While testosterone is often considered a primarily male hormone, it plays a crucial role in women's health as well, influencing sexual desire, bone density, muscle strength, cognitive function, and mood. As women age, particularly during perimenopause and menopause, testosterone levels decline, potentially leading to a range of symptoms. This article explores the potential benefits and risks of low-dose testosterone therapy for women, including the use of testosterone cream.
Testosterone's Role in Women
In females, testosterone is an important hormone that’s sometimes overlooked. It plays a key role in sexual desire, bone health, muscle strength, thinking ability, and mood. Before menopause, females produce three times as much testosterone as estrogen (although this is still much lower than males). However, as females age or undergo procedures like oophorectomy (removal of the ovaries), testosterone levels can decline either gradually or abruptly.
Androgen levels usually start to rise in girls between ages 6 and 8 as part of the very early rumblings of puberty. At this point, the body isn’t directly churning out testosterone. Instead, hormonal precursors called pre-androgens, including dehydroepiandrosterone (DHEA), run the show. Several years later, the ovaries begin producing testosterone alongside the adrenal glands. In our 20s and 30s about half of our testosterone comes from the ovaries and pre-adrenal glands, the rest from the conversion of pre-androgens. Like estrogen and progesterone, testosterone levels fluctuate during the monthly menstrual cycle, usually peaking around the time of ovulation. They fluctuate throughout the day, too, rising overnight. At around age 30, testosterone levels start gently declining at a rate of about 1% to 2% per year; by the time of menopause, levels are approximately half of what they were at their peak.
Potential Benefits of Low-Dose Testosterone Therapy
While not approved for females in the United States, testosterone has been used for more than 60 years in England and Australia to alleviate symptoms of perimenopause and menopause. In the United States, it’s used off-label under careful medical supervision. A 2020 study suggests that adding testosterone to estrogen replacement therapy can improve sexual function and overall well-being in postmenopausal people.
Researchers note that when combined with estrogen as part of hormone replacement therapy (HRT), low dose testosterone may:
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- Improve sexual desire, pleasure, arousal, and orgasm
- Enhance self-image
- Improve somatic symptoms, such as muscle aches and joint pain
- Increase bone density
- Enhance cognitive performance
- Increase blood flow to the genitals
- Improve mood, motivation, and energy
The primary reason for replacing testosterone is to help improve libido. Although some women have reported that testosterone may also improve energy levels, well-being, cognitive function, and joint pains, there is no evidence to date to support these benefits.
Addressing Hypoactive Sexual Desire Disorder (HSDD)
Some evidence suggests that using testosterone can help treat sexual dysfunction, such as hypoactive sexual desire disorder (HSDD), which is marked by distress from a reduced interest in sex. More research needs to be done, but an early study from 2010 found that participants saw significant improvement in sexual function and reduced personal distress over symptoms. No large differences were reported in estradiol levels or unwanted physical changes.
Gender Affirming Care
Some people assigned female at birth may choose to take low dose testosterone as part of their gender affirming care. Taking low dose testosterone may allow for subtle masculinizing effects, like a deeper voice and increased muscle mass, without a fuller transition to a masculine appearance. Low dose testosterone may also allow for gradual physical changes, giving individuals time to assess the effects before deciding on further treatment. Sometimes called a “microdose,” low dose testosterone might be around 20 milligrams per week for injectables, adjusted accordingly for other forms like creams or patches. A microdose is typically smaller than standard HRT doses.
Forms of Testosterone Therapy
Currently, regulatory agencies in many countries, including the United States, haven’t approved specific testosterone formulations for females. Consequently, testosterone prescriptions approved for males are sometimes used off-label for females under careful medical supervision. Off-label use is when a drug that’s approved to treat one condition is used to treat another condition.
If testosterone is used it should be in a non-oral form such as a skin gel, cream, patch or implant under the skin. The dose of testosterone should reproduce blood levels that are seen in young women. There is limited availability of testosterone in a dose formulated for women. The global Position Statement (2019) recommendation is that if a formulation for women is not available, a small amount of an approved male formulation (as recommended by a doctor) can be used, with regular blood monitoring to check blood levels do not exceed those of young women. The international expert panel recommended against the use of compounded testosterone formulations.
