You Are Not Broken – Ep. 326: Australia, Testosterone, Mast Cells, and More

Host: Dr. Kelly Casperson, MD
Guest: Dr. Carrie Cassell
Date: July 13, 2025

Episode Overview

This lively and insight-packed episode explores menopause care, hormone therapy, and healthcare activism—focusing on the unique landscape in Australia. Dr. Casperson and special guest Dr. Carrie Cassell (a prominent Australian GP and menopause expert) share stories, advocate for equity in hormone access, and dive deep into emerging topics like mast cell activation and the importance of continued curiosity in medicine. The tone is candid, supportive, and often humorous as they smash taboos and encourage women to claim empowered, informed health in midlife and beyond.

Main Discussion Themes & Key Insights

1. Australian Experience & the Sydney Opera House Event

• Reflection on a monumental event in March 2025 at the Sydney Opera House, where leading international menopause experts, including Cassperson, gathered.
  • Dr. Casperson: “I got to pet a koala butt. It was fantastic. But the night of the Sydney Opera House event... it was fabulous.” [01:52]
  • Standing Ovations: Uncommon in Australia, signifying a major cultural moment for women's health.
    • Dr. Cassell: “To have two and a half thousand women stand up and applaud, that was something I've never... experienced in an Australian theater before.” [02:40]
• Macro & micro impact: The ripple effect of empowering events,
  • Individual women bringing mothers, sharing breakthroughs such as seeking vaginal estrogen after the event. [03:47]

2. Testosterone for Women in Australia

• Unique access: Australia is the only country with a prescription, female-dose testosterone (Androfem), licensed for Hypoactive Sexual Desire Disorder (HSDD).
  • “We think that probably affects about 1 million Australian women... less than 15,000 get a testosterone.” [05:04]
• Barriers: Despite its availability, underutilization persists due to cost and outdated clinician attitudes.
  • Dr. Casperson: “Doctors ask them if they're partnered and if they're not partnered, they don't get access to testosterone. And to me that's a big problem.” [06:03]
  • Dr. Cassell: “I would find that really offensive.” [07:52]
  • “Do we ask men if they're partnered to give them Viagra?... So, we don't have a page of whether you meet these criteria for this low libido for men...” [07:56]
• Cost Disparity:
  • Nine testosterone products for men are on the government-subsidized PBS; none for women.
  • Women pay over $100/month for Androfem, while men’s testosterone is subsidized.
• Advocacy Efforts:
  • A petition (11,000+ signatures) presses the Australian government to waive pharma fees for listing Androfem on PBS.
  • Dr. Cassell: “We want the government to waive the fee... because our Androfem product is made by quite a small pharmaceutical company and these fees are usually prohibitive... We're now lobbying local MPs to really add that political voice in Canberra...” [12:52]
  • Listeners are encouraged to sign and share (even non-Australians, by belief in equity) [13:44]
  • Notable Quote: "We would be then the only country with testosterone product made for women, licensed for women and affordable for women." [12:52]
• Gender Bias in Care:
  • Insurance double standards (e.g., requiring women to fail marriage counseling before "female Viagra" but no such requirement for men) [08:27]
  • Dismissal of female sexual agency and pleasure (e.g., denying testosterone if not partnered) [06:26, 07:52]

3. Hormones, Cognitive Health & Research Gaps

• Testosterone’s broader benefits: Not just libido—but mood, cognition (verbal recall), and vitality.
  • “Testosterone only helps me with libido is a brain neurochemical. I feel more like myself is absolutely huge.” [15:20]
  • RCTs (randomized controlled trials) show benefits even for word-finding and cognitive processes.
• Dementia as the #1 killer in Australia:
  • “In 2026, dementia is going to be the number one killer of Australians?” [16:43]
  • “It already is. This year it's surpassed heart disease.” [16:43]
  • Low testosterone and estrogen increase risk, particularly in certain genotypes (APOE4).
  • "We've got data showing that low testosterone in women is associated with heart disease, osteoporosis, and increased risk of dementia." [16:58]
• Bone Health & Guidelines:
  • Debates on appropriate DEXA screening age (U.S. at 65, Australia at 70) and estrogen/testosterone’s utility for bone health.
  • Dr. Cassell: “Estrogen is nature's gift to bones.” [18:54]
  • Value in shifting focus from rigid indications to the preventative, system-wide role of hormones. [18:05]

4. Clinician Activism – From Personal Ignorance to Leadership

• Dr. Cassell’s story:
  • Initially dismissive (“That’s not a female hormone...”), then educated by a patient (“It's absolutely amazing. It has changed my life and you need to know how to prescribe it”). [20:09-20:53]
  • Trained under Dr. Louise Newson and became a leading advocate.
  • Developed Healthy Hormones—an online community for both clinicians and the public, providing accessible, reliable menopause education and support. [23:40-24:15]
  • Advocacy success: direct Senate inquiry presentations led to policy wins for hormone access, but education/stigma issues persist.

