A Functional Medicine Approach to Low Female Testosterone

Testosterone is not just a hormone for men. Optimized levels are essential for a sense of well-being, and energy, maintaining muscle mass, preventing body fat storage, reproductive function, and libido in both sexes. In women, testosterone is secreted by both the ovaries and the adrenal glands.

A functional medicine approach to low female testosterone allows treatment of the underlying causes instead of managing or masking the symptoms. This article will discuss low testosterone in females and its possible causes, review some functional medicine labs that can be useful, and explore treatment options.

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Low Female Testosterone Signs & Symptoms

Low testosterone levels are associated with persistent unexplained fatigue, a decreased sense of personal wellbeing, and low libido in women. Additional symptoms include muscle weakness, depressed mood, and weight gain. Additionally, low levels have been linked to the following:

• Bone loss
• Muscle wasting
• Obesity
• Depression
• Heart disease
• breast cancer

Low Female Testosterone Possible Causes

The following are possible causes of low testosterone in women:

Age

In women, androgen levels decline by 50% from the early 20s to the mid-40s. Age-related androgen insufficiency commonly occurs in women in their late 30s and 40s and post-menopausally.

Ovary Removal

In healthy women, the primary hormones produced by the ovaries are estrogens and progesterone, but they also produce testosterone both before and after menopause. When women require bilateral oophorectomy (removal of ovaries), their serum testosterone levels will drop significantly.

Medications

Birth Control Pills

Approximately one out of four sexually active women in the United States uses some form of hormonal contraceptive method. Birth control pills lower testosterone due to raising sex hormone binding globulin  (SHBG), a protein that binds to sex hormones in the body and controls the amount in circulation. A systematic literature review of 42 studies demonstrates that oral contraceptives decrease circulating levels of total T and free T and increase SHBG concentrations.

Statins

In a meta-analysis of 29 studies, statins in their cholesterol-lowering function were shown to lower testosterone levels in both men and women.

Other Meds

Additionally, medications such as ketoconazole have been demonstrated to lower testosterone levels.

High Sugar Diet

Processed sugar can turn off genes responsible for regulating testosterone and estrogen in men and women, leading to imbalances in these essential sex hormones.  

How does this happen? When we overconsume processed sugar in the diet, the liver is forced to convert it into lipids. Increased lipid production reduces the amount of SHBG (sex hormone-binding globulin) protein in the blood.

SHBG plays a crucial role in controlling the amount of testosterone and estrogen available throughout the body. Therefore high levels of sugar equal lower levels of SHBG. Lower levels of SHBG equate to dysregulation of estrogen and testosterone.

Endocrine Disruptors Chemicals (EDC)

EDCs are chemicals that can disrupt the endocrine homeostasis of the human body. These chemicals negatively influence steroid hormone synthesis by interfering with natural hormone production. Moreover, EDCs, especially in pesticides, can reduce the concentration of hormones by affecting their synthesis, transport, metabolism, and elimination.

Chronic Stress

A study done by The University of Texas at Austin shows that cortisol and testosterone work against each other to regulate dominant and competitive behaviors. This means when cortisol is high, testosterone drops.

Low Vitamin D

Vitamin D deficiency is very common in women of reproductive age. Several studies have linked lower vitamin D levels with sex steroid synthesis. In these studies, total and free 25(OH)D were inversely correlated with total testosterone and positively correlated with SHBG in reproductive-age women.

Functional Medicine Labs to Test for Low Female Testosterone

Testosterone

Serum Testosterone, both total and free to get an idea of what's going on with androgens, should be tested. While testosterone levels can be measured on any day of the month, the timing of the test is the most important. Testosterone is best done in the morning because that is when levels are highest.

Sex Hormone Binding Globulin (SHBG)

SHBG is a protein primarily produced in the liver that binds to sex hormones testosterone and estrogen throughout the body and controls the amount in circulation. If SHBG levels are high, fewer sex hormones are available.

DHEAS

Dehydroepiandrosterone sulfate (DHEA-S) is produced by the adrenals to balance cortisol levels and converts into testosterone if levels are low.

Estradiol

Testosterone’s action in target tissues can be mediated through the androgen receptor or the estrogen receptor after aromatization to estradiol. Serum Estradiol can be used to evaluate women with symptoms of estradiol excess, which has a myriad of symptoms but may also manifest as decreased libido or increased body fat.

Adrenal/Sex Hormone Testing

The DUTCH Complete™ uses dried urine samples to evaluate sex hormones, adrenal hormones, cortisol, and melatonin, which are incredibly useful when evaluating energy patterns. The test allows for the examination of testosterone metabolism.

Note: There is a very common genetic variant in Asian women that disallows most testosterone from being converted into the water-soluble form found in urine. This variant metabolism has no known clinical impact (it is neither good nor bad but simply makes urine testosterone falsely lower than it would otherwise be.) If this genetic variant is present, it would be better to test testosterone in blood serum(ideally total and free testosterone).

Gut Microbiome

A well-functioning gut is essential for overall health and to keep hormones balanced. The link between gut health and estrogen demonstrates that one of the principal regulators of circulating estrogens in the gut microbiome. Similarly, the connection between testosterone and the gut microbiome has also been made in identifying a bacteria with the potential to produce androgens.

Vitamin D

Vitamin D levels are associated with sex hormones, and Vitamin D is linked to several health concerns, including osteoporosis, heart disease, cancer, and impaired immune function.

Functional Medicine Treatment for Low Female Testosterone

Hormone Therapy

Although evidence supports the efficacy of topical testosterone in improving libido, well-being, and mood, several roadblocks have prevented the FDA approval of a testosterone formulation for women.

Inclusion of testosterone in hormone replacement therapy is becoming more widespread, but many physicians are improvising by prescribing either compounded testosterone or modified doses of approved male testosterone formulations.

Short-term clinical trials suggest that low-dose testosterone therapy in women appears to be effective, safe, and economical. Long-term side effects include hirsutism, acne, and weight gain.  

DHEA

DHEA is available as an over-the-counter supplement in the United States. It is used to boost testosterone levels with the idea that if the precursor hormone is provided, it will allow the body to convert it to testosterone. However, it’s important to discuss all the pros and cons with your provider and develop a comprehensive plan that suits your needs.

Exercise

While controversy exists regarding testosterone hormone therapy, lifestyle interventions such as exercise and nutrition can improve testosterone levels. Research indicates that exercise affects women’s hormonal health differently compared to men. One study noted that endurance and resistance exercise increases testosterone, estradiol, and growth hormone compared to a control group.

It’s important to note that when it comes to exercise for women, moderation is key—frequent or prolonged intense exercise can cause hormonal disruptions that may impact a woman’s menstrual cycle.

Balanced Diet

Estrogen, progesterone, and testosterone are all made from dietary cholesterol, a dietary fat. If you don’t absorb fat well or eat enough healthy fat in your diet, making the proper amount of hormones may be difficult.

Zinc

A 2021 study aimed to investigate the effect of zinc supplementation on testosterone levels and sexual function in postmenopausal women. Zinc supplementation in the intervention group resulted in a significant increase in testosterone levels compared to the control group.

Vitamin D

A 2021 study demonstrates the importance of vitamin D metabolites related to hormonal regulation in postmenopausal women.

Summary

Management of low female testosterone is complex and lends itself to a functional medicine approach. Because the symptoms of a testosterone deficiency could resemble those of depression, chronic fatigue, or fibromyalgia, misdiagnosis and lack of treatment are very common.  

Improved awareness of the symptoms, conclusive reference ranges for diagnosis, and appropriate available treatments are needed.