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Female Testosterone for HSDD — Off-Label Transdermal Therapy

Testosterone remains off-label in the US for hypoactive sexual desire disorder (HSDD) in women. Transdermal testosterone has moderate efficacy for postmenopausal HSDD, the only evidence-based indication for testosterone therapy in women in the 2019 Global Consensus Position Statement.[2] Use physiologic female dosing and serum levels to avoid excess, not to correct a presumed laboratory deficiency.[1][2][21] Flibanserin has FDA approval for women younger than 65, including postmenopausal women.[20]

For the male testosterone-replacement framework (TRAVERSE 2023, hypogonadism, prostate-cancer safety) see Testosterone Replacement. For the clinical-conditions framework on female sexual dysfunction see Sexual Dysfunction (Women's Health). See Flibanserin and Bremelanotide for their distinct FDA-approved populations.[1][20]

Regulatory Landscape​

RegionStatus
United StatesNo FDA-approved female testosterone formulation. Treatment of female HSDD is off-label.[21]
Europe — historical productTransdermal testosterone patch (Intrinsa) was previously approved for surgically menopausal women receiving estrogen. Intrinsa was subsequently withdrawn.[21]
AustraliaTransdermal 1% testosterone cream (AndroFeme) approved by the TGA for postmenopausal HSDD.[1][22]

The 2006–2007 US prescribing review reported about 2 million testosterone prescriptions for women per year and described compounded prescribing without quantifying its share.[1][25] Compounded formulations are not subject to pharmacokinetic-profiling requirements, and their uncertain absorption may cause overdose and harm.

Indication and Diagnostic Framework​

The only evidence-based indication for testosterone therapy in women is postmenopausal HSDD[2], distress about decreased sexual desire that is not better explained by:

  • Coexisting medical / psychiatric condition.
  • Relationship factors.
  • Effects of a medication (especially SSRIs / SNRIs).
  • Genitourinary syndrome of menopause (GSM) — assess and treat pain and dryness with an appropriate GSM strategy.

Per the 2019 Global Consensus Position Statement (Davis 2019, endorsed by the International Menopause Society, Endocrine Society, EMAS, ISSM, ISSWSH, NAMS, FLASCYM, RCOG, International Society of Endocrinology, Endocrine Society of Australia and RANZCOG): testosterone therapy in postmenopausal women is not recommended for any other indication, including general well-being, cognitive performance, cardiovascular protection, bone density, or musculoskeletal benefit.[2]

Diagnosis is clinical. There is no serum-testosterone threshold that diagnoses HSDD; a low level should not be used to diagnose it. A full biopsychosocial assessment should precede treatment, addressing relationship factors, psychological distress, medications and medical conditions.[2][10]

Mechanism and Rationale​

Endogenous testosterone derives from the ovaries and adrenal glands; a 595-woman cross-sectional reference sample found the steepest serum decline early in reproductive life without an independent natural-menopause effect, and a 24-woman before–after study measured lower testosterone two weeks after bilateral oophorectomy.[1][27][28] The causal contribution of low testosterone to HSDD is unproven; there is no validated serum-testosterone threshold below which HSDD is more likely.[1][2]

Efficacy​

Islam 2019 Lancet Diabetes Endocrinol meta-analysis — the foundational evidence base​

Meta-analysis of 36 RCTs and 8,480 participants of testosterone in women, mostly postmenopausal.[3]

  • Satisfying sexual events (SSEs). Across RCTs in postmenopausal women, testosterone increased SSE frequency (mean difference 0.85; 95% CI 0.52–1.18) versus placebo or an active comparator, such as estrogen with or without progestogen.[3]
  • FSFI. Significant improvement in desire, arousal, orgasm, and pleasure domains.
  • Distress. Significantly reduced.
  • Effects on responsiveness, self-image, and reduced concerns about sexual function, all significantly improved.
  • Testosterone users reported more acne and hair growth than controls. No serious adverse events were recorded, but trials were short.[3]
  • Short-term non-oral lipid findings were reassuring. Testosterone treatment was associated with increased weight overall.[21]

Achilli 2017 Fertil Steril SR/meta-analysis​

Systematic review of 7 RCTs enrolling 3,035 postmenopausal women with HSDD of the transdermal testosterone patch, predominantly the 300 µg/day dose.[4] ACOG PB 213 cites a systematic review of seven RCTs (more than 3,000 women in natural or surgical menopause) of the 300-µg patch as its efficacy evidence, and notes that testosterone is not FDA approved for this indication and is contraindicated in pregnancy.[8]

  • Significant increases in satisfying sexual episodes, sexual activity, orgasms, and desire vs placebo.
  • No statistically significant serious-adverse-event difference was detected during the trials.

