Testosterone in Women Symptoms, deficiency & what actually helps
Most women do not know they have testosterone. Fewer know they need it. Almost none have been told that losing it explains the flat energy, lost motivation, difficulty building muscle, and quiet disappearance of desire that nobody seems to have an answer for.
Low testosterone in women is one of the most common and most overlooked hormonal deficiencies in women's health. This article covers female testosterone symptoms, why testosterone deficiency in women is so frequently missed, the benefits and risks of testosterone therapy, how compounded testosterone works, and what the body needs for treatment to be effective. Written by Krystyl Kulbeck PA-C, a licensed Physician Assistant with functional medicine training.
📋 A note from Krystyl
"Testosterone is the hormone I have found most life-changing for women — and the one most consistently overlooked in standard care. I have watched women spend years being told their exhaustion is depression, their lost drive is just aging, their difficulty building muscle is a training problem. When we check testosterone and find it low — which is common — and treat it appropriately, the difference is often dramatic. Women describe feeling like themselves again. That is not a small thing."
A note on scope: ReBloom is a nutrition and metabolic rebuilding program available to women everywhere. The clinical evaluation, lab testing, and prescribing of testosterone described in this article is provided through Big Sandy Medical Center (BSMC) — Krystyl's clinical practice in Montana — and is available to Montana residents only. If you live outside Montana, this article will help you understand what to ask for and what to look for in a hormone-literate provider in your state.
You used to wake up with energy and purpose. Now getting started on things that once came easily requires effort you do not have. The drive is quieter. The motivation that used to show up automatically has to be coaxed. Your libido has changed — or disappeared. You are doing everything right in the gym and barely building anything. You feel flat in a way that sleep does not fix.
If this sounds familiar, your testosterone has probably been checked — if at all — once, with a number compared against a male reference range, and declared normal. The conversation likely ended there.
It should not have. Here is what the full picture actually looks like.
What It Actually Is
Testosterone in Women — Not a Male Hormone, a Female Essential
Testosterone is classified as an androgen — a category often called "male hormones." This framing has caused decades of clinical neglect for women. Testosterone is not a male hormone that women happen to have in small amounts. It is a female hormone that women produce in amounts appropriate for female physiology — and it is as essential to female health as estrogen and progesterone.
Women produce testosterone primarily in the ovaries and adrenal glands. Levels are highest in the mid-20s and decline gradually from there — with accelerating decline in perimenopause and a significant drop at menopause when ovarian production largely ceases. By the time a woman reaches her 50s, she may have testosterone levels 50% lower than she did in her 20s. This decline is rarely acknowledged, rarely tested for, and almost never treated in standard care.
The fact most women are never told
Women have more testosterone than any other sex hormone in their body
Throughout most of a woman's adult life, testosterone is present in higher total amounts than estradiol or progesterone. It is not a trace hormone. It is a primary hormone — and treating its decline as a minor footnote is one of the biggest gaps in women's healthcare.
Testosterone
~300 pg/mL average (premenopausal)
Highest of all sex hormones
Estradiol (E2)
~100–200 pg/mL average (mid-cycle peak)
~60% of testosterone level
Progesterone
~5–20 ng/mL (luteal phase)
Lowest of the three
What this means clinically: Testosterone is not a trace hormone that women produce in negligible amounts. It is the dominant sex hormone by quantity throughout most of a woman's adult life. Its decline is not minor. Its deficiency is not rare. And the conversation about it belongs in every women's health appointment — not just fertility clinics and sexual medicine practices.
Note: Hormone levels vary significantly across the menstrual cycle, age, and individual physiology. Values shown are approximate averages for illustration purposes. Units differ between hormones — direct numerical comparison is not clinically appropriate; the relative prevalence of testosterone by quantity is the key point.
Where it is produced
Approximately 25% from the ovaries, 25% from the adrenal glands, and 50% from peripheral conversion of androgen precursors — primarily DHEA — in tissues throughout the body. This is why adrenal health matters so much in the testosterone conversation: the adrenal glands are a major production site, and chronic stress that taxes the adrenals directly reduces the precursors available for testosterone production.
