Do Older Women Need Testosterone?

Davis says some of her work is being misrepresented by testosterone proponents.  For example, she points to a 2003 study she conducted, which involved just 31 women.

A doctor on social media “was waving (that) paper around, saying this is evidence that testosterone improves well-being,” Davis says. “It was a pilot study with 31 women, really small. When we repeated it with 255 women, we didn’t get the same outcome. It was probably just a biased sample."

She emphasizes the importance of reliable, repeated findings.

“I could cherry-pick the data and write an article that says testosterone is going to fix everything,” she says, “but cherry-picking the data is not what you want to do. You need to see the results replicated across studies to really believe them.”

3. Experts: Testosterone pellets are risky

Some clinics market testosterone pellets as a convenient therapy option. Implanted under the skin, they release testosterone into the bloodstream for three to six months.

However, guidelines endorsed by 12 major medical societies— including The American College of Obstetricians and Gynecologists and the North American Menopause Society — recommend against hormone pellets.

The pellets are unregulated, irreversible and come with a higher risk of side effects due to their unpredictable release of the hormone, doctors say. There is also limited long-term research on their safety.

“Once they are in your system, they can’t be retrieved,” explains Traci Kurtzer, an ob-gyn at the Northwestern Feinberg School of Medicine. If testosterone levels spike, patients are “stuck with it for three or four months until that pellet wears off.”  

Testosterone metabolizes into estrogen, raising your risk of a blood clot or stroke. Kurtzer said she has seen excessively high estrogen levels in some pellet users. “It makes me very nervous for them … (but) there’s nothing I can give them at that point.” Instead, patients have to “pray and wait it out.”

4. “Bioidentical” hormones aren’t necessarily safer

Many clinics claim their “bioidentical” hormones, including testosterone treatments, are safer and more effective than conventional hormone therapy, but experts warn that’s not always the case.

Unlike FDA-approved treatments, many “bioidentical” hormones are compounded preparations that haven’t gone through rigorous quality testing, says Belinda Yauger, an endocrinologist and ob-gyn at the University of Texas Health San Antonio.

The lack of testing can lead to potential inconsistencies in purity and dosage, says Yauger, who co-authored a 2023 ACOG report highlighting the lack of safety and effectiveness data on compounded bioidentical hormones.

“Often, these compounded medications don't contain just one hormone. They actually contain multiple different ones, and you don't know exactly what you're getting,” she says.

5. Testosterone side effects can be irreversible

Testosterone can cause side effects, especially at levels above what is typical in women. Common issues include acne and oily skin, hair loss on the scalp, increased body hair and weight gain.

In excessive doses, women may develop more distressing symptoms such as voice deepening, an enlarged clitoris and infertility (in premenopausal women). In some cases, those changes are irreversible. There are also concerns about breast cancer and cardiovascular risks.

6. Close monitoring is important if you take testosterone

If you’ve chosen to try testosterone therapy, your health care provider should check your total testosterone level (rather than your “free” testosterone level) before starting treatment, Kurtzer says. A low level should not be used for diagnosis, according to Kutzner and widely adopted clinical guidelines, because the tests can be unreliable. Plus, testosterone levels alone don’t clearly indicate whether a woman has sexual dysfunction, the guidelines say.

However, testing is important to establish your baseline level before you start therapy and to help exclude women who already have high levels from getting the therapy. Kutzner also recommends testing liver function, sex hormone-binding globulin (SHBG) levels and a fasting lipid profile before starting therapy.

Your provider should test your testosterone levels again about three to six weeks after starting therapy and six months after therapy to make sure you stay in the normal range, according to Kurtzer and the guidelines.  To minimize the risk of side effects, she recommends keeping your level under 40 ng/dL.

Your provider should also monitor you for any physical changes that might signal problems. And if you see no improvement after six months, you should stop the treatment.

7. There is no FDA-approved testosterone treatment for women

Although Australia has a 1 percent testosterone cream for women, the FDA has not approved a treatment or dose for women in the United States.

That means U.S. providers who want to prescribe it must either use a compounding pharmacy or prescribe an approved men’s treatment off-label and adjust the dosage down — typically about one-tenth of what men would be prescribed.

A typical prescription would be for a cream or a gel that a woman can apply to her inner knees or the back of her thigh. Insurance usually won’t cover the treatment, which is considered elective. Costs vary depending on the type of medication, dosage and doctor’s fees.

The FDA has approved one related medication, a DHEA-based vaginal suppository called Prasterone (Intrarosa), for women experiencing pain during sex.  DHEA, a hormone produced by the adrenal glands, plays a role in the production of estrogen and testosterone, but it’s not a testosterone replacement.

8. Before starting testosterone, consider if something else could be sabotaging your sex life

Sexual desire is multifaceted, often influenced by emotional, physical and relationship factors. Before opting for testosterone therapy to address low libido, consider potential underlying causes. Could depression or anxiety be playing a role? Are you taking a medication that could be suppressing your sex drive? Or are relationship issues affecting intimacy?

If you have menopausal symptoms such as hot flashes and night sweats, addressing those with estrogen/progesterone hormone replacement therapy can often improve sexual function, Yauger says. Prasterone (Intrarosa) is another FDA-approved option that can be beneficial, she says.

Davis also points out that there is a “huge placebo effect” when it comes to sexual health, because the mind plays a crucial role in sexual well-being.

Before starting testosterone therapy, discuss the pros and cons with your healthcare provider and ask about other treatments. Together, you can determine the best approach based on your unique health profile.