Testosterone in Perimenopause: The Hormone Nobody Put on Your List

Testosterone is the most abundant biologically active hormone in the female body throughout your entire life, and it acts on your muscles, bones, brain, and cardiovascular system. It declines gradually from your forties, long before your estrogen does. And the reason you have never been properly told this has nothing to do with your biology.

Journaling: Daily stories from perimenopausal women

Two women were standing at a break during an event, and they noticed they were wearing the same wool sweater, same colour, same cut, and they laughed about it.

One said: you have excellent taste. And then, because perimenopause does not respect professional contexts, she added: full disclosure, I have a thin summer top underneath this, hot and cold at the same time, a cup of hot tea and I am sweating. It is a whole thing. I think you know what I mean, "peri" is now part of my everyday.

The other woman, around fifty, understood immediately and laughed because she knew exactly what was meant.

And then she asked something almost nobody asks: how has your journey been?

It was such a small question, and it opened everything.

The answer began with energy, not libido, not hot flashes, but energy. The gym, specifically. Going three or four times a week and feeling like a very old woman, simple movements, a pilates class that forces you to take a nap after class, weights that used to be satisfying, suddenly feeling like defeat, and no change in the body to show for it. Not one.

Then she looked to the other woman, and while simulating she was applying cream, she said: Nothing like my new beauty routine, testosterone on my inner thigh daily. They both laughed.

Then she continued: after three months on a testosterone cream, one pump applied to the inner thigh daily, something shifted. She started to see the difference; the weights became manageable again, recovery was faster, the body started looking like itself again, and a blood test showed a testosterone level that had gone from 14 to 64. So she said: I am not one hundred percent as before, but it has improved so much.

The woman in the matching sweater leaned in. She had assumed testosterone was for one thing only, for libido, and she had assumed it was not for her. But while she was listening, she was nodding, because she also liked the gym, and she was feeling exactly the same thing, no energy at all.

She had assumed wrong. And so had her doctors. So let's understand a little bit more about this.

Testosterone is not a male hormone that women have a small amount of

This is the fact that reframes everything else in this article, so it deserves to be stated clearly and without softening.

Young women's ovaries produce approximately three to four times more testosterone than estrogen every single day. Throughout the female lifespan, testosterone concentrations run 10 to 20 times higher than estradiol by measure. Women do not have a small amount of it. It is the dominant biologically active hormone in the female body, documented as such in the research since at least [Dimitrakakis et al., 2002]

So why does almost nobody know this? Because testosterone research was conducted primarily in men for over a century. The research funding, the drug approvals, and the clinical guidelines all followed that history. And because as of 2026, zero testosterone products have been approved by the US Food and Drug Administration (FDA) for women, while more than thirty exist for men. Australia approved the first women-specific testosterone product in 2020, the UK followed in 2025, and in July 2025 an expert panel before the FDA specifically called for fast-tracking female-specific formulations

This is not a biological gap. It is a prioritisation gap, and it has consequences for every woman in perimenopause who has never been told testosterone is on her list.

Now that the reframe is in place, it is worth understanding why testosterone matters across the entire body and not just in the places most people assume.

Testosterone acts across your entire body, not only your libido

Testosterone receptors are distributed throughout the female body, in muscle tissue, bone, the brain, the cardiovascular system, and the skin. This is not a minor detail. It is the reason the effects of testosterone decline are not limited to sexual function.

When testosterone falls, the impacts are felt across all the systems those receptors serve. Muscle responds less readily to exercise, bone density shifts, cognitive sharpness can soften, and energy production at the cellular level becomes less efficient. The body that used to recover from a workout in a day or two now takes three days, then four, and then feels like it never quite recovers at all. That is why the woman in the wool sweater felt such a shift after three months on the cream. The hormone was working across all of those systems at once, not just one.

The libido conversation became the dominant one partly because of how clinical guidelines are written, and we will come to that. But understanding why testosterone matters first requires understanding where it works. And it works everywhere.

With that picture in mind, the next question is when this decline starts. The answer is earlier than most women are told.

Testosterone starts declining in your forties, long before menopause arrives

This is one of the most important and least communicated facts about perimenopause.

The [Australian Women's Midlife Years Study], published in Lancet eBioMedicine in October 2025, tracked 1,435 women in a nationally representative sample and found that testosterone declines gradually from around age 40. Critically, it does not drop sharply at menopause the way estrogen does. There is no sudden menopausal cliff for testosterone. It has been declining slowly and consistently since your early forties.

