Rena Malik, M.D. - Do all Women Need Testosterone in Menopause? Urologist Breaks Down the Science
The podcast explores the multifaceted role of testosterone in women's health, covering its physiological production, effects on sexual function, mood, cognition, bone density, and muscle mass. Testosterone is primarily produced in the ovaries and adrenal glands and affects various tissues through androgen receptors. Observational studies suggest positive associations between testosterone levels and health outcomes like better endothelial function, higher bone density, and reduced risk of cardiovascular events. However, these studies are not randomized controlled trials, so conclusions should be cautious.
Testosterone's impact on sexual function is well-documented, particularly in postmenopausal women, enhancing libido and sexual satisfaction. A meta-analysis of 36 trials showed significant improvements in sexual function with testosterone therapy. However, its effects on mood, cognition, and muscle mass are less clear, with limited and inconclusive data. Testosterone therapy is recommended for postmenopausal women with hypoactive sexual desire disorder after ruling out other causes. Various forms of testosterone replacement are available, but long-term safety data is limited, necessitating further research.
Key Points:
- Testosterone is crucial for women's health, affecting sexual function, mood, cognition, and bone density.
- Observational studies link higher testosterone levels to better health outcomes, but more rigorous trials are needed.
- Testosterone therapy improves sexual function in postmenopausal women but has unclear effects on mood and cognition.
- Therapy is recommended for postmenopausal women with hypoactive sexual desire disorder after other causes are ruled out.
- Various testosterone replacement options exist, but long-term safety data is limited, requiring more research.
Details:
1. ðïļ Introduction to Testosterone
- Testosterone plays a crucial role in sexual function, brain health, bone density, muscle mass, and mood regulation.
- The discussion highlights the potential benefits and considerations of testosterone replacement therapy for women, especially during perimenopause.
- Current clinical guidelines for testosterone therapy in women are explored, with emphasis on understanding who may benefit from such treatments.
- Different types of testosterone replacement options are covered, along with a balanced view of their risks and benefits.
- An appeal is made for listeners to subscribe to the podcast to support content creation, noting that only 20% of listeners are currently subscribed.
2. 𧎠How Testosterone Works
2.1. Testosterone Production and Function
2.2. Health Implications of Testosterone Levels
3. ð Observational Studies on Health Outcomes
3.1. Impact of Testosterone on Mortality and Cardiovascular Health
3.2. Testosterone's Role in Sexual Function
4. ðĄ Testosterone and Sexual Function
- A comprehensive meta-analysis of 36 randomized controlled trials involving over 8,000 post-menopausal women revealed that testosterone treatment led to significant improvements in sexual function. Key benefits included increased frequency of satisfying sexual events, higher sexual desire, enhanced pleasure, arousal, orgasm, and better self-image. However, testosterone showed no marked impact on cognitive function, bone mineral density, body composition, muscle strength, mood, or overall well-being.
- Emerging studies suggest that intravaginal testosterone may alleviate vulvo-vaginal atrophy, a condition common among women taking aromatase inhibitors for breast cancer.
- The effects of testosterone in premenopausal and perimenopausal women remain less clear due to a limited number of studies and inconsistent results. Factors like psychological state and relationship dynamics make it challenging to isolate testosterone's direct impact on sexual desire in these populations.
- In a study with 91 young healthy women, higher testosterone levels were associated with an increased desire for solitary sexual activity, but this was linked to reduced partner-related sexual desire in those experiencing higher stress, as indicated by elevated cortisol levels.
- Stress and hormonal changes during perimenopause can influence sexual desire. Optimizing these factors may enhance testosterone treatment's effectiveness in women with low physiological testosterone levels.
- Testosterone replacement therapy in men, particularly older men, demonstrates benefits such as increased muscle mass, improved mood, cognitive function, and enhanced sexual function, including increased libido and nocturnal erections. While similar benefits might extend to women, biological differences should be considered.
5. ð§ Mood and Cognitive Function
- The study targeted postmenopausal women about 20 years after menopause, aiming to understand testosterone's impact on mood and cognitive function.
- There is limited strong randomized control trial data supporting testosterone's role in improving mood or depression symptoms.
- Data on cognitive function enhancements due to testosterone is inconclusive and lacks comprehensive evidence.
