“I feel amazing, but my hair is falling out,” the woman on the other end of the phone said through sobs. “I know this isn’t an emergency, I feel so ashamed calling you so late, but I need help.”
This patient, who sounded far from amazing, had reached me through our practice after-hours line at 5 pm on a Friday.
Dermatology after-hours calls are usually quick: a refill, a side effect, a canceled appointment. And while part of me wanted to suggest she call back Monday morning to schedule an appointment to discuss her hair loss (a reasonable move), I sensed that it had required courage for her to make this call.
I stepped outside, away from the noise of my laughing kids and barking dogs. “What’s going on?” I asked.
The story that followed was the first of many like it I have heard since that evening. She was perimenopausal and hadn’t been feeling like herself. She went to a functional medicine provider who recommended she start testosterone pellets to improve her energy and her mood, which she started having placed every 3 months. It did everything her doctor told her it would do. And six months in, it did something else: her hair started falling out in fistfuls, and she was convinced she was going bald.
She was the first but not the last patient I cared for who had found the path and promise of testosterone pellets only to discover the heartbreak of hair loss.
The women I saw on testosterone were shedding hair and tears. At that time, I was only 39, and I didn’t comprehend how the benefits of testosterone could ever outweigh the risks.
For the next 6 years, I stayed skeptical. And now at age 45, I am on testosterone therapy myself, and have a completely new understanding of this misunderstood, often mis-prescribed, essential hormone.
So how did I go from fearing to revering testosterone therapy for women? My own shifting hormones shifted my perspective. I set aside trepidation and embraced evidence-based data, biology, and clinical curiosity.
This is what I learned.
Testosterone Is Not Just a Male Hormone
Women have estrogen, and men have testosterone. That’s the basic sex hormone 101 lesson most of us receive. It turns out, women and men both have estrogen and testosterone. And through our reproductive years, women have far more testosterone than estrogen.
It’s made in the ovaries and the adrenal glands, with a meaningful contribution from peripheral conversion of precursor hormones in fat, skin, and muscle. And its receptors are everywhere, not just where you’d expect. Testosterone receptors live in the brain, breast, bone, muscle, blood vessels, skin, hair follicles, and genital tissue. That’s why the symptoms of low testosterone are so wide-ranging and so easy to dismiss as something else.
Women also lose estrogen and testosterone over time, but for different reasons and in different time frames. Estrogen loss begins in perimenopause and declines close to zero after menopause when ovarian production ceases. The rapid drop and ultimate disappearance of estrogen triggers a litany of symptoms that seem to grow in number by the minute, from the dreaded hot flashes to annoying itchy ears.
Testosterone follows a different timeline entirely.
A 2019 study using gold-standard mass spectrometry measurement found that women lose about 25% of their circulating testosterone between the ages of 18 and 39. That means that by the time you hit 40, you’re already operating with significantly less testosterone than you had in your twenties. Why didn’t you notice? For one, the loss is very gradual, and our bodies are better at perceiving more abrupt physiologic changes. Some women weather this decline more easily than others, often without knowing why. And finally, tired is part of the normal narrative of midlife for women, and that script is so loud it drowns out the hormone.
Then, between 40 and roughly 58, women lose another 25%.
And here’s the part that genuinely surprised me when I learned it: menopause itself doesn’t measurably drop testosterone levels. The ovaries keep producing testosterone for years after menopause. Production gradually declines, but without the cliff-edge drop that estrogen experiences when ovarian estrogen production ceases. The adrenal glands and peripheral tissues continue contributing throughout the lifespan. The decline you experience in midlife isn’t a menopause decline. It’s an age decline that happens to coincide with menopause and gets blamed on it.
This matters clinically because it reframes who is a candidate for testosterone therapy. It isn’t only postmenopausal women. Many perimenopausal women, and even some women in their late thirties, are running on a fraction of the testosterone their bodies were optimized for.
My forties hit me hard. My family moved back to Atlanta from Texas at the beginning of the pandemic. I started working at a dermatology practice that I ended up buying in 2022. Between work, a traveling husband, two kids, three dogs, and something going on with my body that just didn’t feel quite right, I felt off.
“You’re just doing too much,” my mother said one afternoon when I called her, driving home from the clinic in tears.
My husband, sensing that I was about to drop a ball and not wanting it to be him, took over the laundry, grocery shopping, and cooking. If “chore play” is a real thing, I should have been all over him.
But I wasn’t. I was married to a supportive man I loved. But I was never in the mood. The idea of even wanting to want sex felt absurd. If hypoactive sexual desire disorder impacts many women, I took it to a new level. My complete lack of libido left me questioning why not wanting sex was even a problem.
I was done having kids, tired and eyes heavy by 8:15 pm, and sex had always been painful for me.
