🎧 Prefer to listen? About 24 minutes.
Contents
- I have watched this pendulum swing before
- What normal actually looks like
- Where I land, and the arithmetic behind it
- What is being sold instead
- The bill nobody reads to you
- Why there is no clean prescription for this
- Where this leaves you
- Schedule a consultation in Fairfield, CT
I am a board-certified endocrinologist with over 20 years of clinical experience and training in functional medicine. I trained when hormone replacement was gospel, and I have practiced through every swing of the pendulum since.
If you are weighing testosterone for women in Fairfield, CT, or anywhere else, start here.
So here is the thesis first, because it is short.
A woman’s testosterone belongs in the female range. For most women, not even at the top of it. For no woman, ever, in the male range.
Small doses that bring a postmenopausal woman to a mid-premenopausal level can help her libido, modestly. What is being sold right now does something else. It pushes women into levels I expect to see in men, and calls it optimization.
It is not optimization. I have a name for it: toximization, achieving toxic levels under the pretense of optimization. I am claiming the term.
I have watched this pendulum swing before
When I was in training in the late 1990s, hormone replacement went to nearly every postmenopausal woman who walked in. It was going to protect her heart, her bones and her brain. It was sliced bread.
Then came 2002. The Women’s Health Initiative, a large trial of oral Premarin plus Provera, reported more heart attacks, strokes and blood clots, with the excess showing up early. The FDA put a black box warning on every estrogen product the following year, and prescriptions collapsed. For 2 decades, women were told to tough menopausal symptoms out unless they were severe. Hormones for prevention, of heart disease, bone loss or anything else, were off the table.
Later analyses told a different story for the women most of my patients actually are. Women who started hormones near menopause, before 60 or within 10 years of their last period, did fine, or better. And the drugs in that trial are not the drugs I would choose today. Oral Premarin is horse estrogen swallowed as a pill, synthetic in every way that matters to me, and Provera is not progesterone.
So medicine quietly corrected course. Transdermal estradiol with micronized progesterone (Prometrium), the bioidentical pair, is now what mainstream menopause care reaches for. In November 2025 the FDA moved to remove most of the boxed warning from menopausal hormone therapy. Estrogen is back where it belongs, for hot flushes that wreck sleep, as I wrote in my sleep article, and for bone, as I wrote in my osteoporosis article.
You would hope the pendulum would settle in the middle. Instead it flew straight past it, into testosterone. Call it roid rage, menopause edition.
What normal actually looks like
Every argument about testosterone in women should start with one number, and almost none of them do. Here it is, from Quest Diagnostics’ mass spectrometry assay, adults 18 to 69:
| Measure | Women | Men |
|---|---|---|
| Total testosterone (ng/dL) | 2 to 45 | 250 to 1,100 |
| Free testosterone (pg/mL) | 0.1 to 6.4 | 35 to 155 |
A healthy woman in the middle of her range runs about 25 ng/dL. A man on a standard dose of replacement gel runs about 566. Do the division: a normal woman makes roughly 1/23 of what a normal man makes. Not half. Not a third. About 4%.
Three things about measuring it.
The method. At female levels, the cheap direct immunoassays many labs still run are unreliable, because small numbers are exactly where they fail. Total testosterone should be measured by mass spectrometry (LC-MS/MS), the reference method.
Free testosterone. Most testosterone in the blood is bound to a carrier protein, SHBG (sex hormone-binding globulin), and can’t reach the tissues. The free fraction is what does the work, so free testosterone is the number that matters biologically. Measure it properly: by equilibrium dialysis, with the free hormone then read by mass spectrometry. Quest calls it “Testosterone, Free (Dialysis) and Total, MS.” A calculated estimate or an analog free testosterone kit is not the same test.
The top of the range is not the target. A reference range is built from healthy people, and by construction only a small slice of healthy women live near its upper edge. For most women, a total testosterone of 45 is not “optimal.” It is higher than anything her own body ever made. For most women, the upper limit of normal is supraphysiologic.
