Testosterone treatment is revolutionising the sexual health landscape for women by restoring libido post menopause, say experts, with interest in this rapidly increasing not just worldwide but in South Africa too.
“Testosterone treatment for menopausal women is such an exciting topic right now,” Cape Town’s Dr Marlena du Toit, a gynaecologist in private practice and programme director of sexual health at the faculty of medicine, Stellenbosch University, told Daily Maverick.
“For the first time, we have solid evidence to treat post-menopausal loss of libido safely and effectively.”
And she isn’t exaggerating. Globally, attitudes towards hormone therapy are shifting, and South Africa is experiencing its own quiet revolution. Since hormone therapy was approved here, Du Toit said interest has grown rapidly.
Low libido is far more common than most women realise. International studies such as the Global Study of Sexual Attitudes & Behaviours show that 30%-50% of post-menopausal women report a drop in sexual desire. About one in three say sex becomes infrequent or disappears altogether in the years after menopause.
“I often see women who feel deeply stressed, even ashamed, because they ‘can’t be turned on’ any more,” said Du Toit. “When testosterone works for the right patient, it can flip that switch. Many tell me they’re having the best sex of their lives, feeling more alive, more confident and noticing real changes in energy and muscle tone.”
But testosterone isn’t a magic potion for everyone.
Professor Tobie de Villiers, a gynaecologist in private practice and past president of the International Menopause Society, described testosterone treatment for post-menopausal women with Hypoactive Sexual Desire Disorder (HSDD) as “a genuine game-changer”.
By menopause, a woman’s testosterone levels have typically dropped to half of what they were in her 20s. This explains why libido often changes dramatically. But diagnosis is never just a blood test.
“We first rule out biological, psychological and social factors,” he said. Blood tests serve as a safety baseline rather than a tool to diagnose desire. And when the right patient receives the correct dose, the results can be powerful.
What arouses women?
Women’s arousal begins in the brain, not the body, unlike men, who often follow a quick linear path, stimulus, arousal, orgasm.
Leading sexual-medicine specialist Professor Rosemary Basson described women’s arousal as circular, relational and heavily influenced by context, not a spontaneous spark that appears out of nowhere.
Du Toit said the progression usually starts from a neutral place. When a woman feels safe, desired, or emotionally connected, or when she draws on positive memories of past intimacy, the brain becomes motivated to respond and desire then begins to surface.
This is why women often need around 15 to 20 minutes before they feel genuinely curious or excited. These signals activate the mesolimbic reward system, the brain’s motivation centre. Dopamine rises, creating feelings of interest, anticipation and pleasure. The body then responds with increased blood flow to the genitals, especially the clitoris which contains 8 000 to 10 000 nerve endings that become highly sensitive during arousal.
This is where testosterone matters. It acts like a key that unlocks the brain’s arousal machinery, amplifying dopamine pathways and making it easier to feel the first flicker of interest.
In women with genuinely low testosterone, replacing it can switch on motivation.
Testosterone doesn’t create desire on its own. It primes the brain so that erotic signals feel louder and easier to respond to.
And yet, as De Villiers points out, science hasn’t decoded the whole picture. There is still mystery in how testosterone interacts with subtle elements of attraction. The pheromones, the scents, the almost imperceptible cues that spark connection.
For now, testosterone treatment is only approved for post-menopausal women, whether they are on hormone replacement therapy, not using hormones at all, or have had a hysterectomy. De Villiers is hopeful that evidence may eventually support its use for peri-menopausal women too.
In younger women, however, libido issues are far more often linked to stress, emotional overload, relationship strain or past trauma rather than a hormonal deficiency.
Testosterone not a relationship repair kit
Experts warn against seeing testosterone as a rescue remedy for unhappy or disconnected relationships.
Marlene Wasserman, a family therapist and founder of the Dr Eve brand, stresses that testosterone is not a magic bullet for couples who have lost intimacy. Yes, it can be life-changing for women who meet the medical criteria, she said, but in her practice she more often sees couples whose sex lives have faded because of stress, disconnection, trust ruptures, trauma or years of emotional neglect.
“You can’t ignore your sex life for decades and then hope a hormone will fix it,” she said.
She also warns about the rise of online compounded hormone products, which may be unsafe and often distract from the deeper emotional work. For most women, desire is responsive, shaped by a blend of biological, psychological and social factors.
What form of testosterone is safest?
Testosterone therapy for women has been used in Europe and Australia since 2019 when the Global Consensus Position Statement on the use of testosterone for women was published. While long-term data on possible risks are limited, De Villiers believes we have enough solid research to prescribe it safely as long as women are monitored and correctly dosed.
In South Africa, the South African Health Products Regulatory Authority (SAHPRA) approved TestaFeme six months ago for postmenopausal women diagnosed with Hypoactive Sexual Desire Disorder.
TestaFeme is a transdermal cream absorbed through the skin. It comes with a graduated applicator for precise dosing, and when used correctly with regular blood tests to ensure levels stay within a healthy physiological range, it is considered safe to use.
There is currently no slow-release testosterone option approved for women in South Africa.
Cost remains a challenge, and most medical aids do not cover testosterone for women. Du Toit often refers patients to reputable compounding pharmacies, which can reduce the cost significantly.
What are the real risks?
Too much testosterone can cause unwanted side effects. Some can be irreversible. These include oily skin, acne, a receding hairline, a deeper voice, weight gain, persistent headaches and polycythaemia.
In clinical practice, Du Toit said the vast majority of women report no side effects beyond improved libido, energy or mood. The most common nuisance is a little extra hair at the application site, which is harmless and easy to manage.
Testosterone is avoided in women with a history of breast cancer, untreated liver disease or certain clotting disorders. This is because there is insufficient evidence about safety in these groups.
Is Viagra an option for women?
Viagra is not a hormone; it improves blood flow to the penis by widening blood vessels, helping men achieve an erection. It does not create desire, which is why it offers very limited benefit to women.
Doctors emphasise that testosterone is not intended as a lifelong therapy for everyone.
Some women choose to stay on it long term because they feel dramatically better. Others use it for a period and taper off once symptoms settle. The key is individualised care and monitoring.
See more from MedicalBrief archives:
Pros and cons of growing trend of testosterone therapy for women
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