The Complete Guide to Testosterone Therapy for Women and Men

Testosterone: One of the Most Important Hormones

for How You Feel and Function

Testosterone is often thought of as a male hormone, but it plays a critical role in both women and men.

In fact, in women, testosterone is more abundant than estrogen or progesterone. It is present in smaller absolute amounts than in men, but it remains a dominant and highly influential hormone.

It influences far more than libido. Testosterone affects muscle mass, metabolism, brain function, energy levels, and overall drive. It is one of the key hormones that determines how motivated, strong, and resilient you feel.¹

In women, even subtle declines can have a noticeable impact on how the body functions, particularly in areas such as energy, strength, and cognitive clarity. Because of this, testosterone is not just about sexual health. It is a hormone that supports overall performance and quality of life.

Testosterone in Women vs Men: Key Differences

Testosterone is a critical hormone in both women and men. Its role in muscle mass, metabolism, brain function, energy, and sexual health is significant regardless of gender.

Many of its benefits are the same in both:

• maintaining muscle mass and strength

• supporting metabolic health and body composition

• improving energy and motivation

• contributing to sexual function and satisfaction

The difference is not whether testosterone matters. It is how much is needed and how changes present clinically.

Women naturally have lower levels, but they are often more sensitive to fluctuations. Even small declines can lead to noticeable changes in energy, motivation, libido, and overall function.

In women, testosterone tends to influence:

• libido and sexual responsiveness

• motivation and drive

• cognitive clarity

• muscle tone and body composition

Men typically have higher baseline levels and experience a more gradual decline over time.

In men, testosterone more commonly affects:

• strength and muscle mass

• energy and endurance

• erectile function

• body fat distribution

Because symptoms can overlap with aging, stress, or lifestyle factors, low testosterone is often overlooked in both groups, but particularly in women, where it is less frequently evaluated.

Why Testosterone Declines

Testosterone levels do not stay constant throughout life, but unlike estrogen and progesterone, they do not fluctuate dramatically during perimenopause. Estrogen and progesterone tend to rise and fall unpredictably during this time. Testosterone, on the other hand, follows a more gradual, steady decline with age.

Because of this, the symptoms of low testosterone are often more subtle and develop slowly over time. Many people do not recognize the change until it begins to affect energy, motivation, strength, or overall function.

Testosterone is produced in multiple areas of the body. In women, it is made by the ovaries, the adrenal glands, and peripheral tissues through conversion from precursor hormones.

In men, it is produced primarily by the testes, with smaller contributions from the adrenal glands.

As we age, production from all of these sources declines.

If you have had your ovaries removed, this change can be much more abrupt. The ovaries are a significant source of testosterone in women, and their removal leads to a sudden drop not only in estrogen and progesterone, but also in testosterone. This is why many women notice a rapid change in energy, libido, and overall function after surgical menopause.

Other factors can further accelerate testosterone decline, including:

• chronic stress, which elevates cortisol and can suppress hormone production

• poor sleep, which disrupts normal hormonal signaling

• insulin resistance and metabolic dysfunction

• decreased muscle mass and physical activity

These factors do not just lower testosterone directly. They also affect how the body uses and responds to it.

Because testosterone declines gradually and is influenced by multiple systems, the changes are often overlooked or attributed to aging alone, even though they reflect a real shift in underlying physiology.

Symptoms of Low Testosterone

Low testosterone does not present the same way in everyone, but there are consistent patterns.

These symptoms often develop gradually and can be easy to overlook or attribute to aging, stress, or lifestyle changes.²

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If you want a deeper understanding into why testosterone matters so much in women, you can read Testosterone in Women: It’s More Important Than You Think.

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Low Testosterone in Women May Cause:

• decreased libido or reduced sexual interest

• lower motivation or feeling less driven

• fatigue or low energy, even with adequate sleep

• loss of muscle tone and difficulty maintaining or building strength

• increased body fat, particularly with no clear change in diet or activity

• brain fog, reduced focus, or mental fatigue

• decreased resilience to stress

Low Testosterone in Men May Cause:

• decreased energy and endurance

• reduced strength and muscle mass

• increased body fat, particularly around the abdomen

• decreased libido

• changes in erectile function

• reduced motivation or drive

• mental fatigue or decreased focus

It is important to understand that these symptoms are not specific to testosterone alone.

