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Estrogen and testosterone are not interchangeable menopause treatments. Systemic estrogen is the main hormone therapy for bothersome hot flashes and night sweats; low-dose vaginal estrogen is used for symptoms such as vaginal dryness. Testosterone may be considered for a narrower group of postmenopausal people with persistent, distressing low sexual desire after other possible causes have been assessed.
Which option, if any, makes sense depends on the symptoms being treated, whether the uterus is present, medical history, treatment route and local prescribing rules. Here is how their uses, benefits and risks differ.
What is the difference between estrogen and testosterone therapy for menopause?
Estrogen therapy can treat menopausal symptoms caused by falling estrogen levels, but its purpose depends on how it is delivered. Systemic estrogen reaches the bloodstream and is used mainly for hot flashes and night sweats. Low-dose vaginal estrogen acts locally to relieve genitourinary symptoms, including vaginal dryness, with much lower systemic exposure. Testosterone is considered for selected postmenopausal patients with persistent, distressing low sexual desire—not as a general treatment for menopause symptoms.
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| Therapy | Main menopause-related use | How it is delivered | Key consideration |
|---|---|---|---|
| Systemic estrogen | Bothersome hot flashes and night sweats; it can also protect bone | Pills, patches, gels, sprays or a vaginal ring, depending on the product and regimen | A person with a uterus generally needs a progestogen alongside systemic estrogen to reduce endometrial cancer risk |
| Low-dose vaginal estrogen | Genitourinary symptoms such as vaginal dryness | Local vaginal preparations, including rings, tablets and creams | Much less enters the circulation than with systemic therapy |
| Testosterone | Selected cases of distressing low sexual desire after other contributors are assessed | Prescribing options and approval status vary by country | Not a routine menopause treatment; a low measured level alone does not establish a need for treatment |
Systemic estrogen and low-dose vaginal estrogen are both estrogen treatments, but the amount that reaches the rest of the body and the symptom they target differ. Likewise, testosterone’s narrow possible role in desire is not the same as estrogen’s role in vasomotor symptoms or local vaginal symptoms. These differences help explain why a clinician may discuss one treatment, more than one, or neither, depending on the concern and the person’s circumstances.
What symptoms can estrogen therapy treat?
Systemic estrogen is the most effective hormone therapy for vasomotor symptoms—hot flashes and night sweats—and can also protect bone, according to The Menopause Society. In contrast, low-dose vaginal estrogen is directed at genitourinary syndrome of menopause (GSM), including vaginal dryness. It has much lower systemic exposure than systemic therapy and a lower risk profile in the patient guidance cited here.
Route is important because local and systemic estrogen are not simply different forms of the same treatment. A patient seeking relief from hot flashes needs a discussion about systemic treatment options; one seeking relief from vaginal dryness may instead discuss local treatment. The symptom target and the patient’s health history help determine the appropriate route.
The Menopause Society describes systemic forms as pills, patches, sprays, gels and a vaginal ring. ACOG also lists local vaginal rings, tablets and creams. Product and regimen matter: a vaginal ring may be used as a local preparation or as a systemic product, so the word “ring” alone does not tell you which kind of treatment is being discussed. Ask whether the specific product is intended to deliver local or systemic estrogen.
Menopause-related hot flashes are common, but their course varies. The North American Menopause Society’s 2023 nonhormone therapy position statement reports that vasomotor symptoms occur in up to 80% of menopausal women, last a mean of 7 to 9 years, and continue for more than 10 years in one-third of women. These are population-level figures, not an individual prediction or a measure of how likely a particular person is to respond to treatment.
Those figures help put the symptom burden in context, but they do not mean that everyone will have hot flashes, that symptoms follow the same timeline, or that hormone therapy is automatically the right choice. A person’s symptoms and priorities, health history and treatment preferences still matter. The fact that systemic estrogen can protect bone is another potential benefit to discuss, but the guidance here does not make it a stand-alone recommendation for every person.
Does estrogen therapy require a progestogen?
If a person still has a uterus, systemic estrogen is generally paired with a progestin or progestogen. Estrogen without that protection can thicken the uterine lining and increase endometrial cancer risk; adding a progestogen reduces that risk, according to ACOG.
Estrogen-only therapy may be an option for some people who do not have a uterus, but treatment should be chosen with a clinician. The decision also depends on symptoms, medical history, preferences and the specific regimen. Do not assume that a local vaginal preparation and a systemic regimen have the same requirements: ask the prescribing clinician how the guidance applies to the exact product and dose.
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This is a practical question to raise before starting systemic estrogen: “I have a uterus—what is the plan to protect the uterine lining?” The answer should be about the particular regimen being proposed, rather than a general assumption that all estrogen products work the same way. If you have had surgery or are unsure whether you still have a uterus, make that part of the conversation.
What are the risks of estrogen therapy?
Risks depend on factors including age, health history, whether the uterus is present, route, dose, formulation and duration. The patient guidance reviewed here identifies blood clots and stroke among the risks of systemic therapy; it also discusses gallbladder disease and breast cancer risk with some regimens. These statements do not establish an individual’s absolute likelihood of harm.
