Just a few years ago, testosterone replacement therapy for women was barely a topic for discussion. The peak era of menopause management and hormone therapy prioritized estrogen and progesterone. However, as awareness and knowledge about menopause and hormone therapy have increased among women, it has become evident that testosterone also warrants consideration.
Discussions regarding testosterone therapy are now taking place in online forums, among peers, and with healthcare providers, signifying a shift in perspectives on women’s health and hormonal treatment.
However, what lessons has the surge in popularity of hormone therapy taught us? It has also brought a flood of misinformation and confusion, as numerous sources offer conflicting opinions.
If you haven’t already, I encourage you to read part 1 of this series where I talk about the physiological role testosterone plays in the body for women and how levels vary based on age, health condition and lifestyle.
In Part 2, I will be overviewing testosterone therapy, who it’s for, side effects and what treatment looks like.
As a reminder, this article is not intended for medical advice and prescribing testosterone therapy is out of my scope of practice as a naturopathic doctor. But as a menopause society certified practitioner, I felt it was necessary to provide this information to the many women seeking guidance and asking me questions regarding this topic. This article is a combination of what we know about testosterone therapy guidance for women, based on the research, alongside my clinical opinion.
Why is Testosterone Not Routinely Prescribed as Part of Hormone Therapy Regimes in Menopausal Women?
Many women want to add testosterone to their hormone therapy but are often denied by their healthcare provider because there are no official prescription guidelines for menopausal women. In Canada, Health Canada has not approved any products for women’s testosterone therapy. Similarly, in the U.S., the FDA does not approve testosterone for menopausal women, so prescriptions are considered ‘off-label’.
But some women are being prescribed testosterone by their healthcare providers. So, what are we missing?
There is an off-label indication. In a statement from the North American Menopause Society regarding the use of testosterone therapy:
“Testosterone therapy is recommended for management of hypoactive sexual desire disorder in select, appropriately screened postmenopausal women”
In other words, if a patient is screened and is showing signs of hypoactive sexual desire disorder (HSDD), testosterone could be prescribed as a treatment if the patient is made aware that the indication is off label. However, this is still not an indicated treatment for HSDD in Canada. This is why many women in Canada are not offered testosterone along with their hormone replacement therapy prescriptions (estrogen & progesterone).
In Canada, the drug Flibanserin (brand name Addyi) is a Health Canada approved prescription used for treating HSDD in premenopausal and naturally postmenopausal women aged 60 or younger. It is a 100 mg daily, non-hormonal, bedtime oral medication that can increase sexual desire. In my personal opinion, I find it very frustrating that a drug like Flibanserin which has strong sedative, mood altering effects is approved for treating sexual desire in women over testosterone, a hormone that exists in our own body that has good research and safety profile.
The Menopause Society also notes that testosterone therapy is not recommended for treatment or prevention of any age-related condition, including sarcopenia or osteoporosis, mood changes or brain fog, or for well-being or other symptoms or concerns.
It appears although we know testosterone has profound impacts in the body for women, it has been looked at only in the silo of sexual function. So, to be a candidate for testosterone therapy, you would have to meet the criteria for hypoactive sexual desire disorder:
Hypoactive Sexual Desire Disorder (HSDD) is defined as:
Lack of motivation for sexual activity as manifested by:
- Decreased or absent spontaneous desire (sexual thoughts or fantasies)
- Decreased or absent responsive desire to erotic cues and stimulation or inability to maintain desire or interest through sexual activity
- Loss of desire to initiate or participate in sexual activity, including behavioral responses such as avoidance of situations that could lead to sexual activity, that is not secondary to sexual pain disorders and is combined with clinically significant personal distress that includes frustration, grief, incompetence, loss, sadness, sorrow or worry.
