I am a board-certified endocrinologist with over twenty 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.
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 can help a postmenopausal woman’s libido, modestly. What is being sold right now pushes women into levels we expect to see in men, and calls it optimization. I have a name for it: toximization, achieving toxic levels under the pretense of optimization. I am claiming the term.
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.
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In 2002, the Women’s Health Initiative (WHI), a large trial of oral Premarin plus Provera, reported more breast cancer, heart attacks, strokes, and blood clots. In 2003, the Food and Drug Administration (FDA) put a boxed warning on every estrogen product, and prescriptions collapsed. The indications survived: moderate-to-severe hot flushes, vaginal atrophy, prevention of osteoporosis. But the label demanded the lowest dose for the shortest duration, pushed bone prevention behind non-estrogen drugs, and ruled out estrogen for preventing heart disease or dementia. For twenty-two years, many women were told to tough it out.
Later analyses told a different story. Over eighteen years, the WHI hormone arms showed no excess mortality, and women who started within ten years of menopause showed no excess coronary risk. Premarin is a mixture of conjugated equine estrogens, not the human-identical estradiol I generally prescribe, and Provera is not progesterone. Medicine quietly corrected course toward transdermal estradiol with micronized progesterone (Prometrium), the bioidentical pair. In November 2025, the FDA moved to remove most of the boxed warning, along with the lowest-dose, shortest-duration mandate. Estrogen is back where it belongs.
You would hope the pendulum would settle in the middle. Instead it flew straight past it, into testosterone. Call it roid rage, menopause edition.
Every argument about testosterone in women should start with one number, and almost none of them do. By Quest Diagnostics’ mass spectrometry assay, adult total testosterone runs 2 to 45 ng/dL in women and 250 to 1,100 in men; free testosterone, 0.1 to 6.4 pg/mL in women and 35 to 155 in men. A healthy woman in the middle of her range runs about 25 ng/dL; a man on standard replacement gel, about 566. A normal woman makes roughly 1/23 of what a normal man makes. Not half. About 4 percent.
Direct immunoassays fail exactly where female numbers live. Total testosterone belongs on mass spectrometry, free testosterone on equilibrium dialysis; a calculated estimate or an analog kit is not the same test. And the top of the range is not the target. By construction, only a small slice of healthy women live near its upper edge. For most women, a total testosterone of 45 is higher than anything her own body ever made. For most women, the upper limit of normal is supraphysiologic.
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), testosterone brought into the premenopausal range does help. The average gain is about one extra satisfying sexual event a month over placebo, per 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 percent 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. Fifty divided by 23 is about 2.2. So about 2 to 2.5 mg a day applied brings an average postmenopausal woman to mid-premenopausal levels. Skin absorption varies, so the measured level, not the arithmetic, sets the final dose. About 5 mg a day is the ceiling for almost every woman. In a dose-ranging study in postmenopausal women, 4.4 mg of gel a day already reached the top of the female range, and 8.8 mg nearly doubled its upper limit.
From 1 to 5 mg for almost everyone. The dose can move. The level cannot.
Look at what is 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 with testosterone in the middle of the normal male range. It is the low-T storefront playbook, 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. 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.
A level of 500 is more than 10 times the female upper limit, squarely in the 400 to 700 range the Endocrine Society suggests 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. Will a woman at 500 build more muscle? Probably. Smoking keeps people thin, too.
The people selling this talk for an hour about libido and almost never spend a minute on virilization. Scalp hair loss. Voice deepening and clitoromegaly, generally permanent. Hirsutism, which often persists after stopping. Acne. Erythrocytosis. Now the irony. Thinning hair is one of the most common complaints I hear from women after menopause, and the standard treatments are spironolactone (Aldactone), which blocks the androgen receptor, and finasteride (Propecia), which blocks conversion to dihydrotestosterone (DHT). 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 the libido benefit stops when the testosterone stops. A deeper voice does not come back.
Even at female doses, safety data stop at about two years. At male-range levels there is not a single safety trial. Nobody selling a woman a 500 can tell her what it does to her heart or her breasts over ten years.
There is also no clean prescription. No testosterone product is FDA-approved for women in the United States. The smallest single doses of the male gels run from 12.5 mg (one AndroGel 1 percent pump) to 50 mg (one Testim tube), 2.5 to 10 times my ceiling. Syringing gel out of a packet is error-prone at home; a 12.5 mg pump every other day averages 6 mg a day on paper while spiking above the female range the day it goes on. That is why I use a reputable compounding pharmacy: At 1 to 2 mg per milliliter, 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.
In September, the FDA held a public workshop on testosterone in menopausal women and signaled a pathway to approving a female product. That would end the workarounds, not the pellet clinics, which never had a dosing problem. They have a target problem.
Every woman on testosterone, and her prescriber, should be able to answer three questions. What is her total testosterone by mass spectrometry? Her free testosterone by dialysis? Where does each sit in the female range? If the total is above 45 ng/dL, the free above 6.4 pg/mL, or either is anywhere near the male range, she is not being optimized. She is being toximized.
A woman’s endocrine system 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 a priceless watch fixed, you take it to a jeweler who actually knows how it works.
Michael Duben is a board-certified endocrinologist in solo private practice in Fairfield, Connecticut, and is affiliated with Bridgeport Hospital. He runs both Endocrinology of Fairfield County, a traditional insurance-based practice, and Restore Health, a cash-based functional endocrinology practice. He completed the Institute for Functional Medicine’s training program.
He did his internal medicine residency at Mount Sinai and his endocrinology fellowship at Montefiore/Einstein, and was a clinical instructor in the Department of Endocrinology at Albert Einstein College of Medicine. He has practiced since 2003, with clinical interests in thyroid disease and thyroid cancer, osteoporosis and bone metabolism, parathyroid disease, pituitary disorders, and obesity and metabolic disease. He has prescribed glucagon-like peptide-1 (GLP-1) receptor agonists since the first one reached the market in 2005, and has lectured to practicing physicians on diabetes and thyroid management.
He designed and built the HIPAA-compliant AI-assisted clinical documentation system he uses in daily practice, without formal training in computer science, along with a range of other tools for his patients and his office. He shares updates on LinkedIn.
