Testosterone for Menopause: Benefits & Risks

[Dr. Jessica Ritch]
Most of the time it's those patients that-- I used to just give a big sigh when I saw the chief complaint coming that it's like hormonal imbalance or they just don't feel right. A lot of people are coming in, they just don't feel like themselves. They know that something's off. They may have the more recognizable symptoms like hot flushes and things, and those people are a little bit easier to pinpoint. They may have more irregular periods and that's a little bit more easier to pinpoint too. Many times it's just, "I don't feel like myself. I'm fatigued. I'm not interested in my partner anymore. I have more mood swings. I maybe have pains in different parts of my body that I wasn't used to having," like in the joints, or, "I'm getting headaches or--" whatever it might be. It's usually like a whole constellation of symptoms.

I would say the most common thing that people are telling me is, "Just don't feel right. I just don't feel like myself. I feel like my body is turning on me," or, "I just don't recognize myself in my own body." Just like when we have to go through and really tease out what's exactly going on with somebody who's got chronic pelvic pain or abnormal bleeding, it's the same sort of thing. We have to tease out, "Okay, well, what do you mean by that?" and, "What is that symptom and how frequently is it happening? Can you track it with your cycles?" It just takes that careful dissection of the history to get to the bottom of things.

[Dr. Mark Hoffman]
We all hear that all the time. We all hear, "I just don't feel like myself," but to then take that and try to tease out actual things. The amount of patience that you have, I think of your kids as being very lucky. My kids have a father who's not nearly as patient.

[Dr. Jessica Ritch]
I'm learning patience.

[Dr. Mark Hoffman]
When patients say, "I don't feel like myself," what's an example of how you might address the things you might find in a patient who says, "I just don't feel like myself," because it's such a fake complaint? It's so hard to know where that can lead.

[Dr. Jessica Ritch]
Right. Just like we're taught in medical school, you start with the broad questions and try to narrow it in. "What do you mean by that?" Then we get into, "Okay, is it the fatigue? Are you feeling that all the time? Are you feeling that at certain parts of your cycle?" When we're talking about low libido or not being interested in your partner. some of that is maybe you just don't like your partner, but some of that is hormonal changes and genitourinary syndrome of menopause and pain with sex. It's really that I'm getting into asking each of those questions.

Honestly, when you start diving into it, you'll realize that it really does affect every part of their body. They may be having headaches, they may be having joint pains. They're having more depression, more anxiety. They're having hot flushes. They're having weight gain. That's one that I hear a lot. Everybody's worried about the weight gain around the abdomen, which is the more central obesity we always hear about. That becomes an issue. A lot of so many women that come to me and they say, "I just turned 40," or, "I just turned 45," or, "I just turned 50," and, "I'm doing all of the same things and I am gaining all of this weight. I just don't feel like getting out of bed anymore." Those are the types of things that we hear a lot.

A lot of it is just reassurance in the first part of things, just telling people, "Okay, you're not going crazy. Your body's not abandoning you, but that this is a change and this is a change that's as big as puberty." Once I can start to have people assess it in that way, they're like, "Oh yes, my body changed pretty drastically and permanently in puberty." Everybody expected that change and they knew that they were going to go through it. For some reason, I think because menopause, and luckily we're talking about menopause a lot more now in these last year or two, but menopause for such a long time has been something that hasn't been talked about, has been completely ignored. So many people are shocked when they get there, no matter what the age of the patient, I always hear them saying, "Oh, but I'm too young for this. I can't be going through this." Really those perimenopausal changes can start as early as the mid-30s, even in normal menopause, let alone premature ovarian insufficiency and things like that.

You really just have to have an ear for it and think about what could be going on. Lab tests can be helpful, but they're not that great. It's really listening to the complaints and trying to work people through that.

[Dr. Mark Hoffman]
Good. The other big thing I want to ask, though, about this in terms of hormones is testosterone. A lot of testosterone questions, and I feel like I don't know anything helpful to tell patients about testosterone. I know that ovaries do produce testosterone, and I understand that when you go into menopause, your ovarian hormone production goes down. That includes testosterone. You're nodding, so I'm hoping that I'm somewhat right here. Tell me what you know about testosterone in the menopausal patient and what we can be telling our patients.

[Dr. Jessica Ritch]
That is true. Definitely, the ovaries are producing testosterone. The testosterone seems to drop off a little bit later than the estrogen does. We tend to lose estrogen a little bit sooner and progesterone. The testosterone drops off a little bit later. I will tell you that my opinion on testosterone has been evolving, and it's still evolving, but here's what we know.

