Episode Summary: Testosterone and Menopause: What Every Woman Should Know
Podcast: The Tamsen Show
Host: Tamsen Fadal
Guest: Dr. Kelly Casperson, MD
Release Date: June 18, 2025
1. Introduction to Testosterone in Women's Health
In this enlightening episode of The Tamsen Show, host Tamsen Fadal engages in a profound conversation with Dr. Kelly Casperson, a board-certified urologist, hormone expert, and author of the podcast You Are Not Broken. The discussion centers on the critical yet often misunderstood role of testosterone in women's health, particularly during menopause.
2. Dr. Kelly Casperson's Background and Journey [00:56 - 04:38]
Dr. Casperson shares her unique path into urology—a field with relatively few female practitioners. She explains her initial attraction to urology due to the immediate, tangible impact it has on patients' lives, offering "instant gratification" by resolving issues like kidney stones or bladder tumors. However, after seven years in private practice, Dr. Casperson experienced a "seven-year itch," feeling unfulfilled and seeking deeper meaning in her work. This led her to focus on female sexual health and hormone function after a patient expressed distress over her sexless marriage. This pivotal moment motivated Dr. Casperson to explore and educate about female hormones, resulting in her book and podcast aimed at addressing the informational void affecting millions of women over 40.
Notable Quote:
Dr. Casperson: "It was one woman and one story that hit you so hard. And I think that happens because during this time, we're all sort of, you know, in that same place, rediscovering ourselves in a lot of ways." [04:15]
3. Understanding Testosterone and Hormones [05:44 - 07:24]
Tamsen introduces the topic by dispelling the common misconception that testosterone is solely a male hormone. She emphasizes that testosterone is actually the dominant sex hormone in women, contrary to the widespread belief that estrogen holds that position. Testosterone operates as a neurohormone, influencing not just sexual health but also cognitive functions.
Notable Quote:
Tamsen Fadal: "Hormones aren't gendered, right? But we, you know, for better, better, for worse, probably for worse, we said estrogen's for women, testosterone's for men." [05:44]
4. Testosterone vs. Estrogen: Myths and Facts [07:31 - 10:44]
The conversation delves deeper into the biochemical roles of testosterone and estrogen. Tamsen explains that cholesterol serves as the precursor for both hormones, highlighting their interconnected pathways. She corrects the myth that testosterone levels drop precipitously during menopause, noting that while testosterone peaks in the 20s and gradually declines, it may even increase in some women after age 70.
Notable Quotes:
Tamsen Fadal: "Testosterone is actually women's dominant sex hormone. It is wrong when people say estrogen is our main hormone, our Main hormone is testosterone." [07:18]
Dr. Casperson: "So wait, we have more test. We actually have more testosterone than we do estrogen, Is that right?" [07:23]
Tamsen Fadal: "That's correct, yes." [07:24]
5. Current Options for Testosterone Therapy in Women [10:44 - 21:15]
The discussion shifts to available testosterone therapies for women. Currently, the U.S. lacks FDA-approved testosterone products specifically for women, leading to off-label use of male formulations at significantly lower doses. Tamsen outlines the three main options women use today:
- Microdosed Androgen Gels: Such as AndroGel or Testum, diluted to one-tenth the standard male dose.
- Compounded Testosterone Creams: Typically starting at around 5 milligrams, offering affordability.
- Testosterone Pellets: Implanted subcutaneously, these provide a high-dose, long-acting option but come with increased risks and costs.
Notable Quotes:
Tamsen Fadal: "Most common things that we're using now, I'd say are three things. Number one, we take a male product... it's very small amount of gel, pretty cheap. Second option is we compound a testosterone cream... and the third option is pellets." [22:01]
Dr. Casperson: "I had pellets initially... felt great, and then three months later, I felt like crap." [23:37]
6. Challenges and Misconceptions in Hormone Therapy [21:15 - 28:14]
Tamsen addresses the significant regulatory and educational barriers hindering the development of female-specific testosterone treatments. Despite decades of use and extensive safety data, the FDA has delayed approval, often citing the need for more breast safety data. This regulatory inertia stems partly from historical gender biases in medicine.
Notable Quotes:
Tamsen Fadal: "In America, our FDA approves medications... We've had a female testosterone go in front of the FDA twice already to the tune of a billion dollars and five years of safety data." [21:15]
Dr. Casperson: "Status quo is women using poorly dosed male products." [26:52]
7. The Role of Testosterone in Libido and Sexual Health [28:14 - 32:00]
The duo explores how testosterone influences libido. Tamsen explains that testosterone enhances neurotransmitter activity, particularly dopamine, which is crucial for the reward pathways associated with sexual desire. However, libido is multifaceted, influenced by factors like relationship quality, stress levels, and overall well-being. Therefore, testosterone therapy alone may not resolve all issues related to low libido.
