Is low testosterone in midlife women linked to reduced sexual desire and lower energy?

An assessment of the association between low testosterone in midlife women, sexual desire, and general well-being shows that these relationships differ significantly in their clinical validation and therapeutic evidence.

Clinical and therapeutic evidence

• Sexual desire: Strong clinical evidence links testosterone to female sexual desire. While absolute serum testosterone levels do not linearly correlate with sexual function or reliably distinguish women with and without hypoactive sexual desire disorder (HSDD), physiological-dose transdermal testosterone therapy is highly effective. In postmenopausal women, it significantly improves sexual desire, arousal, and orgasm frequency, and reduces associated personal distress.
• Well-being and energy: Randomized controlled trials (RCTs) show no consistent, clinical-grade benefit of testosterone replacement for general fatigue, mood, or cognitive function. However, a subjective association remains plausible. In a 2024 retrospective cohort study of women receiving biomarker-guided testosterone therapy, 84.3% reported improvements in energy and fatigue, and other clinic-based studies note subjective improvements in mood and vitality.

Mechanistic explanations

• Androgen receptor signaling: Testosterone acts as a direct agonist on androgen receptors within central nervous system pathways that govern motivation, reward, and sexual desire. Decreased androgen receptor activation is a key pathway leading to reduced sexual desire.
• Metabolic and physical function: Androgens influence female metabolic health and muscle maintenance. A U-shaped relationship has been observed between free testosterone and physical frailty, indicating that very low levels may negatively impact cellular energy production, mitochondrial function, or erythropoiesis, potentially contributing to fatigue.

Clinical implications

• Because absolute hormone levels do not correlate linearly with symptoms, low sexual desire or energy cannot be diagnosed by blood tests alone. Testosterone levels should primarily be used as a baseline safety check prior to therapy rather than a diagnostic tool.
• Current global consensus guidelines support transdermal testosterone therapy solely for postmenopausal HSDD, not for treating general fatigue, low mood, or cognitive symptoms.

Bottom line

Low testosterone is firmly associated with reduced sexual desire in midlife women, supported by robust clinical trials showing that transdermal testosterone therapy effectively treats HSDD. However, an association with low energy or reduced well-being is only plausible; it is observed in clinical practice but is not consistently supported by randomized controlled trials.