Conditions · Testosterone: cream vs pellets · 100% virtual
Testosterone for women: why I prescribe cream and not pellets
The short answer
I prescribe testosterone as a daily cream or gel, not as pellets. Every major guideline — the 2019 global consensus, ISSWSH, ACOG, The Menopause Society — recommends transdermal dosing and specifically advises against pellets, because pellets can push levels well above the normal female range and cannot be adjusted or taken out once they are in.
Last updated August 31, 2026
The difference is not the hormone. It's whether you can take it back.
Both are testosterone. What separates them is control. A cream is a daily dose: if your level runs high, or you notice acne or unwanted hair, we lower it or stop, and those effects usually settle. A pellet is a three-to-six-month commitment placed under the skin, and as ACOG puts it, it "is not designed to be removed, but instead to dissolve over time." If the dose is wrong, you wait it out.
That matters because of what the levels look like. In the largest published comparison — a retrospective study of 384 women on compounded pellets versus 155 women on FDA-approved hormone therapy — mean peak testosterone was about 194 ng/dL in the pellet group versus about 16 ng/dL in the approved-therapy group, and nine pellet patients exceeded 400 ng/dL. Side effects of any kind were reported in 57.6% of pellet patients versus 14.8%, and abnormal uterine bleeding in 55.3% versus 15.2%. That is one retrospective study with real limitations, and it is not proof that pellets caused every one of those outcomes — but it is the best comparison we have, and it points one direction.
Most androgen side effects reverse when the dose comes down. A few — voice deepening and clitoral enlargement — may not. There is a published case of a woman whose testosterone went from 6 to 320 ng/dL on pellets; after they were surgically removed her level normalized and the hirsutism improved, but the clitoromegaly did not. That is the specific reason the guidelines care so much about a dose you can undo.
I should be straight about what testosterone is actually for. The consensus indication is low sexual desire that is causing you distress, in postmenopausal women, after the rest of the picture has been evaluated. The evidence does not support prescribing it for energy, mood, brain fog, bone density, muscle, or weight — the societies say so explicitly. If someone has told you testosterone is the missing piece behind your fatigue, that is a claim ahead of the evidence.
Cream or gel vs pellets, side by side
Daily cream or gel
Applied daily to the skin; the route every major guideline recommends.
Implanted pellets
Placed under the skin in a minor procedure, typically reinserted every 3 to 6 months.
Daily cream or gel
Dose adjusts down or stops the same week. Acne or extra hair usually settles after a reduction.
Implanted pellets
Cannot be dose-adjusted after placement, and is not designed to be removed. Changing course means waiting it out or a second procedure.
Daily cream or gel
Dosed at roughly one-tenth of a man's dose, aiming to keep you inside the normal premenopausal range.
Implanted pellets
Associated with levels above the normal female range in published series — the specific reason the 2019 global consensus names pellets as not recommended.
Daily cream or gel
Blood level rechecked about 3 to 6 weeks after starting or changing, then a couple of times a year.
Implanted pellets
Levels swing across the cycle of each pellet — high after placement, low before the next one, which is what the "crash before my next pellet" feeling describes.
Daily cream or gel
Transfers by skin contact, so it needs washing hands, covering the site, and care around children and partners.
Implanted pellets
No transfer risk. Carries procedure risks instead: site infection, bleeding, and extrusion of the pellet.
Daily cream or gel
No FDA-approved women's product exists, so this is a men's product used off-label at a reduced dose — the approach ISSWSH, ACOG, The Menopause Society and the VA all describe.
Implanted pellets
Also not FDA-approved for women. Compounded pellets were flagged by a 2020 National Academies review as candidates for FDA's difficult-to-compound list; FDA has not acted on that recommendation.
What I weigh before prescribing anything
Why you want it
Low desire that bothers you is the indication the evidence supports. Fatigue, low mood or brain fog are worth taking seriously — but they usually trace to sleep, thyroid, iron, estrogen or something else, and testosterone is not the answer the data supports for them.
Whether the rest of the picture is settled
The consensus is that testosterone is considered after conventional hormone therapy and after the biopsychosocial causes of low desire have been evaluated — relationship, sleep, pain, medications, mood. Skipping that step is how a hormone gets blamed for a problem it cannot fix.
Your starting level
I check a baseline before starting, then recheck about 3 to 6 weeks after we start or change a dose, and a couple of times a year after that. The number is there to keep you in a safe range, not to diagnose you — no testosterone level tells us whether low desire is the problem.
A stop rule agreed in advance
The guidelines say to reassess at about six months and stop if it has not helped. I would rather set that expectation with you on day one than have you spend a year and a lot of money finding out.
What you're already on
If you are on pellets now, I am not going to tell you to have them dug out. ACOG's guidance is to check whether your levels are above the normal range and talk through the options from there — which is exactly what I would do.
Questions worth asking any doctor — including me
Bring these to your next appointment, wherever it is. A doctor who welcomes them is a good sign.
- What is my testosterone level now, and what range are you aiming for?
