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\n Illustration: Olivier Heiligers\n <\/p>\n
The nurse practitioner handed Charlotte Andersen an address. \u201cMeet me in this parking lot,\u201d she said. \u201cI can\u2019t help you here.\u201d By here, she meant the OB\/GYN clinic where she worked and where Andersen had made an appointment \u2014 on the recommendation of a few fellow 40-something girlfriends \u2014 to get on the list for the nurse practitioner\u2019s side business: providing pre- and postmenopausal women with off-label testosterone.<\/p>\n
The business isn\u2019t 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\u2019s health care together endorsed clinical guidelines<\/a> for the use of testosterone creams and patches on postmenopausal women bothered by low sexual desire, only four countries \u2014 Australia, New Zealand, South Africa, and the United Kingdom \u2014 allow products of that ilk to be sold.<\/p>\n Andersen\u2019s friends were not dissuaded by this fine print. They assured Andersen that the nurse practitioner\u2019s treatments had been \u201clife changing\u201d for what they all assumed were perimenopause-related symptoms: fatigue, moodiness, and insomnia.\u00a0\u201cI would say most of my friends are on it,\u201d says Andersen, who lives in Denver. \u201cAnd they mostly do the pellet \u2014 the shot in your butt.\u201d 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.<\/p>\n 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. \u201cShe was kind of pushing that,\u201d she tells me.<\/p>\n But Andersen couldn\u2019t help but fixate on the way the pellet works: Once it\u2019s inserted, it can\u2019t be removed. The testosterone dissolves in the bloodstream over several months and can only exit your system through the body\u2019s usual processes \u2014 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. \u201cThen we\u2019ll do the pellet,\u201d she said.<\/p>\n 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<\/a> and eased their depression and body aches<\/a>. They document the pellet-insertion process<\/a>: 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. \u201cThis place literally saved my life,\u201d says<\/a> 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<\/a> the telehealth platform Joi Women\u2019s Wellness, which prescribes testosterone and other hormone therapies. In that 2024 video, she adds, \u201cThere is help beyond your regular doctor who\u2019s telling you feeling like crap is normal.\u201d<\/p>\n But there\u2019s a serious yet under-the-radar problem with these influencers\u2019 PSAs: There is no established link between testosterone and menopause. \u201cTestosterone doesn\u2019t change as a function of menopause \u2014 it changes with age,\u201d says Dr. Stephanie Faubion, director of the Mayo Clinic\u2019s Center for Women\u2019s 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\u2019t associated with menopause.<\/p>\n And while testosterone therapy has been studied in women for decades, the best and most reliable research \u2014 a 2019 review<\/a> of 36 randomized controlled trials \u2014 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 \u2014 and they\u2019re especially alarmed by the ubiquity of testosterone pellets, which have zero recommended-use cases in women. Many share Andersen\u2019s concerns: If it turns out a patient reacts poorly to the pellet, there\u2019s no way to adjust the dosage or stop the treatment. \u201cPeople are told that the testosterone only lasts three months,\u201d says Dr. Rebecca Dunsmoor-Su, an OB\/GYN and the chief medical officer at Gennev, a menopause telehealth company. \u201cI\u2019ve had patients 9 and 12 months out from insertion who still have extremely high testosterone levels from them.\u201d In addition, pellets are often made by compounding pharmacies. Drugs created in this way are not reviewed<\/a> 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.<\/p>\n A number of women\u2019s health-care providers I interviewed bemoaned the fact that there is not yet an FDA-approved testosterone product for women struggling with low libido \u2014 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.<\/p>\n In 2002, many menopausal women began to avoid HRT, which usually<\/a> 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 \u2014 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<\/a> 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\u2019s 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. \u201cWhat we\u2019re having now is another pendulum swing back,\u201d says Dr. Nanette Santoro, an OB\/GYN and researcher at University of Colorado Medicine. She adds, sarcastically: \u201cAnd now we\u2019re going to add testosterone, because the more hormones, the better.