Are Testosterone and Testosterone Pellets Safe to Use in Perimenopause and Menopause?

What Is Testosterone and When is it Used ?

Testosterone, an androgen found in much higher levels in biological men, is also a natural circulating hormone in biological women and is derived from the adrenal glands and ovaries. With menopause transition, testosterone levels start to naturally decline due ovarian and adrenal aging. With surgical removal of the ovaries, there is a more dramatic drop in testosterone. 

So, I want to let you know a few things about testosterone therapy as a menopause expert and prescriber of testosterone for the last 30 years. First, and this will be no surprise to anyone, we are very behind in research and data on women's health, particularly in hormones for menopause transition and especially for the use of testosterone. Second, testosterone was brought to the FDA for approval back in 2004-2005 and denied due to concerns about lack of clear long term data on breast cancer risks and concerns about adverse lipid levels and increased risk for cardiovascular disease in users. Many of us prescribers did not agree with that decision back then and felt it was too conservative, but likely due to the determination coming on the heels of the release of the Women’s Health Initiative data, which alarmed many on use of menopausal hormone therapy. Last, testosterone replacement has been looked at for treatment of many different conditions, but the only validated, evidence based indication or reason to consider use is for the treatment of hypoactive sexual desire disorder (HSDD) in postmenopause and late perimenopause.  For more on this condition, HSDD, which is low libido not due to medical conditions, medications, painful sex or relationship issues, read: https://www.myalloy.com/blog/why-is-my-libido-low-understanding-sexual-desire-and-the-connections-to. Even though testosterone use is not FDA approved for any indication in biological women, the decision to use it for treatment of HSDD can result from shared decision making between a trained healthcare professional and patient. 

Clinical guidelines for the use of testosterone to treat HSDD are outlined in the Menopause Society Practice Pearl which also states that “although serum testosterone levels do not correlate with the presence or absence of HSDD or its severity, there is a correlation between testosterone concentration during therapy and improvement in sexual desire.” (1) So one does not have to have a testosterone level which is below the normal female range to consider testosterone treatment. However, testosterone should be prescribed very judiciously because there are some potential drawbacks to use.

To summarize, the use of testosterone:  

• can be considered in postmenopause and later perimenopause for individuals with hypoactive sexual desire disorder (HSDD) after other causes are excluded. (2)

• is not recommended for general menopausal symptoms like hot flashes or sleep disturbances.

• should not be used with a history of hormone-sensitive cancers, liver disease, or cardiovascular risk.

• preferably is with low doses of transdermal formulas with close monitoring of testosterone levels. 

• may not result in improved sexual desire and if one is not responding to adequate treatment by 4-8 weeks, there should be a re-evaluation for other causes of low libido.

• might result in some individuals reporting improvements in energy and mood, weight loss or body composition, but these outcomes have not been consistently validated.

• causes no serious adverse events with physiologic use, but can cause adverse side effects (acne, facial hair growth, scalp hair loss, and voice changes and other risks (abnormal lipids, liver and cardiovascular complications), particularly with use of oral testosterone and/or with high doses leading to supraphysiologic levels

• necessitates that the benefits of use be weighed against the potential risks and lack of long-term safety data.

• requires an individualized risk assessment for the user before starting any hormone therapy and shared decision-making with a menopause-trained health professional.

• needs ongoing research to clarify potential dose related short-term and long-term risks, removal from the list of controlled substances and an FDA approved product for women.

What Are Testosterone Pellets and Are They Safe?

Testosterone pellets are small, solid cylinders implanted under the skin to release testosterone over several months. They are often marketed for symptoms like low libido, but also are often touted to reduce fatigue, increase energy or stamina, improve muscle mass and decrease moodiness during midlife. Testosterone pellets are also not FDA-approved for use in biological women and once placed not uncommonly result in supraphysiological (higher than normal female range) testosterone levels due to unpredictable serum absorption from the subcutaneous placement. If side effects result, the challenge is that they are impossible to reduce or remove. 

So even though there are no validated studies demonstrating clear benefits at standard physiologic levels for women, some users do report improvements in energy and mood with testosterone therapy. A recent testosterone pellet study published that touted pellets demonstrated benefits for treatment of overall menopausal symptoms including sexual dysfunction, had a total of 100 participants and no control group to rule out a placebo effect. Participants were screened using the Menopause Rating Scale (MRS) at baseline and then 6 months from treatment onset with 78 completing the surveys. In this study, around ½  of participants reported increases in facial hair and over ¼ reported acne. So doses leading to androgenic side effects for a majority of participants, were needed for these other benefits in the menopause rating scale scores to be achieved at all testosterone levels. (3) 

In summary, concerns about use of testosterone pellets are that they: 

• are not infrequently associated with androgenic side effects such as acne, facial hair growth, scalp hair loss, and voice changes.

• are not standardized, which can lead to unpredictable hormone levels.

• are difficult to remove if side effects occur.

• lack long-term safety data.

• may be associated with more serious risks including possible adverse effects on cholesterol, liver, and cardiovascular health.

How to Talk to Your Healthcare Professional About Testosterone

If you are considering testosterone therapy be prepared to discuss your symptoms, medical history, and treatment goals. Try to connect with a specialist in menopause and/or sexual health by locating one at www.menopause.org or ISSWSH.org. Some helpful guidance for your appointment is to : 

• Ask about the risks, benefits, and FDA approval status of any hormone therapy proposed.

• Request information on evidence-based, FDA-approved options for both menopause symptom relief and treatment of HSDD. 

• Advocate for yourself and recognize that shared decision-making ensures your values and preferences are respected but may be limited by safe prescribing guidelines for your licensed and regulated health care professional.

• Ensure ongoing follow-up is arranged which is important for monitoring side effects and adjusting treatment.

• Take into consideration the financial motivations that might be present for only offering pellets or injections that add an additional visit or procedure fee, rather than the safer, preferred prescription topical testosterone products. 

So, as a doctor who has been responsibly counseling and safely prescribing testosterone treatment for HSDD to my postmenopausal patients for decades, I wanted to share this information on use.  Unfortunately, many practitioners and patients have jumped on the bandwagon, yet are not always providing or being provided this balanced information about using testosterone therapy in menopause transition. At Alloy, our physicians currently do not prescribe testosterone since there is no FDA approved version for women and it is a Schedule III controlled substance, which adds challenges with telehealth prescribing, but we absolutely support our patients who want to use testosterone as part of their hormone plan. 

REFERENCES

1.Sharon J. Parish, Juliana M. Kling.Testosterone Use for Hypoactive Sexual Desire Disorder in Postmenopausal Women. NAMS Practice Pearl Released March 9, 2023 https://menopause.org/wp-content/uploads/professional/practice-pearl-testosterone_.pdf

2. Mary Ann Lumsden, Olaf M Dekkers, Stephanie S Faubion, Angelica Lindén Hirschberg, Channa N Jayasena, Irene Lambrinoudaki, et al. European society of endocrinology clinical practice guideline for evaluation and management of menopause and the perimenopause. Eur J Endocrinol 2025;193(4):G49-G81. PMID:41082911.

3. Jillian Chan, Julia Cunningham, Colin Cunningham, John Cunningham, Catherine Cunningham. The benefits of testosterone therapy for menopausal symptoms. Eur J Obstet Gynecol Reprod Biol X 2026;29:100440. PMID:41551050.