Written in collaboration with Dr. George Ibrahim, MD — Board-Certified Urologist, Fellow of the American Academy of Anti-Aging Medicine (A4M), Member of the North American Menopause Society (NAMS)
You've been tired in a way sleep doesn't fix. Your libido has gone quiet. You're gaining weight in places you never did before, and the mental sharpness you used to rely on feels like it's been replaced by static. You mentioned it to your doctor. They ran some labs, told you everything looked normal, and suggested you might be stressed or getting older.
Here's what most doctors won't tell you: the symptoms of low testosterone in women are real, they're measurable, and they're routinely missed because most physicians aren't looking for them. Testosterone is not a male hormone that women happen to have a little of. It is an essential hormone in female physiology — and when it drops, the effects reach into nearly every system in the body.
At Biltmore Restorative Medicine & Aesthetics, Dr. George Ibrahim has spent more than 30 years treating the hormonal conditions that conventional medicine tends to wave away. This is one of them.
Do Women Actually Have Testosterone?
Yes. Women produce testosterone in the ovaries and adrenal glands throughout their lives. Do females have testosterone at clinically meaningful levels? Absolutely — and that testosterone does not simply provide a fraction of what it does in men. It plays a distinct, active role in female health.
In women, testosterone supports:
- Libido and sexual function — perhaps its most recognized role, and one that declines sharply when levels drop
- Energy and vitality — testosterone contributes to mitochondrial function and overall stamina
- Muscle mass and physical strength — it is an anabolic hormone regardless of sex
- Bone density — low testosterone is a contributing factor to osteopenia and osteoporosis in women
- Mood and cognitive function — testosterone receptors exist throughout the brain; deficiency is associated with depression, irritability, and brain fog
- Motivation and drive — the competitive, goal-oriented edge that many women notice dulling over time
Normal testosterone levels for a woman vary by lab and methodology, but total testosterone in adult women typically falls between 15–70 ng/dL. Free testosterone — the biologically active fraction — is often more clinically informative and is frequently omitted from standard panels. Many practitioners consider a free testosterone level below 1.0–1.5 pg/mL to be suboptimal in symptomatic women, though what a woman's free testosterone level should be is best evaluated in the context of her full hormonal picture and symptoms.
Levels decline progressively with age and can fall sharply during perimenopause, menopause, and after certain surgical or pharmaceutical interventions. By the time a woman reaches her late 40s or 50s, she may have testosterone levels less than half of what she had in her 30s — and her doctor may never have mentioned it.
The Most Common Symptoms of Low Testosterone in Women
The symptoms of low testosterone in women don't always announce themselves clearly. They tend to accumulate quietly and overlap with other conditions — which is exactly why they get missed. Low T symptoms in females are often chalked up to depression, perimenopause, burnout, or simply aging. Sometimes the diagnosis is all of the above. But testosterone deficiency as a distinct, treatable contributor is rarely investigated.
Here is what many women with low testosterone may experience:
1. Low Libido and Decreased Sexual Desire
This is the most consistently documented symptom. Testosterone is the primary driver of sexual desire in women — not estrogen. When levels drop, sexual interest can decline significantly, often described as a complete loss of desire rather than reduced frequency. Many women report this change happening gradually and attribute it to relationship dynamics or stress before recognizing it as hormonal.
2. Persistent Fatigue That Sleep Doesn't Resolve
This is not the tiredness that a good night's sleep fixes. Low testosterone may contribute to a deep, unrelenting fatigue that feels disconnected from how much rest a woman gets. Many patients describe it as feeling like they're running on a fraction of their former energy, regardless of lifestyle factors.
3. Difficulty Building or Maintaining Muscle Mass
Testosterone is an anabolic hormone. Without adequate levels, the ability to build and hold lean muscle diminishes — even with consistent strength training. Women may notice that workouts feel harder, recovery takes longer, and results have plateaued or reversed despite no change in effort.
4. Mood Changes — Depression, Irritability, Emotional Flatness
Testosterone receptors are distributed throughout the brain. When levels fall, many women experience mood changes that don't respond well to antidepressants — a kind of flat, emotionally muted baseline or low-level irritability that feels uncharacteristic. This pattern often leads to an antidepressant prescription when a hormonal panel was what was actually needed.
5. Cognitive Fog and Difficulty Concentrating
Patients frequently describe this as a loss of mental sharpness — words that used to come easily now don't, focus requires more effort, and multitasking feels harder than it once did. Testosterone has demonstrated neuroprotective effects in research, and deficiency is associated with reduced cognitive performance in some women.
