The single most important fact about low testosterone in women is that it is not a diagnosis. There is no blood concentration that defines androgen deficiency in women, and the 2019 Global Consensus Position Statement on the Use of Testosterone Therapy for Women is the authoritative reference on what the evidence does and does not support.[1]
That is a genuinely different situation from men, where diagnosis rests on symptoms plus unequivocally and consistently low concentrations confirmed on repeat fasting morning measurement.[2] For women, the equivalent threshold does not exist.
Why a number cannot do the work here
Three reasons compound.
Assay limitations. Many testosterone assays were developed and validated for male concentrations. Measuring accurately at the far lower female range is technically harder, and a number produced by an assay not designed for it is not a reliable basis for a diagnosis.
No established threshold. No concentration has been established below which women are deficient and above which they are not.
Symptoms are non-specific. Low desire, fatigue and low mood have many causes in women — thyroid disease, depression, medication effects, relationship and life circumstances, and the broader hormonal changes of the menopause transition. A testosterone level cannot arbitrate between them.
What the randomised evidence actually covers
The systematic review and meta-analysis of randomised controlled trial data on the safety and efficacy of testosterone for women is the place that question gets answered properly.[4] It pools the trial evidence rather than the enthusiasm — and that distinction is the whole point of the paper.
The consensus statement translates that evidence into a position on what testosterone therapy in women is supported for.[1] The specific supported indication, and the conditions attached to it, are set out in the clinical article on the women's pillar: testosterone therapy for women.
What follows practically
A testosterone level alone should not drive a treatment decision in a woman. There is no threshold for it to cross.
Other causes deserve real evaluation. Thyroid function, mood, sleep, medications and the wider menopause picture are not boxes to tick before getting to the hormone — several are more likely to be the answer.
Treatment, where indicated, follows a specific pathway. Not the correction of a number.
Frequently asked questions
Should I have my testosterone tested? There is no threshold defining deficiency in women, so a level in isolation will not settle much. Whether testing helps in your situation is a clinical judgement.
What if my level came back low? "Low" implies a reference range that does not carry the diagnostic meaning it has in men. Discuss it in the context of symptoms and other causes.
Is testosterone therapy for women legitimate? There is an international consensus position on its use, based on the randomised evidence.[1][4] Legitimate for a defined indication is different from generally appropriate.
Next in this series
The reason all of this rests on so little evidence is worth examining on its own.
Continue with the research gap.
References
4 sources
- Davis SR, Baber R, Panay N, et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. J Clin Endocrinol Metab. 2019;104(10):4660–4666. doi:10.1210/jc.2019-01603 · PMID 31498871
- Bhasin S, Brito JP, Cunningham GR, et al. Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2018;103(5):1715–1744. doi:10.1210/jc.2018-00229 · PMID 29562364
- Cussons AJ, Bhagat CI, Fletcher SJ, et al. Brown-Séquard revisited: a lesson from history on the placebo effect of androgen treatment. Med J Aust. 2002;177(11-12):678–679. doi:10.5694/j.1326-5377.2002.tb05014.x · PMID 12463999
- Islam RM, Bell RJ, Green S, et al. Safety and efficacy of testosterone for women: a systematic review and meta-analysis of randomised controlled trial data. Lancet Diabetes Endocrinol. 2019;7(10):754–766. doi:10.1016/S2213-8587(19)30189-5 · PMID 31353194
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