The DHEA connection
DHEA-S (dehydroepiandrosterone sulfate) is the primary adrenal precursor to testosterone. Checking DHEA-S alongside testosterone gives the full adrenal picture — because low DHEA-S often explains low testosterone in women who have not yet reached menopause, and because treating DHEA alongside testosterone produces better outcomes than testosterone alone in women with adrenal insufficiency. Krystyl checks DHEA-S as part of every comprehensive hormone panel — not just testosterone in isolation.
The reference range problem
Standard laboratory reference ranges for testosterone in women are wide — often spanning a range that is essentially "not zero to not male." A woman at the bottom of the reference range may be told her testosterone is normal while experiencing every symptom of deficiency. Functional optimization — finding the level at which a specific woman feels and functions best — is a different and more clinically meaningful target than simply landing within a wide reference range.
What Testosterone Does in the Female Body
What Testosterone Does in the Female Body — Far More Than Libido
Testosterone's role in women has been reduced in popular understanding to libido — which dramatically understates its clinical significance. Here is what testosterone actually governs in the female body.
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Energy and motivation
Testosterone supports dopamine pathways in the brain — the neurotransmitter system responsible for drive, reward, motivation, and the ability to initiate action. This is why low testosterone does not feel like sadness (which is more serotonin-related) — it feels like flatness. Like the ignition is there but the engine does not quite catch. Women with low testosterone describe it consistently: things that used to excite them are merely okay. Drive that used to be automatic now requires effort. That is a testosterone story.
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Muscle building and body composition
Testosterone is a primary anabolic hormone — it directly stimulates muscle protein synthesis. Women with adequate testosterone build muscle more efficiently from the same training stimulus. As testosterone declines, the same effort in the gym produces progressively less result — not because training is inadequate but because the hormonal environment supporting adaptation has diminished. This is why women who train consistently but cannot seem to build visible muscle despite doing everything right should have testosterone checked.
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Cognitive clarity and confidence
Testosterone supports dopamine and norepinephrine pathways involved in focus, verbal fluency, processing speed, and the sense of mental sharpness. Many women with low testosterone describe a subtle but significant cognitive shift — words coming less easily, thinking feeling slower, the confidence that used to be automatic becoming harder to access. This often gets attributed to estrogen decline or thyroid issues when testosterone is the primary driver.
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Sexual desire and responsiveness
Testosterone is the primary driver of sexual desire in women — not estrogen. Estrogen affects vaginal tissue health and lubrication, but the desire itself — the spontaneous interest in sex, the ability to feel aroused — is governed primarily by testosterone. The loss of libido that many women experience in perimenopause and menopause is not primarily an estrogen story. It is a testosterone story that is rarely addressed because providers rarely check and even more rarely treat it.
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Bone density
Testosterone contributes to bone density alongside estrogen — it stimulates osteoblasts (bone-building cells) directly. Women with low testosterone have higher rates of bone loss independent of estrogen status. This makes testosterone therapy potentially protective for bone density in postmenopausal women — a benefit that is underappreciated and underutilized in standard care.
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Cardiovascular health
Emerging evidence suggests testosterone plays a role in cardiovascular health in women — supporting healthy cholesterol profiles, vascular function, and cardiac muscle. The cardiovascular picture of testosterone in women is less established than in men, but the direction of the evidence is generally favorable at physiologic replacement doses.
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Mood and emotional resilience
Low testosterone in women is associated with depression, anxiety, and reduced emotional resilience — independent of estrogen status. The flatness and low mood that accompanies testosterone deficiency is frequently misdiagnosed as clinical depression and treated with antidepressants that do not address the underlying hormonal cause. Addressing testosterone first — or alongside — is a clinical consideration that most women are never offered.
"When women tell me they feel like themselves again after starting testosterone therapy, they are not describing a dramatic transformation. They are describing the return of something quiet that they had been missing for years — drive, desire, mental sharpness, the ability to care about things. That is what testosterone does."
— Krystyl Kulbeck PA-C
Recognizing Deficiency
Signs of Low Testosterone in Women — and Why They Are So Often Missed
The symptoms of low testosterone in women are easily attributed to other causes — depression, thyroid, burnout, aging, relationship problems, poor sleep. Because testosterone is so rarely checked and so rarely treated in women's standard care, its deficiency often goes unidentified for years while women are treated for the symptoms rather than the hormonal root cause.