APHRODITE — Davis 2008 N Engl J Med (landmark trial in non-estrogen-using women)​

Double-blind trial randomized 814 postmenopausal women with HSDD not taking estrogen to 150 µg/day, 300 µg/day or placebo. Efficacy was assessed at 24 weeks and safety through 52 weeks, with a subgroup followed longer.[5]

  • At 24 weeks, satisfying sexual episodes increased 2.1 per four weeks with 300 µg/day versus 0.7 with placebo; the 150-µg dose did not significantly improve this primary outcome.[5]
  • Androgenic adverse events were more frequent with 300 µg/day.[5] Four breast cancers were diagnosed in testosterone recipients and none with placebo.[5]

Braunstein 2005 Arch Intern Med — surgically menopausal women​

This was one 24-week dose-ranging trial, with 447 women randomized to placebo or 150, 300 or 450 µg/day patches while taking oral estrogen. 318 (71%) completed it. The 300-µg group improved sexual desire and satisfying sexual activity compared with placebo; higher dosing did not establish greater benefit.[6]

Subsequent reviews​

The 2025 Obstet Gynecol expert update (Kling) confirms consistent efficacy of transdermal testosterone in postmenopausal HSDD and notes that two clinical guidelines now provide expert guidance on testosterone treatment and monitoring for HSDD in women.[11]

Dosing and Formulations​

FormulationStatusRecommendation
Transdermal 1% cream — AndroFeme 1 (Australia)TGA-registered (ARTG, 2020) for postmenopausal HSDDStart 0.5 mL (5 mg) daily on clean, dry upper outer thigh or buttock; avoid the genitalia and perineum. Wash hands after application, cover the dry site to prevent transfer to children or pregnant contacts, wash the site before anticipated skin contact, and avoid bathing, showering or swimming for at least 4 hours.[22] If response is inadequate after 3 months and total testosterone remains in the premenopausal range, titrate incrementally up to 1.0 mL (10 mg) daily with clinical and biochemical monitoring.[21][22] Australian product information also lists tree-nut sensitivity (almond oil), known or suspected breast or androgen-dependent cancer, prior thromboembolism, nephrotic syndrome, and hypercalcemia as contraindications.[22]
Intrinsa transdermal patch (300 µg/day)Withdrawn from European market; never available in the US300 µg/day (no longer commercially available) [21]
Fractionated dose of male transdermal product (e.g., 1% gel)Off-label US practiceAbout one-tenth of the male starting dose: one-tenth of a tube or packet daily (about 4 drops of gel from a resealable tube). The 300 µg/day figure is the delivery rate of the studied transdermal patch, not measured systemic exposure from this fractionated gel. Prefer resealable tubes to packets (evaporation). Distinguish milligrams applied from micrograms delivered by a patch. Warn about transfer to partners, children and pets; wash hands after application, cover the dried site, wash the application site before anticipated skin contact, and wash exposed skin after accidental contact.[21][22]
Compounded transdermal testosteroneNot regulator-approvedCannot be recommended because efficacy and safety data are lacking and dosing and absorption are uncertain (Global Consensus: acceptable only if no authorized equivalent exists; ISSWSH: not recommended)[2][21]
Oral testosteroneNot recommendedAdverse effects on lipoprotein levels (HDL ↓, LDL ↑) and inconsistent absorption[1][2]
Testosterone implants / pelletsNot recommendedMay produce supraphysiologic levels with erratic release, cannot be titrated after insertion, and may be difficult to locate for removal; excess exposure risks virilization.[21]
Testosterone injectionsNot recommendedSupraphysiologic levels; lacks safety data in women
Systemic DHEANot recommended for HSDD (Endocrine Society 2014, ISSWSH 2021; ACOG PB 213 Level A, for sexual interest/arousal disorders)Larger trials with validated instruments have not shown improved sexual function in postmenopausal women with normal adrenal function[7][8][21]

