The effects of low testosterone in women can range from low libido, lack of energy, loss of strength and muscle tone, to cognitive difficulties like trouble concentrating, but an increasing number of patients are now opting for testosterone replacement therapy (TRT) – receiving regular small doses of the hormone that’s almost synonymous with male health – and reporting hugely positive results.
Cisgender women across the internet are touting the anecdotal benefits, and some experts say those stories match what they’re hearing in their offices.
Many describe being asked about TRT multiple times a day. “There’s been increasing attention to it,” said Dr Kathleen Jordan, chief medical officer of Midi Health in the USA, a virtual care clinic focused on navigating perimenopause and menopause. “We call it the ‘book club effect’ – women who have tremendous outcomes share this with their friends, and then we see friends of our patients coming in to inquire about similar solutions.”
But can testosterone therapy for women really lead to such profound health improvements? TIME Magazine asked experts to explain its potential benefits – and limitations.
What it is
Testosterone isn’t simply a male hormone. While women have smaller amounts than men, testosterone plays an important role in regulating the menstrual cycle, maintaining bone density and muscle mass, and enhancing cognitive health, mood, sexual function and energy.
“After 30, our testosterone levels decrease,” Jordan said. “And by the time we’re in midlife, in the premenopause and menopausal phase, they’re down to about 25% of what they were when we were younger.”
Enter testosterone replacement therapy. More than 30 different testosterone products are approved for men by the US Food and Drug Administration (FDA), but the agency has never approved testosterone for women. However, doctors can still prescribe it off-label to women they feel would benefit.
Historically, testosterone was used in combination with oestrogen and progesterone, hormones that decline with age. But these days, it’s also prescribed as a standalone treatment, said Dr Traci Kurtzer, a gynaecologist at the Northwestern Medicine Centre for Sexual Medicine and Menopause, opening the door to people who can’t or don’t want to take other hormones for various reasons.
To determine if a woman is a good candidate for TRT, doctors typically start by checking hormone levels to make sure someone “isn’t already coming in on the high side of normal”. Kurtzer said. (Testosterone levels under 20 ng/dL in women 50 and older are typically considered low.) It’s also important to check sex hormone binding globulin, or SHBG, because if it’s high, “any exogenous testosterone we give someone is just going to be bound up”, she added.
“It’s not going to be useful to them, so it becomes wasted.” The exact dose that women take varies, but the goal is to achieve the same level of testosterone they would have had in their premenopausal years.
There are a few forms of testosterone, including pellets injected under the skin, pills taken orally, and topical gels and creams. Doctors typically prefer a cream or gel that’s applied to the skin, usually to the back of the thigh, calf, or buttocks.
Women need to take 1/10th of the dose men take, which can be difficult to estimate, so many get their prescriptions from compounding pharmacies that specialise in custom dosing.
The downsides of using a compounding pharmacy are that their products aren’t FDA-approved, and dosing can be inconsistent. In one study, some products contained more than 20% of the prescribed dose, while others had essentially no testosterone.
Potential benefits
The best evidence-based use case for TRT for women is increasing sexual function in a safe, effective way. It’s “pretty clear” that low doses of testosterone can improve libido for post-menopausal women experiencing hypoactive sexual desire disorder (HSDD), which means lack of desire without some other underlying cause, Kurtzer said.
“It’s not because they hate their partner, or have pain, or because they’re exhausted from working two jobs and can’t focus.”
According to one research review, TRT improved the frequency of sexually satisfying events, arousal, and orgasm in surgically and naturally postmenopausal women.
Yet the picture gets murkier beyond that. Anecdotally, many women experience a host of benefits, but Kurtzer said there’s simply not enough data to back up all of the hype.
“We really can't say that it's not potentially helpful,” she said. “Could it help with body composition and replacing that muscle? Could it help with physical functioning, energy, and even cognitive health and mood?” Maybe. “The problem is,” she says, “we just don’t have sufficient data.”
The studies that do exist have yielded uncertain results beyond improving sexual function; plus, little is known about the long-term effects of testosterone in women. “We have no long-term studies – even using it for HSDD, the studies really are around two years,” she said.
“With the idea that this is a long-term solution, what’s the trade-off? Are you now impacting that woman’s overall heart disease risk? Are we increasing breast cancer risk? We have no long-term data on that.”
More data exist for men. Large analyses have found no evidence that testosterone increases cardiovascular problems in the short- to medium-term, for example, and a person’s risk of dying early doesn’t appear to change. Another study found that TRT doesn’t increase the risk of prostate cancer, even after more than 15 years of treatment. Yet it’s hard to draw conclusions about women based on these findings, experts say, since dosage isn’t the same (though it’s usually lower) and women’s bodies work differently.
Still, Kurtzer, who has been prescribing testosterone to women for years, hopes research will one day confirm that TRT is as beneficial as some of her patients claim.
“I would love for it to be true that it helps with all those things, because we don’t have a lot of other solutions, and it’s frustrating for people,” she said. “I used to liken it to a drug – and I meant that facetiously – but people who were on it felt so elated and good. But at this point, we just don’t know the detrimental piece of it.”
Side effects of testosterone therapy
One patient who first tried TRT 10 years ago said that initially, it went well, and she felt great. She stopped taking it when the compounding pharmacy she used went out of business. A couple years ago, she decided to start the treatment again, but within a few months, noticed her hair was becoming thin and her face was breaking out. She also became aggressive at work, which was an out-of-character development.
She ended up stopping treatment, and doesn’t plan to try testosterone again, saying it was not worth it.
Some research suggests that in the short term, TRT could lead to hair growth on the face, chest, and back, as well as acne and behavioural and personality changes.
That can be especially true for those receiving pellets, which typically contain higher doses than other forms of testosterone.
“Once they’re in your body, you can't alter or adjust the dose or how long you’re exposed to it,” Kurtzer said. “Those have typically been the people who come to us with complications, because it’s more than their bodies can accommodate.”
It takes about three to four months for testosterone pellets to metabolise out of your system, she added, which is a long time to deal with unpleasant side effects. That’s why experts, including Kurtzer, typically recommend against using pellets.
Still, experts say that one common worry about TRT in women (developing male traits) is overblown.
“Concern about masculinisation is disproportionate to what really happens,” Jordan said. She hasn’t seen patients develop male pattern baldness, grow a beard, or start speaking in a deeper voice, for example. Regular blood testing is helpful, she added, and allows clinicians to make dosage adjustments if side effects like mild masculinisation do occur.
“The way we approach it is we listen to women, figure out what their symptoms are and what health benefit they’re seeking, and what’s going to help them feel well and vital, rather than just saying it’s a blanket anti-ageing treatment that all women should have.
“When it’s done with that sort of guidance and counselling, it can be very safe and effective.”
PubMed article – Testosterone for Treating Female Sexual Dysfunction (Open access)
See more from MedicalBrief archives:
Experts warn against over-prescription of testosterone for women
Post-menopause testosterone patch in the pipeline
Women see GP 10 times before menopause diagnosis – UK expert