They can also be seen with low iron levels, thyroid dysfunction, elevated cortisol and chronic stress and poor sleep or metabolic dysfunction.  This is why looking at symptoms in isolation is not enough.

However, testosterone is a highly influential hormone that affects multiple systems at once. When levels are low, it often contributes to several of these symptoms simultaneously.

Because of this, when testosterone is optimized appropriately, many patients notice improvement across multiple areas, including energy, strength, motivation, and sexual function.

The goal is not to assume testosterone is always the cause, but to recognize that when it is a contributing factor, addressing it can have a meaningful and wide-reaching impact.

Testosterone and Metabolic Health

Testosterone plays a central role in metabolic health. It influences how your body stores fat, uses glucose, maintains muscle, and responds to insulin.³

This is one of the reasons low testosterone is often associated with weight gain, loss of muscle, and difficulty maintaining body composition, even when diet and exercise have not changed.

One of the most important ways testosterone supports metabolic health is through its effect on muscle.

Muscle is metabolically active tissue. It requires energy to maintain, and it plays a major role in how your body handles glucose.

When you eat, glucose enters the bloodstream. Muscle acts as a glucose “sink”, meaning it takes up and stores glucose efficiently, which helps prevent large spikes in blood sugar.

As testosterone supports muscle mass:

• more muscle means better glucose uptake

• blood sugar levels remain more stable

• insulin sensitivity improves

So when testosterone declines, muscle mass decreases →the body becomes less efficient at clearing glucose→and insulin resistance becomes more likely.

This is one of the early shifts that contributes to weight gain and metabolic dysfunction.

This is why muscle is one of the most important drivers of metabolic health, especially as you age. If you want a better understanding of how this impacts women specifically, read The Muscle Crisis No One Is Talking About in Women Over Forty.

Testosterone also influences how the body stores fat.

With lower levels:

• fat is more likely to be stored centrally, particularly around the abdomen

• body composition shifts toward higher fat and lower muscle

• and metabolic rate decreases

In addition, testosterone affects mitochondrial function, which influences how efficiently your body produces and uses energy at a cellular level.

When testosterone levels are optimized, your energy utilization improves, your metabolic efficiency increases, and iit becomes easier to maintain weight and body composition.

This is why optimizing testosterone is not just about improving how you feel. It is a key part of maintaining metabolic health and preventing long-term issues such as insulin resistance, weight gain, and loss of muscle mass.

It also explains why testosterone therapy is often most effective when combined with strategies that support muscle growth and metabolic function, rather than being used in isolation.

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If you are actively working on improving strength or body composition, you can learn more about how I approach muscle preservation and growth here.

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Testosterone and Sexual Function

Sexual function is not just about desire. It is a coordinated physiologic process that involves the brain, blood flow, nerve signaling, and tissue responsiveness.

Testosterone plays a role at multiple levels in this process.⁴

The Brain: Libido, Motivation, and Sexual Interest

Testosterone has a direct effect on the central nervous system.

It influences:

• libido and sexual desire

• motivation and anticipation

• dopamine signaling, which drives reward and interest

When testosterone levels decline, many patients describe:

• decreased interest in sex

• feeling mentally “disconnected” from intimacy

• less spontaneous desire

This is not simply psychological. It reflects reduced signaling in the brain pathways that drive sexual interest and motivation.

The Body: Blood Flow, Vasodilation, and Arousal

Sexual response at the genital level is largely a vascular event.

Testosterone works in conjunction with estrogen to support nitric oxide production, which allows blood vessels to dilate.

This vasodilation is what enables increased blood flow to genital tissue and tissue engorgement and sensitivity.  This improves natural lubrication in women and erectile function in men.

When testosterone declines:

• nitric oxide signaling is reduced

• blood flow becomes less robust

• arousal is slower and less reliable

• tissue responsiveness decreases

This is why many patients describe that even when they want to feel interested, their body does not respond the same way.

This Is Important for Your Health

Sexual function depends on both brain signaling (desire and motivation) and vascular response (blood flow and arousal).  Testosterone supports both systems at the same time.

