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119: Testosterone in Menopause: What We Know, What We Don't
0 Playsin 8 hours
Testosterone is everywhere in menopause conversations right now, often framed as a solution for everything from low energy and brain fog to bone health and longevity. In this episode, Dr. Sarah Court breaks down what actually matters when it comes to testosterone for menopausal women, separating social media hype from clinical evidence. The real questions are not whether women have testosterone or whether levels change with age, but whether testosterone should be prescribed, for whom, and what the data truly supports.
Using current consensus guidelines, this episode explains why testosterone has one narrow, evidence-based indication, hypoactive sexual desire disorder, and why claims about mood, energy, cognition, bone health, and longevity are not supported by high-quality research. Dr. Court also walks through how testosterone is prescribed in the real world, why the lack of FDA-approved products for women creates problems, and what the safety data does and does not tell us about long-term risks. If you have heard confident claims about testosterone as a menopause cure-all, this episode provides the context you need to evaluate those messages with clarity and skepticism.
FOLLOW @MovementLogicTutorials on Instagram
Movement Logic: Free Barbell Mini Course
Instagram: Professor Susan Davis
Instagram: Dr. Kelly Casperson
Global Consensus Position Statement on the Use of Testosterone Therapy for Women — Davis et al., 2019, Journal of Clinical Endocrinology & Metabolism
ISSWSH Clinical Practice Guideline on Systemic Testosterone for Women — Parish et al., 2021
Testosterone Therapy for Women, Systematic Review & Meta-analysis
(Lancet Review) — Islam et al., 2019
Androgen Therapy in Women, A Reappraisal — Davis & Wahlin-Jacobsen, 2015
Kelly Casperson blog post — Testosterone Can Help With Libido, Energy, Focus, & More During Menopause
You Are Not Broken Podcast — Kelly Casperson, MD
YouTube Short: Testosterone and Bone Health
YouTube Short: Testosterone, Motivation & Vitality
Recommended
Transcript
Introduction to Movement Logic Podcast
00:00:00
Speaker
I'm Laurel Biebersdorf, strength and conditioning coach. And I'm Dr. Sarah Court, physical therapist. With over 30 years of combined experience in fitness, movement, and physical therapy, we believe in strong opinions loosely held. Which means we're not here to hype outdated movement concepts.
00:00:15
Speaker
or to gatekeep or fearmonger strength training for women. For too long, women have been sidelined in strength training. Oh, you mean handed pink dumbbells and told to sculpt? Whatever that means, we're here to change that with tools, evidence, and ideas that center women's needs and voices. Let's dive in.
Podcast Topic: Testosterone for Women
00:00:45
Speaker
Welcome to the Movement Logic Podcast. I'm your host, Dr. Sarah Court. I'm a physical therapist. And today we are talking all about testosterone for women and specifically for women who are in the menopause transition.
00:00:59
Speaker
However, before we get into it, I wanna talk a little bit about our barbell mini course that we offer at MovementLogic Tutorial. So the barbell mini course goes over really the bread and butter of lifting weights, the deadlift, the squat, and the bench press. And yes, we teach it with barbells, right? It's in the title. But if you don't have barbells, you can do these same exercises with dumbbells, no problem.
00:01:26
Speaker
It's a really clear guide to principles of things like progressive overload, right? How to know when you need to add more weight. And it's just a really nice way to get you started on weightlifting and on doing these lifts in particular.
Common Misconceptions about Testosterone
00:01:42
Speaker
So if that sounds interesting to you, there is a link in our bio for you to go ahead and grab it.
00:01:48
Speaker
All right, let's get to it. So the question is not, do women have testosterone? Because yes, we do. Not as much as men do, but we do. The question is also not, does testosterone decline with age and menopause?
00:02:02
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It does, as do the other hormones in our body, estrogen and progesterone. The question is also not, has testosterone been historically understudied in women?
00:02:13
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Because yes, that's also true, along with a lot of other things, right? But this is improving. The actual clinical question, the one that matters, is threefold. Part one, should menopausal women be prescribed testosterone?
00:02:28
Speaker
Part two, if so, for which symptoms? And this is the big one. And then number three, what does the evidence actually support? Because at the moment, if you go on social media, testosterone is being marketed like a menopause fix-all.
