Testosterone

What It Is

Testosterone is often thought of as the "male hormone," but women need testosterone too—and it plays a critical role in libido, energy, motivation, assertiveness, confidence, muscle mass, bone density, and cognitive function. While women produce far less testosterone than men (about 1/10th to 1/20th the amount), it's still essential for physical and psychological well-being.

Where it's produced:

• Ovaries → produce about 25% of women's testosterone
• Adrenal glands → produce about 25% of women's testosterone
• Peripheral conversion → about 50% of testosterone comes from conversion of other androgens (DHEA, androstenedione) in fat tissue, skin, and liver

Primary functions:

• Supports libido and sexual desire → testosterone is the primary driver of sexual interest, arousal, and pleasure in women
• Maintains muscle mass and strength → testosterone stimulates protein synthesis and muscle building
• Supports bone density → works alongside estrogen to maintain strong bones
• Enhances motivation, drive, and ambition → testosterone affects dopamine pathways (reward, motivation, goal-directed behavior)
• Supports assertiveness and confidence → testosterone influences dominance behaviors, self-advocacy, risk-taking
• Supports cognitive function → spatial reasoning, executive function, memory
• Affects mood and energy → low testosterone is linked to fatigue, low mood, reduced vitality
• Supports metabolic health → helps regulate fat distribution, insulin sensitivity, lean body mass

Testosterone vs. androgens:

Testosterone is part of a family of hormones called androgens ("male" hormones, though women produce them too). Other androgens include:

• DHEA (dehydroepiandrosterone) → produced by adrenal glands, converted to testosterone and estrogen
• Androstenedione → precursor to testosterone and estrogen
• DHT (dihydrotestosterone) → more potent form of testosterone, formed by conversion of testosterone

When we talk about "testosterone" in women, we're often talking about the combined effect of testosterone and its precursors/metabolites.

Why It Matters During Perimenopause/Menopause

Unlike estrogen and progesterone, which fluctuate wildly and then decline sharply during perimenopause, testosterone declines gradually over decades—starting in the late 20s or early 30s and continuing through perimenopause, menopause, and post-menopause.

The pattern:

• Peak testosterone: Late teens to early 20s
• Gradual decline begins: Late 20s to early 30s (about 1-2% per year)
• Perimenopause: Testosterone continues to decline gradually; ovarian production decreases, adrenal production may compensate (or not)
• Menopause: Ovaries produce less testosterone (though they don't stop entirely, unlike estrogen/progesterone); adrenals become primary source
• Post-menopause: Testosterone levels are about half of what they were in the 20s

Why the decline matters:

1. Libido and sexual function decline → testosterone is the primary driver of sexual desire; when it's low, many women lose interest in sex, struggle with arousal, and experience reduced pleasure
2. Energy and motivation decrease → low testosterone is linked to fatigue, reduced drive, lack of ambition, difficulty initiating tasks
3. Muscle mass and strength decline → testosterone supports muscle building; without it, muscle loss accelerates (especially after menopause)
4. Bone density decreases → testosterone works with estrogen to maintain bones; low testosterone increases osteoporosis risk
5. Body composition changes → loss of muscle, increase in body fat (especially abdominal fat)
6. Mood and confidence shifts → low testosterone is linked to low mood, reduced self-assurance, less assertiveness

Why testosterone decline is often overlooked:

• Gradual decline → unlike the dramatic shifts of estrogen/progesterone, testosterone's slow decline can be hard to notice until it's significant
• Symptoms are attributed to other causes → low libido, fatigue, and mood changes are often blamed on stress, aging, relationship issues, or "just menopause" (meaning estrogen/progesterone)
• Testosterone testing is not routine → many clinicians don't test testosterone in women unless specifically requested
• Cultural narratives downplay women's sexuality and assertiveness → low libido or reduced drive is sometimes seen as "normal" or "appropriate" for midlife women, rather than a hormonal deficiency

Androgen dominance (relatively high testosterone) in early perimenopause:

Some women experience relative androgen dominance in early perimenopause—not because testosterone rises, but because estrogen and progesterone decline faster than testosterone.

