← Rena Malik, MD Podcast
Rena Malik, MD Podcast
Do all Women Need Testosterone in Menopause? Urologist Breaks Down the Science
00:29:22
In this episode, Dr. Rena Malik explores the role of testosterone in women's health, covering its impact on sexual function, brain health, bone density, and mood. She discusses the potential benefits and risks of testosterone replacement therapy, especially in postmenopausal and perimenopausal women, while emphasizing the need for more research to better understand its effects.
Loading summary
Transcript10 lines
- [00:00]
Dr. Rena Malik
Testosterone is making headlines for women, but what does Testosterone do? I'm Dr. Rena Malik, urologist and pelvic surgeon and welcome back to The Rena Malik, MD podcast, your source for evidence based information about your sexual health and more. In today's episode, I'm going to review everything you need to know about testosterone from physiology, if you its impact on sexual function, brain health, bone density, muscle mass and mood. And who is a candidate for testosterone replacement and does it work for women in perimenopause? I'll also discuss the current clinical guidelines for testosterone therapy in women and finally, different types of testosterone replacement that are available to women and the risks and benefits of treatment. Now, before I get into the podcast, if you guys are enjoying the podcast, please be sure to subscribe to the podcast and share this or leave a rating or review on my end. I can see that only 20% of people who listen or watch the podcast are actually subscribed, so do me a favor. It's a great zero cost way to support us and ensure that we continue making content each and every week. Now let's start off with the basics. Testosterone is a steroid hormone and it's made primarily in the ovaries and adrenal glands and through peripheral conversion from androstenedione, another steroid prohormone. In the ovaries. The theca cells get signals from the brain from a hormone called luteinizing hormone, and this produces testosterone. The adrenal glands produce androstenedione, which is again a pro hormone, which is then converted to testosterone in the peripheral tissues. Like fat, testosterone then binds to androgen receptors and these are proteins that are found in various tissues like the brain, muscle, bone, hair, follicles, adipose tissue, breast tissue, the uterus and ovaries, the vagina and the vulva. And when we look at testosterone, about 98% of it is found bound to proteins. These proteins are the sex hormone binding globulin and albumin, and these actually carry it and transport it through the bloodstream. The remaining 2% of testosterone is free, meaning it's not bound to proteins, and it's available to bind to these androgen receptors on cells throughout the body, where it can then exert its effects. You might also hear the term bioavailable testosterone, and this is the amount of testosterone that's available to the body's tissues, which includes both the free testosterone as well as the testosterone that's bound to albumin. Now, albumin actually binds testosterone relatively weakly so that it can quickly be released and then made available to the cells. Now, why is testosterone so hot right now? Observational studies have shown some positive associations between testosterone levels and a variety of health outcomes. For example, higher testosterone levels have been linked to better endothelial function, which is essentially blood vessel health, higher bone density and a lower risk of hip fractures in older women. One study found that women age 70 and older with lower testosterone had roughly double the likelihood of experiencing an ascending ischemic cardiovascular event over a 4.4 year period. And another found a 22% higher risk of osteoarthritis in adults with very low levels of testosterone. Now, an interesting German study followed 2,900 women who are on average 58 years old, about half of them being postmenopausal and a little less than half being perimenopausal for four and a half years. And they found that women with low testosterone levels at the start of the study had a higher risk of dying due to any cause and a higher risk of experiencing a cardiovascular event like a heart attack or stroke during the follow up period of almost five years. Now, this association was strong even after they controlled for factors that might affect some of these risks like age, weight, body mass index, smoking. They also found that women with lower levels of Testosterone had a 38% higher risk of all cause mortality or death than women with higher levels. All of this sounds pretty damn convincing that everyone should probably have a normal level of testosterone and maybe take testosterone replacement. However, it's really we have to be cautious. These are mostly observational studies where they either look at a point in a time or they follow a group of women for some period of time. And it's not a randomized controlled trial. These are not women who got testosterone and women who didn't, and we're not comparing those.
