Testosterone Therapy in Women

See my Evidence Standards for how I grade the research below.

Testosterone is not just a male hormone. Women produce more testosterone by weight than estradiol for most of their reproductive lives, and it is the direct biochemical precursor to estradiol itself. Its decline with age is linked to low libido, fatigue, mood changes, muscle and bone loss, and genitourinary symptoms. Randomized trial evidence supports testosterone therapy for one indication in particular, low sexual desire, and this guide covers that evidence along with the routes testosterone can be delivered through, and what influences the choice between them.

An Essential Female Hormone, and the Building Block of Estrogen Itself

The ovaries and adrenal glands produce testosterone throughout a woman's life, and premenopausal women have higher circulating testosterone than estradiol by mass for most of the month. Testosterone acts through androgen receptors found in the brain, bone, muscle, fat, and genital tissue, and it contributes to sexual desire and arousal, energy and motivation, mood stability, lean muscle mass and bone density, and the health of vaginal and vulvar tissue. It is also, biochemically, upstream of estrogen rather than a separate, competing hormone: in the body's own steroid synthesis pathway, testosterone is converted directly into estradiol by the enzyme aromatase, in the ovaries before menopause and in fat, muscle, and other peripheral tissue afterward. A woman's estradiol supply starts as testosterone before it ever becomes estrogen, which is not widely understood but is basic, established endocrinology. Unlike estradiol, which swings unpredictably through perimenopause before falling (see my Perimenopause guide), testosterone in women declines gradually and roughly linearly from the mid-reproductive years onward, continuing through and after the menopause transition. By the time many women reach menopause, testosterone levels are meaningfully lower than they were in their twenties and thirties, even though standard hormone panels rarely flag this the way they flag estradiol or FSH.

What the Evidence Shows

Here's the state of the evidence, from strongest to most uncertain:

• Well-established for one specific use. Multiple randomized, placebo-controlled trials and a 2019 international Global Consensus Statement agree that testosterone improves sexual desire, satisfying sexual activity, and related distress in women with Hypoactive Sexual Desire Disorder (HSDD).
• Suggestive but less robust, and broader than sexual function alone. A large 2019 meta-analysis found signals for mood, wellbeing, and musculoskeletal outcomes, and a 2026 real-world cohort found significant improvement across energy, musculoskeletal, mood, cognitive, genitourinary, and endocrine symptoms together, but the trial base for these is thinner than for sexual function, and none of them are formal indications yet.
• Route and dosing is where the real gaps sit. The strongest trial data comes from transdermal patches dosed to premenopausal physiologic levels. Injectable and pellet dosing in women have far less dedicated safety and efficacy data.
• Long-term safety isn't yet established beyond about two years of follow-up, particularly for breast tissue.

Testosterone Patch Trials Establish Efficacy for Low Sexual Desire

A Comprehensive Review Confirms Benefit and Names the Open Questions

The 2019 Global Consensus and the 2023 NAMS Practice Pearl

Real-World Evidence for Benefit Beyond Sexual Function

Endogenous Testosterone Is Not Associated with Worse Vascular Health

Routes of Administration: What Influences the Choice

Testosterone can be delivered through a vaginal or labial cream, a subcutaneous injection, a long-acting pellet, a compounded cream or gel applied to the skin, or a sublingual or buccal troche. Each route has a different absorption profile and a different evidence base behind it. None is uniformly superior; the right choice depends on the treatment goal (systemic symptom relief, local genitourinary benefit, or both), monitoring practicality, and individual response. Whichever route is used, the goal is symptom improvement, not a specific number on a lab report. Because androgen receptor sensitivity and other individual factors vary from woman to woman, the testosterone level that relieves symptoms for one patient isn't necessarily the level that does it for another; lab values are a monitoring and safety tool, not the treatment target itself.

