High and Low Testosterone in Women - What Does It Mean?

By: Taryn Smith, MD • Posted on January 15, 2020

High and Low Testosterone in Women - What Does It Mean?

Although testosterone is thought to be a male hormone, it plays an important role in female well-being and BOTH males and females have testosterone. In fact, women produce more testosterone on a gram per gram basis than they do estrogen. Estrogen is the sex hormone responsible for female characteristics and bone health. Testosterone levels fluctuate over time and decline with age. While blood testosterone levels can guide therapy, levels do not account for the testosterone made inside of tissues. Also, blood testosterone levels do not indicate how sensitive the tissues are to testosterone's effects.

Low Testosterone in Women

Causes

  • Surgical removal of the ovaries (causes 40% of loss of total female testosterone)
  • Medications including long term steroids, birth control pills, some antidepressants and more
  • Adrenal insufficiency
  • Hypopituitarism
  • Poor nutritional status
  • Eating disorders like anorexia nervosa

Symptoms

  • Decreased sex drive
  • Poor sleep quality
  • Mood issues (anxiety, depression, decreased motivation)
  • Fatigue
  • Decreased muscle mass or difficulty building muscle

Management of low T in women

Blood testosterone levels are not used to diagnose sexual dysfunction rather to monitor testosterone levels if treatment is initiated. The only evidence-based, FDA approved indication for testosterone therapy in women is for the treatment of Hypoactive Sexual Desire Disorder (HSDD) and Female Sexual Dysfunction (FSD). Current research is insufficient to support the use of testosterone therapy for any other reason.

Testosterone Therapy for Women

  1. There are no FDA approved testosterone formulations for women for the treatment of female sexual dysfunction.
  2. WARNING: Intramuscular and pellet therapy should be avoided. Studies have shown that these treatment methods can lead to significant adverse side effects, including excessive elevation in testosterone levels and prolonged exposure to unsafe levels of testosterone.
  3. Available oral therapies combine estrogen with testosterone. These therapies have been on the market since 1964. Few serious adverse side effects have been reported on post marketing surveillance studies.
  4. Transdermal therapies are the preferred treatment modality. Compounded testosterone creams, gels and ointments are the most commonly prescribed formulations. When used as prescribed, testosterone levels tend to remain within physiologic ranges and side effects are few as long as monitored by hormone expert.
  5. Male products can be used after significant dose reduction (approximately 1/10 of the dose) and with judicious monitoring.

If treatment is initiated for properly diagnosed HSDD/FSD:

  • A 3 to 6 month trial of testosterone is recommended.
  • Therapy should be stopped for women who have not responded to treatment after six months.
  • If long term therapy is indicated, testosterone levels should be monitored periodically.

There are two non-hormonal FDA approved options for treating HSDD in premenopausal women. Both work via neurotransmitter pathways.

  1. Addyi®
  2. Vyleesi®

High Testosterone in Women

Causes

Symptoms

  • Acne and oily skin
  • Hirsutism (excess body hair, particularly on the face)
  • Hair loss
  • Development of masculine characteristics such as enlarging clitoris and decrease in breast size
  • Irregular periods
  • Infertility
  • Insulin resistance

Management

Management depends on the cause of elevated testosterone. In general, therapy includes:

  1. Medications
  2. Lifestyle changes

Medications

• Metformin/Glucophage® for women with insulin resistance or PCOS

• Hormonal contraceptives for women who desire contraception

• Spironolactone

• Glucocorticoids to suppress adrenal function under care of endocrinologist

Lifestyle changes

• Weight loss and exercise can promote regular cycles and reduce insulin resistance as can intermittent fasting

• Various hair removal systems (prescription Vaniqa®, shaving, waxing, plucking, laser) can be used for bothersome hair growth

• Facial cleansers can be used to fight oily skin and acne

Talk to your doctor if you are experiencing symptoms of low or elevated testosterone levels. Together, you can decide what treatment options are best for you.

Be Strong. Be Healthy. Be in Charge!

Taryn Smith, MD, NCMP

Dr. Taryn Smith is a Fellow in the Cleveland Clinic Specialized Women's Health Fellowship Program.


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