30s
Androgen output often falls years before menopause
Clinical endocrinology — ovarian + adrenal
Davison
Female androgen ranges mapped across adult life
Davison et al.
≠ male TRT
Female dosing is not a scaled-down male protocol
Clinical practice constraint
Educational content, not medical advice. Testing and treatment decisions belong with a physician.
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Women make testosterone too
Testosterone is often described as a male hormone, but women make it too, just in much smaller amounts. The ovaries and adrenal glands are responsible, either directly or via precursors such as DHEA that are converted in tissue. In women, testosterone plays a role in desire, energy, muscle and bone, among other things. It is not about becoming like a man, but about having the amount the body is used to.
The decline starts early
Davison and colleagues (JCEM, 2005) measured androgens in a large number of healthy women aged 18 to 75. They found that testosterone and DHEAS fell markedly from early adulthood towards age 40, and that menopause itself did not cause an abrupt extra drop. In other words, much of the decline happens long before menopause. That is why this article is about women under 40.
The decline is not the same for everyone. There is wide variation between women of the same age, and a single measurement says more when it is seen in relation to symptoms and any earlier measurements. That is also why a woman in her mid-thirties can have entirely different values from a friend of the same age.
Symptoms that often get another name
Low androgen activity can show up as reduced desire, falling drive and motivation, a poorer response to training and slower recovery. These symptoms are non-specific. They can be caused by stress, lack of sleep, depression, thyroid problems, iron deficiency and much else. That is why the diagnosis cannot be made from symptoms alone, and why it is reasonable to measure rather than guess.
What the guidelines say
It is important to be honest about what is documented. The Endocrine Society guideline (Wierman and colleagues, JCEM, 2014) advises against diagnosing "androgen deficiency" in healthy women, because there is no clear number that separates normal from low, and because the blood test does not correlate closely with symptoms. The Global Consensus Position Statement on testosterone for women (Davis and colleagues, 2019) concludes that the only well-documented indication for treatment is low sexual desire with personal distress in postmenopausal women. Islam and colleagues (Lancet Diabetes & Endocrinology, 2019) found in a large meta-analysis a moderate effect on sexual function in postmenopausal women, but no documented effect on mood, energy or bone.
For women under 40 this means that measurement is first and foremost a tool to understand what is going on and to find a possible cause. It is not a route to a male protocol.
Possible causes in younger women
In younger women there is often a concrete explanation for low androgens:
The contraceptive pill and other hormonal contraception raise SHBG, the protein that binds testosterone, and can thereby lower free testosterone considerably. Premature ovarian insufficiency, where the ovaries stop working before 40, reduces production. Surgical removal of the ovaries causes an abrupt drop. Disease of the adrenal or pituitary glands, including raised prolactin, can affect hormone balance. Very low energy intake, for example with eating disorders or hard training without enough food, can also lower sex hormones.
Several of these conditions have their own treatment and should be found. That is a more important reason to measure than the testosterone number itself.
Free testosterone and SHBG
Total testosterone is not the whole picture. Most of it is bound to SHBG and is not freely available to tissue. Two women with the same total can have very different free testosterone, depending on SHBG. SHBG should therefore always be measured together with testosterone. Read more in SHBG, the hormone that decides your free testosterone.
Pay attention to the method as well. At the low values women have, ordinary immunoassays are imprecise. Mass spectrometry (LC-MS/MS) is more reliable, and it is a good idea to ask which method the laboratory uses.
Not a male protocol
If a doctor, after a thorough work-up, finds reason for treatment, doses for women are a fraction of those given to men. Copying a male protocol can cause side effects such as acne, increased hair growth and a deeper voice. Treatment in women must be managed by an experienced doctor and followed with blood tests.
Next step
Write down your symptoms and when in your cycle they are worst. Note whether you use hormonal contraception. Take a morning sample with total testosterone, SHBG, calculated free testosterone and ideally DHEAS and prolactin. The first test can be taken locally, where you live. The result is not a diagnosis in itself, but a starting point for a conversation with a doctor. Read also about low testosterone in women after 40.
Questions & answers
Do women need testosterone?
Yes. Women produce testosterone in the ovaries and adrenal glands, and it plays a role in libido, energy and muscle. Normal female levels are far lower than in men.
Can testosterone be measured reliably in women?
Low female levels need a sensitive method, ideally LC-MS/MS, and a morning sample. Assays designed for male ranges can be imprecise at low levels.
What can lower testosterone in younger women?
Among other things, oral contraceptives (which raise SHBG), very low energy intake, heavy endurance training and some medicines. A physician can assess the cause.