Women who ask about testosterone are usually asking about energy, or muscle, or mental sharpness, or libido, or some combination that adds up to not feeling like themselves. What they often get back is a version of "testosterone isn't approved for women," which is true, and which answers a question they did not ask.
The more useful place to start is with what testosterone is doing in a woman's body in the first place, and what a measurement of it actually tells you.
Testosterone is not a trace hormone in women
Testosterone is present in women at concentrations well above those of estradiol. Bruce Dorr, M.D., presenting to the Age Management Medicine Group, puts it as testosterone being the most abundantly produced hormone in women, exceeding estrogen levels several times over. Concentrations decline with age, and the decline begins earlier and runs more gradually than the estrogen changes of the menopause transition, which is part of why it tends to go unremarked.
It is produced in the ovaries and the adrenal glands, and it is also made from precursors — DHEA chief among them — which is why an androgen picture that stops at testosterone alone is incomplete.
What a panel measures, and why each number is there
Total testosterone is everything in circulation, bound and unbound. On its own it is the least informative of the androgen markers in women.
Sex hormone binding globulin (SHBG) is the protein that binds testosterone in the blood. Bound hormone is not available to tissue. SHBG rises with oral estrogen, with thyroid hormone and with several other exposures, and when it is high, total testosterone can look unremarkable while very little of it is actually free.
Free testosterone is the fraction available to act. In women, whose concentrations are a fraction of a man's to begin with, this is the number that usually changes the interpretation.
DHEA-S reflects adrenal androgen production and is the precursor pool. A low DHEA-S with a low free testosterone points somewhere different than a low free testosterone with a normal DHEA-S.
Measured together, these tell you whether there is an androgen deficit at all, and if there is, roughly where it is coming from. Measured as a single total testosterone, they tell you very little.
Where testosterone acts
Androgen receptors are not confined to reproductive tissue. Cheryl Burdette, N.D., presenting to the same group, makes the point that receptors in the brain and in bone matter for a great deal more than libido — which is the frame most patients have been given.
That is a statement about where a hormone can act. It is not, on its own, evidence that supplementing it produces a given benefit, and the two get conflated constantly. What can be said fairly is that the strongest trial evidence for testosterone therapy in women concerns sexual desire, and that for energy, mood, muscle and cognition the evidence is thinner and less consistent — thin enough that anyone promising you those outcomes is going beyond what has been shown.
That is a reason to measure and to interpret carefully. It is not a reason to treat everyone, and it is not a reason to dismiss a woman whose free testosterone is genuinely low.
The regulatory fact, stated plainly
There is no FDA-approved testosterone product indicated for women in the United States. No manufacturer has brought a female-dose product through approval. Any testosterone prescribed to a woman is therefore off-label, in every form, at every practice.
That is a disclosure every patient is entitled to have made to them directly, and a provider who implies otherwise is mistaken. It is a fact about the regulatory landscape rather than a judgment about the therapy.
Dose to the range, then measure
Where testosterone therapy is appropriate, the discipline that matters is dosing toward concentrations within the physiological range for premenopausal women — not above it — and confirming with a follow-up measurement rather than adjusting by symptom report alone.
This is also where delivery method becomes a practical question rather than a preference. Methods that produce peaks above the physiological range are the ones that raise the question of long-term safety data that does not exist, and a dose that has already been administered cannot be adjusted downward. It has to wear off.
How we approach it
We measure androgens — total and free testosterone, SHBG and DHEA-S — as part of a comprehensive panel, because a low free testosterone is a finding worth having whether or not it leads to a prescription. It changes how the rest of the panel reads.
Where testosterone therapy is appropriate, we prescribe it as off-label therapy and we say so. We dose toward the physiological range, and we recheck levels rather than adjusting by symptom report alone.
Where a woman's fatigue, mental fog or low mood turns out to have a thyroid, cortisol or metabolic explanation — which is often — testosterone is not the answer, and the panel is what tells us that.
What to ask any provider who offers testosterone
- What is my free testosterone, and what number are you targeting?
- Did you measure SHBG and DHEA-S, and what did they show?
- Is this off-label? (The answer is yes. A provider who says otherwise is mistaken.)
- What are you measuring at follow-up, and when?
- What happens if the level comes back above the physiological range?
Frequently asked questions
Is testosterone approved for women in the United States?
No. There is no FDA-approved testosterone product indicated for women, so any testosterone therapy prescribed to a woman is off-label regardless of the form it takes.
Why measure free testosterone rather than total?
Because bound hormone is not available to tissue. When SHBG is high, total testosterone can look acceptable while free testosterone sits at the bottom of the range — and the free number is the one that fits the symptoms.
Will testosterone fix my energy?
The strongest evidence in women concerns sexual desire; for energy, mood and cognition it is thinner and less consistent. Measuring is still worth doing, because the result changes what else is worth investigating.
What is DHEA-S doing on a testosterone panel?
It reflects adrenal androgen production, and it is the precursor pool. It tells you where a low testosterone is coming from.
What about pellets?
Delivery methods differ mainly in whether they can be adjusted and whether they produce peaks above the physiological range. Both are worth asking about specifically, because an administered dose cannot be taken back.
