Testosterone in Women — The Missing Piece Nobody Tests
Day 5 of the 30-day Perimenopause Series.
One of the most consistently missed hormones in women's health is testosterone. Ask most primary care providers to run a hormone panel on a perimenopausal woman and testosterone will not be on it. Ask most OB/GYNs and it may be missing too. And yet testosterone is the hormone that most directly affects a woman's energy, libido, mood stability, muscle mass, and cognitive sharpness.
Yes, women have testosterone. Yes, we produce it — in the ovaries and adrenal glands. Yes, it declines during and after perimenopause. And yes, replacing it when it is deficient can transform how a woman feels.
But almost no one is looking.
What Testosterone Does in Women
In women, testosterone is not a masculinizing hormone at normal levels. It is a foundational hormone for:
Energy and stamina — the felt sense of having enough to give.
Libido — both sexual desire and general drive for engagement with life.
Muscle mass and strength — which underlies metabolism, bone health, and injury prevention.
Cognitive sharpness — clarity, focus, and mental stamina.
Mood stability — testosterone deficiency is often mistaken for depression.
Sense of confidence and agency — the ability to advocate for oneself.
Bone density — testosterone converts to estrogen locally in bone tissue.
By the time a woman reaches her mid-40s, her testosterone level is often about half of what it was in her 20s. By postmenopause, it may be a quarter. That drop has real, measurable consequences.
Why Standard Labs Miss It
Even when testosterone is ordered, standard testing is often inadequate for women.
A total testosterone level alone is not enough, because most testosterone in the blood is bound to a protein called sex hormone binding globulin (SHBG) and is not biologically active. Only the small unbound fraction — free testosterone — is available to the tissues.
SHBG rises with oral estrogen (including birth control pills), with hyperthyroidism, and with certain other conditions. A woman with high SHBG can have a normal total testosterone and a functionally low free testosterone. She will feel deficient. Her labs will look fine.
A useful workup includes:
Total testosterone
Free testosterone (calculated or measured directly)
SHBG
DHEA-S — the adrenal precursor to testosterone
Interpretation should be done by someone who understands optimal ranges for women, not just "in range" versus "out of range."
When to Suspect Low Testosterone
The pattern I watch for in my practice:
Persistent fatigue that does not respond to sleep improvement.
Libido that has significantly dropped and is not explained by relational or emotional causes.
Loss of muscle mass despite continued exercise.
Cognitive fog, difficulty with focus, or a sense of "blunted" mental sharpness.
A blunted sense of drive or ambition — a feeling of not caring as much.
Depression that has been treatment-resistant to standard antidepressants.
Any three of these in a woman over 35 warrants a full testosterone workup.
Treatment Considerations
Testosterone replacement in women is off-label in the United States for anything other than hypoactive sexual desire disorder in postmenopausal women. That said, thoughtful clinicians prescribe it in the appropriate clinical context, at physiologic (not male) doses.
Delivery options include:
Compounded transdermal testosterone cream, typically dosed to achieve mid-normal female range.
Testosterone pellets, though these can produce supraphysiologic levels and are harder to titrate.
DHEA supplementation, which can gently support testosterone in some women.
Treatment should always be monitored with serial labs and clinical response. Well-dosed testosterone in a deficient woman does not masculinize. It restores.
Whole-Person Steps
If any of the symptoms above describe you, ask for the full testosterone panel: total, free, SHBG, and DHEA-S.
If your provider says testosterone is "not important for women," get a second opinion.
Prioritize strength training. Muscle tissue itself supports hormonal health.
Ensure adequate protein — testosterone production requires amino acid building blocks.
Consider consultation with a menopause-trained clinician or a functional medicine provider comfortable with female testosterone replacement. The Menopause Society has a certified-practitioner directory.
If You Are in Utah
At Integrative Mind Body Psychiatry, I take the time to ask about your hormones, your sleep, your labs, and the whole life you are actually living. Telehealth for adults, adolescents, and women in hormonal transitions across Utah. Insurance accepted through Headway. Learn more at integrativemindbodypsychiatry.com.
Tomorrow: Day 6 — Alcohol in Perimenopause: Why One Glass Hits Differently Now.
Respectfully,
Beth Makar, RN, Dual-MSN, PMHNP-BC
Comments