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Testosterone is applied to the skin as a gel or cream so that it goes directly into your bloodstream. The doses used in women are much lower than those used for men. The aim is to keep the testosterone at a level that’s not greater than those found in premenopausal women. It may take 3-6 months to feel any benefit from taking testosterone.
Testosterone Cream
1% testosterone cream in 50ml tube. Starting dose is 0.5mls per day (5mg testosterone a day). 50mg testosterone per 5g tube (1%). Use a small, pea-sized amount (approx. 0.5g gel = 5mg testosterone) and rub it into the front of the thigh daily. 50mg per 5g sachet (1%). Use a small, pea-sized amount and rub it into the front of the thigh daily. The sachet should last around 14 days. You can fold over the open top and clip it with a bag clip. 40.5mg per 2.5g sachet. Use a small, pea-sized amount and rub it into the front of the thigh daily. The sachet should last around 8 days. 20mg in 1g. One press delivers 10mg of testosterone. Use 1 press of gel 2 to 3 times a week. Don’t apply the gel to the same patch of skin every time.
Other Forms
- Testosterone gels: Testosterone gels are applied directly to your skin, usually in the armpit, upper arm, shoulder, or inner-thigh areas. AndroGel is a common brand name for this medication.
- Testosterone patches: Testosterone replacement therapy may also be applied to the skin via patch form. A new patch is applied daily to your arm, abdomen, back, or thigh. It’s recommended that you rotate the site of application to reduce possible skin irritation.
- Testosterone injections: These medications are injected into your skin by a doctor about every 1 to 2 weeks, although long-acting treatments may be available that only require injections every 10 weeks.
- Nasal gel: Testosterone is also available via a nasal gel that’s pumped into each nostril 3 times daily. Aside from the most common side effects of testosterone therapy, some nasal gels may also cause nasal congestion or irritation.
- Buccal tablets: Testosterone buccal tablets work via absorption in the gums. These are applied to your gums twice daily.
- Pellets: Another option involves the surgical placement of testosterone pellets under your skin. This procedure is repeated every 3 to 6 months.
Potential Side Effects and Risks
According to a 2019 position statement from the Brazilian Society of Endocrinology and Metabolism, testosterone therapy in females can sometimes lead to masculinizing symptoms and abnormal bleeding in the uterus. There are also concerns about breast cancer and cardiovascular risks.
Possible side effects of high testosterone in females may include:
- Acne and oily skin
- Increased facial and body hair growth
- Deepening of the voice
- Changes in body odor
- Menstrual changes, including stopping periods
- Clitoral enlargement
- Breast atrophy (shrinking of breast tissue)
- Breast sensitivity changes
- Increased muscle mass and strength
- Redistribution of body fat
- Headaches
- Nausea or vomiting
- Changes in skin color or texture, such as darkening or thickening
- Mood changes, including increased aggression or irritability
Serious side effects of high testosterone in females may include:
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- Cardiovascular issues, such as heart attack and stroke
- Liver problems, including liver damage or disease
- Increased risk of blood clots
- Infertility due to suppressed ovulation
Side effects are generally only seen when high doses of testosterone ar given. Hirsutism (excess hair) and acne are usually mild and depend on the dose of testosterone you’re taking.
Preventing Unwanted Hair Growth
To prevent unwanted hair growth, a 2020 review suggests that testosterone can be combined with 5-alpha-reductase inhibitors. These inhibitors block the conversion of testosterone into a more potent form, which is responsible for hair growth. You can also consider permanent hair removal methods.
Topical Testosterone Side Effects
Topical testosterone most commonly causes skin problems like itching or rash. In those with female anatomy, specifically, it can cause unwanted hair growth, acne, or birth defects in pregnant people.
Because you apply topical testosterone directly to your skin, you may develop a reaction at the application site. Symptoms can include:
- Burning
- Blistering
- Itching
- Soreness
- Swelling
- Redness
- Rash
- Dry skin
- Acne
Make sure you always apply the medication on clean, unbroken skin. Follow the application directions on the package carefully and report any skin reactions to your doctor.
