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- [00:04]
A
Welcome to the you are not broken podcast. I'm your host, Dr. Kelly Casperson, a
- [00:09]
B
board certified urologist, thought leader, and conversation starter on midlife living, hormones, and sexuality.
- [00:16]
A
Enjoy the show.
- [00:18]
B
All right, friends, welcome back. Well, this is a dual interview with me and Dr. Lauren Stryker, and we're going to have a back and back conversation about Testosterone. So. So, Dr. Stryker, thank you for coming.
- [00:28]
C
And this is pretty risky because both of us like to talk a lot.
- [00:31]
B
So it's gonna be two podcast interviewers trying to have a conversation, and we're gonna release this on both of our podcasts. Cause we just need to finally have a hopefully nuanced. We were talking before this. Like, it's hard to talk about testosterone in 180 characters. Like, Instagram is not the place to educate people on testosterone.
- [00:52]
C
No. And which is why we get a lot of backlash on it. Because you say one little thing and then everybody jumps on it and says, that's not true.
- [01:01]
B
Apparently Lauren has just informed me that people think I'm trying to get the entire world on testosterone.
- [01:05]
C
You have been accused of that, Dr. Caspersen.
- [01:08]
B
That's on them. Those words have never come out of my mouth. I do think that women should be educated. I do think we need more research. I do think we need a product that can be appropriately dosed.
- [01:19]
C
You and I both agree that women are smart. They just need to be given the facts so that they can figure out what's right for them. And the truth is, while you get accused of being the, you know, the testosterone queen, and I don't have that title yet, but I honestly think I am guessing that we are going to be in agreement on more things than not, if not everything. I mean, we both agree. We both agree testosterone's a human hormone. Right? We're there.
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B
Testosterone's a human hormone. Did you learn that in medical school?
- [01:51]
C
I didn't learn anything in medical school. It's amazing. When I first started my residency in OB gyn, I look back and it's astonishing what I didn't know and that I didn't kill women right and left. And that's because I had people who were watching every single thing that I did. But I really knew very little. But forget medical school. I didn't learn this stuff in residency when we're really supposed to be learning. And I didn't learn anything about menopause. I certainly didn't learn anything about testosterone. When I first started learning testosterone, interestingly, was there was a product called Libi gel which was going for FDA approval. Testosterone of course, is not FDA approved for women. And they tried very hard to get it approved. So there were clinical trials going on, the LIBI Gel trials. And at that time I was already attending and I was asked to participate in the LIBI Gel trials. And I said, sure. And I'm thinking, I don't know anything about testosterone. So that's when I first started to read about it and learn about it and know something about it. And what's so interesting is it never did get FDA approval. Not because it wasn't safe, not because it wasn't effective, but because of some craziness on the part of the FDA that they were requiring things that no pharmaceutical company would do without spending a crazy amount of money. But as we talk about the data, and I know we're gonna get into the data a little bit, a lot of that was from the Liby gel trials, which were 2010, 2011. Right around then is when all those studies were coming out. So what was your journey? When did you first learn testosterone?
- [03:23]
B
So I'm a urologist. So to me I'm like, testosterone, it does not scare me, right? Because I think so many people, because they don't know about it, they're like, it's probably scary. It's got a Class 3 FDA schedule on it, to which so does ketamine and so does codeine with Tylenol. So it must be unsafe. And I think it really gets this bad rap because of abuse of synthetic anabolic steroids that happens in sport. That's what not what most people take this for.
- [03:49]
C
Well, you know, the other thing also in terms of terminology, I and most menopause experts of course, use the term hormone therapy, not hormone replacement therapy. And the reason for that is, is that we're not trying to give higher than normal doses. We're not trying to even necessarily replace exactly what someone was making in terms of hormones. We're doing therapy to get to an appropriate level that's gonna benefit someone in terms of how they feel in long term issues. So that's why we use the term hormone therapy. And I think that's also really appropriate when we talk about testosterone because there isn't a specific level that we're headed for. We're looking for specific goals. Right?
- [04:26]
B
And I think, you know, what I try to say a lot, I think because of the stigma of testosterone is I like to say physiologic dosing. Physiologic dosing, which people will interpret to be like, what level should I be at? And the guidelines say how do you feel?
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C
Right.
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B
Do you feel like it's benefiting you without having side effects?
- [04:45]
C
How do you feel without getting into trouble without side effects? Exactly. And we can talk about that and why it's gotten a bad rap and what happens when people give too much much. But I think we are absolutely in agreement that women benefit from taking testosterone. And some women benefit more than others. And I think at the top of my list, and I want to hear who you most think most benefits. But I look at women who've had ovary removal, because when we look at where testosterone is made, of course, most of it's made in the adrenal glands. Almost half of it's made in the ovaries. And even the post menopause ovary continues to pump out some. Not as much as it used to. You know, the levels go down. But postmenopause women are still making testosterone, but if they've had their ovaries removed, their levels are a whole lot lower and they're generally gonna benefit more. What do you think?
- [05:33]
B
And what's so crazy about that is if you look at data, these are old studies, 1985, 1987, like, this is not groundbreaking work of people saying, when we take their ovaries out, let's give them estrogen and testosterone. They did that. They published the data. They said they do well. And now it's like we're having this brand new conversation again. It's like the iron curtain came down with the WHI and like, we forgot. We've actually done a lot of this
- [05:59]
C
research already and the work has been done. And quite frankly, a lot of that was done in the Liby GEL trials. And the women who were enrolled in Liby Gel were women who'd had a surgical menopause. That was one of the criteria is they wanted to get a group of women who truly were testosterone deficient.
- [06:18]
B
Yeah. And the testosterone that was approved in. In Europe, that is now off the market, that was approval only for surgical menopause women. And one of the arguments was like, listen, it didn't sell because there's just not that many women. I mean, there's still a lot of women who've had their ovaries removed, but it's a small part of the population. And if that drug was only for them, because they didn't say it was for all postmenopausal, it didn't do well, and then it went away.
