For postmenopausal women with low sexual desire that's causing them distress, after other causes have been ruled out, testosterone is the one indication with solid evidence behind it.
A large meta-analysis of 36 randomized trials found testosterone improved satisfying sexual events, desire, arousal and orgasm, with the effect holding even without concurrent estrogen therapy. There is no FDA-approved testosterone product for women in the US, so treatment relies on off-label use of male-dosed products at a fraction of the male dose, with blood levels checked before starting and again to confirm the dose stays in the normal female range. Reported side effects at proper female doses are mainly acne and increased hair growth; long-term safety beyond the trial periods has not been established, and testosterone is also a controlled substance in the US, which adds prescribing friction.
That testosterone works for HSDD is not disputed. The real disagreement is about how it should be delivered, since there's no approved product for women, which has created a gap between a guideline-endorsed dosing standard and a commercial market of compounded pellets and creams that guidelines explicitly do not recommend.
What the research shows, and which source each finding rests on
The 2019 Global Consensus Position Statement, endorsed by 11+ societies, concluded the only evidence-based indication for testosterone therapy in women is hypoactive sexual desire disorder (HSDD) in postmenopausal women, after other causes are addressed.
A meta-analysis of 36 RCTs and 8,480 women found testosterone improved satisfying sexual event frequency (mean difference +0.85 per month), desire, arousal, orgasm and reduced sexual distress; transdermal routes are preferred since oral testosterone worsened LDL/HDL lipids; reported androgenic effects were more acne and hair growth, with no serious adverse events in the (short) trials, but long-term safety is not established.
The APHRODITE trial found a 300 mcg/day testosterone patch increased satisfying sexual episodes in postmenopausal women even without concurrent estrogen therapy.
There is no FDA-approved testosterone product for women in the US; the ISSWSH clinical practice guideline recommends transdermal testosterone dosed to keep total testosterone in the physiologic premenopausal female range, with a baseline level, level rechecks, monitoring for androgen excess, and informed consent about off-label status; compounded products cannot be recommended due to lack of efficacy and safety data.
Where the real disagreement is
Each position is shown with its own sources. A position listed here is not necessarily the accepted view.
Follow the guideline-endorsed off-label standard
ISSWSH guideline; Rachel Rubin and Kelly Casperson, clinical practice
Use an FDA-approved male product at roughly one-tenth the male dose, with a baseline testosterone level, a recheck around 6 to 8 weeks, and monitoring for androgen excess; compounded products lack efficacy and safety data and should be avoided.
What would settle it: Approval of a dedicated female-dose testosterone product, tested and monitored to the same standard as other FDA-approved hormone therapies, would resolve the current reliance on off-label dosing of male products.
What is really going on here
- Before testosterone: has anyone assessed my relationship, mood, medications, sleep, and whether sex hurts?
- If I start testosterone, what dose relative to male dosing, what level are we targeting, when do we recheck, and what are the stop signals?
Questions for your doctor
- Am I a candidate for testosterone given my specific symptoms?
- What baseline blood work do we need before starting?
- What dose, and how does that compare with a standard male dose?
- When do we recheck levels, and what would make us stop or adjust?
Questions with no answer yet
Is the near-total absence of adequately powered trials testing testosterone for anything beyond libido a sign the effect genuinely does not exist, or mainly a reflection of the regulatory and commercial history, since the companies that tried to bring a female testosterone product to market both failed on a sexual-desire indication and no sponsor has funded a non-sexual-endpoint trial since?
Partly studiedWhat is known: The guidelines and the field's own senior researchers explicitly call for the trials that would settle non-sexual endpoints and state they have not been run. The regulatory history includes a 2004 rejection on long-term safety grounds, not lack of efficacy, and two failed commercial programs, after which no sponsor brought a product to market, while testosterone's controlled-substance status in the US adds further friction to funding such trials. Against this, some specific non-sexual endpoints, such as general wellbeing and a hip-fracture recovery outcome, have actually been directly tested and found null, which is a different, stronger finding than simply never studied.
