Here's what you need to know...

  1. The percentage of women between the ages of 18 and 59 who are suffering from "sexual dysfunction" is somewhere around 50%. Much of this sexual dysfunction is related to testosterone deficiency.
  2. Women with low testosterone often find it more difficult to gain muscle or burn fat.
  3. There are several potential causes for testosterone deficiency, among them the use of birth control pills or antidepressants, drinking soy milk, a vegetarian diet, or even psychological factors.
  4. While obtaining actual testosterone replacement is problematical for women in America, there are several courses of action, some pharmaceutical, some through supplements, some through diet, and some through simple lifestyle changes.

Do You Have It?

Female athletes competing at the highest levels of their sport, female trial lawyers, the women CEOs of Fortune 500 companies: all of them probably have it. Maybe you see some of the women who have it in your daily life, too. They're the ones who might dress a little boldly or even flamboyantly. In the gym, they seem to be the ones who put on muscle or lose fat a little easier than a lot of the other women and there always seems to be a guy or two or three chatting them up.

Contrast that with women who don't have it. They might lack ambition and they might prefer to let others make decisions for them. They might dress a little modestly, hoping to blend in rather than stand out. They might not understand all the fuss about sex and when they do give in (they rarely initiate), they usually don't experience much satisfaction. And when it comes to exercise, they find it difficult to lose fat or gain curvy muscle and they never seem to get the results they hope for.

The "it" I'm talking about is high, or at least normal, levels of testosterone. While testosterone replacement for men is big business, no one really pays much attention to the role testosterone plays in women, at least not in pre-menopausal or even young women.

Consider that more than a few studies report that the percentage of women between the ages of 18 and 59 who are suffering from "sexual dysfunction" is somewhere around 50%. This dysfunction is commonly diagnosed as underlying depression with quick referrals to counseling or psychotherapy, but more and more scientists and clinicians are starting to point the finger at female testosterone deficiency and perhaps rightly so, because it plays a huge role in the physiology, the psyche, and sexuality of women as well as men.

Hyenas, Ovaries, and Adrenals, Oh My!

One of the reasons that testosterone gets such short shrift in discussions about women's health is that women just don't manufacture much of it, but therein lies one of the reasons the whole issue is so misunderstood.

Sure, men typically make 8 to 10 times more testosterone than women every day, but that doesn't mean the average healthy man is 8 to 10 times more masculine than the average healthy woman, especially as evidenced by some of the men walking around Whole Foods nowadays. Nope, in women, testosterone is only a part of a complicated chemical profile that results in them being far more sensitive to its effects than men. As such, a little goes a long way.

Conversely, while women are considered to be "all estrogen," the testosterone levels in healthy women are 10 times greater than their estrogen levels. Obviously, the hormonal picture is a lot more complicated than it's given credit for.

About one quarter of a woman's testosterone production comes from her ovaries while another quarter is manufactured in her adrenal glands. The remaining half is produced in peripheral tissues from various chemical precursors produced in the ovaries and adrenals. The main precursor is androstenedione, which became a household word a few years back when a reporter espied a bottle in Mark McGwire's locker. A lot of this androstenedione is converted to estrone, a form of estrogen, but some of it can and is converted to testosterone.

If you need a real-life example of the power of these chemical precursors, consider the hyena, which is a matriarchal species where females run the show. Normally, female hyenas have perfectly reasonable levels of an enzyme that converts androstenedione into estrogen. However, during pregnancy, they experience a drop in this enzyme so that lots of androstenedione is instead converted into lots of Testosterone.

The resultant high levels of testosterone affect the pups in such a way that when females are born, they have masculinized external genitalia with penis-like clitorises and empty scrotal sacks that they could probably use to store coupons, spare change, and hyena makeup. The result is a female mammal that runs roughshod over the hapless hyena males.

Obviously, that doesn't happen in us human types, but nevertheless some conversion of androstenedione to testosterone does occur. All of this is important because they're all contributing factors in a woman's health. Without proper levels of testosterone (and accordingly, its precursors), women might suffer diminished energy levels and even a loss of sense of well being, regardless of age.

Low testosterone also plays a role in weight gain and the ability to put on muscle (just as it does in men), and it can also play a big role in libido. In fact, one of the surest signs of low female testosterone is HSDD, or hypoactive sexual desire disorder, which is characterized by "persistent or recurrent deficiency or absence of sexual thoughts and fantasies and/or desire for, or receptivity for, sexual activity causing personal distress or interpersonal difficulties."

