Low testosterone in women is real. Here’s why it’s so often missed.
Low testosterone in women is real. Here’s why it’s so often missed.
Women make testosterone throughout adult life. It comes from the ovaries and the adrenal glands, it circulates at higher levels than oestradiol, and it plays a part in sexual desire and probably in muscle, bone and brain health too.[1] Levels fall steadily from the early twenties rather than dropping suddenly at menopause, and they fall further after both ovaries are removed.[2]
The symptom with the clearest link to low testosterone is low sexual desire that bothers you. Fatigue, flat mood, weight gain and lost strength often get blamed on it as well, but the evidence there is much weaker. When 36 randomised trials were pooled, testosterone improved sexual function in postmenopausal women but had no measurable effect on body composition, muscle or cognition.[3]
Diagnosis is the tricky part. There is no agreed blood-test cut-off for low testosterone in women, many routine assays struggle at female levels, and a woman’s result doesn’t predict whether treatment will help her.[4][5] The combined pill can also cut free testosterone by around 60% by raising the protein that binds it.[6]
Low desire and flat drive have plenty of possible causes: the pill, antidepressants, an underactive thyroid, low iron, poor sleep, stress. A good workup checks those first. Where low desire with distress persists after menopause, testosterone therapy is a prescription option worth raising with your GP or a menopause specialist.[7]
Women make testosterone too
Testosterone gets filed as a male hormone, which is a big part of why it’s overlooked in women. Women make it throughout life, and some is converted into oestradiol in tissues around the body. For most of adult life a woman carries more testosterone in her blood than oestradiol.[1]
What changes is the amount. A Victorian study of 1,423 women aged 18 to 75 found that total and free testosterone fell steeply with age, and the fall was greatest in the earlier decades, not around menopause.[2] Among women aged 45 to 54, menopausal status made no independent difference to their levels. The ovary keeps producing some testosterone after menopause, which is why women who’d had both ovaries removed had clearly lower levels than women of the same age who hadn’t.
What low testosterone may feel like
The symptom with the clearest link is low sexual desire, especially when it’s a change from how you used to feel and it bothers you. When low desire causes personal distress, doctors call it hypoactive sexual desire dysfunction. A Monash University study of 10,554 Australian women found low desire with distress in about 12% of women aged 18 to 24, rising to a third of women in their early forties and staying there into the early sixties.[8] It was more likely in women taking medications for mood or anxiety.
Online, low testosterone also gets blamed for fatigue, flat mood, weight gain, brain fog and losing strength. Some of that may be part of the picture, but the evidence is thin. In the pooled trial data, testosterone improved desire, arousal, pleasure and orgasm in postmenopausal women and reduced sexual distress. It had no measurable effect on body composition, muscle strength or thinking, although few women contributed data on those outcomes.[3] None of that makes those symptoms less real. It means they usually have other causes worth finding.
Why the blood test so often misleads
A blood test sounds like the obvious answer, but on its own it’s surprisingly unhelpful. The major endocrine guidelines recommend against diagnosing “androgen deficiency” in healthy women at all, because no clear syndrome has been defined and levels haven’t been tied to specific symptoms.[4] A 2024 clinical review came to the same place: androgen deficiency in women still has no specific cut-offs.[9] Three things get in the way.
Routine tests struggle at female levels
A woman’s testosterone sits at a fraction of a man’s, and many routine immunoassays weren’t built to measure such low concentrations accurately.[5] Mass spectrometry is more reliable at these levels, which is why research studies use it.[10]
The number doesn’t track how you feel
In a Danish study of 560 women whose hormones were measured by mass spectrometry, sexual desire did correlate with free testosterone across the group, but the link was modest and varied between age groups.[10] In treatment trials, a woman’s starting level didn’t predict whether testosterone would help her.[4] Current guidance says a total testosterone result shouldn’t be used to diagnose low desire at all, only as a baseline if treatment begins.[11]
The pill changes the picture
The combined oral contraceptive pill raises sex hormone-binding globulin (SHBG), a protein that binds testosterone and holds it out of action. Across 42 studies of healthy young women, the pill lowered total testosterone and cut free testosterone by an average of 61%, while SHBG rose substantially.[6] The authors say the clinical meaning isn’t settled, but it’s one reason to read free testosterone and SHBG together.
