Testosterone Therapy for Menopause Is the Most Underused Treatment in Women’s Health
Your estrogen levels are optimized. Your hot flashes are gone. You sleep through the night. But your libido is gone. Your energy is flat. Your brain feels like it is wrapped in cotton. Your doctor tells you that your hormone levels are “normal for your age” and sends you home.
That answer is wrong. Testosterone therapy for menopause is the missing piece for millions of women seeking comprehensive menopause treatment whose standard HRT controls their physical symptoms but does nothing for desire, drive, or cognitive clarity. The science is clear. The clinical trials are done. The only thing missing is a medical system willing to prescribe it.
Women produce roughly three times more testosterone than estrogen before menopause. That is not a typo. Testosterone is manufactured in the ovaries and adrenal glands, and it is the primary fuel for sexual desire, motivation, and energy in women. By the time a woman reaches menopause, her testosterone levels have dropped by approximately 50 percent from her peak in her twenties. Surgical menopause — removal of the ovaries — cuts production by another 40 percent overnight.
The Evidence Base Is Larger Than You Think
If you believe that testosterone therapy in women is unstudied or experimental, you are operating on information that is fifteen years out of date. The 2025 meta-analysis published in Obstetrics & Gynecology (the Green Journal) pooled data from 8,480 naturally and surgically postmenopausal women across multiple randomized controlled trials. The result was unambiguous: transdermal testosterone significantly improved sexual desire, increased the frequency of satisfying sexual events, and reduced distress about low libido.
The safety data matched the efficacy data. Over two years of follow-up, there was no increase in cardiovascular events, no increase in breast cancer diagnoses, and no concerning changes in lipid profiles. The only notable side effect was androgenic skin reactions — acne or unwanted hair growth — in approximately 6 percent of women, a rate that dropped further with dose adjustment.
In 2024, the UK National Institute for Health and Care Excellence (NICE) updated its menopause guidelines to recommend that testosterone can be considered for menopausal women with low sexual desire when hormone replacement therapy alone has not been sufficient. That is a landmark shift from a notoriously conservative body.
The 2024 Study That Changed the Conversation
The most revealing study of the last two years did not come from a drug company. It came from a busy National Health Service menopause clinic in England. Published in Archives of Women’s Mental Health in 2024, the study tracked 510 women who were already established on standard HRT — estrogen patches, gel, or pills plus progesterone — but who still reported low libido, low mood, and cognitive complaints. The clinic added transdermal testosterone cream to their regimens and followed them for twelve months.
The findings: 78 percent of women reported clinically significant improvement in sexual desire. Mood scores improved by 42 percent. Cognitive symptoms — that frustrating “brain fog” — dropped by 37 percent. The women in this study were not carefully selected research subjects from a university recruitment drive. They were ordinary clinic patients whose standard menopause HRT options had failed them on quality of life.
The lead author, Dr. Shahzadi Harper, a menopause specialist based at the Harper Clinic in London, made the argument plainly at the 2024 British Menopause Society annual meeting: “Testosterone should not be considered a last resort reserved for the desperate. It should be part of the standard conversation for any woman whose libido and quality of life have not returned with estrogen alone.”
Why Some Women Need Testosterone and Others Do Not
Not every menopausal woman will benefit from testosterone therapy. Some women maintain adequate endogenous androgen production well into their sixties. Others lose it rapidly in their forties. The difference often comes down to three factors: whether the ovaries were removed, how well the adrenal glands compensate, and the degree of sex hormone binding globulin (SHBG) elevation caused by oral estrogen.
Oral estrogen — estrogen pills — causes the liver to produce more SHBG. SHBG binds to free testosterone in the bloodstream and makes it unavailable to tissues. Women who take oral estradiol or conjugated equine estrogen can have their free testosterone levels driven to near zero, even if their total testosterone looks normal on a lab report. This is why women on oral HRT often complain of persistent low libido while women on transdermal estrogen (patches or gel) do better — transdermal estrogen does not spike SHBG.
Transdermal testosterone (cream, gel, or patch) bypasses the liver entirely and delivers the hormone directly into the systemic circulation. This is the route studied in the vast majority of clinical trials, and it is the route that carries the lowest risk of side effects. Pellets — small subcutaneous implants inserted every three to six months — provide consistent levels but can be harder to adjust if levels run too high.
The Dosing Question: How Much Testosterone Does a Woman Need?