- [06:44]
C
Correct, Correct. Well, let's. Okay. What I'd like to know is if we are in agreement in Terms of what goals we have when we recommend testosterone for someone and in what situations you think it's appropriate, because you've been talking about it a lot more on your podcast than I have. I have a testosterone episode from season one, but I haven't really been focusing on it. So just to get my folks up to speed, when most people are talking about testosterone replacement, the kind of straight academic, they are talking about it to improve libido. Because the liby gel trials were specifically about treating women with low libido who wanted to make it better. So the data that we have is primarily, primarily for women with low libido, which isn't to say to your point that there may not be other benefits. But that's the data. And that's why people that are sticking to, you know, the ivory tower academicians are the ones that are saying it's okay to give women testosterone, which is still off label because it's not FDA approved. And of course, as I say all the time, off label does not mean it's illegal or inappropriate. It just means the FDA has not given it their blessing. Birth control pills for cramps are off label.
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B
Birth control for skin, for acne is off label.
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C
It's off label. Birth control pills to regulate your cycles is off label. The only thing birth control pills are on label for is to prevent pregnancy. So just we can take the off label thing is not a problem.
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B
80% of women at some point in their life have been on a birth control pill.
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C
That's right. And 30% of them are taking it for something other than contraception.
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B
We digress, we digress.
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C
But the point is when we toss out the term off label, and I just want to be clear that off label is not a bad thing. It's just a category of things that are not FDA approved for specific indications. All right, so this is the thing. It's real easy, I think, for me and other menopause experts to say that post menopause women who are having trouble with low libido will benefit from testosterone supplementation in physiologic dosages to get them to a level that's physiologic and that this may help them. Not 100%. You know, we're looking at 50, 60%
- [08:52]
B
if they're low libido is because of low testosterone. But you gotta know, you gotta know a lot about low libido to be like, testosterone's not gonna help everybody here.
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C
Right. And I always say what people sometimes really need is hrt, which is a husband Replacement therapy to help their low libido. I mean, it's multifactorial. Let's be honest here.
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B
So.
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C
But the point. But, you know, I think it's important, though, because when we say testosterone isn't going to work for everybody, for low libido, of course it's not. Nothing's going to work for everybody.
- [09:18]
B
Which is why people, I think, hate on, like, the testosterone. But estrogen works Great. Not working 22 hours a day is good for your libido. Like, libido is so complex that to put the weight of libido on one hormone is incredibly insulting to how complex humans are.
- [09:38]
C
All right, so I want you to start with talking about. So I said, okay, libido. Why don't you kind of give your laundry list of, if a patient were to come to you and say, my libido's fine, I have no problem with libido. Am I a candidate for testosterone? What's it gonna do for me? What would you tell that woman?
- [09:54]
B
Well, first, I mean, two things. Number one, do I need testosterone? People ask that on Instagram. Do I need testosterone? Nobody needs this. You're probably not gonna die sooner. Like, nobody needs it. But it can be helpful, and I like to clarify that. Number two, I think this is a case of the tail wagging the dog, for lack of a better metaphor. Help me out. But people are like, we only have approval, and we have the most studies for low libido. Yes. Why? Because the FDA said when we approve this, we're gonna approve it for low libido. The money follows what the regulation says they're gonna do it for. So until the FDA says we want to look at this for hypogonadism, which is what it's approved for in men, which I think is true gender equality. Let's get it. For hypogonadism for all genders, you're going to have more studies on low libido. When the FDA is like, that's what we're going to approve it for if we're going to approve it for anything. So it's a very circular argument.
- [10:52]
C
What people don't realize is to get FDA approval costs an average of, you know, what, $100 million in 12 to 15 years to get your drug to the drugstore. And most of them don't even make it. So the more focused somebody is, the more likely it is to be approved. That's why most of these drugs are just for one very specific indication, because they know that it'll get prescribed for other Indications, they just need to get it out there.
- [11:16]
B
Ozempic is not FDA approved for weight loss. Right. It's used off label for that. But they needed a smaller niche. They needed to be in diabetics with weight equaling, blah, blah, blah. Like they had to be very narrow. And then you expand it. But for people to argue that the only indication is for low libido, this is the best. This is the easiest way I've got. Where's libido? Libido's in the brain. Oh, okay. So testosterone works on the brain. Yes, testosterone works on the brain. Okay, one little teeny spot in the brain. No, the brain. Right. And we have data on that. We have data in men. We can use data in men. We are similar beings. Right? And it's like the cognitive changes. And Lauren, you know this. You give a woman testosterone, she'll come back, she might say, my libido is better or it's not, and then she'll say, but. And she will tell you what feels better. I had a woman last week, and I know, I know this is anecdotal, but you can't study some things. It's very hard to study feeling more like myself. It's a very hard thing to study. This woman said, you know that part in the wizard of Oz where you go from black and white to Technicolor? She's like, that's what my brain does on this. And she's like. So I stopped it to see if I was just maybe making that up. My world went into black and white again. And no, she doesn't have vision problems. It's her brain using this testosterone. She's like, the world is interesting again. And it's like, how are you going to get. You're not going to get an FDA approval for the world is interesting and right.
- [12:47]
C
They talk about all these quality of life tests and all that, but I don't know if you've ever looked at the questions on there, but they're kind of silly, I think, and I don't think that's a very good measure.
- [12:57]
B
They're very hard to do as far as measuring like dementia or changes in, like, significant enough to measure dementia. It's very hard to measure that under with short studies.
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C
But the concept, to your point, of hormones that we think of as sex hormones, estrogen and testosterone, being important in places in the body other than the reproductive system for most women is news, quite frankly, for a lot of doctors, it's news, you know, that they don't appreciate the fact that There are hormone receptors throughout the body and the bones and joints. And we talk about all this stuff,
- [13:29]
B
including the brain freaking heart palpitations that go away when you give a woman estrogen.
