HRT for Women: Estrogen and Testosterone

A focused approach to supporting women’s hormone health

Hormone replacement therapy (HRT) comes with nuances and is not a one-size-fits-all treatment. Plus, there are some major differences in approaches to therapy, routes of administration, and how hormones affect women compared to men.

Women’s hormones naturally decline with age, especially after menopause, and with specific health conditions. Hormone replacement therapy (HRT) is used to restore hormonal balance and most commonly involves estrogen. (Estrogen is combined with progesterone when the uterus is still present, mainly to prevent uterine wall thickening and reduce the risk of endometrial cancer.)

The primary goal of HRT is symptom relief, with hot flashes and night sweats being the most often cited by women. Recent research is also demonstrating that, when begun early enough, HRT has cardioprotective effects* and helps to protect bone health.¹

Testosterone replacement is used more selectively. Unfortunately, there are no FDA-approved testosterone products indicated for women. However, it is not uncommon for doctors to prescribe compounded or low-dose formulations for the treatment of female hypoactive sexual desire disorder (HSDD) when other causes have been ruled out.

*Research studies indicate protection, not prevention, of heart disease, and the protective benefit is based on the timing between menopause and the start of TRT.

HRT: Estrogen

What does natural estrogen do?

Regulates body temperature
Maintains vaginal and urinary tissues
Supports bone density
Influences metabolism and cardiovascular health
Affects mood and sleep

What are common symptoms of low estrogen?

Hot flashes and/or flushing
Night sweats
Vaginal dryness and/or discomfort with sex
Sleep disturbances
Mood swings
Increased abdominal fat and metabolic changes
Cognitive disruptions or “brain fog”

Who benefits from estrogen replacement?

Women in perimenopause or early menopause with moderate to severe symptoms; individuals with premature ovarian insufficiency (POI); and women who have had their ovaries removed or damaged will benefit most from HRT. With regard to natural, age-related hormone decline, research shows that HRT has the most protective function and delivers the most relief when treatment starts within ten years of menopause.¹

How is estrogen administered?

Transdermal patches, sprays, and gels are available. Transdermal estrogen is often preferred because it avoids liver metabolism and has a lower risk of blood clots compared to oral forms. For localized treatment, vaginal creams, tablets, or rings are used. These products do not enter the body systemically and instead treat local symptoms like vaginal dryness.

When is progesterone combined with estrogen?

If a woman has a uterus, progesterone must be added to prevent overgrowth of the uterine lining, which could otherwise lead to cancer. If the uterus has been removed, progesterone is usually not required, but may be added for other low progesterone symptoms (insomnia).

HRT: Testosterone

What does testosterone do in women?

Testosterone is involved in sexual desire (libido), metabolic function and energy, muscle mass, mood, and cognitive performance.

What are common symptoms of low testosterone?

The bodily processes that require testosterone become impaired. This looks different for each woman, but can manifest as reduced sex drive, chronic fatigue or low energy, mood changes, and decreased muscle mass. However, these symptoms are nonspecific and can have many causes, so they are not enough on their own to diagnose a testosterone issue.

When and how is testosterone therapy used?

The only well-supported indication is for persistent low sexual desire causing distress (HSDD). It is typically considered only after other causes are addressed and/or after a trial of standard estrogen-based HRT. There is no specific “cutoff” level that defines female testosterone deficiency and improper use of testosterone in women can lead to irreversible effects, so working with a knowledgeable physician is paramount to this form of therapy. Plus, with no FDA-approved testosterone products for women in the U.S., use is considered off-label and requires careful dosing. Studies on the long-term use of testosterone in women are currently lacking.

This brings up an important point about the route of administration. Injections, pellets, and oral formulations are generally not recommended due to safety concerns and difficulty controlling dosage. Rather, low-dose topical creams or gels are most common and preferred.

What to Expect

When starting hormone replacement therapy, your physician will want to carefully review your medical history and symptoms. In some cases, a/b testing may be beneficial to establish a baseline. Once you begin therapy with estrogen, symptom relief often begins within weeks. With testosterone therapy, the results can vary more widely. Some women report immediate changes within days, while others experience a more delayed response within months. If no changes are perceived, some experts suggest stopping therapy at the six-month mark and exploring other options for symptom management.²

The dosing approach for both estrogen and testosterone should be to start with the lowest effective dose, and adjust based on symptom management, not hormone levels; relief matters more than lab values in this regard.

Regular follow-ups are in the best interest of the patient to assess symptom management and any side effects. Estrogen and/or progesterone dosing may take a few trials, at least initially, to get the balance correct, and adjustments are not uncommon even after several years. Ongoing reassessment is especially crucial for testosterone therapy.

Are There Any Risks?

Hormone therapy with both estrogen and testosterone requires careful evaluation, and may not be appropriate in women with:

History of hormone-sensitive cancers (e.g., breast or uterine)
Blood clotting disorders (no increased risk with transdermal estrogen)
Liver disease
Cardiovascular disease (especially for testosterone)
Unexplained vaginal bleeding

It’s also important for patients to understand that more of a hormone does not equate to it working better. Higher doses can increase risk without improving outcomes.

Here is a breakdown of the more common risks and benefits of estrogen and testosterone replacement therapies:

Therapy	Potential Benefits	Potential Risks
Estrogen (± Progesterone)	Reduces hot flashes, improves sleep and quality of life. Helps maintain bone density and prevent bone loss.	Increased risk of blood clots (higher with oral forms; lower with transdermal). Possible gallstones. Breast tenderness, nausea, headache. Breast cancer risk varies based on formulation and patient factors.
Testosterone	May improve sexual desire, arousal, and satisfaction in select patients.	Acne and increased hair growth. Voice deepening (may be irreversible). Changes in cholesterol/lipid profile. Clitoral enlargement.

Is HRT Right For You?

Possibly. And that is a conversation for you and your physician. Some things to consider are:

How many symptoms are affecting daily life
Personal and family medical history
Comfort with potential risks
Willingness to participate in ongoing monitoring

It cannot be stressed enough how important it is to see a qualified physician prior to beginning any form of hormone therapy. If you are exhibiting symptoms of low estrogen or testosterone and considering HRT, schedule a consultation with one of the doctors at Georgia Urology. We provide comprehensive assessments, and we want patients to understand exactly where they stand and what their options are.

Resources:

Khalifey, H. T., Mahereen, R., Adwan, R., Chahine, R., Kaidali, M., Mirza, S. F., Tullah, S. N., Shaikh, S., Hammad, S., & Sukkarieh, H. H. (2026). The impact of hormone replacement therapy on cardiovascular health in postmenopausal women: a narrative review. Frontiers in reproductive health, 8, 1745210. https://doi.org/10.3389/frph.2026.1745210.
Kapoor, E. (2021, December 9). Testosterone — Not just for men. Mayo Clinic Press. https://mcpress.mayoclinic.org/women-health/testosterone-not-just-for-men/.

This page was reviewed by Shaya Taghechian, MD

A native of Atlanta, Dr. Taghechian received her bachelor’s degree in biology and chemistry from Emory University. She continued at Emory University, in the School of Medicine, where she completed her medical degree. Following that, she completed a residency in surgery and urology at the University of Texas in Houston. She joined Georgia Urology in 2011.

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