In competitive athletics, controversy over banned substances often takes center stage. Currently, no clearly established guidelines exist for the use of testosterone therapy for female athletes, even in the presence of a medical condition. Nonetheless, clinicians have treated women with testosterone for decades, striving to alleviate a variety of symptoms, none of which relate to augmenting athletic performance. This practice, however, often comes with uncertain benefits and risks. In this article, we will examine the many ways in which testosterone supplementation can help post-menopausal women navigate a number of unpleasant conditions, while also addressing the fairness of testosterone use among elite/competitive female athletes.
Why Athletes Seek Supplemental Testosterone
Male sex hormones such as testosterone, dihydrotestosterone, and dehydroepiandrosterone modulate the physiological mechanisms that improve athletic performance through a cascade of events in the body. By binding to androgen receptors on the surface of muscle fibers, testosterone increases calcium release from intracellular stores. This, in turn, activates mechanisms that increase the number of muscle fibers and satellite cells and regulate motor neuron size. In this manner, male hormones can enhance skeletal muscle activity, thereby improving both athletic performance and recovery.
The Female Body Tells a Different Story
While female athletic bodies may also benefit in the performance area by supplementing with testosterone, many women in the post-menopausal years have sought out male hormone replacement therapy for a variety of non-sports-related symptoms and conditions.
The symptoms with which post-menopausal women frequently present, all of which potentially relate back to androgen insufficiency, include the following:
- increased moodiness
- unexplained fatigue
- changes in sexual function/diminished interest
- cognitive “fogginess”
- vasomotor symptoms
- bone loss
- diminished muscular strength
The National Institute for Health and Care Excellence (NICE) guidelines state that a female might opt for testosterone supplementation to address and treat low sexual desire if traditional hormone replacement therapy (HRT) alone has not proven effective.
Assessing the Problem Often Proves Challenging
Sadly, despite nearly a century of global use and consistent patient demand, the Food and Drug Administration (FDA) has yet to approve a safe and universal testosterone formulation for women. Diagnostic challenges persist due to inconsistent laboratory assays and hormonal variability. The task of specifically identifying the normal range of testosterone has proved difficult to define; the majority of available tests fail to yield accuracy or precision in women.
Because most testosterone exists as protein bound to sex hormone-binding globulin (SHBG), only a small fraction circulates freely, making it difficult to assess reliably. You can estimate bioavailable testosterone using the Free Androgen Index (FAI). The FAI uses two blood test measurements taken from the same sample:
- Total Testosterone (the total amount of testosterone in your blood, both bound and unbound)
- Sex Hormone-Binding Globulin (SHBG) (a protein that binds to testosterone, making it inactive)
Professionals use a standard formula to calculate FAI: total testosterone divided by SHBG, then multiplied by 100. In a symptomatic woman with an FAI of <1%, a trial of testosterone supplementation seems prudent. Given these difficulties, the medical community prefers to rely more heavily on a symptom-based clinical approach rather than on serum levels.
The Current Position Statement
In the absence of FDA-approved formulations for women, many patients rely on therapies available at compounding pharmacies; however, these products often come with variable quality and oversight, sometimes mimicking the same preparations as one would prescribe for a male but with a dose modification. This regulatory gap limits access to standardized, evidence-based care.
Given the widespread and growing use of unregulated testosterone supplementation in women, the scientific community desperately needs more long-term randomized controlled trials (RCTs) in order to create clear dosing guidelines, safety parameters, and approval pathways. To address this, experts have begun to make a compelling case for a global consensus Position Statement on testosterone therapy for women, based on currently available evidence from previously conducted RCTs.
This Position Statement, developed by a consensus among the participating organizations, strives to inform health care professionals of the known benefits and potential risks of testosterone therapy for women. The aims include the following:
- to provide clear guidance as to which women might benefit from testosterone therapy
- to identify symptoms, signs, and conditions for which evidence does not support the prescribing of testosterone
- to explore areas of uncertainty
- to identify any prescribing practices with a potential to cause harm
Athletic Prowess Specific to Female Competitors
Researchers at Karolinska Institutet and the Swedish School of Sport and Health Sciences investigated the effects of testosterone supplementation in young active women through a randomized, placebo-controlled trial. The results, which appear in the British Journal of Sports Medicine, show a causal relationship between elevated male sex hormone levels and increased aerobic capacity in young women. Researchers also observed increased muscle mass but not muscle strength.
