Still Struggling on HRT? Low Testosterone Might Be Why

Six months ago you started HRT with the hope it would fix everything. The hot flushes stopped back in March. That's sorted. But last Tuesday you fell asleep at your desk. Actually asleep, head on the keyboard, at 3pm and your colleague had to wake you.

And sex? You'd rather reorganise the sock drawer. Defrost the freezer. Clean out the cutlery tray. Anything.

Your GP said give HRT six months. You've given it six months. Still have zero interest in anything that happens in bed that isn't sleeping. The hot flushes are gone. But you're still knackered. Still can't think straight.

We know you've probably worried whether HRT isn't working for you. Whether something else is wrong. Whether you'll ever feel like yourself again

Testosterone might be the missing piece. Women produce it too. And when levels are low, HRT alone often isn't enough.

What Testosterone Actually Does (And Why HRT Alone Sometimes Isn't Enough)

HRT replaces oestrogen and progesterone. Sorts hot flushes, night sweats, mood swings. But it doesn't replace testosterone.

Here's the thing: testosterone isn't yet licensed specifically for menopause in the UK. However, menopause specialists can prescribe it "off-label" for managing low sexual desire in menopausal women. The evidence supporting this? Very well established.

Emerging evidence shows testosterone might help with more than just your libido. Your energy levels, for starters. Testosterone can improve bone density and muscle mass, which makes sense when you realise testosterone receptors exist throughout your body, in your bones, muscles, brain, and other tissues. A 2024 UK pilot study of 510 women found that testosterone improved cognitive symptoms like brain fog by 22% and mood symptoms by 34% over four months. Studies have also shown positive associations between testosterone levels and bone mineral density in postmenopausal women, though the evidence here is still developing. We need larger, longer-term clinical trials to fully understand testosterone's effects beyond sexual function. The ESTEEM trial currently underway in the UK is investigating exactly this, whether testosterone can improve cognition, exercise capacity, motivation, and energy levels in menopausal women already on HRT.

Women produce testosterone in the ovaries and adrenal glands. Your levels gradually decline from your 20s through your 40s, then plateau around menopause. HRT replaces oestrogen. But testosterone? Often gets completely overlooked.

If you've had your ovaries removed, testosterone can drop by more than 50% almost immediately. This is why some women on HRT still feel rubbish. The oestrogen is sorted, but the testosterone isn't.

The Symptoms HRT Doesn't Always Fix

You thought HRT would sort everything. Your GP said give it six months. You've given it six months. The hot flushes have stopped. But you're still struggling.

Common Signs of Low Testosterone (Even When You're on HRT)

Your HRT's sorted the physical stuff. Vaginal dryness gone. Discomfort improved. But your libido? Still nowhere.

Not even the spark of wanting to want sex. Not even the memory of what desire used to feel like. You look at your partner and feel... nothing. Not turned off. Just blank.

That gap between "body working fine" and "actually wanting sex"? That's often low testosterone.

Sound familiar?

Studies show 9-26% of women still experience hypoactive sexual desire disorder (HSDD) even on standard HRT. Women with surgical menopause have even higher rates.

(And we know you're probably wondering whether you're on the wrong type of HRT. Whether your dose is too low. Whether you should try a different formulation. Your menopause specialist can check all of this first before considering testosterone.)

Why Your GP Might Not Have Mentioned Testosterone

Most GPs focus on oestrogen and progesterone replacement. That's standard HRT. Works for the majority of menopausal symptoms.

But testosterone is more complicated:

• It's not licensed for use in women in the UK
• GPs have to prescribe it off-label (taking full responsibility)
• Dosing is tricky. Women need about a tenth of what men use.
• Many GPs aren't trained in testosterone prescribing for women

NICE and BMS say testosterone can be considered for peri/menopausal women with low sexual desire if HRT alone hasn't worked. But "can be considered" doesn't mean "routinely offered." Many women have to specifically ask about it.

This is why you usually need a menopause specialist. They have expertise in testosterone prescribing. They know how to dose it safely for women. They know when it's appropriate to try.

How Do You Know If Low Testosterone Is Your Problem?

If you're on HRT and your menopausal symptoms are sorted (no more hot flushes, night sweats gone), but you're still experiencing some of these persistent issues, low testosterone might be contributing.

Your menopause specialist will want to check:

Is your HRT optimised? Sometimes switching from tablets to patches, or adjusting your progesterone, makes a difference. Oral oestrogen can actually reduce the effectiveness of testosterone by increasing a binding protein. Switching to transdermal oestrogen sometimes helps without adding testosterone.

Are other causes ruled out?