Monitoring ceiling, not a numerical target. ISSWSH uses levels to prevent overdosing, not to treat to a target: total testosterone should not significantly exceed the upper limit of the laboratory's premenopausal reference range. Do not escalate toward that limit when symptoms fail to improve. (For postmenopausal women who request therapy for properly diagnosed HSDD and have no contraindication, the 2014 Endocrine Society guideline suggested a 3–6-month testosterone trial dosed to a mid-normal premenopausal value.)[7][21]

Heald 2026 exploratory pharmacokinetics​

A pharmacokinetic study of 24 postmenopausal women with HSDD using Testogel 16.2 mg/g pump (20.25 mg applied every 3–4 days) alongside estrogen-containing HRT found substantial interindividual variability in testosterone levels (unadjusted Cmax range 1.3–26.1 nmol/L).[12]

Monitoring Protocol​

Based on the Global Consensus and ISSWSH guidance (the Global Consensus screens for overuse every 6 months; ISSWSH every 4–6 months once stable). A NAMS practice pearl summarizes both for clinicians.[2][18][21]

StepAction
BaselineTotal testosterone (prefer LC-MS/MS when available; interpret direct-assay results cautiously at female concentrations), SHBG, fasting lipids and liver tests; complete biopsychosocial assessment.[2][21]
3–6 weeksRepeat total testosterone to confirm levels remain in the premenopausal physiological range
Dose change / excess levelRecheck within 6 weeks after an increase; reduce excessive dosing and recheck in 2–3 weeks
Every 4–6 months once stableClinical assessment for androgen excess + total testosterone
6 monthsDiscontinue if no clinical response
OngoingLong-term safety remains unestablished; physiologic-dose safety data are unavailable beyond 24 months.[2]

Adverse Effects​

Androgenic effects​

  • Mild increases in acne and body / facial hair growth are expected at physiologic doses; these are generally reversible.[1][2]
  • Short-term physiologic-dose trials did not demonstrate an increase in alopecia, clitoromegaly or voice change; monitor for androgen excess.[2][21]
  • Supraphysiologic levels can cause acne, hirsutism, voice deepening and androgenic alopecia; voice change and clitoromegaly may be irreversible. If levels are supraphysiologic, reduce the dose and recheck in 2–3 weeks.[21][22]
  • Mild weight gain reported in some series.[1]

Lipid effects​

  • Oral testosterone adversely affects HDL and LDL cholesterol, one of the rationales for the transdermal-only recommendation.[1][3]
  • Non-oral / transdermal routes have a neutral lipid profile in short-term RCTs.[3]

Cardiovascular​

The cardiovascular safety data are conflicting, and long-term outcomes remain uncertain.

  • The Global Consensus Position Statement found that non-oral testosterone at physiologic doses showed no statistically significant adverse effects on lipid profiles over the short term, and no association with increases in blood pressure, blood glucose, or HbA1c. A nonsignificant trend for increased DVT risk was noted; RCTs excluded women at high cardiometabolic risk.[2]
  • Lopez 2023: In an Optum insurance-claims cohort of 25,796 cisgender women aged 30 years or older, testosterone prescriptions were associated with incident composite CVD (CAD, heart failure, stroke or myocardial infarction; 6,288 women; HR 1.24, 95% CI 1.15–1.34), CAD (HR 1.26, 95% CI 1.14–1.39), and stroke (HR 1.29, 95% CI 1.14–1.45).[15]
  • Agrawal 2024: In a propensity-matched TriNetX claims cohort of adult women with at least three systemic testosterone prescriptions within one year (including younger women), MACE within three years was less frequent than in matched controls (RR 0.64, 95% CI 0.51–0.81); DVT, PE, and breast-cancer diagnoses were also less frequent. Among women aged 56 and older, no statistically significant MACE (RR 0.84, 95% CI 0.64–1.10), DVT, or PE difference was detected. The two claims analyses point in opposite directions, and neither can separate confounding by indication from drug effect.[16]
  • Viana 2026 systematic review: no cardiovascular deaths in 13 RCTs of transdermal testosterone in cisgender women (n = 2,628; 8–52 weeks).[17]