Result: Testosterone is relatively high compared to estrogen/progesterone → androgen-related symptoms surface:

Physical:

• Acne (especially jawline, chin, chest)
• Facial hair growth (upper lip, chin)
• Hair thinning on scalp (androgenic alopecia)
• Oily skin

Emotional/Behavioral:

• Increased assertiveness, reduced tolerance for nonsense
• Confidence surges
• Reduced agreeableness (less people-pleasing)
• Heightened libido (though this can also occur with estrogen surges)

Note: This is temporary for most women; as perimenopause progresses, testosterone also declines, and androgen dominance resolves.

How It Works

Mechanism of action:

Testosterone works by binding to androgen receptors (AR) throughout the body. When testosterone binds to a receptor, it triggers gene expression changes—affecting how cells function.

Where androgen receptors are found:

• Brain (especially areas involved in libido, motivation, mood, cognition)
• Muscles (testosterone stimulates protein synthesis → muscle building)
• Bones (testosterone stimulates bone formation)
• Skin, hair follicles (testosterone affects sebum production, hair growth)
• Reproductive tissues (clitoris, vagina, uterus)
• Fat tissue (testosterone affects fat distribution)

Testosterone's relationship with other hormones:

Testosterone + Estrogen:

• Both support libido → estrogen supports vaginal health, blood flow, sensitivity; testosterone supports desire and arousal
• Estrogen enhances testosterone's effects → estrogen increases sensitivity of androgen receptors, so testosterone works better when estrogen is present
• When both decline (menopause), sexual function suffers more → combined deficiency is worse than either alone
• Testosterone can be converted to estrogen → via the enzyme aromatase (in fat tissue, brain, bones)

Testosterone + Progesterone:

• Progesterone promotes agreeableness, harmony-seeking, conflict avoidance
• Testosterone promotes assertiveness, dominance, risk-taking
• When progesterone declines (perimenopause), testosterone's effects become more prominent → women often report increased assertiveness, reduced people-pleasing, clearer boundaries
• This is not "too much testosterone"—it's the loss of progesterone's buffering effect

Testosterone + DHEA (adrenal androgen):

• DHEA is a precursor to testosterone (and estrogen)
• DHEA is produced by adrenal glands and declines with age and chronic stress
• Low DHEA → low testosterone → fatigue, low libido, reduced resilience
• Some women benefit from DHEA supplementation to support testosterone levels

Testosterone + Cortisol (stress hormone):

• Chronic stress can suppress testosterone production (stress hormones take priority)
• High cortisol can also increase SHBG (sex hormone-binding globulin), which binds testosterone and makes it unavailable → "free" testosterone declines, even if total testosterone is normal
• Result: Stress can worsen low testosterone symptoms

Testosterone + Dopamine (neurotransmitter):

• Testosterone enhances dopamine signaling → dopamine is the "motivation and reward" neurotransmitter
• This is why testosterone supports drive, ambition, motivation, pleasure, and confidence
• Low testosterone → low dopamine activity → reduced motivation, low mood, anhedonia (inability to feel pleasure)

Free vs. bound testosterone:

• Total testosterone: All testosterone in the blood (bound + free)
• Bound testosterone: Testosterone attached to SHBG or albumin (not available for use by tissues)
• Free testosterone: Testosterone not bound to proteins (biologically active, available for use)

Why this matters:

• You can have "normal" total testosterone but low free testosterone (because SHBG is high)
• Symptoms correlate better with free testosterone than total testosterone
• Stress, insulin resistance, hypothyroidism, and estrogen dominance can all raise SHBG → reduce free testosterone

What It Looks Like

When Optimal (Healthy Testosterone Levels)

Physical:

• Strong libido and sexual desire
• Ease of arousal and sexual pleasure
• Good muscle tone and strength
• Healthy energy levels throughout the day
• Stable body composition (lean muscle mass maintained)
• Strong bones

Cognitive:

• Mental clarity and focus
• Motivation to tackle tasks and goals
• Confidence in decision-making
• Cognitive stamina (sustained mental effort)

Emotional/Behavioral:

