Testosterone Therapy for Women in Perimenopause: What You Need to Know About the Forgotten Hormone

Testosterone Is a Female Hormone Too

Most conversations about hormones in perimenopause focus on estrogen and progesterone. But testosterone is also a hormone your body produces, and it plays real roles in your energy, sexual desire, mood, and even cognitive function. Women make testosterone in their ovaries and adrenal glands, just at lower levels than men. And like estrogen, testosterone begins declining years before your periods stop.

Testosterone is sometimes called the forgotten female hormone in menopause care, and that description is accurate. Many gynecologists and primary care providers do not routinely test it or discuss it. The medications available for women are limited because the FDA has never approved a testosterone product specifically for women, which means any prescribing in the United States happens off-label using products designed for men, dosed at much lower levels. That regulatory gap has contributed to both the under-recognition of testosterone's role and to the confusion many women feel when they try to learn about it.

This article covers what testosterone actually does for you, how its decline affects perimenopause, the current state of the evidence on therapy, and practical guidance on finding a provider who takes this seriously.

What Testosterone Does for Women

In women, testosterone contributes to several areas of health. It plays a role in sexual desire, arousal, and satisfaction. It is involved in energy levels and motivation. It has effects on mood and may contribute to feelings of confidence and drive. It supports muscle mass and bone density. And there is growing evidence of a role in cognitive function, including focus and mental clarity.

When women lose testosterone, the effects can overlap significantly with other perimenopause symptoms: fatigue, low libido, difficulty building or maintaining muscle, and a general sense of flatness or low motivation. This makes it hard to tease out what is caused by low testosterone versus low estrogen versus the sleep deprivation that comes from night sweats. In practice, all of these hormones are declining simultaneously, which is part of why perimenopause can feel like so many different systems are affected at once.

The strongest body of evidence for testosterone therapy in women relates to low libido, specifically hypoactive sexual desire disorder (HSDD). Multiple randomized controlled trials and large systematic reviews have found that testosterone supplementation improves sexual desire, arousal, and satisfaction in menopausal and perimenopausal women. Evidence for energy and mood benefits exists but is more variable and less robust.

How Testosterone Levels Decline in Perimenopause

Testosterone levels in women actually begin declining in your late twenties and continue declining gradually through your forties. By the time you reach perimenopause, your testosterone may already be significantly lower than it was at peak levels in your mid-twenties. Unlike estrogen, which can fluctuate dramatically during perimenopause before dropping sharply at menopause, testosterone tends to decline more slowly and steadily over years.

Measuring testosterone in women is complicated by the fact that the normal ranges used in lab tests were largely calibrated for men. What shows up as "normal" on a standard lab panel often does not account for the wide variability in women's natural levels or for the fact that total testosterone is not always the most meaningful number. Free testosterone, which is the portion not bound to proteins and therefore available to your cells, is often more clinically relevant than total testosterone, but many labs do not routinely include it.

Certain factors can push testosterone lower even in otherwise healthy women: oral estrogen therapy (because it raises a protein called sex hormone-binding globulin, which binds up free testosterone), oophorectomy (removal of the ovaries), and adrenal insufficiency. If you have had your ovaries removed surgically, your testosterone loss is immediate and significant, which is one reason surgical menopause often produces more acute low-libido symptoms than natural menopause.

How Testosterone Is Prescribed for Women

Because the FDA has not approved a testosterone product specifically for women, prescribers use a few off-label approaches. The most common are testosterone creams or gels formulated by compounding pharmacies at low doses customized for women. Some providers use commercially available testosterone products approved for men (like testosterone gels) but prescribed at fractions of the typical male dose. Testosterone pellets, which are implanted under the skin by a provider every three to six months, are another option offered by some practices, though dosing consistency with pellets has been a subject of debate in the clinical literature.

Dosing matters significantly. Women need much lower doses than men, and the goal is to bring levels to the normal physiological range for women, not to male levels. Supraphysiologic dosing, where levels exceed what a woman's body would naturally produce, can cause side effects. The target range your provider aims for, and how they monitor it, is an important part of the conversation.

Most evidence-based guidance recommends starting at a low dose, checking testosterone levels after several weeks to assess where levels land, and then adjusting. It can take several months to notice the full effect on libido and energy, so patience is part of the process.

Potential Benefits and the Evidence Behind Them

The clearest evidence is for sexual function. A landmark global consensus statement from the International Society for the Study of Women's Sexual Health (ISSWSH) in 2019 reviewed all available trials and concluded that testosterone therapy is effective for postmenopausal women with HSDD. The evidence for perimenopausal women is somewhat less extensive but points in the same direction.

For energy and mood, the data is more mixed. Some studies show benefits, others do not, and the challenge is that these symptoms have many contributing causes during perimenopause. A trial of testosterone therapy for three to six months is often how clinicians assess whether it is helping an individual patient, since population-level averages do not predict individual response well.

For bone density and muscle mass, testosterone has theoretical benefits because it converts to estrogen in some tissues and has its own anabolic effects. But long-term data in women on those outcomes is limited. Most providers who discuss testosterone for perimenopause focus the conversation primarily on sexual function and secondarily on energy and wellbeing.

Risks and Side Effects to Know About

At physiologically appropriate doses, testosterone therapy in women has a good safety record in clinical trials. The most common side effects when dosing is appropriate are mild and include acne, oily skin, and sometimes mild hair growth in unwanted areas. These tend to be dose-dependent, meaning they are more likely if levels run too high.

At higher doses, or if levels become elevated beyond the normal range for women, more significant effects can occur: voice deepening, clitoral enlargement, and male-pattern hair loss. These effects are why careful monitoring matters, and why the relationship with your prescriber should include regular level checks, especially when starting or adjusting.

One area of ongoing discussion is whether testosterone therapy affects cardiovascular risk. Current evidence does not indicate an increased risk at physiologic doses, but long-term cardiovascular data in women is limited. Breast cancer risk is another area that has been studied. Available evidence does not show that testosterone therapy increases breast cancer risk, and some researchers have proposed it may have a protective effect, though this remains an area of active investigation rather than settled science.

Finding a Provider Who Prescribes Testosterone for Women

Not all gynecologists or primary care providers are comfortable prescribing testosterone for women off-label. Some are not familiar with the dosing guidance, and some are not aware of the clinical evidence. This can be frustrating when you are having a real conversation about symptoms.

The Menopause Society (formerly NAMS) certifies menopause practitioners and maintains a searchable directory at menopause.org. Certified menopause practitioners are generally more up to date on the full range of hormonal options, including testosterone. Integrative medicine physicians and some functional medicine practitioners also commonly work with testosterone for women, though the quality of prescribing can vary more widely in those settings, so asking about their approach to monitoring and dosing is important.

When you see a provider, it helps to come prepared with a clear description of what has changed, when it changed, and how it is affecting your life. Mentioning that you are interested in whether testosterone might play a role, and that you have read about the ISSWSH consensus statement, can help open the conversation. A good provider will order appropriate labs, discuss what normal ranges mean in the context of your symptoms, and explain their prescribing approach before starting.

Medical Disclaimer

This article is for informational purposes only and is not a substitute for medical advice, diagnosis, or treatment. Testosterone therapy for women is prescribed off-label in the United States and requires careful evaluation, dosing, and monitoring by a qualified healthcare provider. Not all women are appropriate candidates, and individual risks and benefits vary. Speak with a licensed provider before starting any hormone therapy.

The information in this article reflects research and clinical guidance available as of early 2026 and may not reflect the most current recommendations.