Yes, painful. And no, I hadn’t really gotten around to talking to anyone about that yet. I was busy, remember?
By the time my 45th birthday arrived, I wanted to collapse at 3 pm every day. I would white-knuckle my way through my last hour of patients, down a glass of no alcohol wine (I love a good placebo effect) to get through elementary school homework, and then watch Bridgerton while signing charts after putting the kids to bed.
One night, as the Bridgerton cast had even more sex than usual, I thought, “This is so interesting that these characters like sex so much.” I said something to that effect to my husband. He looked up and said, “You used to enjoy it too.”
I’m actually tearing up writing this. I couldn’t believe that it required a trip to Shondaland to realize I was actually missing something.
The next week, I worked with my provider to start testosterone. My levels were on the low end of normal, and in my menopause certification preparation, I had become much more comfortable with female physiologically dose testosterone. The crying, shedding women with their pellets had been exposed to doses that were too high, too fast.
I also sought help from a pelvic floor physical therapist. I relearned how to do Kegels, how to incorporate breathwork and diaphragmatic breathing, and, importantly, ruled out any problematic pathology contributing to my dyspareunia, medical-ease for painful sex. When Dr. Kelly Casperson launched a vibrator, I ordered it ahead of the release date.
It was time to revive my vegetative libido.
And I waited. 4 weeks passed. I felt energized in the afternoon. I started picking up more speaking engagements, getting more active on social media, and tried my hand at podcasting.
One morning, as we were getting the kids ready for school, my husband looked at me and said, “You seem measurably happier.”
For a finance guy, this meant something.
So many things got better in the first 12 weeks, and importantly, I didn’t lose hair on my head or grow it on my face.
My libido, however, did not.
What Testosterone Actually Does
When levels are adequate, testosterone supports a long list of functions that women tend to file under “feeling like myself.”
It’s a mood hormone. It contributes to motivation, drive, that essential capacity to give a damn. It supports cognitive sharpness, mental stamina, and the willingness to take up space: to start the new business, to train for a half-marathon, to start saying yes to new opportunities.
Maybe my husband said it best. Testosterone can make a woman feel “measurably happier.”
It’s a body composition hormone. It builds and preserves lean muscle mass, supports bone density, and influences how your body uses energy. The midlife shift in body composition that gets blamed on metabolism is, in significant part, a testosterone story.
It’s a sexual function hormone, but not in the way most people think. Yes, libido. But also arousal, sensation, blood flow, and orgasm. And critically, the libido piece is downstream of the mood and motivation pieces. I am now intimately familiar with how testosterone can improve your mood without putting you in the mood.
Desire isn’t a switch that gets flipped by a single hormone; it’s a function of energy, mood, body image, pain, partnership, and a dozen other things. Testosterone touches several of those upstream variables, which is why its effects on sexual function are real but rarely simple.
What Testosterone Does at the Wrong Dose
Now for the part I spent six years thinking about: what happens when there’s too much.
Testosterone’s actions are dose-dependent and, importantly, predictable. The side effects that brought my crying patients to my exam room aren’t mysterious or random. They’re what testosterone does when levels exceed the physiologic female range.
In the skin, excess testosterone gets converted locally to dihydrotestosterone (a more potent androgen), which drives sebum production. That’s where the acne and oily skin come from.
In hair follicles, the same conversion has a paradoxical effect depending on location. On the face, chest, and abdomen, where androgen receptors are sensitive, follicles convert from fine vellus hair to coarse terminal hair. That’s the unwanted facial hair. On the scalp, in genetically susceptible women, the same process miniaturizes follicles over time, producing the diffuse thinning at the part line that we call female pattern hair loss.
At significantly higher doses, testosterone can cause voice deepening (which is often irreversible) and clitoral enlargement.
The crucial point is this: none of these are random side effects. They are what testosterone does at supraphysiologic doses. Which means the entire question of “is testosterone safe for women?” is actually the wrong question. The right question is at what dose, delivered how, and monitored how often.
That’s the question my crying patients’ providers hadn’t answered well.
There’s a flip-side proof of all this: what happens when we deliberately lower testosterone activity in women’s bodies.
Blocking testosterone at the receptor level with medications like spironolactone or blocking its enzymatic conversion to DHT are two therapeutic strategies for female pattern hair loss. And both can lower libido. The DHT blocker finasteride is FDA-approved for male pattern hair loss, and I’ve grown more cautious prescribing it because of concerns around male sexual dysfunction. This is not talked about nearly enough in women, but low libido is a side effect when you block the activity of testosterone. If you have been prescribed one of these medications for hair loss or spironolactone for hormonal acne, and you aren’t feeling like yourself, it may be related to less testosterone activity in your body. And no, your dermatologist probably didn’t warn you about that.
