Testosterone for Women: What We Prescribe and Why

Testosterone has one well-supported use in women: low sexual desire after menopause. The 2019 international consensus statement, endorsed by the major menopause and endocrine societies, supports that use. At a female dose, a gel or cream with blood levels checked can improve desire, arousal and satisfaction for some women when nothing else explains the loss. Pellets, injections and use for energy, mood or weight are outside the evidence and carry real risks. Golden Leaf Health prescribes testosterone for patients in California only.

What testosterone treats

Women make testosterone, from the ovaries and adrenal glands, and levels fall gradually from the twenties, roughly halving by the fifties, faster after surgical removal of the ovaries. The question is what replacing some of it does.

Supported: hypoactive sexual desire disorder in postmenopausal women, meaning low desire that causes distress and isn’t explained by something else. Randomised trials of transdermal testosterone at physiological female doses showed modest but consistent improvements in desire, arousal, orgasm and satisfaction. That is the indication.

Not supported: energy, mood, wellbeing, brain fog, muscle, bone density or weight. The consensus reviewed the trials and found no benefit for any of these at physiological doses. Women sometimes feel more energetic on testosterone, especially at higher doses, but that isn’t an evidence-based reason to prescribe it, and we don’t.

Not a hormone level problem. A low blood testosterone doesn’t diagnose low desire, and a normal one doesn’t rule it out; blood levels are used to set and monitor the dose, not to decide whether to treat. See hormone testing.

Other causes of low desire

Testosterone comes after other causes are addressed. Most low desire after menopause has causes that need treating first, and testosterone does not treat them:

• Painful or dry sex, which low-dose vaginal estrogen can help; see vaginal dryness.
• Night sweats, broken sleep and fatigue, which can improve when vasomotor symptoms are treated; see sleep problems and fatigue.
• Depression and anxiety, and the antidepressants that treat them.
• Medications: SSRIs, some blood pressure drugs, opioids, hormonal contraceptives.
• Oral estrogen, which raises the protein that binds testosterone and can lower the free fraction; switching to transdermal estrogen may restore desire on its own.
• The relationship, body image, stress.

See the low libido page for these causes. When desire is still low and distressing after they’re addressed, testosterone is the reasonable next conversation.

How we prescribe it

For patients in California, where Golden Leaf Health prescribes testosterone:

1. Assessment first. The first video visit works through the causes above, your history and your estrogen regimen. If the picture fits hypoactive sexual desire disorder, testosterone is discussed as an option, with its limits stated.
2. A baseline blood level. Total testosterone, usually with sex hormone binding globulin, to establish your starting point and rule out a level that’s already high.
3. Transdermal, at a female dose. A gel or cream applied daily to the skin, at roughly a tenth of a male dose. No testosterone product is FDA-approved for women in the US, so this is prescribed off-label from a male product measured down, or compounded at the female dose by a pharmacy. Your clinician says which and why.
4. A follow-up level after a few weeks, to confirm the level sits within the normal female range and not above it. The dose is adjusted on that and on how you feel.
5. A three-to-six-month trial. If desire hasn’t meaningfully improved by then, it’s stopped. Continuing in hope isn’t supported and raises side-effect risk.
6. Ongoing review, with levels checked periodically and the usual yearly review of your whole regimen.

At the right dose, side effects are often minimal: occasionally some hair growth where the gel is applied, or mild acne. They’re the signal to check the level.

Why not pellets or injections

Testosterone pellets, inserted under the skin every few months, and injections produce blood levels far above the female range for weeks at a time. At those levels, side effects can include facial and body hair, acne, scalp hair thinning, voice deepening, clitoral enlargement and adverse changes in cholesterol. Some do not reverse. Pellets can’t be removed or adjusted once placed. The 2019 consensus statement and The Menopause Society specifically advise against them. Golden Leaf Health doesn’t insert pellets or give testosterone injections. If you arrive with pellets in place, your clinician plans the transition as they wear off; see switching menopause providers.

Who shouldn’t take it

Pregnancy or the possibility of it; a history of breast cancer, where the decision sits with your oncologist; severe acne or hirsutism; liver disease; and anyone seeking it for energy, mood or weight, because the evidence doesn’t support that use and the honest answer is to treat those symptoms directly.

If you’re outside California

Golden Leaf Health’s clinicians treat perimenopause and menopause in every state we serve, including the other causes of low desire above, which may address the problem for many women. Testosterone itself is prescribed for our California patients only. If you’re elsewhere and testosterone turns out to be the right next step after the rest has been addressed, your Golden Leaf clinician will say so and advise on finding a local prescriber who follows the same approach: transdermal, female dose, levels checked, no pellets.

Booking

Book a first visit if low desire is affecting you. The visit covers the possible causes; for patients in California, testosterone is an option when it’s the right tool, prescribed the way the evidence says it should be.

Sources: Global Consensus Position Statement on the Use of Testosterone Therapy for Women, 2019, endorsed by The Menopause Society; Mayo Clinic, Low sex drive in women; ACOG, Your sexual health.