- [13:34]
C
That's right. And so much of what we're really studying now and learning about now. I mean, it seems like every day a new article's talking about the impact of estrogen on fill in the blank. I did a podcast episode on estrogen and dry mouth and I thought, how many people can this be? It went off the charts because there are estrogen receptors in the salivary glands. And actually the inside of the mouth is a lot like the inside of the vagina. Just saying. It really is. But that's the point, is that we're still learning so much. All right, so we got away from what I wanted to ask you. So let's talk about what are the kinds of things other than a general sense of wellbeing. I feel like myself. I feel good, I feel energetic. Give me the specific kind of go down your list of what you tell women the specific benefits are potentially of taking testosterone.
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B
So I'm very vague to them because I want to under promise and over deliver. Meaning I'm not going to tell you the world's going to be in Technicolor. Like, I can't tell you what other women tell me and promise that that's going to happen to you. I don't know.
- [14:38]
C
No, that's anecdotal. That's the supplemental E.V. don't do that.
- [14:41]
B
So I say the. The only real approval, not FDA approval, but like authorization in 14 different languages is for low libido. I think it's ridiculous that a woman gets an indication to sleep with another human as the only indication. It actually makes no sense. So what would I tell women? I'm like, listen, women come back saying different things. I can finally make gains in the gym. I'm sleeping better. Does help hot flashes a little bit. Helps mood a lot. A woman's like, I just want to kind of get up and do stuff in my house again. I kind of want to like get up and get my to do list accomplished.
- [15:12]
C
But that's quality of life stuff. That's. I feel better, I feel more like myself.
- [15:16]
B
Which I would argue is the most important thing to help people with in medicine.
- [15:20]
C
I think there are two most important things I think in terms of short term, quality of life, and long term. Is this going to extend my life or make me healthier down the road? I'm in it for the long haul. So when I talk about hormone therapy and people say, when should I go off my estrogen is when my hot flashes are over. And I'm like, oh, my God, no. You know, your entire cardiovascular system, your brain, your bones, your muscles, your vulva, your vagina, everything is gonna continue to benefit until you're dead. So therefore, you stay on until you're dead. So what I wanna know from you, Dr. Kasperson, is if someone says, you know, I'm feeling terrific, I am fine. I wanna know, is testosterone gonna help my bones, my brain, my muscles, all of that? That's going to help me live a longer, healthier life?
- [16:10]
B
We've got data to say yes. And this is where, you know, I hesitate to be pigeonholed into the person who tells everybody to be on testosterone.
- [16:18]
A
Right?
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B
Because people get pissy about that. But it's like, no, no, but let
- [16:20]
C
me interrupt you one second. We both agree, and we have data that shows. We have data that shows that estrogen is going to help in terms of cardiovascular health and brain health and cognitive function. We could go through all that, but we still don't tell everybody. Everybody needs to be on estrogen. There are so many other things, you know, these people who say, well, I'm gonna take estrogen, but I'm gonna eat processed food all day and drink a bottle of wine a night, and, you know, okay, that estrogen's really not gonna help.
- [16:45]
B
Well, then, fair. So, yeah, we have data for the brain. I think testosterone's the missing element for dementia. Like, I will go that far. We've got the data in men, we've got the data in frailty. We have a new paper got published looking at phosphorylation of the tau protein, specifically in women who have the APO4E allele for Alzheimer's disease.
- [17:07]
A
Right.
- [17:07]
B
Like, we have preliminary data on this. Our bodies are complex. We might need more than one hormone. Lauren.
- [17:15]
C
No, no, but I'm just saying. My point is, is we have that data that shows that there's not as many tau tangles in women who take estrogen as opposed to women who don't. Have you ever heard any doctor talk about that? Other than, you know, the little group of. You know what I'm saying? But. So we already have that data for estrogen, and it's not an indication for estrogen.
- [17:33]
B
And.
- [17:34]
C
And then we're saying, okay, so testosterone is potentially. We don't. We don't have the longitudinal data, you know, this. The placebo controlled trial that we give 1,000 women testosterone and 1,000 women placebo. And we watch them for 50 years and then say, you know, less women got Alzheimer's. That's the data that the purists are waiting for.
- [17:54]
B
The Gen X women who are seeing their parents age will not wait for this data to happen. The WHI was a billion dollar study. And we know the good and the bad that came from that and how long that took and that we're still digesting it. Who's holding their breath for the next $2 billion study on this? It's not gonna happen.
- [18:14]
C
It will not happen. No, I know it will not happen. Okay, let me ask you this. Cause I rarely ask questions that I don't know the answer to. Cause that's what always a good podcast host does. Right. But I don't know the answer to this one. And you will. What is it FDA approved for in men other than hypogonadism?
- [18:29]
B
Hypogonadism.
- [18:30]
C
That's it. Like there's no specific other things like, you know, that's it.
- [18:35]
B
It's used off label for libido. It's used off label. It's not FDA approved for men for libido.
- [18:40]
C
That's good. So I did know the answer to that. And I thought I didn't.
- [18:42]
B
It's not unless I'm wrong. But it's.
- [18:44]
C
No, you're never.
- [18:47]
B
That's so nice. But yeah, I mean, we use testosterone off label in men all the time. And that's the other question. Are we gatekeeping differently between genders? I see that a lot more in
- [18:59]
C
I've done how many episodes on the orgasm gap between men and women? You know, it's not just the orgasm gap.
- [19:04]
B
It isn't getting better. By the way, that just got published, horrible. Testosterone helps orgasm. Have you noticed?
- [19:11]
C
Yeah, well, sure, because it's those afferent pathways. I mean, look, there's testosterone receptors throughout the lower third of the vagina, the vulva, the clitoris. We know that. We know that.
- [19:23]
B
Let's go for something that's big. Let's go with osteoporosis and hip fracture. We've got some studies showing that estrogen plus testosterone has better bone markers than estrogen alone. My problem is people saying we have no data. And what I do is I dig up the data we do have and say let's work with what we have. I'm not saying anything that I haven't seen published somewhere or in the bare minimum, is anecdotally coming back to my clinic right when. And women reporting this. But when people say we have no data. They're just massively not curious because I've read most of this stuff.
- [19:58]
C
Well, I think the problem with having no data. No, no, I know you are and that's why I love you. But the problem with having no data is that I feel like we have an obligation to say, like if someone says, let's talk about safety for a minute and then we're going to go back to what it does for you, because we think in terms of safety for testosterone.
