Testosterone Replacement Therapy in Perimenopausal and Menopausal Women
Written and edited by Sarah Bonza MD, MPH, MSCP, FAAFP, DipABLM, NBC-HWC
As a physician dedicated to helping women navigate the complexities of menopause, I often encounter questions about testosterone replacement therapy (TRT). While testosterone is commonly associated with men, it plays a vital role in women’s health as well. For perimenopausal and menopausal women experiencing symptoms such as low libido, fatigue, or brain fog, TRT can be a transformative option. Let’s explore the science, benefits, and considerations surrounding testosterone therapy for women.
The Role of Testosterone in Women
Testosterone is often labeled the "male hormone," but it is also the most abundant biologically active hormone in women. Produced by the ovaries, adrenal glands, and brain, testosterone contributes to several critical functions:
Sexual Health: Testosterone influences libido, arousal, and pleasure. It is often prescribed for hypoactive sexual desire disorder (HSDD), a condition characterized by a lack of sexual interest that causes distress.[1,5]
Cognitive Function: Testosterone supports mental clarity, memory, and mood regulation by interacting with neurotransmitters like serotonin and dopamine.[1]
Physical Health: It helps maintain muscle mass, bone density, cardiovascular health, and energy levels.[2,4]
Unfortunately, testosterone levels decline significantly during perimenopause and menopause. This drop can exacerbate symptoms such as fatigue, reduced libido, and cognitive difficulties.[1,6]
Benefits of Testosterone Replacement Therapy
For women with low testosterone levels who do not find relief from estrogen-based hormone replacement therapy (HRT) alone, adding testosterone can offer several benefits:
Improved Sexual Function: Studies show that TRT enhances sexual desire, arousal, orgasm quality, and overall satisfaction.[3,5]
Enhanced Mood and Cognition: Women on TRT often report better mood stability, reduced anxiety, improved focus, and sharper memory.[1,3]
Physical Strength and Bone Health: TRT supports muscle mass retention and bone density, reducing the risk of osteoporosis.[2,4]
Better Body Composition: It may help decrease visceral fat while improving muscle tone.[2]
For example, one study found that postmenopausal women using transdermal testosterone reported significant improvements in libido and mood after just four months of treatment.[1] Another study demonstrated that higher doses of testosterone improved both psychological well-being and sexual function in surgically menopausal women.[6]
Who Should Consider TRT?
The North American Menopause Society (NAMS) recommends considering TRT for women with HSDD who do not respond to estrogen-based HRT. Symptoms such as persistent low libido or fatigue despite adequate estrogen levels may indicate a need for testosterone evaluation.[3,5] Blood tests measuring total testosterone and free androgen index (FAI) are typically used to confirm low levels before initiating therapy.
Safety and Monitoring
While TRT offers many benefits, it must be approached cautiously:
Dosage: Women require much lower doses than men. Overdosing can lead to side effects such as acne, hair loss, or voice deepening.[6]
Monitoring: Regular blood tests are essential to ensure testosterone levels remain within the female physiological range. Levels are typically checked at baseline and then 3–6 months after starting therapy.[3,8]
Combination Therapy: Testosterone is often prescribed alongside estrogen to maximize benefits while minimizing risks like cardiovascular complications.[7]
Challenges and Future Directions
Despite its potential benefits, TRT remains underutilized due to limited research on its long-term effects in women. Additionally, there are few FDA-approved formulations specifically designed for women. Most prescriptions involve off-label use of male testosterone products at lower doses.[3,8] More robust clinical trials are needed to expand our understanding of TRT’s impact on cardiovascular health and other long-term outcomes.
Conclusion
Testosterone replacement therapy can be life-changing for perimenopausal and menopausal women suffering from symptoms of low testosterone. By addressing issues like low libido, fatigue, and cognitive decline, TRT has the potential to restore vitality during this transitional phase of life. If you’re considering this option, consult with a healthcare provider experienced in menopause management to determine whether TRT is right for you.
