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Testosterone became a controlled substance in the 1990s after decades of misuse, and the cultural narrative around it has never fully recovered. The clinical reality is more nuanced. In this episode, we unpack what testosterone actually does in both women and men, what it is and is not FDA approved for, and how to use it thoughtfully when clinically appropriate.
From the difference between physiologic and supraphysiologic dosing to the labs worth checking before starting therapy, this episode offers the nuance the conversation has long deserved.​​​
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​​​Key Takeaways
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00:00 — Intro and why testosterone deserves a more nuanced conversation
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00:16 — What testosterone actually is
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00:44 — Testosterone in men and women: the full hormonal picture
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01:26 — Production and the HPG axis feedback loop
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01:46 — The role of testosterone across multiple body systems
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02:23 — Impact on sexual health, muscle, bone, metabolism, and mood
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04:12 — FDA approval, clinical use, and where the gap matters
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05:41 — Balancing testosterone levels: physiologic versus supraphysiologic dosing
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06:31 — Final takeaways and how to think about hormone therapy thoughtfully
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References
Alemany M. The roles of androgens in humans: biology, metabolic regulation and health. Int J Mol Sci. 2022;23(19):11952. https://doi.org/10.3390/ijms231911952
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Rojas-Zambrano J, Rojas-Zambrano A, Rojas-Zambrano A, Barahona-Cueva G. Benefits of testosterone hormone in the human body: a systematic review. Cureus. 2025;17:e78785. https://doi.org/10.7759/cureus.78785
Kelly DM, Jones TH, Kalinchenko S, et al. Testosterone: a metabolic hormone in health and disease. J Endocrinol. 2013;217(3):R25–R45. https://doi.org/10.1530/JOE-12-0455
​
Tyagi V, Scordo M, Yoon RS, Liporace FA, Greene LW. Revisiting the role of testosterone: are we missing something? Rev Urol. 2017;19(1):16–24.
​
Li L, Lin W, Wang Z, et al. Hormone regulation in testicular development and function. Int J Mol Sci. 2024;25(11):5805. https://doi.org/10.3390/ijms25115805
​
Dandona P, Dhindsa S, Ghanim H, Saad F, Batra M. Mechanisms underlying the metabolic actions of testosterone in humans: a narrative review. Diabetes Obes Metab. 2020;23(1):18–28. https://doi.org/10.1111/dom.14206
Al-Darawsha T. Testosterone hormone: clinical indications, dysregulation and therapeutic methods. Al-Ameed J Med Res Health Sci. 2024. https://doi.org/10.61631/3005-3188.1005
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Maksimova M, Korochkina E. The role of testosterone in the male reproductive system (review). Legal Regulation Vet Med. 2024;3:51–60. https://doi.org/10.52419/issn2782-6252.2024.3.51
​
Podlasek CA, Mulhall JP, Davies K, et al. Translational perspective on the role of testosterone in sexual function and dysfunction. J Sex Med. 2016;13(8):1183–1198. https://doi.org/10.1016/j.jsxm.2016.06.004
​
Usmani H, Kant R. Testosterone: an insight into its clinical and biochemical assessments. Indian J Med Biochem. 2021;25(1):1–7. https://doi.org/10.5005/jp-journals-10054-0173
​
Vingren JL, Kraemer WJ, Ratamess NA, Anderson JM, Volek JS, Maresh CM. Testosterone physiology in resistance exercise and training. Sports Med. 2010;40(12):1037–1053. https://doi.org/10.2165/11536910-000000000-00000
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Bain J. The many faces of testosterone. Clin Interv Aging. 2007;2(4):567–576. https://doi.org/10.2147/CIA.S1417
Islam RM, Bell RJ, Green S, Page MJ, Davis SR. Safety and efficacy of testosterone for women: a systematic review and meta-analysis of randomized controlled trial data. Lancet Diabetes Endocrinol. 2019;7(10):754–766. https://doi.org/10.1016/S2213-8587(19)30189-5
​
Bianchi VE, Bresciani E, Meanti R, Rizzi L, Omeljaniuk RJ, Torsello A. The role of androgens in women’s health and wellbeing. Pharmacol Res. 2021;171:105758. https://doi.org/10.1016/j.phrs.2021.105758
Davis SR, Wåhlin-Jacobsen S. Testosterone in women—the clinical significance. Lancet Diabetes Endocrinol. 2015;3(12):980–992. https://doi.org/10.1016/S2213-8587(15)00284-3
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Maseroli E, Vignozzi L. Are endogenous androgens linked to female sexual function? A systematic review and meta-analysis. J Sex Med. 2022;19(3):322–340. https://doi.org/10.1016/j.jsxm.2022.01.515
Davis SR. Not just sex: other roles for testosterone in women. Climacteric. 2025;28(4):373–376. https://doi.org/10.1080/13697137.2024.2445301
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Mauvais-Jarvis F, Lindsey S. Metabolic benefits afforded by estradiol and testosterone in both sexes: clinical considerations. J Clin Invest. 2024;134(5):e180073. https://doi.org/10.1172/JCI180073
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Davis SR, Tran J. Testosterone influences libido and well-being in women. Trends Endocrinol Metab. 2001;12(1):33–37. https://doi.org/10.1016/S1043-2760(00)00333-7
​
Kling JM. Testosterone for the treatment of hypoactive sexual desire disorder in perimenopausal and postmenopausal women. Obstet Gynecol. 2025. https://doi.org/10.1097/AOG.0000000000006015
Scott A, Newson L. Should we be prescribing testosterone to perimenopausal and menopausal women? Br J Gen Pract. 2020;70(693):203–204. https://doi.org/10.3399/bjgp20X709265
​
Martín M, Gallardo-González R. Testosterone implant in women: safety and effectiveness of this route of administration. Rev Chil Obstet Ginecol. 2022;87(1):1–8. https://doi.org/10.24875/RECHOG.M21000039