When levels are optimized:

• libido often improves through central nervous system effects

• arousal improves through better blood flow and vasodilation

• overall sexual response becomes more consistent and satisfying

This is why sexual health is not simply a relationship issue or a mindset issue. It is a physiologic process, and when the underlying pathways are supported, function often improves in a meaningful and predictable way.

Testosterone and Brain Function

Testosterone plays an important role in how the brain functions on a daily basis and over time.

It influences our motivation and drive, our focus and attention, the brain’s processing speed, as well as our mood and resilience.

These effects are mediated through its interaction with key neurotransmitters, including dopamine and serotonin, as well as its influence on neuronal signaling and brain energy utilization.⁵

When testosterone levels decline, many patients notice:

• decreased motivation

• mental fatigue

• difficulty concentrating

• reduced clarity or slower thinking

These changes are often subtle at first, but they can significantly affect performance, productivity, and overall quality of life.

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If you want to understand this connection more deeply, including how hormones may influence long-term cognitive health, read Can Hormone Therapy Protect Your Brain from Alzheimer’s?

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Testosterone and Cognitive Health Over Time

Beyond day-to-day function, testosterone also plays a role in long-term brain health.

It has been shown to support neuronal integrity, influence synaptic function and communication between neurons, reduce neuroinflammation and contribute to overall brain resilience.

There is also evidence that testosterone may have a protective role in cognitive decline.

Lower testosterone levels have been associated in some studies with:

• increased risk of cognitive impairment

• higher rates of memory decline

• increased risk of neurodegenerative conditions such as Alzheimer’s disease

While testosterone is not the only factor involved in dementia risk, it is one of several hormones that contribute to maintaining brain health over time.

Protecting Brain Health as We Age

Brain health is not something that changes overnight. It is influenced by long-term patterns in metabolism, inflammation, sleep, and hormone balance. Testosterone is one of the hormones that helps support mental clarity, cognitive performance and long-term neurologic resilience.

When levels are optimized as part of a broader approach, many patients notice improvements in focus, motivation, and overall mental function.

It also highlights that hormone optimization is not just about how you feel today. It is part of a larger strategy to support brain health and reduce the risk of cognitive decline over time.

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If you are noticing brain fog, low motivation, or mental fatigue, learn how I approach brain optimization here.

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Why “Normal” Testosterone Levels Are Misleading

Many patients are told their testosterone levels are “normal,” even when they clearly do not feel well.

The problem is that standard lab reference ranges are based on population averages, and in many cases, that population is not particularly healthy. These ranges reflect what is common, not what is optimal.

Our goal is not to have you fall somewhere within a broad range that includes individuals who may already be experiencing symptoms. The goal is for you to function at a level where you feel strong, energized, mentally clear, and metabolically healthy.

Because of this, simply replacing testosterone to the low or mid-range of normal is often not enough to produce meaningful improvement.

In many cases, levels need to be optimized toward the higher end of the reference range, and in some situations, slightly above it, in order to achieve the desired physiologic effect.

Another important factor is how your body responds to testosterone, not just how much is present in the bloodstream.

As we age:

• receptor sites may decrease in number

• receptor sensitivity can decline

• tissue responsiveness becomes less efficient

This means that even if testosterone levels appear “normal” on a lab test, you may not be responding to it in the same way it did at a younger age.

Because of this, achieving symptom improvement is not just about reaching a number. It is about restoring effective signaling between hormones and tissues. This is why a symptom-based, physiology-driven approach is more effective than relying on lab values alone.

Not All Testosterone Therapy Works the Same Way

How testosterone is delivered has a significant impact on how well it works.

This is not just about convenience. It directly affects absorption, consistency of hormone levels, symptom control, and overall outcomes.

Oral Testosterone

Oral testosterone is not an efficient delivery method.

When taken by mouth, testosterone must pass through the liver before entering the bloodstream. This first-pass metabolism significantly reduces the amount of active hormone available to the body.

Because of this, absorption is inconsistent, effective dosing is difficult and I do not commonly recommend this in clinical practice.

Injections

Testosterone injections have been used for years, particularly in men, and can be effective.

However, they often create fluctuations in hormone levels.

Because injections are typically given once or twice weekly:

• levels peak shortly after injection

• then gradually decline before the next dose

This can lead to a “roller coaster” effect, where patients feel better shortly after dosing, then experience a drop in energy, mood, or symptoms before the next injection.

