Testosterone and Perimenopause: The Hormone Nobody Told You About

Something Went Missing and You Could Not Name It

It was not dramatic. There was no single moment where you noticed it was gone. It was more like slowly realizing the volume had been turned down on something you used to feel reliably.

Your drive. The motivation that used to get you up early or push you through the second half of a project. The desire for physical closeness with your partner. The feeling of caring about things in a way that had some energy behind it.

Maybe you blamed the life you were living. You were tired, you were busy, there was a lot on your plate. Maybe you assumed this was just what your forties felt like. Maybe your doctor nodded along and said something about stress.

But nobody mentioned testosterone.

Most women know that estrogen and progesterone shift during perimenopause. What gets far less attention is that testosterone also declines, starting earlier than most people realize, and that its absence affects things that are deeply tied to how you feel like yourself.

What Testosterone Actually Does in Your Body

Testosterone is often framed as a male hormone. In reality, women produce testosterone throughout their lives, in the ovaries and adrenal glands, and it plays a direct role in several aspects of physical and psychological wellbeing.

Energy and stamina. Testosterone supports cellular energy production and muscle function. Low testosterone is associated with the kind of fatigue that is not simply tiredness, the variety that does not fully resolve with rest.

Libido and sexual sensation. Testosterone is the primary hormonal driver of sexual desire in women. It also affects genital sensitivity. When testosterone levels fall, desire often falls with it, not due to relationship or psychological factors, but because the hormonal signal that generates desire is simply weaker.

Muscle mass and strength. Testosterone supports muscle protein synthesis. As it declines, maintaining muscle mass requires more effort for the same result. Strength gains that used to come relatively easily may plateau.

Motivation and mood. There is a meaningful connection between testosterone and dopamine, the neurotransmitter most associated with drive, reward, and forward momentum. Low testosterone can present as a flatness of mood, a reduction in ambition and enthusiasm, not quite depression but not quite right either.

When you hear this list and recognize yourself in several items, that is not a coincidence.

When Does Testosterone Start to Decline?

Testosterone in women peaks in the mid-twenties and begins a gradual decline that accelerates in the decade before menopause.

By the time many women reach their early to mid-forties, their testosterone levels are already meaningfully lower than they were in their thirties. This decline does not wait for perimenopause to officially begin, and it is not clearly announced by symptoms that are easy to attribute to it. The changes tend to be gradual enough that they read as background noise rather than a clear alarm.

For women who have their ovaries removed surgically, the drop in testosterone is immediate and steep because the ovaries are a primary production site. Symptoms tend to be more acute in this group, which is part of why the connection between testosterone and wellbeing has been better documented in surgical menopause than in natural perimenopause.

But the decline happens in natural perimenopause too. It is just quieter and slower, which is exactly why it goes unrecognized.

What Low Testosterone Actually Feels Like

The way low testosterone tends to get described in clinical literature is fairly dry. Reduced libido. Decreased energy. Loss of muscle mass. In reality, the experience is more specific than that.

The libido piece is often not a dramatic shutdown. It is more that desire stopped being a regular visitor. You can go days or weeks without thinking about sex in any meaningful way. When the opportunity arises, there is no pull toward it. You care about your partner. You can go through the motions. But the wanting is gone, and it has been gone long enough that you have started to wonder if it is coming back.

The energy piece is particularly insidious because it looks like every other kind of tired. You rest, you sleep, and you still do not feel restored. The morning cup of coffee does less than it used to. The second half of the afternoon is a slog. You used to push through fatigue with something that felt like will. Now the well is empty by early evening.

The mood piece is hard to describe to someone who has not felt it. It is not sadness exactly. It is more like the absence of the thing that makes things feel worth doing. A competent, functional flatness. You are getting through the days. You are not depressed, technically. But you miss caring about things the way you used to.

How Low Testosterone Gets Dismissed

If you have brought these symptoms to a doctor, there is a reasonable chance they were attributed to something else. Stress. Sleep deprivation. Depression. Relationship difficulties. Normal aging. The conversation about testosterone, if it happened at all, may have been short.

There are a few reasons for this. Testosterone testing in women is not standardized the way it is in men. Reference ranges are based on younger women, and the assays used to measure low levels in women are less reliable at the ranges that actually matter. This means a result can come back technically normal while still being meaningfully low for your individual baseline.

There is also a cultural piece. Low libido in women is frequently psychologized in ways that low libido in men is not. The hormonal component is often the last thing investigated rather than the first.

Advocating for yourself in this conversation is not easy, but it is worth doing. Asking specifically for a free testosterone level, not just total testosterone, and asking to discuss how the result relates to your symptoms rather than just whether it falls within a reference range, is a reasonable and informed request.

How to Ask Your Doctor About Testing

What Addressing Low Testosterone Can Feel Like

Women who have testosterone deficiency recognized and addressed often describe the experience in terms that are hard to capture in clinical language.

One common description is the sense of returning to yourself. Not to a younger version. Not to some artificial heightened state. Just to the version of you that had agency, drive, and physical aliveness.

Libido tends to return gradually, over weeks to months, rather than immediately. It often begins as the absence of absence. The flat non-wanting shifts to a mild curiosity, then to something more recognizable. For women whose low testosterone was a significant part of relationship difficulty, this can be quietly transformative.

Energy changes are often described as a lifting of a background weight. The afternoon crash becomes less predictable or less severe. Physical exertion starts to feel rewarding again rather than just depleting.

The mood shift is often the thing people are least prepared for. The flatness lifts. Caring about things comes back. Ambition, the small personal kind, returns in ways that had been missing for so long the absence had become the new normal.

What Treatment Looks Like

Testosterone therapy for women is prescribed off-label in the United States, meaning it is not specifically FDA-approved for this use, though it is widely used. Formulations include topical gels and creams, which are the most common, as well as pellet implants. Dosing for women uses much lower concentrations than formulations designed for men.

In other countries, particularly the UK and Australia, low-dose testosterone for women is better established within menopause treatment guidelines and may be easier to access through standard care.

The goal of testosterone therapy in women is to bring levels into a range that is physiologically appropriate for women, not to supraphysiologic levels. Monitoring with periodic blood tests ensures levels stay appropriate and avoids side effects associated with excess, which can include acne, hair changes, and voice changes.

Not every woman with perimenopause-related symptoms needs testosterone therapy, and not every case of low libido or fatigue is primarily hormonal. A thoughtful clinical evaluation matters. But the conversation about testosterone deserves a place in the broader discussion of perimenopause support, not as a last resort after everything else has been tried, but as a legitimate part of the initial assessment.

You Deserve a Complete Picture

Perimenopause is often presented as an estrogen story. Estrogen drops, things change, here are your options. That is true as far as it goes. But your hormonal landscape is more than one hormone, and the symptoms that feel most like a loss of self are often connected to testosterone.

You are not imagining the flatness. You are not just tired or stressed or not trying hard enough. Your body is going through a real hormonal transition that affects multiple systems, and testosterone is part of that picture.

Tracking the specific symptoms that feel most connected, your energy, your drive, your desire, over time gives you a clearer description to bring to your provider. PeriPlan can help you do that. The more precisely you can describe what changed and when, the more useful the clinical conversation becomes.

You deserve a complete picture of what your body is navigating. And you deserve a healthcare provider who is willing to look at the whole picture with you.

This content is for informational purposes only and does not replace medical advice. Always consult your healthcare provider about your specific situation.