Testosterone Therapy for Women in Perimenopause: What It Does, Who It Helps, and How to Get It

The Hormone Nobody Told You About

When people talk about perimenopause and hormones, estrogen and progesterone get most of the attention. Testosterone rarely comes up. But testosterone is present in your body your entire reproductive life, and it plays a real role in how you feel day to day.

If you have noticed a drop in your sex drive, less motivation, harder-to-build muscle, or a flatness in your mood that does not quite match anxiety or depression, testosterone may be part of the picture.

It is not a magic solution. But it is a legitimate part of the hormonal story of perimenopause, and it deserves a real conversation with your provider.

What Testosterone Does in Your Body

Testosterone in women is produced mainly by the ovaries and adrenal glands. Even at lower concentrations than in men, it has meaningful effects.

It supports libido and sexual response. It contributes to muscle mass and strength. It plays a role in bone density. It affects mood, motivation, and mental sharpness. Some research also links it to cardiovascular health and metabolic function.

During your reproductive years, testosterone levels are highest around ovulation. As you move through perimenopause, the ovaries begin producing less of it. By the time you reach menopause, total testosterone levels may be roughly half of what they were in your twenties and thirties.

The decline is gradual and not always dramatic, but it can be significant enough to notice.

Symptoms That May Point to Low Testosterone

Low testosterone in women does not always show up in obvious ways. The symptoms overlap with other perimenopause changes, which is part of why it gets overlooked.

Decreased libido is the most well-documented symptom. This includes not just reduced interest in sex but also reduced response to stimulation. Low testosterone can also look like persistent fatigue that does not improve with rest, difficulty building or maintaining muscle despite consistent exercise, brain fog or reduced mental edge, and a general loss of motivation or drive.

These symptoms can have other causes. Low iron, thyroid dysfunction, poor sleep, high stress, and low estrogen can all produce overlapping effects. That is exactly why testing matters before assuming testosterone is the issue.

How Testosterone Is Tested

Testosterone can be measured in a standard blood panel, but the testing is more nuanced than it sounds.

Total testosterone measures all the testosterone in your blood. Free testosterone measures only the portion that is biologically active. Sex hormone-binding globulin (SHBG) is a protein that binds testosterone and makes it unavailable to tissues. When SHBG is high, you can have a normal total testosterone level and still have low free testosterone.

For this reason, most practitioners who take female testosterone seriously will order total testosterone, free testosterone, and SHBG together. Ask your provider for all three.

Timing matters too. Testosterone levels fluctuate during the day and across your cycle. Morning is generally the best time to test. If your levels come back low-normal but your symptoms are significant, that context matters more than the number sitting at the edge of normal range.

The Off-Label Reality of Testosterone Prescribing

There is currently no FDA-approved testosterone product specifically for women in the United States. This does not mean testosterone therapy is experimental or unsupported. It means the regulatory landscape has not kept up with the evidence.

Providers who prescribe testosterone for women do so off-label, using products designed for men at much lower doses, or through compounding pharmacies that formulate creams, gels, or pellets. The British Menopause Society and other international bodies have published position statements supporting the use of testosterone for hypoactive sexual desire disorder in women. The evidence base is solid.

Being prescribed something off-label is not unusual in medicine. Many medications are commonly used outside their original labeled indication. What matters is that your provider understands the dosing, the risks, and the monitoring required for female use specifically.

Compounded vs. Low-Dose Male Products

Your two main options in the US are compounded testosterone preparations or low-dose use of products designed for men.

Compounded testosterone is made by a compounding pharmacy to a custom formulation, typically a cream or gel applied to the skin. The advantage is that the dose can be very small and precise. The disadvantage is the same as with any compounded product: quality varies between pharmacies, and consistency can be harder to verify.

Using a male testosterone product at a fraction of the standard male dose is another approach some providers prefer. Products like Androgel come in standardized formulations with known concentrations. The challenge is that the doses are calibrated for men, so getting a genuinely low female dose requires careful division.

Your provider's experience with female testosterone matters more than which form you use. Work with someone who has done this before and can monitor you appropriately.

A Note on Pellets

Testosterone pellets are small capsules inserted under the skin that release testosterone slowly over three to six months. You will see them marketed heavily by some clinics.

The appeal is convenience. One insertion, steady release, no daily cream to remember.

The concern is that pellets are very difficult to reverse if your levels go too high. With a cream or gel, you can stop and levels drop within days. With a pellet, you are committed to that dose for months. Testosterone excess in women can cause acne, hair thinning, clitoral sensitivity changes, and voice deepening. Some of these changes, particularly voice changes, can be permanent.

For women new to testosterone therapy, starting with a topical product and adjusting is generally the more conservative and reversible approach. Pellets may be appropriate later if you and your provider have established your ideal dose.

Finding a Provider Who Takes It Seriously

Not every gynecologist or primary care doctor will feel comfortable prescribing testosterone for women. This is a real gap in conventional training.

Providers more likely to take a nuanced approach include OB/GYNs who specialize in menopause medicine, integrative medicine doctors with hormone expertise, and endocrinologists who see women with sexual health concerns. Look for providers who are members of the Menopause Society (formerly NAMS) or who list menopause care as a specific area of focus.

When you make an appointment, be direct. Tell them you want to discuss your hormone levels including testosterone, and ask whether they prescribe testosterone off-label for women. A quick conversation before booking can save you time with a provider who will not engage with the question.

Tracking your symptoms consistently in PeriPlan can help you walk into that appointment with specific, concrete patterns rather than trying to describe a vague feeling. Clear patterns make for better clinical conversations.

Side Effects and Monitoring

Testosterone therapy at appropriate doses for women is generally well-tolerated, but monitoring is important.

Common side effects at proper female dosing include mild acne, increased body hair in some women, and increased libido. These are typically dose-dependent and resolve when the dose is adjusted.

Higher doses or improper formulations can cause more significant androgenic effects including scalp hair thinning, clitoral changes, or voice deepening. Monitoring levels with follow-up blood tests, typically at six to eight weeks after starting and then every six months, allows your provider to catch problems before they become significant.

There is no high-quality long-term safety data on testosterone therapy in women over many decades. Most practitioners are conservative about duration and dosing for this reason. Ongoing conversation with your provider is part of the process.

The Bottom Line

Testosterone is a real part of your hormonal health, not a footnote. Its decline during perimenopause contributes to symptoms that often get misattributed to stress, aging, or low estrogen alone. It deserves to be part of the conversation you have with your provider.

If you are curious about whether testosterone might be relevant to your symptoms, start with the blood tests. Ask for total testosterone, free testosterone, and SHBG. Find a provider who takes female testosterone seriously. Be cautious about pellets until you know how your body responds. And expect monitoring to be part of the plan.

You are not asking for something unusual. You are asking for a full picture of your hormonal health.

This content is for informational purposes only and does not replace medical advice. Always consult your healthcare provider about your specific situation.