Testosterone — the hormone nobody tells women about
Women produce testosterone throughout their lives. It drives energy, libido, muscle mass, bone density, mood, and cognitive function. It declines at menopause — and it is almost never tested, explained, or treated. Rose covers the full picture.
Rose
"I spent months feeling like a different person — exhausted, flat, no motivation, no drive. My estrogen and progesterone were being addressed. Nobody mentioned testosterone. When I finally asked about it and had it tested, my levels were in the lowest quartile for my age. The difference that treatment made was significant. It is the hormone most likely to be overlooked — and the one that most affects how you feel in daily life."
Key takeaways
✓Women produce testosterone in the ovaries and adrenal glands throughout their lives — it is not just a male hormone
✓Testosterone declines steadily from the mid-20s and drops significantly at menopause — both from ovarian decline and adrenal changes
✓Low testosterone in women causes fatigue, low libido, muscle loss, brain fog, low mood, and reduced resilience — symptoms that are often attributed to estrogen or depression
✓Testosterone therapy for women is recommended by the British Menopause Society, The Menopause Society, and the International Menopause Society for low libido
✓It is used off-label for other symptoms — the evidence base is growing but dosing for women is still not standardised
✓Most doctors do not test or offer it — you may need to ask specifically, or find a menopause specialist
✓The safety evidence at physiological doses (replacing what was lost) is reassuring — this is not the same as the pharmacological doses used in sport
What testosterone actually does in women
Testosterone is present in women at roughly one tenth of male levels — but those levels matter enormously. Testosterone receptors are found throughout the body: in the brain, the bones, the muscles, the skin, the cardiovascular system, the vaginal tissue, and the clitoris.
It is an anabolic hormone — it builds and maintains tissue. It is a cognitive hormone — it supports memory, concentration, and processing speed. It is a motivational hormone — it drives dopamine activity and the sense that life is worth engaging with. And it is the primary driver of sexual desire in women, much more directly than estrogen is.
Women produce testosterone primarily in the ovaries and to a lesser extent in the adrenal glands. Ovarian testosterone production falls sharply at menopause — by up to 50% in surgical menopause (where both ovaries are removed) and more gradually in natural menopause. But the decline begins years earlier — testosterone peaks in the mid-20s and declines continuously from there.
What low testosterone feels like — the symptom map
These symptoms overlap significantly with low estrogen and with general perimenopausal experience — which is why testosterone is so often missed. The key distinguishing feature is the quality of the fatigue, the flatness of motivation, and the loss of libido that does not respond to addressing estrogen alone.
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Persistent fatigue
Not the tiredness that sleep fixes. A deeper, bone-level exhaustion that is present even after a good night. Testosterone drives cellular energy production — when it falls, energy falls with it.
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Low or absent libido
The most studied effect of low testosterone in women. Loss of sexual desire, reduced arousal, decreased genital sensation. Often dismissed as psychological — it is physiological.
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Brain fog and poor concentration
Testosterone is a cognitive hormone, not just a sex hormone. Low levels impair working memory, processing speed, verbal fluency, and sustained attention.
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Low mood and motivation
Testosterone drives dopamine activity — the neurotransmitter of motivation and reward. Low testosterone produces a flat, unmotivated, joyless quality that can be mistaken for depression.
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Muscle loss and weakness
Testosterone is an anabolic hormone. Without adequate levels, maintaining muscle mass becomes significantly harder — even with regular exercise. Women notice declining strength and increasing difficulty building muscle.
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Joint and bone pain
Testosterone has direct protective effects on bone density and joint health. Low levels contribute to the musculoskeletal pain and accelerated bone loss seen at menopause.
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Vaginal dryness and discomfort
Testosterone receptors line the vaginal wall and clitoris. Low levels contribute to tissue thinning, dryness, and loss of sensitivity — often alongside estrogen-related changes.
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Irritability and low resilience
Testosterone modulates stress response and emotional regulation. Low levels reduce the buffer against daily stressors — producing a heightened reactivity that women often notice as being unusually fragile or easily overwhelmed.
Getting tested — what the numbers mean
The testosterone testing problem
Standard lab ranges for female testosterone are often derived from small, poorly characterised populations and are not specific to menopausal women. A result within the standard range does not mean your level is optimal for your age, your symptoms, or your stage of menopause.
What to ask for: total testosterone and SHBG (sex hormone binding globulin). SHBG binds testosterone and renders it inactive — high SHBG means less free testosterone available even if total testosterone appears adequate. Free testosterone (calculated from total T and SHBG) is the most clinically meaningful number.
Morning testing gives the most reliable result — testosterone follows a diurnal rhythm, highest in the morning. Avoid testing mid-cycle if you are still having periods — testosterone peaks around ovulation.
What to say to your doctor
"I am experiencing fatigue, low libido, brain fog, and low motivation that has not resolved with my current HRT. I would like my testosterone level checked — specifically total testosterone and SHBG so we can calculate free testosterone. The British Menopause Society recommends testosterone therapy for low libido in menopausal women and I would like to discuss whether I am a candidate."
Full doctor conversation guides →
The evidence — what testosterone therapy does
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Libido and sexual function
Strong evidence
The strongest evidence base for testosterone in women is for hypoactive sexual desire disorder (HSDD) — the medical term for low libido that is causing distress. Multiple RCTs and systematic reviews confirm that testosterone therapy at physiological doses significantly increases sexual desire, arousal, pleasure, and satisfaction compared to placebo.
