The Tea on T: What Men and Women Need to Know

By: Dr. Annahieta Kalantari, Owner of The Whole Human Health and Wellbeing

Dr. Annahieta Kalantari, DO (Dr. AK) is board certified in emergency medicine and is a lifestyle medicine physician. She spent a portion of her career in medicine education, enriching the minds of future doctors. The is now the owner of The Whole Human Health and Wellbeing and changing lives in the Philadelphia area community with concierge services!

Testosterone? Quite Possibly. Pellets? NO!

Hormone replacement therapy is everywhere right now. Personally, I am very interested in the topic because 1) I just hit menopause and 2) I prescribe hormones to patients. A lot of patients experience a lack of energy, loss of libido, sleep disturbances, and so many other symptoms with aging. I can attest to the fact that these changes suck. There is growing evidence supporting HRT in peri- and postmenopausal women to combat these symptoms (see last week’s post for more details on this), but what about testosterone to treat these symptoms in men and women?

At the time of writing this post, testosterone is only FDA-approved to treat men with low levels due to disorders of the testicles, pituitary gland, or brain that cause a condition called hypogonadism.1 That’s it. So, should anyone be on testosterone for any other reason? Let’s see what the evidence says.

Defining Low Testosterone

Defining “low” testosterone relies on both symptoms and lab values that differ between men and women. In adult men, total testosterone is traditionally considered normal when it ranges from approximately 300 to 1000 ng/dL.2 However, emerging evidence suggests that a one‐size‐fits‐all cutoff may not be appropriate—especially in younger men. For example, a recent analysis of men aged 20 to 44 years found that normal values varied substantially by age group. In that study, age-specific normal ranges were 409 to 558 ng/dL for men aged 20–24, 413 to 575 ng/dL for men aged 25–29, 359 to 498 ng/dL for men aged 30–34, 352 to 478 ng/dL for men aged 35–39, and 350 to 473 ng/dL for men aged 40–44. These data highlight that what is deemed “low” testosterone should be tailored to age, rather than applying a universal 300 ng/dL cutoff.3

In contrast, adult women have considerably lower levels, with normal total testosterone generally ranging from about 7 to 70 ng/dL depending on whether they are pre- or postmenopausal.2,4 Factors such as obesity or conditions such as polycystic ovarian syndrome also influence these levels, necessitating a careful consideration of clinical context and assay methodology when evaluating patients for low testosterone.

Evidence for Use in Men

 When it comes to using testosterone therapy to help with aging symptoms, the research is mixed. One study found that while testosterone provided small improvements in areas like sexual function and overall energy, there was also an observed increase in heart-related problems.5

Another review by Corona and colleagues focused on mood, strength, and quality of life. The results were very interesting. They found that many men experienced some benefits in these areas when using testosterone, but the studies that found a clear benefit were funded by the pharmaceutical companies researching their own product.6 They also found that most of these studies involved men who already had clinically low testosterone levels due to medical conditions, not just age-related declines,6making it difficult to apply the results to all men regardless of their testosterone levels.

My takeaway from these studies is that if a male has symptoms and a low lab value, testosterone therapy may be valuable. However, if he is experiencing symptoms and has normal labs, other causes of those symptoms should be investigated. If that investigation comes up empty, he should be presented with the evidence and risks of testosterone so that he can make an informed decision about whether to proceed. And if he does decide to do so, he should be under the care of a physician who can monitor his cardiovascular risks while on therapy. The decision to use testosterone—especially off-label—should be made carefully, weighing both potential gains and possible risks.

Evidence for Use in Women

 Let’s start this section by saying the evidence on the use of testosterone in women is abysmal. There isn’t even a well-established dosing regimen for women. Dosing is off-label and modified from what is prescribed for men.