- [20:16]
B
Oh, I love the safety, testosterone discussion. We definitely need to talk about this.
- [20:19]
C
I think for me is very, very clear cut. We have excellent 12 month data that shows that testosterone in appropriate levels is safe. And I have no reason to think it's not safe long term. But if you were to say, do we have 30 year data? 40 year data? We do not. We don't have that for estrogen either. Well, then you have to point me that direction in women. In women, not men.
- [20:45]
B
Yes, we do. Okay, you ready? Are you ready? Dr. Abdul Trach, PhD, published a study. I can send it to you. So let me set the stage. What if we take a drug and we ask people, are you willing to take this drug? But I want to, I want to give it to you at 10 times the dose. Have we ever done that with any drug? And then these people are like, yes, and I want to keep taking it. And I want to keep taking it for 30 years willingly. Okay, but it's 10 times the dose. No, I wanna keep doing that. All right, so we've let those people keep taking 10 times the dose of the drug for 30 years. And we watched em and they don't have increased risk of cancer and they don't have increased risk of heart disease and they don't have increased risk of blood clot. Who are those people? Trans men.
- [21:33]
C
Yes, I have heard you now that you say that, but it's interesting. But the other thing also is little known fact about me. Before I became interested in menopause, my area of interest was minimally invasive surgery, hysterectomy and alternatives to hysterectomy. And I was the queen and one of the first in Chicago to do outpatient laparoscopic hysterectomy. And who found their way to me? Trans men. Because men, people who are transitioning from female to male and are taking high doses of testosterone for a variety of reasons, want to get rid of their uterus. And in that time it wasn't covered by insurance, of course. So they wanted it to be outpatient and they found their way to me because first of all, I was welcoming and my office and staff were welcoming and we very quickly learned language and appropriateness and all that kind of stuff. But if you are doing a laparoscopic hysterectomy, you need to go through the vagina in order to just technically do what you need to do surgically. So I figured out a way to do it without vaginal access. I kind of jerry rigged something and I made something up, which is the fun of being a surgeon and being kind of creative and solving problems in the operating room. And word got out. So suddenly I was doing hysterectomies on so many trans guys. And the reason, there were two reasons briefly to have their uterus out. One is because some were having reconstructive plastic surgery and they needed to get rid of their vagina and their uterus. But beyond that, it's because they were going to be taking long term testosterone. And one of the metabolic products of testosterone is estrogen. And if you take estrogen long term without progestogen to counteract it, you have an increased risk of uterine cancer. So they all wanted to get rid of their uteruses so that they didn't have to worry about taking long term testosterone. So I'm going to counter you on, we have this test in men. There's a difference between those that have a uterus and those that don't in terms of safety. And I think that that's something that we have to at least throw out there.
- [23:39]
B
Yeah, I mean, the data I've seen on female dose testosterone is that it's anti proliferative to the endometrial lining. So that sort of. Now we're talking about 10 times the dose for that one. But as far as breast cancer, heart disease, like significant stuff that pops up, it's not happening.
- [23:56]
C
That was never the issue from my point of view, and I agree with you on that. But also, it's also not the issue for estrogen. But also, when we talk about the trans population, this is really a whole nother topic, but it's interesting, so we'll just go with it for a little bit. When you talk about the trans population, they have a lot of different ways of taking testosterone, whether it's injected or transdermal or even oral. And like all hormones and like cannabis, it depends on how you consume it, you know, in terms of the impact it's gonna have on the body and how it's gonna be metabolized. But I think that's really important. To point out, because when we look at things like liver and blood clots and all of that, just like estrogen with testosterone, you're only gonna see that with oral. Which is why we. When I say we, I'm talking about, you know, menopause experts and sexual medicine experts that are prescribing for women are recommending transdermal products. And I'm.
- [24:45]
B
I like transdermal products. It's my go to.
- [24:48]
C
Yeah, it's very, like, it's safer.
- [24:50]
B
It's safer. It's very hard to get high, even high physiologic doses with it. It's hard to get into trouble with it. One more thing that just got published, which I think is helpful because I think in this discussion, we always need to look, how do we treat the men? How do we treat the trans men? How do we. What can we learn, right? Because we're so, like, the thing with women is, like, we're so afraid to do anything to them, right? We give people 10 times the doses and we give men, right, all this stuff. So new paper came out looking at trans women. Trans women frequently will have their testicles removed so that they don't have that high dose of testosterone in there. New paper came out saying, hey, maybe we should give these people female physiologic testosterone doses. Because turns out their bodies do better with a little bit of testosterone. So it's an interesting example of being like, we take out the testicles, they have, you know, the adrenal amount of testosterone. We give them estrogen. We thought that was gonna be good enough. Turns out they benefit from that female physiologic dose, testosterone also. So it's like. It's so interesting.
- [25:54]
C
Yeah, I mean, it's so interesting. And there's so many things. But one of the things that's tricky is very often people will say, okay, well, I'm gonna have my blood drawn. What level of testosterone do I need? And, you know, you're smiling. I'm smiling because we know the lab sucks. The level does not. Well, first of. And it doesn't necessarily correlate with the effect that you're gonna have. So that it's not like thyroid medication that you say, this is the level that we want. This is what we're going for. And then we're all happy. You know, it's not like that with testosterone. It's. We don't. We know that we don't wanna go too high because we're gonna get into trouble. But within that, there's a very, very Wide range of where people are gonna get benefits.
- [26:35]
B
I mean, think of.
- [26:36]
A
Think.
- [26:37]
B
Think of what else we need to know. How many androgen receptors do you have? What's your affinity of your androgen receptor to the testosterone? Like, we can't measure any of that in you, which is why your blood level is going to be different. The other thing we know about testosterone, your serum testosterone level, even if the lab is good and accurate, which that's questionable, does not even correlate to the amount of testosterone that's circulating in your brain, right? So the serum test is actually a very blunt tool to say what's actually going on in your end organs. But, like, you know, I volunteered in Africa, and, like, they got an X ray machine at this clinic. Everybody just wanted a fricking X ray, right? And then the doctor's like, you don't need an X ray for everything. And people are like, but I just, you have an X ray machine. Let's get an X ray. And that's how I kind of feel about this. Testosterone labs is like, yes, that's how
- [27:25]
C
funny, because when I volunteered in Africa clinic, it was the ultrasound machine. Every pregnant woman wanted an ultrasound, like, every five minutes.
