Testosterone is increasingly discussed in relation to women’s health. It is a real part of female physiology, with roles extending beyond sexual desire. Yet the evidence for prescribing it depends on the outcome we hope to improve.
What should we do when the biology is interesting, patients describe genuine symptoms, but clinical research has not answered every question?
Gerry at The Health Equation
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Gerry Gajadharsingh writes:
“A recent news article describes a substantial rise in testosterone prescribing to women in the United States, alongside difficulties obtaining preparations designed and licensed for men. It also raises a more important clinical question: what are we actually trying to treat?
Testosterone is sometimes promoted for fatigue, mood, cognition, muscle strength, bone density and general wellbeing. That collection of claims goes well beyond the indication with the strongest clinical evidence: distressing low sexual desire in selected postmenopausal women.
I do not think we should dismiss testosterone as irrelevant to women’s health. Equally, we cannot turn a plausible physiological role into proof that supplementation will improve every symptom associated with midlife.
Women produce testosterone too
Women produce and metabolise androgens throughout life. Testosterone and its precursors are involved in a wider endocrine network that includes the ovaries, adrenal glands and tissues that convert hormones locally.
Androgen signalling has plausible roles in muscle and skeletal physiology. This matters when we consider resilience, physical performance and healthy ageing. But a biological role is not the same thing as evidence that giving additional testosterone improves muscle strength or prevents fractures in women without a defined indication.
Nor is the menopause transition necessarily a sudden testosterone-deficiency event. Female testosterone levels change over adulthood, and the British Menopause Society notes that levels often decline earlier and tend to plateau by menopause. A single low result does not, by itself, explain a person’s fatigue, poor recovery or reduced libido.
What the evidence currently supports
The most consistent trial evidence concerns postmenopausal women with persistent low sexual desire that causes distress. In the UK, NICE advises considering testosterone when low sexual desire associated with menopause persists despite HRT. Assessment must still consider pain with sex, genitourinary symptoms, medication effects, mood, relationship circumstances and the woman’s own priorities.
Treatment, where appropriate, requires careful prescribing and monitoring so that testosterone exposure remains within the physiological female range. In the UK, commonly used testosterone preparations are licensed for men and prescribed off label for women. Long-term safety questions remain.
This is quite different from prescribing testosterone routinely for tiredness, brain fog, poor muscle tone or an isolated laboratory result. These symptoms deserve proper assessment, but evidence does not presently establish testosterone as their general treatment.
Evidence based and evidence informed medicine
In my book, Clinical Reasoning for Complex Patients, I discuss the difference between evidence based and evidence informed medicine. Evidence based medicine has transformed clinical care. Evidence informed practice applies the best available research alongside clinical expertise and the particular patient’s circumstances, values and preferences.
The distinction matters when evidence is incomplete. An absence of trials on a particular combination of symptoms does not prove a physiological mechanism impossible. Yet it also does not give us permission to assume an intervention works. We can formulate a testable hypothesis, explain uncertainty honestly, weigh possible benefit against harm, and revise our view as better research emerges.
My own asthma treatment offers a personal illustration of how guidance evolves. I have used a budesonide–formoterol combination inhaler, Symbicort, for more than twenty years. During that period, evidence and recommendations about how inhaled corticosteroids and formoterol should be used have changed substantially. In 2019, GINA made a particularly notable shift away from short-acting reliever treatment alone for adults and adolescents with mild asthma, and subsequent guidance has developed the role of appropriate ICS–formoterol strategies.
That does not mean my inhaler was unproven for twenty years and then suddenly became the single gold standard for everyone. Combination maintenance treatment and using a suitable ICS–formoterol inhaler as a reliever are different clinical strategies. The lesson is that evidence accumulates, guidelines evolve and a good clinician must keep checking whether an earlier understanding still fits the patient and the research.
What about DHEA and pregnenolone?
DHEA and pregnenolone are sometimes called pre-hormones because they sit within pathways that produce other steroid hormones. Their physiology is fascinating, but the presence of a precursor in a pathway does not establish that supplementing it will correct symptoms or safely restore the whole system.
For systemic oral DHEA in otherwise healthy peri- or postmenopausal women, trials and reviews have produced mixed results; there is insufficient evidence to recommend it routinely for energy, cognition, general wellbeing or musculoskeletal resilience. Vaginal prasterone, a local DHEA preparation, is a separate question. NICE includes it as an option for selected genitourinary symptoms when vaginal oestrogen or non-hormonal products have been ineffective or are not tolerated.
Pregnenolone is another important steroid precursor, with potential neuroactive properties. Clinical evidence for supplementing it to treat menopausal fatigue, cognition or reduced resilience remains much thinner. We should be interested in future research without presenting it as an established part of HRT.
Because these precursors can influence downstream hormone pathways, dose, interactions, adverse effects and a history of hormone-sensitive disease matter. “Natural” does not remove the need for careful evaluation.
The person in front of us
If a woman in midlife reports reduced strength, poor sleep, low desire and fatigue, my first task is not to choose a hormone. I want to understand the time course and examine the wider picture: sleep, nutrition, muscle loading, pain, medication, thyroid function, iron status, metabolic health, mood, genitourinary symptoms and the circumstances of her life. Hormones may be part of that picture, sometimes an important part.
Evidence informed medicine asks us to remain curious without overstating what we know. Testosterone deserves a place in the conversation about female physiology. Its established therapeutic role is narrower than its biological reach. DHEA and pregnenolone deserve rigorous research, not premature certainty.
The question remains the one at the heart of clinical reasoning: why has this particular person developed these particular symptoms at this particular time, and which intervention has a credible chance of helping her safely?
Clinical Disclaimer
This article is for general education and does not constitute individual medical advice. Do not start, stop or alter prescribed hormone or asthma treatment on the basis of this article. Persistent or troubling symptoms merit assessment by an appropriately qualified clinician.
References
- NICE. Menopause: identification and management. NG23, updated 2024. https://www.nice.org.uk/guidance/ng23/chapter/recommendations
- British Menopause Society. BMS Statement on Testosterone, 2023. https://thebms.org.uk/2023/03/bms-statement-on-testosterone/
- Davis SR et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. 2019. https://pubmed.ncbi.nlm.nih.gov/31474158/
- Islam RM et al. Safety and efficacy of testosterone for women: systematic review and meta-analysis. Lancet Diabetes Endocrinol. 2019. https://pubmed.ncbi.nlm.nih.gov/31353194/
- Elraiyah T et al. The benefits and harms of systemic DHEA in postmenopausal women with normal adrenal function. J Clin Endocrinol Metab. 2014. https://pubmed.ncbi.nlm.nih.gov/25279571/
- GINA. GINA 2019: a fundamental change in asthma management. https://ginasthma.org/gina-2019-a-fundamental-change-in-asthma-management/
- GINA. Global Strategy for Asthma Management and Prevention, 2026. https://ginasthma.org/
- Gajadharsingh G. Clinical Reasoning for Complex Patients: The Integrated Regulatory Systems Framework. Chapter 15, Evidence-Based Medicine and Evidence-Informed Medicine. New Generation Publishing, 2026.
Source article that prompted this commentary
Roy M. Testosterone Scripts for Women Rise, Along With Denials and Delays. Reuters report republished by Medscape, supplied for this commentary.