Breast cancer​

  • Short-term transdermal testosterone does not increase mammographic breast density, and available RCT data suggest no increase in breast-cancer risk.[2]
  • Long-term, high-quality breast-safety studies of testosterone in women are lacking; the Global Consensus advises caution in hormone-sensitive breast cancer.[2]
  • Women with prior breast cancer were excluded from RCTs. Glynne 2026 Menopause, a small (n = 47) retrospective open-label study of breast-cancer survivors given transdermal testosterone for about 4 months, reported lower menopausal-symptom scores.[19]

Exclusions and safety assessment​

Screen before prescribing, using the ISSWSH exclusions.[21]

  • Pregnancy and lactation: do not use testosterone. For a woman with reproductive potential considered for off-label treatment, confirm adequate contraception and avoid treatment if pregnancy is planned or suspected because fetal virilization can occur.[21][22]
  • Androgen excess or concurrent antiandrogen therapy (e.g., finasteride, dutasteride): ISSWSH advises against treatment in these circumstances.
  • Liver disease or hyperlipidemia: listed as contraindications in ISSWSH guidance; assess before prescribing.[21]
  • Hormone-dependent neoplasia: consult the treating cancer specialist. Cardiovascular and thrombotic risk: assess individually because randomized safety trials were short and excluded women at high cardiometabolic risk; a history of thromboembolism contraindicates AndroFeme 1.[2][21][22]

Guideline Recommendations​

Society / guidelinePosition
2019 Global Consensus Position Statement (Davis 2019; endorsed by 11 international societies)[2]The only evidence-based indication for testosterone in women is postmenopausal HSDD; moderate therapeutic effect; physiologic dosing; the efficacy recommendation does not extend to injectables, pellets, or supraphysiologic preparations; an approved male formulation at a female-appropriate dose is reasonable if no approved female product exists, keeping levels in the premenopausal range; compounded "bioidentical" testosterone cannot be recommended unless no authorized equivalent exists; total testosterone at baseline, 3–6 weeks, then every 6 months; stop at 6 months without benefit
ACOG 2019 (Practice Bulletin 213)[8]Level B: short-term transdermal testosterone can be considered for postmenopausal women with sexual interest/arousal disorders after counseling about risks and unknown long-term effects; insufficient evidence for premenopausal women. Level C: 3–6 month trial with levels at baseline and after 3–6 weeks; stop at 6 months if no response; if continued, evaluation and levels every 6 months; long-term safety not studied
Endocrine Society 2014[7]Recommends against diagnosing androgen deficiency in healthy women and against general use of testosterone; suggests a 3–6-month trial for properly diagnosed postmenopausal HSDD when not contraindicated, dosed to a mid-normal premenopausal value; recommends against routine DHEA; notes no physiologic female preparation was available in the US and long-term safety data are lacking. Endorsed the 2019 Global Consensus
NAMSEndorsed the 2019 Global Consensus; the 2022 NAMS hormone therapy statement does not give a testosterone-for-HSDD recommendation.[2][18]
VA/DoD 2026 menopause guideline[23]Weak for: suggests transdermal testosterone for menopause-related interest, desire or arousal symptoms; its supporting evidence is limited to postmenopausal women.
AAFP 2025 (Dalrymple)[9]SORT B: short-term (6-month) transdermal testosterone may be used for postmenopausal desire/arousal disorders; the 300-µg patch is the most studied formulation but is unavailable. Monitor for androgen excess.
ISSWSH 2018 Process of Care (Clayton)[10]Hormonal therapy includes off-label testosterone in postmenopausal HSDD; guided by menopausal status within a biopsychosocial framework

Premenopausal Women​

The 2019 Global Consensus makes no recommendation for testosterone use in premenopausal women for sexual function or other outcomes, and ACOG Practice Bulletin 213 finds insufficient HSDD evidence.[2][8] For women with premature ovarian insufficiency, the 2024 ESHRE/ASRM/IMS guideline gives a strong recommendation (low-certainty evidence) to consider testosterone for HSDD after iatrogenic POI and a conditional recommendation (low-certainty evidence) after noniatrogenic POI, once other biopsychosocial causes are excluded.[26]

Despite this, a 2024 claims-database analysis (Agrawal) found that testosterone prescriptions for HSDD are increasing, with the highest rate of increase in women aged 41–55 years; only 2.54% of women diagnosed with HSDD received a testosterone prescription.[14] A 2026 systematic review found only two premenopausal RCTs (n = 31–261) with encouraging but preliminary results, against seven RCTs in postmenopausal women.[13]

For acquired, generalized HSDD in premenopausal women, the FDA-approved options are Flibanserin (daily PO) and Bremelanotide (on-demand SC).[1][20][24] See those pages for the full prescribing frameworks.

