Beyond the lab value: Who is a candidate for testosterone?

Maria Uloko, MD, opens this episode by asking Bruce Dorr, MD, FACOG, URPS, FMCP-M, how he determines, in daily practice, whether testosterone therapy is appropriate for a woman presenting with low desire, fatigue, or a loss of well-being she attributes to low testosterone, and how symptoms, clinical context, and lab values each factor into that decision.

Dorr describes a patient-first approach rather than a lab-first one: Many patients arrive already holding a folder of labs or requesting them, but he evaluates the person in front of him, not a testosterone number. Low desire, he stresses, does not automatically equal testosterone deficiency, so he considers relationship dynamics, concurrent medications, pain, and genitourinary symptoms of menopause before attributing symptoms to hormones.

Labs establish a baseline and a safety boundary for a controlled substance, Dorr explains, but he avoids arbitrary numeric targets in favor of clinical response, and is careful not to over-treat patients toward masculinizing effects they do not want. Dorr notes that although the strongest evidence sits with postmenopausal women with hypoactive sexual desire disorder, his practice regularly includes premenopausal patients and women who have lost ovarian function through surgery, tumors, endometriosis, or premature ovarian insufficiency, where the biologic rationale is compelling but the evidence is thinner.

Uloko responds by reframing the clinical question away from chronological age and toward hormone state. Hard menopausal age cut-offs, she argues, obscure patients, including those on anti-testosterone medications or with ovarian insufficiency in their twenties, whose hormone levels functionally mirror a postmenopausal state regardless of age. She draws a parallel to testosterone therapy in men, where no age cut-off governs treatment decisions. Dorr agrees, adding that perimenopause can begin roughly a decade before cycles stop, reinforcing the case for evaluating clinical presentation over lab thresholds alone.

In the next episode, Uloko and Dorr discuss why testosterone prescribing for women remains so inconsistent across the US, setting up a candid look at dosing, cost, and monitoring in a market with no FDA-approved product.