Where I land, and the arithmetic behind it
I am not against testosterone for women. I prescribe it. I am against the dose.
In a postmenopausal woman whose low desire genuinely bothers her, after the foundation has been looked at (sleep, stress, the relationship, metabolism, everything I covered in my article on low libido in women), testosterone brought into the normal premenopausal range does help. Across dozens of trials, the average gain was about 1 extra satisfying sexual encounter a month over placebo, according to the 2019 global consensus statement endorsed by the Endocrine Society and the major menopause societies.
That is the prize. Real, modest, and earned at female levels. Energy, muscle, bone, mood, brain fog: there is no credible evidence that testosterone fixes any of them in women.
Now the arithmetic. A man who applies 50 mg of 1% testosterone gel a day, the standard AndroGel starting dose, lands at about 566 ng/dL. A woman needs roughly 1/23 of the hormone to reach roughly 1/23 of the level. 50 divided by 23 is about 2.2.
- About 2 to 2.5 mg a day of applied testosterone brings an average postmenopausal woman to the middle of the premenopausal range: mid-normal total testosterone, or more precisely, mid-normal free testosterone measured by dialysis and mass spectrometry. Some need less, some slightly more. Absorption through the skin varies a lot from woman to woman, so the measured level, not the arithmetic, sets the final dose.
- About 5 mg a day is the ceiling for almost every woman. In postmenopausal women, 5 mg a day already lands at the very top of the female range, and 10 mg pushes total testosterone to almost double its upper limit.
Only about 10% of a gel actually crosses the skin, so 2 to 5 mg applied means a few hundred micrograms absorbed. That is the same dose I described in my March article.
That’s it. 1 to 5 mg for almost everyone. The dose can move. The level cannot. A woman above the female range is a level I can’t defend, and neither can anyone else.
What is being sold instead
Now look at what is actually happening. Pellets inserted under the skin every few months. Injections. Creams compounded at male strengths. And blood levels of 200, 300, 500.
I have seen postmenopausal women in my office with testosterone in the middle of the normal male range. I have heard podcasts celebrate those numbers and promote pellets as the way to get them. It is the low-T storefront playbook I have written about for men, repackaged for their wives.
Pellets are the worst of it. The dose is fixed the day it goes in, the level spikes well above the female range in the first weeks, and if it is too high, there is no taking it back out. You wait months for it to wear off. This is not optimization, any more than bolting an aftermarket turbo onto a family sedan, then careening down the highway at 150 miles an hour, redlining the engine and smoking the tires, is optimizing a Toyota Camry.
Put that 500 next to the table above. It is more than 10 times the top of the female range. It sits squarely in the 400 to 700 range the Endocrine Society sets as the target for transgender men, people taking testosterone precisely to masculinize their bodies. These are gender-changing doses, prescribed to women who never asked to change anything.
That is toximization in practice. Raising a woman’s testosterone into, or toward, the male range is the textbook case. It is not optimization. It is toxicity with a marketing budget.
Will a woman at 500 build more muscle? Probably. Smoking keeps people thin, too. Nobody writes “the benefits of smoking” into a public health article, and I am not going to write “the benefits of male-range testosterone” into this one.
The bill nobody reads to you
The people selling this will talk for an hour about libido, energy and strength. They almost never spend a minute on the downside. Here it is, and it has a name: virilization, the development of male characteristics in a female body.
- Scalp hair loss. Thinning hair is one of the most common complaints I hear from women after menopause. Then many of them are put on testosterone levels that drive exactly that pattern of loss.
- Voice deepening. Generally permanent.
- Clitoromegaly, enlargement of the clitoris. Generally permanent.
- Hirsutism, coarse hair on the face, chest and abdomen. It often persists after stopping, because those hairs don’t revert.
- Acne.
- Erythrocytosis, too many red blood cells, which thickens the blood. It is well documented on male-range testosterone, which is why hematocrit is monitored in anyone taking it.