A global consensus statement released in 2019 reviewed all the available data at that time and concluded the only evidence-based indication for testosterone therapy in women is for the treatment of hypoactive sexual desire disorder/dysfunction (HSDD).7 But even this recommendation was nuanced. The group emphasized that the goal is to reach “normal physiologic testosterone levels in premenopausal women” and explicitly stated that there is very little evidence to support testosterone treatment in premenopausal women. They also noted that regular blood draws are not required and that the use of testosterone to improve overall wellbeing and cognitive function is not supported by existing data. Lastly, they stated that cardiovascular and cancer risks is challenging because some women in the studies were also on combination hormone therapy.7

Another review article found significant benefits in testosterone use for women compared to placebo or HRT in terms of sexual function, frequency, desire, arousal, and orgasm. However, it was not without risks. Patients experienced increases in LDL cholesterol and reductions in HDL cholesterol. They also reported weight gain (though the composition, muscle versus fat, was not determined), increased acne, and undesirable hair growth. Some of these adverse effects were less common when using a patch or cream rather than oral preparations.8

Because of the lack of studies, several unknowns remain regarding testosterone therapy in women. Women convert testosterone into estrogen, so the potential effects on endometrial cancer, breast cancer, and cardiovascular events remain unclear. Some studies suggest an increased risk, while others do not.

My take-home message for women is similar to by stance on off-label testosterone use in men. There are proven benefits, but there are also risks. Other possible causes of symptoms should be investigated first. (For more detailed information on this topic, I highly recommend the podcast You Are Not Broken, by Dr. Kelly Casperson – a board-certified urologist and fellow myth-buster who follows the evidence.)

Routes of Administration

There are several different routes of administration available for testosterone therapy, each with its own set of advantages and disadvantages. The most common forms are listed here:

Subcutaneous Pellets

• Advantages: Requires less frequent dosing (every 3-6 months).

• Disadvantages: Unpredictable absorption rates,7 risk of supraphysiologic levels leading to adverse effects such as male pattern balding, excess hair growth, and acne,8,10 and high rates of pellet extrusion, infection, scar formation.8,11

  
  

Injectable Testosterone

• Advantages: Can rapidly achieve desired hormone levels, less frequent dosing (every 1-4 weeks).

  • Disadvantages: Can increase hemoglobin and hematocrit levels,12 raising the risk of blood clots. Injections are painful, and dosing schedule can lead to hormone fluctuations that cause mood and energy swings.13

    
    

Oral Preparations (Tablets, Films)

• Advantages: Easy to use, no injections required, and relatively stable hormone levels.

• Disadvantages: Can increase LDL cholesterol and lower HDL cholesterol. Long-term effects remain uncertain.8

Transdermal Gels and Patches

• Advantages: Provide steady hormone levels and allow for easy dose adjustments.

• Disadvantages: Potential for skin irritation, risk of accidental hormone transfer to contact, increased acne and hair growth,8and a rise in prostate-specific antigen (PSA) levels in men.13

These findings highlight the importance of considering both the benefits and potential risks when selecting testosterone delivery methods. Personally, I say “NO” to the pellets. There is currently only one FDA-approved pellet, which received approval in 1972—before there was a clear understanding of how testosterone is delivered via pellet.13

With only one FDA-approved pellet on the market, compounding pharmacies have filled the gap by creating a myriad of pellet preparations. And while not all compounding pharmacies are bad (I work with one), they are not all regulated the same way—leaving room to “fudge” study results. In 2019, the FDA issued a warning about obtaining pellets from compounding pharmacies, as some neglected to report adverse effects such as heart attacks, cancers, strokes, and blood clots linked to their pellets.14

I find this alarming, and thus, I do not recommend any pellets.

Final Answer?

Is there potential to feel better with testosterone? Absolutely. But at what cost? Financially, this is big business with estimates up to $6 billion per year spent on compounded hormone sales.15 So, this therapy can really hurt your wallet. But the financial hit isn’t the biggest concern. There is a serious health cost as well.

Hormones are not without risk, and every medication should be approached with a risk-benefit analysis. It’s one thing to weigh that risk against a serious medical condition where the treatment benefit far exceeds the potential harms. It’s another thing entirely when we are using testosterone off-label—without the same degree of proven benefit, but the same (or possibly even higher) level of risk.

