Testosterone in Women: Its Role in Perimenopause, Menopause and Libido
Testosterone is often thought of as a “male hormone”, yet it also plays an important role in women’s health. Produced by the ovaries, adrenal glands and through conversion in peripheral tissues, testosterone contributes to sexual desire, arousal, responsiveness and orgasm. It also plays an important biological role in the brain, muscles and bones, although current evidence does not fully support prescribing testosterone specifically for fatigue, mood, cognition, muscle strength or disease prevention.
How do the hormones change?
The menopause transition involves more than simply declining oestrogen levels.
During perimenopause, ovulation can become less predictable and because progesterone is predominantly produced after ovulation, progesterone exposure often becomes less consistent first.
Oestrogen may then fluctuate dramatically, sometimes rising and sometimes falling, before settling at lower levels after menopause. These changes may affect bleeding, temperature regulation, sleep, mood and vaginal comfort.
Testosterone generally follows a different trajectory. Levels tend to decline gradually with age rather than dropping suddenly at natural menopause. As oestrogen falls more rapidly, testosterone may become relatively more prominent, even when testosterone itself is not elevated.
Surgical removal of both ovaries can however, produce a more abrupt reduction in ovarian testosterone.
Could declining testosterone cause symptoms?
Symptoms that may warrant assessment include:
Persistent low sexual desire that causes personal distress
Fewer sexual thoughts
Reduced arousal or responsiveness
Less pleasure or difficulty reaching orgasm
Reduced sexual satisfaction
Fatigue, brain fog, low mood, loss of motivation and reduced strength are sometimes attributed to “low testosterone”, but they are not specific. Similar symptoms can arise from sleep disturbance, thyroid dysfunction, iron deficiency, depression, chronic stress, medicines, including some antidepressants and other menopause-related changes.
Libido is also influenced by oestrogen. Vaginal dryness, reduced genital blood flow or painful intercourse can understandably reduce desire, even when testosterone levels are adequate. Relationship factors, body image, health, workload and emotional wellbeing also matter.
What treatment options are available in Australia?
Treatment should begin with a biopsychosocial assessment rather than a testosterone test alone. Menopausal hormone therapy may improve hot flushes, sleep and other oestrogen-related symptoms. Vaginal moisturisers, lubricants, vaginal oestrogen or prescription vaginal prasterone (DHEA) may improve dryness and painful sex.
Australia has a TGA-registered transdermal testosterone cream for postmenopausal women diagnosed with hypoactive sexual desire dysfunction, or HSDD. Treatment requires a prescription and monitoring to maintain testosterone within the normal female physiological range. Possible adverse effects include acne, increased facial hair and scalp hair thinning. Use during perimenopause or for symptoms other than HSDD is off-label.
Complementary care may include resistance exercise, adequate protein, restorative sleep, stress support and correcting nutritional deficiencies. Maca and Tribulus terrestris have shown possible benefits in small trials, but evidence remains preliminary and they should not be promoted as proven testosterone replacements.⁹˒¹⁰
If changes in libido, vaginal comfort, mood or energy are affecting your quality of life, a comprehensive assessment can help identify the contributing factors and develop a safe, personalised treatment plan.
References:
Davis SR, Baber R, Panay N, et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. J Clin Endocrinol Metab. 2019;104(10):4660–4666.
Parish SJ, Simon JA, Davis SR, et al. ISSWSH Clinical Practice Guideline for Systemic Testosterone for HSDD in Women. Climacteric. 2021;24(6):533–550.
Islam RM, Bell RJ, Green S, et al. Safety and efficacy of testosterone for women: systematic review and meta-analysis. Lancet Diabetes Endocrinol. 2019;7(10):754–766.
O’Connor KA, Ferrell R, Brindle E, et al. Progesterone and ovulation across stages of the transition to menopause. Menopause. 2009;16(6):1178–1187.
Joffe H, de Wit A, Coborn J, et al. Impact of estradiol variability and progesterone on mood in perimenopausal women. J Clin Endocrinol Metab. 2020;105(3):e642–e650.
Torréns JI, Sutton-Tyrrell K, Zhao X, et al. Relative androgen excess during the menopausal transition. Menopause. 2009;16(2):257–264.
Therapeutic Goods Administration. Intrarosa—prasterone for postmenopausal vulvar and vaginal atrophy.
Therapeutic Goods Administration. ANDROFEME 1 testosterone 1% cream—ARTG registration.
Shin BC, Lee MS, Yang EJ, Lim HS, Ernst E. Maca for improving sexual function: a systematic review. BMC Complement Altern Med. 2010;10:44.
de Souza KZD, Vale FBC, Geber S. Tribulus terrestris for HSDD in postmenopausal women: a randomised controlled trial. Menopause. 2016;23(11):1252–1256.