What would test it: A publicly funded, adequately powered, at least twelve-month randomized trial in women dosed to the premenopausal physiologic range, with a single pre-specified non-sexual primary endpoint such as an objective cognitive composite, bone density, or lean mass and strength.
Since blood testosterone levels do not predict who responds to treatment, is there any other measurable marker, a different hormone, a genetic factor, or a receptor-sensitivity test, that could someday identify which women will benefit before they try it?
Not directly studied yetNo research does not mean it does not work, and it does not mean it works. It means nobody has tested it yet.
What is known: The consensus guideline states directly that endogenous testosterone levels did not predict response to therapy, meaning the number on a blood test cannot currently function as a diagnosis or a response predictor. Improving assay technology is noted as a path to eventually redefining normal ranges, but no marker beyond the standard level has been tested as a predictor.
What would test it: Research into alternative biomarkers or receptor-sensitivity measures that might predict individual response, independent of the standard testosterone blood level.
Did years on the combined birth control pill lower my testosterone permanently, even though I stopped years ago?
Studied and negativeWhat is known: The pill clearly suppresses androgens while it is being taken, with free testosterone falling by about 61 percent on average, a well-established finding. Whether elevated binding globulin persists after stopping is a separate question: the one study reporting persistence had no hormone measurement from before the women started the pill and most of its long-term group were separately being treated with testosterone. A same-year rebuttal using its own primary data found no difference in binding globulin between women who had stopped the pill and women who had never used it, and older direct evidence found binding globulin returns to pre-pill levels within the first month after stopping.
What would test it: A prospective cohort measuring hormone levels before starting the pill, during use, and at multiple points after stopping, in a general population sample rather than women already presenting with sexual complaints.
Sources
- 1.Global Consensus Position Statement on the Use of Testosterone Therapy for Women.Davis SR, et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. J Clin Endocrinol Metab 2019;104(10):4660-4666 · Systematic review or guideline
- 2.Safety and efficacy of testosterone for women: a systematic review and meta-analysis of randomised controlled trial data.Islam RM, et al. Safety and efficacy of testosterone for women: a systematic review and meta-analysis of RCT data. Lancet Diabetes Endocrinol 2019;7(10):754-766 · Systematic review or guideline
- 3.Testosterone for low libido in postmenopausal women not taking estrogen.Davis SR, et al. Testosterone for low libido in postmenopausal women not taking estrogen (APHRODITE). N Engl J Med 2008;359(19):2005-17 · Randomised trial
- 4.International Society for the Study of Women's Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women.Parish SJ, Simon JA, Davis SR, et al. ISSWSH Clinical Practice Guideline for the Use of Systemic Testosterone for HSDD in Women. J Sex Med 2021;18(5):849-867 · Systematic review or guideline
The letter grades the type of study behind a claim, not the answer itself.
This page is general information based on published research and public sources. It is not medical advice and not a personal assessment, and it does not replace a conversation with your doctor. Peritale is a wellness product, not a medical device, and is not intended to diagnose, treat, cure or prevent any disease. For any medical question, speak with a licensed clinician.
You are not imagining it
In about seven minutes on your phone, Peritale reads five signal systems and maps your symptoms, so you can see that what you feel is real, follow your hormonal transition over time, and walk into your doctor ready to ask for the care you deserve. Your first check is free, no credit card.
Start Free MappingRelated questions
- What is GSM (genitourinary syndrome of menopause) and why does it affect both my vagina and my bladder?
- Is vaginal estrogen safe, and what happened to that scary warning label about stroke and cancer?
- Can I use vaginal estrogen if I've had breast cancer?
- I keep getting UTIs after menopause and keep getting put on antibiotics - can vaginal estrogen actually help?
- Sex has become painful since perimenopause - is this just something I have to live with?
- What is vaginal DHEA (prasterone) and how is it different from vaginal estrogen?
- Back to topic: Vaginal, sexual and urinary health