*Content reviewed by HotPause Health  Medical Advisor and OBGYN, Dr. Beverly Joyce.

Testosterone in Perimenopause & Menopause: What You Should Know

TLDR: Too Long Didn’t Read:

• There is no FDA-approved testosterone product for women in the U.S. Testosterone in the U.S. is prescribed off-label.
  
• The strongest evidence is for treating hypoactive sexual desire disorder (HSDD) in postmenopausal women, not for treating general menopausal symptoms.
  
• If used, testosterone should be given in very low doses, via transdermal delivery, with careful monitoring in the female physiologic range.
  
• Use of testosterone in perimenopause is much less proven, due to a lack of research. Focus should first be on sleep, mood, vaginal health, and estrogen (if appropriate).

Why Testosterone Comes Up at Midlife

As women age, levels of many hormones, including testosterone, decrease. That decline can contribute to sexual desire changes for some women. However, desire is complex, influenced by mood, relationships, sleep, medical conditions, and more.

No FDA Approval: What That Means

Right now in the U.S.:

• There is no testosterone product specifically approved for women.
  
• Women using testosterone are receiving male-labeled products off-label, and are prescribed a reduced dose. The standard female dose is 1/10th the amount that men receive.
  
• Outside the U.S., only Australia, New Zealand, South Africa, and the United Kingdom have approved female-specific formulations, but those don’t change U.S. regulatory status.

What the Evidence Actually Shows

What we know:

• Postmenopausal women with Hypoactive Sexual Desire Disorder (HSDD), which is defined as low sexual desire not caused by another condition, plus having feelings of distress about it, testosterone given at physiologic doses shows moderate benefit in symptom improvement.
  
• For other uses–mood, weight, cognition, musculoskeletal health, energy, etc.– the evidence is too weak, but some providers do hear about these improvements from their patients anecdotally.
  
• Women in perimenopause (with still-fluctuating hormones), the data are even more limited.

What Professional Guidelines Recommend

Key points from major medical societies:

• Use testosterone to treat HSDD in postmenopausal women after a full evaluation (including relationship, sleep, mood, medications).
  
• Use a transdermal formula (gel, cream, patch); avoid oral testosterone and avoid pellets/compounded products.
  
• Aim to keep serum testosterone within female physiologic ranges, not at male levels.
  
• Monitor for androgenic side-effects (acne, excess hair growth, voice changes).
  
• For perimenopause: first optimize sleep, mood, vaginal health/estrogen if needed, and reassess desire before moving to testosterone.

What Leading Clinicians Are Saying

• Mary Claire Haver, MD: Shares that she uses testosterone off-label herself and emphasizes a careful, evidence-based approach.
  
• Kelly Casperson, MD: Talks about the “female dosing challenge” and the current gap in FDA-approved options for women.
• Rachel Rubin, MD: Says there is global consensus that using testosterone in women works for low libido, specifically in post-menopausal women. Frames testosterone not as a panacea, but as a meaningful tool, one that deserves more respect in women’s health than it currently receives.
  
• Louise Newsom, MD: “Numerous studies have shown that adding testosterone to hormonal therapy can improve sexual function and general wellbeing among women during their menopause. A recent systematic review and meta-analysis of testosterone treatment in women has provided robust support for a trial of testosterone in women when clinically indicated.”
• Others are raising caution around “testosterone for everything” in midlife. The evidence doesn’t support broad claims of boosting mood, weight, or cognition with testosterone.

How It’s Typically Prescribed (If It’s the Right Choice)

If you and your clinician decide to trial testosterone for HSDD, the “how-to” usually goes like this:

1. Find a provider and work together to choose a formulation: Transdermal gel/cream/patch.
   
2. Start a low dose of a male product adjusted for female physiologic levels.
   
3. Get your baseline labs: Total testosterone, sometimes SHBG, and record symptoms.
   
4. Follow-up labs: Check levels and symptoms after a set number of weeks.
   
5. Monitor for side-effects: Acne, body/hair changes, voice changes, which are rare at the correct dose but important.
   
6. Stop or adjust if levels go high, side-effects appear, or if desired improvement isn’t seen after 6 months.

Who Might Be a Good Candidate – and Who Might Not

Might be appropriate:

• Women with a clear diagnosis of HSDD (low desire + distress), after optimizing sleep, relationship, medications, mood, vaginal health/estrogen as appropriate.

May not be appropriate:

• Women in perimenopause without a clear HSDD diagnosis.
  
• Women planning pregnancy.
  
• Women with a history of hormone-sensitive cancers (requires specialist input).
  
• Women with uncontrolled liver disease, cardiovascular disease, or who aren’t willing to commit to monitoring.

Perimenopause: The Special Consideration

Because hormone levels still fluctuate in perimenopause, many experts recommend first focusing on foundational care:

• Sleep quality
  
• Mood/depression/anxiety
  
• Vaginal dryness or painful sex (vulvovaginal symptoms)
  
• Optimizing estrogen (if indicated). 
• After that, if sexual desire remains a problem and distress is present, then a testosterone trial may be considered—but the research is limited given the lack of prioritization of women’s health, particularly in perimenopause and menopause.

Watch-Outs & Things to Ask Your Clinician

Things to be wary of:

• Promises of testosterone solving everything (energy, weight loss, mood).
  
• Use of testosterone pellets (dosing can’t be adjusted; safety is not established).
  
• No monitoring plan or labs scheduled.
  
• Lack of evaluation of other contributors to low desire (mood, medications, relationship, sleep, pain, hormones).

Questions worth asking:

• How will you determine I have HSDD and what other causes are you ruling out?
  
• Which testosterone product and dose are you recommending, and how will you adjust to keep it within female physiologic levels?
  
• How often will you check labs and symptoms? What side effects should I watch for?
  
• Are we also optimizing vaginal health, relationship/sex therapy or sleep/mood first?

Final Thoughts

Testosterone can be a helpful tool for some women, but it is not a universal fix. When used appropriately (for HSDD, postmenopause, low dose, transdermal, with monitoring), it may offer meaningful benefits. But for perimenopause, or using it for broad “energy/mood/weight” claims, there’s insufficient evidence.

If you’re wondering whether it’s right for you: start with a comprehensive discussion with your healthcare provider who understands menopause care. Ask about monitoring, risks, and whether the diagnosis of HSDD is appropriate. Keep in mind that foundational treatments (sleep, mood, vaginal health, estrogen if needed) may need to come first.