Podcast Summary

Podcast: Rena Malik, MD Podcast

Episode: Do all Women Need Testosterone in Menopause? Urologist Breaks Down the Science
Host: Dr. Rena Malik
Date: March 21, 2025

Brief Overview

In this episode, Dr. Rena Malik addresses the growing interest and often misunderstood topic of testosterone therapy in women, particularly during menopause and perimenopause. She reviews the biological basis of testosterone in women, explores its effects on sexual function, mood, cognition, bone health, and muscle mass, and analyzes the available scientific evidence. Dr. Malik also explains clinical guidelines on testosterone therapy, who may be a candidate, available formulations, and potential risks and benefits, while maintaining a science-driven and practical approach throughout.

Key Discussion Points & Insights

1. Testosterone Basics and Why It’s “Hot” Right Now

• Source and Mechanism:
  • Testosterone in women is primarily produced by the ovaries and adrenal glands.
  • Only about 2% is “free,” or bioavailable for use by tissues, while the rest is protein-bound.
  • It acts via androgen receptors in multiple tissues: brain, muscle, bone, hair follicles, breast tissue, uterus, ovaries, vagina, and vulva.
• Health Associations:
  • Higher testosterone is linked to improved blood vessel health, greater bone density, and lower risk of fractures and cardiovascular events.
  • Quote: “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.” (Dr. Malik, 02:45)
  • Observational studies hint (but don’t prove) that lower testosterone may mean higher all-cause mortality and higher rates of osteoarthritis.

2. Strength of the Evidence: Observational vs. Randomized Trials

• Most positive findings are from observational studies, which can’t determine causation.
• Quote: “These are not randomized controlled trials...we’re not comparing women who got testosterone and women who didn’t.” (Dr. Malik, 04:20)
• Calls for caution: compelling associations do not mean universal benefits or indicate routine supplementation for all.

3. Sexual Function – The Best-Supported Use

• Testosterone clearly affects libido, especially in postmenopausal women.
• Mechanism: Enhances both psychological (motivation, reward centers in brain) and physiological (vaginal blood flow and lubrication) aspects of sexual function.
• Evidence:
  • Meta-analysis of 36 RCTs (>8,000 women): Testosterone improved frequency of satisfying sex, desire, pleasure, arousal, orgasm, self-image, and reduced sexual distress.
  • Improvements not seen in mood, bone density, body comp, or cognitive function, though evidence is sparse for these.
  • Intravaginal testosterone shows promise for vaginal atrophy, especially for breast cancer survivors on aromatase inhibitors.
• Quote: “These improvements included increased frequency of satisfying sexual events, enhanced sexual desire, pleasure, arousal, orgasm, and improved self-image.” (Dr. Malik, 07:25)

4. Testosterone in Premenopausal & Perimenopausal Women

• Evidence less convincing due to fewer studies and more psychological and life-stage factors affecting libido.
• Higher testosterone linked to greater solitary desire, but paradoxically, higher stress and testosterone together were linked with lower partner-related (dyadic) desire.
• Stress, relationship dynamics, and hormonal fluctuations all play a large role during perimenopause.
• Quote: “It’s chaotic, right? Your hormones are a roller coaster...brain fog, sleep deprivation, hot flashes...all affect your ability and desire for sex.” (Dr. Malik, 11:37)
• Optimizing stress, relationship, and other health domains is critical before considering testosterone therapy.

5. Other Potential Effects: Mood, Cognition, Bone, Muscle

Mood & Depression

• No definitive evidence testosterone improves mood or reduces depression in women (systematic reviews found no strong association).
• Some data hint lower bioavailable testosterone may relate to depression, but studied women were on average 20 years postmenopause.
• Quote: “We don’t have strong randomized controlled trial data that tells us that testosterone actually improves depression symptoms or mood symptoms.” (Dr. Malik, 15:05)

Cognition

• Very limited data, mostly not conclusive.
• Small study (n=21): Single dose of testosterone improved spatial abilities, with MRI-proven heightened activity in brain’s medial temporal lobe, but this was a short-term and small study.
• Quote: “Women who received that single dose...had better mental rotation performance and ability to understand directions.” (Dr. Malik, 15:05)

Bone Health

• Some association between higher testosterone and greater bone mineral density in women aged 40–60 (2022 study).
• Effects may be indirect via aromatization to estrogen or direct on bone cells.
• Still mostly animal studies or association data.