We do know that women who are getting testosterone supplementation do feel better in terms of less fatigue, more energy. They have improvements in libido and muscle mass, so it can be helpful in those ways. We do know there can be side effects to testosterone, so abnormal hair growth, acne, virilization things like voice deepening, clitoromegaly, things like that, that people don't necessarily want.

We don't know a whole lot about risks. These are not really well studied in women. The studies that we do have typically are followed for six months or less. They're usually using a topical patch that's not available in the United States. It looks like, at least from those small studies, that things are fairly safe in women. When we look at men, of course, the concerns in men are always things like cancers; prostate and testicular cancers, and cardiovascular disease. Some of the newer evidence suggests that it may be safer in men than we had originally thought, but there's really still not a lot of data on women.

It's not something that I start with. The argument I think a lot of people make who do a lot of testosterone therapy is that we would offer this to men. We care more about men's quality of life, it seems, than we care about women's. I agree, there are a lot of things that we do for men that we don't necessarily do for women, but I do think it's more of a conversation. I do think it shouldn't be a, "Well, your testosterone is low and you need testosterone." It should be a conversation about the risks and benefits. Just because somebody's male partner will take anything at any risk to improve their sex life, does not necessarily mean that the woman wants to do the same. It's really a conversation about risks and benefits.

When I'm starting someone on a hormone replacement therapy, I always start with estrogen, and then, of course, progesterone, if they have a uterus, to protect the uterus. Then even if they've come to me for testosterone, I say, "Well, let's just wait on that. Let's see how you feel first with the estrogen," because a lot of the symptoms that they're having in terms of the fatigue and also the libido and energy, those are going to improve with the estrogen alone, which are much better studied. We know the risks and benefits in women of estrogen and progesterone much better than we know testosterone. Then I say, "If you're still having very bothersome symptoms, then we're going to consider adding a topical testosterone," but that can get a little bit trickier.

[Dr. Mark Hoffman]
Is it trial and error, really? Are you measuring testosterone? I know we talked about labs a minute ago, but do you check testosterone levels in women at all? Is there any value in that?

[Dr. Jessica Ritch]
I do check them initially, but again, the initial is really more to rule out the other things, particularly in the perimenopausal person, to see if it's a PCOS issue or something along those lines. If I'm supplementing testosterone, which again, I don't start with, so it's not the majority of my patients who are on testosterone, but if I'm supplementing testosterone, then I will check the levels mostly to make sure that they're not getting crazy high. There are no set therapeutic levels for what a woman's testosterone should be, so it's not like you're titrating a dose to a specific level. It's more like, "Okay, well, what's the normal range of what a woman should have?"

I do have some patients who are on the pellets and other things, not that I've given them the pellets because I do not do that, but who have come in on pellets. Sometimes their levels are three, four times what a normal female should have in terms of a testosterone level. I don't think that's where anybody needs to be.

[Dr. Mark Hoffman]
What are the kinds of things we should be looking for? You mentioned energy and libido. In terms of response and dosing and things like that, we don't need to go through specific doses, but is it similar to estrogen where it's like, "Let's give you a little more, see how you feel. Let's give you a little more, see how you feel." Then you have a point where "Okay, I don't think any more is going to help," and it's more of a trial-and-error type thing?

[Dr. Jessica Ritch]
A little bit. There are some guidelines. There are basically a couple of different ways that you can do testosterone. Some people will do injections in the pellets. Like you said, I don't do that. The pellets I'm not really that comfortable with. I think they're poorly regulated, not well studied, can be inconsistent. There is, of course, FDA-approved testosterone for men. Topical, a gel product that you can use. Generally, for women, we just start at a 10th of the dose of men. Not super scientific. It's like a pea-sized amount that they rub into their skin. That's one way to do it. They probably won't have that covered by their insurance, but because the tube is going to last them so much longer than it would for a man, it's usually one or two tubes in a year.

The other way is to use a compounding pharmacy, which as I said, I'm not a huge fan of compounded bioidentical hormones. I do use compounding pharmacies when I need to, when I can't get something that's commercially available. I have a few in my area that I feel comfortable with, but it's sort of the same thing. We just start at a low dose and then we build up from there. I will talk with the pharmacist specifically about how they make that and how we can dose each patient.

Really then, I'm checking the levels to see, "Okay, are we getting too high?" Then for the effectiveness to see, basically it's always, "How do you feel? How do you feel with that?" Some people feel great with it. I would say the majority feel great. They have more energy. They have their sex lives back, but I do have a lot of people too who are just like, "Whoa, that was too much. I don't want to be on that anymore." It's always trial and error. You have to see how each person is going to respond to it, just like with anything else.