Common drivers of low desire and drive in women
Low testosterone is one possible cause among several, and most of the others are easier to test for and address.
| Driver | How it can show up | Worth checking |
|---|---|---|
| Lower androgens with age or after surgery | Gradual loss of desire; a sharper change after both ovaries are removed[2] | Timeline of the change, surgical history, free testosterone with SHBG |
| Combined oral contraceptive pill | Desire changes that begin after starting the pill[6] | Free testosterone and SHBG, timing against the pill start |
| Antidepressants | Lower desire, arousal or orgasm after starting medication[12] | Medication history; options discussed with the prescriber |
| Underactive thyroid | Tiredness, low mood, weight change, low desire[13] | TSH, free T4, free T3 and thyroid antibodies |
| Low iron stores | Tiredness without anaemia, poor exercise tolerance[14] | Ferritin and a full blood count |
| Short or broken sleep | Lower desire the next day, low energy[15] | Sleep length and quality, signs of sleep apnoea |
Never stop or change a prescribed medication without talking to the doctor who prescribed it. Antidepressants differ a lot in how often they affect sexual function, so it can be a conversation worth having.[12]
What the evidence says about testosterone treatment
In 2019 a global consensus statement, led by Professor Susan Davis at Monash University and endorsed by groups including the Endocrine Society of Australia and RANZCOG, set out where testosterone therapy for women stands.[7] Its one evidence-based use is in postmenopausal women with low sexual desire that causes distress, once other causes have been looked at.
For those women the benefit is real but moderate.[11] In trials the main side effects were acne and extra hair growth, with a small rise in weight overall. Testosterone taken by mouth raised LDL cholesterol, while patches and creams didn’t, which is why non-oral forms are preferred.[3] Long-term safety hasn’t been established, and most regulators haven’t approved testosterone for women, so it’s usually prescribed off-label.[9]
The guidelines are just as clear about what it isn’t for: fatigue, mood, weight, bone health, cognition or general wellbeing.[4] Compounded testosterone products aren’t recommended, because their strength and safety haven’t been tested.[11] Testosterone is a prescription medicine, and whether it suits you is decided individually by your doctor, with blood levels monitored along the way.
Where a functional approach starts
In clinic, low desire and flat drive are the start of a broader look, not a diagnosis. We take the timeline first. When did it change, and what else changed around then? A new pill, a new medication, a baby, a hard year, months of broken sleep. The answer is often sitting in that history before it shows up in a blood test.
Then we check the common drivers that can actually be fixed. That usually means thyroid function (see our thyroid and metabolism page), iron studies with ferritin, and a hormone panel that reads free testosterone alongside SHBG. Low iron without anaemia is an underrated one. In a randomised trial of tired women with a ferritin under 50 and normal haemoglobin, fatigue scores fell by 48% with iron compared with 29% on placebo.[14] We’ve written more about why ferritin alone isn’t always enough.
Sleep matters too. In one study, each extra hour of sleep raised the odds of sexual activity the next day by 14%.[15] If you snore or wake unrefreshed, read about sleep apnoea in women. Stress and relationship strain belong in the assessment too, and current guidance recommends looking at all of them together.[11]
If desire is still low and distressing after menopause once those pieces are addressed, that’s the point to ask your GP whether testosterone is worth a trial, and we’re glad to work alongside your doctor on it. There’s more on our approach on the hormones and stress page, or see the functional testing we use.
Key Insights
Frequently Asked Questions
What are the symptoms of low testosterone in women?
The clearest symptom is low sexual desire, especially a change from your usual that bothers you. Fatigue, low mood, weight change and reduced strength are often blamed on low testosterone too, but trials haven’t shown that testosterone treatment improves them. Those symptoms more often trace back to thyroid function, iron stores, sleep, medications or stress.
Can a blood test diagnose low testosterone in women?
Not on its own. There is no agreed cut-off for women, routine assays are often inaccurate at female levels, and your level doesn’t predict whether treatment will help. A result is most useful read alongside SHBG and your symptoms.
Does the contraceptive pill lower testosterone?