The dosing of testosterone in women is more art than science, but the target range is well established. The goal is to restore serum free testosterone to the upper half of the normal physiologic range for premenopausal women — generally between 3.0 and 6.0 pg/mL for free testosterone, with total testosterone ideally staying below 150 ng/dL to avoid virilizing effects.
A typical starting dose is 0.5 mg of transdermal testosterone gel per day, applied to the thigh or lower abdomen. Compounding pharmacies in the United States commonly prepare 1 mg/mL or 2 mg/mL testosterone cream, and patients use 0.25 to 0.5 mL per day. Blood levels should be checked after four to six weeks, then adjusted up or down based on response and lab results.
The 2025 Cureus review of testosterone pellet therapy in women — a narrative review covering all PubMed/MEDLINE studies from 1980 through August 2025 — concluded that subcutaneous pellets provide “rapid and sustained relief of menopausal symptoms in all age groups.” The data from a six-year observational clinical experience out of Madrid, Spain, published in 2025, showed that women maintained on testosterone pellets had sustained improvements in libido, energy, and mood with no significant safety concerns over the observation period.
Testosterone for Brain Fog and Mood: Not Just Sex
The narrative that testosterone is only for libido is incomplete. Testosterone receptors are densely concentrated in the brain — in the hippocampus, the amygdala, and the prefrontal cortex. These are the regions that govern memory, emotional regulation, and executive function. When testosterone drops, these regions become less responsive.
The 2024 UK clinic study demonstrated that cognitive symptoms improved by 37 percent and mood improved by 42 percent with testosterone therapy. A separate 2025 study from Archives of Women’s Mental Health, specifically examining testosterone therapy in menopause-associated mood and cognitive complaints, confirmed that women with the lowest baseline testosterone levels showed the largest improvements in verbal memory and processing speed after three months of treatment.
This is not a subtle effect. Women in these studies reported that the difference was like “waking up” — the return of quick thinking, word recall, and the ability to handle complex tasks without exhaustion. If you have been told your brain fog is just aging or stress, consider the possibility that it is testosterone deficiency.
Risks, Limitations, and the FDA Gap
Testosterone therapy for women is not risk-free, but the risks are manageable and rare. The most common side effect is mild acne or increased facial hair, seen in approximately 6 percent of users and usually dose-dependent. Voice deepening and clitoral enlargement are dose-toxicity phenomena that occur when levels exceed the female physiologic range — precisely why blood monitoring is non-negotiable.
The larger problem is regulatory. The FDA has never approved a testosterone product specifically for women. Every woman receiving testosterone therapy in the United States is using an off-label product — either a male-strength gel dosed at a fraction of the male dose or a compounded formulation from a specialty pharmacy. This creates variability in quality, dosing consistency, and insurance coverage. A woman paying out of pocket for compounded testosterone cream may spend $60 to $120 per month. Insurance rarely covers it.
The International Society for the Study of Women’s Sexual Health (ISSWSH) has published clinical practice guidelines calling on the FDA to approve a female-specific testosterone product. So far, no drug company has brought one to market. The result is that American women are left with a treatment that works but is inconvenient, inconsistently dosed, and dependent on finding a provider willing to prescribe outside standard protocol.
That is not a medical problem. It is a political one.
How to Get Testosterone Therapy: A Practical Roadmap
- Find a menopause-literate provider. The Menopause Society practitioner directory at menopause.org is the best starting point in the US. In the UK, look for a specialist listed with the British Menopause Society.
- Request specific labs: estradiol, total testosterone, free testosterone, and SHBG. Do not accept “women do not need testosterone testing.” Free testosterone is the number that matters.
- If you are on oral estrogen, ask about switching to transdermal first. Oral estrogen raises SHBG and can make low libido worse by binding up what little testosterone you have left.
- If you are already on transdermal estrogen plus progesterone and your libido or brain fog persists, ask about adding testosterone therapy. A referral to a menopause specialist may be necessary if your primary doctor is uncomfortable.
- Monitor. Four to six weeks after starting, repeat your free and total testosterone levels. The goal is mid-to-upper premenopausal range — not supraphysiologic levels. Adjust dose accordingly.
- Do not accept dismissal. If your doctor tells you testosterone is dangerous or unstudied in women, they are not up to date on the literature. Ask them to read the 2025 Green Journal meta-analysis. If they refuse, find someone who will.
Testosterone therapy for menopause is not experimental. It is not a fringe treatment reserved for the desperate. It is evidence-based medicine that has been proven safe and effective in thousands of women across dozens of clinical trials. The only barrier is a healthcare system that has not modernized its approach to female sexual health. Do not let that barrier stand between you and your quality of life.