What Testosterone Actually Does for Women After 40

Written by Anat Sapan, MD, board-certified OB-GYN · Updated November 2026

Testosterone is a women's hormone too. By menopause, most women make about half as much as they did in their twenties. The strongest evidence for testosterone therapy is for low sexual desire, and newer studies suggest it may also help mood and focus in women whose estrogen therapy has not fully restored how they feel.

When women come to me after one or two other hormone providers, I see the same pattern. They are on estrogen, often progesterone too, and they are better, but not themselves. The energy is not quite back. Motivation is flat. Libido is gone in a way that has nothing to do with how they feel about their partner. Their thinking is clearer, but not sharp.

In most of these cases, testosterone has never been discussed, tested or offered.

Testosterone is not a male hormone

Women make testosterone in the ovaries and adrenal glands throughout life. In absolute terms, a woman's body carries more testosterone than estradiol. It plays a role in sexual desire, motivation, energy, and how we respond to exercise.

Levels peak in our twenties and decline gradually. By menopause they are roughly half of what they were. Women who have had their ovaries removed lose testosterone more abruptly. Because there is no dramatic signal like a hot flash, the decline is usually blamed on stress, aging, the relationship or a busy life.

Common signs that low testosterone may be part of the picture:

Low or absent sexual desire, especially if it is new
Flat motivation and drive, or loss of confidence
Low mood, irritability or anxiety that began in perimenopause
Fatigue that sleep does not fix
Brain fog or trouble concentrating despite estrogen therapy
Difficulty keeping muscle despite consistent exercise

These symptoms have many causes, which is why they deserve a real evaluation rather than a guess.

What the research actually shows

Sexual desire: strong evidence. A 2019 meta-analysis of randomized trials in The Lancet Diabetes & Endocrinology found that testosterone significantly improves sexual desire, arousal, pleasure, orgasm and self-image in postmenopausal women.^[1] The same year, a global consensus statement endorsed by the International Menopause Society, The Endocrine Society, the North American Menopause Society, the Royal College of Obstetricians and Gynaecologists and others recognized low sexual desire with distress (hypoactive sexual desire disorder) as a clear reason to offer it.^[2]

Mood, motivation and energy: promising and growing. A 2024 study of 510 women at a UK menopause clinic, all already on hormone therapy but still struggling, added transdermal testosterone for four months. 52 percent reported better libido, 47 percent better mood, and 39 percent better cognitive symptoms.^[3] It had no placebo group, so it cannot prove cause and effect. But randomized evidence points the same way: in a placebo-controlled trial in the New England Journal of Medicine, women who had their ovaries removed scored significantly better on well-being and depressed mood while on transdermal testosterone.^[14] A randomized, placebo-controlled trial in women with very low testosterone found that replacement improved mood and parts of quality of life, along with bone density and lean muscle.^[6] UK primary-care guidance published in the British Journal of General Practice notes that adding testosterone to hormone therapy can improve mood, concentration, motivation and energy, not just libido.^[13]

Larger trials have not yet shown a consistent effect on depression or overall well-being in every postmenopausal woman, so testosterone does not replace depression care. But when low mood, flatness and loss of drive began with perimenopause and linger despite estrogen, testosterone is often the piece that lifts them in my practice. I have written about why so many women are offered antidepressants instead of hormone therapy.

Bone and muscle: encouraging, but mixed. Small trials that added testosterone to estradiol implants found greater gains in spine and hip bone density than estrogen alone,^[4]^[5] and a 12-month randomized trial in women with very low testosterone found hip bone density improved.^[6] Larger trials at standard doses have not consistently confirmed this, so I see testosterone as a supporting player alongside estrogen, strength training and protein, not a stand-alone osteoporosis treatment.

Is testosterone safe for women?

At doses that keep blood levels in the normal female range, short-term studies show it is well tolerated. The most common side effects are acne and some increase in body or facial hair. Voice changes and hair loss are uncommon and are mainly a risk when doses run too high.

Breast safety. This is where the science has shifted most. A systematic review of randomized trials found no significant increase in breast cancer risk with transdermal testosterone.^[15] In another randomized trial, postmenopausal women on estrogen and progestin had a fivefold rise in breast cell proliferation, a marker linked to cancer risk; adding a testosterone patch prevented that rise.^[7] Laboratory research now shows the androgen receptor acts as a tumor suppressor in the most common type of breast cancer.^[8] Long-term studies of women using testosterone implants found lower breast cancer rates than expected for their age,^[9]^[10] and a 2024 analysis of insurance records found about half the rate of similar women not on testosterone.^[11] These are observational findings and cannot prove protection, and safety data beyond a few years remain limited. Women with a history of hormone-sensitive breast cancer need an individual discussion.

Heart health. Oral testosterone worsens cholesterol and is not recommended.^[2] Skin-applied testosterone has not shown that effect. In a randomized trial of older women with heart failure, transdermal testosterone improved walking distance, exercise capacity, muscle strength and insulin sensitivity,^[12] and the 2024 records study found fewer heart attacks and strokes among women on testosterone.^[11] A 2023 review of the cardiovascular research concluded that low-dose testosterone given with estrogen may improve several heart-risk markers, while high doses may worsen cholesterol and insulin sensitivity, which is one more reason dose matters.^[16] Encouraging, though not yet proof of heart protection.