Counseling and Prescribing Pearls​

  • Strongest evidence is in postmenopausal HSDD. ISSWSH also discusses selected late-reproductive-age women, but that evidence is limited.[21]
  • Address GSM-related pain and dryness; treatment of contributing conditions may proceed alongside HSDD therapy when appropriate.[21]
  • Address relevant psychosocial and medical contributors; psychological and pharmacologic treatment can be combined.[21]
  • Diagnosis is clinical. A low testosterone level does not diagnose HSDD.
  • Set realistic expectations: the meta-analysis estimates +0.85 SSE/month versus placebo, without comparison with other HSDD drugs.
  • Transdermal route only. Oral testosterone is not recommended.
  • Use testosterone levels to prevent excessive dosing, not to target the upper end of the female range.[21]
  • Counsel explicitly on the off-label status in the US and the lack of long-term safety data as part of informed consent.
  • Discontinue at 6 months if no symptomatic response.
  • Heald 2026 PK data show substantial interindividual variability. Monitor serum levels; do not assume fixed-dose or fixed-level relationships.[12]
  • Compounded products vary in concentration or quality; when possible, use a regulator-approved formulation (a locally available female formulation or fractionated doses of approved male transdermal products with careful monitoring).
  • For AndroFeme 1, switch conjugated equine estrogen to a non-conjugated regimen before treatment, avoid concomitant tibolone, and monitor INR or prothrombin time more often when starting or stopping testosterone in patients taking anticoagulants.[22]
  • Women with prior breast cancer were excluded from RCTs.[19] Involve the treating oncology specialist.[19]

See Also​

References​

1. Davis SR. Sexual dysfunction in women. N Engl J Med. 2024;391(8):736–745. doi:10.1056/NEJMcp2313307

2. Davis SR, Baber R, Panay N, et al. Global consensus position statement on the use of testosterone therapy for women. J Clin Endocrinol Metab. 2019;104(10):4660–4666. doi:10.1210/jc.2019-01603

3. 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. Lancet Diabetes Endocrinol. 2019;7(10):754–766. doi:10.1016/S2213-8587(19)30189-5

4. Achilli C, Pundir J, Ramanathan P, et al. Efficacy and safety of transdermal testosterone in postmenopausal women with hypoactive sexual desire disorder: a systematic review and meta-analysis. Fertil Steril. 2017;107(2):475–482.e15. doi:10.1016/j.fertnstert.2016.10.028

5. Davis SR, Moreau M, Kroll R, et al. Testosterone for low libido in postmenopausal women not taking estrogen. N Engl J Med. 2008;359(19):2005–2017. doi:10.1056/NEJMoa0707302

6. Braunstein GD, Sundwall DA, Katz M, et al. Safety and efficacy of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women: a randomized, placebo-controlled trial. Arch Intern Med. 2005;165(14):1582–1589. doi:10.1001/archinte.165.14.1582

7. Wierman ME, Arlt W, Basson R, et al. Androgen therapy in women: a reappraisal: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2014;99(10):3489–3510. doi:10.1210/jc.2014-2260

8. American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology. Female sexual dysfunction: ACOG Practice Bulletin Number 213. Obstet Gynecol. 2019;134(1):e1–e18. doi:10.1097/AOG.0000000000003324

9. Dalrymple SN, Hoeg L, Thacker H. Female sexual dysfunction: common questions and answers. Am Fam Physician. 2025;111(5):433–442. PMID 40378324

10. Clayton AH, Goldstein I, Kim NN, et al. The International Society for the Study of Women's Sexual Health process of care for management of hypoactive sexual desire disorder in women. Mayo Clin Proc. 2018;93(4):467–487. doi:10.1016/j.mayocp.2017.11.002

