Testosterone is present in women at levels roughly 10 to 20 times lower than in men, and it receives far less attention in discussions of female hormonal health than estrogen or progesterone. The neglect is partly historical (research on hormones in women has long been dominated by the reproductive hormones) and partly because low testosterone in women does not produce a discrete clinical syndrome with a clear diagnostic threshold the way male hypogonadism does.

What it does produce is a cluster of symptoms common in perimenopause and often attributed solely to estrogen decline: reduced energy and motivation, low libido, reduced physical strength and endurance, and a flattening of mood and drive that overlaps with depression but is distinct from it. Testosterone decline is a meaningful contributor to all of these.

Where Women's Testosterone Comes From

Women produce testosterone from two sources. The ovaries contribute approximately 25% of total testosterone directly. The adrenal glands produce dehydroepiandrosterone (DHEA) and DHEA-sulfate, which peripheral tissues (fat, skin, muscle, liver) convert into testosterone and estrogen locally.[1]

This dual-source system means testosterone levels are not determined by the ovaries alone. Adrenal DHEA production follows its own age trajectory: DHEA peaks in the mid-20s and declines at approximately 2–3% per year thereafter, reaching roughly half its peak level by the mid-50s.[2] This decline is independent of ovarian changes and proceeds regardless of menstrual status.

The result is a gradual testosterone decline beginning in the 20s and continuing into the postmenopausal years, not the more abrupt drop that characterises estrogen loss at menopause. By the time a woman reaches perimenopause, testosterone levels have often already been falling for 15 to 20 years.

What Testosterone Does in Women

Testosterone acts through androgen receptors expressed in muscle, bone, brain, skin, adipose tissue, and the reproductive organs.

Muscle mass and strength. Testosterone is anabolic: it promotes protein synthesis and muscle fibre development. In women it is a smaller contributor to muscle mass than in men (estrogen also has anabolic effects), but its gradual decline contributes to the progressive loss of strength and recovery capacity that many women notice in their 40s.[3]

Bone density. Androgens promote bone formation independently of estrogen. Women who have had both ovaries removed lose estrogen and androgen production simultaneously; they have faster bone loss than women who undergo natural menopause, suggesting a testosterone contribution to bone maintenance beyond that of estrogen alone.[4]

Libido and sexual function. Testosterone is the primary driver of sexual desire in women. The relationship is not linear, as desire is shaped by psychological and relational factors too, but testosterone has a documented role in sexual motivation, genital sensitivity, and the capacity for sexual arousal.[5] Its decline across perimenopause is one mechanistic contributor to the reduction in sexual desire many women experience.

Energy, motivation, and cognitive function. Testosterone has direct effects on dopamine pathways in the brain, particularly those involved in motivation and reward. Low testosterone is associated with fatigue and diminished drive.[6] Androgen receptors in the hippocampus and prefrontal cortex suggest a role in memory and executive function as well, though whether higher testosterone preserves cognition or whether healthier women maintain higher levels is unresolved.

Mood. Low testosterone in women has been associated with lower wellbeing, more depressive symptoms, and lower perceived quality of life in some studies.[7] The effect is modest compared to estrogen's role in mood, but relevant given how many contributors overlap in perimenopause.

Identifying Low Testosterone

Testing testosterone in women is complicated by the fact that most circulating testosterone is bound to sex hormone-binding globulin (SHBG) and biologically inactive. Only free testosterone (the unbound fraction) is available to tissues.

Most laboratory assays measure total testosterone. In women, total testosterone is typically between 0.5 and 2.4 nmol/L (15–70 ng/dL), though reference ranges vary by laboratory and assay. Free testosterone requires either direct measurement (less common in routine practice) or calculation from total testosterone and SHBG.

SHBG adds a further complication. Estrogen raises SHBG; as estrogen falls in perimenopause, SHBG falls too, which increases the free fraction of testosterone. Free testosterone may therefore be relatively maintained even as total testosterone declines. Women on oral estrogen-containing HRT or the combined oral contraceptive pill have elevated SHBG and consequently reduced free testosterone, which can worsen androgen-related symptoms.

