Low Testosterone in Perimenopause: Symptoms Women Experience and What Can Be Done

Testosterone Is Not Just a Male Hormone

When most people think of testosterone, they think of men. But women produce testosterone too, in smaller amounts, and it plays important roles in your health that are entirely distinct from what you typically associate with male hormones. Testosterone is produced in women by the ovaries and the adrenal glands, and it has receptors in the brain, bone, muscle, heart, and reproductive tissues. Its effects in women are meaningful and multidimensional, and when it declines, the consequences can be significant.

In women, testosterone contributes to sexual desire, the ability to reach arousal and orgasm, energy and motivation, muscle strength and mass, bone density, mood stability, and cognitive sharpness. Many women describe the subjective experience of adequate testosterone as a kind of vitality or drive, a sense of being fully engaged in life. When testosterone is low, the absence of these qualities can feel like a dimming of something essential. It's often described as flatness rather than depression, and it's a symptom pattern that is frequently missed or attributed to other causes.

The challenge is that testosterone in women has been dramatically understudied compared to testosterone in men. There are no FDA-approved testosterone products for women in the United States. Lab reference ranges for female testosterone are poorly standardized and often unreliable. Many providers are uncertain about how to assess, interpret, or treat testosterone deficiency in women. This leaves a significant gap in care for a condition that is genuinely common and genuinely impactful.

How Testosterone Declines in Women

Unlike estrogen, which tends to remain relatively stable until perimenopause and then declines more sharply, testosterone in women declines gradually across the entire reproductive lifespan. Peak testosterone production occurs in the mid-20s, and by the time most women reach their early 40s, their testosterone levels are already roughly half what they were in their 20s. This gradual decline means that many women begin experiencing testosterone-related symptoms well before perimenopause, and may not connect those symptoms to hormone decline.

Perimenopause accelerates the process. As the ovaries begin to shift away from consistent ovulation, ovarian testosterone production decreases. Estrogen decline in perimenopause also indirectly affects testosterone availability because sex hormone binding globulin (SHBG) levels change with estrogen, altering how much testosterone circulates in free, biologically active form versus protein-bound, inactive form. Starting oral estrogen therapy can increase SHBG and therefore reduce free testosterone, which is one reason why some women feel a decline in libido and energy after starting oral HRT even though their estrogen is now adequately replaced.

Women who undergo surgical menopause through oophorectomy (removal of the ovaries) experience an immediate and dramatic decline in both estrogen and testosterone, since the ovaries are the primary site of production for both. These women typically experience more acute and severe testosterone deficiency symptoms than women going through natural perimenopause, and they represent one of the clearest clinical cases for testosterone replacement therapy.

Symptoms of Low Testosterone in Women

The symptom picture of low testosterone in women has some overlap with low estrogen, which makes clinical assessment challenging. But there are some patterns that are more characteristic of testosterone deficiency specifically. Loss of sexual desire (libido) is the most commonly reported and studied symptom. Women describe a loss of spontaneous desire, difficulty getting interested even when other factors for intimacy are present, and a reduction in the mental and physical engagement that was previously present.

Fatigue with a particular quality, what some women describe as a motivational flatness or lack of drive rather than purely physical tiredness, is another characteristic pattern. Women with low testosterone often describe feeling physically capable but lacking the spark to initiate activities they previously enjoyed. This can look like depression on the surface, but the emotional quality is different: not sadness or hopelessness, but a muted engagement with life that doesn't respond well to antidepressants.

Muscle weakness and difficulty maintaining muscle mass despite adequate exercise is another testosterone-related symptom. Cognitive symptoms, including word-finding difficulties and a sense of mental dullness, may also be partly related to testosterone, since testosterone has direct effects on neurological function. Hair thinning can occur with very low testosterone, though it can also occur with very high testosterone (more typical in PCOS), so this symptom requires clinical context. The pattern of symptoms matters more than any single marker.

Why Lab Testing for Testosterone in Women Is Complicated

Getting a meaningful testosterone measurement in women is more complicated than simply ordering a blood draw. The main issues are that female testosterone levels are much lower than male levels (typically 10 to 15 times lower), and the assay methods used by most commercial labs are calibrated for the male range. At the low concentrations found in women, standard immunoassay methods have poor precision, meaning the same woman's blood can produce meaningfully different results on different machines or on different days.

The gold standard for measuring testosterone in women is liquid chromatography-tandem mass spectrometry (LC-MS/MS), which is more precise at low concentrations. This method is available through some specialty labs but is not used universally. If testosterone testing is going to meaningfully inform clinical decisions, using the more accurate method matters.