Stone T, Stachenfeld NS. Pathophysiological effects of androgens on the female vascular system. Biol Sex Differ. 2020;11(1):1–15. https://doi.org/10.1186/s13293-020-00323-6
Manalo ES, Irabon IA, Fajutagana SV. The role of testosterone in menopause management: a review of literature. Fertil Reprod. 2021. https://doi.org/10.1142/S2661318221500110
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Smith TJ, Batur P. Prescribing testosterone and DHEA: the role of androgens in women. Cleve Clin J Med. 2020;88(1):35–42. https://doi.org/10.3949/ccjm.88a.20030
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Full Transcript​
Why Testosterone Deserves a More Nuanced Conversation
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Today we're talking about something that, in the 90s, became a controlled substance because of its abuse potential. Truthfully, I don't think it needs to be a controlled substance. It's a vital hormone in our bodies. Today we're talking about testosterone. The good, the bad, the hairy.
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In this episode, we'll cover what testosterone actually is, why we need it, what it's FDA approved for, and how to use it wisely if it's something you opt to use.
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What Testosterone Is
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Testosterone is a steroid hormone. It's an androgen, made from cholesterol. It's not just a male hormone. Women have testosterone too. In fact, across a woman's lifetime, she has higher absolute levels of testosterone than estrogen or any other hormone. Testosterone is just as much a female hormone as it is a male one.
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In men, testosterone is made in the testicles, specifically in cells called the Leydig cells. In women, it's made in the ovaries and in the adrenal cortex, the small glands that sit on top of the kidneys.
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Production and the HPG Axis Feedback Loop
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In the body, testosterone production is governed by a feedback loop. It's how the brain communicates with the ovaries in women and the testes in men. This is called the HPG axis, the hypothalamic-pituitary-gonadal axis.
When someone isn't producing sufficient testosterone, there's usually a miscommunication somewhere along this feedback loop. That's one of the things that can go wrong. Women can also produce too much testosterone, but that's a separate conversation.
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The Role of Testosterone in Sexual Development and Reproduction
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Testosterone is important for sexual development and reproduction. It drives male development, reproductive organs, and secondary sex characteristics like voice tone. If a woman takes too much testosterone, her voice can change.
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It also affects hair growth patterns. Women who struggle with PCOS, often associated with elevated testosterone, may notice hair on the chin or accelerated leg hair growth. When I start patients on testosterone therapy, we have a conversation about how they may notice faster hair growth and need to shave more often.
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In men, testosterone supports sperm production. In both men and women, it supports libido and sexual function.
Muscle, Bone, and Metabolism
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Testosterone is also essential for muscle, bone, and metabolism. It promotes muscle protein synthesis, the process by which the body builds muscle. It helps maintain bone density, supporting the thickness and strength of the bones. It also influences fat distribution, how well the body uses sugar, and the way cholesterol moves around the body, what's known as lipid metabolism.
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Studies have linked low testosterone to obesity, metabolic syndrome (when the body doesn't process sugar effectively), and even type 2 diabetes.
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Brain, Mood, and Wellbeing
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Testosterone also impacts the brain and mood. Too much can make a person aggressive. Too little can produce low mood, fatigue, and depression. It influences cognition, awareness, and behavior.
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The aggressive behavior associated with testosterone misuse in the 1980s is part of why it became a controlled substance in the 1990s. That cultural memory still shapes how testosterone is perceived today.
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In clinical practice, I often see patients, both men and women, whose testosterone is low, who feel less drive, less energy, and lower mood. Identifying that on labs and bringing testosterone back into a physiologic range can meaningfully shift how someone feels.
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FDA Approval and Clinical Use
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Just because testosterone is clinically useful doesn't mean it's broadly FDA approved. It's important to be honest about this distinction.
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Testosterone is FDA approved for postmenopausal women with low libido, a condition called hypoactive sexual desire disorder (HSDD). But women are more than their libido. There are many other meaningful benefits to addressing low testosterone in women, including improvements in mood, energy, muscle preservation, and bone density. We need the FDA to expand its view on this.
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In men, testosterone is FDA approved for hypogonadism, defined as a total testosterone level below 250 ng/dL with accompanying symptoms.
