How to Get TRT: A Step-by-Step Guide to Testosterone Therapy for Women

Why Testosterone Matters for Women, Not Just Men

Testosterone is a female hormone. Your ovaries and adrenal glands produce it throughout your reproductive life, and it shapes libido, mood, bone density, muscle mass, and cognitive sharpness. Most women don't realize their testosterone level at age 40 is roughly half what it was at age 20, a decline that begins years before estrogen starts to shift.

Research published in the Journal of Clinical Endocrinology & Metabolism shows that total testosterone in women drops steadily from the mid-20s onward, with the sharpest fall occurring in the surgical menopause transition. By the time you reach natural menopause, ovarian testosterone output has declined significantly, though the adrenal contribution continues at a reduced rate.

This guide is written from a women's-health perspective because the steps to get testosterone therapy differ meaningfully from the male pathway. Doses are different, labs are interpreted differently, formulations differ, and the risk calculus around pregnancy and hormone-sensitive conditions is distinct.

Step 1: Recognize the Symptoms That Warrant Evaluation

Your symptoms are the starting point. No lab result replaces a clear clinical picture.

Symptoms linked to low testosterone in women

• Persistently low or absent sexual desire that is distressing to you (the hallmark of HSDD)
• Reduced arousal and difficulty reaching orgasm, despite adequate estrogen status
• Unexplained fatigue that does not improve with sleep or thyroid optimization
• Loss of muscle mass and increased fat accumulation, especially visceral fat
• Low mood, flat affect, or reduced motivation not fully explained by depression or thyroid disease
• Thinning pubic and axillary hair
• Brain fog that feels distinct from estrogen-related cognitive changes

Life-stage patterns to know

Reproductive years. Low testosterone in your 20s and 30s is most often linked to oral contraceptive use. Combined oral contraceptives raise sex hormone-binding globulin (SHBG), which binds free testosterone and renders it biologically inactive. One study in the Journal of Sexual Medicine found that women on OCs had significantly lower free androgen index scores than non-users, with some women experiencing persistent low libido even after stopping the pill.

PCOS. If you have polycystic ovary syndrome, your testosterone may actually be elevated rather than low. PCOS is the most common cause of androgen excess in women. ACOG Practice Bulletin 194 recommends measuring free and total testosterone as part of the PCOS diagnostic workup. Testosterone therapy is generally not appropriate here.

Perimenopause. Estrogen volatility dominates the narrative in perimenopause, but testosterone also continues its decline. Women in late perimenopause often notice a convergence of low-desire symptoms layered on top of vasomotor symptoms.

Postmenopause. This is the life stage with the strongest evidence base for testosterone therapy in women. The 2019 Global Consensus Position Statement on the Use of Testosterone Therapy for Women, endorsed by The Menopause Society (formerly NAMS), the British Menopause Society, and the Endocrine Society, recommends testosterone for postmenopausal women with HSDD.

Step 2: Get the Right Lab Tests

A single testosterone number means little without context. You need the right panel, drawn at the right time.

Which labs to order

| Test | Why it matters for women | |---|---| | Total testosterone | Baseline; interpret against female reference range (not male) | | Free testosterone | Reflects biologically active fraction; more clinically relevant than total | | SHBG | High SHBG (often from OCs or liver conditions) suppresses free T even when total T is normal | | DHEA-S | Adrenal androgen precursor; falls with age and adrenal insufficiency | | LH and FSH | Distinguish ovarian vs. Hypothalamic causes; confirm menopausal status | | Estradiol | Testosterone therapy works better when estrogen deficiency is also addressed | | Thyroid panel (TSH, free T4) | Thyroid disease mimics low-T symptoms almost exactly | | CBC and metabolic panel | Baseline before therapy; testosterone raises hematocrit |

Timing matters in premenopausal women

If you still have cycles, draw labs in the early follicular phase (days 2 to 5 of your cycle). Testosterone fluctuates across the cycle, peaking around ovulation. A mid-luteal or premenstrual draw may give a falsely low reading.

Lab reference ranges: a word of caution

Most commercial labs use reference ranges calibrated on male populations or on pooled female samples that include postmenopausal women. The Endocrine Society's 2014 clinical practice guideline on androgen therapy in women explicitly states that no validated, population-based reference range exists for total testosterone in women using current immunoassay methods. Mass spectrometry (LC-MS/MS) is the preferred method for measuring female testosterone because immunoassay kits are designed for the higher male range and are imprecise at female concentrations.

Ask your provider whether your lab uses LC-MS/MS. Many do not. This matters because an immunoassay result of 18 ng/dL carries a wider error margin than the same result by mass spectrometry.

Step 3: Find the Right Prescriber

This step trips up many women. Most primary care providers are not trained in female testosterone therapy, and the off-label status in the US means prescribers need to be willing to work outside the FDA approval framework.

Who can prescribe testosterone to women?

