What Does A Low Testosterone Level Mean In Menopause?

Low Testosterone in Menopause: Understanding a Hormone That Gets Overlooked

When women think about menopause, the hormones that come to mind are estrogen and progesterone. The hot flashes, the mood changes, the sleep disruption, the vaginal dryness: these are all linked to estrogen decline, and they dominate the conversation. Testosterone barely gets a mention in most menopause discussions, despite the fact that it plays a meaningful role in energy, libido, muscle maintenance, bone health, and cognitive function throughout a woman's life.

Dr. Heather Hirsch, a physician specializing in menopause and hormone therapy, addresses what a low testosterone level actually means in the context of menopause. This is a question that many women do not even think to ask, partly because they do not know that women produce testosterone at all, and partly because most providers do not routinely check it. The result is a significant knowledge gap that leaves many women dealing with symptoms that could potentially be addressed.

How Testosterone Changes Through a Woman's Life

Women produce testosterone primarily through two sources: the ovaries (which produce about 25 percent of circulating testosterone directly, with additional testosterone produced from ovarian androgen precursors) and the adrenal glands (which produce DHEA and DHEA-S, which are converted to testosterone in peripheral tissues). Together, these sources produce approximately 100 to 400 micrograms of testosterone per day, roughly one-tenth to one-twentieth of male production.

The decline begins earlier than most women realize. Testosterone levels start dropping in the late 20s, and by age 40, many women have testosterone levels that are half of what they were at their peak. This decline is gradual and independent of menopause itself. While estrogen drops sharply at menopause when the ovaries stop producing it, testosterone decline is a slow erosion that begins decades earlier.

After menopause, the ovaries continue producing some testosterone, which is why some women maintain adequate testosterone levels even after estrogen production has ceased. However, if the ovaries are surgically removed (oophorectomy), testosterone production drops by approximately 50 percent immediately, which can cause a sudden and dramatic onset of androgen deficiency symptoms.

Symptoms of Low Testosterone in Women

The symptom profile of low testosterone in women overlaps significantly with general menopause symptoms, which is part of why it goes unrecognized. The hallmark symptom is low libido that is persistent, that causes personal distress, and that is not fully explained by relationship factors, medication effects, or other medical conditions. While low libido is common in menopause, testosterone-related low libido often has a distinct quality: it is more than reduced interest but a complete absence of sexual thoughts, fantasies, or responsiveness.

Beyond libido, low testosterone in women can manifest as persistent fatigue that does not improve with adequate sleep, difficulty building or maintaining muscle despite regular exercise, a general sense of reduced vitality and motivation, difficulty with concentration and mental sharpness, and depressed mood that is not responsive to conventional antidepressant treatment. These symptoms are often attributed entirely to estrogen deficiency or to aging itself, and the possibility of testosterone deficiency is not explored.

The challenge is that there is no universally agreed-upon testosterone level that defines deficiency in women. Unlike men, where the reference ranges and diagnostic thresholds are relatively well-established, female testosterone ranges are wide, the assays used are often not sensitive enough to accurately measure the low concentrations relevant to women, and the correlation between blood levels and symptoms is less clear-cut. This makes diagnosis more dependent on clinical assessment than laboratory values alone.

Testing and Interpretation

If you suspect low testosterone is contributing to your menopausal symptoms, getting tested is a reasonable step. The important details matter: request a testosterone level measured by LC/MS/MS (mass spectrometry) rather than the standard immunoassay, which is inaccurate at low female levels. Free testosterone, either measured directly by equilibrium dialysis or calculated from total testosterone and SHBG, is more clinically relevant than total testosterone alone because it reflects the biologically active fraction.

DHEA-S, a precursor hormone produced by the adrenal glands, should also be checked. Low DHEA-S can indicate adrenal androgen deficiency, which is a separate but related contributor to symptoms attributed to low testosterone. Some providers prescribe DHEA supplementation as a starting point before considering testosterone therapy, as DHEA can partially convert to testosterone through peripheral metabolism.

Interpreting the results requires context. A testosterone level in the lowest quartile of the premenopausal reference range, combined with symptoms consistent with androgen deficiency, in a woman who has already optimized estrogen and progesterone replacement, is a reasonable basis for a therapeutic trial of testosterone. A low level without symptoms does not warrant treatment, and symptoms without low levels suggest a different cause.

