Testosterone is having a menopause moment. But what does it actually do?

Low libido? Brain fog? No energy? Feeling flat? Testosterone is increasingly being talked about as the hormone midlife women may be “missing”. But does the evidence match the hype?

Spend any time in menopause groups online and testosterone is hard to miss.

Women talk about getting their energy back, thinking more clearly, feeling stronger, being more motivated and, perhaps most often, rediscovering a sex drive that seemed to have packed its bags and left somewhere in midlife.

It can start to sound as though testosterone is the final piece of the menopause puzzle. Another hormone to add to the mix if oestrogen and progesterone haven’t quite delivered the version of midlife we were hoping for.

But there is a sizeable gap between what testosterone is being credited with online and what research has actually shown it can do.

So should we all be on it?

With so many benefits being attributed to testosterone, the obvious question is where it actually fits into menopause care.

Christchurch-based gynaecological endocrinologist and menopause specialist Dr Anna Fenton says testosterone absolutely has a place in women’s health, but the evidence for its benefits is much more specific than the online conversation might suggest.

“There is very good evidence that it is effective in improving libido and arousal for women where that has changed and it’s causing distress.”

And that last part is important.

A lower sex drive at some point in midlife does not automatically mean a woman has a testosterone deficiency or needs treatment. The condition for which testosterone has the clearest evidence is hypoactive sexual desire disorder, usually shortened to HSDD.

It is, as Fenton puts it, a “terrible name”.

In simple terms, it describes low libido that is causing a woman distress.

“That’s where the evidence lies with testosterone.”

What about energy and brain fog?

This is where the gap between the online conversation and the research becomes much wider.

Testosterone is now being credited with helping everything from energy and motivation to headaches, brain fog, mood, bones and muscle.

Fenton says those claims have moved well ahead of the evidence.

“There’s no evidence to support that currently.”

Researchers have studied testosterone in women before, during and after menopause, she says, and so far have not demonstrated consistent benefits outside sexual function.

“There is no evidence to support benefits in any other area of quality of life, bone benefit, heart benefit or anything else.”

That does not mean women never report feeling better in other ways.

Fenton has patients using testosterone who tell her their energy or brain fog has improved.

But an individual woman noticing an improvement is not the same thing as a treatment consistently producing that result when it is tested across large numbers of women.

“In terms of the studies where you’re looking at large numbers of women, and they’ve looked specifically to see whether it does help these things, they have failed to see any consistent benefit.”

Research is continuing and Fenton expects more evidence to emerge.

For now, though, claims that testosterone reliably improves energy, cognition or general wellbeing go beyond what the evidence can currently support.

Can you test whether your testosterone is low?

It sounds logical enough.

If testosterone is a hormone, surely a blood test can tell you whether you are deficient and therefore need more of it?

Again, it is not quite that simple.

Fenton says measuring testosterone in women is difficult because the levels are so low that many standard laboratory tests do not measure them particularly accurately.

There is an even bigger problem with using a blood result to diagnose a deficiency.

“There is no specific level of testosterone in women below which you start to run into symptoms.”

In other words, there is no established number that allows a doctor to look at a result and say your testosterone is below this point, therefore that is why you feel the way you do.

“There is no kind of cut-off for a deficiency syndrome.”

That makes the idea of treating a woman simply because a blood test says her testosterone is “low” much less straightforward than it might appear online.

There is a women’s testosterone product. So why are women using men’s gel?

Fenton identifies AndroFeme 1 as the only product currently on the market developed specifically for women.

The catch for New Zealand women is that it is not funded.

Fenton says it was considered for Pharmac funding but turned down. A testosterone gel formulated for men is available funded and can be prescribed off-label to women.

And that is where she has concerns.

The male product contains a much larger dose, which means women need to use a very small fraction of the amount designed for men.

“It’s actually quite hard to titrate down to a fifth or a quarter of a pump,” she says.

Most concerningly, Fenton says she sees women using male testosterone products whose levels have ended up well into the male range because accurately controlling such a small dose can be difficult.

“We see women running with testosterone levels that are well in the male range, with the potential side effects that come with that.”

It is a useful reminder that “testosterone for women” and a small amount of a testosterone product designed for men are not necessarily the same thing.

What do we know about long-term safety?

This is perhaps the biggest unanswered question.

Fenton says the data available so far is reassuring, but nowhere near as extensive as the evidence now available for menopausal hormone therapy.

“At the moment we’ve got relatively short-term studies following relatively small numbers of women.”

What we have so far suggests testosterone appears safe from both a cardiovascular and breast perspective, she says.

But that comes with an important qualification.

“We don’t have the same level of really robust long-term safety data that we have now with hormone therapy.”

That does not mean testosterone is unsafe.

It means the evidence has limits, particularly when women are considering taking it for many years.

And that is a rather different message from the one sometimes delivered online, where testosterone can sound like a routine missing ingredient of menopause care.

So who is testosterone actually for?

Fenton’s answer is much narrower than the long list of benefits attached to testosterone on social media.

It is an evidence-based treatment option for women experiencing a significant change in libido and arousal that is causing them distress.

Beyond that, there are still more questions than answers.

That may change. Research into testosterone in women is continuing, and Fenton says more data is coming.

But right now, feeling tired, foggy, flat or less motivated does not in itself mean you have a testosterone deficiency, and a low blood result does not provide a simple diagnosis either.

The important distinction is between what testosterone may eventually be shown to help with, and what we can confidently say it helps with now.

For the moment, the clearest evidence is for women experiencing distressing loss of sexual desire and arousal.

There is a place for testosterone in women’s health.

It just may not be the answer to everything we have started asking it to fix.

About Dr Anna Fenton

Dr Anna Fenton is a Christchurch-based gynaecological endocrinologist and menopause specialist.

A note about medical information

This article is for general information and education only. It is not personalised medical advice and is not a substitute for advice from your own health professional. Your symptoms, medical history and individual circumstances can affect whether testosterone treatment is appropriate for you.