Is It Worth Taking Testosterone In Menopause?

It’s Q&A Day at 10almonds!

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In cases where we’ve already covered something, we might link to what we wrote before, but will always be happy to revisit any of our topics again in the future too—there’s always more to say!

As ever: if the question/request can be answered briefly, we’ll do it here in our Q&A Thursday edition. If not, we’ll make a main feature of it shortly afterwards!

So, no question/request too big or small 😎

❝Why are some people recommending taking testosterone for menopause, doesn’t testosterone go up in menopause anyway?❞

A good question with an interesting answer!

To answer the second part first though: testosterone goes up relative to estrogen, and this relative rise of testosterone is part of what’s responsible for androgenic (masculinizing) effects that occur in menopause. This is a process that, if untreated, will continue to have cumulative effects over time for the rest of one’s life.

See also: Menopause, & When Not To Let Your Guard Down

However, while testosterone goes up relative to estrogen, it actually goes down in terms of its own actual numbers—it’s just that testosterone undergoes a slow, gradual decline, while estrogen plummets quickly. Thus, because of the shortage of estrogen to oppose its masculinizing effects, even the technically now-lower total amount of testosterone is able to do more than the previously higher (but opposed by estrogen) levels were able to do.

It’s worth noting that prior to menopause, most women produce about 3x more testosterone than estrogen—it’s just that estrogen is a lot more powerful, mol for mol, mg for mg.

So of course, when that estrogen drops off, testosterone takes the wheel.

See also: What You Should Have Been Told About The Menopause Beforehand

You may be wondering where this testosterone comes from: circulating testosterone is produced by the ovaries (25%) and the adrenal glands (25%), and the rest comes from peripheral conversion of adrenal androgens in fat cells (50%). So, if for example you have a bilateral ovariectomy (also called oophorectomy), then you’ll only actually take a 25% hit to testosterone levels, assuming normal function beforehand. In contrast, someone having a bilateral orchiectomy (also called orchidectomy, and is the removal of the testes) would take a 95% hit to testosterone levels, assuming normal function beforehand.

This is because the ovaries/testes are (usually, aside from in some intersex conditions) specialized to produce mostly estrogen or testosterone, respectively, since they were differentiated during gestation (prior to that, they were the same basic undifferentiated gonads).

Alright, that’s the “doesn’t testosterone go up in menopause anyway?” part covered, now onto the “why are some people recommending taking testosterone for menopause?” part!

Why it gets prescribed

Testosterone—albeit at much lower levels than for men—can be important in women for bone density and muscle mass, cognitive function, mood, sexual function, and energy.

See: Female androgen insufficiency: the Princeton consensus statement on definition, classification, and assessment

Of those 5 things, there is one that stands out as the reason that’s usually the reason, and that’s…

❝Numerous studies have shown that adding testosterone to hormonal therapy can improve sexual function and general wellbeing among women during their menopause. A recent systematic review and meta-analysis of testosterone treatment in women has provided robust support for a trial of testosterone in women when clinically indicated. In postmenopausal women, testosterone supplementation improved several domains of sexual response, including sexual desire, pleasure, arousal, orgasm, and self-image.❞

Read in full: Should we be prescribing testosterone to perimenopausal and menopausal women? A guide to prescribing testosterone for women in primary care

You may be wondering: are there any side effects?

And the answer is yes, but with nuance that’s worth understanding:

❝A significant rise in the amount of LDL-cholesterol, and reductions in the amounts of total cholesterol, HDL-cholesterol, and triglycerides, were seen with testosterone administered orally, but not when administered non-orally (e.g. by transdermal patch or cream).

An overall increase in weight* was recorded with testosterone treatment. No effects of testosterone were reported for body composition, musculoskeletal variables, or cognitive measures, although the number of women who contributed data for these outcomes was small.

Testosterone was associated with a significantly greater likelihood of reporting acne and [facial] hair growth, but no serious adverse events were recorded.❞

*However, since no effects were reported for body composition (i.e. they probably didn’t record it), there is a strong chance that the increase in weight was due to testosterone-induced increase in muscle mass, not an increase in fat. If anything, testosterone will tend towards reducing body fat percentage (which is why men’s healthy body fat levels are lower than women’s healthy body fat levels, on average; it is hormones that mediate this).

Read in full: Safety and efficacy of testosterone for women: a systematic review and meta-analysis of randomised controlled trial data

Further,

❝Androgenic Side Effects:

Exogenous androgen given to women in sufficient quantities or for a sufficient duration can promote androgenic side effects such as acne, hirsutism, and, in extreme cases, virilization.

Virilization includes deepening of the voice, clitoromegaly, masculinization of body habitus, and androgenic alopecia.❞

About some those terms:

• Androgenic alopecia = male pattern baldness; actually the same condition as female pattern baldness, but the visual pattern is slightly different according to testosterone levels.
• Clitoromegaly = the clitoris is receiving hormone-mediated instructions to be a penis (bearing in mind, these two organs are analogous, and were the same undifferentiated organ before they were normally differentiated during gestation), and as such, the visible glans clitoris (the part you can see) will grow (up to an inch or so) and start responding to stimulation like a penis instead of like a clitoris (what feels good to it will change accordingly), and the sensation of orgasm will change too. While many people might not mind this, it’s definitely something worth knowing about in advance!

Read in full: The Safety of Testosterone Therapy in Women

So, while we are neither your gynecologist nor your endocrinologist, we can say that the decision-making process might look something like this:

1. Are your T-levels in healthy female ranges (5–55ng/DL, or 0.2–1.9nmol/L)? If so, supplementation will not be indicated for most women.
2. If they’re below that, are you experiencing any of the problems commonly associated with such, of which the most evident is usually sexual function (where other* causes of loss of sexual function have been ruled out or otherwise adequately addressed)?
3. If you are, do you want to fix that more than you want to avoid the side effects of taking T?

*for example, such as discussed in Come As You Are – by Dr. Emily Nagoski

If so, then talking to a potential prescriber seems like a fine option.

But! There is one last problem, and it’s hardly insurmountable, but it is an inconvenience. For obvious reasons, that vast majority of supplemental testosterone produced is made for men. Now, in and of itself this isn’t an issue; it’s the exact same substance and will work the exact same way in you as it will in a man.

However, it does mean that the doses in which testosterone is most readily available, tend to be aimed at delivering testosterone in normal male quantities, which is about 10x what you’ll want (unless your intention is actually to trans your gender, in which case, congratulations on your manliness). This means that, assuming you want a normal female amount of testosterone, then—depending on the source—you may have to get a bit fiddly with it, since you’re going to be taking the amount that the manufacturer expected to be a daily dose, and making that last 10 days.

For example, if you get T-gel in a dispenser at the standard 1.62% percent/20.25mg per pump, then if a man is prescribed 2 pumps per day then you might be prescribed 0.2 pumps per day. It’s the medical equivalent of a recipe that calls for ⅕ of an egg, which is awkward, and does create risks of accidentally taking more than you wanted.

One last note…

If the issue is libido, you might want to try progesterone (if you’re not already on it) before you try testosterone, as that does boost libido, and is also responsible for a number of other important things, including playing a critical role in bone turnover rates:

Progesterone Menopausal HRT: When, Why, And How To Benefit

And if it’s specifically vaginal dryness that’s the issue, often testosterone is the opposite of what’s needed (though DHEA can help):

Vaginal Dryness In Menopause | Causes & Solutions

Enjoy!