Recent research published in journals Fertility and infertility Studies suggest that checking testosterone levels with a blood test is not an effective way to diagnose low libido or other sexual difficulties in middle-aged women. Scientists found subtle connections between certain hormones and physical experiences such as arousal and orgasm, but these hormones were not related to sexual desire itself. The results of this study provide evidence that measuring testosterone and its chemical components should not be a standard part of the evaluation of women seeking medical help for sexual concerns.
For more than 80 years, medical professionals have prescribed testosterone to treat low libido in postmenopausal women. Because of this established medical practice, it is commonly believed that decreased blood testosterone levels may be the underlying physiological cause of sexual difficulties in midlife women. Some health care providers suggest that testing the blood levels of this hormone may help pinpoint those who would benefit most from testosterone therapy.
Susan R. Davis, Vice-Chancellor’s Distinguished Professor and Director of the Women’s Health Research Program at Monash University, wanted to investigate these assumptions. “There are many hypotheses and beliefs about hormones and sexual function, particularly testosterone and sexual function, and we wanted to establish the relationship between hormones and sexual function in women as a basis for future research and clinical decision-making,” Davis said. Davis is also Director of the Women’s Endocrinology Clinic at Melbourne’s Alfred Hospital.
Previous studies on how sex hormones relate to female sexual function have faced several technical and methodological limitations. Early studies often used traditional testing methods that struggled to accurately measure the naturally low testosterone levels found in women. These older tests, known as immunoassays, tend to lack the precision needed to pick up small changes in female hormone levels.
Previous research has also sometimes failed to account for women’s unique stages of menopause, a biological detail that has a huge impact on sexual health. The transition to menopause involves major changes in ovarian function and hormone production. Not dividing women into premenopausal and postmenopausal groups can make it difficult to understand how different hormones affect the body at different stages of life.
To address these gaps, the authors of the new study utilized a high-precision testing method called liquid chromatography with tandem mass spectrometry. This advanced technology separates and identifies molecules based on their weight and chemical properties, allowing for accurate measurements of testosterone even at very low concentrations. Scientists can also measure testosterone and its chemical precursors from a single blood sample.
By combining this advanced testing technique with comprehensive behavioral research, the research team aimed to determine whether blood levels of these hormones actually correspond to women’s sexual experience. Specifically, they wanted to see if testosterone was associated with desire, arousal, orgasm, or overall sexual response. They also wanted to know whether women who reported severe sexual difficulties had significantly lower hormone levels than women who did not have such difficulties.
The researchers analyzed data from a wide-ranging project known as the Australian Women’s Midlife Study. This cross-sectional project recruited participants matched in age and geographical location to the general Australian population. For this particular analysis, the team included 731 participants between the ages of 40 and 69.
The sample was precisely divided based on reproductive stage and consisted of 136 premenopausal women with a median age of 45 years and 595 perimenopausal or postmenopausal women with a median age of 61 years. Premenopausal women were defined as women with regular menstrual cycles. The perimenopausal and postmenopausal groups included those experiencing irregular cycles or those whose menstruation had stopped completely.
To measure sexual function, participants completed a detailed 37-item questionnaire designed to include sexual orientation and partner status. The study asked women to recall their sexual experiences over the past 30 days. Your answers generate specific numerical scores for desire, arousal, orgasm, and sexual responsiveness, with higher scores indicating better overall sexual function.
The team took extensive steps to ensure that other medical and lifestyle factors did not skew the results. They excluded people who were pregnant, breastfeeding, using hormone therapy, or taking drugs that altered hormone levels. Additionally, participants with thyroid dysfunction or abnormal prolactin levels were excluded, as these conditions may independently cause hormonal and sexual disorders.
Additionally, the researchers excluded women who had moderate to severe depression or who were taking psychiatric medications. Depression is strongly associated with sexual difficulties, independent of natural hormone levels. By excluding these participants, the scientists aimed to isolate the direct relationship between naturally occurring sex hormones and sexual function.
Eligible participants visited a local clinic and provided a blood sample for clinical testing. The lab used advanced mass spectrometry techniques to measure serum levels of testosterone, along with two precursor hormones known as dehydroepiandrosterone and androstenedione. Precursor hormones are raw materials produced by the adrenal glands and ovaries that the body uses to manufacture other active hormones, such as testosterone and estrogen.
The data revealed that many women who participated in the study experienced sexual difficulties. The overall prevalence of low libido was approximately 24 percent, and 19 percent reported difficulty with arousal. About 10 percent of participants reported difficulty reaching orgasm, and nearly 8 percent struggled with their overall sexual response.