Oral estrogen carries a higher clot risk than some nonoral routes, according to the patient materials cited here. That difference does not make every nonoral option risk-free or establish which route is appropriate for a particular patient. A clinician can weigh personal risk factors and the expected benefits of treating the symptoms.
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1Fix the driver behind crashes, sound loss and screen glitches2Repair Windows errors before they cause bigger problems3Scan for outdated or missing drivers - takes under a minutePossible bothersome effects include spotting, breast soreness, nausea, bloating and headache. The Menopause Society says benefits generally outweigh risks for most healthy patients who start systemic hormone therapy before age 60 or within 10 years of menopause onset, after appropriate counseling. This is general guidance, not a personal eligibility rule or a substitute for an individualized discussion.
The available patient guidance does not provide a reliable table of absolute risk differences for each formulation, dose, duration and patient profile. A broad risk list cannot tell an individual what their personal probability will be; that assessment needs to account for their circumstances.
When weighing the risks, it is useful to separate a general warning from a personal estimate. The guidance identifies risks that should be discussed, and it notes that route can matter—for example, oral estrogen has higher clot risk than some nonoral routes. It does not provide enough information to calculate a particular person’s absolute risk from those broad statements. Age, medical history, regimen and duration all belong in a clinician’s assessment.
Also distinguish systemic treatment from low-dose vaginal treatment when asking about risk. The Menopause Society’s patient guidance describes the latter as having little systemic absorption and lower risks than systemic hormone therapy. That is not a reason to assume every vaginal product is identical or that individual questions do not matter; bring the product name and dose to the discussion and ask how its intended use affects your situation.
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What is testosterone used for after menopause?
Testosterone is considered for a much narrower indication: persistent, distressing low sexual desire in selected postmenopausal patients, often described as hypoactive sexual desire disorder (HSDD). British Menopause Society guidance says psychosocial, relationship-related, medication-related and other contributors should be assessed first; under its UK guidance, a trial of conventional hormone replacement therapy should precede consideration of testosterone.
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A low testosterone result by itself does not diagnose distressing low desire or establish that treatment is needed. The British Menopause Society’s clinician tool notes that circulating testosterone levels correlate poorly with symptoms. The decision should be based on a careful assessment of the person’s concern and possible contributing factors, rather than a laboratory number alone.
The BMS tool, Testosterone replacement in menopause (December 2022), puts the assessment this way: “Testosterone supplementation should only be considered in women who complain of low sexual desire after a biopsychosocial approach has excluded other causes such as relationship, psychological and medication related HSDD e.g. SSRIs/SNRIs.” In practical terms, the clinician should ask what the person is experiencing, whether it is distressing to them, and whether relationship circumstances, psychological factors or medicines could be contributing. This assessment is not a reason to dismiss the concern; it is a way to consider its possible causes before choosing treatment.
Testosterone is not a substitute for estrogen when the goal is relief from hot flashes or vaginal dryness. Nor is it a routine addition to menopause hormone therapy for everyone. Its possible role is limited to selected patients whose low desire remains distressing after relevant contributors and conventional treatment have been considered.
There is no basis in the guidance described here for treating a laboratory result in isolation or routinely adding testosterone as a general “hormone balance” measure. If a clinician raises it, useful questions include what symptom or diagnosis is being targeted, what other causes have been considered, what conventional options have been tried or discussed, and what the local prescribing rules allow.
Is testosterone approved for menopause treatment?
Approval and prescribing practice differ by country. In the United States, ACOG states that no testosterone formulation is FDA-approved for managing menopausal symptoms. Its 2023 clinical consensus, reaffirmed in 2026, advises against routine compounded hormone therapy when approved formulations exist and recommends against testosterone pellets because of safety-data gaps and the difficulty of removing a pellet once inserted.
ACOG identifies possible testosterone-related effects including acne, unwanted hair growth (hirsutism) and virilization, some of which may be irreversible. It also says the long-term effects on cardiovascular health and breast cancer risk are unknown. If compounded testosterone is being considered, ACOG recommends shared decision-making.
In the United Kingdom, British Menopause Society material describes using products licensed for men outside their product license. That is a UK prescribing context; it should not be generalized to the United States or assumed to describe the rules in another country. Ask a clinician about the local approval status and the reasons for any proposed off-label treatment.
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Random freezes, missing sound and display glitches usually trace back to one bad driver. Find and replace yours safely.Free scan · under a minuteThese differences make country-specific guidance important. “Not FDA-approved for menopausal symptoms” describes the US approval status; it does not by itself describe prescribing rules in every country. Conversely, the UK practice described by BMS does not establish what is approved or appropriate elsewhere. Ask whether a proposed treatment is licensed for the intended use locally, and whether it is being prescribed outside its license.
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Compounded products and pellets also raise different practical considerations from a standard, adjustable prescription. ACOG cautions against routine compounded hormone therapy when approved formulations exist and specifically advises against testosterone pellets because they cannot readily be removed if concerns arise. ACOG’s recommendation to use shared decision-making if compounded testosterone is considered means the patient and clinician should discuss the uncertainty and options, not that compounding is a routine first choice.