Energy & Motivation
→Persistent flat energy not resolved by sleep
→Loss of drive and motivation
→Difficulty initiating tasks that used to be automatic
→Things that used to excite you now feel merely okay
Body & Performance
→Difficulty building muscle despite consistent training
→Poor recovery from exercise
→Increasing body fat despite good habits
→Decreased strength despite training
Mind & Mood
→Brain fog and difficulty finding words
→Reduced confidence and assertiveness
→Low mood or mild depression
→Reduced emotional resilience
Intimacy & Vitality
→Reduced or absent sexual desire
→Reduced arousal and responsiveness
→Loss of the sense of vitality and aliveness
→Feeling older than your age
If several of these resonate, testosterone levels are worth investigating — alongside DHEA-S and the full hormone panel. A single testosterone number checked against a wide reference range is not a complete picture.
Montana residents: Reach out to Krystyl at Big Sandy Medical Center to begin a full hormonal evaluation. Outside Montana: Search for a hormone-literate provider in your state — see guidance at the bottom of this article.
Treatment
Compounded Testosterone for Women — What It Is and How It Works
There is currently no FDA-approved testosterone product specifically formulated for women in the United States. All testosterone therapy for women is prescribed off-label — meaning it is legal, clinically supported, and widely practiced by providers with expertise in hormonal health, but outside the standard FDA approval pathway designed around male physiology and male doses.
This is where compounding becomes clinically essential. Compounded testosterone allows a provider to prescribe a formulation specifically designed for female physiology — at the doses and delivery methods appropriate for women. It is not a workaround. It is the precision that standard commercial testosterone products do not offer for women.
What compounded testosterone is
Compounded testosterone is prepared by a licensed compounding pharmacy to Krystyl's specific prescription — formulated as a topical cream applied to the skin. Topical delivery avoids the first-pass liver metabolism that oral testosterone causes, providing more consistent absorption and a steadier hormone level than oral preparations. The cream is applied to an area of thin skin — typically the leg — where absorption is consistent and measurement is practical.
Compounding allows the dose to be precisely calibrated for female physiology — which requires doses far lower than commercial testosterone products designed for men. Starting doses are low and adjusted based on symptom response and follow-up lab testing. The goal is not to maximize testosterone levels but to restore them to the range where that individual woman feels and functions optimally.
Why topical cream — and why it is applied where it is
Topical testosterone cream is the preferred delivery method for women because it allows consistent low-dose administration without the peaks and troughs associated with injections or the imprecision of pellets once implanted. Applied to the leg — an area of reliable skin thickness and blood flow — absorption is predictable and measurable.
The application site also matters for avoiding unintended transfer to others — particularly children and partners — which is a real consideration with any topical hormone preparation. Applying to an area that is typically covered by clothing and allowing it to fully absorb before contact reduces transfer risk significantly.
What to expect — timeline and experience
Testosterone therapy does not work overnight. Most women begin noticing subtle improvements in energy and motivation within 4–8 weeks. Libido changes typically follow at 6–12 weeks. Muscle-building benefits become more apparent at 3–6 months of consistent use alongside progressive strength training. The full benefit of testosterone therapy in terms of body composition, bone density, and cognitive clarity can take 6–12 months to fully appreciate.
This timeline requires patience — and it is one reason Krystyl monitors carefully throughout rather than making early judgments about whether therapy is working. The body's response to testosterone restoration is gradual because the systems it supports — dopamine pathways, muscle protein synthesis, bone remodeling — all operate on biological timescales, not days.
Benefits & Risks — The Complete Picture
Benefits and Risks of Testosterone Therapy in Women — The Complete Picture
Every clinical decision involves a benefit-risk assessment. Krystyl does this individually for every patient. Here is the honest, complete picture of what the evidence shows on both sides.
