Illustration: Olivier Heiligers
The nurse practitioner handed Charlotte Andersen an address. “Meet me in this parking lot,” she said. “I can’t help you here.” By here, she meant the OB/GYN clinic where she worked and where Andersen had made an appointment — on the recommendation of a few fellow 40-something girlfriends — to get on the list for the nurse practitioner’s side business: providing pre- and postmenopausal women with off-label testosterone.
The business isn’t illegal, but some might still consider it dubious. No testosterone product for women is currently approved by the U.S. Food and Drug Administration. And while in 2019, a dozen international societies dedicated to women’s health care together endorsed clinical guidelines for the use of testosterone creams and patches on postmenopausal women bothered by low sexual desire, only four countries — Australia, New Zealand, South Africa, and the United Kingdom — allow products of that ilk to be sold.
Andersen’s friends were not dissuaded by this fine print. They assured Andersen that the nurse practitioner’s treatments had been “life changing” for what they all assumed were perimenopause-related symptoms: fatigue, moodiness, and insomnia. “I would say most of my friends are on it,” says Andersen, who lives in Denver. “And they mostly do the pellet — the shot in your butt.” The pellets are tiny implants that are surgically placed in a butt cheek every three to six months. In women, they typically contain one-tenth of the dose that would be prescribed to men who have low testosterone (that dose ranges from 150 mg to 450 mg), but the amount varies from provider to provider and patient to patient.
In a strip-mall parking lot, Andersen stood nervously beside her car as the nurse practitioner pitched the benefits of pellet therapy: better mood, better sex drive, and more energy, all in one dosage. “She was kind of pushing that,” she tells me.
But Andersen couldn’t help but fixate on the way the pellet works: Once it’s inserted, it can’t be removed. The testosterone dissolves in the bloodstream over several months and can only exit your system through the body’s usual processes — mainly urination. What if something went wrong? In the end, the nurse practitioner wrote Andersen a prescription for a three-month supply of a testosterone cream from a compounding pharmacy as a starting point. “Then we’ll do the pellet,” she said.
As more millennials age into perimenopause, the product market of supplements and serums has expanded to meet them. Already, women age 35 and up are spending $13 billion annually on managing menopause symptoms, according to one survey estimate, and market predictions estimate the industry will grow to more than $24 billion by 2030. Within that milieu, a new cadre of social-media influencers has emerged: middle-age women touting testosterone therapy via creams, gels, and the aforementioned pellets. They rave about how testosterone has given them their energy back and eased their depression and body aches. They document the pellet-insertion process: A medical professional makes a small incision in the hip or buttocks (after numbing the area), and under the skin goes a tiny waxy bead about the size of a grain of rice. “This place literally saved my life,” says Marcella Hill in a January 2024 video of the Utah med-spa where she gets her pellets. Hill has nearly 1 million followers across TikTok and Instagram and has promoted the telehealth platform Joi Women’s Wellness, which prescribes testosterone and other hormone therapies. In that 2024 video, she adds, “There is help beyond your regular doctor who’s telling you feeling like crap is normal.”
But there’s a serious yet under-the-radar problem with these influencers’ PSAs: There is no established link between testosterone and menopause. “Testosterone doesn’t change as a function of menopause — it changes with age,” says Dr. Stephanie Faubion, director of the Mayo Clinic’s Center for Women’s Health and medical director of the Menopause Society. Testosterone decreases gradually in women as they age, just as it does in men, but that decline isn’t associated with menopause.
And while testosterone therapy has been studied in women for decades, the best and most reliable research — a 2019 review of 36 randomized controlled trials — so far shows only benefits in sexual function, and only for postmenopausal women who have low sexual desire and are bothered by it. Many medical experts are concerned about the rising use of testosterone therapy for other symptoms — and they’re especially alarmed by the ubiquity of testosterone pellets, which have zero recommended-use cases in women. Many share Andersen’s concerns: If it turns out a patient reacts poorly to the pellet, there’s no way to adjust the dosage or stop the treatment. “People are told that the testosterone only lasts three months,” says Dr. Rebecca Dunsmoor-Su, an OB/GYN and the chief medical officer at Gennev, a menopause telehealth company. “I’ve had patients 9 and 12 months out from insertion who still have extremely high testosterone levels from them.” In addition, pellets are often made by compounding pharmacies. Drugs created in this way are not reviewed by the FDA for efficacy, safety, or quality, which means dosages can be inconsistent. Like all unregulated supplements, testosterone pellets and cream may deliver a higher or lower dose than advertised.
A number of women’s health-care providers I interviewed bemoaned the fact that there is not yet an FDA-approved testosterone product for women struggling with low libido — and not just because so many of their patients could benefit from it. The lack of a standardized product has also brought about a confusing gray area in the practice of medicine. Some doctors share misinformation about testosterone, conflating its use with female empowerment or gender equality, and others mistakenly lump testosterone into the larger, ongoing movement to destigmatize hormone replacement therapy in menopause.