Muscle Mass & Strength

• Effects in men are proven; in women, most large studies find no clear link between total testosterone and muscle mass or strength.
• Some studies suggest free/bioavailable testosterone (not total) may matter more.
• Factors like age, genetics, and oral contraception may affect free testosterone levels.

6. Defining “Normal” and Who Should Get Testosterone

• “Normal” testosterone for women hard to define; levels vary with age, cycle phase, and individual factors.
• Guidelines suggest treatment only for women with diagnosed hypoactive sexual desire disorder (HSDD) after ruling out other causes.
• Quote: “We need to figure out what is normal for you. If you’re working on the other issues...then we can discuss testosterone replacement therapy.” (Dr. Malik, 21:45)

7. Testosterone Therapy: Options, Risks, and Benefits

• Forms:
  • Transdermal patches (not U.S. available)
  • Creams and gels (applied daily; most physiological)
  • Compounded injectables (not standard pharmacy)
  • Pellets (long-acting; not recommended due to dosing concerns)
• Benefits:
  • Improved sexual function, reduced sexual distress in hypoactive women
• Risks:
  • Acne, hair growth (mostly supraphysiologic doses)
  • Rarely clitoromegaly
  • Long-term safety unknown; need more research
• Quote: “Testosterone does play a significant role in women’s health…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.” (Dr. Malik, 24:45)

8. Research Gaps & Final Thoughts

• Women are underrepresented in medical research on testosterone.
• More high-quality, long-term, diverse studies are necessary to clarify mood, cognition, bone, and muscle effects.
• Until then, treatment should be individualized and science-based.

Notable Quotes & Memorable Moments

• On observational studies vs. causation:
  “All of this sounds pretty damn convincing that everyone should probably have a normal level of testosterone and maybe take testosterone replacement. However, we have to be cautious…these are not randomized controlled trials.” (Dr. Malik, 03:40)

• On personalized care:
  “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…because again, I think we don’t know very well what normal is.” (Dr. Malik, 19:57)

• On the importance of self-advocacy and ongoing research:
  “Women are not studied as well or as rigorously as our male counterparts…we do need more research…Hopefully that will help us understand better: is there really an improvement in cognition, bone health, muscle health, mood, all of those things?” (Dr. Malik, 25:10)

Timestamps for Key Segments

• 00:00 – 04:49: Introduction to testosterone’s role, health associations, and why research is getting attention
• 06:30 – 09:19: Detailed evidence on sexual function, libido, and results from meta-analyses (postmenopausal focus)
• 10:09 – 13:48: Effects in premenopausal/perimenopausal women, importance of non-hormonal factors like stress and relationship status
• 14:18 – 15:58: Mood and depression evidence (lack thereof), cognitive studies
• 17:27 – 20:49: Bone and muscle health; which metrics matter most; what’s known and unknown
• 20:49 – 23:30: Defining normal testosterone; guideline recommendations for therapy
• 23:30 – 25:50: Types of therapy, risks, and approach to individualization

Conclusion

Dr. Malik delivers an evidence-based, practical guide to the science (and limitations) of testosterone therapy in women. While testosterone is essential for women’s health—especially in libido and sexual function—the decision to pursue therapy must be individualized, based on comprehensive workup and in line with current guidelines. Excitement about observational links should be tempered until more robust data are available for other health outcomes.

Bottom Line:

• Testosterone replacement is appropriate mainly for women with low sexual desire after excluding other causes.
• Benefits beyond sexual function remain unproven.
• Long-term safety is not established—individualize and discuss with your doctor.

For further information, discussion, or personalized care, Dr. Malik encourages listeners to consult their own healthcare professionals and continue advocating for evidence-based, patient-centric care.