One of the earliest studies that showed an association between female sexual desire and decreased testosterone was published in 1959, but acceptance was mighty slow. I guess it's not too surprising, though, since women weren't even scientifically proven to have orgasms until Masters and Johnson starting outfitting women's private parts with electrodes. Luckily, the association between testosterone and female sex drive is pretty well established now. Studies have shown, for instance, that a woman's testosterone levels rise during ovulation and there's a corresponding rise in frequency of intercourse during this time. While ovulating women might not always initiate sex, they're at least more receptive to sexual advances. Consider too that behavioral endocrinologists have noted that women who are ovulating often dress a little more hoochily, allegedly to attract sexual partners, but it's probably done on a subconscious level.

Unfortunately, there's not much data on what really constitutes "normal" female testosterone levels, but our current best guess is that a total plasma level of under 25 ng/dl in women under 50 years old is considered deficient. The trouble is, docs don't typically measure the testosterone level of females. In fact, historically, the only time doctors bothered to even think about female testosterone levels is when they suspected a scant few women of having levels that were too high, as perhaps evidenced by excess facial hair, loss of scalp hair, infertility, or acne.

Things are starting to change, though, and it's high time as the number of women with decreased libido (and, likely, many of the other symptoms of low testosterone) is now estimated to be between 10 and 15 million, and not all of them are in their forties or beyond; many in fact are in their 20's and 30's. If true, it certainly constitutes an epidemic of low testosterone, but what could have caused this epidemic?

Birth Control

The Irony of the Birth Control Pill

Back in 1950, a woman named Margaret Sanger teamed up with a wealthy, like-minded feminist named Katherine Dexter McCormick. Together, they conceived of and funded the development of the first birth control pill, Enovid. It was a breakthrough for women everywhere. It liberated them sexually, but paradoxically, perversely, pathetically, it also did a lot to kill the female libido and muted or nullified orgasms. While women were sexually free, they didn't take much advantage of that freedom. Sales of cats, yarn, and knitting needles increased dramatically.

A side effect of the birth control pill (and estrogen therapy, too) is that it decreases ovarian production of testosterone, along with causing a tenfold increase in a chemical named steroid hormone binding globulin (SHBG). What SHBG does is "bind up" much of the remaining testosterone, making it unavailable for use. The result is a moribund sex drive and the possible manifestation of some of the other symptoms of low T. What's even more worrisome is that the pill might have long-lasting effects on female libido. In a study of 125 young women participating in a sexual dysfunction clinic, women who had been off the pill for a year still had SHBG levels 7 times higher than non-users.

Roughly 11 million American women use the pill, but there are plenty of other drugs that affect testosterone levels, too. Tragically, doctors rarely if ever mention low testosterone as a possible side effect of these drugs, especially when given to women. These drugs include anti-depressants, particularly the selective serotonin uptake reinhibitors, or SSRIs, antihistamines, blood pressure medications, antibiotics, stomach and intestinal meds, and sleeping pills. (Recreational drugs and alcohol can also reduce T levels.)

Often, women taking these drugs report delayed or absent orgasms, but many are likely suffering from some of the other repercussions of low testosterone (lack of energy, weight gain, inability to gain muscle, etc.) that they might not readily associate with low levels of the hormone. But there are non-pharmaceutical causes of low T in women, too, some of which stem from a surprising source: diet.

Soy Milk and Vegetarian Diets

I don't know if it was the advertisers, the granola crunchers, or a mass conspiracy initiated by a cadre of evil yoga instructors that convinced women that drinking soy milk every day was healthy. The truth seems to be that there are chemicals in soy milk known as isoflavones that monkey with women's (and men's) hormones. While it seems a certainty that soy might have some beneficial effects on menopausal women in mimicking estrogen and thus relieving some of the symptoms of menopause, some research has shown that, like birth control pills, soy elevates levels of SHBG and negatively affects levels of testosterone in younger women.

Likewise, there's some evidence that vegetarian diets in general, whether they contain soy or not, also affect T levels. Many plants contain chemicals such as daidzein (found also in soy), enterolactone, and equol, which bind with hormone receptors, thus blocking testosterone (and estrogen, too) from binding to cell receptors. Some of this low T might also be a result of the zinc deficiencies seen in a lot of vegetarians as low levels of the mineral often correlate with low levels of the hormone.

