Testosterone: Confidence, Libido, and the Death of People-Pleasing

Is testosterone really making women “ragey”… or is it just giving us fewer f*$ks to give? Or is it all down to age and experience?

In Episode 4 of On the ’Mones, pharmacist Kate Thomas dives into one of the most misunderstood hormones in women’s health: testosterone. Along the way, she unpacks a petty (and infuriating) pharmacy encounter that sparks a much bigger conversation about boundaries, ageing, assertiveness, and how much bad behaviour women in healthcare are expected to tolerate.

This episode covers:

• What testosterone actually does in women (hint: it’s not a “male hormone”)
• Why women naturally produce testosterone - and what happens as levels decline in perimenopause and menopause
• The evidence-based role of testosterone in HRT
• Hypoactive Sexual Desire Disorder (HSDD): what it is, how common it is, and why it’s so under-treated
• Why HSDD is a clinical diagnosis, not a blood test result
• How testosterone therapy compares to how easily erectile dysfunction is treated in men
• Safety, side effects, and monitoring of transdermal testosterone (including AndroFeme)
• Why testosterone doesn’t cause “rage” - but can reduce people-pleasing and tolerance for bullshit
• The difference between assertiveness and aggression in midlife women

Woo of the Week:
Kate takes aim at “natural testosterone boosters,” DHEA supplements, and adrenal support blends, breaking down why these products are often less safe, less predictable, and less evidence-based than properly prescribed testosterone therapy.

You’ll also hear:

• Why supplements that “boost testosterone naturally” are basically hormone roulette
• The difference between oral DHEA, vaginal DHEA, and prescription testosterone
• Why control and precision, not “natural”, are what actually make treatments safer

If you’re navigating perimenopause, menopause, libido changes, or feeling like you tolerate far less nonsense than you used to, this episode will give you language, clarity, and evidence to back yourself.

Key takeaway:
Testosterone isn’t a personality transplant.
It’s not a cure-all.
And it doesn’t fix context.

But for the right woman, with the right diagnosis, at the right dose, it deserves a seat at the grown-up medical table. Whether you are in perimenopause, approaching menopause, or simply trying to understand your hormones, I've got you. 

🎧 Listen now to Episode 4 of On the ’Mones - where hormones, healthcare, and real life collide.

