Testosterone – the Forgotten Hormone

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Unfortunately, many gynecologists and menopause society guidelines only recommend testosterone for low libido. Many providers, even NAMS-certified providers, are often unaware of the important role testosterone plays in people assigned female at birth or even demonize it, telling stories of a patient’s negative experience on it. (Note: often times these negative experiences are when patients are on the pellet with a practitioner that doesn’t know how to correctly adjust the dose, and therefore the patient is getting unnecessarily large doses of testosterone). These types of stories add to people’s misconceptions of testosterone, which is often talked about as a “male” hormone, when in reality people of all sexes have testosterone, as it plays an important role in our bodies! Taking testosterone within the normal female range is not going to cause a person to grow a beard or transition – the HRT doses are to replace what you’ve lost and stay within the female range of testosterone. 

“Systemic testosterone therapy for postmenopausal women, in doses that approximate physiological testosterone concentrations for premenopausal women, is associated with mild increases in acne and body/facial hair growth in some women, but not with alopecia, clitoromegaly or voice change (Level I, Grade A).” [Source: Global Consensus Position Statement on the Use of Testosterone Therapy for Women]

This lack of understanding about the role testosterone plays in people born with ovaries is a massive disservice to us. Did you know that our ovaries produce 3 times more testosterone than estrogen prior to menopause? For many people who have low levels of testosterone and start taking it, it can be a lifesaver and can make them feel like themselves again! The ovaries are a main producer of testosterone, so if a person has an oophorectomy at a young age, they may find taking it to be really beneficial. Some people prefer to go on estrogen HRT first for their symptoms, and if they persist, look into testosterone replacement. In my own case, my estrogen levels are fine, but my both my free and total testosterone was extremely low. Within 6-8 weeks of taking testosterone, I stopped having hot flashes, aches and pains, and hormone-induced anxiety; my food intolerances went down and I can eat more variety of foods, and I have more energy and mental clarity. It’s been life changing.

“And in our clinic experience here at Newson Health, patients tell us that in addition to improved libido, testosterone can help improve other menopause-related symptoms such as anxiety, brain fog, and fatigue as well as improving exercise intolerance. Many menopause specialists, and increasingly general practitioners, are realizing the widespread benefits of testosterone replacement for most women. Benefits of testosterone can include improved muscle mass and strength, enhanced concentration and memory, and better sleep.” [Source: Newson Health – Menopause and Wellbeing Center].

What kind of safety information do we have?

There is some safety information on testosterone HRT for women and people with ovaries, but we don’t have as many studies as that of with estrogen HRT.

“More adequately powered, double-blind RCTs, without selection bias and with consistent reporting of standardized outcomes, are needed to comprehensively establish the benefits and risks of testosterone therapy for women.” [Source: Global Consensus Position Statement on the Use of Testosterone Therapy for Women].

There have been studies done on testosterone short term in cis-women, such as for a year, as well as longer term for trans men and cis-men. Take a look at the resources below for some of the information we have on safety. As far as I know, the short term data on testosterone finds it to be safe with little side effects if the doses remain at female levels.

Some providers will not prescribe testosterone as part of HRT, due to the lack of long term safety data (and the fact that most menopause guidelines only recommend it for Hypoactive sexual desire disorder in post-menopausal women). However, as some providers say, it’s highly unlikely that long term data on testosterone in cis-women will ever be studied, due to the cost and lack of interest from pharmaceutical companies. Additionally, we lack long term data on many drugs that are used long term. Here’s an interesting reel from Jackie Piasta, WHNP-BC, on the data and different viewpoints from clinicians on whether to prescribe or not based on this.

Do we have testosterone products for females?

Recently, in Australia, a 1% testosterone cream was developed, which is really exciting! However, in the U.S., we don’t have a female-specific product approved, so doctors either prescribe the male-specific FDA approved testosterone, which then females use at 1/10 the dose, or a compounded cream testosterone cream from the pharmacy.

“There is an unmet need for the provision and approval of testosterone treatments specific to women, formulated with the aim of approximating physiological testosterone concentrations for premenopausal women (Expert Opinion).” [Source: Global Consensus Position Statement on the Use of Testosterone Therapy for Women]. 

What about pellets?

Most providers, even the ones that regularly prescribe testosterone to patients, are in agreement that pellets are not recommended for patients.

“Use of any testosterone preparation that results in supraphysiologic concentrations of testosterone, including pellets and injections, is not recommended (Expert Opinion).” [Source: Global Consensus Position Statement on the Use of Testosterone Therapy for Women].

I know people who swear by their hormonal pellets, and they work with providers who know how to properly monitor their testosterone levels while on them. It’s not to say that all pellets are bad, but rather the majority of providers out there don’t know how to properly dose pellets, leading to their patients having extremely high testosterone levels and therefore a lot of unwanted and even scary side effects!

Do I need to get my testosterone levels checked?

HRT is typically recommend based on symptoms, but some doctors will take your baseline testosterone levels prior to starting it and then 3-6 months later to see if you are absorbing it and staying within female levels. Here’s a helpful video from Jackie Piasta, WHNP-BC on testosterone tests.

Just because your testosterone is low doesn’t mean that you need to take testosterone HRT.