Benefits — what the evidence supports
Libido and sexual function
The most robust evidence for testosterone therapy in women is in the area of hypoactive sexual desire disorder (HSDD). Multiple randomized controlled trials demonstrate meaningful improvement in sexual desire, arousal, and satisfaction with testosterone therapy in postmenopausal women. The International Society for the Study of Women's Sexual Health (ISSWSH) and the British Menopause Society both endorse testosterone therapy for HSDD in appropriate candidates. (Davis et al., 2019 — Global Consensus Position Statement)
Muscle mass and physical function
Studies show that testosterone therapy in postmenopausal women improves muscle strength, lean body mass, and physical function — particularly when combined with resistance training. The anabolic effect of testosterone on muscle protein synthesis is real and clinically meaningful. For women who are training consistently but not seeing the adaptation they expect, testosterone optimization can be a significant factor. (Huang et al., 2023; multiple systematic reviews)
Mood, energy, and cognitive function
Evidence supports improvements in energy, mood, and well-being with testosterone therapy in women with documented deficiency. Cognitive benefits — particularly in verbal memory, processing speed, and mental clarity — are reported consistently in clinical experience and are supported by emerging research. (Glaser & Dimitrakakis, 2013; Somboonporn et al., 2005)
Bone density
Testosterone contributes to bone density independently of estrogen — through direct stimulation of osteoblasts and indirect effects on calcium metabolism. Studies show that testosterone therapy preserves and in some cases improves bone mineral density in postmenopausal women. For women with osteopenia or osteoporosis risk, this is a clinically meaningful additional benefit. (Davis & Wahlin-Jacobsen, 2015)
Risks — what to understand honestly
Androgenic side effects — dose-dependent and manageable
The most commonly cited side effects of testosterone therapy in women — acne, facial hair, voice changes, clitoral enlargement — are associated with supraphysiologic dosing. At doses appropriate for women using physiologic replacement, these effects are uncommon and typically mild when they occur. They are dose-dependent — meaning the solution when they appear is dose reduction, not discontinuation.
Cardiovascular effects — context matters
Concerns about cardiovascular risk from testosterone in women come largely from studies of supraphysiologic doses and from extrapolation from male cardiovascular data — neither of which applies to physiologic replacement in women. At appropriate doses, the current evidence does not support significant cardiovascular risk for most women. Individual cardiovascular risk factors should be evaluated before initiation and monitored throughout.
Breast cancer — the current evidence
The relationship between testosterone and breast cancer risk in women is an active area of research. Current evidence does not demonstrate increased breast cancer risk from physiologic testosterone replacement — and some observational data suggests a possible protective effect. This is not fully established, and women with a personal history of hormone-sensitive breast cancer should have a detailed individual discussion before considering testosterone therapy.
Contraindications — who should not use testosterone
Testosterone therapy is not appropriate for all women. Current or recent history of hormone-sensitive breast cancer or endometrial cancer, pregnancy or breastfeeding, and severe polycythemia are contraindications. Women with significant acne, hirsutism, or clinical signs of androgen excess should be evaluated carefully before initiation. A thorough clinical evaluation — including the full hormone panel — identifies these situations before therapy begins.
How Monitoring Works at BSMC
How to Monitor Testosterone in Women — Beyond a Single Lab Number
This section describes how Krystyl approaches hormone evaluation and monitoring at Big Sandy Medical Center — her clinical practice in Montana. If you are a Montana resident, this is what your care would look like. If you live outside Montana, this is what you should be looking for — and asking about — when you find a hormone-literate provider in your state.
1
Baseline serum labs — the starting picture
Before initiating any hormone therapy, Krystyl obtains a comprehensive baseline panel including total testosterone, free testosterone, SHBG (sex hormone binding globulin), estradiol, progesterone, DHEA-S, cortisol, and thyroid function. Free testosterone is often more clinically meaningful than total testosterone — SHBG binds testosterone and makes it unavailable to tissues, so a woman can have a "normal" total testosterone but functionally low free testosterone if SHBG is elevated. DHEA-S gives the adrenal picture. Thyroid function is checked because thyroid disorders produce many of the same symptoms as testosterone deficiency and must be distinguished.
2
Salivary testing — when accessible, a different and valuable picture
Salivary hormone testing measures the unbound, bioavailable fraction of hormones — the portion that is actually active in tissues. This can provide a more functionally relevant picture than serum testing, particularly for cortisol (which follows a diurnal rhythm that serum testing at a single point in time may miss) and for free steroid hormones. Salivary testing is not covered by most insurance and is cash-pay — but for women with complex or atypical presentations, it adds meaningful clinical information that serum testing alone does not capture. Krystyl incorporates salivary testing where clinically appropriate and accessible.