- [04:50]
Dr. Rena Malik (Promotional Segment)
Are you sick of going to the doctor only to have them talk at you for 15 minutes and leave without knowing knowing exactly why they're prescribing you this certain medication and what exactly the next step is to take to optimize your health? Wouldn't it be great to finally find a doctor who actually listens to you, answers your questions, and doesn't rush you out the door? Well, at my practice, Reena Malik, M.D. i aim to do just that. I specialize in taking care of patients who have issues with their sex lives, issues with their bladder, with their hormone health, or are having pain in their pelvic region or with sex. My goal is to give you the time and attention you deserve so you can leave with a clear understanding of your condition as well as our treatment plan that's optimized for your goals. During your visit, I'm 100% present with you for an entire hour and after you leave you can reach me. It is super easy to send me a message through our secure portal and I'll get back to you within 24 to 48 hours. No questions asked, no hidden fees. Scheduling is easy. Just Visit our website renamelicmd.com appointments we see patients in both Irvine and Beverly Hills, California. And I see patients virtually in California, Florida, Illinois, Maryland, New York, New Jersey, and Virginia. Oh, and don't forget Texas. If you're outside these states, consider seeing me for an educational visit. I look forward to seeing you.
- [06:31]
Dr. Rena Malik
So I want to dig into the data based on the strongest evidence that we have and with what we are sure about and what we're still not sure about. So let's start off with the one that we're pretty sure about, which is how Testosterone affects sexual function. Now, testosterone in female sexual function in particular for sex drive or libido, is very well documented, particularly in postmenopausal women. How does this work? Well, testosterone enhances libido by sort of a complex mechanism because testosterone not only has brain effects but also has effects all over the body. So in the brain, testosterone might act directly on not only the hypothalamus but also the limbic areas of the brain which are responsible for sexual motivation and reward. It might also influence other neurotransmitters or signals in our brain like dopamine and serotonin, which again are really important for sexual behavior. In the peripheral tissues, testosterone has been shown potentially to improve vaginal blood flow and lubrication, which might then allow for more what we call sexual responsiveness. So getting aroused and actually feeling responsive to sexual advances. Now studies have consistently shown a positive correlation between testosterone levels and desire or libido, as well as arousal and overall sexual satisfaction. There was a meta analysis done with 36 randomized controlled trials with over 8,000 women and within it they found that there was significant improvement in a variety of aspects of sexual function in postmenopausal women who were treated with testosterone compared to those who got a placebo. These improvements included increased frequency of satisfying sexual events, meaning they had more sex and it was more satisfying, enhanced sexual desire, pleasure, arousal, orgasm and improved self image. They also had decreased sexual concerns and decreased distress related to sex. However, when looking at this data, they didn't actually see any significant impact on cognitive function, bone mineral density, body composition, muscle strength, mood or well being in this analysis. However, they do claim that there's not a lot of data on many of these outcomes to make definitive conclusions. So that's where we're going to cover some of the data that we do have at this time on these variety of different topics. But there's one more thing about sexual function and testosterone that many people are not talking about, and that's because these are still ongoing. But there are some ongoing studies looking at intravaginal testosterone or using testosterone in the vagina to improve vulvovaginal atrophy or thinning of the vagina. And this does show promise, particularly women who, who might have to be on aromatase inhibitors for breast cancer.
- [09:20]
Dr. Rena Malik (Promotional Segment)
Quick break from this episode to let you know. I am so grateful that you're spending part of your day with me. I started creating content online to empower people to learn more about their bodies without needing to go see a doctor, pay a copay, wait in a waiting room, or find parking. And it has been one of the most rewarding experiences of my life. If you want to help support our mission of providing free education, please consider joining our premium membership. There you will have access to ad free episodes which are released early, as well as free transcripts and the opportunity to ask me anything. And these questions are answered in our monthly AMA episodes. Support the show and join today at renamallicksupercast.com can't wait to see you there.