- [27:33]
B
And so, like, that's how I feel with labs, is like, what lab should I be at? What's the optimal lab? And if you notice on my Instagram, I never say what I think the optimal testosterone lab's going to be, because the people are going to hone in on that. And it's way more nuanced than that. I think you should get one at baseline to make sure you don't have a person with high testosterone in perimenopause or menopause. I haven't found that person yet, but I'm looking and then check it six to eight weeks after to see that they're actually absorbing it, to see where they are. And the other thing to tell women on testosterone is when that second lab comes back, it'll be flagged as high because the labs stay high on the female dose after about 40. And I'm like, I don't care what it says. How do you feel? Do you want to stay on this?
- [28:18]
C
And are you growing a mustache? And are you having acne? And are you losing hairline hair? So you're looking like your balding uncle. You know, that's the kind of stuff we look at the level. I think that's the most important because when I look at, okay, what levels do I get? I get testosterone level like you do, just to make sure it's not too high. Just kind of know where we're starting from. I get a sex hormone binding globulin, shbg. I don't know. If you do, we can talk about that a little bit. It's interesting that if you look at the criteria, the recommended criteria, including iSwish, which we're both involved in, and iSwish has a protocol, and in their protocol is liver function tests and lipids. And I'm looking at that and I'm going to.
- [28:58]
B
Why?
- [28:59]
C
Because if you're giving a transdermal testosterone that does not get metabolized by the liver, it's gonna avoid that trip through the liver. It's not gonna have any impact at all on liver function and on lipid. So let me ask you, first of all, what labs you get to start. And then I wanna spend a few minutes talking about sex hormone binding globulin. Cause I think that's an important concept
- [29:19]
B
I learned through ishwish. I was doing free testosterone percentage for a while. In my experience, as I've grown confident in treating women and the doses I'm giving women, I just do a total testosterone mass spectrometry for the female because it's more accurate at the lower dose or at the lower levels. That's really it.
- [29:39]
C
You don't get a sex hormone binding globulin.
- [29:41]
B
Oh, yeah, sex hormone binding globulin. Yeah, But I don't get LFTs. I like to know what their cholesterol is just because I think it's heart. Healthy discussion is worth having. You know, hormones don't exist in a. But the data doesn't support that physiologic dose. Female testosterone changes lipids.
- [29:56]
C
But I think also people need to understand that when we get recommendations from societies, whether it's the Menopause Society or iswish or whatever, these are just recommendations. It's not the law. You know, this is just guidelines.
- [30:06]
B
People use it as a law, which is wild.
- [30:10]
C
Well, it's problematic. And it's like everything else in life, Kelly. We use it when it helps us. Like when people say, do I ever have to stop using my hormone therapy? And I'm like, no. The menopause society says you can use it forever. If they didn't say, say that, I just wouldn't say anything. I just said, it's like, mom, you know, you use it when. When it's going to benefit you. And otherwise you just ignore whatever. Whatever the protocol is totally.
- [30:33]
B
Like, I always going into lab, I always check a thyroid because I think TSH can masquerade as menopause symptoms a lot.
- [30:41]
C
When people say, should I get my hormone levels checked? I always say, yes, you should get your thyroid levels checked. Because Too often, by 1 out of 10, women have alterations in their thyroid function midlife, and it's. They're not getting screened and they feel like caca and they think it's menopause, when in fact it's thyroid disease.
- [30:57]
B
Yeah, yeah, exactly. And I've caught that a couple of times. So I'm not a primary care doctor. I refer back. But hormones are only gonna do what hormones are good. Like, they're not gonna. They're not gonna change your life, Fill up your bank account, make every ache and pain go like, it's just like. The hope that is put on these hormones sometimes is not realistic. But I would say I'm more optimistic with these hormones than a lot of people. Just because women come back to you and they say, I feel like myself again, that's the most joy you can get as being a doctor is for somebody to tell you that.
- [31:30]
C
So let's discuss. I'm actually, I'm in the midst of recording a Q and A podcast because I get so many questions that come in like you, and not one of them is enough for a whole podcast. So I've just kind of piled them up and I'm gonna do a whole Q and A podcast. But one of the questions that came in that I was gonna use, but we can talk about it now, is a woman who said to me, I really wanna take testosterone, but my sex hormone binding globulin, my SHBG, is very, very high. And I have been told that I likely will not get a response. So, number one, is that true? And number two, what can I do to bring it down? So, just to start for the uninitiated, sex hormone binding globulin is a protein that we all have in our bodies, but among other things, it binds testosterone. And if testosterone is bound to sex hormone binding globulin, it's not activ. It's the free testosterone that does all the wonderful things we've been talking about. So if somebody has a high sex hormone binding globulin, then they are less likely to respond to the kinds of dosages of testosterone that we normally give.
- [32:35]
B
I'm nodding in agreement for people who can't see me on the podcast.
- [32:39]
C
So one of the labs I get is a sex hormone binding globulin. And if it's high, I tell the woman, we can certainly Try testosterone therapy, but you fall into the group that you may not get much of a response because it's all gonna get bound up so that it's not gonna do what it needs to do. What do you tell people and how do you approach that patient?
- [32:59]
B
Yeah, well, they might, I mean, they might need higher doses, right? Cause you're trying to.
- [33:02]
C
That's one of the questions is, do you, do you give higher dosages or is that just gonna give them a mustache?
- [33:06]
B
I would just start out with regular doses and see what their response is. Cause there's so many things that contribute to this. And then I would say, is there anything modifiable you can do to help decrease your sex storm? Are you on oral estrogen? Are you on birth control? Can you modify that?