00:02:45
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Libido, energy, focus, confidence, muscle, bone, brain health, longevity. But the evidence does not support that list.
00:02:56
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Just a little reminder, the menopause industry, and make no mistake, it is an industry now, is estimated to be between 17 and 18 billion dollars.
Expert Opinions: Susan Davis vs. Kelly Kasperson
00:03:08
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That's billion with a B. I'm just bringing that up in case you're wondering why certain people might be really pushing different types of menopause drugs or supplements and and positioning themselves as someone who is an expert in the menopause world. We've got our menopause, and this is a bit of a spoiler, but I'm going to be talking about one of the members of the menopause that doesn't always get mentioned with the bigger names.
00:03:36
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We're also going to take some time in this episode to look at dosing and safety recommendations, because there is currently no FDA-approved testosterone product for women.
00:03:48
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It's important to know. All right, so before we talk about testosterone itself, we have to talk about who is shaping this narrative. Because there's a difference between clinical relevance, adjacent expertise...
00:04:03
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and being the person who actually writes the guidelines that define standard of care. So I'm going to contrast two people who are involved in this world as a way to show you the difference between the behavior of a real scientist versus the behavior of someone who is suggesting outcomes that are unproven as a way to garner attention and popularity and ultimately probably money.
00:04:29
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One is an internationally recognized authority who helped define the evidence base, and her name is Professor Susan Davis. The other is a popular clinician educator whose public messaging often extends beyond what consensus guidelines support, and that is Dr. Kelly Kaspersen.
00:04:50
Speaker
All right, so let's take a look at Professor Susan Davis. Dr. Davis is a clinical endocrinologist and women's health researcher at Monash University in Melbourne, Australia.
00:05:01
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She has held leadership roles in international menopause societies and is a lead author on the global consensus position statement on the use of testosterone therapy for women. I just and just want to give you a little time.
00:05:16
Speaker
to sit with that, right? I'm going to say it again. She's the lead author on the global consensus position statement on the use of testosterone therapy for women, which has been endorsed by multiple major professional organizations. This matters because this global consensus document is not opinion. It's a synthesis of randomized controlled trials, safety data, and long-term outcomes.
00:05:41
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The central conclusion of the global consensus position statement is very clear, and I'm going to quote it.
Testosterone and Hypoactive Sexual Desire Disorder
00:05:50
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The only evidence-based indication for the use of testosterone in women is for the treatment of post-menopausal women who have been diagnosed with hypoactive sexual desire disorder, also known as HSDD, following formal biopsychosocial assessment.
00:06:09
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Hypoactive is the opposite of hyperactive, right? If hyperactive is too much, hypoactive is too low. So hypoactive sexual desire disorder is the clinical term for low libido or low sexual desire.
00:06:23
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That's it. That's the indication for testosterone in women. It's really specific, really narrow on purpose. In this consensus document, they also state that there is no evidence supporting the use for general wellbeing.
00:06:39
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There is insufficient evidence for mood, depression, cognition, brain health, bone or muscle outcomes, and there is no recommendation for
Debunking Myths about Testosterone Benefits
00:06:50
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disease prevention or longevity.
00:06:53
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This is what disciplined, evidence-based medicine sounds like. It's specific, it's limited, it does not over promise. Sometimes it's disappointing for that reason.
00:07:05
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So let's contrast this with Dr. Kelly Kasperson. Dr. Kasperson is a board certified urologist with a public focus on sexual health and menopause education.
00:07:17
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This gives her adjacent clinical relevance, particularly around libido and genitourinary symptoms. So yes, she belongs in the conversation,
00:07:27
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The issue is not that she's discussing testosterone. The issue is how broadly testosterone is framed in her public messaging. So let's take a look at some examples from her own public content.
00:07:39
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In a blog post from her own website titled, Testosterone can help with libido, energy, focus, and more during menopause. Dr. Kelly Kasperson explicitly frames testosterone as beneficial not just for sexual desire, but for energy and focus as well.
00:07:56
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In recent FDA testimony, she stated, and this is a quote, testosterone is the most abundant gonadal hormone in the body and women deserve access. The science is solid and the need is undeniable.
