Low Testosterone in Females: Causes, Symptoms & Treatment

Testosterone plays a measurable role in female bone density, muscle mass, sexual desire, and energy levels, and when it drops too low, the effects can be surprisingly disruptive. The challenge is that “too low” in women has no universally agreed-upon clinical threshold, and the standard blood tests used to measure it are often inaccurate at the concentrations found in female blood. The result is a condition that many women experience but that medicine has been slow to define, diagnose, or treat with approved therapies.

What Testosterone Does in the Female Body

Women produce far less testosterone than men, but the hormone still has real physiological work to do. It contributes to bone formation by acting directly on bone-building cells and by converting into estradiol, which further supports bone density through a separate pathway.¹ In older women, higher circulating free testosterone is associated with greater bone mineral density at the hip and spine, along with greater lean body mass.² The anabolic effect on muscle tissue is particularly relevant after menopause, when the age-related loss of lean mass and muscle strength tracks partly with declining bioavailable testosterone.³

Testosterone also influences sexual desire. This is the area where low levels are most frequently discussed clinically, because reduced desire (sometimes called hypoactive sexual desire disorder, or HSDD) is the symptom that has attracted the most research into testosterone replacement for women.⁴ Beyond libido, testosterone receptors are distributed widely across the brain, and some research links low levels to fatigue and reduced cognitive performance, though those connections are harder to pin down than the skeletal and sexual effects.

Why Testosterone Declines

The most common cause of lower testosterone in women is simply aging. Testosterone, along with its precursor hormones, drops steeply across the reproductive years, with the steepest decline happening in earlier decades rather than later ones.⁵ A cross-sectional study of women at midlife found that median testosterone concentrations dropped between the early forties and late fifties, reaching their lowest point around age 58 to 59, then modestly rebounding.⁶ Precursor androgens like androstenedione and DHEA follow a similar downward trajectory but do not recover in the same way.

One persistent misconception is that menopause itself causes a sudden crash in testosterone. The data do not support that. Multiple studies have found that after accounting for age, menopausal status adds no additional independent effect on androgen levels.⁵ The decline in androgens follows a steady age-related slide in both Black and White women across the reproductive lifespan and menopausal transition.⁷ Menopause may change how you feel the effects of already-declining testosterone, because the estrogen drop makes the relative androgen picture shift, but it is not the driving force behind falling testosterone levels.

Surgical Removal of the Ovaries

Bilateral oophorectomy (removal of both ovaries) is a different story. It removes one of the two major sites of testosterone production in women and causes an immediate, lasting drop. In one study, women who had both ovaries removed had testosterone levels roughly 25% lower than women who went through natural menopause, and this gap persisted regardless of how long ago the surgery occurred.⁸ This matters clinically because oophorectomy is sometimes performed alongside hysterectomy, and the resulting androgen deficit may go unrecognized for years.

Oral Contraceptives

Combined oral contraceptive pills are among the most underappreciated causes of low testosterone in younger women. The estrogen component of the pill stimulates the liver to produce more sex hormone-binding globulin (SHBG), a protein that latches onto testosterone and renders it biologically inactive. A systematic review and meta-analysis found that all types of combined oral contraceptives significantly lowered free testosterone, with a mean decrease of about 61%.⁹ The effect on free testosterone was remarkably consistent across different pill formulations, even when total testosterone varied between preparations.¹⁰ For most women, this is not a problem. But for those who already have lower baseline androgens, the additional suppression can push free testosterone to very low levels, contributing to symptoms like reduced desire or fatigue that often get attributed to the pill’s other effects.

Pituitary and Adrenal Disorders

The adrenal glands are the other major source of androgens in women, so conditions affecting the pituitary gland or adrenal function can lead to significant testosterone deficiency. In a study comparing 55 women with acquired hypopituitarism to 92 controls, testosterone, free testosterone, androstenedione, and DHEA-sulfate were all markedly reduced across all subgroups of hypopituitary women.¹¹ The deficit was worst in women who had both central hypogonadism and secondary adrenal insufficiency, since both androgen-producing pathways were impaired simultaneously.¹² Chronic stress, autoimmune adrenalitis, and pituitary tumors can all lead to this kind of compound androgen deficiency.