\u201d<\/p>\n 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. \u201cNow they are convinced, primarily by influencers, that testosterone is going to fix everything,\u201d she tells me, listing off brain fog, mood disorders, fatigue, and loss of muscle and bone density as common patient complaints. \u201cIf used safely within a safe normal female range, testosterone really doesn\u2019t increase energy or muscle building or any of those things,\u201d says Dunsmoor-Su, who in 2021 wrote<\/a> about her concerns around testosterone therapy for the journal Obstetrics & Gynecology. To get those effects, she adds, women\u2019s testosterone would need to be near a level more typically seen in men.<\/p>\n Delivering testosterone to women at higher dosages is understudied, but many researchers and physicians I spoke to also stressed \u201cmasculinizing\u201d physical side effects like scalp-hair loss, acne, a deepened voice, and an enlarged clitoris. \u201cI\u2019ve had patients who come in with full beards,\u201d 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 \u2014 we know this, Dunsmoor-Su says, from trans medicine: \u201cYou 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\u2019t go back.\u201d<\/p>\n Some proponents of testosterone therapies push back against all the hand-wringing, arguing that there are studies suggesting a benefit \u2014 it\u2019s 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\u2019t women be allowed to receive the same kind of relief?<\/p>\n \u201cWe can\u2019t use testosterone in women because there might be side effects? All medications have side effects!\u201d 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: \u201cWe use other medications that have only been studied in men on women, and we don\u2019t blink an eye. So why are we limiting this one?\u201d 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. \u201cIt\u2019s so frustrating to me that I have to meet someone in a parking lot and basically DIY this,\u201d Andersen says. If there is a fix out there, many women reason, why shouldn\u2019t they be able to access it?<\/p>\n The first time Dawn realized something was off with her clitoris, she was taking a shower.\u00a0She looked down. Had it always looked like that? \u201cIt looked bigger,\u201d she tells me. This was in January, about four months after she\u2019d gotten her first testosterone pellet, and at first she thought she was imagining things. \u201cBut as time went on, I was like, That is not what it used to look like,\u201d 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. \u201cHe\u2019s like, You\u2019re being ridiculous,\u201d Dawn says. He hasn\u2019t noticed a difference: \u201cBut to me, I know it\u2019s big.\u201d<\/p>\n About a decade and a divorce prior, she\u2019d 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. \u201cIt changes your personality,\u201d she says. After getting her first pellet inserted, she felt more energetic and her joints stopped aching. She felt like herself again.<\/p>\n That\u2019s the thing about testosterone therapy: Anecdotally, it rocks, especially in the beginning. Many women told me that, at first, they\u2019d never felt better in their lives. \u201cI would tell my husband, I just feel like a Terminator,\u201d 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. \u201cI started telling all my co-workers and friends my age, I found a fountain of youth,\u201d she says. Before, she couldn\u2019t run a mile without stopping. Now she could easily run five miles at a time. \u201cI just felt awesome,\u201d she adds. Another woman, a 51-year-old yoga instructor and a friend of Andersen\u2019s 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.<\/p>\n Give most people enough testosterone and they\u2019ll feel great for a while, Dunsmoor-Su acknowledged. \u201cThat doesn\u2019t mean it\u2019s healthy or the right thing to do,\u201d she says. \u201cIf I give people enough cocaine, I can make them feel great for some period of time, too.\u201d<\/p>\n 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\u2019s sake, a trans man would take the whole packet.) The process is prone to error. \u201cOne of my patients took the whole packet,\u201d Santoro says, adding that this patient was actually a nurse.<\/p>\n 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.\u00a0In 2019, the FDA reported<\/a> 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.<\/p>\n Many women\u2019s health-care providers told me they\u2019re sympathetic to patients who ask whether testosterone can address their overall feeling of wellness. \u201cWomen are exhausted,\u201d 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. (\u201cShe\u2019s like an encyclopedia,\u201d 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<\/a> today<\/a> are likely to be working as compared to previous generations, and it\u2019s becoming increasingly common<\/a> for women to have children later in life \u2014 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. \u201cEverybody says, Oh, it\u2019s because they\u2019re menopausal,\u201d she says. \u201cIt\u2019s also age related. It\u2019s an age where men start to get other conditions, too.\u201d<\/p>\n