While drugs and diet are clearly potential causes of low T in women, simply being obese or chronically avoiding exercise might also cause low levels. There are psychological and emotional correlates too, and simply failing to be in a caring relationship and/or suffering from a chronic lack of intimacy might be enough to tank T levels. And of course there are plenty of medical causes, some minor and some more severe, among them adrenal insufficiency, hypopituitarism, and premature ovarian failure.

How to Get Your Testosterone Mojo Back


The Pharmaceutical Approach

Admittedly, treating low T in women in their 20's or 30's medically is controversial, but given the importance the hormone plays in physical and mental well being and given the number of possible pharmaceutical, dietary, or lifestyle factors that might contribute to low T, it might be worth considering.

Perhaps surprisingly, the U.S. is way behind in the medical treatment of low T in women. Doctors in Australia and some European countries can prescribe creams, patches, or subcutaneous pellets, but there are no approved meds in the U.S. American doctors are limited to off-label testosterone preparations, spells, and incantations. (And yeah, I'm implying that we're a little primitive in this regard.)

Still, there are plenty of possible avenues for women in the U.S., some relatively orthodox and some highly unorthodox. Despite their legal limitations, doctors, primarily gynecologists, can write a prescription for women to get testosterone creams prepared specifically for them at a compounding pharmacy. The pharmacist simply prepares a personal transdermal testosterone cream that the patient can apply to her skin once a day.

More progressive docs can actually give testosterone injections, but there are drawbacks to this route. For one, there's the whole needle phobia thing, plus the patient has to go to the doctor's office for a shot every two to six weeks. Some women, too, metabolize the drug more quickly than others. That means while a shot every two to four weeks might work well for some women, others would find themselves dragging a bit, energy wise, before they were due for their next shot as levels dropped back prematurely into the low range.

Dosages are also a bit problematical in that there aren't really any set standards. Some docs might inject 75 to 100 mg. of testosterone cypionate every four to six weeks, but other women can do well on as little as 15 mg. every two weeks. It would require some diligent trial and error and flawless cooperation between patient and doctor to figure out just how much was needed.

While there aren't any approved testosterone cream products for women in the U.S., there are creams made for men and that, while definitely controversial, provides a possible course of action for women that have been diagnosed with low T. Androgel 1% is a colorless gel that contains 1% testosterone and men apply it to their shoulders, upper arms, or abdomen after a shower. The cream provides continuous delivery of testosterone for about 24 hours.

Now while I'm certainly not recommending this, it would be possible to use Androgel 1% to treat low T in women, as long as they used the 1% preparation (instead of stronger versions) and didn't exceed 2.5 grams of cream a week. Like men, they would rub the cream into the skin, preferably the abdomen, after showering and drying. Again, this would be something best decided after a conversation with a progressive doctor.

The Supplement Approach

Another possible course of action is taking a testosterone precursor in supplement form. While there are plenty of supplements that raise T levels in men, almost all of them work by coaxing the testes either directly or indirectly to produce more testosterone. No such known equivalent (coaxing the ovaries or adrenals to produce more testosterone) exists in women.

However, women have the option of using DHEA. The substance is a hormone secreted by the adrenals and it's a precursor to estrogen and testosterone. As with testosterone, levels of this hormone peak in the 20's and start to decline every decade. Using this over-the-counter supplement, however, can quickly elevate flagging testosterone levels. A 2002 study on women between 35 and 55 reported increases in desire, arousal, lubrication, and orgasm in women who took 50 mg. of DHEA per day.

Similarly, an article in a 2002 edition of the World Journal of Urology suggested that women with low T start with 50 mg. of DHEA every morning. If, in 2-3 months, there's no improvement (they recommended having T levels tested by a physician, of course), the dosage could be increased to 75 mg. or even a 100 mg. a day, if needed. DHEA is no low-T panacea, though. It may not raise levels significantly, or the bulk of the chemical may be converted to estrogen instead of testosterone.

The Lifestyle Approach

There are several relatively simple lifestyle changes a woman can make that might elevate T levels. Most obviously, if a woman believes her birth control pills are causing a problem and she feels she can adjust to a different type of birth control, she might stop using them (if indeed she's using them exclusively to prevent conception). She might also reevaluate her need for any of the various medications I mentioned, and perhaps seek alternatives that might not affect testosterone levels. For instance, there's some evidence that the antidepressant wellbutrin actually increases libido, but whether it helps the sex mojo through raising T levels or by some other mechanism isn't well understood.