6. Weight Gain, Particularly in the Midsection
Lower muscle mass means a slower metabolism. Combined with the hormonal shifts of perimenopause, low testosterone may contribute to a pattern of fat accumulation — particularly in the abdominal region — that resists dietary interventions that previously worked.
7. Vaginal Dryness and Changes in Sexual Sensation
While often attributed solely to declining estrogen, testosterone also plays a role in genital tissue sensitivity and lubrication. Women with low testosterone may notice reduced sensation and a decreased response to sexual stimulation, even when estrogen levels are within range.
8. Hair Thinning
Testosterone contributes to hair follicle cycling. Low levels may manifest as diffuse hair thinning — a gradual reduction in hair density that is distinct from androgenetic alopecia and often overlooked in standard workups.
9. Decreased Bone Density
Over the longer term, testosterone deficiency may contribute to bone loss. This is particularly relevant in women who undergo surgical menopause or who have had prolonged oral contraceptive use that suppresses free testosterone levels.
10. Loss of Motivation and Competitive Drive
Many women describe this one last — and it may be the one that finally brings them in. The internal drive that used to be automatic starts to feel like it requires constant effort. Goals that once felt compelling feel distant. This is not a personality change. It is a hormone change.
What Causes Low Testosterone in Women?
Understanding the causes helps explain why this is not simply an inevitable consequence of aging — and why testing, not assumption, is the right approach.
Age and hormonal transition. Testosterone production declines gradually through a woman's 30s and 40s, with a more pronounced drop during perimenopause and menopause.
Surgical menopause. Oophorectomy — removal of the ovaries — eliminates a primary source of testosterone production and can cause a rapid, dramatic decline in levels.
Oral contraceptive use. Combination oral contraceptives suppress ovarian testosterone production and increase sex hormone-binding globulin (SHBG), which binds free testosterone and reduces its availability. Women who have been on oral contraceptives for years may have chronically suppressed free testosterone levels.
Adrenal dysfunction. The adrenal glands are a secondary source of testosterone precursors. Chronic stress, adrenal fatigue, and conditions like adrenal insufficiency may reduce testosterone output.
Hypopituitarism. Pituitary dysfunction affects the entire hormonal cascade, including signals that regulate testosterone production.
Chronic stress and elevated cortisol. Sustained cortisol elevation competes with and suppresses sex hormone production — a physiological trade-off that favors survival hormones over reproductive ones.
Autoimmune conditions. Certain autoimmune disorders affecting the ovaries or adrenal glands may impair testosterone production.
What Are Normal Testosterone Levels for Women — And How Is It Actually Tested?
This is where standard medicine frequently falls short. The reference ranges used by most commercial labs are notoriously wide, and a result that falls within the "normal" range may still represent a significant decline from a woman's personal baseline.
Total testosterone is the most commonly ordered measurement, but it can be misleading. A significant portion of circulating testosterone is bound to proteins — primarily sex hormone-binding globulin — and is biologically inactive. Free testosterone is what the body can actually use. Many women with "normal" total testosterone have low free testosterone and experience every symptom on the list above.
A thorough hormonal evaluation at a physician-led practice typically includes:
- Total and free testosterone
- SHBG (to assess binding capacity)
- DHEA-S (a testosterone precursor produced by the adrenal glands)
- Estradiol and progesterone (for a complete hormonal picture)
- Thyroid panel (hypothyroidism mimics many low-testosterone symptoms)
A result that reads "within normal limits" on a standard panel is not the end of the evaluation. It is the beginning of a conversation about what optimal looks like for this specific patient.
How Is Low Testosterone Treated in Women?
Physician-supervised testosterone therapy for women is not new. It has been studied for decades, and the evidence base for its use in appropriately selected patients is substantial. What varies is how it's administered, at what dose, and how closely it's monitored — which is precisely why physician oversight is not optional.
Under the supervision of a board-certified physician, testosterone therapy for women may be delivered in several forms:
Topical creams or gels. Applied to specific skin areas, these allow for dose flexibility and gradual titration. Custom-formulated compounded preparations are commonly used because commercially available testosterone products are dosed for men and require adjustment for female physiology.
Subcutaneous pellets. Small pellets inserted under the skin provide a sustained, steady release of testosterone over three to six months. Many women prefer this method for its convenience and consistency.