In addition, injections can be uncomfortable and require ongoing administration.

Topical Creams and Gels

Topical testosterone is another commonly used option, but absorption can be highly variable.

Factors that influence absorption include:

• skin thickness

• application site

• individual differences in skin permeability

• consistency of use

Because of this, some patients absorb very little, others absorb unpredictably and hormone levels as well as symptom control can be inconsistent. This variability can make it more difficult to achieve stable, reliable results in some patients.

Testosterone Therapy in Women

An important point is that there are currently no FDA-approved testosterone products specifically designed for women. As a result, treatment often involves adjusted dosing of formulations originally developed for men or the use of compounded therapies.

This makes proper dosing, monitoring, and clinical experience even more important.

Pellet Therapy: Consistency and Stability

Testosterone pellets are designed to provide a steady release of hormone over time.

They are placed under the skin and gradually release testosterone into the bloodstream.

Because of this:

• hormone levels remain more stable

• there are fewer peaks and troughs

• symptom control is more consistent

This avoids the fluctuations seen with injections and the variability seen with topical therapies. When properly dosed and carefully monitored, patients often experience more predictable results, symptom improvement is more sustained and adherence is easier, as there is no daily or weekly administration.

Why Consistency and Absorption Matter

Testosterone therapy is not just about getting the hormone into the body. It is about how consistently and effectively it is delivered. Unstable or unpredictable levels can limit results, even if the dose itself is appropriate.

Choosing the right delivery method is a critical part of achieving optimal outcomes and is one of the most important decisions in the treatment process.

Safety and Common Misconceptions

Testosterone therapy, particularly in women, is often surrounded by misconceptions.

Concerns about voice changes, hair loss, aggression, liver damage, and negative effects on cholesterol are common. These concerns are understandable, but they are often based on inappropriate dosing, outdated data, or misunderstanding how testosterone is used clinically.

When testosterone is prescribed appropriately and monitored carefully, it is generally safe and well tolerated.

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If you want a breakdown of common myths and misconceptions, check out The Truth About Testosterone Therapy for Women.

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Concerns About Masculinizing Effects

Many women worry about side effects such as:

• deepening of the voice

• increased facial or body hair

• acne

These effects are typically associated with excessive dosing or supraphysiologic levels over time. When testosterone is dosed appropriately for women, levels are kept within a physiologic range, and side effects are uncommon and should be addressed early.

Proper monitoring and dose adjustments are key to preventing these issues.

Hair Loss

Hair thinning or shedding is a huge concern, especially for women entering perimenopause.

It is important to understand that many women are already experiencing hair changes during this time, often before starting any hormone therapy.

This can be related to:

• thyroid dysfunction

• low iron levels

• chronic stress and elevated cortisol

• unhealthy gut biome

• aging-related miniaturization of hair follicles

These factors are frequently the primary drivers of hair loss, not testosterone therapy.

Testosterone itself is not inherently harmful to hair. In fact, it is often a supportive hormone for hair growth, particularly in the midline and crown, where adequate hormone signaling and blood flow are important.

The concern with hair loss is not testosterone directly, but how it is metabolized. In some patients, testosterone is converted into dihydrotestosterone (DHT), a more potent androgen that can contribute to androgenic alopecia in genetically predisposed individuals.

If patients convert a large proportion of testosterone to DHT, they may notice:

• hair follicles become more sensitive to DHT

• follicles gradually miniaturize

• hair may become thinner over time

This is a genetic predisposition, not something that occurs in all patients. For the majority of patients, testosterone therapy does not cause hair loss, and improvements in overall hormone balance may actually support healthier hair growth.

For the smaller group of patients who are more sensitive to DHT, this risk can be identified and monitored, and treatment strategies can be adjusted as needed.

This is why it is important to evaluate the full picture. Addressing underlying contributors such as thyroid function, iron levels, stress, and overall metabolic health is often more impactful for preventing or reversing hair loss than focusing on testosterone alone.

Voice Changes

Permanent voice changes are one of the most feared side effects, but they are rare when therapy is appropriately managed.

They are typically associated with prolonged exposure to higher-than-necessary levels.

