Menopause is a significant phase in a woman's life, marking the end of her reproductive years. While it brings about a range of changes, both physical and emotional, one aspect that has garnered attention in recent years is the role of testosterone therapy for women during menopause. Estrogens are the principal sex hormones we associate with women, however, the androgens - testosterone (a sex steroid) and dehydroepiandrosterone (DHEA) play important roles in your reproductive tissues, mood, cognition, breast, bone, muscle, and other systems.
Testosterone is not just an ovarian hormone. Women produce testosterone in 3 areas of the body: the adrenal glands (25%), the ovary (25%), and the conversion from other hormones in your body’s tissues (50%). Unlike the sex hormones estrogen and progesterone, the production of testosterone does not come to a screeching halt in menopause. Instead, testosterone slowly begins its decline in one’s 30s. Once a woman enters menopause, the ovary still produces testosterone.
Many practitioners recommend hormone testing to determine if your estrogen, progesterone, and testosterone are low. We know your estradiol and progesterone will be low in menopause - that is the definition! Testing testosterone is also not useful to determine if you are deficient. There is no absolute testosterone level that determines if a woman is deficient. That’s right - no blood, saliva, or urine test can accurately determine if you have “low” testosterone, otherwise known as an androgen deficiency. Despite multiple clinical studies, the medical community just doesn’t know what an accurate “low” or “normal” level is for a woman at every age. Furthermore, a decline in testosterone has not been shown to correlate with clinical symptoms of low mood, decreased muscle mass, or weight gain. In fact, despite what you may see advertised on social media and the internet, The Endocrine Society, The American College of Obstetricians and Gynecologists, and The Menopause Society do not recommend prescribing testosterone to improve mood, hot flashes, night sweats, bone health, muscle mass or for weight management. The only evidence-based reason for women to supplement testosterone is to treat a low sex drive in menopause after you have optimized your estrogen and progesterone with hormone therapy.
Here are the top 9 things you should know about testosterone use in women based on the medical evidence:
- Testosterone converts to estrogen in your tissues. This is why it is recommended to begin perimenopause/menopause treatment with estrogen, not testosterone.
- Women who are looking to optimize their natural testosterone should consider transdermal estrogen when beginning hormone therapy (patch, gel, spray, vaginal ring). Oral estrogen can decrease your circulating testosterone level.
- Birth control pills can decrease your circulating testosterone, which is why a low sex drive is a common side effect of users. Changing to an IUD with an estradiol patch, gel, spray or vaginal ring can help jump-start your libido while treating your menopause symptoms.
- Improvement in muscle mass and lean body mass usually require high doses of testosterone but those high doses come with increased risks - see #6 below.
- For women who are suffering from bothersome low libido that does not improve with estrogen replacement and are in healthy relationships with their significant other, a trial of topical testosterone is recommended (with guidelines published in the medical literature) for 6 months. If at 6 months your sex drive doesn’t improve, testosterone was not the cause. Currently, there is no FDA-approved testosterone product for women in the U.S. When testosterone is prescribed for a bothersome low sex drive, a man’s product is prescribed to be used at 1/10th of the dose.
- Testosterone supplementation is safe for women when following evidence-based practices. When using off-label products like compounded creams and pellets, testosterone has some risks: pesky hair growth on your chin, cheeks, and upper lips as well as menopause acne, hair loss on your head, deepening of your voice, and enlargement of your clitoris. There are no studies on its long-term use but upsetting your body’s estrogen/testosterone balance could cause an increased risk of cardiovascular disease. According to the American Heart Association, your natural estrogen protects your cardiovascular system before menopause by preventing your blood vessels from becoming stiff and filled with plaque. Recent medical literature suggests beginning hormone therapy with estrogen before age 60 and within 10 years of your final period can help decrease your overall cardiovascular disease risk.
- The hormone DHEA converts to testosterone in your body. In some European countries, there are formal position papers on the use of oral DHEA to improve sex drive, bone health, and obesity. In the U.S., DHEA is an over-the-counter supplement taken orally. It is also available by prescription for use in your vagina to treat dryness and painful sex since DHEA gets converted to testosterone and estrogen in your tissues. If you decide to give an oral DHEA supplement a try, do so under the care of a menopause specialist who will test your blood DHEA levels. Most labs report DHEA levels based on age and menopause status, making lab testing helpful to ensure safety.
- Compounded testosterone is not recommended by The Menopause Society, The American College of Obstetricians and Gynecologists (ACOG), The International Society for the Study of Sexual Health in Women (ISWISSH), The Endocrine Society, and more.
- Testosterone pellets are not recommended by any medical society. Hormone pellets are a no-no at any menopause stage!
So what does one do to combat feeling fatigued, flabby, and not in the mood in perimenopause and menopause? First, treat your symptoms with estrogen and add progesterone if you have a uterus. You can use hormone therapy safely even if you are still getting a period every month.
Once your energy improves with hormone therapy, add resistance training to boost your muscle mass, improve your metabolism, and reshape your body, bringing your internal and external sexy back. When most women find improvement in their menopause symptoms and have happy vaginas and overall health, they feel better about themselves and their desire naturally improves. If you feel good, are happy with yourself and your relationship with your significant other, are not suffering from menopausal symptoms, and still lack desire, you may be suffering from hypoactive sexual desire, and giving testosterone a try is absolutely indicated.
Testosterone has a vital role in menopause care, but the scientific evidence points to it being helpful for some, not everyone. If you believe you would benefit from testosterone, give estrogen a try first. Estrogen always comes before testosterone in evidence-based menopause care.