Read more about topics in this episode: www.medicationclarity.com.au

Transcript

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SPEAKER_00 0:00

You're listening to On the Moans, where we have conversations about hormones, midlife, and the moments that make us wonder, is it just me? I'm Kate. I'm a 48-year-old pharmacist and newly minted perimenopausal oversharer. This is where we talk openly about the changes we aren't prepared for, so we never have to feel alone in them again. I acknowledge the Camaragle people of the Iora Nation, the traditional custodians of the land which I am recording today. I pay my respects to elders past and present, and I extend that respect to all Aboriginal and Torres Strait Islander peoples listening. Always was, always will be, Aboriginal Land. Hello friends, welcome to episode four of On the Moans. We'll talk about testosterone and its place in HRT, and I've got another beautiful woo of the week. But first, can we talk about Fluffy the Dog Brown and a very petty interaction I had with the dog zoner Susan that really got my blood pressure up. This interaction has been living rent-free in my head. I really need to move on, but I'm ruminating on it. I know, I know. Having negative thoughts is like drinking poison and expecting the other person to die, blah blah blah. I was working in the pharmacy, and for anyone who hasn't worked in community pharmacy, here's a little bit of context. We keep a lot of people's prescriptions on file. Either they ring a head, email a head, or just know they're there so they don't lose or misplace them at home. In Australia, if we give a prescription back to a patient by law, it has to have one of those pharmacy backing folders, you know, with our name and phone number and details on it. So over time I've developed a bit of pattern recognition. If I get given a script with a backing folder, I assume we're giving it back to the person. If the script has no backing folder, I assume we probably keep it on file in the pharmacy. And this becomes relevant. A script is handed to me by the shop girl. It's a vet script for eye drops for a dog. The name on the script is Fluffy the Dog Brown. No backing folder. Totally normal. We do heaps of vet scripts, mostly for dogs. Actually, always for dogs. So I dispense it as normal, and then because everyone else in the shop is busy, I step out from behind the dispensary area and call script for brown. And this sour-faced old woman steps forward and says in the most condescending tone imaginable, I'm Fluffy's owner. The script isn't for me. Okay, love. So I laugh because duh. And say, Yeah, I got that, given the name is Fluffy the Dog Brown. And so far, so good. Or so I think. And then I ask, very neutrally, do we keep your scripts on file here? Because remember, no backing folder. And she replies, sharp as a whip. As I said, it's not my script, it's for the dog. And no, you don't keep it. I keep it. Because otherwise, how would I be able to get it when I need it if you kept it here? And at this point, I'm still trying to be light, still trying to be upbeat, but I can feel a bit of tone creeping into my own voice, and my heart rate has risen a notch. So I gesture to the literal wall of script files all lined up behind me and say with a smile, which is probably more of a grimace, to be fair, I'm just checking because as you can see, we keep many people's scripts on file. They just let us know when they need them. But of course you can take it back. I'm not trying to keep it from you. I'm just asking so I know I'm doing the right thing for you. Which is true, although my tone is no longer angelic. And by this time I've started to walk over to the till so she can pay and leave and take her negative energy with her. I say, How would you like to pay? And she looks at me like I've asked her the most offensive question of her life and says, Cash. Of course, I always pay cash because if I used my card, you would charge me a fee. And at this point I am now seething internally. But it's not my shop, it's not my business. So instead of saying what I actually want to say, my frontal lobe engages and I manage through gritted teeth. Are you okay? You seem very upset. And look, I'll be honest, I wasn't being completely genuine. I really didn't give a toss at this stage whether she was okay or not. And she replies, Yes, I'm perfectly healthy. So I say, You might be perfectly healthy, but are you okay? Because you seem very agitated. And she launches into a story about a sandwich she bought the other day, and the shop supposedly didn't keep cash, and when she got home, she'd been charged a transaction fee, even though they said they didn't charge fees, but they did, and so on and so on. Honestly, by this point, I've taken her cash, I've given her her change, I've handed over Fluffy's eye drops. So I start to turn and walk back to the dispensary, and as say as I do, gosh, that must have been really difficult for you. And I am shaking with rage. I get back to the dispensary and I say to my boss, Oh my god, that old woman was such a grumpy, sour, miserable and my boss glances up, sees her leaving, and says, Oh yeah, that's Susan. She's always unpleasant. That's just how she is, and goes back to her job as if this was nothing out of the ordinary. And something inside me just it snaps because suddenly I'm