unPAUSED with Dr. Mary Claire Haver
Episode: The Testosterone Conversation with Dr. Kelly Casperson: Beyond Libido
Date: April 23, 2026
Guests: Dr. Kelly Casperson (urologist, surgeon, podcaster, author of You Are Not Broken)
Episode Overview
This episode dives deep into the misunderstood and overlooked role of testosterone in women’s health, challenging medical myths, systemic bias, and discussing implications for libido, energy, brain health, sexual function, and more. Dr. Mary Claire Haver and Dr. Kelly Casperson provide a frank, science-based discussion on the broader purpose of testosterone, the treatment gap between men and women, and the need for equity in sexual medicine. The conversation also touches on issues like vaginal estrogen, pelvic floor dysfunction, genital urinary syndrome of menopause (GSM), medications that impact sexual health, and practical approaches to care.
Key Discussion Points & Insights
1. The Fundamental Misunderstanding of Testosterone in Women
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Testosterone is not just a "male hormone"; it's critical for women, too.
- “I didn’t even know it was a female hormone. ... I only thought of testosterone as a bad hormone.” – Dr. Haver [04:40]
- “Ovaries make testosterone ... and you actually need testosterone to make estrogen.” – Dr. Casperson [05:33, 06:01]
- Women have four times more testosterone than estrogen, even in normal cycles. Units are different due to lower estrogen quantities. [07:21]
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Testosterone receptors are everywhere: brain, bone, muscle, clitoris, vulva, vagina, eye, tear ducts.
- “Brain, bone, muscle, clitoris, vulva, vagina, eye, tear ducts.” – Dr. Casperson [07:40]
2. Expanding Beyond Libido—Testosterone's Multifaceted Impact
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Testosterone helps:
- Desire, motivation, arousal, orgasm, blood flow, energy, neuronal (brain) health, and may affect mood and mitochondria (cellular energy). [09:03–18:07]
- Quotable:
- “Testosterone is not just a libido medication. It’s a motivation medication. Libido being one part of motivation.” – Dr. Casperson [18:07]
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Challenging stereotypes and lack of research:
- The “absence of evidence does not mean evidence of absence”—historical lack of research is not proof of harm or ineffectiveness. [08:41]
- Male drugs are fast-tracked and widely accepted, female sexual health treatments are scrutinized, delayed, or denied FDA approval. [15:26]
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Testosterone and energy: Stories of women regaining motivation, starting projects, or reclaiming life after restoration of hormones. [19:40–21:32]
- “She was like, ‘That's my testosterone deck.' ... Motivation to do something. It works in the brain.” – Dr. Casperson [20:22]
3. Data, Safety, and Systemic Inequity
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Men have options; women do not.
- ~20% of men have low testosterone; a dozen FDA-approved products exist for them. 100% of women will develop low testosterone; zero FDA-approved products exist for them. No insurance coverage for off-label or compounded options. [16:12–16:44]
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Barriers to approval:
- Women’s health studies were held to a higher standard post–Women's Health Initiative: “Men’s testosterone got FDA approved with six-month safety data. [The female patch] had years of safety data—not enough.” – Dr. Casperson [14:33]
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Long-term male and trans-male safety data exists: No increased cancer, stroke, or death risk even at 10x female doses over decades. [10:38]
4. What Testosterone Can't Fix
- “Testosterone does not fix relationship problems.” – [16:46]
- Critical to distinguish biological vs. relational sources of sexual issues. [17:06]
5. Practicalities of Testosterone Replacement for Women
- No standard product or dose for women: Women must use tiny, imprecise fractions of male-prescribed products, often paid entirely out of pocket, creating a barrier to care. [37:06]
- Pellets: High dosing risk, not always evidence-based, can shock the system and cause side effects; extreme caution and proper counseling essential. [38:02–40:18]
6. Beyond Testosterone: The Broader Picture of Sexual Health
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Genital Urinary Syndrome of Menopause (GSM):
- Encompasses atrophy, dryness, urinary symptoms, decreased elasticity, pain, and more.
- “7% of women with GSM received vaginal estrogen within 18 months of diagnosis ... highly safe, highly effective, highly cost efficient, and saves lives.” – [49:45–49:57]
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Pelvic floor dysfunction and vaginismus: Often treated as psychological, but have real physiological/structural roots.
- “Vaginismus is not purposeful ... tightness that prevents penetration.” – [51:25]
- Social myths and cultural obsessions with “tightness” are problematic and exploitative. [52:28]
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Labiaplasty and sexual appearance: Cultural emphasis places financial and psychological burden on women. [53:10–54:53]
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Vibrators and sexual aids: Technological aids are normal in other parts of health, so why not for sexual function?