What the evidence shows
• Significant improvement in sexual desire in 70-80% of treated women in RCTs
• Improvement in arousal, lubrication, orgasm, and sexual satisfaction
• Endorsed by BMS, IMS, The Menopause Society, and Endocrine Society for this indication
• Effect is specific to testosterone — adding estrogen alone does not replicate it
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Cognitive function and mood
Moderate evidence
The evidence for cognitive and mood benefits is promising but less definitive than for libido — partly because dosing and trial design vary significantly. Women consistently report subjective improvements in mental clarity, motivation, and emotional resilience. Objective cognitive testing shows more modest but real improvements in verbal memory and processing speed.
What the evidence shows
• Testosterone receptors are widely distributed in the brain — particularly in areas governing memory and executive function
• Observational data strongly links low testosterone to cognitive decline in women
• RCT data shows improvements in verbal learning and memory at physiological replacement doses
• Mood and motivation improvements are consistently reported — mechanism likely via dopamine pathway
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Muscle, bone, and energy
Moderate evidence
Testosterone is an anabolic hormone — it directly supports muscle protein synthesis and bone density. The evidence for energy and body composition effects is less studied in women specifically, though the physiological mechanism is clear and the clinical experience of many women on testosterone therapy is consistent.
What the evidence shows
• Testosterone contributes to bone mineral density maintenance alongside estrogen
• Muscle mass preservation is supported at physiological doses combined with resistance training
• Women on testosterone therapy consistently report improved energy and reduced fatigue
• Exercise response — strength gains and muscle building — appears to improve with adequate testosterone
Formulations — what is available
Testosterone cream (compounded)
Applied to inner arm or thigh daily — most common UK formulation
Advantages
✓ Dose flexibility — can be adjusted precisely
✓ Absorbed transdermally — avoids liver metabolism
✓ Well tolerated by most women
Considerations
• Compounded — consistency between batches varies
• Transfer risk to partners or children if not careful
• Not licensed specifically for women in many countries
Testosterone gel (AndroGel, Testogel)
Licensed for men — used off-label for women at much lower doses
Advantages
✓ Consistent pharmaceutical formulation
✓ Widely available on prescription
✓ Transdermal — good absorption profile
Considerations
• Licensed for men — dosing requires adaptation
• Sachet sizes designed for male doses — requires careful splitting
• Transfer risk
Testosterone pellets / implants
Inserted under the skin every 3-6 months
Advantages
✓ No daily application
✓ Consistent steady delivery
✓ Preferred by some women who struggle with gel compliance
Considerations
• Minor surgical procedure
• Cannot adjust dose once inserted
• Less common, not available everywhere
Intrarosa (prasterone)
Vaginal DHEA pessary — converts to testosterone and estrogen locally
Advantages
✓ Local effect on vaginal tissue
✓ No systemic testosterone exposure
✓ Addresses vaginal symptoms specifically
Considerations
• Local action only — does not address systemic low testosterone symptoms
• DHEA, not testosterone directly
Safety — addressing the concerns
The short answer: physiological replacement is safe
The safety concerns around testosterone in women largely stem from misunderstanding. The doses used in women are 10-20 times lower than those used in men — the goal is to restore levels to what they were in the woman's own early adulthood, not to elevate them beyond physiological range.
At physiological doses, the evidence does not show increased cardiovascular risk, liver toxicity, or breast cancer risk. Some studies suggest testosterone may actually be protective against breast cancer — though this is not yet definitive.
Side effects at appropriate doses are uncommon but can include mild acne, some increase in body hair, or clitoral sensitivity changes. These are dose-dependent and generally resolve with dose adjustment. Virilisation (voice deepening, significant hair growth) is a sign of supraphysiological dosing and should not occur with properly managed therapy.
Rose on this
"Testosterone is the hormone most likely to change how you feel day-to-day in perimenopause — and the one least likely to be mentioned, tested, or offered. The research is there. The society endorsements are there. What is missing is the conversation in the consulting room. You may have to start it yourself. It is worth starting."
From Rose
"There is a version of you that feels like yourself again — motivated, clear-headed, present, able to enjoy your life. For many women, that version requires addressing all three hormones, not just the two that get all the attention. Do not let testosterone be the hormone nobody tells you about."
What we do not know yet
?The optimal testosterone dose for women for non-libido indications (cognitive, energy, mood) — current dosing is largely extrapolated from libido research
?The long-term cardiovascular and breast cancer effects of testosterone therapy in women — current evidence is reassuring but follow-up periods in most studies are under 10 years
?Whether SHBG-lowering strategies could be used as an alternative to testosterone supplementation for women with high SHBG and adequate total testosterone
?The specific cognitive domains most responsive to testosterone therapy — current evidence is suggestive but not definitive on which aspects of cognition benefit most
Written by
Rose
Navigating perimenopause · Researcher · Founded rosemyfriend.com
Research basis
PubMed · Cochrane reviews · NICE guidelines · British Menopause Society · The Menopause Society
Read methodology →
Rose provides evidence-graded educational information — not medical advice. Always discuss health decisions with a qualified healthcare provider.
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