From my clinical experience, a LOT of women feel these symptoms throughout their lifetime and especially through perimenopause and menopause. In fact, the prevalence of women who report at least one sexual dysfunction in their lifetime is approximately 40% to 50%. This very medical term of HSDD (which honestly should be renamed) is one of the only gateways for women receiving testosterone therapy. In my personal opinion, I find something like sexual desire so difficult to fit into a “checkbox” of symptoms. Sexual desire and function is so multifactorial – it varies greatly between individuals and cannot be objectively compared from one woman to another. Our childhood, upbringing, relationships, sexuality, environment, stress/lifestyle, body image, and health condition all influence our sexual desire. In other words, it is very difficult to adjust and monitor this change for a lot of women. On top of this, I do not know many women who have been asked or screened regarding sexual function and desire by their primary healthcare provider.
There are other sexual disorders that can occur simultaneously alongside HSDD such as female genital arousal disorder and female orgasm disorder. If your symptoms or lack of desire is related to inability to maintain lubrication, reach orgasm or reduced intensity of orgasm or delayed in perimenopause, head over to my other article on genitourinary health after this and consider talking to your health care provider about vaginal estrogen moisturizers.
Research on Testosterone Therapy for Women
Testosterone Therapy & Hypoactive Sexual Desire Disorder (HSDD):
There are multiple randomized controlled trials that have shown the efficacy and safety of transdermal testosterone therapy in cases of post-menopausal women with HSDD.
In a 2008 study by Davis et al. 814 menopausal women with concurrent HSDD were randomized to either placebo group or testosterone group over 24 weeks. The testosterone subjects received doses of testosterone at 300 μg/day via the patch. Participants in the 300 μg group had significantly greater Satisfying Sexual Events (SSEs) over 4 weeks when compared to the placebo group. A follow up review in 2012 (Davis 2012), concluded the same result and made this note regarding safety of testosterone therapy: “Available safety data for testosterone, although not conclusive, were reassuring with respect to cardiovascular, breast, and endometrial outcomes. Interim data from a long-term phase III safety trial of a testosterone gel demonstrates a continued low rate of cardiovascular events and breast cancer in postmenopausal women at increased cardiovascular risk.” (Davis, 2012)
A more recent meta-analysis and systematic review (Islam 2019) echoed this statement on the efficacy and safety of transdermal testosterone in HSDD.
Testosterone Therapy & Mood & Cognition in Menopausal Women
In a pilot study completed in the UK, 510 menopausal women on estrogen and progesterone hormone therapy were given transdermal testosterone therapy (Androfem 1% -10mg/ml -0.5ml daily) for 4 months. Results of the study showed a significant improvement in mood and cognition warranting further research (Glynne 2025).
Testosterone & Body Composition in Menopausal Women
When you think of testosterone replacement therapy and muscle building, you might think about the people you see competing in body building competitions. It is absolutely not the same. When testosterone is used in a menopausal woman, it is prescribed in very low doses to just slightly increase baseline levels. In body building, they use anabolic steroids which are synthetic derivatives of testosterone and other modified compounds in combination at much higher doses designed to maximize muscle-building effects, and as a result yield more aggressive adverse effects.
As previously stated, the Menopause Society stance on testosterone therapy is that it is not indicated for treatment of sarcopenia (loss of muscle mass) or osteoporosis. This is because there is an overall lack of research on this topic and variability in results, but we do know that physiologically, testosterone can act to help improve muscle mass.
In a small article published in the Menopause journal (Davis 2000), postmenopausal women were given estrogen alone or estrogen plus testosterone. In the women treated with estrogen alone, body fat measures decreased and were linked to improvements in lipid profiles, while adding testosterone was associated with increased lean body mass (muscle mass) and a lower fat-to-lean ratio compared with estrogen alone. More research is needed as body composition and waist to hip ratio can be a risk factor for cardiometabolic disease in menopausal women.
What Preparations of Testosterone are Being Used in Canada?
There are no official Health Canada approved testosterone products available for women. Women will typically be prescribed a small % of testosterone preparations for men, or compounded formulas. This is another part of the challenge of women receiving appropriate treatment from their healthcare provide – there is minimal guidance on dosage options.