A perimenopausal woman in her mid-forties may already have meaningfully lower testosterone than she did at 25, entirely independently of where she is in the hormonal transition. This matters because symptoms connected to testosterone decline can begin well before a woman meets any conventional definition of perimenopause. She may still be mostly regular, she may have no hot flashes, and she may still be running on significantly less testosterone than her body is used to.

Which raises the obvious question: what does that actually feel like?

What low testosterone actually feels like in a female body

This is the list the woman in the matching sweater had never been given.

A fatigue that is different from ordinary tiredness. Not resolved by a good night's sleep. A heaviness in the body that sits there regardless of how much rest you get, like the battery is permanently at thirty percent and charging it makes no difference.

Reduced physical capacity. You go to the gym and find that what used to be manageable now defeats you. Recovery takes longer. Progress stalls or reverses. The weights that used to be satisfying become a source of quiet grief.

Loss of muscle mass and changes in body composition. The body looks different even when nothing in your diet or exercise routine has changed. Fat redistributes, muscle definition fades, and you look at yourself in the mirror and think: where did I go? It is worth noting here that testosterone is not the only reason this happens, because estrogen and progesterone are also part of this picture. But if you go to the gym regularly, take your protein, maybe work with a personal trainer, you will recognise this specific feeling of being stuck while tired, with no energy to push through it and nothing to show for the effort.

Brain fog and reduced mental sharpness also come into the picture. Not necessarily dramatic, but a softening of focus, thinking that feels slower, words that do not come as quickly.

And then there are the mood changes: a flatness, reduced motivation, a sense of not quite feeling like yourself. Not depression necessarily, but a dimming of something.

Low or absent libido is named here, but deliberately not first, because the conversation starts with libido far too often and the other symptoms go unrecognised for years. It is also worth saying plainly: if you do not have a partner and are not dating, this one can be genuinely hard to detect.

These are the symptoms that send women to their doctors, where they are frequently told their results look normal and sent home with advice to prioritise their sleep.

Before we look at what the evidence says about testosterone treatment, we want to address the thing that stops most women from even getting to that conversation.

Testosterone at physiological doses does not masculinise

The most common reason women dismiss testosterone before hearing the evidence is fear. That fear deserves a direct, honest response.

To understand why the fear is misplaced at the doses we are talking about, it helps to know that testosterone use exists on a spectrum with two very different categories. The first is physiological replacement, meaning doses calibrated to restore a woman's testosterone to the normal range for her biology, typically one-tenth of male doses or less. The second is supraphysiological use, meaning doses that push levels far beyond anything the female body would naturally produce, the territory of anabolic steroids and some poorly controlled implant treatments.

The [2013 paper in Maturitas] "Testosterone therapy in women: Myths and misconceptions," directly addressed ten of the most persistent clinical misconceptions about testosterone in women. At physiological female doses, testosterone does not cause masculinisation, voice changes, or significant body hair growth. The most commonly reported adverse event at female doses is mild and reversible acne at the site of application, and even that is rare.

The bodybuilder appearance, the voice that drops, the pronounced facial and body hair: those come from supraphysiological doses, from anabolic steroids or from testosterone pellets. A [2025 review from the Federal University of São Paulo] found that pellets consistently produce levels far above the normal premenopausal female range, to the point where safety cannot be confirmed. Pellets are not the delivery method major clinical guidelines recommend for women, and they are also the origin of most of the images women hold in their minds when they hear "testosterone therapy."

Physiological cream or gel at a dose calibrated for female biology is a categorically different conversation. The fear is real, and it is based on a completely different type of use.

Now let's get close to the reality of how to get a testosterone prescription. Hold your hands.

How testosterone is prescribed for women, and why your options are limited

The options are limited because the regulatory investment simply has not been made.

In countries without a licensed women-specific testosterone product, which includes the United States and most of Europe, the available route is compounded cream or gel. A doctor writes a prescription specifying the exact concentration and dose calibrated for female physiology, and a compounding pharmacy produces it. This is actually a more precise approach than adapting a male product downward, because the dose is defined specifically to the patient's needs.

In the US, the cost of compounded testosterone can be higher, and some women have found the alternative of using a male testosterone product adapted and calibrated downward for women's hormone replacement therapy (HRT) use. If that is your only route, it is strongly worth asking your doctor for detailed guidance on the right dosage, because the margin requires care.