In 2002, many menopausal women began to avoid HRT, which usually consists of estrogen therapy or a combination of estrogen and progesterone therapies. Their hesitance stemmed from an infamous study that led to flawed interpretations linking the treatment to an increased risk of heart problems and breast cancer — even though numerous studies since have shown the health benefits of taking supplemental estrogen can outweigh the risks. Last fall, a JAMA Health Forum study found that as of March 2020, just 5 percent of postmenopausal women were using HRT, as compared to 27 percent in 1999. As the cultural conversation shifts and discussion about HRT goes mainstream, it’s not yet clear whether American women have changed their minds about HRT for menopause symptoms, although a recent Canadian study showed the use of HRT in women ages 45 to 65 increased by 21 percent from 2020 to 2023. But what is clear in the U.S., at least, is that curiosity has been piqued. “What we’re having now is another pendulum swing back,” says Dr. Nanette Santoro, an OB/GYN and researcher at University of Colorado Medicine. She adds, sarcastically: “And now we’re going to add testosterone, because the more hormones, the better.”
Just a few years ago, if patients asked Dunsmoor-Su about testosterone, they were usually wondering whether it might improve their sex life, she says. “Now they are convinced, primarily by influencers, that testosterone is going to fix everything,” she tells me, listing off brain fog, mood disorders, fatigue, and loss of muscle and bone density as common patient complaints. “If used safely within a safe normal female range, testosterone really doesn’t increase energy or muscle building or any of those things,” says Dunsmoor-Su, who in 2021 wrote about her concerns around testosterone therapy for the journal Obstetrics & Gynecology. To get those effects, she adds, women’s testosterone would need to be near a level more typically seen in men.
Delivering testosterone to women at higher dosages is understudied, but many researchers and physicians I spoke to also stressed “masculinizing” physical side effects like scalp-hair loss, acne, a deepened voice, and an enlarged clitoris. “I’ve had patients who come in with full beards,” says Dunsmoor-Su. A few times, she has correctly guessed that a patient has been using testosterone pellets after noticing their larger-than-usual clitoris during a gynecological exam. Many of her patients shrug off the side effects, assuming that they can always choose to stop the therapy and everything will go back to normal. But these side effects are irreversible — we know this, Dunsmoor-Su says, from trans medicine: “You give them testosterone at a male level. They transition. They develop male features. If they lose their insurance coverage and lose their testosterone for some period of time, those features don’t go back.”
Some proponents of testosterone therapies push back against all the hand-wringing, arguing that there are studies suggesting a benefit — it’s just that those studies were conducted on men. They sometimes frame it as a feminist issue within medicine: If men have a dozen approved testosterone products for low testosterone caused by medical conditions, shouldn’t women be allowed to receive the same kind of relief?
“We can’t use testosterone in women because there might be side effects? All medications have side effects!” says Dr. Kelly Casperson, a urologist in Bellingham, Washington, who has become a public figure advocating that more midlife women deserve access to testosterone therapy. She adds: “We use other medications that have only been studied in men on women, and we don’t blink an eye. So why are we limiting this one?” Many women I spoke to were infuriated at the thought that there was a treatment that could help them feel better, and that getting it required byzantine methods. “It’s so frustrating to me that I have to meet someone in a parking lot and basically DIY this,” Andersen says. If there is a fix out there, many women reason, why shouldn’t they be able to access it?
The first time Dawn realized something was off with her clitoris, she was taking a shower. She looked down. Had it always looked like that? “It looked bigger,” she tells me. This was in January, about four months after she’d gotten her first testosterone pellet, and at first she thought she was imagining things. “But as time went on, I was like, That is not what it used to look like,” says Dawn, who is 52 and lives outside of New York. (She requested we use her first name only and keep her location vague to protect her privacy.) Her clitoris now protrudes more than it used to, making her extra self-conscious when she went swimsuit shopping this summer. She worried aloud to her boyfriend about whether it was visible through the bikini bottoms. “He’s like, You’re being ridiculous,” Dawn says. He hasn’t noticed a difference: “But to me, I know it’s big.”
About a decade and a divorce prior, she’d thrown herself into fitness and discovered a love for CrossFit and weight lifting. Becoming an active person in midlife changed her for the better, increasing her confidence and connecting her to a new community. But last summer, she started feeling tired all the time, and her joints ached to the point that she could no longer grasp the barbells. Menopause changed more than her relationship to her favorite hobbies. “It changes your personality,” she says. After getting her first pellet inserted, she felt more energetic and her joints stopped aching. She felt like herself again.
That’s the thing about testosterone therapy: Anecdotally, it rocks, especially in the beginning. Many women told me that, at first, they’d never felt better in their lives. “I would tell my husband, I just feel like a Terminator,” says Kristen Flynn, who is 52 and works as an insurance coordinator in Ohio. She first tried testosterone pellets in October 2022, hoping it would ease her brain fog. Within days of the insertion, she could concentrate again. “I started telling all my co-workers and friends my age, I found a fountain of youth,” she says. Before, she couldn’t run a mile without stopping. Now she could easily run five miles at a time. “I just felt awesome,” she adds. Another woman, a 51-year-old yoga instructor and a friend of Andersen’s in Colorado, got her first pellet in January 2023. Before that, she and her husband would sometimes go six weeks or longer without having sex. Shortly after getting the pellet, they did it four times in one weekend.