Vaginal or Labial Cream

The vaginal and vulvar mucosa is thin and highly vascular, one of the most absorbent sites on the body for a topically applied steroid, and vaginal tissue expresses unusually high levels of 5-alpha-reductase, the enzyme that converts testosterone into the more potent DHT, confirmed at the molecular level by Cellai et al. (Endocrinology, 2021). That combination gives a strong local androgenic effect together with meaningful systemic absorption from the same application, and trials of intravaginal testosterone (Davis et al., JCEM, 2018; Melisko et al., JAMA Oncology, 2017) have shown improvement in vaginal dryness and related symptoms, since vaginal tissue carries both androgen and estrogen receptors. Older tissue studies proposed that vaginal tissue also aromatizes testosterone into estradiol locally; the Cellai 2021 study found aromatase activity in vaginal tissue "almost undetectable," arguing against a meaningful local estrogen-conversion effect, so the local benefit is better explained by direct androgen receptor activation than by local estrogen production. In the Melisko trial, about 12% of women using vaginal testosterone cream had a transient rise in serum estradiol, worth knowing for patients where any estrogen exposure is a specific concern.

Subcutaneous Injection

Testosterone cypionate injected under the skin lets the clinician set and adjust the dose directly, rather than relying on how well a cream or gel happens to be absorbed that week. How much a level rises and falls between doses is mostly a function of the size and frequency of each dose, not simply whether it's given subcutaneously or intramuscularly: a smaller, more frequent dose produces flatter levels regardless of route, while a larger, less frequent dose produces a higher peak, whether that's an IM injection, an SQ injection, or a pellet, which delivers a much larger depot released more slowly and can produce a higher peak for that reason. There is no published pharmacokinetic or outcomes study of subcutaneous testosterone cypionate dosed at female-physiologic levels; the nearest data (McFarland et al., J Endocr Soc, 2017) comes from transgender men dosed to male-range levels.

Pellets

Pellets offer a long-acting option that doesn't require daily or weekly dosing. Because a pellet delivers a much larger total dose released slowly over months, the resulting peak can still run higher than other routes even though the release itself is gradual, the total dose matters as much as the release rate. The safety evidence here is genuinely unsettled: a 2024 systematic review (Espitia de la Hoz, Rev Colomb Endocrinol Diabetes Metab, 2024;11(2)) found only observational, not randomized, data on pellets, and documented supraphysiologic testosterone levels along with adverse events including acne, hirsutism, and erythrocytosis (an elevated red blood cell count) in some series. A more recent single-center study, published in 2025, reported no increase in erythrocytosis with long-term pellet use in its cohort. No randomized trial data exists for this route, which makes regular monitoring, of testosterone and hematocrit, especially important.

Compounded Cream or Gel to the Skin

Applied to the skin, testosterone cream or gel is, objectively, the route with the strongest randomized-trial base of any covered here. The Shifren, Braunstein, and INTIMATE NM1 trials above all used a transdermal patch delivering testosterone through skin, so the dosing and safety profile within trial dose ranges is the best characterized of the five routes. Compounded creams and gels aren't standardized products the way a trial patch is, so absorption can vary with application site and technique, a consideration for monitoring and dose adjustment.

Sublingual or Buccal Troche

A troche dissolved under the tongue or against the cheek is absorbed through the oral mucosa, bypassing first-pass liver metabolism the way injectable and topical routes do, without an injection or a topical application. Dedicated pharmacokinetic data on sublingual or buccal testosterone specifically in women is limited, and absorption can vary more from dose to dose than with the routes above, which is a consideration for monitoring.

Monitoring and Safety

The treatment target is symptom improvement, not a specific lab value. Because individual factors, receptor sensitivity among them, affect how a given testosterone level translates into how a patient actually feels, the dose that works for one woman can differ meaningfully from the dose that works for another. Lab values still matter, but as a monitoring and safety check rather than the goal itself: levels are checked periodically and timed relative to dosing so a result reflects actual exposure, not a peak or trough, to confirm absorption, guide dose adjustments, and catch a level that has climbed well above the typical premenopausal range, which is where the major consensus statements caution that side effects and unknown long-term risk increase. Acne and excess hair growth are dose-related and roughly 50 to 70 percent more likely than placebo across trials. Adverse cholesterol changes are specifically a concern with oral testosterone, which is generally avoided for this indication. Monitoring continues for as long as therapy does, not just at the start, since the dose that keeps a patient feeling well can shift over time.

What the Research Doesn't Yet Show

Next Step

This page covers the evidence for testosterone therapy in women and what influences the choice between delivery routes. Whether it's right for you, and which route, is an individual clinical decision made with your provider.