In Australia, AndroFeme 1% cream has been licensed since November 2020. The UK's Medicines and Healthcare products Regulatory Agency (MHRA) approved it in 2025, though it is not yet available on the National Health Service (NHS). In the US, there is still nothing licensed for women as of 2026. In July 2025 an expert panel before the FDA heard calls from specialists including Dr. Kelly Casperson to fast-track female-specific formulations. The hearing took place. The approval has not followed.

More than thirty approved testosterone products exist for men in the US, and zero for women. Australia was first, the UK followed five years later, and the rest of the world is still waiting.

Given those options, let's look at what is actually available and how it differs.

Cream, gel, and pellet: three meaningfully different things

Transdermal cream or gel is the most widely recommended route for women. Applied to the inner thigh or outer labia, it produces steady absorption at a controlled and adjustable dose, and this is the delivery method that clinical guidelines consistently favour.

Compounded cream is the same approach, but custom-formulated at the exact concentration a doctor specifies for a specific patient. In the absence of a licensed women's product in most countries, it is both the most precise and the most appropriate option.

Pellets are subcutaneous implants that dissolve over approximately six months. The problem is that they consistently produce supraphysiological testosterone levels in women, far above the normal premenopausal female range, and adjusting downward is not possible once the pellet is implanted. The 2025 Federal University of São Paulo review found that safety at these levels cannot be confirmed, and major clinical guidelines do not recommend pellets for women. This is also the delivery method most associated with the masculinisation effects that drive so much fear around testosterone therapy. The connection is not coincidental.

With the options laid out, let's look at what women who cannot or choose not to take pharmaceutical testosterone can do in the meantime.

Natural approaches to testosterone support: what we know so far

For women who cannot access testosterone therapy, or who are exploring options before committing to a prescription, this is what the evidence currently shows. One honest note before going through each: none of these approaches directly raises testosterone the way physiological replacement does, but several may genuinely help with the symptoms connected to declining testosterone, including energy, fatigue, mood, and muscle support. That matters, and it is worth knowing.

DHEA (Dehydroepiandrosterone) is a supplement that acts as a building block your body can use to produce both testosterone and estrogen. It is widely used for energy, mood, and general hormonal support, and has been studied for various potential benefits including physical performance and wellbeing. Some research, including work published by [Harvard Health], shows promising results, though findings across studies are inconsistent and more research is needed. The honest limitation is that you cannot control whether your body converts it toward testosterone or estrogen, or how much of either. That said, women who have tried DHEA tend to report more positive than negative experiences, and for some it does seem to move the needle on energy and mood even when the science has not yet fully caught up with why.

Zinc is a mineral most women know from immune support and skin health, and it is also a common go-to for hair growth, nail strength, and wound healing. What is less widely known is that zinc plays a supporting role in the processes involved in producing sex hormones, including testosterone. Research in perimenopausal women specifically is limited, so it cannot be relied upon as a dedicated testosterone intervention, but it is a low-risk supplement that many women are already taking for other good reasons, and supporting hormonal production is quietly one of them.

Ashwagandha, specifically the KSM-66 extract, is an adaptogenic herb with a long history in Ayurvedic medicine, traditionally used to reduce stress, support energy, and restore vitality, and it has become one of the most popular supplements in the women's health space for exactly those reasons. A 2019 trial found increased hormone levels in participants, though the same trial found no difference from placebo for fatigue or sexual function specifically. What it does have a strong and consistent reputation for, backed by both research and women's lived experience, is supporting stress resilience and sleep quality. Since both of those directly affect how the whole hormonal system functions, that is a meaningful contribution, even if it is not a direct testosterone fix.

Maca root is a Peruvian plant that has been used for centuries to support energy, stamina, and fertility, and it has gained real popularity in the perimenopause space for mood and libido support. Small trials suggest improvement in sexual function scores, and while it does not appear to raise testosterone directly, women's experience with it tends to be genuinely positive for mood and energy. The science is still working out the mechanism, but the tradition and the testimonials are not nothing, and for many women it is a gentle and well-tolerated place to start.

Resistance training is the most consistently evidence-supported non-pharmaceutical approach of all. Unlike the supplements above, it works directly on the system rather than supporting it from the edges. It supports healthy testosterone levels, builds and preserves muscle, improves bone density, and directly addresses the physical symptoms that come with testosterone decline. If you are looking for one concrete place to put your effort while figuring out the rest, this is it, and the research will not argue with you.

