https://www.listennotes.com/e/20d17e353ff24352b70bcd399eb953b6

Foreign.

I'm going to ask some questions to get a general understanding about hormone replacement in women. I'd like to know what symptoms might indicate low testosterone in women.

So low testosterone in women is also low estrogen in women. So your ovaries make most of your testosterone, which then gets converted into estrogen. And again, women have about 20 times more testosterone than estrogen when they're know, 20 to 50 years old. And we always think about estrogen replacement, but it really came from testosterone. That's why I put a little focus on the testosterone aspect, which is a precursor to estrogen in my book Testosterone Strong Enough for Man but Made for Women, really kind of review how we got to estrogen and how we're kind of shifting more towards testosterone, which is the master sex hormone for women. Now, men have 10 times more testosterone than women, but women have 20 times more testosterone than they have estrogen.

So it's common then for women to have low testosterone levels?

Yes. So and they kind of go hand in hand. So if your testosterone low, so is your estrogen. When a woman is in her youthful years, her ovaries are able to make all kinds of sex hormones. That's where they mainly come from. And as you go through your eggs from having menses over and over again prior to menopause, your ovaries and the structures with the ovaries start to fail and the hormone production gets erratic. On some days you'll produce plenty, other days you're producing next to nothing. And that's when symptoms start occurring which, which can be classic menopausal symptoms, like what we think about hot flashes, or we call vasomotor symptoms, hot flashes, night sweats, brain fog. And it can be more like insidious, where you're just not feeling yourself anymore. A little less energy, more dry eyes, dry skin, dry vagina, less libido, less energy, less sharpness. These are all the result of declining sex hormones. Now, there's other things that can cause some of those symptoms as well, but principally it's the sex hormones estrogen, progesterone and testosterone, which, testosterone being the dominant hormone. And there's a certain age where the average woman become menopausal in America is about 54 years old, but it concurred years before then or years after. But it's not just a one time, bam. Your menopausal menopause is actually defined as no period for one year or surgical menopause. You've had your ovaries removed. So it doesn't just occur like a Light switch. But it's a pretty fast moving switch, but not as fast as a light switch. And maybe one year to a decade before menopause, women may experience perimenopausal symptoms. And this is a result of inconsistent hormones for the most part. Start. We are counting women right in menopause or in that immediate time around there, because that's when it's more obvious or something going on. But it can occur before then. Now there is laboratory work that can be done to see if you're in menopause or not. They are not particularly helpful. So if you were to have a. Some people have heard of these continuous glucose monitors where you wear a monitor on your arm to check your blood sugar. I'm actually wearing right now a 24 hour blood pressure monitor because my blood pressure has been kind of borderline and this is actually measuring my blood pressure every five minutes for 24 hours. We don't have a 24 hour estrogen test or 24 hour testosterone test. But estrogen particularly would be peaks and valleys, peaks and valleys. So based on when you draw it, you might get a false sense of security. That's okay, or it's not okay. There's another test we look at. These are the hormones from the brain stimulating your ovaries to make hormones. And we can say, well, if the one from the brain is asking for it and your ovaries are not producing it, yeah, you're in perimenopause. And then eventually your brain stops asking for estrogen. Now you're kind of in menopause. But really when we think about how we manage blood pressure, we don't check a blood pressure drug level. We check your blood pressure, how hard your heart is beating and how much it resists force. And a woman is in menopause, it's generally based on symptoms and the classic definition of your periods have stopped and it's been a year or you've had your ovaries removed, then it's actually very abrupt. So although blood work is occasionally done or commonly done, doesn't guide therapy at all. It doesn't really tell you when you should start. So I think that is maybe over relied upon. It's almost like we have a love affair with tests. But these tests, not that accurate. There's nothing wrong with doing them. You'll hear about saliva tests and urine tests. I'm not a big fan of those. I think they're very hard to interpret. So you can do standard blood work testing by your primary doctor and they'll say well, you're approaching menopause, you're in perimenopause or you're in menopause, but you kind of know that because you're at a certain age and you no longer have a period and it's been a year, you're in menopause. There's not a laboratory diagnosis of that. So I think they're kind of over relied upon. So if you go to your doctor and you're feeling terrible and you have all the menopausal symptoms and they check your estrogen and testosterone level, they're not that bad. Well, check in at three hours from now, maybe six hours from now, they're not going to be the same and that's not really, not really done. You're not going to make an appointment for another year. So I think that while they may be helpful, we should guide treatment decisions based on clinical evidence. We call evidence based medicine in your individual symptom.

That makes a lot of sense, which answered my questions for testing and you've gone over and above on answering that. So what types of testosterone therapy then do you offer in office? Now that we've come to the conclusion to deliver to the.