saying, in healthcare we go on and on and on about not tolerating bad behaviour, but we do every single day. In the hospitals where I worked, there were signs everywhere. We do not tolerate bullying or abuse of staff. And then you walk past a room and there's a nurse being verbally abused whilst trying to care for someone, or the ward clerk cops it from a family member because something outside of their control did or didn't happen, or and we just accept it because it's how people are. And later, when I've cooled down, I'm thinking about two things. The first is this I didn't manage myself well. I was passive aggressive. What I should have said was something like, I don't like the way you're speaking to me. I'm trying to do the right thing for you, and you're being very rude. Calm, clear, boundaried, not sarcastic, not poking, not needling. And that part is on me. It reminds me of my lovely friend who had an altercation, a small accident in her Fiat 500 with some man's massive BMW in a car park. And he got out of his car and he was effing and blinding at her, and she's all of five foot two, a petite little thing, and she's in her sixties, and he's standing over her yelling, and she just puts her hand up and said, I don't need your negative energy, and walked away to call her insurer, and it really took the air out of his sails. I need to be more put together to be able to reply directly. Oh well, better luck next time, Kate. The second thought is the one that really got me. Is my visceral reaction a sign that I'm getting older and I just don't have the fucks left to give? Or is this a side effect of my testosterone supplementation? Because context, I'm on Androphem 1%. I've had a modest but genuinely great response. No side effects that I've noticed. No weird hair growth, no hair loss, no oily skin, no acne. But do I have rage? The evidence-based answer is at physiologically female doses, testosterone does not cause rage. What it can do is increase assertiveness, reduce tolerance for bullshit, improve confidence, reduce people pleasing. And if you've spent decades working in healthcare swallowing your reactions, that shift can feel intense. So what was it? Was it the hormones? Maybe a tiny bit. But honestly, I think it's more likely age, experience, and a growing intolerance of being spoken to like crap. Incidentally, I can't tell you the number of people who come into the shop and talk to me one way, but then find out I live in the same suburb that they do, because I literally live about 400 metres away from the pharmacy, and they change their tone. Maybe, just maybe, testosterone gave me enough internal permission to notice it. The lesson for me wasn't testosterone makes me ragey, it was I need to get better at clear, calm boundaries. Not passive aggressive, not sarcastic, not seething silently, just please don't speak to me like that. Because that protects me and it doesn't turn me into someone I don't like. If you work in healthcare and this story made your shoulders tense, I hear you. And if you're noticing you tolerate less nonsense than you used to, that might not be a hormone problem. That might just be wisdom. So far on the moans, we've met the girl band in episode one, the estrogens in episode two, we met progesterone in episode three, so today we're meeting the hormone that causes the most side eye, the most misinformation, and frankly, the most unnecessary fear in women and doctors. Testosterone. Because somewhere along the line we decided testosterone was a male hormone, and if women have anything to do with it, we'll immediately grow a beard, punch a wall, and leave our families to join a motorcycle gang. Which is not how biology works. Women make testosterone naturally, always have, always will. In fact, women produce more testosterone than estrogen on a daily basis, just at much lower absolute levels than men. Testosterone in women is involved in sexual desire and arousal, sexual thoughts and motivation, energy and vitality, muscle strength and lean body mass, bone density, mood and sense of well-being, cognitive sharpness and confidence. And importantly, testosterone does not act alone. It works in concert with estrogen and progesterone. Refer to episode one and the girl band analogy. Think of estrogen as the nurturer, progesterone as the karma, and testosterone as the spark. In women, testosterone comes from three main places. Ovaries, about 25%, adrenal glands, about 25%, and peripheral conversion, the other 50%. And that last one matters. Women convert precursor hormones like DHEA and androstenidione into testosterone in tissues like fat, skin, muscles, brain. Which means testosterone isn't just a sex hormone, it's a neuroactive hormone and a metabolic hormone. And as we age, particularly through perimenopause and menopause, testosterone levels decline gradually, often earlier and more quietly than estrogen. There's no dramatic crash, just a slow fade. When testosterone is low, it can appear as HSD or hypoactive sexual desire disorder. This is not I'm tired, I hate my partner, my kids won't leave me alone, I'm stressed at work. This is persistent distressing loss of sexual desire that is not better explained by relationship issues, is not due to depression or another medical condition, is not due to medication side effects, and causes personal distress. And that last bit matters. If you don't care, it's not a problem. If you do care and it's impacting your quality of life and your relationship, then it may be a problem. Around 10 to 15% of women meet the criteria for HSDD at any given time. Rates are higher in midlife and postmenopause. Makes sense as we've finished reproducing. Men can go on reproducing for forever, but us women, we get to stop. So this is not rare and it's not a niche problem. Yet it is one of the least proactively treated conditions in women's health. It's a clinical diagnosis, not a blood test diagnosis. Core criteria of HSDD and all must be present to get testosterone replacement. 