Symptoms That May Signal Low Testosterone

The tricky part of low testosterone in women is that its symptoms overlap with many other conditions, including depression, thyroid disease, iron deficiency, and the general upheaval of perimenopause. There is no symptom that uniquely points to low testosterone. Still, certain patterns tend to appear together.

Reduced sexual desire is the most studied symptom. In a trial of postmenopausal women not taking estrogen, those given a 300-microgram daily testosterone patch reported roughly three times the increase in satisfying sexual episodes compared with placebo, alongside significant improvements in desire and reductions in distress.¹³ The fact that replacing testosterone improved these outcomes suggests the hormone was part of the problem, though it is worth noting the improvement was described as modest rather than dramatic.

Persistent fatigue is another commonly reported symptom. A cross-sectional study of women living with HIV found that those with testosterone insufficiency were about twice as likely to report clinically significant fatigue and had worse scores on measures of cognitive function compared with women whose testosterone levels were in the normal range.¹⁴ The relationship between testosterone and mood is murkier. In that same study, women with low testosterone tended to have higher rates of clinical depression, though the association did not quite reach statistical significance. And a randomized trial of combined estrogen-testosterone therapy found no significant effect on cognitive fatigue, despite theoretical reasons to expect one.¹⁵ The honest summary is that fatigue and brain fog are plausible consequences of low testosterone, but the evidence connecting them is thinner than the evidence for sexual symptoms.

Musculoskeletal effects may also be apparent over time. Androgens increase both muscle mass and bone density in premenopausal women, and they continue to support both in later life.¹⁶ A woman whose testosterone is very low is unlikely to notice day-to-day weakness attributable specifically to that deficit, but over years, the cumulative effect on bone density and lean mass matters, particularly in the context of osteoporosis risk after menopause.

Why Testing Is Harder Than It Should Be

If you suspect low testosterone, getting a reliable blood test is more difficult than you might expect. The standard immunoassay platforms used in most commercial labs were designed to measure testosterone in the male range and lose accuracy at the lower concentrations typical in women. A comparison of five common immunoassays against the gold-standard method (liquid chromatography-tandem mass spectrometry, or LC-MS/MS) found that every immunoassay overestimated testosterone levels in women and children, and none was sufficiently reliable at low concentrations.¹⁷ A separate study of one widely used clinical platform showed that results ran about 20% lower than mass spectrometry at the low end of the range, with minimal correlation between the two methods below 100 ng/dL.¹⁸

The practical takeaway is that if your doctor orders a testosterone level and the lab runs it on a standard immunoassay, the number could be meaningfully off in either direction. Mass spectrometry is the more accurate method, but not all labs offer it, and it is more expensive. Some clinicians work around this by also measuring SHBG and calculating a free androgen index or calculated free testosterone. These calculated values tend to correlate well with the gold-standard equilibrium dialysis method, as long as the underlying total testosterone and SHBG assays are reliable.¹⁹ Direct analog assays for free testosterone, by contrast, perform poorly and are generally not recommended for clinical decisions in women.

Even with a reliable measurement in hand, there is no consensus on what threshold qualifies as “deficiency” in women. Professional societies have not established a cutoff below which symptoms are expected to appear, partly because the relationship between blood levels and symptoms is not as tight as it is in men, and partly because normal ranges vary enormously depending on the assay used and the woman’s age.

Testosterone Treatment and What the Evidence Supports

The strongest evidence for testosterone therapy in women exists for one specific indication: distressing low sexual desire in postmenopausal women. A systematic review concluded that transdermal testosterone increases both sexual desire and the frequency of satisfying sexual activity in naturally and surgically menopausal women with HSDD, while decreasing personal distress about the problem.²⁰ In individual trials, the effective dose for the testosterone patch was 300 micrograms per day; lower doses did not consistently outperform placebo, and higher doses did not add further benefit.²¹

The improvement, while real, is generally described as modest. In the largest placebo-controlled trial of postmenopausal women not on estrogen, the testosterone group gained roughly 2.1 additional satisfying sexual episodes per month over baseline, compared with 0.7 in the placebo group.¹³ That placebo response is a reminder that expectation and attention play a role in sexual function outcomes, and it is the reason some researchers describe the net testosterone benefit as moderate rather than transformative.

For symptoms beyond low desire, such as fatigue, mood, bone density, and muscle mass, the evidence is weaker or still developing. There are physiological reasons to think testosterone replacement could help with these outcomes, and observational data linking higher endogenous testosterone to better bone and muscle measures are persuasive, but large randomized trials specifically testing testosterone for these endpoints in women are largely absent.