• Assertiveness without aggression
• Confidence and self-assurance
• Healthy drive and ambition
• Resilience to setbacks
• Willingness to take (appropriate) risks
• Advocacy for self and others
• Reduced people-pleasing
• Healthy competitive drive (when desired)

When Low (Testosterone Deficiency)

Physical:

• Low or absent libido → reduced sexual interest, lack of spontaneous desire
• Difficulty with arousal → takes longer to become aroused, reduced sensitivity
• Reduced sexual pleasure → orgasms are less intense or harder to achieve
• Fatigue → low energy, exhaustion, difficulty initiating activity
• Muscle loss → reduced muscle mass and strength, even with exercise
• Weight gain (especially abdominal fat) → loss of muscle, increase in body fat
• Bone density loss → increased osteoporosis risk
• Joint pain → testosterone supports connective tissue health

Cognitive:

• Reduced motivation → difficulty initiating tasks, low drive, apathy
• Low mental energy → cognitive fatigue, reduced stamina for mental tasks
• Brain fog → difficulty concentrating, slower thinking (though less common with testosterone deficiency than estrogen deficiency)

Emotional/Behavioral:

• Low mood → feeling flat, low vitality, reduced zest for life
• Reduced confidence → self-doubt, imposter syndrome, reluctance to speak up
• Less assertiveness → difficulty advocating for self, reduced boundary-setting
• Anhedonia → inability to feel pleasure or excitement (linked to dopamine)
• Reduced competitive drive → less interest in achieving, winning, excelling
• Passivity → tendency to defer to others, avoid conflict, withdraw

When High (Excess Testosterone, Less Common in Women)

High testosterone in women is rare but can occur with:

• Polycystic Ovary Syndrome (PCOS) → ovaries produce excess androgens
• Adrenal tumors or disorders → excess androgen production
• Testosterone supplementation (over-dosing)

Symptoms of high testosterone:

Physical:

• Acne (especially jawline, chest, back)
• Excess facial or body hair (hirsutism: upper lip, chin, chest, abdomen, back)
• Male-pattern hair loss (thinning at temples, crown)
• Oily skin
• Deepening voice (rare, usually with very high levels)
• Clitoral enlargement (rare, usually with very high levels)
• Irregular or absent periods (if premenopausal)

Emotional/Behavioral:

• Increased aggression or irritability (more than assertiveness)
• Restlessness, agitation
• Heightened libido (can be welcome or overwhelming)

Note: In perimenopause/menopause, relative androgen dominance (high testosterone relative to low estrogen/progesterone) is more common than true high testosterone. Symptoms are similar but less extreme.

Phase Impact

Baseline (Regular Cycle, Pre-Perimenopause): Testosterone levels are relatively stable throughout the menstrual cycle (unlike estrogen and progesterone). Levels are higher than they will be in menopause but already declining slowly from the peak in the 20s. Libido, energy, motivation, and assertiveness are generally healthy.

Electric Cougar (Early Perimenopause): Testosterone is still relatively robust (compared to later stages), and progesterone is declining. Result: relative androgen dominance for some women → heightened libido, increased assertiveness, confidence surges, reduced people-pleasing. Some women experience acne or facial hair during this phase. This is often a phase of heightened drive and ambition.

Wild Tide (Mid-Perimenopause): Testosterone continues gradual decline. For some women, libido and energy remain strong (especially if estrogen surges are still occurring). For others, testosterone deficiency symptoms begin to surface: fatigue, reduced libido, loss of motivation. Symptoms are inconsistent—some days feel energized and confident, others feel flat and exhausted.

Henapause (Late Perimenopause, 7-11 Months Without Period): Testosterone has declined significantly from peak levels. Libido often decreases noticeably. Energy and motivation may be lower. Muscle mass begins to decline more rapidly. Some women feel this as a loss of vitality or "spark." Others adapt without significant distress.

The Pause (Menopause, 12+ Months Without Period): Testosterone levels are about half of peak levels (from the 20s). Ovaries still produce some testosterone (unlike estrogen/progesterone, which drop to near-zero), but far less than before. Adrenals become the primary source. Libido, energy, and motivation may stabilize at a lower baseline—some women adapt, others struggle.

