When most people think about testosterone, they think about men. This is one of the most consequential blind spots in women's healthcare. Testosterone is not a male hormone — it is a critical hormone for women, and when it declines, the effects are profound, pervasive, and almost universally misattributed to something else. I have seen countless women whose lives were transformed when we finally identified and addressed low testosterone. They had been told they were depressed, burned out, getting older, or simply not trying hard enough. The real answer was a hormone that nobody had thought to test.
Why Women Need Testosterone
Testosterone is produced in women by the ovaries and adrenal glands, and it plays essential roles across multiple body systems. It drives mitochondrial function and cellular energy production — making it one of the most common and most overlooked causes of persistent fatigue in women. It is the primary driver of sexual desire. It builds and maintains lean muscle tissue, and women with low testosterone lose muscle mass more rapidly and struggle to build strength despite exercise. Testosterone contributes to bone mineral density alongside estrogen, and testosterone receptors are distributed throughout the brain — low testosterone is associated with depression, anxiety, poor concentration, and reduced motivation that are routinely treated with antidepressants rather than hormone optimization.
The Testing Problem: Why Low Testosterone in Women Is Missed
The primary reason low testosterone in women goes undiagnosed is that most doctors do not test for it. When they do, they often use the wrong test. Standard testosterone testing measures total testosterone — but only free testosterone (typically less than 2% of total) can actually exert biological effects. A woman can have a normal total testosterone and severely low free testosterone if her SHBG is elevated. This is extremely common in women on oral contraceptives and in women with thyroid dysfunction. Without measuring free testosterone and SHBG together, the diagnosis is missed. In my practice, I measure free testosterone, total testosterone, SHBG, DHEA-S, and the DUTCH test for a comprehensive view of androgen metabolism.
Symptoms of Low Testosterone in Women
The most common presentations I see include fatigue that does not respond to sleep — a bone-deep exhaustion not relieved by rest, reflecting mitochondrial fatigue driven by testosterone deficiency. Loss of motivation and drive: women with low testosterone often describe losing their edge, feeling flat and disengaged from work and life in ways that are foreign to their previous personality. Low libido — the most recognized symptom, yet still routinely dismissed or attributed to relationship issues rather than investigated hormonally. Muscle loss and inability to build strength despite consistent training. Depression and anxiety — testosterone has direct antidepressant and anxiolytic effects in the brain, and treating the hormone often resolves the mood symptoms without pharmaceutical intervention. And brain fog and poor concentration.
The Functional Medicine Approach to Testosterone Optimization
My approach begins with accurate testing, proceeds through a systematic assessment of the factors driving the deficiency, and builds a protocol that addresses root causes. For women with low DHEA-S, adrenal support is the foundation — you cannot optimize testosterone without first supporting the system that produces it. For women with elevated SHBG, addressing the underlying drivers can free up existing testosterone and improve bioavailability without any direct testosterone intervention. For appropriate candidates, I use bioidentical testosterone in physiological doses — typically topical creams or gels — with the goal of restoring testosterone to the optimal range for that individual patient. Lifestyle interventions that support testosterone production include resistance training (the most potent natural testosterone stimulus in women), adequate sleep, stress management, and a diet that supports steroid hormone synthesis.
— Dr. Jay Wrigley, NMD