The Provider Gap

One of the biggest barriers to appropriate testosterone evaluation and treatment in menopausal women is the knowledge gap among providers. Many gynecologists and primary care doctors are not comfortable prescribing testosterone for women, partly because of the lack of FDA-approved products, partly because the evidence base is still developing, and partly because testosterone therapy for women was not part of their training. This leaves many symptomatic women without access to a treatment that might help.

Finding a provider who specializes in menopause management and who is knowledgeable about androgen therapy in women can make a significant difference. The North American Menopause Society (NAMS) maintains a provider directory of certified menopause practitioners. Providers who are certified through NAMS are more likely to be familiar with the evidence for testosterone therapy and comfortable prescribing it when indicated.

Who Should Watch This

This video is important for menopausal and perimenopausal women who are dealing with persistent fatigue, low libido, or reduced vitality despite being on estrogen and progesterone therapy. It is also valuable for women approaching menopause who want to understand the full hormonal picture beyond just estrogen. Anyone who has had their ovaries surgically removed should understand the testosterone implications of that procedure. And women whose providers have been dismissive of their symptoms or unwilling to explore testosterone testing will find validation and practical guidance for seeking appropriate evaluation.

Taking Action: Steps to Get Properly Evaluated

If you suspect that low testosterone is contributing to your menopausal symptoms, taking the right steps toward evaluation can make the difference between getting answers and hitting dead ends. Start by scheduling an appointment with a provider who has specific expertise in menopause management. General gynecologists and primary care doctors may be willing to order testosterone testing, but they may lack the experience to interpret the results in the proper context or to initiate treatment if appropriate.

When you request testosterone testing, specify that you want total testosterone and free testosterone measured by LC/MS/MS (mass spectrometry). Many labs will default to the standard immunoassay if not specified, which is unreliable at the low concentrations relevant to women. SHBG and DHEA-S should be included in the panel as well. Schedule the blood draw in the morning when testosterone levels are naturally highest, and avoid strenuous exercise the day before testing, as it can transiently affect hormone levels.

Bring a written summary of your symptoms to the appointment. Include when each symptom started, how it has progressed, what you have tried that has or has not helped, and how the symptoms affect your daily life. This documentation helps your provider assess the clinical picture more accurately and makes the best use of limited appointment time.

If your initial provider is unable or unwilling to evaluate testosterone as a factor in your symptoms, consider seeking a second opinion. The NAMS (North American Menopause Society) provider directory at menopause.org can help you find a certified menopause practitioner in your area. Many of these practitioners also offer telemedicine consultations, expanding access for women in areas without local menopause specialists.

The recognition that testosterone matters for women's health is growing, but it has not yet reached the mainstream of medical practice. Advocating for yourself by asking the right questions, seeking the right tests, and finding the right provider is unfortunately still necessary. Dr. Hirsch's video equips you with the knowledge to do that advocacy effectively, and that knowledge is the first step toward getting the care you deserve.

The growing recognition of testosterone's role in women's health represents a positive shift in how we think about menopause management. For decades, the conversation was limited to estrogen and progesterone, leaving a significant number of women with incompletely addressed symptoms. The inclusion of testosterone in the menopause management toolkit, when used appropriately, offers the potential for more complete symptom relief and improved quality of life for women who have not found sufficient benefit from conventional HRT alone.

This is not about replacing estrogen and progesterone with testosterone. It is about recognizing that the hormonal changes of menopause involve more than just two hormones, and that thorough management may require addressing all three. Dr. Hirsch's contribution to this conversation is valuable precisely because she normalizes the evaluation and treatment of testosterone deficiency in women while maintaining the scientific rigor that patients deserve. Use the information in this video as a starting point for your own evaluation, and do not settle for incomplete answers when your quality of life is at stake.

For women who have been told that their fatigue, low libido, or reduced vitality is just a normal part of aging, this video offers a different perspective. Not every woman with these symptoms has testosterone deficiency, but for those who do, recognizing and treating it can be genuinely transformative. The first step is asking the question and getting the right tests. Everything else follows from that initial act of self-advocacy.