3
Follow-up labs — adjusting based on response
Labs are rechecked 6–8 weeks after initiating or adjusting therapy — enough time for levels to stabilize but early enough to catch any out-of-range readings before they become symptomatic. Subsequent monitoring typically occurs every 3–6 months once a stable dose is established. The goal is not to hit a specific number — it is to find the level at which that individual woman feels and functions optimally, with labs confirming physiologic range.
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Symptom tracking alongside labs
Lab values and symptom experience do not always move in parallel — a woman can have labs in range and still feel suboptimal, or can feel significantly better at levels that look low on paper. Krystyl tracks symptom response alongside lab values, using both to guide dosing decisions. The woman's lived experience is clinical data — not secondary to the numbers.
5
The full hormone panel — because nothing works in isolation
Testosterone does not work optimally in a body where other hormones are significantly dysregulated. Estrogen, progesterone, cortisol, thyroid, and insulin sensitivity all affect how testosterone is produced, bound, converted, and utilized in tissues. Krystyl checks the full panel — and treats the system, not just the number. A woman with high cortisol from chronic stress will see limited benefit from testosterone therapy until the cortisol burden is addressed. A woman with significant insulin resistance may need that addressed alongside hormone therapy for optimal results.
The Most Important Thing
The Foundation Women Need Before Testosterone Therapy Works
This is the clinical insight that separates hormone optimization from hormone prescription. Testosterone therapy is a powerful tool. But it works best — and sometimes only works — inside a body that is already being supported at a foundational level.
Hormones are not the solution to lifestyle problems. They are amplifiers of a healthy foundation. Prescribing testosterone into a body that is chronically under-slept, chronically under-fueled, chronically stressed, and losing muscle is like adding high-octane fuel to an engine with a cracked block. The fuel is good. But the engine cannot use it properly.
What the foundation looks like
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Adequate consistent nutrition. Testosterone is synthesized from cholesterol. Chronic caloric restriction suppresses testosterone production and elevates cortisol that further suppresses it. Eating enough — consistently — is the prerequisite for hormone optimization to work.
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Progressive strength training. Testosterone without the stimulus of resistance training produces less muscle adaptation. The hormonal signal and the training stimulus work together — one amplifies the other. Women on testosterone therapy who are also strength training consistently see dramatically better body composition outcomes than those using testosterone alone.
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Cortisol management. Chronic cortisol elevation suppresses testosterone — both by competing for adrenal precursors and by directly inhibiting gonadal testosterone production. A woman with significantly elevated cortisol may see limited benefit from testosterone therapy until the cortisol burden is addressed. Sleep, stress management, and adequate fueling are cortisol interventions as much as they are lifestyle choices.
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Protected sleep. The majority of testosterone production in women occurs during sleep — particularly during deep sleep stages. Consistently poor sleep does not just leave you tired. It is a direct testosterone production deficit. Protecting sleep quality is not optional in the context of testosterone optimization.
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The full ReBloom foundation. Every pillar of ReBloom — consistent fueling, progressive strength, nervous system safety, food trust rebuilt — is a direct support for the hormonal environment that testosterone therapy works within. ReBloom is not hormone therapy. But it builds the body that hormone therapy works best in.
The honest clinical reality: Some women need testosterone therapy because their levels are genuinely low and the deficit is real and significant. Some women have testosterone levels that are functionally low because cortisol is suppressing production and the foundation is depleted — and addressing the foundation first produces hormonal recovery without exogenous hormone therapy. A comprehensive evaluation distinguishes between these presentations.
This is what ReBloom supports regardless of where you live: building the foundation — consistent fueling, progressive strength, cortisol management, protected sleep — so that when you do work with a provider on hormones, your body is ready to respond.