Early symptoms, such as subtle voice fatigue or change, can be addressed by adjusting therapy before permanent changes occur.

Liver Health

Concerns about liver damage are primarily associated with oral testosterone, which is not commonly used in modern hormone therapy.

Non-oral delivery methods, such as injections, topicals, and pellets, bypass the liver and do not carry the same level of risk.

Mood and Aggression

Testosterone does not inherently cause aggression when used appropriately.

In fact, many patients report:

• improved mood

• increased motivation

• better stress resilience

These effects are related to testosterone’s role in supporting dopamine signaling, energy levels, and overall brain function. There is a common misconception that testosterone therapy leads to irritability or “rage,” but this is largely based on the effects of anabolic steroid use, not physiologic hormone replacement.

Anabolic steroids are typically used at supraphysiologic doses, often far exceeding what the body would naturally produce. At those levels, hormone balance is disrupted, mood regulation can be affected and irritability and aggression may increase.

This is very different from testosterone therapy, where the goal is to restore levels within a physiologic range that the body can regulate and respond to appropriately.

This is why consistency and proper monitoring are essential to achieving the benefits of therapy without unwanted side effects.

Cholesterol and Cardiovascular Risk

There is a lot of confusion around testosterone and cardiovascular risk.

Much of this concern comes from older studies or data involving supraphysiologic dosing, rather than appropriately managed hormone therapy.

Testosterone plays an important role in cardiovascular and metabolic health.

It supports:

• maintenance of muscle mass

• insulin sensitivity

• reduction in visceral fat

• overall metabolic efficiency

These factors are directly tied to cardiovascular risk. Low testosterone levels have been associated with exactly the opposite:   increased visceral fat, insulin resistance and metabolic syndrome, and higher rates of cardiovascular disease.⁸

When testosterone therapy is appropriately dosed, carefully monitored and combined with lifestyle optimization, current evidence suggests it can be used safely and may provide metabolic and cardiovascular benefits in appropriately selected patients.⁹

Testosterone Is Not a Standalone Solution

Testosterone is a powerful hormone, but it does not work in isolation.

Optimizing testosterone without addressing the other systems that support metabolism, muscle, and recovery will limit results.

To get the full benefit of testosterone therapy, the body has to be in a state where it can respond to it.

Muscle and Resistance Training

Testosterone supports muscle growth, but it does not build muscle on its own.

Muscle is stimulated through resistance training. Without that stimulus:

• muscle gains are limited

• metabolic benefits are reduced

• body composition changes are less significant

This is why strength training is a critical part of any testosterone optimization plan.

Protein Intake and Nutrition

Muscle growth and repair require adequate protein.

If protein intake is insufficient, your body cannot effectively build or maintain muscle, your recovery is impaired and the metabolic benefits are blunted. Nutrition also affects insulin sensitivity, inflammation, and overall hormone signaling.

Weight and Metabolic Health

Excess body fat, particularly central or visceral fat, can negatively impact hormone balance.

This is the unhealthy fat that causes:

• increased inflammation and cancer risk

• worsening of insulin resistance

• altered hormone conversion and signaling

Weight management is not just about appearance. It directly affects how testosterone functions in the body.

Thyroid Function

Thyroid health plays a key role in energy production and metabolic rate.  It’s called the “master gland” because thyroid affects every organ in our body.

If thyroid function is suboptimal:

• energy levels remain low

• metabolism slows (feeling sluggish, constipation, feeling cold all the time)

• weight increases, especially around the middle

• response to testosterone may be limited

Optimizing thyroid function is often necessary to fully improve symptoms.

Sleep and Recovery

Sleep is one of the most important regulators of hormone function. Poor sleep can lower testosterone levels, impair recovery, and increase fatigue and brain fog. Even with testosterone therapy, inadequate sleep will limit how well the body responds.

Cortisol and Stress

Chronic stress and elevated cortisol have a direct impact on hormone balance.

High cortisol can suppress testosterone production, impair muscle growth, increase fat storage and worsen insulin resistance.

Managing stress is not optional. It is a key part of restoring overall hormonal balance.

Putting It All Together

Testosterone creates the potential for improvement, but the rest of your physiology determines how much of that potential is realized.

