Testosterone helps libido in menopause – can it treat other symptoms?

Mood swings, brain fog, plummeting libido – menopausal symptoms can be debilitating. Many women turn to hormone replacement therapy for relief. These treatments almost exclusively focus on restoring the plummeting oestrogen and progesterone levels women experience in mid-life. Yet studies now suggest another hormone could have benefits too: testosterone. While most research has looked at its effect on libido and sexual health, preliminary evidence indicates testosterone could help with a wide range of menopause symptoms, from mood changes to muscle loss.

We often think of testosterone as a male hormone, but it is also found in women, just usually at a tenth of the level as in most men, says Sarah Glynne at the Portland Hospital in London, who has worked as an adviser on menopause treatment guidelines for the British Society of Sexual Medicine. Because of this misconception, research on how it influences women’s health has been limited, she says. But that is starting to change. More evidence is revealing the hormone’s crucial role in the female sex drive, and some early studies indicate it is even important for brain, muscle, bone and bladder health.

Roughly half of testosterone in women comes from the ovaries. The rest is made in the adrenal gland, located atop the kidneys. Levels tend to peak during a woman’s 20s and then gradually decline starting in their 30s. By middle age, ovarian production of testosterone is about half what it used to be, says Sharon Parish at Cornell University in New York. While this tends to occur around menopause, it probably isn’t a direct result of it, she says.

Little is known about how this drop-off affects health, but what is clear is it can lead to low libido. “[Testosterone] has a very important benefit for sexual function,” says JoAnn Pinkerton at UVA Health in Virginia. It plays a role in sexual arousal, desire and vaginal lubrication. So it makes sense that nearly half of menopausal and postmenopausal women in the US report struggling with libido and pain during intercourse, mostly as a result of hypoactive sexual desire disorder (HSDD), a condition in which an absence of sexual fantasies or desire for at least six months causes distress. Meanwhile, a survey of more than 1800 postmenopausal women in Europe found more than a third reported reduced sex drive and more than half were less interested in sex.

The idea that declines in testosterone levels drive lack of libido dates back to the 1940s. Since then, study after study has shown testosterone replacement therapy improves sexual function in menopausal and postmenopausal women. For instance, a 2005 study of 533 women with HSDD due to surgical removal of their uterus and ovaries found those treated with a twice-weekly testosterone patch alongside oestrogen therapy reported more satisfying sexual experiences than those on oestrogen alone. A 2010 study showed similar results among 272 menopausal women.

In 2019, a meta-analysis of more than 80 studies comprising 8480 women found treating postmenopausal women with testosterone significantly increased sexual desire, the frequency of satisfying sexual activities, pleasure, arousal, orgasm and self-image. As a result, about a dozen professional medical organisations, including the International Menopause Society, the Royal College of Obstetricians and Gynaecologists and the North American Menopause Society endorsed the use of testosterone for HSDD.

One reason testosterone heightens libido is because it interacts with brain receptors that activate neural pathways governing desire, says Parish. So far, only four countries have approved a testosterone product designed for women: Australia, New Zealand, South Africa and, as of July, the UK. The US Food and Drug Administration (FDA) hasn’t followed suit due to concerns there isn’t enough data tracking potential long-term side effects. But Parish believes this is misplaced, noting some studies have followed participants for years and found no increased risk of heart, breast or uterine issues.

“Most providers who take care of menopausal women would love to have an FDA-approved, safe and effective transdermal [testosterone] therapy for women,” says Pinkerton. “We really think there is a need for it, particularly in the libido space.”

The right blend

Some doctors suggest the therapy could have benefits beyond the bedroom, too. A 2023 analysis of seven studies on testosterone in postmenopausal women found it may increase muscle mass, lower body fat and improve insulin sensitivity and cholesterol. In 2024, Glynne and her colleagues evaluated use of the hormone in 510 perimenopausal and postmenopausal women also using oestrogen. After four months of treatment, about half the participants reported fewer anxiety attacks and crying spells. About 40 per cent also reported improvements in depression, concentration and fatigue, and more than a third saw memory improve and irritability decrease. “What I hear most often is women saying they feel more like themselves. They feel stronger. They feel more robust,” says Glynne.

But others are sceptical. Pinkerton notes these studies don’t include a control group and rely on self-reported improvements, raising doubts about whether it is testosterone or the placebo effect driving them. “Basically, there is some research on cognition, mood, muscle strength and cardiovascular and bone [health],” says Parish. “While these show promising outcomes, we don’t have efficacy or safety data in any substantial randomised controlled trial to warrant recommendations for those indications.”

Most studies use testosterone therapy in conjunction with oestrogen, but some have found testosterone alone still meaningfully improves sexual function. However, there is a higher incidence of side effects such as acne and excess hair growth, so it isn’t usually recommended. Glynne says she usually treats her patients with oestrogen first and then tacks on testosterone if symptoms still persist.

Researchers agree that clinical trials investigating testosterone’s effects beyond libido are desperately needed. Plus, there are still questions about the impact of timing, dose and duration, says Pinkerton.

What is clear is current menopause treatments aren’t sufficient for many people, especially those with a history of hormone-sensitive breast cancer who can’t or don’t want to risk oestrogen therapy, as it can spur the growth or recurrence of these cancer cells. “It is a big black hole at the moment that we need lots more data on,” says Glynne.