Do I need testosterone?

For a lot of women reading this, the answer is no, or at least not yet, and I'd rather say that on the first page than bury it.

I'm on testosterone. I think the subject is badly covered and that women get dismissed when they ask about it. Both of those can be true while the honest evidence summary is still narrower than you'd hope. So here's what the research actually supports, what it doesn't, and where I think the interesting question sits.

What the evidence supports

In 2019, eleven professional bodies published a joint position statement on testosterone therapy for women. The Endocrine Society, ACOG, the North American Menopause Society, the Royal College of Obstetricians and Gynaecologists, and seven others.

Their conclusion was narrow. The only evidence-based indication for testosterone in women is hypoactive sexual desire disorder, meaning distressing low sexual desire. Not low desire on its own. Low desire that bothers you.

For everything else, they found the data insufficient to recommend it.

(Davis et al., Journal of Clinical Endocrinology and Metabolism, 2019.)

What "insufficient data" does and doesn't mean

This is where a lot of writing on this subject goes wrong in both directions.

"Insufficient data" does not mean testosterone was tested for fatigue, mood, cognition and bone and found useless. It mostly means the trials that would answer those questions haven't been run properly in women, at the right doses, measuring the right things.

It also doesn't mean the effect is there and being suppressed. Sometimes when the trial finally gets run, the answer is no.

Here's a recent example of exactly that.

A trial that found nothing

STEP-HI, published in JAMA Network Open in 2025, enrolled 129 women aged 65 and over who had recently had surgical repair of a hip fracture and still had measurable mobility problems. Eight US sites, phase 3, double-blind, placebo-controlled. For 24 weeks, participants did a supervised high-intensity exercise program including progressive resistance training, and were randomized to topical testosterone gel or placebo gel on top of it.

The result: adding testosterone did not significantly improve six-minute walking distance compared with exercise plus placebo.

That's a well-designed trial in exactly the population where you'd expect a benefit, and it came back negative for that outcome. I'm including it because a site that only reports the encouraging studies isn't worth reading.

(Binder et al., STEP-HI Randomized Clinical Trial, JAMA Network Open, 2025, n=129. DOI 10.1001/jamanetworkopen.2025.10512.)

The muscle question, with the caveat that matters

The strongest causal evidence that testosterone builds muscle in women comes from a dose-response trial published in Menopause in 2014. Hysterectomized women, standardized on estradiol, were randomized to weekly intramuscular testosterone at four escalating doses (3, 6.25, 12.5 and 25 mg) or placebo, for 24 weeks, with DXA body composition and muscle power measured.

Testosterone increased lean body mass and muscle power in a dose-dependent way. Multiple doses tested, with a gradient across them, which is more persuasive than a single-dose trial.

The caveat is the whole point though. The clear gains showed up at the higher doses, producing testosterone levels above the female physiological range. Guideline-concordant therapy deliberately targets concentrations within the normal premenopausal range. The trial also used intramuscular injection, not the transdermal route typical in current practice.

So it demonstrates that testosterone can build muscle in women. It does not demonstrate that the doses a guideline-following clinician would actually prescribe will do it. Those are different claims, and they get conflated constantly.

(Huang et al., Menopause, 2014.)

The flatness, which is what I actually care about

Testosterone gets filed under libido. That's the approved indication, that's what the trials measured, and that's what a clinician hears when you raise it. So if your complaint isn't desire, you don't get offered it, and the research that would settle whether you should hasn't been done.

The symptom I care about is the flatness. Not sadness, and not tiredness. The thing where you do what you used to love and notice, somewhere in the middle, that nothing is reaching back. Clinically it's anhedonia, a reduced capacity to feel pleasure and, more to the point, reduced pull toward things.

I had it for thirty years while being treated for depression the entire time. That's not a coincidence or a failure of my medication. SSRIs work on serotonin. Anhedonia of this kind runs on dopamine, and testosterone acts on those pathways. They're different systems, and treating one does nothing for the other. On testosterone, mine lifted about ninety percent. Not all of it. About ninety percent.

So when I say this is the most important unanswered question in the subject, I'm not being coy about where I stand.

