Among the most confusing topics for women in midlife is the hormone testosterone and how that might fit into their HRT plan. It’s both overlooked by many providers as not important for women AND it’s overprescribed at too high dosages that are potentially dangerous for women as well.
And given that there is currently no FDA-regulated testosterone preparation for women, it’s a bit of a mess.
But it is available for women, it should be evaluated in midlife and it should be used when warranted. This article will help you understand testosterone’s role in your health and well-being as well as how to know if you need it and how to safely use it.
Testosterone + Women
Like estrogen and progesterone, testosterone is a steroid hormone that is part of the androgen family along with DHEA, androstenedione, and dihydrotestosterone. It is made in the adrenal glands and ovaries. Testosterone along with the other androgens have actions of their own throughout the body as well as being precursors for estrogen.
Like our other sex steroids, estrogen and progesterone, testosterone impacts systems throughout our body affecting mood, energy, motivation, muscle mass, bone health, overall vitality as well as what it’s best known for: boosting libido. Testosterone along with estrogen has a role in a woman’s sexual health including desire, arousal and satisfaction.
Women in their 20s and 30s have their peak levels of testosterone where we have three to four times as much testosterone as estrogen. This is largely to drive reproduction during these most fertile years. After this, testosterone levels will start to decline and by the time we are fully into menopause they are about half what they were at their their highest.
However, many women during perimenopause and early menopause have normal or even elevated testosterone . So, unlike the predictable decline in estrogen and progesterone throughout midlife, testosterone needs to be highly individualized and always tested before starting replacement therapy. As well, it’s important to address testosterone both in light of a woman’s diet, lifestyle, and exercise plan, as well as if they are also using estrogen their in HRT regimen (more on that below).
Testosterone can have many benefits for women including increased sexual desire and function, healthier bones and muscles, better cognition and motivation, improved pelvic floor health and more optional body composition. And when done at appropriate levels, testosterone can even show some reduction in breast cancer risk. At higher levels though, those more like male physiological levels, we see more side effects as well as increased risk for clotting, heart disease and liver disease.
What If My Testosterone Is Low?
If testosterone is showing low on lab testing or symptoms of low testosterone are present in women in their 20s and 30s and even into their early 40s, I do not recommend testosterone replacement straight away, but rather identify and address all causes of the low testosterone which includes stress, nutrient deficiencies, lack of sleep, inadequate protein and not enough heavy strength training. Most often these measures will perk up low testosterone in these women.
When a woman is in her 40s and 50s with low testosterone but wants to also explore estrogen as well, my advice is generally get stable on estrogen first and revisit testosterone if still low in 6-12 months. When we add too many hormones at once it increases the risk of side effects and because testosterone converts to estrogen we can get a real murky picture of what’s causing what and how to best adjust dosages or your regimen as a whole.
Avoiding Too Much of A Good Thing
The goal of using testosterone in women dealing with low androgens in midlife is to put them into a normal physiological range for women thus improving their symptoms such as low libido, improved mood, better energy, etc. The goal should never be to push them into supraphysiological level or into a male hormone profile.
This is a real problem especially with testosterone injections and pellet therapy where levels often get very high. This is completely unnecessary when women can feel great at optimal female levels. Certain side effects of testosterone at these very high levels such as enlargement of the clitoris and lowering of the vocal range are not reversible without surgery.
Sadly, I see this far too often in practice: testosterone prescribed without testing and only monitoring with symptoms, testosterone prescribing in younger women without addressing lifestyle factors first and generally over prescribing often with pellets getting levels very high.
If your prescriber pushes dosages higher without proper testing, advocates for pellets (which they are financially incentivized to do) or tells you it’s ok to have very high lab levels well into male physiology ranges as long as you feel good it’s time for a new provider.
Side effects of testosterone due to too high of levels or due to poor testosterone metabolism include:
- Acne
- Hirsutism (darker, coarse hair growth on face, stomach, arms, etc.)
- Hair loss (often at the front, crown or seen as a widening part)
- Irritability
Many of these can be remedied by supporting breakdown of testosterone down less aggressive pathways with nutrients like zinc, chrysin, saw palmetto, and those found in my clear+normalize product. This metabolism is easily seen on DUTCH testing . These side effects may also indicate your dose is too high. All of these issues are usually resolved by supporting androgen metabolism or adjusting dose.
For women experiencing low libido, sexual dysfunction or other symptoms of low testosterone during midlife, testosterone and DHEA-S should be tested via blood testing (saliva and urine testing not as accurate for androgens) and considered as part of a broader treatment plan.
If you are using testosterone as part of your HRT plan, getting levels into the premenstrual physiological levels for women is ideal as there is increased risk of elevated lipids, stroke and androgenic side effects (again, some are not reversible by stopping testosterone such as enlargement of the clitoris and deepening of the voice) at these very high, supraphysiological doses that a women would never achieve naturally.