When these systems are addressed together:

• muscle mass improves more effectively

• metabolic health improves

• energy and recovery are more consistent

• long-term results are more sustainable

This is why a comprehensive approach is always more effective than focusing on a single hormone alone.

What a Comprehensive Evaluation Looks Like

When I evaluate a patient, I am not just looking at one lab value. I am looking at how multiple systems are functioning together. This includes hormone levels, your symptoms and trends, your metabolic health and body composition, as well as lifestyle factors.

This allows for a more individualized and effective treatment plan.

Frequently Asked Questions About Testosterone Therapy

What are the symptoms of low testosterone in women? Common symptoms include low libido, fatigue, decreased motivation, loss of muscle tone, increased body fat, and brain fog. These symptoms often develop gradually and are frequently mistaken for stress, aging, or menopause.

What are the symptoms of low testosterone in men? Men may experience low energy, reduced strength, increased body fat, decreased libido, changes in erectile function, and reduced motivation. These changes often occur slowly over time.

What is a normal testosterone level for women? Standard lab ranges are based on population averages and may not reflect optimal levels. Many women experience symptoms even when levels fall within the “normal” range. Treatment is typically based on symptoms, not just a number.

What is a normal testosterone level for men? Reference ranges vary, but being within a broad “normal” range does not always mean optimal function. Many men experience symptoms of low testosterone despite levels that are technically within range.

Is testosterone therapy safe for women? When properly dosed and monitored, testosterone therapy is generally safe for women. Side effects are uncommon when levels are kept within an appropriate physiologic range.

Will testosterone therapy cause side effects in women? Possible side effects include acne, mild hair growth, or hair thinning, but these are typically dose-related and manageable. More serious effects, such as voice changes, are rare when therapy is appropriately managed.

What is the best way to take testosterone? The best method depends on the individual. Options include injections, topical creams, and pellets. Each differs in absorption and consistency, and the goal is to maintain stable hormone levels.

Are testosterone pellets better than injections or creams? Pellets provide a steady release of testosterone over time, avoiding the fluctuations seen with injections and the variability of topical absorption. This can lead to more consistent symptom improvement for many patients.

How long does it take for testosterone therapy to work? Many patients notice improvements in energy, mood, and motivation within a few weeks. Changes in muscle mass and body composition typically take longer and depend on lifestyle factors.

Do women need testosterone after menopause? Many women experience a decline in testosterone with age, which can affect energy, libido, and muscle mass. In some cases, therapy can help restore these functions when appropriately prescribed.

Can testosterone help with weight loss? Testosterone can support weight management by improving muscle mass, insulin sensitivity, and metabolic function. However, it is most effective when combined with proper nutrition and resistance training.

Can testosterone improve libido and sexual function? Yes. Testosterone supports both sexual desire and the physiologic processes involved in arousal, including blood flow and nerve signaling.

Next Steps

If you are experiencing changes in energy, motivation, strength, or sexual function, these are not random changes. They are often signs that hormone levels and overall physiology have shifted. The goal is not to guess or manage symptoms individually. It is to understand what is driving those changes.

A comprehensive evaluation allows us to assess hormone balance, metabolic health, and contributing factors so we can build a plan that improves both how you feel now and how your body functions over time.

Contact Us

Selected Research

¹ North American Menopause Society. Hormone Therapy Position Statement

² Endocrine Society. Clinical Practice Guidelines on Testosterone Therapy

³ Davis SR et al. Global Consensus Position Statement on Testosterone Therapy for Women

⁴ Kingsberg SA et al. Vulvovaginal Atrophy and Sexual Health. Journal of Sexual Medicine

⁵ Traish AM et al. Testosterone and Metabolic Syndrome. Current Opinion in Endocrinology, Diabetes and Obesity

⁶ Resnick SM et al. Testosterone and Cognitive Function. Neurology

⁷ Trüeb RM. Androgenetic Alopecia: Pathogenesis and Treatment. Dermatology Clinics

⁸ Traish AM et al. Testosterone Deficiency and Metabolic Syndrome. Current Opinion in Endocrinology, Diabetes and Obesity

⁹ Morgentaler A et al. Testosterone Therapy and Cardiovascular Risk: Advances and Controversies. Mayo Clinic Proceedings