5. Conferences & Medical Education

• Reflections on innovative conferences (post-Sydney Opera House):
  • Interactive, story-based, energizing—contrasting the "dry, flat” norm of medical education.
  • “Once you've had that...if they're not keeping you, like, active and engaged, social media has wrecked bad speakers for us. All of the speakers are telling you their why...” [25:43]
  • Storytelling as a tool to move clinicians from guilt and missed opportunities toward transformation and better care [27:06–29:43]
  • Real-world impact—life and years lost due to lack of menopause care; emotional discussion of preventable tragedies [27:54–29:43]

6. Mast Cell Activation, PMDD, and Complex Female Syndromes

• Emerging science:
  • Dr. Cassell, spurred by the podcast's own Dr. Goldstein episode, explores the connection between:
    • Mast cell activation
    • Hypermobility/Ehlers-Danlos
    • Trauma
    • Perimenopausal "clusterfuck syndrome" (CFS)
  • “I have this group of patients who have lucked out, and I say that heavily, sarcastically...pmdd, adhd, endometriosis or adenomyosis, allergies...perimenopause, and it is a train wreck.” [33:19]
• Diagnosis:
  • Largely clinical; labs like tryptase are unreliable.
  • Key: Listen for clusters of symptoms (PMDD, urticaria, allergies, gut issues, mood, hypermobility). [36:27]
• Treatment:
  • Lifestyle: "Eat a real food diet", low-histamine foods, good sleep, movement (especially weightlifting), breath work (nasal breathing).
  • Medications: H1 (loratadine, fexofenadine) + H2 (famotidine/Pepcid) antihistamines, sometimes supplements (vitamin C, magnesium, vitamin D, luteolin, quercetin).
  • Clinical example: “Adding in the antihistamine as well has been a game changer. Urticaria is gone...their mood is better and calmer across the month.” [42:18]
• SSRI Withdrawal and Mast Cell Activation:
  • Some women struggle to discontinue SSRIs as they tamp down mast cell activity—withdrawal can trigger flares; requires ultra-slow tapers, sometimes antihistamine support. [48:00]
• Cultural context:
  • Vigilant not to dismiss “everything is wrong” women; much of this may be biology, not “all in their head.”
  • Reference to Dr. Elizabeth Komen's All in Her Head and the historic pattern of labeling biologic women’s disease as “psychological.” [43:02]

7. DHEA Use and Prescribing Practices

• Australia vs. U.S.: Vaginal DHEA (Intrarosa) is more affordable ($40 AUD/month) and more accessible for some—but still underused overall.
  • Survey underway to understand barriers to prescribing among Australian clinicians. [51:36]

Notable Quotes

• On the ripple effect of empowerment:

  • “There was just such an amazing feeling just being able to bring all those women together and know that each of those women was going to go and speak to another hundred women. Like, the ripple effect from an event like that is just mind blowing.”
    —Dr. Carrie Cassell [03:14]

• On the stigma of prescribing testosterone only to partnered women:

  • “Do we ask men if they're partnered to give them Viagra? Is that ever asked?”
    —Dr. Casperson [07:56]
  • “Libido is so much more than just a desire to have sex. It's just a desire to be alive and do stuff.”
    —Dr. Cassell [06:26]

• On doctor-led change:

  • “You need to be listening to symptoms. Just like perimenopause, a lot of the chemicals that are probably changing are not easily accessible...I think it's at the minute in Australia we don't have easy access to testing.”
    —Dr. Cassell [36:27–37:47]

• On hormones and cognitive health:

  • “We know that osteoporosis and dementia are connected. So if you've got osteoporosis, you're much more likely to have dementia...Anything that supports mitochondrial function, which estrogen does...makes basic scientific sense that supporting hormones and all the other things...that's what's dying or what has been dying when dementia hits 20 years later.”
    —Dr. Cassell [53:51]

• On the need for equity:

  • “Testosterone for a woman— we deserve it. We deserve to be able to try it.”
    —Dr. Cassell [52:34]

Timestamps for Key Segments

• Introduction, guest welcome, Sydney trip reflection: 00:03–04:12
• The Sydney Opera House event & cultural significance: 01:52–04:12
• Testosterone in Australia: history, access, and underutilization: 04:47–06:03
• Gender bias in hormone prescribing: 07:52–08:54
• PBS and cost barrier discussion, petition details: 09:05–13:49
• Hormones, cognition, and osteoporosis/dementia links: 16:43–18:54
• Dr. Cassell’s journey to menopause advocacy: 20:09–23:40
• Healthy Hormones community & Australian events: 23:40–25:12
• Conference reflections on education and impact: 25:12–29:43
• Historical look at hormone use in women: 30:53–31:42
• Mast cell activation, CFS, fatigue and emerging science: 31:57–45:59
• Diagnostics and management for mast cell activation: 36:27–43:02
• SSRIs, withdrawal & mast cell connection: 48:00–50:32
• Vaginal DHEA in Australia vs. US: 50:32–51:36
• Final advocacy wrap-up, closing remarks: 52:34–57:27

Resources and Actions

• Sign the petition: Support including female-dose testosterone (Androfem) for women on Australia's PBS.
• Explore Healthy Hormones: For clinicians and laypeople (Australian-focused but open to international members)
• References for further learning:
  • Dr. Louise Newson, Dr. Mary Claire Haver, Dr. Andrew Goldstein, Dr. Tanya Dempsey (mast cells)
  • Book: All in Her Head by Dr. Elizabeth Komen

Takeaways

• Women’s hormone care continues to be shaped by activism, shared stories, and challenging gender bias—globally.
• Australia’s unique landscape brings both hope (innovative products, events) and challenges (access, stigma).
• Mast cell activation and complex female health syndromes are areas where curiosity and cross-disciplinary medicine can change lives.
• Listeners are encouraged to support the movement for equitable hormone access and to remain curious, compassionate advocates for women’s health—both for themselves and their communities.