The Evidence Base
Research Evidence for Testosterone Therapy in Women
✓ Strongly Evidenced
Testosterone therapy significantly improves sexual function in postmenopausal women. The 2019 Global Consensus Position Statement on testosterone use for women — endorsed by 11 international menopause and sexual medicine societies — concluded that there is strong evidence supporting testosterone therapy for hypoactive sexual desire disorder in postmenopausal women, and that it is safe at physiologic doses. (Davis et al., 2019)
Testosterone improves muscle mass and strength in women. Multiple systematic reviews and RCTs demonstrate improvements in lean body mass and muscle strength with testosterone therapy in women. (Huang et al., 2023 →)
Physiologic dose testosterone does not increase breast cancer risk. Current evidence from observational studies and RCTs does not support increased breast cancer risk from testosterone therapy at physiologic doses. (Glaser et al., 2019 →) Some data suggests possible protective effects.
~ Well-Supported with Appropriate Nuance
Cognitive and mood benefits. Clinical evidence supports improvement in energy, mood, and well-being with testosterone therapy. Cognitive benefits are reported consistently in clinical experience and observational research but require larger RCTs for stronger evidentiary standing.
Bone density protection. Evidence supports testosterone's contribution to bone density in women, with some studies showing preservation and improvement with therapy.
⊙ Clinical Reasoning Applied to the Evidence
The specific use of compounded topical testosterone cream, application to the leg, the combination of serum and salivary testing, the decision to check DHEA-S and the full hormone panel alongside testosterone — these reflect Krystyl's clinical training, functional medicine approach, and patient outcomes in her practice. The individual mechanisms are evidence-based. Their specific combination in clinical practice represents Krystyl's judgment about what produces the best outcomes for her patients and she stands behind this approach clinically.
If This Article Resonated
Testosterone deficiency in women is common, clinically significant, and treatable. Most women are never told this.
You have been told now. Here is what to do with it.
If You Live in Montana
Big Sandy Medical Center
Krystyl provides full clinical hormone evaluation, lab testing, and compounded testosterone prescribing at BSMC. This is where the clinical care described in this article happens — available to Montana residents.
Search for a provider who specializes in women's hormonal health in your state. Look for terms like "menopause specialist," "functional medicine," or "hormone-literate provider." The Menopause Society provider directory is a good starting point.
"Feeling like yourself again is not too much to ask. It is the baseline you deserve. ReBloom builds the foundation. A hormone-literate provider addresses the rest. Both matter. Neither replaces the other."
— Krystyl Kulbeck PA-C
What ReBloom provides — regardless of where you live:
The nutrition foundation, progressive strength program, cortisol support, and metabolic rebuilding that makes hormone therapy work better — and that sometimes allows hormonal recovery without it. ReBloom is available everywhere. Clinical prescribing requires a licensed provider in your state.
Frequently Asked Questions
Low testosterone in women — questions Krystyl gets most
What are the symptoms of low testosterone in women?
The most common symptoms of low testosterone in women include: persistent flat energy not resolved by sleep, loss of drive and motivation, difficulty building muscle despite training, low libido or absent sexual desire, brain fog, reduced confidence, low mood, and poor exercise recovery. These are frequently misattributed to depression, thyroid dysfunction, or simply aging — which is why testosterone deficiency in women goes undiagnosed for years. (ISSWSH Global Consensus →)
Do women really need testosterone?
Yes. Testosterone is women's dominant sex hormone by quantity throughout most of adult life — present in higher amounts than estradiol or progesterone. It governs energy, motivation, muscle building, libido, cognitive clarity, bone density, and mood. By the time a woman reaches her 50s, she may have testosterone levels 50% lower than in her 20s. This decline is rarely acknowledged or treated in standard care.
Is testosterone therapy safe for women?
At physiologic doses appropriate for women, testosterone therapy is well-supported by evidence and generally safe. The 2019 Global Consensus Position Statement endorsed by 11 international societies concluded strong evidence supports testosterone for low libido in postmenopausal women. Side effects like acne and facial hair occur at supraphysiologic doses — not at doses appropriate for women. Individual assessment and monitoring are essential. (Davis et al., 2019 →)
How is testosterone prescribed for women in the US?
There is no FDA-approved testosterone product specifically for women in the US — so it is prescribed off-label by providers experienced in hormonal health. Compounded topical testosterone cream applied to the skin is the most common approach, allowing precise low-dose formulation appropriate for female physiology. Monitoring includes serum testosterone, free testosterone, SHBG, DHEA-S, and the full hormone panel.
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