, 142(5), 1266–1273.

Crandall, C. J., Mehta, J. M., & Manson, J. E. (2023). Management of menopausal symptoms: A review. JAMA, 329(5), 405–420.

Davis, S. R., Baber, R., Panay, N., Bitzer, J., Cerdas Perez, S., Islam, R. M., Kaunitz, A. M., Kingsberg, S. A., Lambrinoudaki, I., Liu, J., Parish, S. J., Pinkerton, J., Rymer, J., Simon, J. A., Vignozzi, L., & Wierman, M. E. (2019). Global consensus position statement on the use of testosterone therapy for women. The Journal of Clinical Endocrinology & Metabolism, 104(10), 4660–4666. https://doi.org/10.1210/jc.2019-01603

Dichtel, L. E., et al. (2020). Low-dose testosterone augmentation for antidepressant-resistant major depressive disorder in women: An 8-week randomized placebo-controlled study. American Journal of Psychiatry, 177(10), 965–973.

Lobo, R. A., Archer, D. F., Kagan, R., Kaunitz, A. M., Constantine, G. D., Pickar, J. H., Graham, S., Bernick, B., & Mirkin, S. (2018). A 17β-estradiol-progesterone oral capsule for vasomotor symptoms in postmenopausal women: A randomized controlled trial. Obstetrics & Gynecology, 132(1), 161–170. https://doi.org/10.1097/AOG.0000000000002645

Lopez, D. S., Mulla, J. S., El Haddad, D., et al. (2023). Testosterone replacement therapy in relation with cardiovascular disease in cisgender women and transgender people. The Journal of Clinical Endocrinology & Metabolism, 108(12), e1515–e1523. https://doi.org/10.1210/clinem/dgad388

Palacios, S., Rebelo, C., Casquilho, A., et al. (2024). POESIT recommendations on management of body-identical hormones in menopausal symptoms. Climacteric, 27(4), 340–350.

Wierman, M. E., Arlt, W., Basson, R., Davis, S. R., Miller, K. K., Murad, M. H., Rosner, W., & Santoro, N. (2014). Androgen therapy in women: A reappraisal: An Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 99(10), 3489–3510. https://doi.org/10.1210/jc.2014-2260