Low Testosterone in Women: Symptoms, Testing and What the Evidence Supports

What does testosterone do in women?

Testosterone is not only a male hormone. Women make it in the ovaries and adrenal glands, and also convert it from precursors such as DHEA. Blood levels in women are roughly a tenth to a twentieth of men's. Testosterone plays a role in sexual desire and arousal, and it's also a building block the body converts into estradiol.

Much testosterone in the blood is bound to sex hormone-binding globulin (SHBG). Anything that raises SHBG, such as oral estrogen or birth control pills, lowers the "free" fraction, which is one reason women on oral estrogen sometimes notice lower desire.

When do testosterone levels drop in women?

Testosterone declines gradually with age, starting in a woman's 20s and 30s, rather than dropping suddenly at natural menopause. The ovaries keep making some testosterone after menopause. The exceptions are:

• Removal of both ovaries, which lowers testosterone sharply as well as estrogen. Early surgical menopause is linked with effects on sexual health along with bone, heart and mood (Faubion 2015).
• Adrenal or pituitary disease, which can reduce androgen production.
• Medications, including oral estrogen and oral contraceptives (through higher SHBG), glucocorticoids and some opioids.

What are the symptoms of low testosterone in women?

This is where much online content overstates the case. The symptom most consistently linked with testosterone is low sexual desire. Even there, the connection to blood levels is weak: in a community study of 1,021 Australian women aged 18 to 75, there was no clinically significant relationship between low total or free testosterone and low scores for desire, arousal or satisfaction (Davis 2005).

Fatigue, low motivation, brain fog, weight gain, loss of muscle tone and thinning hair are often attributed to "low T." They are real problems, but they have many more common causes in midlife, including poor sleep, hot flashes, depression, thyroid disease, anemia, medications and stress. The Endocrine Society's guideline, endorsed by ACOG and other societies, recommends against diagnosing "androgen deficiency syndrome" in healthy women because there is no well-defined syndrome and no data tying androgen levels to specific symptoms (Wierman 2014).

Can a blood test diagnose low testosterone?

Testing still has a role: a baseline before treatment, checking levels on treatment to make sure they stay within the normal female range, and investigating signs of too much androgen, such as acne or excess hair growth, which point to different conditions entirely.

Does testosterone therapy work for women?

For one indication, yes. A meta-analysis of 36 randomized trials with 8,480 participants found testosterone improved sexual desire, arousal, orgasm, pleasure and satisfying sexual events, and reduced distress, in postmenopausal women. It did not show benefits for body composition, muscle, bone or cognition, and it increased acne and hair growth. Oral testosterone raised LDL cholesterol, while patches and creams did not (Islam 2019).

Based on this, the Global Consensus says the only evidence-based indication is hypoactive sexual desire disorder (HSDD) in postmenopausal women, after other causes are addressed, using a non-oral form at a dose that keeps levels within the premenopausal female range, with reassessment after about 6 months (Davis 2019). Guidelines recommend against testosterone for energy, mood, cognition, bone, heart or general well-being (Wierman 2014).

Should testosterone be added to estrogen therapy?

Not routinely. Most women's hot flashes, sleep and vaginal symptoms respond to estrogen (plus a progestogen if they have a uterus) without testosterone. If distressing low desire persists after estrogen-related symptoms are treated, other causes have been addressed, and you are postmenopausal, a clinician may discuss a trial of transdermal testosterone. If you're on oral estrogen, switching to a patch or gel is sometimes tried first, because oral estrogen raises SHBG and lowers free testosterone. A trial typically means checking a baseline level, re-checking after several weeks, and stopping if there's no meaningful benefit by about 6 months.

What are the risks of testosterone therapy in women?

• Androgenic side effects: acne, increased facial or body hair, scalp hair thinning. At excess doses, voice deepening and clitoral enlargement, which may be permanent.
• Unknown long-term effects on heart disease and breast cancer risk (ACOG 2023).
• No FDA-approved product for women in the US. Clinicians prescribe off-label, often a small fraction of a men's gel or a compounded cream. Compounded products are not FDA-approved and their strength can vary.
• Pellets. ACOG recommends preparations other than pellets because there are few safety data and a pellet can't be removed if levels run high.
• Not for pregnancy or for women trying to conceive.

DHEA supplements are sometimes marketed as a "natural" testosterone booster; guidelines don't recommend routine use. Vaginal DHEA (prasterone) is FDA-approved, but only for painful sex due to menopause. See DHEA for women.

What else helps low desire and low energy?

Because low desire usually has several contributors, the most effective plan often addresses more than one:

• Treat menopause symptoms. Better sleep and relief from hot flashes and vaginal dryness often lift energy and interest. Vaginal estrogen or moisturizers help painful sex.
• Review medications, especially antidepressants and oral hormones.
• Address mood, stress and relationship factors, including with sex therapy or counseling.
• Strength training and protein for muscle and energy, which help whatever your hormone levels.
• FDA-approved desire medicines exist for premenopausal women with HSDD. Our guides to testosterone and libido and the libido treatments hub compare options.

Where Amie fits

Amie does not prescribe testosterone. If hot flashes, night sweats, poor sleep or vaginal dryness are part of your picture, treating estrogen-related symptoms may be a reasonable first step. Amie's licensed clinicians can review your history and, if appropriate, prescribe Amie HRT+, a compounded estradiol and progesterone cream. It is not FDA-approved, and the clinician decides whether it suits you. For more on estrogen therapy, read our hormone replacement therapy guide.

The bottom line