- If this dose turns out to be too high for me, how quickly can it be changed or stopped?
- Which of my symptoms do you actually expect testosterone to help, and which are you treating another way?
- How often will you recheck my level, and what result would make you lower the dose?
- At what point do we agree to stop if it hasn't helped?
- Is what you're prescribing an FDA-approved product used off-label, or a compounded one — and what's the difference in how it's tested?
- Do you or the practice have a financial interest in the product or procedure you're recommending?
Print these — and the questions for every other condition — on one page →
Questions I hear about this
Are testosterone pellets safe for women?
There are no randomized trials of testosterone pellets in women — a 2024 systematic review looked and found none. What exists is observational: one retrospective comparison found much higher hormone levels and substantially more side effects in pellet users than in women on FDA-approved therapy, and there are published case reports of virilization. Because of that, the 2019 global consensus, ISSWSH, ACOG, The Menopause Society and the VA all recommend against pellets and in favor of transdermal dosing. There is also industry-funded work reporting low complication rates; it comes from a pellet company's own reporting system, has no comparison group, and counts procedural complications rather than hormonal ones.
Are the side effects reversible?
Mostly, yes. Acne, oily skin and increased facial or body hair are dose-related and usually improve when the dose comes down or stops — which is the practical advantage of a daily cream. The exceptions are voice deepening and clitoral enlargement, which are associated with levels well above the normal female range and may be permanent. That asymmetry is the whole argument for a dose you can take back.
Is testosterone FDA-approved for women?
No. There is no FDA-approved testosterone product for women in the United States, in any form — cream, gel, injection or pellet. What guidelines describe is off-label use of an approved men's transdermal product at roughly one-tenth of the male dose. Anyone telling you their pellet is FDA-approved for women is mistaken. I would rather say that plainly than let it be discovered later.
Why do I feel great after a pellet and terrible before the next one?
That pattern is what a depot dose does: the level is highest in the weeks after placement and lowest before the next insertion. A daily cream is designed to hold a steadier level instead. If you are living on that cycle right now, it is worth checking where your level actually sits at both ends.
Will testosterone help my energy, mood, or weight?
The evidence says no, and I would rather tell you that before you pay for it. The 2019 consensus reviewed the trial data and found no established benefit for mood, general wellbeing, cognition, bone density, muscle strength or body composition. The Menopause Society said the same again in 2024. Low energy in midlife usually has a cause worth finding — thyroid, iron, sleep apnea, depression, undertreated menopause symptoms — and finding it beats adding a hormone that the data says will not move it.
I'm already on pellets. What now?
Nothing urgent, and no one should scare you. The reasonable next step is to see where your testosterone level actually is — ideally at the high point after an insertion, not just before the next one — and to look at whether the symptoms you started for actually improved. From there we can decide whether to let them run out and switch to a dose you control. That is a conversation, not an emergency.
How long is testosterone safe to take?
Honestly: the trial safety data run to about 24 months, and that is where the consensus statements stop. Long-term breast and cardiovascular safety in women are not established for any route. That is not a reason to refuse treatment for a real problem, but it is a reason to use the lowest dose that works, keep levels in range, and revisit the decision rather than treating it as permanent.
Sources
- Global Consensus Position Statement on the use of testosterone therapy for women — Davis SR et al., J Clin Endocrinol Metab (11 societies), 2019.
- Clinical practice guideline for the use of systemic testosterone for hypoactive sexual desire disorder in women — Parish SJ et al., ISSWSH, J Sex Med, 2021.
- Compounded bioidentical menopausal hormone therapy (Clinical Consensus No. 6) — ACOG, Obstet Gynecol, 2023.
- Safety assessment of compounded non-FDA-approved hormonal therapy versus FDA-approved hormonal therapy in treating postmenopausal women — Jiang X et al., Menopause, 2021.
- Practice Pearl: testosterone use for hypoactive sexual desire disorder in postmenopausal women — Parish SJ, Kling JM, The Menopause Society, 2023.
- The clinical utility of compounded bioidentical hormone therapy — pellets and the difficult-to-compound list — National Academies of Sciences, Engineering, and Medicine, 2020.
- Benefits and risks of testosterone pellets in women: a systematic review — Espitia de la Hoz F, Rev Colomb Endocrinol Diabetes Metab, 2024.
- Transdermal testosterone (off-label) for HSDD — clinical summary — US Department of Veterans Affairs, Pharmacy Benefits Management, 2025.
Related here: Menopause & hormone care · Conditions I evaluate for
Bring me this history — it's the part of the visit I care about most
One visit, $150, paid after we talk. No subscription, no package — and if I'm not the right physician for your situation, I'll say so. If medication is right for you, I try your insurance first.
I'm licensed in 15 states: Alabama, California, Florida, Georgia, Illinois, Indiana, Mississippi, Missouri, New Jersey, New York, Oklahoma, South Carolina, Tennessee, Texas, Washington. Please check yours before booking.
Book my $150 visitNot sure yet? Ask me a question first.