When examining hormone levels, the researchers found that none of the hormones measured were associated with sexual desire. After controlling for variables such as age, BMI, relationship status, and past trauma, testosterone levels did not predict whether women experienced a lack of sexual interest. This lack of association was consistent across all menopausal periods.
“There was no relationship between the hormones we measured and sexual desire or libido,” Davis said. “We found a ‘sign’ that women who reported lower orgasms tended to have slightly lower blood levels of testosterone than other women as a group. but There was a large overlap in testosterone levels between women with and without orgasms, so blood levels were not helpful in differentiating symptoms in individual women. ”
The data revealed complex, nonlinear associations between some hormones and other physical aspects of sexual function. In premenopausal women, testosterone levels showed a subtle S-shaped relationship with orgasmic ability. This means that orgasm scores don’t simply increase because testosterone increases. Instead, the relationship fluctuated at specific hormonal change points.
For women in the perimenopausal and postmenopausal groups, androstenedione levels were associated with both arousal and orgasm scores. Similar to the premenopausal group, these relationships were nonlinear. Although these statistical associations existed, the researchers noted that hormones only explained a small portion of the overall variation in women’s sexual function scores.
Researchers looked specifically at women who reported severe sexual difficulties and noticed some differences in their hormonal profiles. Perimenopausal and postmenopausal women who specifically had trouble reaching orgasm tended to have slightly lower median levels of testosterone, dehydroepiandrosterone, and androstenedione compared to women without this difficulty. A similar pattern emerged for women reporting persistent problems with sexual response.
Because health care providers sometimes use testosterone therapy to treat low sexual desire, people may misinterpret these findings to mean that testosterone plays no role at all in women’s sexual health. However, the authors point out that circulating blood concentrations are only a proxy for the hormone concentrations actually present in the body’s tissues. Although the body produces testosterone locally in tissues such as the brain, vagina, and fat, testosterone has direct effects that are not fully reflected in standard blood draws.
Standard blood tests only capture what’s floating around in the bloodstream, missing local hormonal activity that influences sexual response. Doctors cannot determine whether a woman has a functional hormone deficiency in her brain or pelvic tissues just by looking at the test results. This disconnect explains why doctors cannot rely on blood tests to guide treatment plans, even if patients ultimately respond well to hormone therapy.
“Hormonal testing is therefore not helpful in assessing hypogonadism or in treating hypogonadism,” Davis explained. Prescribing additional testosterone may increase hormone levels in certain tissues and increase desire in some women, but baseline blood tests cannot predict who will benefit from the treatment.
This study has several limitations that provide context for the results. This study was cross-sectional, meaning that only one snapshot in time was taken. This study design does not allow scientists to determine cause and effect because it does not allow them to track over several years whether a decline in hormones directly causes a decline in sexual function.
Additionally, the researchers did not standardize blood collection times and relied on one blood sample for each participant. In premenopausal women, blood samples were not timed to specific stages of the menstrual cycle. Historical data have shown that median hormone levels change only slightly across the menstrual cycle, but the lack of precise timing may have resulted in minor measurement errors.
Additionally, the team was unable to capture all the psychosocial factors that may influence sexual health. “While we considered many variables in our analysis, we did not take into account the length of the relationship or the inconsistencies in the relationship,” Davis said.
Future studies may include collecting multiple blood samples over time to see whether fluctuations in hormone levels correspond to long-term changes in women’s sexual function. Rather than simply measuring what’s circulating in the bloodstream, scientists may also be able to take a closer look at how precursor hormones are directly converted into active hormones within specific body tissues.
The researchers also plan to investigate whether prescribing hormones has a therapeutic effect even when baseline blood tests are not diagnostic. “We are recruiting premenopausal and perimenopausal women with decreased sex drive into a study to see whether testosterone improves sex drive in these women,” Davis added.
The lack of a clear link between blood testosterone and sex drive highlights that sex drive is highly dependent on a complex combination of psychosocial and biological factors that cannot be captured by a simple blood test. Current evidence suggests that measuring these hormones is not a reliable diagnostic tool for clinicians, and physicians should investigate broader psychological and relational factors when treating midlife women. You can follow Davis and her ongoing research on Instagram (professorsusandavis).
The study, “Testosterone, preandrogens, and sexual function: Results from the Australian Women’s Midlife Study,” was authored by Yuanyuan Wang, Rakibul M. Islam, Alice Hodge, David J. Handelsman, Md Nazmul Karim, Molly Bond, and Susan R. Davis.