Let me be clear: I am not anti-hormone and prescribe them readily. But I do so only after investigating other possible causes for a patient’s symptoms and only after a thorough, informed discussion so that patients fully understand what they’re signing up for.

I also do not upsell any medications. I have no financial gain in this game, and that transparency helps build trust when I have these conversations with my patients.

While I am a doctor, I am not your doctor. If you’re considering testosterone therapy, have the discussion with your physician about what you’re experiencing and what the best next steps are for you.

Disclaimer: This blog post is for informational purposes only and should not substitute for professional medical advice. Always consult a healthcare professional before initiating any therapy.

Want to learn more? Reach out to Dr. AK!!

The Whole Human Health and Wellbeing

(Located in the Philadelphia suburbs/Montgomery County)

https://thewholehumanhealthandwellbeing.com

610-840-6553

drak@wholehumandoctor.com

References

1. Food and Drug Administration. FDA cautions about using testosterone products for low testosterone due to aging; requires labeling change to inform of possible increased risk of heart attack and stroke with use. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-cautions-about-using-testosterone-products-low-testosterone-due

2. Labcorp. Testosterone, Total: Women, Children and Hypogonadal Males (LC-MS/MS). Accessed February 18, 2025. https://www.labcorp.com/tests/070001/testosterone-total-women-children-and-hypogonadal-males-lc-ms-ms

3. Zhu A, Andino J, Daignault-Newton S, Chopra Z, Sarma A, Dupree JM. What is a normal testosterone level for young men? Rethinking the 300 ng/dL cutoff for testosterone deficiency in men 20-44 years old. The Journal of urology. 2022;208(6):1295-1302.

4. Skiba MA, Bell RJ, Islam RM, Handelsman DJ, Desai R, Davis SR. Androgens during the reproductive years: what is normal for women? The Journal of Clinical Endocrinology & Metabolism. 2019;104(11):5382-5392.

5. Xu L, Freeman G, Cowling BJ, Schooling CM. Testosterone therapy and cardiovascular events among men: a systematic review and meta-analysis of placebo-controlled randomized trials. BMC medicine. 2013;11:1-12.

6. Corona G, Rastrelli G, Di Pasquale G, Sforza A, Mannucci E, Maggi M. Testosterone and cardiovascular risk: meta-analysis of interventional studies. The journal of sexual medicine. 2018;15(6):820-838.

7. Davis SR, Baber R, Panay N, et al. Global consensus position statement on the use of testosterone therapy for women. The journal of sexual medicine. 2019;16(9):1331-1337.

8. Islam RM, Bell RJ, Green S, Page MJ, Davis SR. Safety and efficacy of testosterone for women: a systematic review and meta-analysis of randomised controlled trial data. The lancet Diabetes & endocrinology. 2019;7(10):754-766.

9. Casperson K. Testosterone can help with libido, energy, focus and more. You Are Not Broken.

10. Jiang X, Bossert A, Parthasarathy KN, et al. Safety assessment of compounded non-FDA-approved hormonal therapy versus FDA-approved hormonal therapy in treating postmenopausal women. Menopause. 2021;28(8):867-874.

11. Manica LAH, Cohen PR. Testosterone pellet associated dermatitis: report and review of testopel-related cutaneous adverse effects. Cureus. 2017;9(8)

12. Ohlander SJ, Varghese B, Pastuszak AW. Erythrocytosis following testosterone therapy. Sexual medicine reviews. 2018;6(1):77-85.

13. McCullough AR, Khan M. Testosterone replacement options. Urologic Clinics. 2022;49(4):679-693.

14. Food and Drug Administration. Statement on improving adverse event reporting of compounded drugs to protect patients. https://www.fda.gov/news-events/press-announcements/statement-improving-adverse-event-reporting-compounded-drugs-protect-patients

15. Stuenkel CA, Manson JE. Compounded bioidentical hormone therapy: the National Academies weigh in. JAMA Internal Medicine. 2021;181(3):370-371.