00:08:08
Speaker
Now, Dr. Kaspersen doesn't list outcomes like energy or bone health, but what she is doing is making this broad claim that the science is solid, the need is undeniable without clarifying that the evidence base only supports one narrow indication hypoactive sexual desire disorder.
00:08:28
Speaker
She's also stated on YouTube that testosterone is important for building bone and that it helps with mental clarity, motivation, and overall vitality, but she has no evidence beyond anecdotal to prove it.
00:08:41
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right, so let's get really clear about the claims. versus the actual evidence that's out there, if it hasn't felt clear yet. So the claim that testosterone helps libido, energy, and focus is instead of two truths and a lie, it's two lies and a truth.
00:08:58
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Testosterone helps libido. Yes, it improves sexual desire in postmenopausal women with diagnosed HSDD. But there is no high quality evidence supporting improvements in energy or focus.
00:09:12
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If we're trying to claim that the science supporting testosterone for menopausal women is quote unquote solid, sure, it's solid for one indication. It is not solid for broad menopausal symptom management.
00:09:27
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The claim that testosterone improves mood and brain function, there is literally zero evidence. Systematic reviews show no consistent benefit for mood or cognition in postmenopausal women.
00:09:41
Speaker
Now let's look at one that is a little less in this vague category of like energy, wellbeing, mood. So this is something where we're using biological plausibility, and we'll talk about that in a second, instead of actual human data to try to connect testosterone and bone health.
00:10:01
Speaker
So this is where this conversation around the use of testosterone gets especially important in my opinion. Dr. Kasperson has publicly described testosterone as one of her favorite supplements for osteopenia.
00:10:17
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So we need to ask the obvious question, does testosterone actually build bone in menopausal women? So yes, testosterone is involved in bone physiology.
00:10:29
Speaker
Some testosterone is aromatized to estrogen, which we know is critical for bone maintenance. Androgens may influence bone turnover at the cellular level.
00:10:43
Speaker
So that's something called biological plausibility. right? The biology of it suggests that yes, it may be involved in some way. But biological plausibility is not the same thing as clinical proof.
00:10:59
Speaker
The global consensus position statement directly addresses bone outcomes, and the conclusion is unambiguous. This is a quote, there is insufficient evidence to support the you there is insufficient evidence to support the use of testosterone to improve bone mineral density in postmenopausal women.
00:11:19
Speaker
Let's look at it from the other side. If testosterone were meaningfully anabolic for bone in women, we would expect consistent increases in spine or hip bone mineral density across randomized controlled trials at physiologic female doses.
00:11:35
Speaker
And we do not see that. When bone density improves in hormone studies, estrogen, not testosterone, is almost always the primary driver.
00:11:46
Speaker
And the International Society for the Study of Women's Sexual Health Clinical Practice Guideline does not list bone health osteopenia, or osteoporosis as indications for testosterone therapy.
00:11:59
Speaker
This matters because we do have strong evidence for ways to improve bone health in post-menopausal women. Progressive resistance training, impact loading, adequate protein and energy intake, estrogen therapy in appropriate candidates, as well as a variety of medications for osteoporosis treatment. But testosterone is not on that list.
00:12:20
Speaker
So when testosterone is framed casually as a supplement for osteopenia, that's not just unsupported. It risks distracting women from interventions that do actually reduce fracture risk.
00:12:34
Speaker
Testosterone has biological plausibility for bone, but there is no convincing clinical evidence that it builds bone in menopausal women. If it did, it would be in the osteoporosis guidelines, and it isn't.
00:12:47
Speaker
So I also want to talk a little bit about how testosterone is actually prescribed to women and where things go
U.S. Testosterone Prescription Practices
00:12:54
Speaker
wrong. Before we decide whether or not testosterone should be used, we need some important context about how testosterone is actually prescribed to women in the U.S. because Right now, there are no FDA-approved testosterone products specifically for women.
00:13:10
Speaker
So that means every prescription of testosterone to a woman is technically off-label, even when it's being used in the one situation where evidence supports it, which is hypoactive sexual desire disorder.
00:13:22
Speaker
That lack of an approved product is what creates both the workarounds and the problems that we see in real-world practice. So let's talk about the different products that are out there that can be used. The most evidence-aligned option is transdermal testosterone or a gel, cream, or a patch.