Injectable formulations. Less commonly used in women but available when clinically appropriate.
The goal of treatment is not to maximize testosterone levels — it is to restore them to a range where symptoms improve and the patient feels like herself again. Dosing is individualized. Monitoring typically includes follow-up labs at specified intervals to assess levels, symptom response, and any need for adjustment.
Because standard pharmaceutical testosterone is formulated for men, many women are treated with custom-formulated compounded medications prepared by a licensed compounding pharmacy based on a physician's prescription. This allows precise, female-appropriate dosing that commercial products cannot provide.
What to expect: many women begin noticing improvements in energy and mood within four to six weeks. Libido and physical changes may take longer. This is a physician-managed, individually titrated process — not a one-size-fits-all protocol.
Frequently Asked Questions
What depletes a woman's testosterone?
Several factors can reduce testosterone in women, including aging, the hormonal transition of perimenopause and menopause, surgical removal of the ovaries, long-term oral contraceptive use, chronic stress, and adrenal or pituitary dysfunction. Identifying the underlying contributor is part of a thorough evaluation.
Oral contraceptives are a particularly underappreciated cause. They suppress ovarian production of testosterone while simultaneously increasing the proteins that bind and inactivate the testosterone that remains — a double reduction that can leave women with functionally low testosterone despite years of feeling "fine" on labs.
Can low testosterone cause weight gain in women?
Low testosterone may contribute to weight gain, particularly in the midsection. Testosterone supports lean muscle mass, which drives metabolic rate. When muscle mass declines due to low testosterone, the body's ability to burn calories at rest decreases, and fat accumulation — especially visceral fat — may increase. This effect often compounds with the estrogen-related changes of perimenopause.
How can a woman increase her testosterone level?
Physician-supervised hormone therapy is the most direct and evidence-informed approach to restoring testosterone levels. Supportive lifestyle interventions — resistance training, adequate sleep, stress management, and limiting alcohol — may help preserve testosterone levels but are unlikely to fully correct a deficiency on their own. The first step is accurate testing to establish a baseline, not supplementation based on symptoms alone.
Is testosterone therapy safe for women?
When properly prescribed, individually dosed, and monitored by a qualified physician, testosterone therapy is generally well-tolerated by women. Potential side effects — such as acne, hair changes, or voice changes — are typically dose-dependent and can be managed through monitoring and adjustment. Women with certain hormone-sensitive conditions require careful evaluation before starting therapy. A thorough consultation with a physician experienced in female hormone optimization is the appropriate first step.
Do all women with these symptoms have low testosterone?
Not necessarily — which is exactly why testing matters. Many of these symptoms overlap with thyroid dysfunction, iron deficiency, sleep disorders, and perimenopause. A physician-led evaluation rules out other contributors and establishes whether testosterone deficiency is a primary factor. Treating symptoms without testing is guesswork. Testing without clinical context is equally incomplete.
Why Women in Asheville and Greenville Choose Biltmore for Hormone Optimization
There is a significant difference between a physician who supervises hormone therapy and a practitioner who follows a standard protocol.
Dr. George Ibrahim is a board-certified surgical urologist, a graduate of Duke University School of Medicine, a Fellow of the American Academy of Anti-Aging Medicine (A4M), and a member of the North American Menopause Society (NAMS) — an organization whose entire focus is the clinical management of menopause and hormonal transition in women. He is not practicing outside his lane. He built his practice around this lane.
At Biltmore Restorative Medicine & Aesthetics, every hormone evaluation is physician-led. Every treatment plan is built from the ground up for the individual patient — not pulled from a protocol that worked for someone else. If your labs came back "normal" and you were told to come back in a year, that is not a second opinion. That is a dismissal.
Women across Western NC and Upstate SC come to Biltmore's Asheville and Greenville locations because they have already been through the dismissal. They want a physician who will look at the full picture — not just whether a number falls within a wide reference range, but whether that number makes sense for this patient, at this stage of her life, with these symptoms.
That is what physician-led hormone optimization looks like. And that is what we do.
If these symptoms sound familiar, the first step is a conversation — not a guess.
Schedule a Consultation with Dr. Ibrahim's Team in Asheville or Greenville →
The information in this article is for educational purposes only and does not constitute medical advice. Please consult a qualified physician before beginning any treatment program. Individual results may vary. All treatments at Biltmore Restorative Medicine & Aesthetics are provided under the supervision of a board-certified physician.
