In the minds of most healthcare practitioners and consumers, the term “hormone therapy” refers only to estrogen and perhaps progesterone. The important hormones testosterone (“T”) and DHEA appear to be forgotten.
Of course, we are aware of the necessity for adequate levels of T in men. Men with low testosterone suffer a plethora of difficulties, from osteoporosis to erectile dysfunction and fatigue and depression to an increase in metabolic syndrome and cardiovascular disease. So, why should things be different for women?
Truth is, it’s not.
Just as in men, T levels in women decline with age, although certainly not the dive that estrogen levels take after the menopause transition. As in men, however, some women’s T diminishes to a far greater extent than others. This is especially true for surgical or chemotherapy-induced menopause, where all at once a woman can lose 30-50% of her T. The postmenopausal ovary is an ongoing site of androgen production, even though the production of estradiol ceases. This appears to be a fact ignored or forgotten by the vast majority of gynecologists and other providers of healthcare for women.
Although produced in amounts far reduced in women compared with men (~ 1/10th or less than male levels,) testosterone is a female hormone as well, and interacts both in sexual response (especially desire), energy, and feelings of wellbeing. There appears to be an optimal range of T for cardiovascular health in women, with an increased risk of coronary events at both upper and lower levels of bioavailable T. According to all available research, testosterone treatment in women at doses used for treating diminished sexual desire does not adversely affect the cardiovascular safety profile, nor does it lead to an increased frequency of stroke or cardiovascular events. Neither does T, in evidence-cased research studies, show any increased risk of mammary growth or breast cancer.
So, why do most clinicians other than sexual medicine practitioners and menopause specialists forget the T when working with menopausal hormone supplementation and replacement?
There are several reasons:
Primarily, most practitioners simply don’t think of it; testosterone production, supplementation, and replacement are not taught in most training programs.
Another significant factor is that there is presently no packaged, commercial T product for women that is available on the market, so practitioners savvy enough to recognize and test for T deficiency do not have a recognized, easily available appropriately dosed product, and must rely instead on approximation of women’s dosage utilizing a male product, or must be trained and skilled in the art of compounding to find the proper dosage. This may further complicate the issue and lead to under treatment, as the usual test ordered by clinicians for men, a “total testosterone” is worthless in women. Instead, it is imperative to also measure levels of both serum albumin and sex hormone binding globulin (“SHBG”), both of which bind with the T molecule and remove it from circulation. This will accurately determine the levels of free and bioavailable testosterone truly available to the individual.
Following are instances where you may have to lobby your own GYN or PCP to check for, and if appropriate administer, supplementary T therapy:
- Surgical removal of your ovaries will always significantly lower T. If your ovaries are removed or rendered inoperative by cancer chemotherapy, you should demand replacement supplementation from your practitioner, who most times will not remember without a gentle prod.
- At time of menopause, especially if your libido has taken a dive, and does not return to near baseline after HT has taken hold.
- Instances of diminished sexual desire – understanding that in most instances diminished sexual response is secondary to multiple factors including diminished estrogen, aging, and changed body image. Certainly, the largest sexual organ we have is between our ears, but if your estrogen levels have been normalized, and you are practicing lifestyle improvement and you still have diminished desire, T should be evaluated by a practitioner knowledgeable and experienced in the use of T for women.
- If you are on an appropriate dose of estrogen that has ameliorated most all of your symptoms, but still suffer from hot flashes, especially at night, a low T level just might be the culprit.
There is no reason that you should lose energy and sexual response and enjoyment after menopause, keeping the normal aging process in mind. If this is happening, see a Certified Menopausal Practitioner and/or sexual medicine specialist for evaluation. If one is not available, you may have to educate your individual primary care doc, ask for a referral, or go out of network to find a knowledgeable and caring practitioner.
After all, you are worth it!