Exercise, specifically weight training, is also reported to raise T levels in women and men. The results seem to be transient in that it only lasts a few hours, but even a transient rise in T, if repeated daily or near daily, might have far-reaching effects.

Sex itself is even reported to elevate T levels, but whether this rise is more pronounced in women who are in a caring relationship as opposed to those just tearing one off with a one-night stand isn't known. It is known, however, that women who are in a committed relationship often experience a rise in T, whereas, seemingly paradoxically, and perhaps evidence that nature is one smart but sometimes cruel bitch, T levels in men in committed relationships often drop precipitously (perhaps to make sure the male doesn't stray).

There are also somewhat less clear psychological approaches to raising T in women. Men often experience a rise in T after winning a competition of practically any kind. Similarly, if men are living stress-free lives and feel good about themselves, T levels rise accordingly. Hell, a man can win a ping-pong game and suddenly feel like having any woman near him scrubbed and brought to his victory tent for some celebratory sex.

Self-esteem seems to play a powerful role in T levels in women, too, and while there's not much research to support this, my experience as a writer on many aspects of behavioral endocrinology for the last 15 years leads me to believe that these things are true of women, too. Winning a competition would likely lead to an increase in T, however transient. In fact, anything done to reinforce the notion of being a "winner" might go a long way.

I even suspect, perhaps nuttily, that if a low-T woman simply dressed better, or even did something as seemingly inconsequential as wearing sexy underwear that would perhaps be seen by no one but the wearer, might have slight psychological effects that provoked positive physiological effects, i.e., a rise in testosterone.


Come Out of the Closet

Any way you look at it, despite its reputation in literature, folklore, and popular culture, testosterone is not strictly the purview of sweaty men for whom grunting has displaced several hundred vocabulary words. It plays a huge rule in women's health, psyche, and libido, just as it does in men. It's high time that testosterone came out of the female closet, put on some Louboutins, and strutted her stuff.

Questions and Answers About Female Testosterone Replacement

Q: If my testosterone levels are low, what specific benefits might I see from T replacement?

A: Generally, women who increase their testosterone might experience an increase in bone and muscle mass, loss of excess body fat, and an increase in sexual desire and sexual satisfaction, along with more energy, ambition, and enjoyment of life.

Q: Are there any dangers associated with taking prohormones or using testosterone?

A: If a female takes too much testosterone or its precursors, it can result in unwanted body hair growth and, in extreme circumstances (taking way too much testosterone over an extended period of time) result in a deepening of the voice, growth of the clitoris, acne, shrinking breast size, alopecia (loss of hair on the head), and unwarranted anger. It might also lead to other more serious side effects, as often happens when you poke Mother Nature with too big of a stick.

Studies on women who replace their testosterone to clinical levels, however, generally haven't experienced any adverse effects on lipid levels, carb metabolism, or blood pressure or cardiovascular health in general. Neither have there been any reported increases in breast cancer that were associated with T replacement.

Q: Can testosterone help women put on muscle and burn body fat?

A: Yes, women with low levels of testosterone often find it more difficult to put on muscle, burn fat, or succeed at athletics. Consider that female bodybuilders, figure athletes, and even bikini competitors often use varying degrees of steroids, which are nothing but synthetic versions of testosterone. Obviously, almost all female bodybuilders are using amounts that cause societally undesirable and generally irreversible physical changes like those mentioned above.

Q: Can taking testosterone impair fertility?

A: Only if T levels are raised well above normal for an extended period of time. However, T therapy might well affect the sex of a child. At least one study showed that women who are in occupations that typically correspond with high levels of testosterone - trial lawyers, for instance - have male children 58% of the time. Conversely, women in occupations with typically high estrogen levels and low testosterone levels, like beauty queens, usually have twice as many female babies as male babies.

Q: Are there any women who shouldn't consider testosterone replacement under any circumstances?

A: Women who are pregnant or could become pregnant should refrain from using testosterone replacement of any kind. Similarly, those with high cholesterol, liver or heart disease, or breast or uterine cancer should avoid it. Regardless, any woman considering testosterone replacement or therapy should consult her physician.