The importance of testosterone for women

What happens to this hormone during menopause and how it can affect you

• Testosterone has a significant influence on libido but also brain processing
• Levels of this hormone drop during the perimenopause and menopause
• Some women find testosterone replacement can help to alleviate their symptoms

Testosterone is an important hormone. It’s often referred to as the “male hormone” but while men have higher circulating levels of testosterone than women, it’s the most abundant biologically active hormone in women. In fact, before the menopause, women produce three times more testosterone than oestrogen.

Testosterone is produced by your ovaries, adrenal glands and the brain but, like with oestrogen, levels decline around the time of the perimenopause and menopause and stay low thereafter. This fall in testosterone can lead to a lack of energy, brain fog and reduced libido (sex drive).

What does testosterone do?

The hormone is perhaps best known for influencing libido – the level of interest in sex, and the amount of pleasure felt from it. But testosterone has a significant impact beyond this – you have testosterone receptors all over your body so its effects can be felt all over.

Testosterone plays a substantial role in a number of physiological processes in the brain. It strengthens nerves in the brain, and contributes to mental sharpness and clarity. It strengthens arteries that supply blood flow to the brain, which protects against loss of memory. It regulates serotonin levels and plays a role in its uptake in your brain, which helps improve overall mood. Testosterone also stimulates the release of dopamine, another neurotransmitter responsible for your feelings of pleasure.

Testosterone also helps with muscle mass and bone strength, cardiovascular health, and overall energy levels and quality of sleep.

What happens if I have low testosterone?

Levels of testosterone in women gradually decline as you enter your 30s but drop around the time of the perimenopause and menopause. If you have a surgical menopause (if you have your ovaries removed, or an operation or treatment that impacts ovarian function), you can experience a more sudden drop in hormones than women who go through naturally.

When your levels of testosterone reduce, you may find that you desire sex less often and when you do have sex, it’s not as enjoyable as it used to be (even when you still desire and love your partner). It’s normal to go through phases of less interest in sex but if you have a total lack of interest, lasting for more than 6 months that has consequences on your relationship and/or self-esteem, you might be diagnosed with Hypoactive Sexual Desire Disorder (HSDD).

RELATED: hypoactive sexual desire disorder: what you need to know

Other symptoms of lower testosterone include dysphoric mood (anxiety, irritability, depression), lack of wellbeing, physical fatigue, bone loss, muscle loss, changes in cognition, memory loss, insomnia, hot flashes, joint pains and urinary complaints including incontinence.

Do I need to replace my testosterone?

A low testosterone level alone does not necessarily mean replacement testosterone is needed.

The 2015 NICE Menopause guidelines say that testosterone can be considered for menopausal women with low sexual desire – if HRT alone has not been effective [1]. The guidance does not mention or support the use of testosterone in any other circumstances yet there is good evidence to show that the benefits of testosterone could help many more women in their perimenopause and menopause.

One paper, Testosterone therapy in women: Myths and misconceptions, said “to assume that androgen deficiency does not exist in women, or that T therapy should not be considered in women, is unscientific and implausible.” [2]

Menopause specialists and, increasingly, GPs are realising the widespread benefits of testosterone replacement for most women. NHS data suggests that 4,675 women aged 50 and over obtained testosterone gel using an NHS prescription in November 2022, a sharp increase from 429 women in November 2015, and this has been largely attributed to a rise in demand from female patients [3].

Testosterone can be considered soon after the onset of perimenopausal or menopausal symptoms, when you go to seek help for your symptoms. You do not usually need to have a blood test before treatment is started; your symptoms are enough of a guide for your doctor to agree to prescribe testosterone. Testosterone can be taken alongside oestrogen and progesterone.

Blood tests are needed a few months after starting testosterone treatment to ensure your levels are within the ‘female’ range. The dosage will be adjusted accordingly, depending on both your levels and whether you have ongoing symptoms of low testosterone. The blood tests can look at both the total testosterone levels in your body, and also the amount which is freely available by adding a SHBG level (sex hormone binding globulin) to calculate your FAI (free androgen index).

How is testosterone treatment given?

Testosterone is usually given as a cream or gel, which you rub into your skin like a moisturiser. It is then absorbed directly into your bloodstream.

AndroFeme®1 cream is made for women. It is licensed in Australia but can be prescribed here and is a regulated preparation.

Testogel, Testim and Tostran are gels that are made for men but can be prescribed off licence and safely used in lower doses for women.

Your clinician will tell you how much testosterone to use. It should be rubbed onto clean, dry skin on your upper outer thigh or buttocks, it usually takes about 30 seconds to dry. You should wash your hands thoroughly after using it. Applying the cream or gel at the same time each day will have the best effect and help you remember to apply it. Avoid swimming or showering until around 30 minutes after application and initially avoid using perfume, deodorant or moisturising creams on the area.

Some menopause specialists give testosterone as an implant, which is a tiny pellet inserted under the skin that usually stays there for six months.

It can sometimes take a few months for the full effects of testosterone to work in your body, whether this is using the cream, gel or the implant.

Benefits of testosterone replacement

Many women find that taking testosterone as part of their HRT provides further improvements than taking oestrogen alone (with or without a progesterone). Benefits you might experience include:

• Increased libido and sexual arousal levels
• Improved energy and stamina
• Improved muscle mass and strength
• Improved concentration, clarity of thought and memory
• Improved sleep

Newson Health carried out an audit in its clinics of 1,200 perimenopausal and postmenopausal women prescribed transdermal testosterone for at least three months. As expected, the audit found an improvement in symptoms associated with low libido, but the biggest symptom improvement was seen in mood and anxiety-related symptoms.

This was an observational study, which has limitations, so more research is needed – the National Institute of Health Research is currently researching the benefits and risks of testosterone on women in menopause with the aim of increasing the evidence base for testosterone as a treatment for symptoms beyond altered sexual function [4].

Risks of testosterone replacement

There are usually no side effects with testosterone treatment as it is given to replace the testosterone that you are otherwise lacking. Very rarely women notice some increased hair growth in the area in which they have rubbed the cream, this can be avoided by rubbing it into places with few hair follicles (upper outer thighs and buttocks are the recommended sites) and regularly changing the area of skin on which you rub it in.

As the dose is so low, testosterone used in this way does not usually increase your risk of developing facial hair, voice deepening or skin changes.

You should have a blood test to check your testosterone levels after around three months of starting treatment and then have regular (usually annual) blood monitoring to reduce the risk of any side effects occurring.

If you use AndroFeme®1, this contains almond oil so should not be used if you have an allergy to almonds. 

Long-term use of safely prescribed testosterone replacement is not associated with any adverse health risks and is shown to be beneficial for the health and strength of your muscles, bones, cardiovascular health and brain health.

References

1. NICE Guidance
2. Glaser R, Dimitrakakis C. (2013), ‘Testosterone therapy in women: myths and misconceptions’, Maturitas. 74(3):230-4. doi: 10.1016/j.maturitas.2013.01.003
3. Pharmaceutical Journal
4. NIHR