A patient asked me recently, with genuine frustration: “Why does nobody talk about testosterone in women?” She was 47. She had researched oestrogen extensively, was well-informed about progesterone, and had taken a proactive approach to her hormonal health. But testosterone had been conspicuously absent from every conversation she’d had, every article she’d read, every consultation she’d attended.
She was right to be frustrated. Testosterone is produced in women — by the ovaries and the adrenal glands — from early adulthood. It declines over time, as oestrogen does, but its clinical significance in women’s health has been systematically under-researched and under-acknowledged for reasons that have more to do with medical culture than with the science.
The science, when you look at it, is quite compelling.
What testosterone does in the female body
Testosterone in women is not a male hormone that happens to be present in small quantities. It is a physiologically active hormone with specific and important functions.
In muscle: testosterone promotes protein synthesis and muscle maintenance. It is one of the primary anabolic signals responsible for lean mass preservation. Women with low testosterone — which includes most women in their late 40s and 50s who haven’t specifically optimised for it — have measurably reduced lean mass compared to those with adequate levels.
In bone: testosterone, alongside oestrogen, maintains bone mineral density. Testosterone has direct osteoblastic effects independent of oestrogen.
In the brain: testosterone affects cognition, motivation, mood, and libido through direct neurological action. Low testosterone is associated with reduced drive, difficulty initiating, flat affect, and reduced sexual desire — none of which are inevitable consequences of ageing, but which are extremely common consequences of hormonal depletion that the medical system has tended to normalise rather than treat.
In skin: testosterone influences sebum production and skin thickness. It maintains the dermal collagen network alongside oestrogen, and its decline contributes to the thinning and drying that characterises postmenopausal skin [1].
In my practice at SW1 Clinic, I measure total and free testosterone as part of every hormonal assessment in women over 40. The proportion of patients with clinically low levels — below 0.5 nmol/L free testosterone, or consistent with symptoms at any level — is striking. It is one of the most undertreated hormonal conditions I see.
How women’s testosterone declines
Unlike oestrogen, which has a relatively defined perimenopausal transition, testosterone in women declines more gradually and earlier. Peak testosterone in most women occurs in the early 20s. By the age of 40, many women have levels significantly below their peak. By the time of surgical menopause — where both ovaries are removed — testosterone drops by approximately 50% acutely, producing immediate and often severe symptoms.
The adrenal glands continue to produce DHEA-S — a testosterone precursor — after menopause, but adrenal production also declines with age. For women whose adrenal reserve is compromised by chronic stress, the loss of both ovarian and adrenal contribution produces profound testosterone deficiency.
Natural menopause produces a less acute testosterone decline than surgical menopause, because the ovaries continue to produce some testosterone post-menopause. But the cumulative decline over the perimenopausal decade is still clinically significant for many women.
The symptoms that get attributed to everything else
The symptoms of low testosterone in women are recognisable once you’re looking for them. Fatigue that is distinct from sleepiness — a motivational flatness, a difficulty generating energy for things that used to feel energising. Reduced muscle recovery from exercise. Reduced libido — not just reduced interest, but a qualitative change in the sense of desire and sensation. Cognitive flatness: reduced drive, reduced competitive edge, a sense of existing rather than engaging.
These symptoms are reliably attributed to stress, overwork, depression, ageing, or general perimenopausal change. The diagnosis of low testosterone is rarely arrived at without the patient specifically asking for it.
This is a failure of the medical system to take women’s androgens seriously — and it has real consequences for quality of life.
The evidence base and the cultural gap
A 2019 global consensus statement endorsed by multiple major endocrinology and women’s health societies concluded that testosterone therapy in women has a clear evidence base for hypoactive sexual desire disorder — low libido — and showed promising evidence for effects on mood, energy, and musculoskeletal health [2]. The statement also acknowledged that the evidence base is limited by the almost complete absence of formulations specifically tested and approved for women in most countries.
This absence of approved formulations is the clinical problem. Testosterone therapy for women works. The evidence supports it. But outside of a few countries, there are no pharmaceutical products specifically licensed for women. Practitioners who offer it do so using products licensed for men in lower doses — which is clinically rational but creates regulatory and liability complexity that discourages many physicians from engaging.
In Singapore, testosterone for women can be prescribed by physicians with appropriate training and clinical justification. It is not mainstream. But it is available. And in my patient population, appropriately selected women who commence testosterone therapy describe improvements — in energy, in body composition, in mood, in skin quality — that are consistently meaningful [3].
The Asian context
In Asian cultural contexts, female sexuality and desire are not subjects that sit comfortably in medical consultations. The libido dimension of testosterone deficiency is therefore often the last symptom a woman will volunteer — sometimes years after it has been affecting her relationship and her sense of self.
I’ve learnt to ask directly and specifically, and to frame it as a medical question rather than a personal one. The body’s desire capacity is a health metric. Its decline deserves the same clinical attention as blood pressure or bone density.
I find that once the clinical framework is in place — once a woman understands that low testosterone is a measurable, physiological state with treatment options — the relief of having language for the experience is considerable. Naming it removes the weight of personal blame.
What you can actually do
Request a total and free testosterone level at your next hormonal assessment. In Singapore, this can be ordered by any physician. If the results suggest deficiency and your symptoms are consistent, find a physician who is knowledgeable about testosterone therapy in women and willing to have a detailed conversation about risks, benefits, and realistic expectations.
For lifestyle approaches: resistance training is the most potent natural testosterone-stimulating intervention available. Adequate sleep, cortisol management, and zinc-adequate nutrition all support testosterone production.
My book Get Your Sexy Back covers the full hormonal picture for women in the menopausal transition, including testosterone, in practical detail.
Testosterone is not the hormone of men. It is the hormone of vitality — and women need it too.
The reason nobody told you this is not because the science doesn’t exist. It’s because the science has been inconvenient for a medical system that wasn’t designed to ask.
References
[1] Worboys, S., et al. (2001). Evidence that parenteral testosterone therapy may improve endogenous testosterone levels in postmenopausal women. Climacteric, 4(4), 310–314. [VERIFY — confirm before publishing]
[2] Davis, S. R., et al. (2019). Global consensus position statement on the use of testosterone therapy for women. Journal of Clinical Endocrinology & Metabolism, 104(10), 4660–4666. https://doi.org/10.1210/jc.2019-01603 [VERIFY — confirm before publishing]
[3] Shifren, J. L., et al. (2000). Transdermal testosterone treatment in women with impaired sexual function after oophorectomy. New England Journal of Medicine, 343(10), 682–688. https://doi.org/10.1056/NEJM200009073431002 [VERIFY — confirm before publishing]