I had tried spironolactone myself a few years ago to treat some new and very bothersome inflammatory hormonal acne. I felt incredibly fatigued and emotionally dead. This was before my reeducation on women’s hormone health, so while I stopped the medication and found other ways to manage the breakouts, I didn’t directly connect those side effects to the impact it had on my testosterone level.
In hindsight, this was a very revealing experience about my testosterone status. But I still had the crying woman in my head, and I hadn’t yet learned how to prescribe testosterone safely for women.
Let’s look at that next.
The Practical Guide: How to Do This Safely
If the science convinced you testosterone might be worth exploring, this is the section you’ll actually use. It’s also the part I wish someone had handed me before I started learning this on my own.
Two questions to answer when starting testosterone therapy: what form, and how much. Get those right, and the side effect profile that frightened me for six years largely disappears.
Find the Right Provider
Unless your doctor finished residency in the past 15 minutes, she probably didn’t learn how or when to prescribe testosterone for women. Dermatologists learn to block it. OB-GYNs lower their impact by prescribing oral contraceptives. Testosterone has been treated as either a culprit or a necessary casualty, never as something we should be replacing.
As women started figuring out long before their primary care docs that testosterone could make them feel better, an industry arose around rogue prescribing. Pellets hit the scene.
Red flags when evaluating a provider:
Recommending pellets as a first-line option
Skipping baseline labs before prescribing
No clear plan for follow-up bloodwork
Cash-only models with no individualized assessment
Promising specific outcomes (”you’ll lose 20 pounds, your libido will come roaring back”)
Good providers in this space tend to be cautious in a specific way: they’ll talk you out of starting if your symptoms are explained by something else first.
Get the Right Workup
A reasonable baseline workup includes total and free testosterone, SHBG (which determines how much of your testosterone is actually bioavailable), estradiol, FSH, a thyroid panel, ferritin, vitamin D, and a metabolic panel.
Why so many labs? Because the symptoms of low testosterone (fatigue, low mood, low libido, brain fog) overlap almost completely with hypothyroidism, iron deficiency, perimenopausal estrogen fluctuations, and untreated sleep apnea. Testosterone won’t fix any of those, and missing them means you’ll spend months blaming the wrong hormone.
Choose the Right Form
There is no FDA-approved testosterone formulation for women in the U.S., a problem fueled by an outdated classification of testosterone as a controlled substance, dating back to the anabolic steroid panic of the 1980s and 90s. The workaround is simple: prescribe a male product at a female dose, or use a compounding pharmacy.
FDA-approved testosterone gel, prescribed off-label. This is what I recommend most often, and what I use myself. AndroGel and Testim are 1% testosterone gels approved for male hypogonadism; women are prescribed roughly one-tenth of the male dose, applied daily to the skin. The product is FDA-regulated, dosing is precise and easy to titrate, and cash prices typically run $20–$40 a month with a coupon. Insurance won’t cover it.
Compounded testosterone cream. A reasonable second-line option if the gel isn’t a fit. The advantage: it’s formulated for women rather than scaled down from a male product. The disadvantage: compounded products aren’t FDA-regulated, so quality and concentration vary. Use a compounding pharmacy your provider trusts.
Pellets. I rarely take an absolutist stance on medical treatment, but pellets are an exception. If you are a woman and your provider recommends pellets, run, don’t walk, out of that office.
The problem is structural: pellets deliver a fixed dose over months, with levels often peaking well above the physiologic female range and then declining unpredictably. If side effects develop, there is no way to dial the dose back. You wait for the pellet to dissolve. The Global Consensus Position Statement on testosterone therapy for women specifically advises against formulations that produce supraphysiologic concentrations. Pellets do exactly that.
If you’re currently on pellets and feeling well, this isn’t a directive to stop. It’s a reason to have an informed conversation with your provider about transitioning to a daily transdermal option.
Monitor Like You Mean It
Starting testosterone is not a set-and-forget prescription. Reasonable monitoring: baseline labs before starting, repeat labs at 6–8 weeks, then every 6–12 months once you’re stable. The goal is to keep total testosterone in the upper end of the physiologic female range, not to push into male-range territory.
In addition to bloodwork, watch for the symptoms that signal you’ve gone too high: new acne, oily skin, increased facial or body hair, scalp shedding, voice changes, or unusual irritability. The beauty of a daily transdermal product is that you can adjust quickly when you see them.
It’s also worth knowing that some women develop side effects even at appropriate doses, due to highly sensitive androgen receptors. There is no test for receptor sensitivity — your skin is the signal.
What to Realistically Expect
Most women who respond to testosterone notice changes in energy, mood, and mental clarity within 4–12 weeks. Body composition changes (improved lean mass, better workout recovery) typically take 3–6 months. Libido is the slowest and most variable, in part because libido is downstream of so many other things, as I learned firsthand.