Yes. The combined pill raises SHBG, the protein that binds testosterone, and lowers free testosterone by around 60% on average. What that means for each woman’s desire and energy is less clear, but if your symptoms began after starting the pill, it’s worth raising with your doctor.
Is testosterone therapy safe for women?
In trials, testosterone applied through the skin to keep levels within the normal female range caused no serious adverse events, and the most common side effects were acne and extra hair growth. Long-term safety hasn’t been established, and it’s mainly supported for postmenopausal women with distressing low desire. It’s a prescription decision to make with your GP or a menopause specialist.
Ready to find answers?
If your desire or drive has changed and nobody has looked at the whole picture, we can help you work out what’s behind it and work with your GP where needed.
References
- Davis SR, Wahlin-Jacobsen S. Testosterone in women: the clinical significance. Lancet Diabetes Endocrinol. 2015;3(12):980–992. doi:10.1016/S2213-8587(15)00284-3
- Davison SL, Bell R, Donath S, Montalto JG, Davis SR. Androgen levels in adult females: changes with age, menopause, and oophorectomy. J Clin Endocrinol Metab. 2005;90(7):3847–3853. doi:10.1210/jc.2005-0212
- Islam RM, Bell RJ, Green S, Page MJ, Davis SR. Safety and efficacy of testosterone for women: a systematic review and meta-analysis of randomised controlled trial data. Lancet Diabetes Endocrinol. 2019;7(10):754–766. doi:10.1016/S2213-8587(19)30189-5
- 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. doi:10.1210/jc.2014-2260
- Rosner W, Auchus RJ, Azziz R, Sluss PM, Raff H. Position statement: Utility, limitations, and pitfalls in measuring testosterone: an Endocrine Society position statement. J Clin Endocrinol Metab. 2007;92(2):405–413. doi:10.1210/jc.2006-1864
- Zimmerman Y, Eijkemans MJ, Coelingh Bennink HJ, Blankenstein MA, Fauser BC. The effect of combined oral contraception on testosterone levels in healthy women: a systematic review and meta-analysis. Hum Reprod Update. 2014;20(1):76–105. doi:10.1093/humupd/dmt038
- 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. doi:10.1210/jc.2019-01603
- Zheng J, Islam RM, Bell RJ, Skiba MA, Davis SR. Prevalence of Low Sexual Desire With Associated Distress Across the Adult Life Span: An Australian Cross-Sectional Study. J Sex Med. 2020;17(10):1885–1895. doi:10.1016/j.jsxm.2020.07.007
- Rosato E, Sciarra F, Minnetti M, Degjoni A, Venneri MA. Clinical management of androgen excess and defect in women. Expert Rev Endocrinol Metab. 2024;19(1):21–35. doi:10.1080/17446651.2023.2279537
- Wåhlin-Jacobsen S, Pedersen AT, Kristensen E, et al. Is there a correlation between androgens and sexual desire in women? J Sex Med. 2015;12(2):358–373. doi:10.1111/jsm.12774
- Parish SJ, Simon JA, Davis SR, et al. 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. J Sex Med. 2021;18(5):849–867. doi:10.1016/j.jsxm.2020.10.009
- Serretti A, Chiesa A. Treatment-emergent sexual dysfunction related to antidepressants: a meta-analysis. J Clin Psychopharmacol. 2009;29(3):259–266. doi:10.1097/JCP.0b013e3181a5233f
- Atis G, Dalkilinc A, Altuntas Y, Atis A, Caskurlu T, Ergenekon E. Sexual dysfunction in women with clinical hypothyroidism and subclinical hypothyroidism. J Sex Med. 2010;7(7):2583–2590. doi:10.1111/j.1743-6109.2010.01815.x
- Vaucher P, Druais PL, Waldvogel S, Favrat B. Effect of iron supplementation on fatigue in nonanemic menstruating women with low ferritin: a randomized controlled trial. CMAJ. 2012;184(11):1247–1254. doi:10.1503/cmaj.110950
- Kalmbach DA, Arnedt JT, Pillai V, Ciesla JA. The impact of sleep on female sexual response and behavior: a pilot study. J Sex Med. 2015;12(5):1221–1232. doi:10.1111/jsm.12858
