Testosterone Testing in Females
Obtaining testosterone levels in women in non-research settings is not recommended according to current clinical guidelines. 1
Primary Guideline Recommendation
The Infectious Diseases Society of America provides a strong recommendation (though based on low quality evidence) that testosterone level testing should not be performed in women outside of research contexts. 1 This represents the most direct clinical guidance available on routine testosterone screening in females.
Specific Clinical Scenarios Where Testing May Be Considered
Despite the general recommendation against routine testing, there are limited circumstances where testosterone measurement may have clinical utility:
Menopausal Women with Osteoporosis
- Serum testosterone may be measured as part of additional hormonal assessment in menopausal women with osteoporosis, particularly when other signs of hormonal imbalance are present. 2
- Free testosterone provides a better index of gonadal status than total testosterone in this population. 2
- When measuring total testosterone, it should be expressed as a ratio of SHBG to total testosterone, with a ratio <0.3 indicating hypogonadism. 2
Suspected Hyperandrogenic States
- Very high testosterone levels (>2-3 standard deviations above normal reference) typically present with virilization signs, menstrual irregularities, and rapid onset of symptoms requiring prompt investigation. 3
- These cases warrant evaluation for conditions such as ovarian steroid-cell tumors or polycystic ovary syndrome. 3
- Laboratory interference should be suspected when very elevated testosterone levels occur without corresponding clinical manifestations. 3
Important Clinical Caveats
Reference Ranges and Interpretation
- Normal reference ranges for premenopausal women (age 30) are: total testosterone 15-46 ng/dL, free testosterone 1.2-6.4 pg/mL, and bioavailable testosterone 1.12-7.62 ng/dL. 4
- Testosterone levels decline with age in women, decreasing to approximately 50% of peak levels by menopause. 5
- Substantial interindividual variability exists, making diagnostic interpretation challenging. 5
Menstrual Cycle Considerations
- Testosterone exhibits relatively small variations across the menstrual cycle compared to overall variability, so timing of sample collection is less critical than in males. 4
- Even in healthy women, menstrual irregularities correlate with higher circulating androgen levels. 6
Common Pitfalls to Avoid
- Do not routinely order testosterone testing for non-specific symptoms such as fatigue, low libido, or mood changes in women, as this contradicts guideline recommendations. 1
- Be aware of laboratory interference when results don't match clinical presentation; diethyl ether extraction can help identify assay interference. 3
- Recognize that oral contraceptives and hormone replacement therapy cause declines in androgens due to increased SHBG, which may confound interpretation. 5