Do Not Diagnose Androgen Deficiency or Treat with Testosterone
The Endocrine Society explicitly recommends against making a diagnosis of androgen deficiency in women at this time, and against the use of testosterone therapy in women, because there is neither a well-defined clinical syndrome nor validated normative data for testosterone levels across women's lifespans 1.
Why These Lab Values Are Problematic
Your patient's low free testosterone (0.39 pg/mL) and bioavailable testosterone (8.7 ng/dL) appear abnormal when compared to reference ranges from research studies. However, these findings must be interpreted with extreme caution:
Assay Limitations Are Critical
- Most testosterone assays lack the sensitivity and specificity needed to accurately measure the very low concentrations found in women 1. The Endocrine Society specifically calls for development of better assays before any clinical diagnosis can be made 1.
- Free testosterone represents only 1-3% of total testosterone in women, making measurement technically challenging and prone to error 1.
- Calculated free testosterone (derived from total testosterone and SHBG) may be more reliable than direct measurement 2, 3, but even these require accurate total testosterone measurement by mass spectrometry, not standard immunoassays 4.
Normal Total Testosterone and SHBG Argue Against True Deficiency
- When total testosterone and SHBG are normal, as in your patient, the calculated free testosterone should theoretically be normal 5.
- The discrepancy between your patient's normal total testosterone/SHBG and low free/bioavailable testosterone likely reflects assay inaccuracy rather than true pathology 4.
What to Do Instead
1. Evaluate for Specific Underlying Conditions
Look for conditions that cause clear-cut androgen deficiency 6:
- Hypopituitarism (but FSH/LH are normal here)
- Primary adrenal insufficiency (check morning cortisol, ACTH stimulation test if indicated)
- Bilateral oophorectomy (surgical menopause)
- Medications: oral contraceptives, oral estrogens, glucocorticoids 6
2. Address Symptoms Directly
If the patient has symptoms (fatigue, low libido, decreased well-being):
- Evaluate for depression, thyroid dysfunction, anemia, sleep disorders, relationship issues
- These are far more common causes of these non-specific symptoms than androgen deficiency
- The symptoms attributed to "androgen deficiency" are non-specific and overlap with numerous other conditions 1, 6
3. If You Must Retest Testosterone
- Use liquid chromatography-tandem mass spectrometry (LC-MS/MS) for total testosterone measurement 3, 4
- Measure during the follicular phase of the menstrual cycle 7, 4
- Obtain fasting morning sample 4
- Calculate free testosterone from total testosterone and SHBG rather than measuring directly 2, 3
Critical Pitfalls to Avoid
Do not prescribe testosterone based on these lab values alone. The evidence shows:
- No data on safety beyond 24 weeks of testosterone use in women 1
- No validated diagnostic criteria for "female androgen deficiency syndrome" 1
- Compounding pharmacies and over-the-counter testosterone products lack quality assurance 1
- Even in surgically menopausal women (the only population with short-term efficacy data), long-term safety is unknown 1
The Bottom Line for This Patient
With normal total testosterone, normal SHBG, and normal gonadotropins, this 44-year-old woman does not have a recognized androgen deficiency disorder. The low free and bioavailable testosterone values most likely represent assay limitations rather than true pathology. Focus your evaluation on other causes of her symptoms and avoid testosterone therapy, which lacks both validated indications and long-term safety data in women 1.