- [33:23]
C
Yeah. Because when you go down the list of okay, why, why would someone have a high sex hormone binding globulin? Well, some of it is just aging and life, it will get higher. But I think one of the number one things that we see in the post menopause population is if someone is taking estrogen orally, not transdermally or vaginal or anything else. But if someone is taking oral estrogen just like birth control pills, and that's true for perimenopause women, it's gonna shoot your SHBG high. And so sometimes just switching someone to a transdermal estrogen product is going to make the difference. And I think that's something that's missed a lot. That's kind of an easy, easy fix. Thyroid dysfunction also, like to your point where you say you check thyroid because if someone has untreated thyroid disease, that's also gonna mess up their sex hormone binding globulin. But, you know, so it's interesting because, I mean, I feel pretty comfortable with testosterone, but I'm not, not necessarily comfortable with giving someone significantly higher doses than I normally would because I'm so worried about side effects. And so if I have someone that has a really high sex hormone binding globulin, and if they're not responding to physiologic, I don't know that I'm comfortable going a whole lot higher.
- [34:33]
A
Yeah.
- [34:33]
B
And to me, you know, I'd start them on the standard dose, recheck their levels, see where they got with that, see what their goals are. Why does she want to be on testosterone? Is there something else you can do for that? That certainly things can be nuanced. I don't want to miss us talking of giving our opinion on pellets.
- [34:50]
C
Pellets are malpractice is my opinion. What's your opinion, Dr. Gasperson? Not that I have an opinion. It is not a safe way to give testosterone. People get sky high levels and they get into trouble and you can't control. Once that pellet's in there, you've got. No, you can't dig it out. You have to sit there and wait and wait and wait.
- [35:10]
B
Both you and I have seen some scary shit.
- [35:13]
C
Yeah.
- [35:14]
B
Enlarged Adams out there.
- [35:14]
C
Yeah. Clitoris that any guy would be proud to own is a penis. You know, kind of.
- [35:18]
B
The hair loss is the biggest one. Which hair doesn't like significant hormone changes, whether that's thyroid or anything. So hair freaks out. I mean, I tell women it's like going from. Especially if you're starting out low, which most people are when they get hormones, you're at sea level and you get flown in a helicopter to Everest base camp and dumped out. Right. It's like, it feels very shitty. But some people love it.
- [35:44]
C
They love it. But the other thing also, Kelly, is I think that this is an important point because when you say, okay, what's your opinion? And aside from the fact that we know that pellets have an increased risk of side effects, including an increased risk of pre cancers in the uterus and cancers because of these very high dosages of hormones. But that aside, when we talk about what's giving testosterone therapy a bad name, it's pellets. If we were not having to counteract the problems with pellets, it would be a much easier job for us to talk about safety and efficacy of testosterone therapy. But we are really fighting two battles at once. We're trying to educate people on safe use and we're trying to fight that battle of. And then we've got the pellet pushers out there and the problem is all peace. The problem with pellet pushers is that they are creating problems as a downstream effect of other people who are trying to give hormone therapy responsibly.
- [36:42]
A
I agree.
- [36:42]
B
And I mean, I think the hallmark, in my opinion, the hallmark of a hormone expert is somebody who knows multiple ways to treat you. Is it a cream? Is it a gel? Is it a pill? Is it a patch? Is it a. Blah, blah, blah.
- [36:55]
C
I'm amazed the number of people that think their only option for local vaginal estrogen therapy is a cream that no one has ever talked to them about. You know, inserts and tablets and rings and.
- [37:04]
B
And dhea, which is so. Is so beautiful. But the, the hormone expert, in my opinion, has a Has a restaurant menu.
- [37:12]
C
So what I did in my, in my menopause clinic is I used to have baskets. So I had my hot flash basket, I had my vaginal dryness basket. And I would literally sit down with the woman and I would say to my assistant, let me have my vaginal dryness basket, please. And she would bring the basket in and I would put every product on the desk and I say, these are the six products that will solve your problem and I'm going to tell you the pros and cons of each. And you say either yes or no and we'll throw it back in the basket and see what we're left with. Because people need to have choices. And when people say you wrote an entire book on vaginal dryness, you know, my slip sliding away, turning back the clock on your vagina. Yeah, I did because I have like one chapter on every product. But we've been talking really about systemic testosterone in terms of libido and even well being and muscles and all that. We really haven't touched on using testosterone in the vagina and on the vulva. And I think we should talk about that for a minute because it's different, it's very different in terms of our approach. And you know, to be clear, we've mentioned that there's testosterone receptors, particularly in the lower third of the vagina and on the vulva as well. But my approach, I'm assuming your approach to making sure those receptors are happy is not necessarily to give systemic testosterone that sometimes we use, and this is compounded off label. There's no product for vaginal testosterone use. But in general for women who were having a really tough time and were not responding to estrogen alone, and we ruled out other causes of problems, very often we would end up giving a concoction of either estrogen and testosterone mixed together for the vagina and the vulva, or dhea, which is a precursor for both estrogen and testosterone.
- [38:55]
B
Yes. And in the breast cancer, in the breast cancer survivorship literature, testosterone alone.
- [39:00]
C
I know, and it's interesting.
- [39:02]
B
That's where I'd say the majority of the research is, or the published research on localized testosterone is cause they were pushed, their hand went back in the never ever to estrogen phase, which I think is being more liberalized now in the survivorship community. But that's where a lot of the data is.
- [39:17]
C
Yeah, but I do think it's worth mentioning, at least I tell people that I have no problem with using a local testosterone on parts of the vulva and in the vagina. But I do tell people not to put it directly on their clitoris.
- [39:31]
B
I'll do estrogen cream on the clitoris. And if I see a clitoris that's atrophic, they're having issues with sensitivity or arousal. And if they're not estrogen cream responders. Right. Then I'll do the combined estrogen testosterone to the clitoris.
- [39:45]
A
Okay.
- [39:46]
C
But it will make the clitoris bigger,
- [39:47]
B
of course, which is what we're going for when it's an atrophic clitoris.
