Testosterone: Strong Enough for a Man, but Made for a Woman

Abstract

Testosterone, the most abundant biologically active hormone in women, has been historically and erroneously characterized as a “male hormone,” resulting in a longstanding gap in women’s healthcare. This misconception has led to the under recognition and undertreatment of androgen deficiency in women, despite its broad physiologic importance. Throughout a woman’s lifespan, testosterone levels are 10–20 times higher than estradiol levels, making testosterone the predominant sex hormone in female physiology. Declines in testosterone with aging contribute to symptoms often misdiagnosed as mood or pain disorders, including fatigue, anxiety, cognitive decline, musculoskeletal weakness, sexual dysfunction, and metabolic changes. Evidence demonstrates that physiologic testosterone replacement improves mood, energy, cognition, bone and vascular health, and sexual function, with minimal risk of virilization when appropriately dosed. Contrary to earlier beliefs, testosterone therapy has not been associated with increased breast cancer risk; instead, mounting data suggest protective effects. A 9-year retrospective study of 2,377 women treated with testosterone or testosterone/estradiol pellet implants showed a 35.5% reduction in invasive breast cancer incidence compared with age-matched SEER rates, supporting testosterone’s antiproliferative and anti-estrogenic actions on breast tissue. Additional studies indicate potential benefits of testosterone therapy in reducing breast cancer recurrence and improving quality of life in survivors. Despite extensive evidence supporting its safety and efficacy, the U.S. Food and Drug Administration has yet to approve a testosterone formulation for women, a gap that contrasts with clinical practice in Europe and Australia. Recognition of testosterone deficiency as a legitimate medical condition in women, and implementation of evidence-based guidelines for its management, are urgently needed. Addressing this issue requires improved physician education, updated clinical protocols, equitable insurance coverage, and regulatory approval of female-specific testosterone therapies. Reframing testosterone as a hormone vital to both sexes, rather than exclusively “male,” is essential for optimizing women’s health, longevity, and overall quality of life.