Safety of Testosterone Therapy
Potential Adverse effects: The available data suggest that side effects of testosterone therapy tend to be mild with low doses of transdermal testosterone. Testosterone prescribed to women in higher doses for an extended duration, and not monitored by their healthcare provider, can result in side effects such as acne, hirsutism, and, in extreme cases, virilization. Virilization includes deepening of the voice, clitoromegaly, and androgenic alopecia (Lina Al-Imari, 2012).
Breast Cancer: Short-term studies are reassuring, with no clear increase in risk, but long-term data is limited. History of breast cancer is a contraindication (Lina Al-Imari, 2012).
Endometrial Cancer: No clear increased risk seen in studies at physiologic doses, but monitoring is advised. Unexplained vaginal bleeding should always be investigated (Lina Al-Imari, 2012).
Cardiovascular Health: Short-term data are generally reassuring when levels stay in the normal premenopausal range. Long-term heart and stroke risk remains uncertain (Lina Al-Imari, 2012).
Cholesterol and Metabolic Health: Oral testosterone can worsen cholesterol levels. Transdermal (through the skin) therapy appears more neutral when used at physiologic doses (Lina Al-Imari, 2012).
Liver Health: Liver concerns are mainly linked to older oral androgen formulations. Transdermal therapy has not shown significant liver risk in studies (Lina Al-Imari, 2012).
Bone Health: Evidence suggests testosterone may support or improve bone density, particularly when combined with estrogen (Lina Al-Imari, 2012).
Overall: Physiologic-dose transdermal testosterone appears reasonably safe in the short term, but long-term safety data especially for breast and cardiovascular outcomes are still limited, which is another reason it is not prescribed to women very often (Lina Al-Imari, 2012).
Evaluating Testosterone Levels on Bloodwork
Large studies show that blood levels of steroid hormones such as testosterone do not reliably predict low sexual desire or dysfunction (davis, jama). Even in older women, where very low DHEA-S showed the strongest link to reduced sexual responsiveness, most women with low levels had normal sexual function. In other words, there is no specific testosterone level that defines or diagnoses HSDD. You can have normal testosterone levels and still struggle with lower sexual desire. This presents yet another challenge for women wishing to initiate testosterone therapy in menopause, as testosterone levels are not routinely tested. In part 1, I included a chart which describes health conditions and medications which result in more elevated or lower testosterone levels. Getting a complete medical history and workup on factors which may influence testosterone levels and sexual function is key.
Are There “Optimal” Blood Levels of Testosterone During Therapy?
When women are treated with testosterone, better sexual outcomes tend to occur when blood levels stay within the normal premenopausal physiologic range. The goal of testosterone therapy is not to push testosterone as high as possible (also to avoid adverse side effects), but to restore levels to what is typical for a healthy premenopausal woman and monitor for changes and improvement in symptoms. Total testosterone levels should be measured at baseline and re-assessed 3-6 weeks after initiating testosterone therapy. When blood levels are maintained and monitored properly, side effects are rare.
The Bottom Line on Testosterone Therapy
- There is a huge lack of research: There is a shockingly low amount of research on testosterone therapy for women in menopause, and what research does exist are typically smaller studies with conclusions like ‘more research is needed …’ The lack of research is really what is driving the lack of clarity and guidelines around prescribing for women.
- Lack of appropriate screening for menopausal women: Women in Canada already have challenges with receiving the appropriate menopausal care due to the profound lack of menopause training for primary healthcare providers. This means women are not being screened and asked the appropriate questions when it comes to menopausal symptoms, especially not for hypoactive sexual desire disorder (HSDD). Many women do not feel comfortable discussing their challenges with intimacy and sexual health with their healthcare provider. On top of this, menopausal women have a plethora of symptoms (vasomotor, brain fog, mental health, insomnia etc) that will come ahead of their changes in desire. How can the only condition (HSDD) that testosterone is somewhat indicated for be something that NO practitioner is ever asking about?