Now the irony. The standard treatments for female pattern hair loss are spironolactone (Aldactone), which blocks the testosterone receptor, and finasteride (Propecia), which blocks the conversion of testosterone to DHT, the form that shrinks hair follicles. So I meet women paying for testosterone pellets on one end and for drugs to block that same testosterone on the other. A toxic cocktail, bought twice.
And notice the asymmetry. The libido benefit stops when the testosterone stops. A deeper voice does not come back.
Then there is what nobody knows. Even at female doses, the trials follow women for only about 2 years, so long-term effects on the breast and the heart are not settled. For women held at male-range levels, there is not a single safety trial. Nobody selling you a 500 can tell you what it does to your heart or your breasts over 10 years.
📞 On testosterone and not sure where your level sits? Bring your labs. Call (203) 760-5544 to schedule an evaluation in Fairfield, CT.
Why there is no clean prescription for this
There is no FDA-approved testosterone product for women in the United States. Every prescription is off-label, built from a product designed for men, and the smallest doses those products dispense are the problem:
| Product | Smallest single dose |
|---|---|
| AndroGel 1% pump, and generics | 12.5 mg |
| AndroGel 1.62% pump | 20.25 mg |
| 1% gel packets | 25 mg |
| Testim 1% tube | 50 mg |
Every one of them is 2.5 to 10 times my ceiling, and 5 to 20 times what most women need.
Clinicians try to work around it. Squeezing a few drops from a tube, or drawing gel out of a packet with a syringe, is fiddly and error-prone for daily use at home. The other common workaround, a full 12.5 mg pump every other day, averages about 6 mg a day on paper. In practice it spikes above the female range on the day it goes on, then drops off. That is not a defensible strategy.
That is why I use a reputable compounding pharmacy. A cream compounded at low concentration puts 1 to 2 mg in a full milliliter, so a small measuring error stays a small dosing error. Here compounding is not a shortcut around evidence. It is the practical way to hit a female dose on purpose.
And whatever the source, the level gets checked: total testosterone by mass spectrometry, free testosterone by dialysis. Then the dose follows the number.
Where this leaves you
If you are a woman on testosterone, ask 3 questions. What is my total testosterone, measured by mass spectrometry? What is my free testosterone, measured by dialysis? And where does each one sit in the female range? If your total is above 45, your free testosterone is above 6.4, or either is anywhere near the male range, you are not being optimized. You are being toximized.
If low desire genuinely bothers you, testosterone may have a place, at a dose measured in single milligrams, after the foundation has been addressed. If you have been told testosterone will fix your energy, your muscles, your mood or your brain, you have been sold something.
And if you are on pellets and your hair is thinning, your voice has changed or your skin has broken out, that needs looking at now, not at the next insertion.
The bottom line is this: a woman’s endocrine system, premenopausal or postmenopausal, is more delicately tuned than the finest Swiss watch, with feedback loops, balances, counterbalances and regulatory pathways of almost infinite complexity. What unscrupulous testosterone clinics do is take a sledgehammer to that watch, then proudly display the results and claim victory. If you want your priceless watch fixed, see a jeweler who actually knows how it works.
Schedule a Consultation in Fairfield, CT
I am a board-certified endocrinologist with 23 years of clinical experience, fellowship-trained at Montefiore and Albert Einstein College of Medicine and trained at Mount Sinai, with training through the Institute for Functional Medicine. I practice both conventional endocrinology and functional medicine, which is exactly why I can tell you where the line is. You can read more about my background and approach here.
Testosterone in women deserves an endocrinologist, not a pellet schedule.
Restore Health LLC
501 Kings Highway East, Suite 103, Fairfield, CT 06825
(203) 760-5544
Book your consultation, see what to expect as a patient, browse the full blog archive, listen to the audio health guides, or see the areas I serve throughout Fairfield County and beyond.
Related reading: women’s hormone health, low libido treatment for women, why you can’t sleep, and my evidence review of peptide therapy.