How to cite: Fosnight A. Beyond Replacement: The Evolving Role of Testosterone in Female Patients. Grand Rounds in Urology. October 2025. Accessed Jan 2026. https://grandroundsinurology.com/beyond-replacement-the-evolving-role-of-testosterone-in-female-patients/
Summary
Ms. Fosnight, MSPAS, PA-C, CSCS, CSE, MSCP, IF, HAES, Founder, Fosnight Center for Sexual Health, Asheville, North Carolina, reviews the evolving role of testosterone therapy in individuals assigned female at birth, emphasizing that testosterone is not a gendered hormone and plays a clinically meaningful role in sexual health, energy, mood, body composition, and genitourinary function. The presentation focuses on appropriate patient selection, evaluation, dosing strategies, and safety considerations for off-label testosterone use in women.
The discussion begins by outlining endogenous testosterone physiology in individuals assigned female at birth, including ovarian, adrenal, and peripheral sources, and the age-related decline that often precedes changes in estradiol. Ms. Fosnight describes multiple contributors to low testosterone levels, including menopause, cancer treatments, increased sex hormone binding globulin, chronic inflammation, medications such as spironolactone and opioids, disordered eating, sleep disorders, and chronic stress.
Ms. Fosnight reviews patient-reported symptoms, including decreased sexual desire, fatigue, diminished sense of well-being, loss of motivation, mood changes, genitourinary symptoms, muscle loss, changes in body composition, and sleep disturbances. The presence of testosterone receptors in the clitoris, vestibule, and anterior vaginal wall is highlighted as clinically relevant for genitourinary health.
Evaluation strategies focus on symptomatic patients only and include serum total testosterone, sex hormone binding globulin, and calculated free testosterone. Ms. Fosnight emphasizes the importance of calculated free testosterone rather than relying solely on total testosterone reference ranges.
Therapeutic options are reviewed, noting the absence of FDA-approved testosterone formulations for women in the United States. Recommended approaches include transdermal therapy at approximately one-tenth the dose used for male patients, with careful counseling regarding off-label use, cost, and delayed onset of symptom improvement. Alternative delivery methods and their limitations are discussed, along with safety considerations such as transference risk, androgenic side effects, and avoidance of supraphysiologic levels.
She highlights the presence of testosterone receptors in the clitoris, vestibule, and anterior vaginal wall as clinically relevant for genitourinary health.
About The 12th Urology Today Conference:
Presented by chair Ryan P. Terlecki, MD, FACS, the 12th Urology Today conference was designed to keep urologists, urologic oncologists, and other healthcare providers educated on the most pertinent issues in urology practices. Areas of focus included urologic oncology, men’s health and reconstruction, female urology, pediatric urology, kidney stones and related conditions, and methods of providing the best care amidst the required logistics of the business side of medicine.