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Total Versus Free Testosterone
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In clinical practice, we look at more than one number. Total testosterone reflects what's circulating in the blood. Free testosterone is the unbound portion, the part the body can actually use. These two values give a more complete picture than either alone, which is why hormone evaluation requires nuance and why working with a provider who specializes in hormones matters.
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Balancing Testosterone Levels
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A big reason testosterone got such a bad reputation is what happened in the 1980s. People misused it. They pushed levels well beyond what the body would naturally produce. Too much of anything can be harmful.
Too much chocolate cake will make you vomit, but a slice is the perfect amount. Testosterone is no different. Balance matters. Staying within a physiologic range matters. That's the difference between thoughtful therapy and the misuse that shaped the cultural narrative.
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The Bottom Line
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Testosterone benefits both men and women. You can have too much. You can have too little. What matters is assessing your goals, how you're using it, the formulation you're using, and how it makes you feel.
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Hormones aren't inherently good or bad. They are part of how the body functions, and as we age, levels naturally decline. Addressing low testosterone, when it's contributing to symptoms, can support many other parts of how a patient feels and functions.
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Medicine is an art. It isn't black and white. It's about working in the gray, in partnership with the patient, so they're treated as a human being and not just a lab number. If you suspect your testosterone might be contributing to fatigue, low drive, low mood, or loss of strength, it's worth a conversation with a provider experienced in hormones.
Testosterone, used in the right person, at the right time, in the right formulation, with the right management, can be exactly what someone needs. It isn't all that bad. It isn't all that hairy. It can be just what you need.
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FAQs​
Do women need testosterone?
Yes. Women produce testosterone in the ovaries and adrenal glands, and across the lifetime, women have higher absolute levels of testosterone than estrogen or any other sex hormone. It plays a meaningful role in libido, mood, energy, muscle, bone, and metabolism in women, not only in men.
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Is testosterone therapy FDA approved for women?
The only FDA-approved indication for testosterone in women is hypoactive sexual desire disorder (HSDD) in postmenopausal women. Many of the broader benefits women experience on testosterone, including improvements in mood, energy, muscle, and bone, are technically off-label, even when clinically appropriate.
What is the difference between total and free testosterone?
Total testosterone is the full amount circulating in the blood, including the portion bound to proteins. Free testosterone is the unbound, biologically active portion that the body can actually use. Two people with identical total testosterone levels can have very different free testosterone levels and very different symptom profiles, which is why both values are clinically useful.
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Will testosterone make a woman bulky or masculine?
At physiologic replacement doses, no. Women do not have the hormonal profile to develop a masculine build from physiologic testosterone replacement. Mild side effects such as accelerated leg hair growth, mild acne, or more frequent shaving can occur in some women, and dosing can be adjusted accordingly. The masculinizing effects associated with testosterone misuse are a feature of supraphysiologic dosing, not physiologic replacement.
Is testosterone replacement appropriate during perimenopause and menopause?
It can be, particularly for women with low libido, fatigue, low mood, or loss of muscle tone that isn't adequately addressed by estrogen and progesterone alone. The decision should be made with a clinician experienced in hormone therapy, and dosing should be individualized based on baseline labs, symptoms, and treatment goals.
How is testosterone monitored during therapy?
Through periodic labs assessing total and free testosterone, sex hormone-binding globulin, estradiol (which testosterone can convert into), red blood cell parameters, lipid profile, and other markers depending on the clinical context. Monitoring intervals are typically more frequent at the start of therapy and after dose changes, and less frequent once a stable response is established.
Can lifestyle changes raise testosterone naturally?
Yes, to a meaningful degree. Resistance training, adequate sleep, stress management, weight optimization, blood sugar regulation, sufficient protein and healthy fats, and addressing micronutrient deficiencies (particularly zinc, magnesium, and vitamin D) can all support endogenous testosterone production. For some patients, lifestyle alone is sufficient. For others, lifestyle is foundational but not the full answer.
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Terms used:​
1. Androgens - a group of male sex steroid hormones (including testosterone and DHT) that develop and maintain masculine characteristics, such as muscle mass, body hair, and voice deepening
2. PCOS - Polycystic Ovary Syndrome; a common hormonal disorder affecting 10–13% of women, characterized by irregular periods, high androgen levels (causing acne/hirsutism), and small cysts on the ovaries
3. Libido - a person's overall sexual desire and motivation for sexual activity
4. Lipid metabolism - involves the synthesis (anabolism) and degradation (catabolism) of lipids to produce energy, store fat, and construct cell membranes
5. Metabolic syndrome - a cluster of conditions that significantly increase the risk of heart disease, stroke, and type 2 diabetes
6. Cognition - the mental processes involved in gaining knowledge and comprehension, including thinking, knowing, remembering, judging, and problem-solving
7. HSDD - Hypoactive Sexual Desire Disorder; a persistent or recurrent lack of sexual desire or fantasies that causes significant personal distress or interpersonal difficulty
8. Hypogonadism - a condition where the sex glands (testes or ovaries) produce little or no hormones, leading to low testosterone or estrogen, infertility, and sexual dysfunction