CARDIOLOGY INSIGHTS

Testosterone Therapy in Women

How it helps and When to be Cautious

SONAL CHANDRA, MD

Testosterone therapy in women is being used far more often- driven by a growing body of evidence, a broader cultural willingness to discuss sexual health, and an explosion of direct-to-consumer wellness platforms offering hormone optimization, the number of women using testosterone has risen sharply.

Here’s what’s supported, what isn’t, and what should be monitored for safety.

Indications, Risks, and What Needs Watching

Why the Surge in Use?

Several forces have converged to drive increased testosterone use in women. First, the research on female sexual dysfunction has matured considerably since the early 2000s. Studies have demonstrated that low serum androgen levels correlate with reduced sexual desire, arousal, and satisfaction in peri- and postmenopausal women, and that testosterone supplementation (at physiologic doses) improves these outcomes more reliably than any other available intervention.

The menopause space has been transformed by patient advocacy. Women are more informed, more vocal, and more willing to push for solutions to symptoms that were previously dismissed as inevitable aging. Testosterone has become part of that conversation, at times appropriately, sometimes prematurely.

The Physiology: Why Testosterone Matters in Women

Not Just a Male Hormone

Testosterone is not exclusively a male hormone. Women produce it primarily in the ovaries and adrenal glands at roughly one-tenth of male levels, but it plays meaningful roles in sexual function, bone density, muscle mass, cognitive sharpness, energy, and mood. Levels decline gradually through adulthood and fall more steeply in the years surrounding menopause, particularly in women who undergo bilateral oophorectomy, which removes the dominant source of ovarian testosterone production abruptly.

Serum testosterone levels in women are also influenced by SHBG (sex hormone-binding globulin), which binds testosterone and renders it biologically inactive. Oral estrogen therapy raises SHBG significantly, which can leave a woman with normal total testosterone but substantially reduced free (bioavailable) testosterone: a nuance that is often missed in standard lab panels.

Validated Indications for testosterone supplementation

Hypoactive Sexual Desire Disorder (HSDD): in Post-menopausal women: transdermal testosterone meaningfully improves sexual desire, arousal, pleasure, and satisfaction in postmenopausal women, including those on concurrent estrogen therapy and those not using estrogen.

Surgically induced menopause: acute androgen deficiency caused by bilateral removal of ovaries- strongest indication for testosterone replacement therapy (TRT)

The evidence supporting TRT for mood, cognition, fatigue, bone density, and body composition is still not strong, yet prescriptions for these indications are rising. That doesn’t invalidate patients’ symptoms or rule out a meaningful role for testosterone; it reflects a gap between biological plausibility and the strength of current clinical data.

TRT is not recommended for premenopausal women or those with active or recent breast cancer, or those seeking cognitive, cardiovascular, cognitive, or bone benefits as the primary indication.

What to Avoid with TRT

Supraphysiologic Dosing

Compounded testosterone formulations — creams, troches, pellets — often deliver doses that push women into the male reference range. Pellet implants in particular have been associated with consistently supraphysiologic levels (higher than the body’s natural range) and are difficult to reverse or titrate once implanted. Pellet therapy is among the fastest-growing offerings in hormone optimization clinics, frequently marketed as superior to transdermal formulations, but we we remain in need of supporting evidence.

Prescribing Without Baseline Testing

Testosterone should not be initiated without establishing a baseline serum level. Prescribing testosterone to a woman who is not actually androgen-deficient is not supported by evidence and exposes her to side effects without benefit.

Common Side Effects Being Reported

At physiologic doses delivered transdermally, testosterone is generally well tolerated. Side effects become more common and more significant at higher doses, particularly with compounded formulations.

Acne and oily skin: The most commonly reported side effects at any dose. These are dose-dependent and often the first signal of excess dosing. They typically resolve with dose reduction.

Unwanted hair growth (hirsutism): Facial and body hair growth, again dose-dependent and frequently reported with supraphysiologic dosing. May be partially irreversible if treatment continues at high doses.

Voice changes: Among the most concerning and potentially irreversible side effects. Deepening of the voice has been reported with sustained supraphysiologic testosterone and may not fully reverse after discontinuation.

Scalp hair thinning (androgenic alopecia): Paradoxically, while body hair increases, scalp hair can thin due to a response mediated by DHT conversion at scalp hair follicles.

Mood changes and irritability: Some women report increased emotional volatility, particularly when levels fluctuate or are high.

Erythrocytosis: Testosterone stimulates red blood cell production. While clinically significant polycythemia (high red blood cell level) is more commonly seen in men, hematocrit should be monitored in women as well, particularly with higher-dose formulations.

Lipid changes: Transdermal testosterone has minimal effects on lipid profiles. Oral and sublingual formulations, including troches, and pellets can reduce HDL though the impact of that change on cardiovascular risk isn’t fully clear yet.

Recommendations: Monitor free testosterone, Hematocrit/Hemoglobin, SHBG, Lipid panel, LFT (if using oral/pellet), undergo breast exam and mammography, pelvic exams, skin and hair assessments, monitor blood pressure, and your own symptomatic response to TRT.

The vast majority of randomized trials are 12 to 24 weeks in length. The longest trials extend to approximately 24 months. There are no long-term randomized data on breast cancer risk, cardiovascular events, or other hard outcomes with testosterone use in women. The absence of evidence of harm is not evidence of absence of harm, particularly over treatment periods that in clinical practice extend for years or decades.

What You Should Know

With testosterone therapy more broadly, HDL reductions have been observed in some studies/meta-analyses, but what that means for long-term CV risk is not fully established.

A signal for venous thromboembolism (blood clot- DVT/PE) has been reported, though confounding use of concurrent estrogen limits causality conclusions.

In some RCTs of physiologic testosterone replacement, short-term CV risk markers did not worsen (and in certain populations there was a signal for modest improvement), but these are limited and not definitive for outcomes.

At physiologic doses (keeping levels in the normal female range), available studies are generally reassuring on short-term cardiovascular risk markers, but we do not yet have strong long-term data on heart attack, stroke, or mortality, so it should be used selectively, monitored carefully, and oral/supraphysiologic dosing should be avoided.

Testosterone is not the answer to every hormonal question a woman in midlife might have. But for the right patient, with the right indication, prescribed at physiologic doses with appropriate monitoring, it is a meaningful and evidence-supported therapy. The work is in distinguishing one from the other.