- [10:09]
Dr. Rena Malik
Now what about for premenopausal women or perimenopausal women? Will testosterone help sexual function? And interestingly, the evidence for testosterone's effects in this age group is less conclusive. And the reason is because there's fewer studies. There are inconsistent findings. And while some studies find it helpful, others are really finding no impact. Now this is likely because there's a whole bunch of factors that go into sexual desire. This can be including psychological factors, relationship factors, which makes it really challenging to isolate specific effects of testosterone. And so in fact, when they looked at a study of 91 young healthy women and they asked them questionnaires about sexual desire and they also measured their salivary testosterone as well as their cortisol levels. And they found that while desire for self stimulation or, you know, solitary desire was correlated with higher testosterone levels, when they looked at desire for sexual activity with a partner, or what they called dyadic desire, higher testosterone was linked to actually lower desire, particularly when women had higher levels of stress, which was noted by higher cortisol levels. Now I say this all the time. But stressors of women who are in their perimenopausal time are often at their peak. They are often, usually much busier at work because they're more senior in their jobs, they're taking on bigger projects or higher stakes of projects. They may have aging parents, they may have children at home who need their attention, and they may be in longer term relationships where that spark of intimacy has gone down. And if you're not making it a priority, it will go down. So ultimately, you know, there is a lot of stress and other factors, and now there's much more awareness around the changes that happen hormonally during perimenopause. But essentially it's chaotic, right? Your hormones are a roller coaster and you might have symptoms of brain fog, of sleep deprivation, hot flashes, and all of these are going to affect your ability and desire for sex. So I think likely that's the reason we're not seeing it. But I think if you're optimizing for all those other factors, testosterone can often be useful in patients who have low physiologic levels of testosterone. We're going to talk more about how to replace testosterone at the end of the podcast, but I want to talk more about the other factors that testosterone is reported to benefit. Now, when we talk about men and testosterone, I've made videos about this before, but men have rigorous data on the benefits of testosterone replacement, particularly for men who have low testosterone. A lot of the data is in older men, but we do see benefits in muscle mass, in mood, in cognitive function, and in terms of sexual function with increased libido as well as nocturnal erections. And so are these same benefits going to be seen in women? And, you know, I would suspect, expect that while we're not identical in terms of biology, I think that ultimately the way testosterone functions in our bodies is very similar. So now let's get into the next topic, which is mood regulation. So it is implicated in both mood regulation and cognitive function. And the reason that people link testosterone to mood is that testosterone influences neurotransmitter systems, as I mentioned earlier, split particularly serotonin and dopamine. And these are also very much involved in mood. It also interacts with the hypothalamic pituitary axis, which is really important in stress response. However, the exact pathways and the extent to which testosterone affects mood is still really unclear. While ultimately for female data, some studies do suggest a link between low testosterone and depression, the evidence is not definitive.
- [13:49]
Samantha Christine
Hey, guys, I'm Samantha. Christine, host of the Empower Podcast right here on the Pursuit Network. If you're into wellness that fits into real life with honest convos, workout tips that actually make sense, nutrition hacks that support your lifestyle, and a lot of encouragement to become your strongest self, you'll feel right at home on my show. Whether you're a busy mom in a season of rebuilding or just trying to stay consistent with the all or nothing mindset, the Empower Podcast is for you. New episodes drop every Wednesday wherever you listen to podcasts. So come hang out. I'd love to have you so they.
- [14:18]
Dr. Rena Malik
Did a Systematic Review in 2021 and they looked at eight observational studies. Remember the term observational? These are not randomized trials. And they looked at 8,000 women, and in those studies they found no strong association between total testosterone and depression in postmenopausal women. However, one study did indicate that there was probably an association between bioavailable testosterone and depression, meaning the lower the bioavailable testosterone, the higher rates of depression. However, this study looked at postmenopausal women and the average age of these women was 20 years after menopause. So will testosterone improve your mood? It's hard to say. At this point in time, we don't have strong randomized controlled trial data that tells us that testosterone actually improves depression symptoms or mood symptoms. However, there is a plausible mechanism Next up, let's talk about cognitive function similar to mood. There is very little data in this space and inconclusive findings, meaning that the impact of testosterone on cognition is sort of unclear. However, I wanted to share one interesting study that I found. Again, this is a small study, but I thought it was so fascinating. So it was 2015 looked at 21 women who got a single dose of Testosterone compared to 21 women who got a placebo treatment. And then they were given tasks to measure their spatial abilities. They had to imagine essentially how an object would look if rotated. They also had to navigate and understand a virtual environment, and during this time they were in the virtual environment. They also measured their brain performance with mri, and they found that women who received that single dose one dose of testosterone had better mental rotation performance and ability to understand directions in that virtual environment. They also noted that there was some increased activity in the brain, particularly in the medial temporal lobe of the brain. So women who navigated this virtual environment successfully only had this heightened activity in their brain if they took testosterone. Whereas women who navigated the environment successfully and didn't take testosterone, we didn't see that increased activity. So again, interesting findings that perhaps Testosterone does improve certain aspects of cognition, in this case spatial recognition. However, this was really short term. It's one dose and again, a small study, but I think ultimately very interesting.