Some women don’t respond meaningfully to testosterone at all. The honest framing: testosterone is one tool, not the tool.
As a Type 1 diabetic, I learned from an early age that when a hormone is missing, it’s critical to give it back. The impact of insulin, the hormone I must replace forever as my body no longer produces it, is relatively straightforward. But I have learned the importance of modifying lifestyle factors to help it perform better and keep me healthier. I eat a plant-forward and protein-rich diet to minimize glucose spikes. I exercise regularly. I pay attention to what foods and activities lead to unwanted highs and lows and do my best to minimize those exposures. Insulin alone is essential for my metabolic survival. I’d literally die without it. But even insulin performs better with adjustments around diet, exercise, and stress management.
Testosterone’s impact is a little hazier. Yes, if you have low testosterone, then giving it back can help you feel better. Despite my dedication to restful sleep, healthy diet, and exercise, I was still feeling very sluggish. Adding testosterone has helped.
Like so many things, it’s the dose that makes the poison. When I think back to the woman who called me 6 years ago, shedding tears and hair, I see her so much more clearly now than I did then. I see myself in her. Had I had these symptoms at that time, I may also have pursued pellets and their promise of relief. I don’t judge any woman for doing her best to take care of herself. I hold the system that makes testosterone access for women unnecessarily difficult, and providers looking to capitalize on female desperation, accountable.
As for my vegetative libido, the lack of response is not a failure of testosterone to work. It’s an indicator that there are other factors that need to be addressed. I don’t see it as a treatment failure; I have gained so much in other areas of my life. Instead, I see it as an indicator I need to keep exploring what other factors are contributing.
I love my husband deeply. I am grateful that I can talk with him openly about this journey without him taking it personally or as rejection. Those conversations are part of the resuscitation strategy and continue to strengthen our marriage, and make me want to want again.
We will continue to work, as we do, together through this phase. And in the meantime, the choreplay is fantastic.
References
Davis SR, Baber R, Panay N, et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. Journal of Clinical Endocrinology & Metabolism. 2019;104(10):4660–4666. (The international consensus statement endorsed by 11 medical societies, including the International Menopause Society, the Endocrine Society, and the North American Menopause Society. Establishes HSDD in postmenopausal women as the only evidence-based indication for testosterone therapy in women, and advises against formulations producing supraphysiologic levels, including pellets and injections.)
Islam RM, Bell RJ, Green S, Page MJ, Davis SR. Safety and efficacy of testosterone for women: a systematic review and meta-analysis of randomised controlled trial data. Lancet Diabetes & Endocrinology. 2019;7(10):754–766. (The meta-analysis underpinning the Global Consensus Statement; reviewed 36 randomized controlled trials with over 8,000 participants.)
Skiba MA, Bell RJ, Islam RM, Handelsman DJ, Desai R, Davis SR. Androgens during the reproductive years: what’s normal for women? Journal of Clinical Endocrinology & Metabolism. 2019;104(11):5382–5392. (The mass spectrometry study showing women lose approximately 25% of their circulating testosterone between the ages of 18 and 39.)
Wang Y, Islam RM, Bond M, Davis SR. Testosterone and pre-androgens by age and menopausal stage at midlife: findings from a cross-sectional study. eBioMedicine. 2025. (The most recent and most rigorous study on this question to date: a community-based sample of 1,435 Australian women aged 40–69, measured by mass spectrometry. Found testosterone declines from age 40 to a nadir at 58–59 years, with no measurable impact of natural menopause itself. Concluded the data do not support menopause as an indication for testosterone supplementation.)
Parish SJ, Simon JA, Davis SR, et al. International Society for the Study of Women’s Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women. Climacteric. 2021;24(6):533–550. (Practical clinical guidance on dosing, monitoring, and patient selection, including the recommendation to use FDA-approved male testosterone gels at approximately one-tenth the male dose.)
Laughlin GA, Barrett-Connor E, Kritz-Silverstein D, von Mühlen D. Hysterectomy, oophorectomy, and endogenous sex hormone levels in older women: the Rancho Bernardo Study. Journal of Clinical Endocrinology & Metabolism. 2000;85(2):645–651. (Established that the postmenopausal ovary remains a critical source of androgen throughout the lifespan; bilateral oophorectomy reduces circulating testosterone by approximately 50% even in postmenopausal women.)
The Menopause Society Position Statement on Testosterone Therapy. Available at menopause.org. (For finding a Menopause Society Certified Practitioner near you.)
Thank you for discussing this topic in such an authentic, helpful manner.
So glad you're opening this up. The number of women who've been told their symptoms are just stress and sent home is staggering. Posts like this are exactly the conversation we need more of.