- Lack of emphasis on clinical benefit: We know that a lot of menopausal women that use testosterone therapy feel better. I see the benefits for women clinically when they come to my office and are already taking testosterone. If there is one huge theme that has arisen from the whole hormone therapy debacle from the early 2000s that is now emphasized by ALL menopause societies across the board is that we treat the individual. So, if we have an individual in our office that is taking combination hormone therapy (estrogen and progesterone) and feeling like she could still feel better, that her frustration in sexual function is continuing – can we not consider a prescription based on potential clinical benefit? With proper monitoring and dosage adjustments as necessary? Given the reassuring safety profile of low-dose, physiologic testosterone therapy, it is reasonable to consider that some women may be underserved when this option is not discussed or offered, even as we acknowledge that longer-term research is still evolving.
Have questions about menopause or hormone therapy?
References
Davis, S. R., Baber, R., Panay, N., et al. (2024). Testosterone therapy for women: Updated clinical guidance. Climacteric. https://www.tandfonline.com/doi/10.1080/13697137.2024.2445301
Davis, S. R., Davison, S. L., Donath, S., & Bell, R. J. (2005). Circulating androgen levels and self-reported sexual function in women. JAMA, 294(1), 91–96. https://doi.org/10.1001/jama.294.1.91
Davis, S. R., McCloud, P., Strauss, B. J., & Burger, H. (2000). Effects of estradiol with and without testosterone on body composition and lipids in postmenopausal women. Menopause, 7(6), 395–401. https://pubmed.ncbi.nlm.nih.gov/11127762/
Elraiyah, T., Sonbol, M. B., Wang, Z., et al. (2014). Clinical review: The benefits and harms of systemic testosterone therapy in postmenopausal women with normal adrenal function: A systematic review and meta-analysis. The Journal of Clinical Endocrinology & Metabolism, 99(10), 3543–3550. https://pubmed.ncbi.nlm.nih.gov/36198811/
Global Consensus Position Statement on the Use of Testosterone Therapy for Women. (2019). Climacteric, 22(5), 429–434. https://pubmed.ncbi.nlm.nih.gov/31353194/
Islam, R. M., Bell, R. J., Green, S., Page, M. J., & Davis, S. R. (2019). Safety and efficacy of testosterone for women: A systematic review and meta-analysis of randomised controlled trial data. The Lancet Diabetes & Endocrinology, 7(10), 754–766. https://pubmed.ncbi.nlm.nih.gov/31353194/
Journal of Obstetrics and Gynaecology Canada. (2016). The safety of testosterone therapy in women. Journal of Obstetrics and Gynaecology Canada, 38(9), 813–823. https://www.jogc.com/article/S1701-2163(16)35385-3/pdf
Metabolism Journal Article. (2023). Testosterone therapy and body composition in women. Metabolism. https://linkinghub.elsevier.com/retrieve/pii/S0026-0495(23)00201-9
Parish, S. J., Goldstein, A. T., Goldstein, S. W., et al. (2021). International Society for the Study of Women’s Sexual Health clinical practice guideline for the use of systemic testosterone for hypoactive sexual desire disorder in women. The Journal of Sexual Medicine, 18(5), 849–867. https://pubmed.ncbi.nlm.nih.gov/33814355/
The Lancet Healthy Longevity. (2025). Testosterone therapy and long-term outcomes in women. The Lancet Healthy Longevity. https://www.thelancet.com/journals/lanhl/article/PIIS2666-7568(25)00122-9/fulltext
The Menopause Society. (2024). The Menopause Society statement on hormone therapy misinformation. https://menopause.org/wp-content/uploads/2024/09/TMS-statement-on-HT-Misinformation.pdf
Wierman, M. E., Arlt, W., Basson, R., Davis, S. R., Miller, K. K., Murad, M. H., & Santoro, N. (2014). Androgen therapy in women: A reappraisal. The Journal of Clinical Endocrinology & Metabolism, 99(10), 3489–3510. https://pubmed.ncbi.nlm.nih.gov/22304681/