- [16:47]
Dr. Rena Malik (Promotional Segment)
Are you feeling in a rut in the bedroom wishing you had the kind of sex life you could brag about? I've spent years helping patients and creating content for people all around the world to improve and optimize their sex life. Today you can get my knowledge for 100% free with my new ebook called Better Sex, Better Life. In this ebook, I review my top 10 tips for improving your sex life, all from the comfort of your own home. All you have to do is go to renamalicmd.com morepleasure to download it for free today.
- [17:27]
Dr. Rena Malik
Now next up is bone health. Now this is another area that people are very interested in and the mechanisms by which testosterone might improve bone mineral density, which again is really important because we want your bones to stay strong so you don't fall and break them when you age. It's probably multifaceted. It actually affects both osteoblasts and osteoclasts and affects indirectly because testosterone can be aromatized to estrogen and this can ultimately improve. We know estrogen improves bone health. So actually in 2022 there was a study done that found a positive association between testosterone levels and lumbar bone mineral density in nearly 2200 women who were aged somewhere between 40 and 60 years of age, potentially saying that, hey, this might be protective against osteoporosis. And generally in animal studies they found that testosterone has an anabolic or growing effect on cartilage and matrix synthesis, which again is helpful for joints. Ultimately, this is still animal studies. They do still think this is very interesting. Now next up is muscle mass and strength. Now we know in men that testosterone improves muscle mass. Now testosterone's anabolic effects are likely because of its interaction directly with androgen receptors in muscle cells, which leads to then increased protein synthesis, reduced protein breakdown, and ultimately enhanced muscle fiber growth. Now, a systematic review was done looking at 10 observational studies with over 4000 women and saw no strong evidence of a direct relationship between total testosterone and muscle mass, strength or performance. However, some studies do suggest that there may be a link between free or bioavailable testosterone and muscle mass. Now remember, free testosterone is the testosterone that's immediately available for your body to use, and bioavailable is a testosterone that is more so available for your body to use. And so these are actually the important amounts of testosterone that you have. So having more Free testosterone is important, and so some people genetically have higher rates of sex hormone binding globulin, which then binds up more testosterone. This also tends to increase as we age. Or if you're on hormonal contraception, oral contraceptives, then you can also see an increase in your sex hormone binding globulin, which can make less free testosterone available. So potentially in those cases, or if you have a low free testosterone, maybe if they look at this more closely, we will see a significant improvement. So let's take all this together. Bottom line, sexual function improves with testosterone. Yes. Other factors like muscle mass, mood, cognition, bone health, maybe. So now that you understand how testosterone works and how it might affect our bodies, how much testosterone do women really need? Now typically we'll say something like women have about 110 of the testosterone men have. However, defining what normal is in women is a bit challenging. One is because we have natural variations of throughout our menstrual cycle and across different age groups. Studies have reported different ranges based on small sample sizes and using different methods. And also many things can impact testosterone. Once they looked at factors that are correlated with testosterone, they found that age, having your ovaries removed, using estrogen or using steroids were all associated with having lower levels of testosterone. Whereas women who were overweight or were black race had higher, on average, higher testosterone levels. So what is normal when some people will naturally have a higher level at baseline? So there was one study that looked at 161 premenopausal women from 18 to 49 years old who had regular menstrual cycles. And they measured blood samples and they found that on Average for a 30 year old woman, normal ranges, which is from the 5th to the 95th percentile, were 15 to 46 nanograms per deciliter and free tea was anywhere from 1.2 to 6.4 picograms per milliliter, or 45 to 222 picomoles per liter. Also important to realize that total testosterone does vary over the course of the menstrual cycle and it is as high as 15% higher during the mid cycle phase, which is between days 12 and 14 of the cycle. However, even these ranges are limited because sometimes there's less precise assays that are used and so it may not be applicable. I think ultimately what would be great is if we knew what your testosterone was when you were feeling great and then we could measure it again when