Testosterone (total and free), women

Pick Ordered or Not ordered to see the note.

Indicated when

• —Evaluating hirsutism, to test for elevated androgen levels in women with an abnormal hirsutism score [1]
• —Suspected androgen excess or PCOS, as part of a broader clinical and laboratory work-up (link: pcos)

Not indicated when

• —Diagnosing 'low testosterone' or a female androgen deficiency syndrome in a woman with low libido, fatigue, or low mood: no such syndrome has a validated blood-level threshold [2]
• —Guiding or monitoring the dose of testosterone therapy by targeting a specific blood level: direct assays are unreliable at the concentrations found in women [2]
• —General fatigue or low-libido screening without a formal assessment for hypoactive sexual desire disorder (HSDD)

Why not

Standard direct immunoassays for total and free testosterone were designed and calibrated for the much higher concentrations found in men, and the Global Consensus Position Statement states plainly that these direct assays 'are highly unreliable in the female range' [2]. There is also no validated reference range that defines a female testosterone 'deficiency': the only evidence-based indication for testosterone therapy in women is HSDD, which is a clinical diagnosis, not a lab diagnosis. Ordering the test to explain fatigue or low libido risks an unreliable number driving a treatment decision that guidelines say should rest on clinical assessment instead.

Better first step

For hirsutism or suspected androgen excess, testing is appropriate [1]. For low libido, use a structured clinical or sexual-history assessment for HSDD (e.g., ISSWSH or ICD-11 criteria) rather than a blood test; a testosterone level does not confirm or exclude HSDD and is not required to start or monitor treatment.

Typical ND rationale

An ND may order testosterone in a woman reporting low libido, fatigue, or difficulty losing weight, or with acne and unwanted hair growth, reasoning that a low or high number will explain the symptom and guide treatment, in the same way it might in a man.

Ontario coverage & CONO orderability

OHIP status

insured

Testosterone (L340) and testosterone, free (L608) are listed by name in the 2026 Schedule of Benefits for Laboratory Services, with no sex-specific restriction and no restricting condition noted, so both are insured when a physician orders them after clinically assessing the patient (Reg. 552 s.22). ND-ordered testing is patient-paid regardless [7].

CONO orderable

Yes — CONO list #115, #116, #182, #183

CONO list items 115 (Testosterone, blood), 116 (Testosterone free, blood), 182 (Testosterone, saliva) and 183 (Testosterone free, saliva).

Linked conditions

• pcos ↗
• menopause ↗

Counselling script

“If you have signs of extra androgen, like new hair growth or acne, testing testosterone makes sense and I'm glad to order it. For low sex drive on its own, the standard blood test for testosterone isn't accurate at the levels found in women, and there's no lab number that defines a deficiency in women. Let's assess it properly instead, with a few questions about how this is affecting you, since that guides treatment better than a level would.”

Revisit if

• —New or worsening hirsutism, acne, or menstrual irregularity develops
• —A structured HSDD assessment suggests a trial of therapy is being considered

References

1. [1]Endocrine Society (2018). Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline. linkSuggest testing for elevated androgen levels in all women with an abnormal hirsutism score
2. [2]International Menopause Society / Endocrine Society and other societies (2019). Global Consensus Position Statement on the Use of Testosterone Therapy for Women. linkDirect assays for total and free testosterone are highly unreliable in the female range; the only evidence-based indication for testosterone therapy in women is HSDD
3. [3]Endocrine Society (2014). Androgen Therapy in Women: A Reappraisal: An Endocrine Society Clinical Practice Guideline. linkolder guidelineEndocrine Society guidance on androgen therapy in women, including caution around unvalidated indications
4. [4]Ontario Ministry of Health (2026). Schedule of Benefits for Laboratory Services (effective April 1, 2026) — L340 Testosterone. linkTestosterone (L340) listed in the 2026 OHIP Schedule of Benefits for Laboratory Services
5. [5]Ontario Ministry of Health (2026). Schedule of Benefits for Laboratory Services (effective April 1, 2026) — L608 Testosterone, free. linkTestosterone, free (L608) listed in the 2026 Schedule
6. [6]Government of Ontario (e-Laws) (2026). Health Insurance Act, R.R.O. 1990, Reg. 552: General, s. 22 (insured laboratory services). linkA lab test is insured only when ordered by a physician, midwife, or NP who has clinically assessed the patient
7. [7]Ontario Ministry of Health (2026). Ontario Health Insurance Plan: Schedule of Benefits for Laboratory Services (effective April 1, 2026). linkTests ordered by anyone other than an authorized provider, including NDs, are not insured services