Testosterone is sometimes presented as the missing answer to menopause: the hormone that will restore desire, clear thinking, and energy together. The evidence supports a narrower conversation. Some postmenopausal women with low sexual desire that causes distress benefit from treatment. That finding deserves attention, alongside the limits of the trials and the reasons a prescription should follow a careful assessment.
Desire is more than a hormone concentration
Sexual desire belongs in a conversation about health without becoming a performance target. A change matters because of what it means to the person experiencing it. There is no required frequency of sex, and another person’s expectations should not define the goal of care.
The NHS overview of low sex drive describes several possible contributors, including relationship difficulties, stress, depression, vaginal dryness, medicines, and long-term health conditions. These possibilities can overlap. A consultation that starts and finishes with testosterone misses much of the clinical picture.
It can help to describe what has changed: interest, comfort, pleasure, or the circumstances in which intimacy feels possible. Those are different questions. An explanation that takes them seriously gives treatment a purpose beyond moving a laboratory value. The NHS advises speaking to a GP when low desire is worrying, including when a medicine may be contributing; prescribed medicines should not be stopped independently.
What the randomised trials actually found
In a 2019 systematic review in The Lancet Diabetes & Endocrinology, Rakibul Islam and colleagues pooled 36 randomised trials involving 8,480 participants. In postmenopausal women, testosterone improved measures of sexual desire and reduced sexual distress compared with placebo or comparator treatment. The average difference in satisfying sexual events was about 0.85 per month.
That average is useful context, rather than a promise or a target. It does not mean every participant experienced an additional event, or that event counts capture everything important about sexual wellbeing. The review also measured desire, arousal, and pleasure. A meaningful response is something the patient and clinician discuss, rather than infer from a single number.
The same review did not establish cognitive or musculoskeletal benefits; relatively few women contributed data for those outcomes. Its findings cannot justify presenting testosterone as a treatment for all the symptoms that happen to arrive around menopause. Evidence for a specific problem should stay attached to that problem.
Where testosterone fits in menopause care
NICE’s current menopause guidance says clinicians can consider testosterone for low sexual desire associated with menopause when HRT alone has not been effective. This is a conditional option, rather than a recommendation that everyone taking HRT needs another hormone. NICE also emphasises individualised care and referral when the most suitable management is uncertain.
A useful treatment conversation therefore has a sequence: identify the difficulty, consider contributing factors, discuss appropriate options, and agree how benefit will be assessed. Someone can want help with low desire without wanting testosterone. Equally, a person who has not benefited from other appropriate care deserves a discussion of the evidence without having their concern dismissed.
The NHS explanation of menopause treatment distinguishes care for vaginal discomfort from other menopausal symptoms and notes that testosterone gel or cream may improve low libido for some people. A medicine intended to help desire should not be expected to resolve painful sex or every other barrier to intimacy. Those concerns need their own assessment.
A blood test cannot establish the diagnosis
The 2019 global consensus statement on testosterone for women identifies postmenopausal hypoactive sexual desire disorder, assessed clinically, as the evidence-based indication. Often shortened to HSDD, this describes low desire associated with distress. The statement says there is no androgen blood threshold that separates women with sexual dysfunction from those without it.
This matters when an online result comes labelled “low”. A concentration is not a measurement of a person’s relationship, comfort, or wish for treatment. Testing can serve a different purpose: helping a prescriber avoid excessive exposure before and during therapy. A reassuring result also does not invalidate a patient’s symptoms.
The consensus statement reports insufficient evidence to recommend testosterone for disease prevention or other clinical conditions. It also cautions that evidence in premenopausal women is insufficient. Those limits matter when discussing midlife hormone treatment.
The preparation and follow-up matter
The 2021 ISSWSH clinical practice guideline describes clinician-supervised transdermal treatment, meaning delivery through the skin, with assessment of symptoms, adverse effects, and testosterone concentrations. It discourages preparations such as pellets and injections for this purpose, where exposure can be inappropriate or difficult to adjust. This is not a situation for borrowing somebody else’s gel or estimating a dose from an online discussion.
The guideline describes checking for benefit over time and discontinuing treatment when there is no meaningful improvement by six months. Follow-up is part of the treatment, rather than an optional test afterwards. Before prescribing, the clinician should explain the product, the intended exposure, and what would prompt reassessment. This article does not provide a starting dose: formulations differ, and prescribing requires an individual assessment.
A useful distinction is between a monitored therapeutic trial and an open-ended commitment. Agreeing what improvement would look like, and what would lead to stopping, makes the decision easier to revisit. Continuing simply because a blood result has changed is a different proposition from continuing because symptoms have meaningfully improved.
Risks deserve a separate conversation
The 2019 trial review found an increased likelihood of acne and hair growth with testosterone. The global consensus statement describes mild increases in acne and facial or body hair in some women at physiological exposure. These trial-observed effects deserve discussion alongside the potentially irreversible changes associated with excessive exposure.
The British Menopause Society’s 2023 statement warns that excessive doses can cause potentially irreversible effects, including voice deepening, clitoral enlargement, and male-pattern hair loss. It also rejects treating testosterone as an automatic third component of HRT. More is not an evidence-based route to a better result.
Its clinical prescribing tool lists pregnancy, breastfeeding, active liver disease, and a history of hormone-sensitive breast cancer among circumstances requiring avoidance or particular caution. These should be disclosed before any treatment decision; cancer history warrants specialist consideration. The tool also highlights preventing skin transfer from gels or creams to partners or children. Product-specific instructions matter.
These cautions should be discussed alongside possible benefit, without making patients responsible for assessing their own eligibility. A history that changes the risk balance is a reason for expert advice. New adverse effects during treatment merit contact with the prescriber, rather than self-adjusting the amount used.
What this means in practice
- If a change in desire is troubling, consider booking a GP discussion and describing what has changed in your own words.
- Bring a medicines list and mention discomfort, mood, and relationship concerns that you would like included in the assessment.
- Ask which symptom a proposed treatment is intended to help and what evidence supports that use.
- If testosterone is discussed, ask about the preparation, follow-up, adverse effects, and how benefit or stopping will be judged.
- Tell the clinician about pregnancy possibility, breastfeeding, liver disease, or hormone-sensitive cancer history before any prescribing decision.
What we don’t know
The global consensus statement noted that controlled safety data did not extend beyond 24 months and that higher-risk women were often excluded. It could not establish long-term breast or cardiovascular safety. Short trials without a serious safety signal cannot settle what happens after years of exposure, particularly in people unlike the trial participants.
Women deserve better evidence about both sexual wellbeing and the wider hormonal changes of midlife. For now, the strongest conversation is specific: a distressing symptom, a careful assessment, a possible treatment, and an honest account of uncertainty.
Photo: Marcelo Chagas on Pexels. Illustrative stock photograph; the model is not identified as having any medical condition.