Give most people enough testosterone and they’ll feel great for a while, Dunsmoor-Su acknowledged. “That doesn’t mean it’s healthy or the right thing to do,” she says. “If I give people enough cocaine, I can make them feel great for some period of time, too.”
The safest route for American providers who want to responsibly prescribe testosterone to women is to use an FDA-approved gel formulated for men and instruct patients on how to carefully measure out one-tenth of the packet each day. (For comparison’s sake, a trans man would take the whole packet.) The process is prone to error. “One of my patients took the whole packet,” Santoro says, adding that this patient was actually a nurse.
Another pellet alternative: Enlist a compounding pharmacy to create a cream or gel with a dosage formulated for women. But with any compounding pharmacy comes unpredictability. And these treatments are generally not covered by insurance, which means this option can be both risky and expensive. The dozen women I spoke with told me they spent between $300 and $500 on testosterone therapy for a 10- to 12-week supply. In 2019, the FDA reported that the compounded hormone-therapy-maker BioTE Medical had failed to report more than 4,200 adverse events that had occurred between 2013 and 2018.
Many women’s health-care providers told me they’re sympathetic to patients who ask whether testosterone can address their overall feeling of wellness. “Women are exhausted,” says Dr. Susan Davis, an endocrinologist at Monash University in Melbourne, Australia. Davis has been studying testosterone therapy in women since the 1990s and is considered by many to be the foremost expert in the field. (“She’s like an encyclopedia,” says Santoro.) Yet Davis also cautioned that there are other factors at play. She pointed out that women may not feel well for a host of reasons having nothing to do with hormones: More older women today are likely to be working as compared to previous generations, and it’s becoming increasingly common for women to have children later in life — an exhausting endeavor. Midlife is also when many illnesses are more likely to occur in women, some of which are associated with menopause, but not all, Davis argued. “Everybody says, Oh, it’s because they’re menopausal,” she says. “It’s also age related. It’s an age where men start to get other conditions, too.”
In July, Casperson appeared on a FDA panel on menopause and hormone replacement therapy, arguing for the need for a testosterone product for women. During the five-minute talk, she linked testosterone to better bone health, energy, and even ambition, citing published research and anecdotes from her own patients. She ended with a plea: Fast-track a female-dosed drug; approve it for hypogonadism, or low testosterone, not just low sexual desire; and work with the DEA to declassify low-dose testosterone for women. “We can’t dismiss this as a lifestyle drug for women who know the secret handshake,” she said.
Six months and two pellets into her testosterone experiment, Flynn’s then-25-year-old son humbled her: “Mom, I can see your scalp,” he said. Flynn, the Ohio woman who at first felt like a Terminator on testosterone therapy, had gotten her pellets at a nearby med-spa, where she felt somewhat pressured to try them. (“When I think back on it, she had crappy hair,” Flynn says of the staffer who sold her on the pellets. “She had really big bald spots above her temples.”) After a month on the compounded cream, Andersen, too, experienced hair loss; as with Flynn, she was alerted to it by her then-14-year-old daughter. “She was like, Mom, this is embarrassing. You need to cut it,” Andersen says. For Danielle Saucier, who is 38 and lives in Louisiana, the worst side effect was extreme anxiety. After getting a testosterone pellet late last fall, she had around 20 panic attacks over the following five months, resulting in six trips to the emergency department and one 72-hour stay in a psychiatric unit. Both Flynn and Saucier switched providers and were each told by their new ones that the testosterone levels in their blood remained high much longer than the three months they were told about in advance.
Yet for some women, these downsides aren’t deal-breakers. Dawn credits the pellets with a renewed sense of confidence. No way is she giving that up. In fact, she tells me she’s considering increasing her dose; after a little more than a year on the pellets, her joints have started aching again, so she assumes she needs more. The change to her clitoris doesn’t particularly concern her, nor do the coarse hairs that routinely sprout from her chin. She has a system: “I have a dermaplane at my desk. I have one in my pocketbook. I have one in my car.”
The Colorado yoga instructor says she hasn’t experienced any side effects, and she isn’t particularly worried about the lack of research on the dose she’s taking. She frequently makes a point of telling her friends how she got the pellets, which have improved her sleep, her energy, and especially her sex life. “It’s been a joke that I’m saving the marriages in our suburb,” she tells me. The other day, her husband texted her while he was out for beers with his over-50 soccer league: Hey, what is it specifically that you’re on? He then sent a picture of four of his friends, who were facing the camera with pleading faces and prayer hands. “He’s like, ‘They’re begging because I told them that it’s changed our sex life,’” she says. She sent back a screenshot of a description of testosterone pellets and her prescriber’s name.
This article is for informational purposes only and is not intended to serve as medical advice. Consult with a doctor before starting any kind of treatment.
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