How Do Testosterone Levels Impact Women?

You may not know this, but the androgen hormone testosterone has multiple functions on the overall health of women. And although not in the same quantity as men, women also produce testosterone in their ovaries and adrenal glands.

In fact, women actually need small amounts of it as part of the mix of hormones that keep mood, energy levels, sex drive, and bodily functions running smoothly.

What does testosterone do for women?

Let’s take a look at some of the major functions below.

It maintains sex drive. Testosterone is known as a male sex hormone, but women have levels of the hormone in their system as well — just as men have low levels of estrogen in their bodies as well.

The hormone is part of what drives desire, fantasy, and thoughts about sex, and even helps provide the energy for sex in women.  Adequate testosterone concentrations are positively associated with sexual function in women [1] and a wealth of research demonstrates that testosterone therapy can be effective in the treatment of female sexual dysfunction.

It promotes cognitive health. According to guidelines published in clinical research, testosterone has a neuroprotective effect in women [2]. In fact, a well-controlled research study  showed that postmenopausal women with Alzheimer’s disease had lower levels of testosterone and estrogen than the control group. Another found that higher testosterone levels in the plasma of pre-menopausal women was linked to better performance in mathematical and spatial-relations tasks.

It keeps bones healthy. The appropriate amount of testosterone supports bone growth and strength, while too much or too little can harm them. Evidence-based research demonstrates that both testosterone and estrogen are essential for bone formation [3].

Impact of low testosterone in women

According to the Endocrine Society, testosterone levels decrease somewhat between the ages 20 and 40 in women, but there does not appear to be an abrupt and profound reduction, similar to that of estrogen, at the time of menopause.

Common symptoms associated with low testosterone in women include:

• Affected sexual desire
• Affected sexual satisfaction
• Depressed mood
• Lethargy (low energy)
• Muscle weakness

Nevertheless, some postmenopausal women experience lower testosterone levels that can cause a decrease in sex drive. In some women, testosterone patches have been found to improve libido. Low testosterone levels can also cause other health issues, such fatigue, and increased risk for bone loss, and fractures.

Diagnosing low testosterone

The symptoms of low testosterone in women are commonly underdiagnosed or misdiagnosed. Some of the conditions that low testosterone may be mistaken for include: stress, depression, and the side effects of menopausal changes in women.

Plasma levels are used to test a woman’s testosterone levels. The numbers that determine if a woman’s testosterone levels are high or low can vary by the laboratory performing the test.

According to clinical data, plasma total testosterone levels of less than 25 ng/dL in women under 50 years old is considered to be low. Testosterone levels lower than 20 ng/dL in women aged 50 and older are considered low.

Due to the women’s hormone levels constantly fluctuating on a daily basis, doctors may have difficulty detecting low testosterone levels.  If a woman still has her period, she should ideally take the blood testosterone test about 8 to 20 days after her menstrual period starts.

Impact of high testosterone in women

According to the Mayo Clinic, in the chart below are the normal range of testosterone levels for females:

An imbalance of testosterone in the female body can have damaging effects on a woman’s health and sexual drive.

High levels of free testosterone may potentially cause polycystic ovarian syndrome (PCOS), a condition that interferes with monthly periods and the body’s ability to ovulate. About 10% of women of childbearing age are affected with this health problem.

Symptoms of PCOS:

• Missed Periods or an Irregular Menstrual Cycle: The excessive level of androgens that is associated with PCOS can make periods infrequent, irregular, or nonexistent.
• Infertility: Since women with PCOS may not ovulate, they have difficulties getting pregnant.
• Excess Hair Growth: The hormonal imbalances associated with PCOS can lead to hair growth on the back, chest, stomach, face, thumbs, and toes.
• Ovarian Cysts: Since eggs may not be released from the ovarian follicles of women with PCOS, the immature follicles can fuse together to form large, painful ovarian cysts.
• Skin Problems Women: with PCOS may experience oily skin, acne, dark patches of skin.
• Miscarriage: If women with PCOS do get pregnant, there is and increased risk for miscarrying.

High levels of testosterone in women can have health consequences such as insulin resistance, diabetes, carbohydrate intolerance, obesity, high cholesterol, high blood pressure, and heart disease.  As women with PCOS age, the presence of these risk factors increases their risk for heart disease.

What happens when women take testosterone?

Research shows that the hormone testosterone may improve sexual function in specific groups of women, but data on safety and effectiveness are limited.

Testosterone therapy might be appropriate if:

• You have reduced sex drive, depression and fatigue after surgically induced menopause, and estrogen therapy hasn't relieved your symptoms
• You are postmenopausal, taking estrogen therapy and have a decreased sex drive with no other identifiable causes

Long-term safety data on testosterone therapy for postmenopausal women who have a history of breast or uterine cancer or those who have cardiovascular or liver disease is lacking.

Testosterone therapy comes in many forms, such as creams, gels, patches or pills. The method of administration and dose relate to safety risks, so it's important to discuss pros and cons with your doctor.

Testosterone preparations are not approved by the FDA for use in women. So, if testosterone is prescribed, it's for off-label use.

Side effects of testosterone therapy for women can include acne, extra hair growth, weight gain, and fluid retention. Some women have mood swings and become angry or hostile. In rarer circumstances, women develop deeper voices and baldness. Clitoral enlargement is another rare side effect. Side effects are relatively uncommon if testosterone is taken at low doses. Too much testosterone, however, increases the chances of side effects.

Doses prescribed for men are definitely not appropriate for women.

Take home points

• Androgens play an important physiologic role in women and can promote sexual health.
• Clinicians should avoid making a diagnosis of androgen deficiency in women, as the syndrome is not well defined.
• Well-designed, randomized, placebo-controlled trials are needed to establish long-term safety, efficacy, and appropriate dosing of testosterone therapy in women.
• Evidence suggests that testosterone therapy in women is associated with few adverse events when serum hormone levels remain within physiologic ranges.
• Currently, the only evidence-based indication for testosterone therapy in women is for the treatment of hypoactive sexual desire disorder postmenopausal women, but only after a thorough evaluation and consideration of other causes of the sexual concerns.
• Transdermal therapy is the preferred method of delivery.
• Serum testosterone levels should be monitored at regular intervals to avoid supraphysiologic dosing [4].

The long-term safety of testosterone therapy for women also is unknown, and given the limited research on effectiveness and safety and the number of potential serious side effects, testosterone isn't a common treatment for sexual dysfunction in women.

References:
1.    Randolph, J.F., Jr., et al., Masturbation frequency and sexual function domains are associated with serum reproductive hormone levels across the menopausal transition. J Clin Endocrinol Metab, 2015. 100(1): p. 258-66.
2.    Margaret E. Wierman, W.A., Rosemary Basson, Susan R. Davis, Karen K. Miller, Mohammad H. Murad, William Rosner, Nanette Santoro, Androgen Therapy in Women: A Reappraisal: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, 2014. 99(10): p. 3489–3510.
3.    Mohamad, N.V., I.N. Soelaiman, and K.Y. Chin, A concise review of testosterone and bone health. Clin Interv Aging, 2016. 11: p. 1317-1324.
4.    Smith, T. and P. Batur, Prescribing testosterone and DHEA: The role of androgens in women. Cleve Clin J Med, 2021. 88(1): p. 35-43.