Target Free Testosterone Levels in Females on HRT: Not Routinely Monitored
There is no established target level for free testosterone in perimenopausal or postmenopausal women undergoing hormone replacement therapy, and testosterone monitoring is explicitly not recommended for guiding treatment decisions. 1, 2
Why Testosterone Levels Are Not Targeted in Standard HRT
The evidence-based guidelines are clear on this point:
Clinically available laboratory assays do not accurately detect testosterone concentrations at the values typically found in women, making measurement unreliable for clinical decision-making 2
No testosterone level has been clearly linked to a clinical syndrome of hypoandrogenism or testosterone insufficiency in women 2
Endogenous testosterone levels have not been clearly linked to sexual function in postmenopausal women 2
Standard HRT regimens (estrogen with or without progestin) do not include testosterone supplementation, so there is no target testosterone level to achieve 1
When Testosterone Therapy Is Considered (Separate from Standard HRT)
If a clinician is specifically considering testosterone therapy (which is distinct from standard estrogen-based HRT):
Laboratory testing of testosterone levels should be used only to monitor for supraphysiologic levels before and during therapy, not to diagnose testosterone insufficiency 2
The goal is to maintain testosterone levels within the normal physiologic range for women and avoid supraphysiologic dosing that increases adverse effects like hirsutism and acne 3, 2
Postmenopausal women with decreased sexual desire associated with personal distress and with no other identifiable cause may be candidates for testosterone therapy, but this requires ruling out physical, psychosocial factors, and medication effects first 2
Management Algorithm for HRT Without Testosterone Monitoring
For standard HRT management in perimenopausal/postmenopausal women:
No routine laboratory monitoring (including testosterone, estradiol, or FSH) is required - management is symptom-based 1
Use the lowest effective dose for the shortest duration necessary to control menopausal symptoms 1, 2
Annual clinical review focusing on symptom control and adverse effects is the recommended monitoring approach 1
Critical Pitfall to Avoid
Do not order testosterone levels to guide standard HRT dosing or to diagnose "androgen deficiency" in women considering routine menopausal hormone therapy - this practice lacks evidence support and the assays are unreliable at female physiologic ranges 2