One of the most frustrating things I hear from women in menopause sounds something like this:
“My hot flashes are so much better. But I’m still exhausted.”
Or:
“I’m sleeping better, but I still don’t feel like myself.”
Maybe it’s brain fog. Maybe your energy disappeared somewhere in your late 40s and never really came back. Your libido is different. Your workouts feel harder. You’re more irritable than you used to be, or your muscles and joints seem to complain about things they once handled without a second thought.
And this can be particularly confusing when you’re already on hormone therapy.
If the hot flashes are better, shouldn’t you feel better?
Not necessarily.
I think we sometimes make the mistake of using hot flashes as a shorthand for whether menopause treatment is “working.” They’re important, of course. But menopause affects far more than temperature regulation, and hormone therapy doesn’t exist in a vacuum.
There’s sleep. Muscle. Metabolic health. Thyroid function. Nutrition. Stress. Iron status. Mood. Cardiovascular health. And yes, there are other hormones—including testosterone—that deserve thoughtful consideration.
A recent study gives us an interesting reason to look at that last piece more closely.
Feeling Better Is More Complicated Than Stopping Hot Flashes
Researchers recently evaluated 279 women who were already using transdermal estrogen, with or without progesterone, and whose hot flashes were controlled.
On paper, you might look at that and say their hormone therapy was doing its job.
But listen to what the women were actually reporting.
More than 92% had fatigue. Nearly 90% reported low libido and memory problems. More than 86% had difficulty concentrating, and 82% reported irritability.
That disconnect is important to me.
A treatment can successfully improve one symptom without addressing everything affecting a woman’s health.
And that’s why I don’t think menopause care should ever become a checklist where we ask whether the hot flashes are gone, check a box, and move on.
The better question is: How do you actually feel?
Testosterone Is Part of Women’s Physiology, Too
Testosterone still gets discussed as though it belongs exclusively to men.
It doesn’t.
Women produce testosterone, and androgen receptors are found in tissues throughout the body, including the brain, muscle, bone, breast, and vascular tissue. Testosterone levels also change with age independently of the menopause transition.
That does not mean every woman needs testosterone.
But it does mean testosterone belongs in a scientifically serious conversation about women’s physiology.
And this is where the recent research becomes interesting.
Researchers added transdermal testosterone to the treatment of the women in the study without initially changing their estrogen dose or route. When symptoms were reassessed about four months later, significant improvements were reported in 15 of the 24 symptoms measured and across several symptom categories, including energy, cognition, mood, musculoskeletal, genitourinary, and endocrine symptoms.
Those findings caught my attention.
They also require some perspective.
Interesting Research Isn’t the Same as an Answer
I love emerging research. I also think we do patients a disservice when an interesting study immediately becomes a treatment trend.
This was a retrospective chart review.
There was no placebo group and no control group. The women knew they were receiving a new treatment. Follow-up averaged only 116 days, and the study did not evaluate certain adverse outcomes such as changes in lipids, hematocrit, or androgenic effects.
That’s important.
So I wouldn’t read this study and say:
“You’re tired on estrogen? You need testosterone.”
I would read it and say:
“Maybe our definition of successful menopause treatment has been too narrow.”
We need more clinical trials and longer-term data before we can answer many of the questions women understandably have about testosterone therapy.
But we don’t need to wait for those studies to recognize that persistent symptoms deserve a more complete evaluation.
Before Blaming Your Hormones, Look at the Whole Picture
Here’s where I think midlife medicine becomes particularly interesting.
A 52-year-old woman who tells me she’s exhausted could have a hormonal issue. She could also have iron deficiency, sleep apnea, or inadequate protein intake combined with declining muscle mass. Often, it’s several of these things at once, and that possibility is the one most easily overlooked.
The body doesn’t organize itself into specialties. Your sleep affects your metabolic health. Your metabolic health affects energy. Muscle influences glucose regulation and long-term function.
Hormonal changes can affect sleep, body composition, bone, sexual health, and how you feel. Midlife symptoms rarely arrive with a label telling us which system caused them, which is why good medicine has to investigate before it assumes.
I Don’t Treat a Testosterone Level in Isolation
This is another place where I think women deserve nuance.
I do check testosterone levels, and having a baseline is useful. But we don’t currently have a universally established “optimal” testosterone level for women that tells us exactly how someone should feel, which is exactly why clinical context matters so much.
A lab value on its own doesn’t explain everything. I want to know:
Are you sleeping? Are you maintaining muscle? How is your body composition changing? What’s happening metabolically? What does your thyroid function look like? What are you eating? How are you exercising? What’s happening with your sexual health? What changed, and when?
Those answers tell us far more than one isolated number ever could.
Hormone Therapy Shouldn’t Be “Set It and Forget It”
This may be my biggest takeaway. Your body at 47 isn’t necessarily your body at 52, and your treatment may need to change with it.
Sometimes that means adjusting hormone therapy. Sometimes it means investigating something that has nothing to do with hormones. And in appropriately selected women, it may mean having a thoughtful conversation about testosterone, including what we know, what we don’t know, and the limitations of the available evidence. The answer should come from the individual woman in front of us, not from a trend.
Feeling Better Is the Beginning, Not the Finish Line
I’m glad when a woman’s hot flashes disappear. I’m glad when she finally sleeps through the night. But I don’t want our ambitions for women’s health to stop there.
I want to know whether she’s maintaining muscle. Whether she has energy. Whether her metabolic and cardiovascular health are moving in the right direction. Whether her bones are protected.
Whether she’s exercising and recovering well. Whether she feels mentally sharp. Whether her sexual health matters to her, and if it does, whether we’re actually talking about it.
And ultimately: does she feel healthy, strong, and like herself? That’s a much bigger goal than treating hot flashes.
So if you’re taking hormone therapy and still wondering why you don’t feel the way you expected to, don’t assume that means it failed. It may simply mean there’s more of your health story left to understand.
At Nova Wellness, we take a comprehensive, physician-led approach to menopause and midlife health. If you’re still experiencing symptoms despite hormone therapy, we can look beyond a single hormone or symptom and explore the bigger picture together.
This article is for educational purposes only and is not a substitute for personalized medical advice.