At Bonza Health, we’re committed to empowering women through evidence-based care tailored to their unique needs. Together, we can explore solutions that help you reclaim your energy and joy.
References
[1] Balance Menopause. The importance of testosterone for women. https://www.balance-menopause.com/menopause-library/importance-of-testosterone-for-women
[2] HerKare. Why women may need testosterone replacement therapy. https://herkare.com/blog/women-may-need-testosterone-replacement-therapy/
[3] Scott A, Newson L. Should we be prescribing testosterone to perimenopausal and menopausal women? A guide to prescribing testosterone for women in primary care. Br J Gen Pract. 2020;70(693):203-204. Published 2020 Mar 26. doi:10.3399/bjgp20X709265
[4] Fatih Aktoz, Ali Can Gunes, Cemal Tamer Erel. What is the Role of Testosterone Therapy in Postmenopausal Women? A SWOT Analysis. Clin. Exp. Obstet. Gynecol. 2023, 50(8), 159. https://doi.org/10.31083/j.ceog5008159
[5] Donovitz GS. A Personal Prospective on Testosterone Therapy in Women-What We Know in 2022. J Pers Med. 2022;12(8):1194. Published 2022 Jul 22. doi:10.3390/jpm12081194
[6] American Family Physician. Testosterone replacement for menopausal women. https://www.aafp.org/pubs/afp/issues/2001/0315/p1199.html
[7] Rhys C Britton, Nicole F Beamish, The Impact of Testosterone Therapy on Cardiovascular Risk Among Postmenopausal Women, Journal of the Endocrine Society, Volume 8, Issue 1, January 2024, bvad132, https://doi.org/10.1210/jendso/bvad132
[8] Uloko, M., Rahman, F., Puri, L.I. et al. The clinical management of testosterone replacement therapy in postmenopausal women with hypoactive sexual desire disorder: a review. Int J Impot Res 34, 635–641 (2022). https://doi.org/10.1038/s41443-022-00613-0
[9] Mayo Clinic. Testosterone therapy in women: Does it boost sex drive? https://www.mayoclinic.org/diseases-conditions/menopause/expert-answers/testosterone-therapy/faq-20057935
[10] British Menopause Society. Testosterone replacement in menopause. https://thebms.org.uk/wp-content/uploads/2022/12/08-BMS-TfC-Testosterone-replacement-in-menopause-DEC2022-A.pdf
[11] Healthline. Low Dose Testosterone in Females: The Benefits and Risks. https://www.healthline.com/health/low-dose-testosterone-for-females
[12] The Menopause Charity. Testosterone and the menopause. https://themenopausecharity.org/2022/05/01/testosterone-and-the-menopause/
[13] Smith T, Batur P. Prescribing testosterone and DHEA: The role of androgens in women. Cleve Clin J Med. 2021;88(1):35-43. Published 2021 Jan 1. doi:10.3949/ccjm.88a.20030
[14] Davis SR, Baber R, Panay N, et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women [published correction appears in Climacteric. 2019 Dec;22(6):637. doi: 10.1080/13697137.2019.1673555.]. Climacteric. 2019;22(5):429-434. doi:10.1080/13697137.2019.1637079
[15] Johansen N, Lindén Hirschberg A, Moen MH. The role of testosterone in menopausal hormone treatment. What is the evidence?. Acta Obstet Gynecol Scand. 2020;99(8):966-969. doi:10.1111/aogs.13819
[16] NBC News. More women seek testosterone therapy, prompted by influencers. https://www.nbcnews.com/health/womens-health/testosterone-women-hormone-replacement-therapy-what-know-rcna179380
[17] Simply You Wellness. Testosterone and DHEA: A Guide for Women in Perimenopause and Menopause. https://simplyyouclinic.com/2024/05/28/testosterone-and-dhea-a-guide-for-women-in-perimenopause-and-menopause/
[18] Australasian Menopause Society. Testosterone and women. https://www.menopause.org.au/health-info/resources/testosterone-and-women