11. Kling JM. Testosterone for the treatment of hypoactive sexual desire disorder in perimenopausal and postmenopausal women. Obstet Gynecol. 2025. doi:10.1097/AOG.0000000000006015

12. Heald A, Illangasekera Y, Rehman H, et al. A single-centre study to describe the changes in serum testosterone concentration following application of testosterone gel in postmenopausal women with hypoactive sexual desire disorder already receiving this as part of usual care in conjunction with oestrogen-containing HRT. Clin Endocrinol (Oxf). 2026. doi:10.1111/cen.70119

13. Furlan VA, Hammad MAM, Quesada S, et al. Testosterone therapy for female sexual dysfunction: a systematic review of the literature demonstrating outcomes in premenopausal and postmenopausal women. J Sex Med. 2026;23(8):qdag206. doi:10.1093/jsxmed/qdag206

14. Agrawal P, Lee YS, Grutman AJ, et al. Characteristics of systemic testosterone therapy for female hypoactive sexual desire disorder — a claims database analysis. J Sex Med. 2024;21(4):288–293. doi:10.1093/jsxmed/qdae013

15. Lopez DS, Mulla JS, El Haddad D, et al. Testosterone replacement therapy in relation with cardiovascular disease in cisgender women and transgender people. J Clin Endocrinol Metab. 2023;108(12):e1515–e1523. doi:10.1210/clinem/dgad388

16. Agrawal P, Singh SM, Hsueh J, et al. Testosterone therapy in females is not associated with increased cardiovascular or breast-cancer risk: a claims database analysis. J Sex Med. 2024;21(5):414–419. doi:10.1093/jsxmed/qdae032

17. Viana DPDC, Câmara LC, Alto LSM. Cardiovascular mortality associated with testosterone therapy in cisgender women and transgender men: a systematic review. Front Endocrinol (Lausanne). 2026;17:1789504. doi:10.3389/fendo.2026.1789504

18. Parish SJ, Kling JM. Testosterone use for hypoactive sexual desire disorder in postmenopausal women. Menopause. 2023;30(7):781–783. doi:10.1097/GME.0000000000002190

19. Glynne S, Kamal A, Neville A, et al. Use of transdermal testosterone to treat menopausal symptoms in women with a history of breast cancer: a small, retrospective, open-label study. Menopause. 2026. doi:10.1097/GME.0000000000002777

20. Sprout Pharmaceuticals. Addyi prescribing information, revised December 2025. Accessed September 11, 2026.

21. Parish SJ, Simon JA, Davis SR, et al. International Society for the Study of Women’s Sexual Health clinical practice guideline for the use of systemic testosterone for hypoactive sexual desire disorder in women. J Sex Med. 2021;18(5):849–867. doi:10.1016/j.jsxm.2020.10.009

22. Lawley Pharmaceuticals Pty Ltd. "Australian Product Information: AndroFeme 1 (testosterone) 1% w/v cream." Revised August 7, 2025. Product information.

23. Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for Menopause: Provider Summary. Version 1.0. August 2026. Recommendation 26. Provider summary.

24. Cosette Pharmaceuticals, Inc. "VYLEESI (bremelanotide) US prescribing information." DailyMed. Revised March 2024. Label.

25. Snabes MC, Simes SM. "Approved hormonal treatments for HSDD: an unmet medical need." J Sex Med. 2009;6(7):1846–1849. doi:10.1111/j.1743-6109.2009.01294.x

26. Panay N, Anderson RA, Bennie A, et al. "Evidence-based guideline: premature ovarian insufficiency." Hum Reprod Open. 2024;2024(4):hoae065. doi:10.1093/hropen/hoae065

27. Davison SL, Bell R, Donath S, Montalto JG, Davis SR. "Androgen levels in adult females: changes with age, menopause, and oophorectomy." J Clin Endocrinol Metab. 2005;90(7):3847–3853. doi:10.1210/jc.2005-0212

28. Stanczyk FZ, Chaikittisilpa S, Sriprasert I, Rafatnia A, Nadadur M, Mishell DR Jr. "Circulating androgen levels before and after oophorectomy in premenopausal and postmenopausal women." Climacteric. 2019;22(2):169–174. doi:10.1080/13697137.2018.1535584