Does variability and decline in ovarian androgen production during perimenopause lower total and free testosterone before menopause?

The hormonal landscape of perimenopause is characterized by complex shifts in ovarian and adrenal activity. While it is true that ovarian androgen production becomes more variable as follicle counts diminish, the clinical outcome is not typically a reduction in systemic testosterone levels before menopause.

Hormonal and Mechanistic Findings

• Ovarian Variability: Theca cells in the ovary, which produce androgens, show highly variable activity during perimenopause. This is driven by fluctuating luteinizing hormone (LH) pulses and compensatory signals like TGF-β1 as the follicle pool depletes. However, this does not translate into a simple decline in circulating levels.
• Adrenal Compensation: Research, including longitudinal data from the Study of Women's Health Across the Nation (SWAN), shows that adrenal androgens like DHEA and DHEAS often reach a peak or show a "positive inflection" during the early perimenopausal years. This adrenal activity often compensates for any reduction in ovarian output.
• Testosterone Stability: Total testosterone levels generally remain stable throughout the transition from premenopause to perimenopause. Because estradiol levels drop significantly during this time, many women actually experience a state of relative androgen excess rather than a deficiency.
• Free Testosterone Dynamics: Free testosterone levels—the biologically active fraction—do not typically decline before menopause. In some cohorts, free testosterone has been shown to increase during the transition due to changes in sex hormone-binding globulin (SHBG) and the influence of rising insulin levels, which can stimulate androgen production.

Clinical Implications

While patients may experience symptoms often attributed to "low testosterone," such as changes in libido or body composition, these are frequently driven by the relative shift in the estrogen-to-testosterone ratio or the decline in estradiol, rather than a quantifiable drop in total or free testosterone.

Bottom line

The claim is unsupported regarding clinical outcomes. While ovarian androgen production becomes variable, total and free testosterone levels do not typically decline during the perimenopausal transition; instead, they remain stable or may slightly increase due to adrenal compensation and changes in binding proteins.