Phoenix Phase (Early Post-Menopause, 2-10 Years After Last Period): Testosterone continues slow decline. Women on HRT (estrogen + progesterone) may notice that libido doesn't fully return unless testosterone is added to the regimen. Those not on HRT may notice continued fatigue, low libido, muscle loss, or reduced drive. Some women feel content with lower libido; others experience it as a loss.

Golden Sovereignty (Established Post-Menopause, 7+ Years After Last Period): Testosterone remains low. Women who have added testosterone to HRT often report sustained libido, energy, and vitality. Those without testosterone therapy have often adapted or accepted the change. Muscle mass and bone density are priority concerns, as low testosterone accelerates loss of both.

Testing & Optimization

When to Test

Testing testosterone can be helpful if you suspect deficiency:

When testing makes sense:

• Low or absent libido (especially if distressing)
• Persistent fatigue despite adequate sleep
• Loss of muscle mass or strength despite exercise
• Low mood, reduced motivation, or anhedonia
• Before starting testosterone therapy (to establish baseline)
• To monitor testosterone levels on testosterone therapy

What tests measure:

Total testosterone:

• Measures all testosterone (bound + free)
• Normal range for women: 15-70 ng/dL (varies by lab and age)
• Post-menopausal women often fall in the 10-40 ng/dL range

Free testosterone:

• Measures biologically active testosterone (not bound to proteins)
• Better predictor of symptoms than total testosterone
• Requires calculation (from total testosterone + SHBG) or direct measurement

SHBG (sex hormone-binding globulin):

• Protein that binds testosterone (and estrogen)
• High SHBG → less free testosterone available
• Low SHBG → more free testosterone available
• SHBG is affected by estrogen, insulin, thyroid hormones, stress

Best timing for testing:

• Morning (8-10 AM) → testosterone levels peak in the morning
• Any day of cycle (testosterone doesn't fluctuate much with cycle)

Why testing is tricky:

• "Normal" ranges are wide and often don't reflect optimal levels for symptom relief
• Free testosterone is more meaningful than total, but not all labs measure it
• Symptoms matter more than numbers

Optimization Strategies

1. Testosterone Therapy (Bioidentical)

Testosterone therapy is highly effective for:

• Low libido and sexual dysfunction (in the context of low testosterone)
• Fatigue and low energy
• Loss of motivation and drive
• Muscle loss and weakness
• Mood and confidence (when low testosterone is the cause)

Forms of testosterone therapy for women:

Topical cream or gel:

• Most common form for women
• Applied to skin (inner thigh, abdomen, or vulva/clitoral area for sexual function)
• Dosing: 1-5 mg daily (much lower than men)
• Allows for flexible dosing

Subcutaneous pellet:

• Small pellet implanted under the skin (releases testosterone over 3-6 months)
• Less common, more invasive, harder to adjust dose

Intramuscular injection:

• Rarely used in women (dosing is harder to titrate)

Vaginal/clitoral cream:

• Compounded testosterone cream applied directly to genital tissues
• Highly effective for sexual function (arousal, sensitivity, pleasure)
• Minimal systemic absorption (mostly local effects)

What it helps:

• Libido and sexual desire (often the most dramatic improvement)
• Energy and motivation
• Muscle mass and strength (when combined with resistance training)
• Mood, confidence, assertiveness
• Cognitive function (some evidence for improved focus and mental clarity)
• Bone density (works synergistically with estrogen)

Risks and benefits:

Benefits:

• Significant improvement in libido, sexual function, and quality of life for many women
• Improved energy, motivation, and vitality
• Supports muscle mass and bone density
• Minimal side effects when dosed appropriately

Risks:

• Acne (if dose is too high or individual is sensitive)
• Facial hair growth (usually mild, reversible if dose is lowered)
• Hair thinning (rare at physiologic doses; more common with high doses)
• Clitoral enlargement (rare at low doses; usually not problematic)
• Voice deepening (very rare at low doses; may be irreversible)
• Cholesterol changes (testosterone can lower HDL "good" cholesterol; monitor lipids)
• Cardiovascular risk (unclear; most studies show no increased risk at physiologic doses, but long-term data in women is limited)

