Beyond libido: the multifaceted role of testosterone in women

INTRODUCTION: Testosterone physiology in women remains poorly understood despite more than 80 years of clinical knowledge. Longstanding gender biases and the misconception that testosterone is primarily a male hormone have contributed to its underrecognition in women. Testosterone is, however, the most abundant biologically active sex steroid in women and plays important roles across multiple physiological systems throughout the lifespan. METHODS: A comprehensive literature search was conducted in PubMed and Scopus for studies published from January 1974 to December 2025. Three authors independently screened articles using predefined inclusion and exclusion criteria. This narrative review included experimental, observational, and clinical studies evaluating endogenous testosterone production, regulation, and physiological functions in women, with emphasis on musculoskeletal, metabolic, cardiovascular, neurological, reproductive, genitourinary, and sexual health. RESULTS: Endogenous testosterone in women arises from ovarian, adrenal, neural, and peripheral conversion pathways and persists after menopause. Physiologic testosterone levels contribute to bone maintenance, muscle mass, metabolic homeostasis, endothelial function, cognition, mood regulation, sexual function, and reproductive physiology. Testosterone concentrations vary with age, reproductive status, hormonal milieu, and other physiologic factors, complicating the interpretation of circulating levels and their relationship with clinical outcomes. Emerging evidence also suggests potential roles in neuroprotection, immune modulation, pelvic floor integrity, and fertility, although the strength of evidence varies across physiologic domains. DISCUSSION: Testosterone is an important yet underrecognized component of female physiology, with effects extending beyond sexual function. A broader understanding of endogenous androgen physiology provides important context for female sexual and reproductive health and highlights the interconnected nature of androgen signaling across physiologic systems. Further research is needed to better characterize testosterone physiology in women, standardize its assessment, and clarify the clinical significance of alterations in endogenous androgen levels.