• Relationship problems affecting intimacy
• Depression or anxiety (which directly affect libido and energy)
• Medication side effects (antidepressants like SSRIs commonly reduce sex drive)
• Pain during sex (needs treating with vaginal oestrogen first)
• Thyroid problems (which cause similar symptoms)
• Vitamin deficiencies (B12, iron, vitamin D can all cause fatigue and brain fog)
• Life stress (exhaustion from work, caring responsibilities, chronic sleep deprivation)

If your HRT is optimal, other causes are addressed, and you're still struggling after at least 3-6 months on HRT, that's when testosterone becomes an option to explore.

Do You Need Testing Before Treatment?

Yes, you'll need blood tests before starting testosterone. The British Menopause Society recommends checking your baseline testosterone levels first. This shows where you're starting from and makes sure your levels aren't already high (which would make testosterone treatment unsuitable).

Why the tests matter:

• They establish your starting point before treatment
• They help monitor your levels during treatment (making sure you stay in the safe range)
• They rule out unusually high testosterone, which might suggest something else going on like PCOS
• They confirm expected drops if you've had your ovaries removed

At Voy Menopause, we offer a quick start test for anyone considering testosterone replacement.

The British Menopause Society is clear: blood tests cannot reliably diagnose perimenopause or menopause in women over 45. FSH levels fluctuate too much to be useful. The same principle applies to testosterone for diagnosing low desire.

Testing usually isn't needed if:

• You're just curious about your levels with no symptoms
• You want a test before trying HRT first (HRT is the first-line treatment)
• You're hoping a number will "prove" your symptoms are real (your symptoms are valid regardless of test results)
• You're buying over-the-counter tests (these aren't reliable and waste money)

What the Testing Actually Involves

If you're considering testosterone replacement, you'll need a blood test first. At Voy Menopause our test kit is delivered to your door within 2–3 days of purchase, free of charge. Blood collection is easy and done at home using a simple Tasso device (an autodraw device that takes your blood for you), with full instructions included. You'll get an expert-validated report with a complimentary 20-minute appointment to discuss your results and what to do next.

The markers we look for:

• Total testosterone - your baseline level
• SHBG (sex hormone binding globulin) - a protein that binds testosterone, affecting how much is available to your body
• Free testosterone - the amount not bound to proteins
• FAI (Free Androgen Index) - a calculation based on total testosterone and SHBG that shows how much testosterone is actually active
• Oestradiol - the main form of oestrogen your body produces, to check your HRT is optimised

The test needs to be done in the morning when testosterone levels are highest. If you're still having periods, timing matters (testosterone varies through your cycle).

But here's the critical bit: whether you feel better on treatment matters more than hitting a specific number. The test gives us your starting point and helps us monitor safety, but your symptoms are what really guide treatment decisions.

What Happens If Your Testosterone Is Low?

First: being on HRT already. NICE and BMS guidelines say try conventional HRT (oestrogen, with progesterone if you have a womb) before considering testosterone.

Your symptoms should be sorted on HRT. If you're still having hot flushes or night sweats, your HRT needs optimising first. Testosterone won't fix inadequate oestrogen replacement.

If you're on HRT, your menopausal symptoms are sorted, but you're still experiencing distressing low libido , that's when testosterone becomes an option.

Your menopause specialist will want to rule out other causes:

• Relationship problems
• Mental health issues
• Medication side effects
• Pain during sex
• Thyroid problems
• Vitamin deficiencies
• Life stress

If other causes are addressed and you're still struggling, testosterone replacement can be considered.

What Testosterone Treatment Looks Like Alongside HRT

You don't stop HRT to start testosterone. You add testosterone on top.

Testosterone is prescribed as a gel or as a cream that you apply to your skin daily. Usually to your lower abdomen or upper thighs. You use about one-tenth of the dose men use.

What’s available in the UK:

Available through Voy (formulated for women):

• Androfeme — a testosterone cream designed specifically for women. You use a pea-sized amount daily.
• Testocream — one pump gives you the right amount. Simple.

Licensed for men (used off-label for women):

• Testogel, Tostran, and Testim — your menopause specialist will give you precise instructions on how much to use, since these are formulated at male doses.

What to expect:

Patience required. Testosterone takes 3-6 months to show effects. Sometimes longer.

Regular monitoring. Blood tests every 6-12 months to check your levels stay in the normal female range.

Possible improvements:

• Libido (the big one most women notice first)
• Energy levels
• Mood
• Concentration and mental clarity

The reality check: About 20-30% of women don't notice benefits. If you've seen no improvement after six months, stopping treatment is completely reasonable. It doesn't work for everyone, and that's okay.