DHEA as an Alternative

Dehydroepiandrosterone, better known as DHEA, is an androgen precursor that the body can convert into testosterone. It is widely sold as a dietary supplement and marketed for libido, energy, and general well-being in postmenopausal women. The evidence for these claims is thin. A randomized trial of 50 milligrams of daily oral DHEA in postmenopausal women with low libido found no significant improvement in sexual function, well-being, or menopausal symptoms over placebo after 26 weeks.²² A broader review of the available literature reached the same conclusion: published trials are too small, too short, and too inconsistent to support routine use of DHEA for these purposes, and safety data are lacking.²³ Because DHEA is classified as a supplement rather than a drug in the United States, its quality, dosing, and purity are not regulated as rigorously as prescription medications.

Side Effects and Safety of Testosterone Therapy

The most commonly reported side effects of testosterone therapy in women are androgenic skin changes: acne and increased facial or body hair.²⁴ A meta-analysis confirmed these two effects and also found small shifts in cholesterol, with total cholesterol, triglycerides, and HDL (“good” cholesterol) declining and LDL (“bad” cholesterol) rising slightly.²⁵ Deepening of the voice and clitoral enlargement have been reported at higher doses but are uncommon at the physiological replacement doses used in clinical trials.

The cardiovascular and breast cancer questions loom larger in many women’s minds. A claims database analysis comparing women on testosterone therapy with matched controls found that treated women had a lower risk of major cardiovascular events and a lower risk of breast cancer rather than a higher one.²⁶ A separate analysis tracking breast cancer incidence in women treated with subcutaneous testosterone found that diagnosed cases occurred at a rate well below both the general population rate and the rates observed in large studies of hormone therapy users and nonusers.²⁷ These findings are reassuring, but they come from observational data and claims databases rather than from the kind of large, long-term randomized trial that would settle the question definitively. At the doses used for female replacement, the current evidence does not point to increased cardiovascular or breast cancer risk, but long-term safety data spanning decades simply do not exist yet.

No Approved Products for Women

Despite the accumulating evidence, no testosterone product has been approved by the U.S. Food and Drug Administration for use in women. More than 30 FDA-approved testosterone formulations exist for men.²⁸ The gap is partly regulatory and partly driven by the difficulty of conducting the large, years-long safety trials the FDA would require for approval. It is also shaped by lingering concern from the Women’s Health Initiative era, when hormone therapy broadly fell out of favor following reports linking estrogen-progestin combinations to cardiovascular and cancer risks. Those findings did not involve testosterone, but the general wariness they created toward female hormone therapy spilled over.

In practice, clinicians who prescribe testosterone for women use products approved for men at much lower doses, or they work with compounding pharmacies to create custom formulations. Compounded preparations are not subject to the same batch-by-batch quality testing as commercial drugs, which introduces some variability. The transdermal route (patches, gels, creams) is generally preferred over oral testosterone because it avoids the first-pass liver metabolism that can amplify lipid side effects. If you are considering testosterone therapy, finding a clinician who is familiar with female-specific dosing and who monitors levels with a reliable assay is important, since the margin between therapeutic and excessive dosing is narrower in women than in men.

Exercise and Lifestyle Factors

Resistance training can produce a transient spike in testosterone. A study of young healthy women found that a single bout of heavy resistance exercise raised both total and free testosterone by roughly 25%, though levels returned to baseline fairly quickly afterward.²⁹ Whether these repeated acute surges translate into meaningfully higher resting testosterone over time is not well established, but regular strength training independently supports the same outcomes that testosterone helps with, namely muscle mass, bone density, and mood. For women with mildly low testosterone and no underlying pathology, consistent weight-bearing exercise, adequate sleep, stress management, and maintaining a healthy body-fat range represent the most evidence-supported starting points before considering any pharmacological approach.

Severe caloric restriction and overtraining can push testosterone in the opposite direction by disrupting the hypothalamic signals that drive hormone production. Endurance athletes and women with eating disorders frequently show suppressed androgens alongside disrupted menstrual cycles, a constellation sometimes called relative energy deficiency in sport. In these cases, addressing the energy imbalance tends to restore hormonal function more effectively than any supplement.