• OB-GYNs with menopause or endocrinology subspecialty interest
• Reproductive endocrinologists
• NAMS-certified menopause practitioners (find one at menopause.org)
• Women's-health NPs and PAs with hormone therapy experience
• Endocrinologists with a women's-health or sexual medicine focus
• Telehealth platforms with a named clinical reviewer on the prescribing team

Questions to ask before your first appointment

1. Do you prescribe testosterone off-label to women, not just men?
2. Do you use LC-MS/MS labs or standard immunoassay?
3. Which formulation do you typically use for women, and why?
4. How do you monitor for side effects like polycythemia and androgenization?
5. What is your approach if I am perimenopausal and still cycling?

A practical framework for evaluating a prescriber: a knowledgeable clinician will always review your full hormone panel in context of your symptoms and life stage, not just hand you a prescription because your total testosterone is below a threshold. Symptom burden plus biochemistry together drive the decision.

Step 4: Choose a Formulation

No FDA-approved testosterone product exists for women in the United States as of 2025. That means your prescriber will use one of the following off-label options, or a compounded product.

Transdermal gels and creams

This is the most common approach for women in the US. Compounding pharmacies prepare gels or creams at female-appropriate concentrations, typically 0.5 mg to 2 mg per 0.5 g application, applied to the inner arm or thigh daily. The goal is to keep serum testosterone in the upper end of the normal female range, not the male range.

The 2019 Global Consensus Statement recommends aiming for serum total testosterone levels in the upper quartile of the normal female reference range, specifically advising against supraphysiologic levels. This is a key distinction from male TRT.

Testosterone pellets

Subcutaneous pellets placed under the skin of the buttock or flank release testosterone slowly over 3 to 6 months. They are popular but carry real risks specific to women: pellets cannot be removed if side effects emerge, and dosing errors that push testosterone into the supraphysiologic range may cause permanent voice deepening or clitoral enlargement. A 2019 case series in the Journal of Sexual Medicine documented androgenic adverse effects in women receiving pellet therapy at doses that exceeded physiologic female ranges. Exercise caution with pellets until you have established your individual response to testosterone.

Testosterone patches (international)

In the UK and Australia, a 300-mcg patch (Intrinsa/AndroFeme equivalent) was approved for postmenopausal women, though it was withdrawn from the UK market for commercial rather than safety reasons. Some US prescribers import or compound equivalent patch formulations. The PATCH trial, published in The Lancet Diabetes & Endocrinology, demonstrated that a 300-mcg transdermal testosterone patch significantly improved sexual function scores compared to placebo in postmenopausal women.

Intramuscular injections

Testosterone cypionate or enanthate injections, typically 0.1 to 0.25 mL of 200 mg/mL solution every 1 to 2 weeks, give very high peak levels immediately after injection that then fall sharply. This creates a hormonal rollercoaster that many women find uncomfortable. Injections are less favored for women than transdermal methods, though some providers use them for women who have difficulty absorbing transdermal preparations.

Step 5: Understand Pregnancy, Lactation, and Contraception Requirements

This section is not optional reading. Testosterone is a confirmed teratogen. If there is any chance you could become pregnant, you must have this conversation before starting therapy.

Pregnancy

Testosterone is classified as FDA Pregnancy Category X for female virilization of a female fetus. The FDA drug label for testosterone products states that testosterone is contraindicated during pregnancy. Exposure during the first trimester may cause virilization of external genitalia in a female fetus, a finding documented in animal studies and human case reports.

If you are in your reproductive years and considering testosterone therapy, you need reliable contraception. Barrier methods alone carry a failure rate of approximately 13% with typical use. The most reliable options are intrauterine devices (copper or hormonal) or progestin-only implants, which do not suppress testosterone the way combined oral contraceptives do. Your prescriber should document your contraception plan before writing the first prescription.

If you are trying to conceive, testosterone therapy must stop before attempts at conception begin. There is no established safe washout period in human data, but given the half-life of transdermal testosterone and the risk to fetal development, most clinicians recommend discontinuing therapy at least one full menstrual cycle before attempting conception.

Lactation

Testosterone is lipophilic and transfers into breast milk. There is no established safe level of testosterone exposure for a nursing infant, and no adequate human lactation studies exist. The Endocrine Society recommends against testosterone therapy in breastfeeding women. If you are postpartum and breastfeeding, delay testosterone evaluation until after weaning.

Postmenopausal women and contraception

If you are confirmed postmenopausal (12 consecutive months of amenorrhea in the absence of other causes), pregnancy risk is effectively zero and contraception requirements do not apply. FSH above 30 mIU/mL on two occasions at least 6 weeks apart, in the context of amenorrhea, is a reasonable biochemical confirmation, though clinical judgment applies.

Step 6: Start Low, Monitor Carefully

Female testosterone therapy is not a set-and-forget prescription. Monitoring protects you from both undertreatment and overtreatment.