00:13:44
Speaker
These are originally formulated for men. but they can be prescribed at a much lower dose for women, somewhere around one-tenth or less of a typical male dose. This approach is preferred in clinical guidelines because most of the trials in women used transdermal delivery. It also allows for gradual absorption. It makes it easier to titrate the dose up or down, and it carries a lower risk of sustained superphysiologic testosterone levels. Superphysiologic levels means more than your body would produce on its own.
00:14:17
Speaker
So it has a lower risk of creating that situation. With that said, it's not perfect. There is a real risk of accidental transfer to partners or children if people aren't careful. And because these products were not designed for female dosing, precision really matters. This approach only works when there's good patient education and active monitoring.
00:14:39
Speaker
Still, when testosterone is prescribed for women with HSDD, this is the preferred route according to global consensus and ISSWSH guidelines.
00:14:51
Speaker
Then we get into compounded testosterone creams or gels, which is where things start to get really messy. Because these are testosterone products made by compounding pharmacies, often marketed as bioidentical and formulated specifically for women with custom doses like half a milligram or one milligram. They're commonly used because there's no FDA-approved female product, and clinicians want something that looks female-specific, and you know the marketing language is appealing to patients. But there are real problems here.
00:15:23
Speaker
Compounded testosterone products, or any compounded products for that matter, don't undergo batch-to-batch consistency testing. The actual delivered dose can vary significantly for what's on the label, and many lack solid pharmacokinetic data.
00:15:39
Speaker
Multiple analyses have shown that compounded hormone products can deliver more or less hormone than intended, which leads to unpredictable blood levels and can increase the risk of exposure to a supra-physiologic level of testosterone in your body.
00:15:56
Speaker
That's why consensus guidelines do not recommend compounded testosterone, unless no alternative exists, and even then they emphasize extra caution and close monitoring.
00:16:07
Speaker
And just to be very clear, bioidentical does not mean safer, more physiologic, or better studied. Another delivery method that comes up a lot is testosterone pellets.
00:16:18
Speaker
And these are small pellets implanted under the skin, usually every three to six months, delivering testosterone continuously over time. They're popular because they're convenient and they're heavily marketed as a, you know, set it and forget it solution. But this is where the guidelines get really firm.
00:16:36
Speaker
Pellets carry a high risk of supra-physiologic testosterone levels, more than your body would produce on its own. Once they're implanted, you cannot adjust the dose or stop the exposure if levels get too high.
00:16:50
Speaker
Blood levels often spike well above female physiologic ranges, and androgenic side effects are more common, things like acne, excess hair growth, voice changes, and clitoral enlargement, some of which can be irreversible.
00:17:05
Speaker
So because of that dosing inflexibility and safety risk, pellets are not recommended for women by major guidelines. There's also an injectable testosterone, even though these formulations were designed for male replacement therapy.
00:17:21
Speaker
The problem is that the injections create large peaks and troughs in hormone levels. It makes it very difficult to keep testosterone within the narrow physiologic female range. Even small dosing errors can result in overdosing. So injectable testosterone is really discouraged for women.
00:17:38
Speaker
There's also oral testosterone, but it's rarely used and it's generally avoided because of adverse effects on lipid profiles, liver metabolism, and it has less favorable safety data overall.
00:17:51
Speaker
And the guidelines do not recommend oral testosterone for women. So this brings us to what is really the most important and least clearly explained part of this conversation, which is the dosing.
Importance of Monitoring Testosterone Levels
00:18:04
Speaker
When testosterone is prescribed appropriately for women, the goal is not high to normal male levels. And it's definitely not whatever makes you feel amazing. The goal is physiologic female testosterone levels. And that target range is narrow.
00:18:20
Speaker
Testosterone has a small therapeutic window in women. Tiny dose changes can produce big shifts in blood levels. As I discussed, compounded products may vary in concentration, they may absorb unpredictably, and they lack reliable pharmacokinetic data. So that's why we then often see women with unexpectedly high testosterone levels and androgenic side effects, despite being told they're on low doses.
00:18:47
Speaker
And then you end up with clinicians reacting after the problems show up instead of just preventing them. The other huge part with testosterone use is that responsible testosterone prescribing for women requires monitoring, period. That includes baseline symptom assessment, baseline testosterone levels, follow-up levels to ensure you're not overshooting,
00:19:10
Speaker
And if there is no meaningful benefit within a few months, the therapy should be discontinued. This is not conservative and this is not my advice. i It is not within my scope to give this advice. This is what the consensus guidelines repeatedly emphasize.