The realistic picture: natural approaches are a genuine part of the picture for many women and worth exploring honestly. What they are unlikely to do is fully replace physiological testosterone when levels are genuinely depleted and symptoms are significant. Both things can be true at the same time, and knowing that helps you make the right choices for your situation.

What the evidence actually says about testosterone for women, and where it stops

The libido connection to low testosterone is already well established, but the energy and muscle story is just as real, documented in observational data and biologically well-supported. The clinical evidence on testosterone in women is genuinely growing and promising, even if it is not quite as settled as the current social media conversation sometimes implies. Being honest about that distinction is part of what makes this information actually useful. This part goes into a little more detail, and if that is not your cup of tea, you are welcome to skip ahead. But for the women who want the nitty gritty, here it is.

There is emerging evidence on energy, physical performance, and muscle preservation that deserves to be taken seriously. Women consistently report improvement in these areas, and a 2025 retrospective series of 100 patients over ten years, published in a peer-reviewed journal, found improvements in energy, muscle weakness, sleep, and mood alongside libido. A pilot study published in Archives of Women's Mental Health in 2024 to 2025 found that transdermal testosterone improved mood and cognitive symptoms in peri- and postmenopausal women [Glynne, Kamal et al.]. These are not large randomised controlled trials (RCTs), so they cannot establish causation definitively. But the consistency of what women report across studies and clinical settings is meaningful and should not be dismissed.

A positive association between testosterone and bone mineral density was also found in postmenopausal women in a 2022 analysis of [National Health and Nutrition Examination Survey (NHANES) data] involving 1,058 participants. Association, not causation, but worth noting.

On safety: approximately 80 years of observational data show no significant adverse effects on cardiovascular markers or breast cancer risk at premenopausal physiological ranges, though there is no long-term RCT to confirm this definitively. The observational record is reassuring without being the final word. The energy and muscle story is the one the research is working hardest to confirm right now, and the trials running at Monash are the ones to watch.

The most recent data about women and testosterone, and what we are still waiting for

2025: testosterone declines gradually from around age 40, with no specific menopausal drop.

The most significant recent study is the [Australian Women's Midlife Years Study], published in Lancet eBioMedicine in October 2025, tracking 1,435 women in a nationally representative sample. It found that testosterone declines gradually from around age 40 with no specific menopausal drop. This matters because it means perimenopausal women may already have meaningfully lower testosterone than they did in their twenties, regardless of where their cycle currently is.

Currently in progress: testing whether testosterone cream prevents muscle and bone loss after menopause.

The PAMELA trial at Monash University is the first adequately powered RCT specifically testing whether testosterone cream prevents muscle and bone loss after menopause. The ETHEL study, also at Monash, is investigating whether testosterone prevents early cardiovascular changes in postmenopausal women at risk of heart failure. Neither has reported results yet. These are the trials that will either confirm or significantly expand what the observational record currently suggests.

Where we need more clarity, to help all women: the demographic gap in the existing research.

Almost all existing research on testosterone in women has been conducted on white, Western, postmenopausal women, with minimal data from Latin America, Asia, Africa, or the Middle East, and almost no data specific to the perimenopausal transition as distinct from established postmenopause. This is a research prioritisation failure, not a biological difference. Women from these communities deserve research that reflects their reality.

Here is what we want you to take from all of this.

You walked into this article probably wondering why your body stopped responding the way it used to. The gym sessions that go nowhere. The recovery that takes too long. The fatigue that sleep does not fix. The sense of yourself that has quietly dimmed. And perhaps nobody had put testosterone on your list.

The two women in matching wool sweaters had that conversation at an event one afternoon. One of them walked away with a framework she had never been given. You have it now too. And the next time you sit in a doctor's office describing these things, you have the language to ask a better question. You know where to start. That is worth something.

Questions Women Ask about Testosterone

The questions below come from the conversations women are having after reading this article. Some are practical. Some are about uncertainty. All of them deserve a direct answer.

Everything you just read was written to inform, not to prescribe. We are women in perimenopause researching a lot, not medical professionals, and the role of unfogged.co is to find what the evidence actually says, be honest about where it stops, and give you the clearest possible picture of a landscape that is genuinely complicated.

We encourage you to take this to your doctor, or to find one who will have this conversation with you seriously. We also encourage you to keep reading beyond this article, because no single source, including this one, should be your final stop.