1. Persistently low or absent sexual desire. This includes few or no sexual thoughts or fantasies, reduced interest in sexual activity, reduced initiation of sex, reduced responsiveness to sexual cues. This must be clearly different from the woman's previous baseline. 2. Duration. At least six months. Minimum duration of six months. And this is important. Not weeks, not a rough patch, not a bad month. The low sexual desire must be persistent, not situational or transient. And three, personal distress, and this is the most important criterion. The woman must experience distress, frustration, sadness, loss of identity, relationship strain. If you don't care, it's not HSDD. Low desire without distress is a normal variation, not a disorder. Shall we put these criteria into perspective? For men to get prescribed Viagra or similar, the diagnosis of erectile dysfunction is difficulty achieving or maintaining an erection sufficient for sexual activity. That's it. No requirement that it lasts six months, causes personal distress, though it often does, is unexplained by stress, relationship issues, fatigue, aging, or life circumstances. In practice, a man can say, I'm having trouble getting or keeping an erection, and that alone is usually sufficient to prescribe a PTE5 inhibitor, like Viagra, or Cialis, Tadalophil. The only evidence-supported indication for testosterone therapy in women is HSDD, not weight loss, energy, muscle mass, cognition, hormone optimization, anti-aging, biohacking, or anything else you can think of that testosterone can likely impact. Just HSDD. And when used at physiological female doses, testosterone is both effective and safe. Important points are it's a transdermal testosterone cream designed specifically for women. Delivers micro doses, almost homeopathic doses, compared to male formulations, applied daily to the skin, often thigh or buttock. This is not bodybuilder testosterone. This is replacement to female physiological levels. Does it work? Yes, for the right woman. Clinical trials show around 60 to 70% of women with HSDD respond to transdermal testosterone. Benefits include increased sexual desire, increased sexual thoughts, increased satisfaction, reduced sexual distress, and importantly, blood levels don't predict response particularly well. Androgen levels are taken prior to initiation of treatment as a baseline only to see if supplementation via cream actually raises levels and not as an indicator of response. This is a clinical diagnosis, not a lab number diagnosis. Side effects? Because if a treatment has an effect, then it also has the potential for a side effect. And this is where fear tends to run ahead of evidence. At female physiological doses, side effects are dose dependent, usually mild, usually reversible. Potential side effects include mild acne, increased body or facial hair, oily skin, scalp hair thinning, rare at appropriate doses, and voice deepening, very rare, and associated with supra physiological dosing. In properly prescribed dosing, acne or hair changes occur in less than 10%. Voice changes are exceptionally rare, and clitoromegaly is extremely rare at female doses, and importantly, no convincing evidence of increased breast cancer risk, no evidence of increased cardiovascular risk at physiological doses. But monitoring matters. This is not a set and forget therapy. Best practice includes baseline assessment, symptom-based follow-up, periodic testosterone levels to avoid overdosing, review benefit at around three to six months. And if there's no benefit by six months, stop it. Because hormones are not magic and they only work when they're treating the right problem. Testosterone therapy in women is not a personality transplant, a cure all for burnout, a substitute for sleep, boundaries, or pleasure, a libido guarantee if your relationship is a bin fire. Hormones support physiology, they don't fix context. But what frustrates me as a pharmacist is that doctors are comfortable prescribing antidepressants that affect libido, blood pressure meds that affect libido, contraceptives that affect libido. But when a woman says, I've lost my sexual desire and it's distressing, we suddenly clutch our pearls. I did a TikTok Instagram video on it when I started, and again six weeks later, and the number of women who wrote comments like my GP won't prescribe it, or I thought it was just me was astounding. Testosterone is not experimental. The data exists, the guidelines exist. Women deserve informed options. So, in summary, women make testosterone naturally, it plays a critical role in sexual desire and well-being. HSDD is common and real. Transdermal testosterone helps 60 to 70% of women with HSDD. Side effects are