Starting dose and titration

A typical starting transdermal dose is 0.5 to 1 mg/day for women. Some clinicians start as low as 0.25 mg/day in women who are highly sensitive to androgens or who have acne-prone skin. Reassess at 6 weeks with a repeat total testosterone level (by LC-MS/MS), a symptom review, and a side-effect screen.

Do not expect full effect in 6 weeks. The 2019 Global Consensus Statement notes that meaningful improvement in HSDD typically requires 3 to 6 months of consistent therapy at adequate levels. Women sometimes abandon therapy prematurely.

Monitoring schedule

| Timepoint | Tests and assessments | |---|---| | Baseline | Full hormone panel, CBC, lipids, liver function | | 6 weeks | Total and free testosterone (LC-MS/MS), symptom score | | 3 months | Testosterone, hematocrit, symptom review, side-effect check | | 6 months | Full panel repeat, lipid profile, blood pressure | | Annually | All of the above, plus breast exam and appropriate cancer screening |

Side effects to watch for

Androgenic side effects in women occur when testosterone is pushed above the physiologic female range. They include:

• Acne (often the first sign of over-treatment)
• Increased facial or body hair (hirsutism)
• Scalp hair thinning at the temples (female-pattern androgenic alopecia)
• Clitoral enlargement (usually reversible with dose reduction)
• Voice deepening (may be permanent if prolonged)
• Elevated hematocrit (polycythemia)

If any of these appear, discuss dose reduction with your prescriber before stopping abruptly.

Step 7: Address Conditions That Change the Calculus

Several common women's-health conditions alter whether testosterone therapy is appropriate, what dose makes sense, or what monitoring you need.

PCOS

As noted above, most women with PCOS already have elevated androgens and do not need supplemental testosterone. However, women with PCOS who have undergone bilateral oophorectomy or who have adrenal suppression from long-term glucocorticoid therapy may develop true androgen insufficiency. In these rare cases, very low-dose therapy may be appropriate, but only after confirming subnormal free testosterone by LC-MS/MS.

Endometriosis

There is limited evidence on testosterone therapy in women with endometriosis. Some case series suggest transdermal testosterone may reduce estrogen-dependent endometriosis lesion activity, but this is not an established indication. Ongoing research at the University of Sydney is exploring this area. Discuss risks with an endometriosis specialist before starting therapy if you have a confirmed diagnosis.

Breast cancer history

The 2019 Global Consensus Statement states that data on testosterone and breast cancer risk are "reassuring but insufficient" and advises that women with a history of breast cancer should only receive testosterone therapy under specialist guidance, with full informed consent. Testosterone is not currently recommended as a routine treatment for breast cancer survivors outside of a clinical trial.

Female pattern hair loss

Testosterone may worsen androgenic alopecia in women who are genetically susceptible. If you have significant scalp hair thinning before starting therapy, discuss whether a 5-alpha-reductase inhibitor (such as finasteride or dutasteride) might be co-prescribed to block conversion of testosterone to dihydrotestosterone (DHT), the potent androgen responsible for follicle miniaturization. Finasteride carries its own teratogen risk and requires strict contraception.

Thyroid disease

Thyroid disease is the most common hormonal condition in women, affecting approximately 1 in 8 women at some point in their lifetime. Hypothyroidism raises SHBG and suppresses free testosterone, creating a picture that can mimic androgen insufficiency. Always optimize thyroid status before attributing symptoms solely to low testosterone.

Who This Approach Is Right For and Who Should Wait

Likely appropriate

• Postmenopausal women with HSDD confirmed by validated questionnaire (e.g., DESIRE scale or FSFI) and subnormal or low-normal testosterone by LC-MS/MS
• Perimenopausal women with persistent HSDD and androgen insufficiency biochemically confirmed, after ruling out thyroid disease, depression, and relationship factors
• Women post-oophorectomy (surgical menopause) who experience abrupt testosterone loss

Proceed with caution or specialist referral

• Women with PCOS (check levels carefully before prescribing)
• Women with hormone-receptor-positive breast cancer history
• Women with significant androgenic alopecia or hirsutism at baseline
• Women in whom SHBG is markedly elevated (address the underlying cause first)

Not appropriate

• Pregnant women or women actively trying to conceive
• Breastfeeding women
• Women with polycythemia vera or hematocrit consistently above 50%
• Women with untreated severe liver disease

What to Expect From Treatment

Symptom improvement follows a predictable sequence for most women. Sexual desire and arousal are usually the first benefits to emerge, often within 6 to 12 weeks at adequate serum levels. Energy and mood improvements tend to follow over months 2 to 4. Changes in body composition, specifically modest reductions in visceral fat and improvements in lean mass, take longer and require adequate protein intake and resistance training alongside therapy.

A 2019 systematic review and meta-analysis in The Lancet Diabetes & Endocrinology analyzed 36 randomized controlled trials covering 8,480 women and found that testosterone therapy significantly improved sexual function, including desire, arousal, orgasm, and pleasure, compared to placebo or comparator. The same review found no significant increase in serious adverse events at physiologic female doses over trial durations of up to 24 months.