Notable Quotes:
Tamsen Fadal: "Sex is incredibly complex. Testosterone can help, but libido is not just about hormones." [28:27]
Dr. Casperson: "Libido is incredibly complex. Testosterone increases dopamine pathways, but if sex is a chore, testosterone won't make you desire it." [28:52]
8. Genital Urinary Syndrome of Menopause (GSM) [38:07 - 40:25]
GSM encompasses a range of symptoms resulting from decreased hormones during menopause, such as vaginal dryness, urinary urgency, and recurrent urinary tract infections (UTIs). Tamsen emphasizes the lifesaving role of vaginal estrogen in reducing the risk of severe UTIs and other pelvic complications. Despite its safety and efficacy, less than 4% of eligible women utilize hormone therapy for GSM.
Notable Quotes:
Tamsen Fadal: "GSM stands for genital urinary syndrome of menopause... It can lead to severe complications like sepsis and death from recurrent UTIs." [38:21]
Dr. Casperson: "UTIs are so deadly and so dangerous, and they increase with age." [39:35]
9. Safe Use of Vaginal Estrogen [36:42 - 37:57]
Vaginal estrogen is highlighted as a safe and effective treatment for most women experiencing GSM. Tamsen dispels fears surrounding breast cancer, citing extensive studies that affirm its safety for breast cancer survivors and the general population. She urges women to consult with their oncologists if undergoing cancer treatment but reassures that vaginal estrogen is suitable for 99.9% of women.
Notable Quotes:
Tamsen Fadal: "There's no asterisk: 99.9% of people can be on vaginal estrogen." [36:50]
Dr. Casperson: "GSM is increasing due to ignorance about hormonal changes post-menopause." [38:21]
10. Recommendations for Women Feeling Disconnected [44:13 - 46:44]
For women who feel disconnected from themselves, experience low libido, or suffer from GSM, Tamsen advises starting with education. She recommends resources such as her podcast, books, and online sex education courses to empower women with knowledge. Additionally, she suggests seeking out specialized healthcare providers trained in women's sexual health and hormone therapy.
Notable Quotes:
Tamsen Fadal: "Education, I think is number one and understanding that libido. There are treatment options, but a lot of things for libido aren't medication." [44:13]
Tamsen Fadal: "International Society for the Study of Women's sexual health is the Venn diagram of sex and hormones." [45:44]
11. Future Directions and Regulatory Challenges [46:31 - 47:11]
Tamsen discusses the need to deregulate testosterone, which is currently classified as a DEA Schedule III drug, severely limiting its accessibility for women. She criticizes the lingering stigma from past athletic doping scandals, emphasizing that testosterone is a naturally occurring hormone essential for women's health. Deregulating it would pave the way for more accessible and appropriately dosed female testosterone therapies.
Notable Quotes:
Tamsen Fadal: "We need to deregulate testosterone. It's a hormone our body naturally makes, yet it's heavily restricted." [46:31]
Dr. Casperson: "We're gonna get this conversation finally and it's a big deal." [46:39]
12. Closing Remarks and Upcoming Book [47:11 - 48:00]
The episode concludes with a preview of Tamsen's upcoming second book, The Menopause Moment: How Hormone Science and Mindset Create Optimal Longevity, set to release in September. She underscores the importance of integrating hormone science with mental well-being to enhance longevity and quality of life during and after menopause.
Notable Quotes:
Tamsen Fadal: "This book is like the 201 to the amazing 101 books that my friends have already written." [47:11]
Dr. Casperson: "I cannot wait to have you back on to talk about it." [47:40]
Key Takeaways:
- Testosterone is the Dominant Hormone in Women: Contrary to popular belief, testosterone plays a crucial role in women's health, influencing libido, muscle mass, and overall well-being.
- Current Therapy Options are Limited and Off-Label: Women often rely on microdosed male testosterone gels, compounded creams, or high-dose pellets due to the absence of FDA-approved female-specific testosterone products.
- Education is Empowering: Understanding hormonal changes and available therapies is essential for women navigating perimenopause and menopause.
- Safety and Efficacy of Vaginal Estrogen: Extensive research supports the safe use of vaginal estrogen for treating GSM, benefiting nearly all women except those with specific contraindications.
- Regulatory Barriers Persist: The classification of testosterone as a DEA Schedule III drug hinders the development and accessibility of appropriate hormone therapies for women.
- Comprehensive Approach to Libido: Low libido is multifaceted, requiring a combination of hormonal therapy, relationship dynamics, and personal well-being considerations.
Additional Resources:
- Dr. Kelly Casperson's Website: KellyCaspersonMD.com
- International Society for the Study of Women's Sexual Health: ishwish.org
- Tamsen Fadal's Podcast and Books: Available on thetamsenshow.com
For those seeking to deepen their understanding of hormone therapy and its impact on women's health, this episode serves as an essential guide, bridging the gap between medical expertise and personal empowerment.