- [39:51]
C
I am going to quote a good friend of both of us, Dr. Rachel Rubin, who says that a big clitoris is not more sensitive than a small clitoris because the biggest clitoris, of course, is a penis. And we know that a clitoris is at least tenfold more sensitive than a penis because of the number of nerve endings and the density.
- [40:14]
B
I don't think I'm disagreeing with that. To me, I'm like, size doesn't matter. But when it's atrophile, you know, you have diminished labia minora. Right. You have signs of atrophy. That's where I'm not just trying to get you a bigger clitoris. I'd shoot you up with five pellets if I wanted to do that.
- [40:28]
C
But you do have to be careful with that, is my point.
- [40:29]
B
Well, here, this is interesting, which I see a lot on social media. It's not in my community going, if you go back to male testosterone, some of the earlier male testosterone products, they had a patch and a gel, I believe were applied to the scrotum. The reason is there's tons of receptors. It got into their body really well and then they moved away from that. Right. So, number one, even with the Ishwish approved local doses, percentage wise, I've seen systemic lab values with labial vaginal testosterone cream. So watch out for that. I've seen it happen.
- [41:04]
C
Especially if people have very, very thin tissue. You know, it's counterintuitive because people that have the thin tissue are very often the ones that will absorb the most. And sometimes they're afraid if this goes for estrogen too, they'll say, well, I'm just gonna use a little bit, so. Cause you know, I'm scared. And it' like, no, that's when you slather it on. Because that's going to make your tissue thicker and it's not going to absorb as much.
- [41:23]
B
Exactly. I don't know what group is doing this, but some groups of hormone people are giving systemic testosterone and telling Women to apply it to their labia and clitoris to get it into their bodies. There's no data on that. And why do you. You don't need to touch your genitals every day to put on your daily transdermal testosterone dose. So I think that confuses people. When you're given systemic testosterone via application to your genitals, you can do it, but it's not necessary.
- [41:54]
C
All right, so one thing I wanna circle back to that we got away from before we. I wanna talk about your book. Cause that's, you know, of the moment. But let's talk about muscles. Because if we think in terms of the reasons why women are curious about testosterone or might wanna go on it, one of them is the medical word is sarcopenia, you know, muscle wasting, which, and it's not just about, oh, I can't run a mile anymore, we know, ending up in nursing homes and falling and all kinds of other life altering and life threatening things.
- [42:22]
B
A major reason that you have to go into assisted living. You can't do your activities of daily living. Yeah.
- [42:27]
C
So the question is, do you think we have the data in women to support giving women systemic testosterone specifically to stave off sarcopenia? So we've established that we both think it's safe, we both think it can be used long term. But now we're saying, okay, do we have data that shows it's going to help your muscles?
- [42:50]
B
This is what people need to know. This is the, like testosterone or hormones won't do it all for you. Any gender data giving testosterone by itself, without weightlifting, without eating appropriately for muscles will do nothing for your lean body mass. You have to lift weights, you have to eat appropriately. Especially the Gen Xers. We're trained to starve ourselves. We don't eat for muscles, we don't lift for muscles. So do I think giving women testosterone to save off sarcopenia is gonna work? Absolutely not.
- [43:21]
C
Yeah. Well, I have never seen any data to support that. And in fact, there's some data that shows it really doesn't do a heck
- [43:29]
B
of a lot because you have to lift and you have to lift.
- [43:31]
C
You have to lift, you have to eat protein, you have to get. Stop the processed food, for God's sakes.
- [43:36]
B
Yeah, stop the process food. So, yeah, I mean, that's why when you get into saying stuff like that on the Internet of like testosterone for muscles, the asterisks and the longer conversation is like, it won't do anything if you don't behave in a way to create muscles in your Body.
- [43:54]
C
And I think one thing we should mention, because we assume everybody knows this, but they may not, is we're not getting into dosage nor do we want to. That's something that you really need to meet with a clinician and see what's right for you. But do not borrow your husband's testosterone because men require 10 times the dose of women. And I guarantee you that if you use your husband's testosterone in the dose that he is using, it will not end well. He'll be mad that his testosterone is gone and you'll be mad that you're growing a mustache. So don't do that. You need to. This is not a do it yourself project. You need to work with someone who can really advise you into how to do this in a way that's not only gonna be effective for you, but safe. Safe. Now talk about your book, because we only have a few minutes left.
- [44:38]
B
The book is called you are not broken. Stop shoulding all over your sex life. I wrote it because women kept telling me all these things that could just be cured if we got a decent adult sex education.
- [44:50]
C
Right?
- [44:50]
B
We get a teenage disease and prevent and pregnancy prevention plan if you were lucky growing up. But that's before you're in relationships. That's before you're in a long term relationship. That's before you're in a career. What we really need is an adult, adult sex ed to be like, oh, did you know that just putting something in my vagina does make 70% of women not have an orgasm? Did you know that the stress in my life actually affects my interest in having sex?
- [45:15]
C
Right.
- [45:16]
B
Like all of the sex ed stuff that nobody ever got taught because you weren't an adult. You probably weren't even having sex when you had sex ed.
- [45:24]
C
No. Well, sex ed was all about safe sex. It had nothing to do with pleasure.
- [45:28]
B
Pleasurable sex. Yep. So, and the other. I think the other big myth that we get fed is the Hollywood spontaneous desire at every moment for the rest of your life.
- [45:36]
C
Dr. Casper Sim. Within 14 seconds of penis and vagina. Most women don't have an amazing earth shattering orgasm like in the movies. Are you kidding?
- [45:45]
B
There's this one. There's this movie. What is it called? It's Charlie's Theron and she's sleeping. She's very sexually attracted to Seth Rogen. She's like president and he's like a pothead. It's implausible. But like the. Okay. But like, it's like their desire for each other is building up for like 45 minutes straight and then it's like a simultaneous orgasm. It's like, that's not how your long term relationship is gonna be. You comparing yourself to that is like, it only makes you feel bad, right? So really, like, I wrote this book because I had started the podcast and that I love reading and people. I'm like, people just like to consume content in different ways. So I kind of threw it together in this book and. And I'm telling you, like you understanding that you're normal goes so far in you helping you have an amazing sex life. Women are like, oh, I'm normal.