“These are expected results to some extent, but the fact that there is now a scientific study is relevant to the discussion regarding the regulations for hyperandrogenism in female athletes,” says gynecologist Angelica Linden Hirschberg, a professor at the Karolinska Institutet in Sweden, who spearheaded the study in 2018.
Dr. Hirschberg’s work involved 48 physically active women aged 18 to 35, who were randomly assigned to receive either 10 mg of testosterone per day or a placebo over 10 weeks. Neither the participants nor those administering the substance knew who received the testosterone versus the placebo. The researchers then measured the women’s aerobic capacity (a treadmill fitness test), anaerobic capacity (a bike stress test), and muscle strength using various tests.
They noted significant differences in creatine kinase and lactate dehydrogenase values –substances that help the body turn glucose into usable energy — pre-race as compared to immediately post-race, and again after 24-48 hours. Furthermore, statistical differences appeared in both the squat-jump and hand-grip test results following the ultramarathon, but not to any appreciable extent. Testosterone, estradiol, and the testosterone/estrogen ratio significantly correlated with muscle fatigue and likewise served as indirect markers of muscle damage. A multivariate analysis further corroborated testosterone’s protective role against muscle damage and severe fatigue. Fluctuations in endogenous testosterone levels also aligned with greater fatigability and muscle damage after the competition.
Enter the Anti-Doping Regulations
While we have learned that testosterone supplementation in moderation may have a profoundly positive effect on menopausal symptoms for many women, the rules differ for competitive athletes.
Current anti-doping regulations for competitive athletes prohibit testosterone replacement therapy, even when prescribed for medical reasons for women; male athletes, however, may receive supplemental testosterone with a medical exemption certificate. This restriction disproportionately affects women navigating hormonal changes such as perimenopause and menopause.
Denying testosterone therapy to female athletes potentially compromises their health. Testosterone treatment offers critical benefits, including improved body composition, functional capacity, insulin sensitivity, and cholesterol balance. It can also improve outcomes in cognitive decline, metabolic disorders, and reduced bone density.
A relatively recent research paper collected the views and experiences of various female athletes. It found the following startling statistics:
- 79% of women stopped or reduced exercising, due to menopause symptoms (55%), muscle and/or joint pain (51%) and loss of stamina (41%)
- Of those who later increased their exercise levels, 64% attributed this to hormone replacement therapy
- Of those using testosterone, 73% felt it helped them return to or increase their levels of physical activity
- 41% of competitive female athletes expressed a desire to use testosterone for menopausal symptom relief but were prohibited from doing so
Chris Cooper, Professor Emeritus of Biochemistry at the University of Essex, stated that despite growing interest in the issue, the challenge in gaining ethics approval to give healthy women testosterone had resulted in a lack of empirical studies.
Who Determines Fairness?
Some female athletes feel this conundrum represents a clash between the medical community and the competitive athletic community. According to the Universal Declaration of Human Rights and the Olympic Charter, “The practice of sport is a human right,” meaning equal access for all athletes regardless of gender. In reality, however, the anti-doping regulations actually create a strong health disparity for female competitors by denying them the use of testosterone replacement therapy even when deemed medically necessary for their overall health and functioning. Interestingly, the World Anti-Doping Agency (WADA) does allow women access to replacement estrogen and progesterone therapy.
One case that caused a significant upheaval involved South African Olympic gold medalist Caster Semenya. Ms. Semenya presents with a condition known as differences of sexual development (DSD). This condition describes how an individual’s reproductive organs/genitalia present as “mismatched” at birth – an individual may have male chromosomes yet display female genitalia, or have XX chromosomes yet have a penis. Some individuals actually display characteristics of both sexes at birth.