perhaps you're having symptoms. So we can see is there a change because again, I think we don't know very well what normal is. Now, what do the guidelines say for testosterone? So the current guidelines for testosterone therapy in women are generally cautious. The global consensus position statement recommends that testosterone therapy be used only for postmenopausal women with hypoactive sexual desire disorder and only after other causes have been ruled out. Now, I've talked about low sexual desire or low libido in a podcast previously, which I'll link in the description and show notes. But ultimately, it's very complex and you need to rule out a whole bunch of different factors that might play a role in why desire is down. And once that has been addressed, then we know that potentially there is a hormonal component. Now, the International Society for the Study of Women's Sexual Health, or ishwish, that guideline extends this recommendation to include late reproductive age premenopausal women, AKA those who are perimenopausal, who have hypoactive sexual desire disorder. So in my practice, I will typically get an early morning testosterone level on my patients. And if it's low, I tend to use that rule of one tenth of a male testosterone. So in that case, if 300 is low for a male, 30 is on the lower end for a female. However, you know, if you're feeling good at 30, I think that's fine. Again, we need to figure out what is normal for you. If you're working on the other issues that are causing low libido and we've dealt with those issues, or we're working on them, then we can discuss testosterone replacement therapy. Now, what is is an option if you decide to proceed. So there are transdermal patches not available in the us There are creams and gels which you apply daily, and these are generally more physiologic in terms of getting them to you in a more normal frequency and then injectable testosterone. And this is available, but usually needs to be compounded because it's not available at your regular pharmacy in doses that are appropriate for women. There are also pellets. I don't personally place pellets because I think that they can. We don't know how you're going to necessarily respond to pellets. And so you can get supra physiologic or very high amounts of testosterone very early on after the pellets are placed. And so that's generally why they're not recommended. But some people really like the convenience of them. They're inserted and placed every four months or so to then sort of Maintain normal testosterone levels. Potential benefits for testosterone replacement includes improved sexual function and reduced sexual distress like we talked about. Now, potential risks include acne and hair growth and most of that is typically in patients who are getting really high or supraphysiologic doses. Now, in rare circumstances, I have seen or heard about clitoromegaly or having clitoral enlargement when you take testosterone. Again, when you're at the super physiologic or high amount of testosterone. Now, long term safety data are still limited and so we don't know how long, you know, if you take it for 20 years, is it still safe? And are we going to need more ongoing research? But what I would say is testosterone does play a significant role in women's health. And I think there are really important ways to use testosterone, but it's really important to be empowered to understand the science behind it and what we know for sure and what may be useful. And I think there are limitations of the data we have because women are not studies as well or as rigorously as our male counterparts. And so we do need more research using larger patients, more diverse populations with longer follow up periods and with consistency across research studies. And I think hopefully that will help us understand better. Is there really an improvement in cognition, bone health, muscle health, mood, all of those things when taking testosterone replacement? And yes, it may be. So I think discuss with your doctor about what is right for you. Thank you guys so much for joining me today on the podcast. Please make sure to leave comments. If you're watching this on YouTube or on Spotify, you can leave a comment. If you enjoy my content, please make sure to subscribe to the podcast. It's a zero cost way to support us and share this with your friends. Tag me on social media and as always, we're gonna take care of yourself because you're worth it.
- [26:22]
Samantha Christine
Hey guys, I'm Samantha Christine, host of the Empower podcast right here on the Pursuit Network. If you're into wellness that fits into real life with honest combos, workout tips that actually make sense, nutrition hacks that support your lifestyle, and a lot of encouragement to become your strongest self, you'll feel right at home on my show. Whether you're a busy mom in a season of rebuilding or just trying to stay consistent with the all or nothing mindset, the Empower Podcast is for you. New episodes drop every Wednesday wherever you listen to podcasts. So come hang out. I'd love to have you.