What Every Woman Should Know About Testosterone
When women come to me frustrated and exhausted — low energy, reduced libido, a quiet but persistent sense of flatness that sleep and self-care haven't touched — and when their estrogen and progesterone levels have been addressed without fully resolving the picture, the conversation I find myself having, again and again, is about testosterone.
Testosterone is not a male hormone. It is a human hormone — present in women throughout their lives, essential to a range of physiological functions, and declining in many women during the same years that other hormone changes are already demanding attention. The fact that most women have never been told this is one of the more significant gaps in how we educate women about their own biology.
Testosterone is not a male hormone. It is a human hormone.
What Testosterone Actually Does in the Female Body
Testosterone belongs to a class of hormones called androgens — a group that also includes DHEA, DHEA-S, androstenedione, and dihydrotestosterone. These hormones serve as precursors to estrogen production and play independent roles in maintaining the health of multiple body systems.
In women, testosterone contributes to sexual desire and arousal — perhaps its most well-known function, though also the most oversimplified. Beyond libido, it plays a role in maintaining muscle mass and bone density, supporting energy levels and motivation, regulating mood, and preserving cognitive function. It is produced primarily in the ovaries and the adrenal glands, with additional conversion occurring in peripheral tissues.
During the reproductive years, testosterone levels follow a gradual, age-related decline — one that often begins in the late twenties and continues steadily. Because this decline is gradual and lacks the dramatic hormonal event that marks menopause, it often goes unnoticed until the cumulative effect on energy, desire, and body composition becomes impossible to ignore.
When Does Testosterone Decline Become Clinically Relevant?
The most common clinical presentation of low testosterone in women is hypoactive sexual desire disorder, or HSDD — defined as persistently reduced sexual desire that causes personal distress. Approximately 10 to 15 percent of premenopausal women and a higher proportion of postmenopausal women report symptoms consistent with HSDD. It is the most prevalent sexual health complaint among women, and it remains substantially undertreated, partly because no FDA-approved testosterone product exists for women in the United States.
But low testosterone can also manifest more broadly: in reduced energy and motivation that isn't explained by other factors, in difficulty maintaining muscle mass despite appropriate exercise and protein intake, and in a general sense of diminished vitality that women often describe as feeling unlike themselves.
Testosterone levels should be assessed using a total testosterone assay — the most practical and widely available measurement — along with sex hormone-binding globulin (SHBG), which affects how much testosterone is biologically available. There is no single "low" testosterone level that defines the threshold for clinical concern. Instead, the goal is to understand the level in the context of symptoms and to use it as part of a broader clinical picture rather than as a standalone diagnostic criterion.
What Evidence-Based Treatment Looks Like
Because no testosterone product is currently FDA-approved specifically for women in the United States, testosterone therapy for women is typically prescribed off-label. The most commonly used formulations are compounded topical creams or reduced doses of testosterone gels approved for men — typically approximately one-tenth of the standard male dose, which corresponds to around 300 micrograms per day delivered transdermally.
The goal of treatment is to restore testosterone levels to the premenopausal physiological range — not to supraphysiological levels, which carry different risk profiles. Monitoring with periodic lab testing is part of responsible prescribing.
It is important to know what the current evidence does and does not support. Clinical trial evidence clearly supports testosterone therapy for treating HSDD in postmenopausal women who have no other identifiable cause for their reduced desire. The evidence for broader benefits — energy, mood, cognitive function, body composition — is more preliminary, though mechanistically plausible and the subject of active research.
What the evidence does not support: pellet implants and intramuscular injections for women. These delivery methods produce supraphysiological testosterone levels that are difficult to monitor and adjust, and they carry a different risk profile than physiological transdermal dosing. The international clinical practice guidelines from the International Society for the Study of Women's Sexual Health explicitly recommend against pellets, injections, and oral formulations for women. This matters because pellet therapy is aggressively marketed in some clinical settings, and women deserve to know that its use is not supported by the same evidence base as transdermal options.
Before Jumping to Testosterone Therapy
A thorough evaluation should precede any decision about testosterone therapy — not because the treatment is inherently risky when appropriately dosed and monitored, but because HSDD and low energy have multiple potential contributing causes, and addressing only one of them produces incomplete results.
A comprehensive assessment includes a detailed history of sexual function and when changes began, a review of all medications (many of which reduce libido or energy, including SSRIs and antihypertensives), evaluation of relationship and psychological factors, assessment of other menopausal symptoms that may be contributing, and evaluation for genitourinary syndrome of menopause, which can independently impair sexual comfort and response.
When estrogen deficiency is also present, treating it first — or concurrently — is appropriate, since many of the physical barriers to comfortable sexual function (vaginal dryness, dyspareunia, reduced clitoral sensitivity) respond directly to estrogen restoration and may resolve some of the sexual concern without testosterone at all.
The Conversation Worth Having
If reduced libido, persistent low energy, or a general sense of flatness have been part of your experience in midlife, and if those symptoms haven't been fully explained or addressed by other treatments, testosterone is worth raising explicitly with your provider. It is a legitimate clinical conversation — not a vanity concern, not a request for an enhancement — and it is supported by an increasingly robust body of evidence.
Aging does not have to mean accepting a diminished version of your vitality. What it means is advocating clearly for a complete evaluation, understanding what the evidence supports, and working with a provider willing to engage seriously with all the hormonal factors that shape how you feel and function.
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Medical Disclaimer: The information provided in this blog is for general educational and informational purposes only and is not intended as, nor should it be considered, medical advice. This content does not establish a physician-patient relationship and is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay seeking it because of something you have read in this newsletter. If you think you may have a medical emergency, call your doctor or emergency services immediately.
References
Davis SR, Baber R, Panay N, et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. J Clin Endocrinol Metab. 2019;104(10):4660-4666.
International Society for the Study of Women's Sexual Health. Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women. Mayo Clin Proc. 2021;96(2):477-497.
Simon JA, Goldstein I, Kim NN, et al. The role of androgens in the treatment of genitourinary syndrome of menopause (GSM). Maturitas. 2018;108:24-29.
Wierman ME, Arlt W, Basson R, et al. Androgen therapy in women: a reappraisal: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2014;99(10):3489-3510.
Shifren JL, Monz BU, Russo PA, Segreti A, Johannes CB. Sexual problems and distress in United States women: prevalence and correlates. Obstet Gynecol. 2008;112(5):970-978.
