Testosterone is often incorrectly described as a “male hormone.” In reality, it plays a significant and well-established role in female physiology across the lifespan.

Despite this, its clinical relevance in women remains under-recognised, particularly in the context of perimenopause and menopause.

This article, the first in a two-part series, outlines:

• The physiological role of testosterone in women

• The causes and timing of decline

• The clinical features associated with reduced levels

The second article will address assessment, diagnosis, and prescribing within current UK guidance.

Androgen Function and Clinical Relevance

Testosterone is an androgen and represents the most abundant biologically active steroid hormone in women during both reproductive and post-reproductive life.¹

It is produced by:

• The ovaries

• The adrenal glands

• Peripheral conversion in tissues including adipose

Testosterone exerts its effects through:

• Direct binding to androgen receptors

• Conversion to oestradiol via aromatisation

Androgen receptors are widely distributed, including in:

• Central nervous system

• Bone and skeletal muscle

• Cardiovascular tissue

• Skin and hair follicles

• Vulvovaginal and urogenital tissues

This distribution underpins the broad clinical impact of testosterone in women.

Clinical Features of Low Testosterone in Women

Reduced testosterone levels may present with a constellation of symptoms affecting multiple domains:

• Reduced sexual desire, arousal, and response

• Persistent fatigue and reduced motivation

• Low mood and diminished emotional resilience

• Impaired concentration, memory, and cognitive function

• Loss of muscle strength and reduced physical performance

• Reduced bone mineral density

• Changes in skin integrity, hair quality, and joint health

• Vulvovaginal and urogenital symptoms

The 2019 Global Consensus Position Statement (endorsed by the British Menopause Society and other international bodies) identifies hypoactive sexual desire disorder (HSDD) as the primary evidence-based indication for testosterone therapy in women.³

However, in clinical practice, presentations are frequently multifactorial and extend beyond sexual function alone.

Timing and Causes of Testosterone Decline

Testosterone levels decline progressively from the late twenties onwards.⁴ While gradual, several factors may accelerate or exacerbate this reduction:

Perimenopause and Menopause

The most common cause of clinically significant androgen decline, reflecting changes in ovarian function.

Surgical Menopause

Bilateral oophorectomy results in an abrupt reduction of approximately 50% of circulating testosterone, often associated with significant symptom burden.

Combined Oral Contraceptive Use

• Suppression of ovarian androgen production

• Increased Sex Hormone Binding Globulin (SHBG)

• Reduced free (bioavailable) testosterone

  
  

Chronic Stress

Sustained cortisol elevation may impact androgen synthesis and availability.

Endocrine Disorders

Including hypothyroidism and hyperprolactinaemia.

Medications

Including:

• Antidepressants

• Antihypertensives

• Long-term corticosteroids

  
  

Surgical Menopause: A Clinical Gap

Women undergoing surgical menopause experience a sudden and substantial reduction in androgen production.

Despite this, testosterone replacement is not routinely incorporated into standard management alongside oestrogen and progesterone.⁷

This may contribute to persistent symptoms such as:

• Fatigue

• Reduced libido

• Mood disturbance

• Cognitive changes

This remains an area where clinical awareness and practice continue to evolve.

Relevance in Perimenopause and Menopause

Hormone Replacement Therapy (HRT) effectively addresses many symptoms related to oestrogen deficiency, including:

• Vasomotor symptoms

• Sleep disturbance

• Vaginal dryness

  
  

However, some women report ongoing symptoms despite appropriate oestrogen therapy, including:

• Reduced libido

• Persistent fatigue

• Cognitive symptoms

• Reduced sense of wellbeing

In such cases, androgen insufficiency may be a contributing factor.

Clinical Importance

The focus of women’s hormonal health has traditionally centred on oestrogen. While appropriate, this approach does not fully reflect the complexity of endocrine physiology.

The evidence base supporting testosterone therapy in women has expanded, with international consensus recognising its role within defined clinical indications.³

However:

• Awareness among patients remains limited

• Training in prescribing testosterone for women is variable

• Access to specialist assessment is inconsistent

  
  

Next Steps

The second article in this series will address:

• Clinical assessment of suspected androgen insufficiency

• Appropriate use of blood testing

• Prescribing considerations in line with NICE and British Menopause Society guidance

• Monitoring and safety

Testosterone is a physiologically important hormone in women, with effects across multiple systems.

Declining levels, particularly during midlife or following surgical menopause, may contribute to a range of symptoms affecting quality of life.

Recognition of its role is essential to ensure a comprehensive and evidence-based approach to women’s health.