00:19:27
Speaker
I'm just reading you the information. And it matters even more given that we don't really have long-term cardiovascular and breast safety data for testosterone in women.
00:19:40
Speaker
So as far as the safety of taking testosterone, the most accurate answer is kind of unsatisfying. We don't have strong evidence of harm in the short term, but we don't have good enough data to declare it safe in the long term. Because most of the studies we have on testosterone in women are short, somewhere between six months to maybe two years.
00:20:02
Speaker
In those studies, we don't see any clear increase in heart attacks or strokes, and we don't see a clear signal for increased breast cancer risk. But those studies were not designed to answer long-term safety questions. The one thing that does show up when you look at cardiovascular risk more closely is changes in cholesterol. Testosterone can lower HDL, which is the quote-unquote good cholesterol, and and that effect becomes more pronounced at higher doses or with oral formulations.
00:20:35
Speaker
Lower HDL doesn't automatically mean a heart attack, but it is a known cardiovascular risk marker, especially in postmenopausal women who already tend to see worsening lipid profiles after menopause.
00:20:48
Speaker
And again, because the trials are short, we don't know what these lipid changes mean over, you know, five, 10, 20 years of exposure. So we just don't have that data yet.
00:21:00
Speaker
And then breast health is also murky. Short-term trials don't show and a clear increase in breast cancer or breast density, but the studies are not very well put together and they exclude women with a history of breast cancer.
00:21:18
Speaker
Testosterone can be aromatized into estrogen. So in theory, it could increase estrogen exposure, but how much that matters clinically is still unknown.
00:21:30
Speaker
So if you hear claims that testosterone is heart safe, breast safe, or even protective, it's kind of an overstatement. The honest position, the one that's reflected in the guidelines, is that long-term cardiovascular and breast safety in women remains uncertain.
Appropriate Use of Testosterone in Women
00:21:47
Speaker
The bottom line is this. Short-term, carefully dosed testosterone for a very specific indication appears reasonably safe. in the populations that have been studied.
00:21:58
Speaker
But we do not have the data to support long-term, high-dose, or set-it-and-forget-it use, especially when it comes to cardiovascular and breast health. No signal of disaster is not the same thing as evidence of safety.
00:22:13
Speaker
And that uncertainty is exactly why responsible guidelines emphasize cautious dosing, careful monitoring, and regular assessment, not blanket enthusiasm.
00:22:26
Speaker
So testosterone is not the villain, but it is also not a cure-all. There is one evidence-based indication for testosterone therapy in menopausal women, and that is hypoactive sexual desire disorder that is properly diagnosed, conservatively treated, and also monitored carefully.
00:22:47
Speaker
That is the one way to use testosterone. And So if you're getting it in any other way, if you're getting it in a way where you have not been diagnosed for HSDD or you're curious about these other possible positive effects, like for your sense of well-being or for your bones, it is not indicated for those things. And if you start to take it, I would guess anyone who prescribed it for you for reasons other than HSDD is doing so in a way that is irresponsible because they're likely not going to be doing follow-up monitoring with you in terms of things like your testosterone blood levels.
Warnings Against Non-Evidence-Based Claims
00:23:27
Speaker
When testosterone is marketed for energy, brain fog, bone, muscle, or longevity, that is not evidence-based medicine. That is hormone optimism outrunning the data.
00:23:40
Speaker
And this is why it matters who you get your information from. So our recommendation, if you are on Instagram, is to follow Professor Susan Davis. She puts out lots of very educational videos about testosterone and other hormonal concerns. I would recommend not following Dr. Kelly Kasperson because she over promises that on the potential positive benefits of testosterone and has no evidence-based research or proof to back it up.
00:24:15
Speaker
All right, that's it from me for today. Happy holidays. I hope you enjoyed this episode and I hope that it was useful to you. Don't forget if you are interested in learning some of the basics of lifting weights, whether it's with barbells or dumbbells, you can get our free Barbell Money Course for signing up for our mailing list.
00:24:36
Speaker
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00:24:48
Speaker
That's what the kids say. We'll see you in two weeks.