Precautions
Testosterone should not be taken if you are pregnant, if you could be pregnant or if you are at risk of pregnancy. This is because testosterone could affect the baby’s development. If you are unsure if this applies to you, please discuss this with your doctor or other healthcare professional.
During close and relatively long periods of skin contact testosterone may be transferred to another person unless you cover the treated area. Transfer can potentially result in the other person showing signs of increased testosterone - masculinisation effects as described in the side effects above. Wearing clothes covering the application area or washing the application area before contact protects against such transfer.
Topical testosterone can cause side effects in females and children who come in contact with it by touching your skin or clothing, so it’s best to let the applied medication try completely before coming in contact with others. Children may develop aggressive behavior, enlarged genitals, and pubic hair. Females may develop unwanted hair growth or acne. Testosterone transfer is especially dangerous for pregnant people because it can cause birth defects.
To prevent these problems, don’t allow skin-to-skin contact of the treated area with other people. Keep the treated area covered or wash it well before letting others touch you. Also, don’t allow others to touch any bedding and clothing that may have absorbed testosterone from your skin.
Cardiovascular Risks
The FDA has issued a warning of the potential increased risk of cardiovascular events among people using testosterone products. Be sure to consult with your healthcare professional to discuss any concerns you may have before using.
Prostate Cancer Risk
One 2015 review of existing observational studies concluded that the evidence was not strong enough but that larger studies in the future may find different results. A doctor should conduct a prostate cancer screening before prescribing testosterone medications.
Venous Thromboembolism Risk
Some people who take topical testosterone may also be at an increased risk of developing deep vein thrombosis (DVT) or pulmonary embolism (PE). See a doctor if you experience pain and warmth in your legs, or if you have unusual shortness of breath.
Other Conditions
Topical testosterone may not be recommended for males with a history of urinary issues, or for those at high risk for prostate cancer. While testosterone is not known to cause prostate cancer, it may fuel its growth if already present.
You also shouldn’t use topical testosterone if you have:
- Suspected breast cancer
- Blood clots
- Untreated sleep apnea
- An elevated red blood cell count
- Plans to have children
Emotional Effects
Most males can tolerate testosterone treatment quite well, but a small number develop emotional side effects from the hormonal changes. These can include:
- Rapid mood swings
- Overreaction to everyday situations
- Nervousness
- Anxiety
- Crying
- Paranoia
- Depression
Although emotional side effects are rare, they can be serious. Be sure to discuss any symptoms with your doctor.
Important Considerations
Loss of sexual desire (libido) can be caused by many different medical and psychological conditions. Low levels of the class of hormones called androgens may be one of the factors leading to your loss of libido. As testosterone is an androgen, testosterone therapy may be offered to help boost your libido.
It is very important that your doctor check your progress at regular visits to see if the medicine is working properly. Blood and urine tests may be needed to check for any problems or unwanted effects.
Levels of testosterone in your body gradually reduce as you become older, and they reduce very abruptly in women who have had an oophorectomy (an operation in which their ovaries are removed). When women’s testosterone levels decrease, some may find that they desire sex less often, and when they do have sex, it’s not as pleasurable as it used to be, even though they still desire their partner. For many women, the lower testosterone level has no impact on libido whatsoever.
When to Seek Medical Attention
If you’re experiencing possible symptoms of hypogonadism, it’s important to see a doctor for an exact diagnosis. Testosterone levels may decrease with age, but some of the associated symptoms, such as fatigue and weight gain, may also be related to other underlying health conditions. Once a doctor prescribes topical testosterone, they will discuss the potential side effects of the medication with you before use. However, you should seek emergency medical help right away if you experience any of the following:
- Shortness of breath
- Chest pain
- Slurred speech
- Pain or weakness on one side of your body
Drug Interactions
Topical testosterone may interact with corticosteroids, insulin, and oral anticoagulants. Tell your doctor if you take any of these types of medications before starting testosterone replacement therapy.
Availability
Topical testosterone is available by prescription only. While some over-the-counter (OTC) products may claim to increase testosterone levels, these don’t contain the same active ingredients. They may also be unsafe.
Tell your doctor about any testosterone-promoting herbs or supplements you’re currently taking. Topical testosterone is a powerful prescription drug that you should only use under your doctor’s supervision.