uncommon at correct doses, and it deserves a seat at the grown-up medical table. Woo of the week, and this one comes up every single time women start talking about testosterone. Because the minute you mention testosterone for women, someone will say, But isn't there something natural I could try first? And what they usually mean is DHEA or a supplement claiming to boost testosterone naturally. So let's debunk. These products are marketed as hormone balance, adrenal support, libido support, testosterone booster for women, anti-aging, and the pitch is almost always the same. This helps your body make its own testosterone without using hormones. Which sounds reassuring, I guess. Gentle, safer, but it is deeply misleading. Let's start with DHEA. Dehydroepyandrosterone is not a vitamin, it's not a herb, it's not a nutrient. It is a steroid hormone precursor. Your adrenal glands make it naturally. Levels peak in early adulthood and then decline steadily with age. So yeah, it's real. And yeah, it sits upstream of testosterone and estrogen. Oral DHEA is absorbed. It's absorbed well from the gut. It undergoes first-past metabolism in the liver. Blood levels of DHEA and DHEAS rise measurably after oral dosing. Which is exactly why it gets marketed so aggressively. The big problem with DHEA is that when you take oral DHEA, you are not taking testosterone. You are taking a hormone that your body might convert into testosterone, estrogen, or nothing. And that conversion is wildly unpredictable. It depends on your age, your genetics, your liver metabolism, your body fat, tissue-specific enzymes, whether Jupiter is in the third house, I mean who would know? One woman might experience acne, facial hair, oily skin, another might experience breast tenderness, spotting, estrogenic effects, and another might feel absolutely nothing. Same dose, different outcome. And from a pharmacist's perspective, that's chaos. When you look at the data, libido results are mixed. Effects are small and inconsistent, no strong evidence for treating HSDD, no reliable dose response relationship, which matters because dermal testosterone does have evidence when used properly. DHEA is not gentler, it's less precise. And then there are the testosterone boosters. They're usually combinations of tribulus, maca, fenugreek, ashwagander, zinc, adaptogenic blends, whatever that means, adrenal support complexes, again, I don't know. In women, these supplements mostly do not meaningfully raise testosterone. Any libido effect is usually placebo, mood related, stress-related, or due to improved sleep or energy, not hormones. And here's the key point. If a supplement truly raised testosterone in women in a predictable, meaningful way, it would be regulated as a medicine. Testosterone is a controlled hormone. Your prescription only lasts six months, which makes me angry actually, because the amount of testosterone in 1% Androphem is borderline negligible and you'd have a really hard time abusing it. And as if it wasn't hard enough to convince your prescriber of your HS. DD symptoms in the first place, but now you have a script that only lasts six months before it expires. Come on now. So when supplements claim to boost testosterone, optimize hormones, balance androgens, what they really mean is we hope something downstream changes, maybe. It's not treatment, it's gambling. What makes me angry is that women with sexual distress are often told try something natural first, try supplements, see how you go. Even when they met the criteria for HSDD, they've had symptoms for years, they're distressed, and it was hard enough to speak up about it in the first place. Meanwhile, men with erectile dysfunction are not told to maybe try a herbal supplement first and see how you feel in six months. Can you imagine? If men couldn't get a consistent regular hard-on, it would be a crisis. DHEA and these blends offer no diagnosis requirement, no duration requirement, no distress requirement, no monitoring, no stop rules. It's potentially a hormone exposure without precision, accountability, or follow-up. And that's not empowerment, that's abdication of care and understanding. An important nuance of vaginal DHEA, just to be clear, prescription vaginal DHEA is for genito-urinary syndrome of menopause, has minimal systemic absorption, is not used to treat libido or HSDD. It's not the same as oral DHEA supplements. Here's the line I want you to remember. DHEA and testosterone boosters aren't safer than testosterone, they're less controlled. And control is what makes a medicine safe. If a woman has persistent low sexual desire for at least six months that causes personal distress and isn't better explained by something else, then the evidence-based conversation is about diagnosis, risk and benefit, targeted therapy, monitoring, and stopping if it doesn't help. Not endless supplements, not guesswork, and not hormone roulette. Natural does not mean safer, smarter, gentler, or evidence-based. And over-the-counter does not mean harmless, appropriate, or effective. You know, sometimes the most conservative option is the precise one. If there's one takeaway from this episode, it's this control is safety. Whether it's hormones, supplements, or how we let people speak to us, precision beats chaos every time. Thanks for listening, and I'll see you next week on the moan.