- [46:33]
C
Because one of my slides when I talk about this is the medical term for women who do not have an orgasm during intercourse. Penile vaginal penetration. We have a medical term for that. And the medical term is normal. There's zero expectation. And you said 30% are not even. I think that's awfully high.
- [46:54]
B
Well, yeah. And of the 30%, there is clitoral
- [46:56]
C
stimulation happening, of course, because of pubic bone on clitoris or someone's holding a vibrator in the right place. So there's that. But is that. Do you have a second edition coming
- [47:05]
B
out or it's just a re. It's a re. So I self published and it did so well that a publisher bought it.
- [47:12]
C
I see. Cause I thought it was maybe an updated.
- [47:16]
B
The only thing that's updated. I will give props to her because it's the only thing that I was like, this needs to be updated is when I wrote the book, initially we didn't know how many nerve endings were in the female clitoris except for the cow studies. And so I put Maria Yolko and Blair Peters paper in there because now we actually know that was definitely worth putting updating. But I mean, a lot of this is, you know, it's new in the fact that it hasn't trickled down to the lay population.
- [47:41]
C
But that's exactly the point. I mean, you and I talk about this so much that we kind of assume that these are things everybody knows. And I cannot tell you how many people listen to my podcast. Your podcast. Read my books. Read your books and say, I had no idea. And it's this reminder that we have to keep saying the same things again and again, but also throw some new things out there for the people who do know. So I think that's what we look at as our role.
- [48:06]
B
I read the true definition of an expert is somebody who doesn't get bored by saying the same stuff over and over again. But it's like, you know, for me on the testosterone and Instagram, it's like to start the conversation.
- [48:18]
C
Right?
- [48:18]
B
To start the conversation. And you know the other interesting thing, just to be picky for a second, people are like, the experts are saying everybody should be on hormones. 5% of women are on hormones. 95% of women aren't.
- [48:32]
C
Well, and when you say 5% or 6%, that's how many get a prescription, how many of them continue to fill it once they've read the black box warning, which is a whole nother topic, you know, so. And in fact, one of the things I'm doing, I'm working on some stuff in the cannabis. And I was working this morning with the graduate student that were writing this up for publication, and I said, a key part of this paper is why. Why are women turning to cannabis? They're turning to cannabis because we only have 6% of people that are treating their menopause symptoms. They don't trust Big Pharma. They don't trust their doctors. Their doctors aren't giving them information yet they're willing to do this huge experiment with something we know nothing about and use cannabis. And is it. Well, that's a whole nother. I won't get into that topic together. I'll save it. But the point is that women have always been looking for solutions. And a million years ago, when I was on Oprah with Suzanne Somers, and you want to do a do over in life, and I want to do it over. Because what I appreciate now that I didn't appreciate then is the reason that people were buying Suzanne Somers books and listening to her nonsense was because their own doctors weren't helping them and they were desperate for help and for information.
- [49:39]
B
Why don't doctors know this, Lauren?
- [49:41]
C
I'm trying to fix that. Well, you and I are both doing that. I have some bigger picture thing that I can't talk about yet, but something kind of exciting to help doctors learn this stuff because they need to. But on the good news, the menopause conference this year that both you and I will be attending, sold out for the. The first time ever. And this is attended by healthcare clinicians, you know, doctors, nurse practitioners. So that's. That's huge.
- [50:01]
B
I'm an optimistic person. I think the tides are Gen X is not gonna age lying down unless it's lying down with a vibrator and maybe some cannabis. But like they see there, this whole thing about aging well, and the thing about hormones is hormones don't treat disease, hormones prevent disease. You have to have the conversation now, not when you're 83 and can't get off the fricking toilet.
- [50:26]
C
Well, not to mention, again, a whole other topic. The issue with the WHI wasn't that the hormones were bad. It said it was poorly designed. And these women were given hormones after the damage was done. It's not there to repair your cardiovascular problems. It's there to prevent them and your bone loss and all of that. I mean, we all know that estrogen prevents progression from low bone mass osteopenia to osteoporosis. Once you have osteoporosis, you've got to do something beyond estrogen to help your bones. You know, the damage is done. So we could go on for, like, all day. What are you doing today? We can just keep going.
- [50:58]
B
We should really podcast more often.
- [51:00]
C
You know what? I. We have to talk about this because
- [51:02]
B
podcasters who podcast with each other, it's a fun time.
- [51:05]
C
It is fun. And. And I don't think we interrupted each other too much, did we?
- [51:09]
B
I think we did good.
- [51:10]
C
I think we did really well. Let's get people.
- [51:12]
B
The people let us know. But I'm sure they're going to want more.
- [51:14]
C
I. I think this is great.
- [51:15]
B
Thank you so much. I will see you in Chicago. This might air after NAMs, but, you know, people don't know know that.
- [51:21]
C
Yeah, exactly.
- [51:22]
B
All right, I love you.
- [51:23]
C
Love you, too. Bye.
- [51:25]
A
Thank you for listening to this week's episode of you are Not Broken. If you want to dig deeper with me, sign up for my adult sex education masterclass where you learn adult things like communication skills, anatomy lessons and desire types, and how to talk to your doctor about sexual health concerns. If you want the adult sex education masterclass for free, join my monthly membership for more in depth, depth, exclusive content, more time with yours truly. A private podcast, coaching and educational empowerment and you can watch my interviews live
- [51:55]
B
and get them immediately without advertising.
- [51:58]
A
Head over to www.kellycaspersonmd.com for the membership and adult sex ed masterclass members. Get the master class for free. This podcast is presented solely for educational, entertainment and informational purposes of only. I am a doctor, but not your doctor in this format and all of my platforms and guests, including on this podcast, are not giving individual medical advice or practicing medicine. See and consult with your own care team for your individual needs and concerns. This podcast is not intended as a substitute for the care and advice of a physician, therapist or other qualified professional. This podcast does not constitute the practice of medicine. In case you were curious about this, that, and no doctor patient relationship is formed. But I still love you. Using the information on this podcast or any of my platforms is at your own risk. Until next time, remember, you are not broken.