Pellets and injections. I do not use them. They often push levels well above the normal female range, and once placed, a pellet cannot be removed if side effects appear.

How I prescribe testosterone

I use topical testosterone, because the dose can be adjusted in small steps and stopped at any time.
Your symptoms guide the dose more than any lab number. During treatment I follow SHBG, and sometimes total testosterone, to help fine-tune it.
Testosterone is often part of a plan with estrogen and progesterone, but sometimes I use it on its own, depending on your symptoms, especially in early perimenopause.

Why your doctor probably never mentioned it

There is no FDA-approved testosterone product for women in the United States. Men have many. The male products deliver roughly ten times the dose a woman needs, so prescribing for women means using small, off-label doses or carefully compounded preparations.

Australia has had an approved testosterone cream for women for years. In the UK and Europe, the one licensed women's product was withdrawn in 2012 for commercial reasons, not safety. In September 2026, the FDA held its first workshop on testosterone for women in two decades, and I wrote about what I want the FDA to hear.

The result is that many physicians were never trained to offer it, and many women were never told it exists.

Frequently asked questions

Will testosterone make me grow facial hair or deepen my voice?

At normal female doses, significant hair growth is uncommon and voice changes are rare. Both are mainly risks of excessive dosing, which is why I start low and adjust based on how you respond.

Do I need blood tests first?

Not necessarily. Your symptoms matter most, and a blood level alone cannot diagnose low desire or low energy. Once treatment starts, I follow SHBG, and sometimes total testosterone, to help adjust the dose.

How long does it take to work?

Most women who benefit notice changes within 6 to 12 weeks. I reassess at about three months and again at six.

Can I take testosterone without estrogen?

It really depends on what symptoms you have and where you are in your journey. For some women, especially in early perimenopause, testosterone alone is the right fit. For others, it works best alongside estrogen and progesterone.

Does testosterone cause weight gain?

Not at normal female doses. Many women find it easier to stay active and build strength.

Is testosterone safe after breast cancer?

It depends on the type of cancer and your oncologist's input. This needs an individual conversation, not a general answer.

The bottom line

If you are on estrogen and progesterone and still feel something is missing, testosterone may be the missing piece, especially if low desire, flat motivation or fatigue are part of your story. The evidence is strongest for sexual desire and growing for mood and focus. Dosed carefully and monitored, it can complete a hormone plan that is otherwise only partly working.

Dr. Anat Sapan, MD, is a board-certified OB-GYN and menopause specialist offering telemedicine care to women in California, Florida, Illinois and New York. Book a complimentary discovery call.

References

Islam RM, et al. Safety and efficacy of testosterone for women: a systematic review and meta-analysis of randomised controlled trial data. Lancet Diabetes Endocrinol. 2019. Link
Davis SR, et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. 2019. Link
Glynne S, et al. Effect of transdermal testosterone therapy on mood and cognitive symptoms in peri- and postmenopausal women: a pilot study. Arch Womens Ment Health. 2024. Link
Savvas M, et al. Increase in bone mass after one year of percutaneous oestradiol and testosterone implants. Br J Obstet Gynaecol. 1992. Link
Davis SR, et al. Testosterone enhances estradiol's effects on postmenopausal bone density and sexuality. Maturitas. 1995. Link
Miller KK, et al. Effects of testosterone replacement in androgen-deficient women with hypopituitarism: a randomized, double-blind, placebo-controlled study. J Clin Endocrinol Metab. 2006. Link
Höfling M, et al. Testosterone inhibits estrogen/progestogen-induced breast cell proliferation in postmenopausal women. Menopause. 2007. Link
Hickey TE, et al. The androgen receptor is a tumor suppressor in estrogen receptor-positive breast cancer. Nat Med. 2021. Link
Glaser RL, et al. Incidence of invasive breast cancer in women treated with testosterone implants: a prospective 10-year cohort study. BMC Cancer. 2019. Link
Donovitz G, Cotton M. Breast cancer incidence reduction in women treated with subcutaneous testosterone. Eur J Breast Health. 2021. Link
Agrawal P, et al. Breast cancer and major adverse cardiac events in women on testosterone therapy: a claims-database analysis. J Sex Med. 2024;21(5):414-419. Link
Iellamo F, et al. Testosterone therapy in women with chronic heart failure: a pilot double-blind, randomized, placebo-controlled study. J Am Coll Cardiol. 2010. Link
Scott A, Newson L. Should we be prescribing testosterone to perimenopausal and menopausal women? Br J Gen Pract. 2020;70(693):203-204. Link
Shifren JL, et al. Transdermal testosterone treatment in women with impaired sexual function after oophorectomy. N Engl J Med. 2000;343(10):682-688. Link
Gera R, et al. Does transdermal testosterone increase the risk of developing breast cancer? A systematic review. Anticancer Res. 2018;38(12):6615-6620. Link
Britton RC, Beamish NF. The impact of testosterone therapy on cardiovascular risk among postmenopausal women. J Endocr Soc. 2023;8(1):bvad132. Link