Does this necessarily place Ms. Semenya in the category of a trans female athlete? Current rules state that trans female athletes must keep their levels of natural testosterone below 5 nanomoles per liter of blood in order to compete in the female category. Semenya challenged these new rules, stating that athletes with DSD must take testosterone-reducing medication to compete in track events from 400m to the mile, or must change to another distance event. The athlete deemed the rules discriminatory and unfair.
Other Factors Can Influence Testosterone Levels in Both Genders
For competitive natural athletes who choose to abstain from testosterone supplementation, either as a matter of preference or due to regulatory restrictions, maintaining healthy testosterone levels takes a bit of extra work. It requires energy balance and optimal nutrition, including adequate macronutrients and micronutrients, especially for athletes prone to dieting and food restriction. Sleep, often overlooked, can greatly affect testosterone levels; testosterone secretion aligns closely with the rapid eye movement (REM) phase of sleep, highlighting the need for proper sleep hygiene and addressing sleep disorders.
As personal trainers, we know that moderate-to-high-intensity free-weight resistance exercises have the greatest effect on naturally increasing testosterone. Yet so much else remains on a spectrum, from unclear to controversial. Endocrine-disrupting chemicals can lower testosterone levels, as can cold-water plunges/immersion, while saunas do not seem to exert any effect. Radiofrequency electromagnetic radiation from modern electronic devices may harm the hypothalamic-pituitary-gonadal axis, and over-the-counter products like nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen may decrease testosterone levels.
Relative Energy Deficiency in Sport (RED-S), resulting from overtraining and under-fueling over extended periods, can diminish circulating testosterone levels, as can an excess of endurance-type exercise. In ultra-marathon runners, as mileage increases and recovery windows shrink, testosterone often trends downward, cortisol remains high for longer, and IGF-1 declines as the body attempts to reduce its metabolic demands. These occurrences generally indicate an adaptive response to prolonged stress and insufficient energy intake.
Safety Before Efficacy
When considering testosterone supplementation, athletes need to question not only its efficacy but also its overall safety. Testosterone appears safe when delivered transdermally and used at low doses. A dearth of long-term safety data on the use of testosterone in menopausal women exists beyond 2 years’ worth of use. However, transdermal testosterone does not seem to be associated with increased blood pressure and likewise has no adverse effects on the lipid profile. Evidence also shows no changes in renal function, liver function, or blood cell indices with transdermal testosterone in women.
A major concern for women with any type of hormone replacement therapy involves the risk, if any, of breast cancer. When used for a short period, no measurable increase in the risk of breast cancer was determined, and the hormones do not appear to stimulate the endometrium. However, doctors remain unsure of the safety of administering testosterone to women who currently have breast cancer, a decision best left to an oncologist.
Side effects can occasionally occur, including acne and increased hair growth at the site of application, but increased facial hair, alopecia (hair loss in areas where it typically grows), or voice deepening typically do not occur if testosterone levels remain within the female physiological range.
The discussion surrounding supplemental testosterone use in females remains complex. For non-athletic menopausal females, the decision seems a bit more straightforward. However, if severe menopausal symptoms pose a health risk to active, elite female athletes, the scales shift. As for the fairness of this situation and the ethics of transparency in competitive events, only more research will determine the path forward.
References
pubmed.ncbi.nlm.nih.gov/31615775/
blog.accessmedlab.com/why-the-fittest-men-in-the-room-can-have-the-lowest-t
pmc.ncbi.nlm.nih.gov/articles/PMC10745353/
pmc.ncbi.nlm.nih.gov/articles/PMC8508191/
pubmed.ncbi.nlm.nih.gov/41630126/
pubmed.ncbi.nlm.nih.gov/42110023/
pmc.ncbi.nlm.nih.gov/articles/PMC7098532/
pmc.ncbi.nlm.nih.gov/articles/PMC6821450/
drlouisenewson.co.uk/knowledge/the-impact-of-denying-female-athletes-testosterone
academic.oup.com/jsm/article-abstract/22/7/1298/8155759?redirectedFrom=fulltext&login=false
news.ki.se/increased-performance-in-female-athletes-after-testosterone-supplementation
theguardian.com/science/2019/oct/15/testosterone-boosts-womens-athletic-performance-study-shows