The one trial people cite against this, and why it doesn't settle it

If you raise anhedonia with a well-read clinician, you may get pointed at Dichtel 2020 in the American Journal of Psychiatry. It's the study that looks like it closes the question. It doesn't, and the authors say so themselves.

101 women, eight weeks, double-blind, two sites, low-dose transdermal testosterone added on top of antidepressants. The result was flatly null: depression scores fell from 26.8 to 15.3 on testosterone and from 26.3 to 14.4 on placebo. A p-value of 0.91. No difference in fatigue, sexual function, or the brain imaging measure either.

I'll give it real credit first, because this is where most critiques cheat. The measurement was impeccable. Mass spectrometry at Mayo, free testosterone by equilibrium dialysis. The assay complaint I make everywhere else on this site does not apply here. This was a well-run trial.

Here's why it still doesn't answer the question:

The placebo response was 49%, and the authors flag it themselves. In their own words, the placebo response rate "was high (49%), which might have accounted in part for the lack of observed treatment effect." When the people who ran the trial tell you it may not have been able to detect an effect, believe them. A trial where half the placebo arm improves is a hard place to find a drug signal.
It measured the wrong thing. The outcome was MADRS, a general depression scale. There was no anhedonia instrument. If your claim is about motivational flatness specifically, measuring overall depression tests a different question.
It was the wrong women. Participants had active antidepressant-resistant major depression, with baseline scores around 26. That is not the same population as women whose depression is controlled and who are left with residual flatness. Not the same people, not the same question.
It was powered to detect a 5-point difference. Anything smaller was invisible by design.
Eight weeks. Androgen effects commonly take three to six months.

What that trial genuinely refutes is the broad claim that testosterone augments antidepressants for general treatment-resistant depression in women. That claim is dead, and it deserved to be. It does not touch the narrower question about anhedonia, which nobody has properly tested.

Where that leaves it, said plainly

I'm not going to tell you testosterone is a proven treatment for anhedonia in women, because the trial that would prove it has not been run and I won't pretend otherwise. That's the line I won't cross, and you should distrust anyone selling you across it.

What I will tell you is this. The mechanism is real, the one null trial was aimed at a different question and its own authors flagged why it couldn't see an effect, and in the meantime women describing exactly this symptom are being sorted into "depression," medicated on the serotonin system, and never asked about the dopamine one. I was one of them for thirty years.

That's worth raising with your doctor. Go in knowing it's an off-label conversation about an unsettled question, not a proven indication, and you'll have a better one.

So who might reasonably raise it

Not a diagnostic checklist. A rough sense of who has grounds to have the conversation:

Distressing low sexual desire, where other contributors have been looked at. This is the indication with actual evidence behind it.
Symptoms that persisted after estrogen and progesterone were optimized. If hormone therapy helped some things and left others untouched, that's a reasonable thing to bring up.
Surgical menopause, where the drop is abrupt rather than gradual.
The flatness described above, with the honest caveat that you'd be asking about something the evidence hasn't settled.

And who probably shouldn't yet:

Anyone who hasn't had thyroid, iron, B12 and sleep looked at. Those produce overlapping symptoms and are easier to fix.
Anyone hoping it will do what a resistance training program would do. See STEP-HI above, where testosterone was added on top of supervised high-intensity training and didn't improve the outcome measured.
Anyone whose estrogen and progesterone haven't been addressed. Testosterone used alongside them is the subject of this site, and the sequence matters.

What I'd want you to take away

The case for testosterone in women isn't that it's a proven fix for a long list of midlife symptoms. It isn't, yet, and the honest evidence base is narrower than the enthusiastic version.

The case is that the question was never properly asked for most of that list, that the one approved indication is real, and that women get turned away using a lab number the guidelines say shouldn't be used that way. That's a different and more defensible argument, and it's the one this site makes.

What I am and am not. I'm a medical technologist. I read primary research and I explain study design, including who was in the trial and what was actually measured. I'm not a physician, I'm not diagnosing you, and none of this is a treatment recommendation. Take it to a clinician who knows your history.

The six-part email series goes through the rest: what testosterone does, why the trials missed it, why your labs read "normal," the side effects nobody quantifies honestly, and how women are getting prescriptions.