Sunday, August 31, 2014

To Use or Not to Use Testosterone: That Is the Question

Many women throughout life do not experience the sexual desire and responsiveness that they would like. Some will consider using testosterone (T), "the male hormone", to help them enjoy sex more. It frequently does help, but it doesn't work in isolation and it's not the only thing testosterone does for women. When searching the Web, its possible to find the occasional article about a woman who describes that her upper body strength got better, her balance and coordination improved, her attitude and ability to take on challenges returnedall after beginning testosterone therapy; however, most of the articles focus on enhancing sexual desire and responsiveness.

Testosterone is every bit as much a women's hormone as it is a man's hormone. Men have a small amount of estrogen; women have a small amount of testosterone. There's a reason for this. It benefits all of us. Women actually have much more testosterone in their bodies than estrogen. Testosterone is the building block from which humans make estradiolthe strongest estrogen in the body; however, if one were to count the number of molecules of testosterone compared to estradiol, women have a ten times more testosterone than estradiol. A small amount of either one is very potent.

When may women experience testosterone deficiency?
Some women never develop the ability to make sufficient amounts of testosterone. They will always be somewhat thin, have poorly developed muscles, dry skin, little or no body hair, and have an underdeveloped sex drive and sexual sensitivity. They may be very submissive and lack authority. They may also be anxious and have little self-assurance. They will tend to avoid sports and physical activities. They may have a higher childish voice and a smooth, thin, childlike face. They are testosterone deficient from puberty forward.

Many women develop testosterone deficiency later in life. This has many causes. It may be due to birth control pills, patches or rings, profound stress, surgical menopause (ovaries removed) or natural menopause in their early 50s. These women will notice that they are losing muscle bulk and strength, pubic hair, sex drive and sensitivity. They may be able to achieve orgasm, but it will be increasingly difficult, and they may experience significant itching or pain during sex. They may find themselves getting more passive, and they may lose interest in physical activity and the sports they previously enjoyed. They may become nervous and irritable, have lengthy bouts of depression, and begin to worry excessively. The fatigue pattern is all day long and gets worse with exercise; so many of these women avoid exercise. They are pale and fragile, appear older, and gain weight in their breasts, abdomen, and hips. And if that wasnt enough, they may develop more cellulite and varicose veins.

Laboratory Levels
It is important to get laboratory testing to document T levels. The normal range for serum total T is between 30 and 80 ng/dL.  But T levels have to be interpreted for the individual woman. Women who have had higher T levels for  decades will need higher testosterone levels when they start experiencing T deficiency. Women who have always had lower T levels may need just a little boost in their testosterone level in order to feel normal again.

Historically low T women may only need a level between 20 and 40. Chronically high T women may need to be in the 75-100 range.

A physician also needs to determine the level of sex hormone binding globulin (SHBG). This is a protein that binds to and carries testosterone and estradiol in the blood. The amount of testosterone or estradiol that is not attached to SHBG is the free estradiol or the free testosterone, respectively. Only free T molecules are available to stimulate the cells. The total testosterone measures both the free and the bound testosterone. So, if SHBG is high, less estradiol and testosterone will be delivered to the cells. This is how birth control pills work to get rid of acne. They contain a strong chemical estrogen that raises SHBG that then binds up natural testosterone. This eliminates acne and, sometimes, sex drive and sexual responsiveness.

On the other hand, as menopausal womens estrogen levels drop, the ovaries frequently continue to produce some testosterone. As estrogen drops so does SHBG, thus more testosterone is released from SHBG to activate the cells. This is why some women get more facial hair and begin losing hair on the top of their head and at their temples as they progress through menopause.

Beyond Sex
While experts on the Web talk about sexual function as the primary benefit of testosterone replacement, testosterone does many wonderful and critical things for a woman's body. Testosterone stops hot flashes and night sweats. Testosterone is necessary to build bone. Estrogen preserves the bone that a woman has, but testosterone and progesterone strengthen bone. Testosterone builds muscle and enhances coordination. It gives women vitality, self-confidence, self-esteem, and the ability to embrace lifes challenges.  It corrects urinary incontinence. Many integrative doctors have witnessed that testosterone and other androgens reduce a womans risk of osteoporosis, depression, atherosclerosis, anxiety, and arthritis.

Testosterone is not made just in the ovaries, but also in the fat and the adrenal glands. Clearly, the body knows that testosterone is important for women because it's made in these three different tissues. But eventually after menopause testosterone levels begin to drop. This usually occurs within five years of the last period.

Treatment for low T
There is no FDA-approved version of testosterone for women for sexual dysfunction or for any other reason. Isn't this odd? There is a drugmethyl-testosteroneit is combined with conjugated estrogens in the form of Estratest®. The problem with methyl-testosterone is that it is swallowed and it causes liver damage. And the oral estrogens are similar to Premarin® which caused an increased risk of heart attack, blood clots and stroke in the Womens Health Initiative (WHI) study in 2002. The increase wasnt large but it was real. Fortunately, many physicians are able to prescribe natural testosterone instead of this damaging drug for women who need testosterone. Not just for sexual dysfunction but for the entire array of symptoms that may develop due to testosterone deficiency.

While younger women who are on the pill may need testosterone for short periods of time to maintain their interest in sex and their physical strength, older women may need testosterone in addition to estradiol and progesterone to be the women that they used to be before they went through menopause. Not every woman needs hormone replacement therapy; not every woman needs testosterone; but for women who do need these hormones, bio-identical hormones are available and they are safe.