Free testosterone, the biologically active fraction not bound to SHBG, is often more clinically relevant than total testosterone, but it's even harder to measure accurately at female concentrations. Many labs calculate free testosterone mathematically from total testosterone and SHBG rather than measuring it directly, which introduces additional uncertainty. In practice, many menopause specialists use clinical symptoms as the primary guide for testosterone replacement decisions, with lab values serving as supportive context rather than the definitive criterion. This is actually the approach recommended in international consensus guidelines on testosterone therapy for women.

Who Benefits Most From Testosterone Therapy

The strongest evidence for testosterone therapy in women is for hypoactive sexual desire disorder (HSDD), the clinical term for low libido that causes distress. Multiple randomized controlled trials and a 2019 Global Consensus Position Statement from major menopause societies concluded that testosterone therapy is effective for improving sexual desire, arousal, and satisfaction in women with HSDD, and that short- to medium-term use (up to 24 months studied) appears safe.

Beyond sexual function, the evidence for testosterone for other symptoms is less rigorous, though clinically suggestive. Many menopause specialists observe significant improvements in energy, mood, and cognitive function in women who start testosterone at appropriate doses, and these clinical observations are consistent with what we know about testosterone's physiological roles. The research base simply hasn't caught up to the clinical observation because testosterone therapy for women has been dramatically underfunded and understudied.

Women who are most likely to benefit include those with documented low testosterone (by whatever measurement is available), those whose libido or energy symptoms are prominent and have not responded adequately to optimal estrogen therapy, women who have had surgical menopause with oophorectomy, and women who have been on oral HRT and experienced a decline in free testosterone due to increased SHBG. Women with specific contraindications, such as active or history of hormone-sensitive cancers, or those already at the high end of the female reference range, may not be appropriate candidates.

Available Forms of Testosterone for Women

Since there are no FDA-approved testosterone products specifically for women in the United States, the available options involve either compounded preparations or off-label use of products approved for men at much lower doses. In other countries, notably Australia and the United Kingdom, testosterone products for women exist (such as Androfeme cream in Australia), but these are not available in the US through standard channels.

Compounded testosterone cream or gel at concentrations appropriate for female dosing is the most common approach in the US. A typical female dose is 0.5 to 2mg daily applied to the skin, compared to male doses that are often 50 to 100mg daily. This dramatic difference in dose means that even small amounts of male-formulated products are too concentrated for safe female use without careful dilution. Using male testosterone products unadjusted for female dosing is one of the ways women end up with supraphysiologic testosterone levels and the associated side effects.

Male testosterone products (gels, creams, or injections) used at very carefully titrated lower doses are another approach that some providers use. This requires a provider who is experienced in calculating appropriate female doses and monitoring carefully. Pellet therapy, which has been discussed in the context of compounded hormones generally, is a form of testosterone delivery that carries specific risks in women due to the non-adjustable sustained dosing that can lead to supraphysiologic levels. Most menopause specialists prefer adjustable-dose topical applications over pellets for women. Tracking symptoms consistently with PeriPlan or similar tools helps you communicate your response to testosterone therapy clearly and supports timely dose adjustments.

What to Expect and How to Monitor

If you start testosterone therapy, setting realistic expectations helps you evaluate whether it's working. Sexual desire improvements, when they occur, typically emerge within 3 to 6 weeks of reaching an adequate dose. Energy and mood improvements may take somewhat longer, often 6 to 12 weeks. Muscle and body composition changes take longer still, on the order of several months of consistent therapy alongside appropriate exercise.

Monitoring is important to catch supraphysiologic levels before side effects develop. Side effects of excessive testosterone in women include acne, increased body or facial hair, voice deepening (which may be permanent), and clitoral enlargement. These effects are dose-related and are avoided with careful dosing and regular monitoring. Testing testosterone levels 4 to 6 weeks after starting or adjusting a dose, then every 6 months once stable, is a reasonable monitoring interval.

The target is the upper end of the normal female reference range, not anywhere near male levels. A free testosterone level that is physiologically normal for a woman in her 20s or early 30s is a reasonable therapeutic target. If you're working with a compounding pharmacy for testosterone, using a PCAB-accredited pharmacy that tests its products for potency gives you more confidence that what's in the preparation is what you're expecting. As with all elements of HRT, the ongoing conversation with your provider is the key to a treatment that serves your needs rather than just your labs.

Medical Disclaimer

This article is written for general informational purposes only and does not constitute medical advice. Testosterone therapy decisions, including dosing and monitoring, should always be made in partnership with a qualified healthcare provider who knows your full medical history. The information here is not a substitute for a clinical evaluation. If you have concerns about low testosterone or perimenopause symptoms, please consult a licensed medical professional.