How should someone decide which therapy to discuss?
Start with the symptom that needs relief. A consultation can then address the treatment route, personal risks and—if systemic estrogen is considered—whether a progestogen is needed.
- Identify the main symptom. Note whether the concern is hot flashes or night sweats, vaginal dryness, low sexual desire, or more than one of these. Different symptoms may call for different approaches.
- Discuss systemic versus local treatment. Ask whether systemic estrogen is relevant for vasomotor symptoms or whether a local vaginal preparation is more appropriate for genitourinary symptoms.
- Clarify uterus status and regimen. If the uterus is present and systemic estrogen is being considered, ask how the recommended progestogen reduces endometrial risk and which regimen is appropriate.
- Review individual risk factors and preferences. Discuss medical history, route, dose, formulation, duration and any relevant concerns about clots, stroke, gallbladder disease or breast cancer.
- For low desire, look beyond a hormone result. Discuss relationship, psychological, medication-related and other possible contributors. If testosterone is proposed, ask why it is being considered, whether conventional treatment has been considered, what approval rules apply locally and how potential adverse effects will be addressed.
It can help to bring a short symptom history to the appointment: which symptoms are present, what is most bothersome, and what questions or treatment preferences you have. This is not a diagnostic checklist, but it can make the conversation more focused. If you are discussing low desire, you can also mention medicines or relationship and psychological factors that may be relevant, while keeping in mind that the clinician should assess the situation sensitively and in context.
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These discussions are especially important because the benefits and risks cannot be determined from the hormone name alone. A clinician should assess the symptom, the person’s circumstances and the specific treatment being considered. Hormone therapy is prescription treatment, not a generic product to choose without an individualized discussion.
Independent reader supportYour contribution helps us test, update, and keep practical guides available for everyone.Further reading
For an additional patient-friendly overview, ACOG’s book Menopause: What Your Ob-Gyn Wants You to Know is presented alongside its menopause information. It can provide further background, but it is not a substitute for advice about an individual’s symptoms or treatment.
Frequently Asked Questions
Is testosterone better than estrogen for menopause?
Neither is generally “better”; they are used for different concerns. Systemic estrogen is the most effective hormone therapy for bothersome hot flashes and night sweats, while low-dose vaginal estrogen can address genitourinary symptoms such as vaginal dryness. Testosterone has a much narrower possible role for selected postmenopausal patients with persistent, distressing low sexual desire after other contributors are assessed.
What does HSDD mean?
HSDD stands for hypoactive sexual desire disorder, a clinical term used in discussions of persistently low sexual desire that is distressing to the person. A clinician assesses the concern in context rather than treating the label—or a hormone result—as a diagnosis by itself.
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Can someone use estrogen and testosterone at the same time?
They address different symptoms, so using one does not automatically make the other necessary. Whether testosterone is appropriate alongside another menopause treatment depends on an individual assessment and the prescribing rules where the patient lives.
Why might a clinician ask about medicines or relationship factors before discussing testosterone?
Low desire can have medication-related, psychological, relationship and other contributors. British Menopause Society guidance recommends considering those factors as part of a biopsychosocial assessment before testosterone is considered.
Do I need progesterone with estrogen if I still have a uterus?
A person with a uterus generally needs a progestin or progestogen with systemic estrogen. Estrogen alone can thicken the uterine lining and increase endometrial cancer risk; adding a progestogen reduces that risk. Ask the clinician how this applies to the exact product and regimen being considered.
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Are testosterone pellets easy to stop if side effects occur?
ACOG recommends against testosterone pellets in its US guidance because of safety-data concerns and the difficulty of removing them after insertion. Anyone offered a pellet can ask about alternatives and how the proposed treatment could be stopped or adjusted.
Does a low testosterone blood test mean I need testosterone?
No. The British Menopause Society clinician tool says circulating testosterone levels correlate poorly with symptoms, and a low result alone does not diagnose distressing low desire or establish a need for treatment. The concern and possible contributing factors should be assessed in context.
Is vaginal estrogen the same as systemic estrogen?
No. Low-dose vaginal estrogen is directed at genitourinary symptoms and has much lower systemic exposure than systemic therapy, which is used mainly for hot flashes and night sweats. Ask whether a specific product is local or systemic; some product names or forms, such as a vaginal ring, can refer to different treatment uses.
Is testosterone FDA-approved for menopausal symptoms in the United States?
ACOG states that no testosterone formulation is FDA-approved for managing menopausal symptoms in the US. Prescribing practices differ in other countries, so ask about local approval status and whether any proposed use is off-label.
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The Bottom Line
Bottom line: Systemic estrogen is used mainly for bothersome hot flashes and night sweats, while low-dose vaginal estrogen targets genitourinary symptoms such as vaginal dryness. A person with a uterus generally needs a progestogen with systemic estrogen. Testosterone is not a routine menopause treatment; it may be considered only for selected postmenopausal patients with distressing low sexual desire after other contributors are assessed. The right discussion depends on the symptom, uterus status, personal risks, route and local prescribing rules.