How to Take Testosterone
Testosterone can be taken topically in a cream or gel or it may be taken as a troche which melts in the mouth. Topical testosterone is preferable since it eliminates any potential for swallowing testosterone, which could potentially have some effect on the liver. Testosterone may also be administered by an injected pellet beneath the skin. The pellet slowly dissolves and releases testosterone over 3-6 months.

Most commonly, testosterone cream is applied to various parts of the body; however, it is never applied to the breasts since it will be converted to estrogen too quickly. If applied to normal skin on the inner aspect of the arms, the neck, or the inner thighs, one must rotate application sites. If testosterone is applied to the same spot on the skin for an extended period of time then there is potential for the spot to get hairy. If one rotates application sites no portion of the body gets hairy. 
Generally testosterone is applied once or twice a day. It may also be used immediately prior to sex to enhance the sexual experience. Testosterone also may be applied to the genitalia. This is especially helpful when a woman has significant sexual dysfunction or urinary incontinence.

Another way to raise testosterone naturally is to take supplemental DHEA (dehydroepiandrosterone). This is a hormone made primarily by the adrenal glands and is the main substrate for the production of testosterone in women. Women taking DHEA frequently raise their testosterone levels over several months. DHEA-sulfate blood levels are used to determine if a woman would benefit from oral DHEA. A physician can easily order this test.

DHEA levels decline with age. Younger women have higher levels 200-375 mcg/dl; older women have lower levels. Frequently as women progress through menopause, returning their DHEA levels to that of an average 50-year-old woman, around 200mcg/dl, will give them more endurance and resiliency and will also raise their testosterone modestly.

Blood levels should be rechecked after using testosterone or DHEA for a minimum of two months.

What nutrients are necessary for optimal testosterone function?
Zinc 20mg 1-2 daily prevents the body from converting testosterone into estradiol too quickly. One also needs healthy cell membranes for testosterone and all other hormones to work well. This starts with adequate amounts of omega-3 fats. Eat flaxseeds, flaxseed oil, and walnuts. Take fish oil supplements or Udo’s Oil with DHA. Or eat oily ocean fish two to three times a week.

What are the symptoms if one overdoses on testosterone?
Women can get testy and cocky the same way men can; however, the first symptom of excessive androgen effect is generally that ones skin or scalp gets too oily. This usually precedes acne on the face, chest or back, which precedes the growth of extra facial hair. Hair loss on the top of the head and the temples can also be a sign of excessive androgen effect. If a woman ignores these symptoms, she may become excessively pushy, grow much more body hair, experience a deepening of her voice, and/or notice enlargement of her genitals. Women should stop testosterone therapy before this happens and allow levels to go down and then use a lower dose when resuming use. Most of these symptoms will resolve over months when doses are adjusted.

Some women are more sensitive to the loss of hair on the top of the head and temples and overgrowth of hair or acne on the face.  They are converting testosterone, not into estrogen, but into a stronger androgen called dihydrotestosterone (DHT).  This may occur at normal or even optimized levels of testosterone. This frequently occurs in women who have polycystic ovary syndrome (PCOS) without testosterone therapy. They always have high free testosterone levels caused by the PCOS.

There are two ways to prevent or limit this. A medication which is usually prescribed to reverse prostate overgrowth in men works very well. The medication is Propecia®. A low dose once or twice a week usually works well. There is also a supplement, Saw palmetto 187-250 mg, which is taken twice daily. Doses for both Propecia and Saw palmetto need to be adjusted to a woman’s individual response.

I tried it and it didnt work
This happens and there is always a reason. If thyroid function is not optimized, the cells will not see testosterone.

Consuming alcohol will convert testosterone to estrogen much faster. And many drugs interfere with proper functioning of testosterone.

Testosterone works with estradiol and progesterone. These must be present for optimal effects.

Rarely, the cream or gel may not have been compounded correctly and one needs to switch to a more reliable compounding pharmacy.

And lastly, testosterone has to be applied regularly to maintain levels. Levels will drop to their original level within 1-2 days if testosterone is not reapplied.

Final Thoughts

Testosterone gives vitality and drive to men and women. It makes the physical and mental bodies stronger. There is nothing to fear about getting a lab test and if one has low T, consider trying testosterone along with other hormones to complement testosterone.


Angie Archer said...

My husband has low testosterone and has been on T-gel but he read that its not healthy to stay on it so he stopped taking it. Do you recommend using T-Gel?

Dr. Vaughan said...

Thank you for your question, Angie. Are you local to the Piedmont Triad? If so, I'd recommend that your husband call our office for a consultation. Or, he might want to sign up for one of my free talks covering men's health. (My Facebook page,, is where you can find information on my upcoming talks.)

Unknown said...

I'm 56 y.o. woman who has sex twice a month. I have been applying 1 pump of T. gel the day before sex, and then 1 pump 4 hours prior to that's only 4 pumps total per month. I've had absolutely no masculinization or any adverse reactions. Sex and energy levels are great around the days I take the T-gel. I test blood levels of hormones tomorrow. I feel so much better with the T-gel. I think my body has been craving it, because I work out hard at the gym daily. However, I'm not taking this to gain muscle. I'm taking it to improve sex and energy. I would like to up my dose of T-gel to a pump every other day. I can't afford compound hormones. I'm on my own trying to figure this out, because doctors don't prescribe T-gel to women. Thanks for any input you can give.