Another less talked about issue with testosterone going too high is that they will suppress any testosterone that you are producing and there is published data that when high dose testosterone is stopped and levels come back down there is some withdrawal phenomena. This can include depression and even suicidal ideations. Not to mention, high testosterone can feel really bad with mood issues ranging from irritability to anger or aggression to even the desire to have an affair although you’re in a committed relationship.
It can be a real mess and potentially dangerous. It’s simply not necessary when women feel better and resolve their low testosterone symptoms with an appropriate female physiological dose without added risk. And again, if levels go high because of a pellet or an injection there’s usually nothing you can do but wait it out and suffer through the side effects until those internal levels go down on their own
Estrogen+Progesterone First Approach Is Optimal
Some providers see low libido or other common symptoms of low testosterone or even low testosterone on testing and start prescribing it without a consideration for how estrogen will fit into the HRT regimine. It’s unwise and short sighted and usually done to get some quick results without taking the next steps and a woman’s bigger picture into consideration.
If we are going down the HRT route for all its benefits there is good clinical rationale for balancing estrogen and progesterone first or at least along with testosterone for women as needed, because low estrogen and low testosterone share many common symptoms AND testosterone converts to estrogen making a testosterone first approach very murky.
Symptoms of both low estrogen and low testosterone:
- Fatigue
- Low libido
- Brain fog
- Lack of motivation
- Weight gain
- Difficulty losing body fat
- Difficulty building muscle
As well side effects of too much estrogen and too much testosterone include:
- Acne
- Bloating
- Weight gain
- Irritability
- Headaches
- Irregular bleeding or spotting
- Water retention
It can be confusing which hormone is causing the issue when both are started at the same time or testosterone started first. Because estrogen is such an important female hormone AND because testosterone will convert to estrogen, it makes the most sense for the vast majority of women to get estrogen sorted out first, balanced with progesterone of course, and then seeing if testosterone is still low and needed.
This approach often works best in part because once the pool of estrogen is higher, the body will need to convert less testosterone into estrogen via aromatase enzymes, perking up testosterone just by adding estrogen. Once this is stable, then an evaluation of testosterone can be done more accurately. Testosterone might very well still be needed but it’s much less of a bumpy ride and you can avoid a whole lot of unpleasant side effects by sorting estrogen out first.
I am a fan of testosterone, but when needed and at an appropriate dose. Why not just get the benefit without the negative effects?
What About Women With PCOS?
This is a unique situation that I cover in greater detail in this article. While women with PCOS may not do very well on supplemental testosterone, they may also notice greater significance of low testosterone symptoms when their testosterone does start to decline. as they are used to having more androgen around.
As a women with PCOS myself, I had a less than ideal experience with HRT reltated to DHEA and testosterone that you can read about here.
Testosterone Therapy: Your Options + Best Approach
Testing levels of testosterone, both total and free as well as assessing SHBG (sex hormone binding globulin) via a blood test (not urine, saliva, etc.) is important before starting testosterone.
Levels are also more stable than levels of estrogen during perimenopause so testing is considered more reliable. Testing also allows you to monitor levels so that you are getting into the premenopausal female physiological range and not higher. As well knowing SHBG is helpful if you aren’t responding well to your HRT including testosterone as you may really need to explore dietary and nutrient strategies to support lowering SHBG to get more free hormone in your system (it’s free, not hormone bound to SHBG that has activity in your body). Email me if you need more support, this gets complicated!
Testosterone is available in topical creams and gels, troches, injections and pellets. Topical or transdermal is preferred as dose can be monitored more closely and if side effects occur, it’s easy to use less or stop a topical. It is also available orally but that as well is not recommended.
There is not an FDA regulated testosterone formula for women so the best options are using a compounded formula OR using a much smaller amount of a male FDA approved formula, though the later is harder to get the right dose for women. More on compounding pharmacies and HRT in this article.
Dosage should be 1/10th of a standard male dose of 1% transdermal testosterone which is 5mg/day (0.5ml) up to 10mg/day (1.0 ml) if necessary. It takes about 6-12 weeks to see maximal effects.
Get estrogen sorted first (most of the time, there are exceptions) if you are a woman in perimenopause and using or planning to use a full HRT regimen.
If you are a woman in your 20s thru early 40s, look to lifestyle and supplemental strategies before starting testosterone because it is often fairly easy to improve with nutrient, diet and lifestyle strategies and avoid further hormone imbalances (i.e. estrogen) and side effects.
Side effects can happen and it’s important to suss out if that is related to metabolism of testosterone vs. dosage benign too high. DUTCH testing here is very helpful (more on this test in this article). Nutrients found in this formula support androgen metabolism.
As with all cream or gel based hormones, wash hands thoroughly and use a separate towel to wipe hands vs. the rest of your family as there is a concern for transference to partners, children and even pets.