Testosterone and Perimenopause: What Women Need to Know

When most people hear testosterone, they think of men. But women produce testosterone too, and it plays a more significant role in female health than many people realise. During perimenopause, declining testosterone can contribute to symptoms that women and their doctors sometimes overlook or attribute solely to estrogen changes.

Understanding testosterone's role gives you a more complete picture of what is happening in your body and opens up treatment conversations you might not otherwise have.

This article is for informational purposes only. Testosterone therapy for women should only be considered under medical supervision. Please consult your healthcare provider before making any treatment decisions.

Testosterone in Women

Women produce testosterone in the ovaries and adrenal glands, at roughly one-tenth the level of men. Despite the smaller quantities, it plays important roles:

Supporting sexual desire and arousal
Contributing to energy levels and motivation
Maintaining muscle mass and strength
Supporting bone density
Influencing mood and cognitive function

Research published in the Lancet Diabetes and Endocrinology found that testosterone levels in women decline gradually from the late 20s onward, dropping by approximately 50 percent between the ages of 20 and 45. This decline is independent of menopause, meaning it starts well before the perimenopause transition (Davis and Wahlin-Jacobsen, 2015).

During perimenopause, the situation becomes more complex. While estrogen and progesterone fluctuate dramatically before declining, testosterone follows a steadier downward trajectory. However, the relative balance between these hormones shifts. In some women, the proportional increase in androgens relative to declining estrogen is responsible for symptoms like acne and facial hair growth. In others, low testosterone contributes to fatigue, low mood, and reduced libido.

Symptoms Linked to Low Testosterone

Research has associated low testosterone in women with several symptoms that overlap with the broader perimenopause experience:

Low libido This is the most studied area. The Global Consensus Statement on Testosterone Therapy for Women, published in the Journal of Clinical Endocrinology and Metabolism in 2019, concluded that there is good evidence that testosterone therapy improves sexual desire, arousal, and satisfaction in postmenopausal women (Davis et al., 2019).

A major randomised trial published in the New England Journal of Medicine found that transdermal testosterone significantly improved sexual function and reduced distress related to low desire in postmenopausal women (Davis et al., 2008).

Fatigue and low motivation Many women describe a loss of drive and vitality during perimenopause that goes beyond the fatigue caused by poor sleep. Research suggests testosterone plays a role in energy and motivation through its effects on dopamine pathways in the brain. Studies in the European Journal of Endocrinology have found associations between low testosterone and persistent fatigue in women, though causality is harder to establish than with libido.

Muscle weakness and reduced exercise capacity Testosterone supports muscle protein synthesis. Research published in the Journal of Clinical Endocrinology and Metabolism found that testosterone therapy improved lean body mass and physical function in postmenopausal women. This has implications for exercise during perimenopause, where some women find that their usual training produces diminishing returns.

Mood The relationship between testosterone and mood in women is less clear-cut than with libido. Some studies have found improvements in mood and wellbeing with testosterone therapy, but the evidence is not as consistent. A systematic review in Psychoneuroendocrinology found a modest positive effect on mood, particularly in women who also had low libido (Achilli et al., 2017).

Brain fog Testosterone receptors are present throughout the brain. Research published in Neuroscience has shown that testosterone supports cognitive function including verbal memory and spatial reasoning. Some preliminary studies suggest that testosterone therapy may improve cognitive symptoms during the menopause transition, but more research is needed.

Testing Testosterone Levels

Measuring testosterone in women is more nuanced than measuring estrogen or thyroid hormones.

The International Menopause Society recommends that testosterone should be measured using a sensitive assay (liquid chromatography-mass spectrometry) rather than the standard immunoassays used in many labs, which were designed for the much higher levels found in men and are less accurate at the lower female range.

There is no universally agreed threshold for "low" testosterone in women. This is partly because levels vary widely between individuals and partly because the relationship between blood levels and symptoms is not straightforward. Some women with levels in the low-normal range have significant symptoms, while others with technically low levels feel fine.

The Global Consensus Statement recommends that testosterone therapy should be considered based on clinical symptoms (particularly low sexual desire causing distress) rather than blood levels alone.

If you want your levels checked, ask your doctor to test:

Total testosterone
Free testosterone (the biologically active fraction)
Sex hormone-binding globulin (SHBG), which affects how much testosterone is available to your tissues

Testosterone Therapy for Women

What is available

In the UK, testosterone is not yet licensed specifically for women, but it is widely prescribed off-label by menopause specialists. The British Menopause Society supports its use for women with low sexual desire that has not responded to HRT alone.

In Australia, a female-specific testosterone cream (AndroFeme) has been available for several years. In most other countries, women use either male preparations at reduced doses or compounded formulations.

The most common form is a transdermal cream or gel applied to the skin daily. Women typically use about one-tenth of the male dose.

What the evidence supports

The Global Consensus Statement from 2019, signed by representatives from the International Menopause Society, the Endocrine Society, and other major bodies, concluded:

There is good evidence for testosterone therapy for hypoactive sexual desire disorder (low libido causing distress) in postmenopausal women
There is insufficient evidence to support testosterone therapy for other indications (fatigue, mood, cognitive function) as a primary treatment
Testosterone should only be prescribed alongside estrogen therapy (not as a standalone treatment) for postmenopausal women
Testosterone levels should be monitored to keep them within the normal female range

Safety

The same consensus statement found that short-term testosterone therapy (up to 24 months) at physiological female doses appeared safe, with no significant adverse effects on cardiovascular health, liver function, or breast cancer risk. Longer-term safety data is limited.

Potential side effects at appropriate doses are generally mild and include acne and increased facial hair growth. These are dose-dependent and usually resolve if the dose is reduced.

At excessive doses (well above the normal female range), testosterone can cause voice deepening, significant hair growth, and clitoral enlargement. This is why medical supervision and dose monitoring are important.

What to Discuss with Your Doctor

If you think low testosterone might be contributing to your symptoms:

Start with the basics. Make sure your HRT (if you are taking it) is optimised first. Many symptoms attributed to low testosterone improve with adequate estrogen replacement.
Be specific about your symptoms. Low libido that is causing you distress is the strongest indication for testosterone therapy. If fatigue or mood are your main concerns, other approaches may be more appropriate as first-line treatment.
Ask about the evidence honestly. A good clinician will explain that the evidence is strongest for sexual function and more limited for other symptoms.
If testosterone is prescribed, ensure you are monitored. Levels should be checked at 3 to 6 month intervals to make sure they stay within the normal female range.

Our guide to talking to your doctor about perimenopause has more advice on preparing for these conversations.

Sources:

Davis, S.R. and Wahlin-Jacobsen, S. (2015). Testosterone in women: the clinical significance. Lancet Diabetes and Endocrinology, 3(12), 980-992
Davis, S.R. et al. (2019). Global consensus position statement on the use of testosterone therapy for women. Journal of Clinical Endocrinology and Metabolism, 104(10), 4660-4666
Davis, S.R. et al. (2008). Testosterone for low libido in postmenopausal women not taking estrogen. New England Journal of Medicine, 359, 2005-2017
Achilli, C. et al. (2017). Efficacy and safety of transdermal testosterone in postmenopausal women with hypoactive sexual desire disorder: a systematic review and meta-analysis. Psychoneuroendocrinology, 79, 128-138
British Menopause Society (2024). Testosterone replacement in menopause. BMS tools for clinicians