If you've seen no improvement after six months, stopping treatment is completely reasonable.

Is Testosterone Safe to Add to HRT?

Short answer: yes, when prescribed properly by a menopause specialist and monitored appropriately.

The evidence shows testosterone (at female physiological doses) doesn't increase breast cancer risk in the short term. It doesn't affect blood pressure. It doesn't harm liver or kidney function. It doesn't increase blood clot risk.

We don't have long-term data beyond about two years. But the short-term data is reassuring.

Side effects are uncommon when levels are monitored:

• Acne
• Increased hair growth where you apply the gel
• Weight gain

These happen mainly when doses are too high. Your specialist monitors specifically to prevent this.

The scary side effects (deepening voice, male-pattern baldness, clitoral enlargement) only occur with very high doses. Much higher than you'd ever have naturally. Regular monitoring prevents this.

Situations where testosterone needs extra caution:

• History of hormone-sensitive breast cancer (needs discussion with oncologist)
• Active liver disease
• Pregnancy or breastfeeding
• Competitive athletics (testosterone is a banned substance)

When to See a Menopause Specialist About Testosterone

If you've been on HRT for at least 3-6 months, your menopausal symptoms are sorted (hot flushes, night sweats gone), but you're still experiencing:

• Persistent low libido that's bothering you
• Exhaustion despite HRT and adequate sleep
• Brain fog, poor concentration, memory problems
• Low mood or anxiety that HRT hasn't helped
• Loss of muscle strength

And these symptoms are affecting your quality of life or relationships, book an appointment with a menopause specialist.

They'll do a thorough assessment. They'll check whether your HRT is optimised. They'll rule out other causes. And if testosterone might help, they can prescribe and monitor it safely.

(We know accessing a menopause specialist can be challenging. NHS waiting times can be long. Private appointments expensive. But this needs specialist expertise. Many GPs aren't comfortable prescribing testosterone off-label, which is understandable.)

Ready to explore whether testosterone treatment could help your persistent symptoms? A menopause specialist can assess your individual situation.

References

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1. British Menopause Society. Testosterone replacement in menopause. https://thebms.org.uk/wp-content/uploads/2022/12/08-BMS-TfC-Testosterone-replacement-in-menopause-DEC2022-A.pdf

^²

1. British Menopause Society. Menopause Practice Standards. https://thebms.org.uk/wp-content/uploads/2022/07/BMS-Menopause-Practice-Standards-JULY2022-01D.pdf

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1. British Menopause Society. BMS Statement on Testosterone. https://thebms.org.uk/2023/03/bms-statement-on-testosterone/

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1. NHS. Menopause - Treatment. https://www.nhs.uk/conditions/menopause/treatment/

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1. NICE. Menopause: diagnosis and management (NG23). https://www.nice.org.uk/guidance/ng23

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1. British Menopause Society. BMS statement on over-the-counter menopause tests. https://thebms.org.uk/2022/06/bms-statement-on-over-the-counter-menopause-tests/

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1. Leiblum SR, Koochaki PE, Rodenberg CA, Barton IP, Rosen RC. Hypoactive sexual desire disorder in postmenopausal women: US results from the Women's International Study of Health and Sexuality (WISHeS). Menopause. 2006;13(1):46-56. https://pubmed.ncbi.nlm.nih.gov/16607098/

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1. Hamoda H, Panay N, Arya R, Savvas M. The British Menopause Society & Women's Health Concern recommendations on the management of women with premature ovarian insufficiency. Post Reproductive Health. 2017;23(1):22-35. https://pmc.ncbi.nlm.nih.gov/articles/PMC7098532/

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1. Davis SR, Baber R, Panay N, et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. Journal of Clinical Endocrinology & Metabolism. 2019;104(10):4660-4666. https://pubmed.ncbi.nlm.nih.gov/31498871/

^¹⁰

1. Wierman ME, Arlt W, Basson R, et al. Androgen therapy in women: a reappraisal: an Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology & Metabolism. 2014;99(10):3489-3510. https://pubmed.ncbi.nlm.nih.gov/25279570/

^¹¹

1. Panay N, Anderson RA, Nappi RE, et al. Premature ovarian insufficiency: An International Menopause Society White Paper. Climacteric. 2020;23(5):426-446. https://pubmed.ncbi.nlm.nih.gov/32969266/

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1. Somboonporn W, Davis S, Seif MW, Bell R. Testosterone for peri- and postmenopausal women. Cochrane Database of Systematic Reviews. 2005;(4):CD004509. https://pubmed.ncbi.nlm.nih.gov/16235365/