- “Why is the pelvis the only area that we’re like ... but not technology there?” – [57:49]
- “I just want you to experience pleasure and blood flow. If orgasms happen, awesome.” – Dr. Casperson on designing a vibrator for comfort and accessibility [62:17–62:36]
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Lubrication and arousal: Media and porn misrepresent physical readiness; dryness is not a character flaw.
- “Ability to produce moisture is not directly correlated to interest in having sex with a partner.” – [64:00]
7. Medications & Sexual Health
- Medications interfering with sexual function:
- Birth control pills: Can decrease libido, increase SHBG, and cause vaginal changes; informed consent is crucial. [65:24–66:36]
- Antidepressants: 60–80% of users may experience sexual side effects; often unaddressed by clinicians. [66:39–66:58]
- New GLP1s (weight loss/diabetes drugs): Data emerging, may either lower or support sexual desire depending on context. [67:31–68:41]
8. Key Takeaways and Calls to Action
- "You are not broken. You are undereducated. ... This is not a personality flaw. This is biology." – Dr. Casperson [68:44]
- Most OBGYNs lack sexual medicine training; finding a knowledgeable provider is key. Resources: ISSWSH (International Society for the Study of Women's Sexual Health), patient communities, Dr. Haver’s list. [69:01]
- Vaginal Estrogen:
- Underused, cost should be <$20, can be applied internally and to the external genitalia.
- Reduces UTIs, death from sepsis, may reduce rectal cancer; has zero increased breast cancer risk. [73:26–74:23]
Notable Quotes & Moments (with Timestamps)
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Testosterone’s role in women:
- "In our bodies, we have four times the amount of testosterone than estrogen." — Dr. Casperson [06:20]
- "You put testosterone in a woman, put her in an fMRI, her whole brain lights up." — Dr. Casperson [09:13]
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Medical Inequity:
- “20% of men will have low testosterone ... about 12 products. 100% of women will have low testosterone. Zero products. Like, to me, make it make sense.” — Dr. Casperson [16:17]
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Motivation and Testosterone:
- "Testosterone is not just a libido medication. It's a motivation medication." — Dr. Casperson [18:07]
- “That’s my testosterone deck ... I have motivation to finish a project.” — Dr. Casperson [20:22]
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Practical barriers:
- "Insurance doesn’t cover things that aren’t FDA-approved. And they have to microdose. It's completely inaccurate. ... Or they’re pushed to pellets because that's the most profitable." — [37:06]
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Who benefits from testosterone?
- "Does it work in everybody? No, it doesn't work in everybody. But those are my bar. ... You'll know after about four months or so." — Dr. Casperson [34:23]
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GSM, estrogen, and real-world impact:
- "Within 18 months of that diagnosis, 7% of women were given vaginal estrogen, which is the bread and butter treatment for GSM." — [49:45]
- “Vaginal estrogen... would save Medicare $13 billion a year just in decreased urinary tract infection costs.” — [73:29]
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Women’s feelings are not imaginary:
- "What if women feeling miserable isn't it? What if we can try things and adjust things and they feel better?" — Dr. Casperson [32:30]
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Empowerment:
- "There is nothing more satisfying than a woman saying, I feel like myself again. Why don't we try it?" — Dr. Casperson [33:03]
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On vibrators:
- "When you improve technology down there, same stuff—vibration technology... why is the pelvis the only area that we’re like, but not technology there?" — [57:49]
Timestamps for Key Segments
- Testosterone in Women, Myths & Biochemistry: [04:34–07:27]
- Testosterone’s Impact, Brain & Body: [09:03–13:35]
- Gender Disparity in Treatment & FDA Barriers: [14:00–16:44]
- Symptoms, Energy, and Case Examples: [18:07–21:32]
- Lab Work & Holistic Screening: [29:29–32:05]
- Practical Prescribing Challenges (Products, Dosing, Pellets): [36:13–40:18]
- Vaginal Estrogen, GSM, Underuse, and UTI Prevention: [46:25–74:23]
- Medications that Impact Sexual Health: [65:21–68:41]
- Empowerment, Finding Care, and Closing Thoughts: [68:44–75:56]
Final Reflections
This episode asserts, with evidence and empathy, that women’s sexual and hormonal health deserve equal scientific, social, and medical attention. It highlights underdiagnosed, under-addressed factors affecting midlife women, and the urgent need for education, advocacy, and access. While testosterone is not a panacea, Dr. Casperson and Dr. Haver stress that curiosity, open dialogue, and individualized care can restore lives and empower women to "set the world on fire"—if only the stigma and systemic neglect can be overcome.
Resources Mentioned
- Dr. Kelly Casperson:
- Instagram, Substack, Podcast: You Are Not Broken, Books: You Are Not Broken, Menopause Moment
- Dr. Mary Claire Haver:
- Professional Societies: ISSWSH (ISSM)
"You are not broken. You are undereducated. You are likely under cared for. But this is not a personality flaw. This is biology." – Dr. Kelly Casperson [68:44]