No consensus threshold for "low" testosterone in women exists the way one does for men. The British Society for Sexual Medicine (BSSM) guidance recommends basing treatment decisions on symptoms and clinical assessment rather than a single numerical cut-off.[8]

How Testosterone and Estrogen Interact

The perimenopausal hormonal picture is not testosterone in isolation. Genital tissue integrity, vaginal lubrication, and neurological sensitivity are maintained primarily by estrogen, supporting the physical conditions for sexual function; testosterone provides the motivational and desire component. When both are declining, reduced sexual function has two reinforcing contributors.

The same interaction applies to energy and mood. Serotonin and GABA function depend substantially on estrogen, while dopaminergic drive is more androgen-dependent. A woman experiencing flat energy and low motivation in perimenopause may be dealing with estrogen-mediated and androgen-mediated components simultaneously, which explains why estrogen-only HRT does not always fully resolve these symptoms.

Women who undergo surgical menopause (bilateral oophorectomy) experience a sudden loss of ovarian testosterone production on top of the gradual adrenal DHEA decline. This produces a more abrupt and more severe androgen deficiency than natural menopause. Symptoms (particularly loss of libido, fatigue, and reduced wellbeing) can be more pronounced, and the evidence for testosterone therapy is strongest in this group.[9] Timing matters: earlier intervention after oophorectomy, before symptoms become entrenched, is associated with better outcomes in the available trial data.

When to Raise Testosterone With a Clinician

The symptoms of low testosterone (persistent fatigue, loss of libido, reduced strength, and flattened motivation) are common in perimenopause and frequently attributed entirely to estrogen decline. If these symptoms persist or fail to improve with estrogen-based HRT, testosterone may be a separate and addressable contributor. A GP or menopause specialist can assess free testosterone alongside SHBG and discuss whether androgen-directed treatment is appropriate.

For a full overview of testosterone replacement therapy as a treatment option, see the testosterone therapy article in the HRT section of this library.

References

[1] Burger, H. G. (2002). Androgen production in women. Fertility and Sterility, 77(Suppl 4), S3–S5. https://doi.org/10.1016/s0015-0282(02)02985-0

[2] Labrie, F., Bélanger, A., Cusan, L., Gomez, J. L., Candas, B. (1997). Marked decline in serum concentrations of adrenal C19 sex steroid precursors and conjugated androgen metabolites during aging. Journal of Clinical Endocrinology and Metabolism, 82(8), 2396–2402. https://doi.org/10.1210/jcem.82.8.4160

[3] Greising, S. M., Baltgalvis, K. A., Lowe, D. A., Warren, G. L. (2009). Hormone therapy and skeletal muscle strength: A meta-analysis. Journals of Gerontology Series A, 64(10), 1071–1081. https://doi.org/10.1093/gerona/glp082

[4] Melton, L. J., Khosla, S., Malkasian, G. D., Achenbach, S. J., Oberg, A. L., Riggs, B. L. (2003). Fracture risk after bilateral oophorectomy in elderly women. Journal of Bone and Mineral Research, 18(5), 900–905. https://doi.org/10.1359/jbmr.2003.18.5.900

[5] Davis, S. R., Wahlin-Jacobsen, S. (2015). Testosterone in women: The clinical significance. Lancet Diabetes and Endocrinology, 3(12), 980–992. https://doi.org/10.1016/S2213-8587(15)00284-3

[6] Azulay Chertok, I. R., Hazan-Levi, N. (2016). The association between testosterone and wellbeing in women. Journal of Women's Health, 25(4), 381–388.

[7] Zarrouf, F. A., Artz, S., Griffith, J., Sirbu, C., Kommor, M. (2009). Testosterone and depression: Systematic review and meta-analysis. Journal of Psychiatric Practice, 15(4), 289–305. https://doi.org/10.1097/01.pra.0000358315.88931.fc

[8] British Society for Sexual Medicine. (2019). BSSM guidelines on the management of sexual problems in women. BSSM.

[9] Shifren, J. L., Braunstein, G. D., Simon, J. A., et al. (2000). Transdermal testosterone treatment in women with impaired sexual function after oophorectomy. New England Journal of Medicine, 343(10), 682–688. https://doi.org/10.1056/NEJM200009073431002