- A 2015 study involved 42 women, split into two groups, receiving either testosterone or a placebo.
- Participants undertook spatial ability tasks, such as mental rotation and virtual navigation, to assess cognitive function.
- MRI scans indicated that women who received testosterone showed improved mental rotation performance and increased brain activity, especially in the medial temporal lobe.
- This increased brain activity was absent in the placebo group, despite successful task performance, suggesting a unique cognitive effect of testosterone.
- These findings point to a potential enhancement in spatial cognition from testosterone, though the study's short-term and small-scale nature limits its conclusiveness.
- Further studies with larger samples and longer durations are necessary to confirm these preliminary findings and understand the broader implications for hormone therapy in cognitive health.
6. ðĶī Bone Health and Muscle Mass
- A 2022 study of nearly 2,200 women aged 40 to 60 found that higher testosterone levels are positively associated with lumbar bone mineral density, suggesting a protective effect against osteoporosis.
- Animal studies show testosterone may enhance joint health through cartilage and matrix synthesis, although human confirmation is pending.
- Testosterone interacts with androgen receptors to boost muscle growth by increasing protein synthesis and reducing breakdown, promoting muscle fiber expansion.
- A systematic review of over 4,000 women revealed no strong evidence linking total testosterone to muscle attributes, though some links exist between free or bioavailable testosterone and muscle mass.
- Factors such as age, ovary removal, and certain medications are linked to lower testosterone levels, while higher levels are associated with being overweight or of black race.
- Average testosterone levels in premenopausal women vary widely; a study of 161 women aged 18 to 49 found a broad normal range for 30-year-olds from the 5th to the 95th percentile.
7. ð Understanding Normal Testosterone Levels
- Free testosterone levels range from 1.2 to 6.4 P per Mill or 45 to 222 PES per liter, providing a benchmark for assessing hormonal balance.
- Total testosterone levels can increase by up to 15% during the mid-cycle phase of the menstrual cycle (Days 12 to 14), indicating a natural fluctuation that can impact hormonal assessments.
- Current guidelines for testosterone therapy in women emphasize caution, recommending its use only for postmenopausal women with hypoactive sexual desire disorder, after excluding other causes to ensure targeted treatment. This cautious approach reflects the need to balance benefits with potential risks.
8. ð Clinical Guidelines for Therapy
- The International Society for the Study of Women's Sexual Health (ISWSH) guidelines extend recommendations to include late reproductive age premenopausal women, particularly those who are perimenopausal with hypoactive sexual desire disorder.
- In clinical practice, an early morning testosterone level is typically measured, and if low, a guideline of one-tenth of a male testosterone level is considered (e.g., if 300 is low for a male, 30 is low for a female).
- The approach acknowledges that what's normal can vary for each individual, and treatment is adjusted based on addressing other issues causing low libido.
- These guidelines are applied by assessing individual hormone levels and tailoring treatment to the patient's specific needs, ensuring a personalized approach to therapy.
- For example, in cases where low libido is identified, practitioners assess testosterone levels and integrate lifestyle or psychological interventions as necessary.
9. ð Testosterone Replacement Options
- Transdermal patches for testosterone replacement are not available in the US; however, creams and gels are accessible and applied daily, providing a more physiological method of hormone delivery.
- Injectable testosterone must be compounded since standard pharmacies do not carry doses suitable for women, requiring custom preparation for safe and effective administration.
- Pellets are another option but are generally not recommended due to unpredictable responses and the risk of achieving super-physiologic testosterone levels; these are inserted every four months.
- The benefits of testosterone replacement include enhancements in sexual function and a decrease in sexual distress, offering significant improvements to quality of life.
- However, potential risks, especially at super-physiologic doses, include acne, increased hair growth, and clitoral enlargement, necessitating careful dose management.
- There is a critical need for more long-term safety data, particularly focusing on women, to understand the implications on cognition, bone health, muscle health, and mood.
- Current studies lack diversity and adequate follow-up periods, highlighting the importance of more rigorous research on a wider demographic to validate safety and efficacy.
- Engaging with a healthcare provider is crucial to evaluate the most appropriate and safest testosterone replacement option for individual needs, considering potential benefits and risks.