Do you need more testosterone?
Answer: Probably not. Here's what to know.
Yup, we’re talking about the Real Housewives again. (But just a little bit, I swear.)
This past season on the “Real Housewives of Orange County,” multiple women discussed how they routinely have testosterone pellets injected. Gretchen Rossi was even shown pantless, butt in the air as a doctor injected pellets into her rear. The women bonded, or maybe commiserated, saying the hormone revved up their sex lives — maybe a little too much.
They’re not the only ones talking about taking testosterone during perimenopause and menopause, though: The New York Times wrote about it this fall, and then again just a few weeks ago. New York Magazine’s The Cut had a recent feature on the topic. So did Vox.
With the media onslaught about the use of testosterone as a course of treatment for menopause-related health symptoms, I needed to understand why this was happening — and what it actually meant for people’s bodies.
Cue the expert
So I called Dr. Margaret Wierman, the chief of endocrinology at the University of Colorado-Anschutz and senior author of the position statement on testosterone therapy for women issued by the Endocrine Society and 10 other medical societies.
First, Wierman gave a quick definition: Most simply, testosterone is an androgen — a sex hormone that plays a key role in developing male sex characteristics and also helps with bone density, muscle development, red blood cell function and sexual desire.
In cisgender women, testosterone is mostly produced by the ovaries. It’s converted into estrogen by aromatase, an enzyme that is necessary for sexual development in both sexes and can impact cognition, mood and bone health.
We know that testosterone is important for cisgender men’s bodies and directly impacts their sexual health. And lately, many people have wondered about whether it could play a role for cisgender women’s health as they age.
Scientists and health researchers largely agree that for the average cisgender woman, testosterone should measure somewhere between five and 40 nanograms per deciliter. And yes, postmenopause these levels decline — but everyone’s testosterone levels decline as they age. That’s not necessarily the sign of a problem, Wierman said.
“Over the last 50 years, people have looked for a role for testosterone in women and tried to define an Androgen Deficiency Syndrome,” similar to how the deficiency has been defined for men, Wierman said. But so far, they haven’t made that connection.
What the research found
One study in the 2010s showed that for a very specific demographic — postmenopausal women with abnormally low sexual desire who had no cardiac risks, risk of hypertension or risk of breast cancer — testosterone supplementation via a patch resulted in one additional episode of sexual intercourse per month that was satisfying.
“People had suggested that maybe if we just looked hard enough, we could find a role for testosterone,” Wierman said. “If we were in the right range for supplementation, we could find a role for testosterone on cognition, on bone density, on all of these kinds of things. But the data really showed that it had an effect on this subset of hypoactive sexual desire disorder” — but nothing else.
When the data was taken to the Food and Drug Administration (FDA), the agency found the benefit was very low compared with the risk, as they had concerns about both breast cancer and cardiovascular risks. The FDA panel that reviewed this patch for American women unanimously rejected it because of safety concerns. At the same time, the testosterone patch was taken off of the market in Europe. Currently, it’s only available in Australia.
“And yet it keeps coming back,” Wierman said of the topic of prescription testosterone for women. “There have been no studies since we did the review. I was part of the international review where we met across the globe to look at the data, and it’s just not there.”
In the 2019 position statement, the Endocrine Society concluded that while testosterone therapy may be appropriate for women with hypoactive sexual desire dysfunction, or extreme lack of sex drive, the available evidence does not support the use of testosterone for any other symptoms or medical condition.”
“Off-label must be good”
Some patients, though, are still seeking out testosterone to address everything from declining sex drive to muscle mass protection to maintenance of a youthful appearance. Many turn to unapproved treatments because they don’t feel heard by doctors about the challenges they face — both physical and emotional — as they age.
This means some people end up receiving off-label, compounded testosterone or other prescription testosterone products like creams or gels from health care providers. That sometimes means prescriptions for small doses of drugs formulated for men, with doctors closely monitoring to see how well patients tolerate it and how it helps with things like libido and fatigue.
More common, though, are the injectables and pellets that have become so widely available — many offered through various kinds of anti-aging or alternative health clinics, and not mainstream doctors’ offices, and without ongoing clinical supervision. Those pellets deliver testosterone at way higher levels than any body produces naturally. Because of this, Wierman said the Endocrine Society doesn’t even suggest that cisgender men use them.
Like athletes on steroids
But might testosterone make you feel better? Maybe — but that doesn’t mean you should be taking it.
“So does it treat depression with an activating sort of effect? Well, there’s a lot safer medicines available to treat depression than taking testosterone,” she said. Changes in how you might feel because of testosterone are a result of it being a natural steroid hormone. (If you’ve ever taken prednisone, you know how even that can make you feel revved up.)
Taking it also can mask the actual causes of why women are experiencing certain symptoms and further delay them from the most effective, specific course of treatment, Wierman said.
“Do you have sleep apnea? Are your estrogen hormones out of whack? Do you have a mood disorder? Do you have a problem in your relationship? Are you anemic? All those kinds of things that somebody would go to the doctor for which do happen at perimenopause or menopause — but now everyone is looking for this silver bullet that’s not there.”
The side effects
Wierman pointed at a host of well-documented side effects when testosterone is used outside the normal range. They include male pattern balding, the development of facial hair and body hair, and changes in fat and muscle that can result in a more stereotypically “masculine” physique.
She said there has also been research showing marked worsening of the cholesterol panel, with higher bad cholesterol (LDL) and lower HDL (or good cholesterol).
There have also been reports of impacts on mental health, not dissimilar to the stories of “roid rage” we often associate with athletes and anabolic steroids.
So what about your sex life?
Wierman said that a lot of the conversation she hears about testosterone being necessary to help women’s sexual satisfaction in midlife is misguided, too.
“Sexual function in women is different than in men,” Wierman said. For women, it’s not a straightforward switch — sexual desire is more like a circle, where there’s a starting point and then a number of factors contribute to where you are on the circle’s arc.
“You have whether you fought with your husband this morning, whether your kids are calling in the middle of the night, whether because you’re menopausal you’re having painful intercourse that hasn’t been treated — and then because the actual act is painful, you don’t really feel like it. There’s also whether or not you feel sexy because you’re going through menopause — maybe you’ve gained some weight and that whole innate self-love is off. Then there’s the act of being able to have an orgasm. Sexual desire is this big circle and actual satisfaction can be interrupted at all of these different levels.”
What women really need, she said, are good doctors who want to listen, ask questions and identify what’s really at play. That includes ensuring that the people who would benefit from estrogen therapy — which can help with vaginal pain, urinary tract infections, and mood and sleep disruption, among other symptoms associated with perimenopause — get that.
“There are safer ways. That’s where the science is,” said Wierman when it comes to thinking about hormones and midlife health and how testosterone fits into this conversation. “Where the science is, is giving us all these pieces of data that now allow us to give the right hormones at the right time to the right people and also treat all the rest of the things that are happening in midlife.”
Help some journalists out!
The Marshall Project, a 19th News Network Partner and a nonprofit newsroom that covers the American criminal justice system, is beginning a project exploring what the menopause experience looks like for incarcerated people — and they’re looking for folks who can help inform their reporting.
The team there is looking to connect with women’s health experts, formerly incarcerated people, health care providers or others who provide support to people in prison, and relatives and friends of someone going through menopause while incarcerated. Survey responses will be used for the creation of a guide that The Marshall Project Team will make available to incarcerated people experiencing menopause.
Have something to share? Participate in their survey here.