Who should avoid testosterone therapy:

• Pregnant or breastfeeding (testosterone can affect fetal development)
• Breast cancer (unclear; discuss with oncologist—some allow, others don't)
• Cardiovascular disease (individualized decision; monitor closely)

Monitoring:

• Test testosterone levels 4-6 weeks after starting therapy (adjust dose if needed)
• Monitor for side effects (acne, hair growth, mood changes)
• Check lipid panel periodically (testosterone can affect cholesterol)

2. Lifestyle Strategies

Support testosterone production and function naturally:

Strength training:

• Resistance exercise is the most effective lifestyle intervention for testosterone
• Stimulates testosterone production and preserves muscle mass
• Frequency: 2-3x per week, focusing on major muscle groups

Adequate protein:

• Protein supports muscle mass and testosterone production
• Target: 0.8-1.2 grams per kg body weight per day (higher if active or trying to build muscle)

Healthy fats:

• Testosterone is made from cholesterol → need adequate dietary fats
• Sources: Olive oil, avocado, nuts, seeds, fatty fish, eggs

Manage stress:

• Chronic stress suppresses testosterone and raises SHBG (reducing free testosterone)
• Practices: Meditation, breathwork, therapy, boundaries, adequate rest

Adequate sleep:

• Testosterone is produced during sleep; sleep deprivation lowers testosterone
• Target: 7-9 hours per night

Limit alcohol:

• Alcohol suppresses testosterone production and increases estrogen (via aromatase)
• Moderation is key

Maintain healthy body composition:

• Excess body fat (especially abdominal fat) increases aromatase activity → converts testosterone to estrogen → lowers testosterone
• Resistance training + adequate protein + calorie balance support healthy body composition

3. Supplements

Evidence is limited; some women find benefit:

DHEA (dehydroepiandrosterone):

• Precursor to testosterone (and estrogen)
• Produced by adrenal glands; declines with age and stress
• Dosing: 25-50 mg daily (start low, monitor symptoms and labs)
• Evidence: Some studies show improved libido, mood, and energy; others show minimal benefit
• Caution: Can increase testosterone AND estrogen; monitor for acne, hair growth, or estrogen dominance symptoms

Zinc:

• Supports testosterone production and function
• Dosing: 15-30 mg daily
• Deficiency is common; supplementation may help if deficient

Magnesium:

• Supports testosterone production and reduces SHBG (increasing free testosterone)
• Dosing: 300-400 mg daily

Vitamin D:

• Supports testosterone production
• Dosing: 1000-4000 IU daily (or enough to achieve blood level of 40-60 ng/mL)

Omega-3 fatty acids:

• Supports hormone production and reduces inflammation
• Dosing: 1000-2000 mg EPA+DHA daily

Note: Supplements are not a replacement for testosterone therapy if deficiency is significant. Discuss with clinician.

When to Review with Clinician

You should discuss testosterone if:

• Libido is low or absent and this is distressing
• Fatigue is persistent despite adequate sleep and stress management
• Motivation, drive, or confidence has declined noticeably
• Muscle mass or strength is declining despite exercise
• Mood is low, flat, or anhedonic (inability to feel pleasure)
• Interested in testosterone therapy but unsure if it's right for you
• Currently on estrogen/progesterone HRT but libido hasn't improved
• On testosterone therapy and want to reassess dose or monitor for side effects

Red flags requiring medical attention:

• Sudden or severe fatigue (could indicate thyroid, anemia, or other medical issue)
• Depression with suicidal thoughts (requires urgent care)
• Unexplained weight loss or muscle wasting (requires medical evaluation)
• Signs of very high testosterone (severe acne, voice deepening, rapid hair growth) → may indicate PCOS, adrenal disorder, or over-dosing

Related Terms

• estrogen
• progesterone
• libido
• confidence-surges
• androgen-dominance
• muscle-loss
• fatigue
• motivation
• assertiveness
• boundary-crystallization
• electric-cougar-puberty
• dhea