So let's say we did woman's, you know, she's classic, was in menopause, maybe she tried a patch or something like that and it didn't work. So let's talk a little bit about the history of hormone replacement, how we got to where we're at now. So if you went back say 100 years and I've read some old textbooks, they treated menopause as hysteria or as a mental illness. And their very treatments aimed at reducing the mental illness or hysteria. And then we realized, well, this is probably a hormone issue. And one of the first hormone replacements was ground up sheep ovaries. And they would do what's called. And it's not that crazy as it sounds, we actually still use ground up animal organs for hormone replacement. Think armor thyroid, that's from armor hot dogs. You know, they make it out of pigs and they actually take the thyroid out of pigs and dry it out and grind it up. It's called desiccated thyroid and it works pretty effectively. So they were using ground up sheep ovaries and that seemed to reduce symptom of menopause. The next step was Premarin, which stands for pregnant mare urine. Premarin, this is a 5 year old mare's urine, is putting out all kinds of non human estrogens and some human estrogens. And that seemed to work pretty effectively for symptoms of menopause. And at first they were actually using dried up horse urine product and eventually they synthesized the exact same thing from, from actually from soybeans. And that was going on in the 70s and 80s. And then we found that using Premarin by itself would cause uterus lining to grow. Think about your periods and women start having periods again and potentially even get uterine cancer from the uterus overgrowing. So we had to add progesterone to it. Progesterone combats uterine overgrowth of Premarin. Now there's other, other targets for progesterone, but that's when we understood in the 80s and 90s. So we added in progesterone and then Premarin became the number one worldwide drug for, in the world for any, any cause. And it is basically for treating menopause so much that we did a large study in the report in the 90s that showed that women on Premarin and progesterone outlived their peers that were put on nothing less. All cause mortality. And then a paradigm shift occurred with something called a Women's Health Initiative trial reported in 2002 and 2004. And this was the biggest disservice to Women's Health in modern history because they did a study to show one thing and he actually sort of gave the wrong answer. And we didn't know it for about 10 years that we were misled. So in the Women's Health Initiative trial, not going to go into this at length. It's been talked about elsewhere, it's been ripped apart to shreds. But when it came out in 2002, 2004 suggested there was a slight increased risk of breast cancer. Now the absolute increase of risk of breast cancer on women on something called PremPro was 8, 100 to 1%, no increased risk of death. They also suggested possibly increase the risk of heart disease. And now in retrospect, we know that women on Premarin had less breast cancer and women on any form of estrogen had less heart attacks, probably 40% less if they started them within 10 years of menopause. So completely misinterpreted. I shouldn't say it was misinterpreted. Probably was interpreted based on the question they were answering. Should we take people who are in menopause 20 years who have never been on anything and put them on the most aggressive synthetic drug that's a hormone based known. And the answer is maybe not. There's not really a significant benefit. Minimal harm but minimal benefit. But the flip side, if we just continue treating women with the same drugs, even these drugs that we might malign a little bit, more women would have lived. More women would have lived. And those doctors that were around at that time, me included, and we saw this on USA Today. I was in San Francisco, I lived there. I was in San Francisco and I saw it in USA Today as a big story. Then it was on the news that hormones caused breast cancer. And in reality, estrogen cause less breast cancer than taking nothing. But that being said, that kind of shifted things around. We were using instead of Premarin plus a natural progesterone, we're using Premarin plus a synthetic progestin, which is not a progesterone. We're using a non human form of estrogen. And this led to a ceasing of prescribing hormone replacement therapy for women. They were put back into menopause and created all kinds of new drugs. Diabetic medications, bone density medications, antipsychotics, antidepressants, anti anxiety medications, sleeping pills to take the place of hormones that worked just fine. But. And doctors knew it, but we heard the study and it became, you can't, can't do this anymore. So the tide shifted and some doctors started using what we would call bioidentical or natural hormones, which was actually using women's based estrogen. They weren't that common back then, but they were available. Estradiol is the classic female hormone. That's your dominant hormone. There's two other estrogens, our main estrogens, but estradiol is a biggie. And there's progesterone rather than the synthetic progestins. And then there's testosterone, which is being used in other countries. We saw in other countries where women on testosterone and estrogen, they had way less breast cancer than seen in these large trials in women. Way less breast cancer, probably 30 to 70% less breast cancers. And this led to the introduction of testosterone as a component of hormone replacement therapy in women. Now, interestingly, some of the big drug companies made a testosterone product for women to be as a patch to introduce it for sexual arousal disorder or decrease libido or decrease sexuality. And the panel on the FDA in this case is all men. They said they did not want to expose women to the risk of heart disease cancers just to have more sex. And in reality, they could have been further off. Testosterone is both cardiac protective and breast cancer protective. But it never got approved because it was not like for men. They approved Viagra. No problem for women. They said, now you don't really need the sex. And they came up with a reason not to based on this risk that did not, did not exist. So that led to kind of the shift. And doctors in contemporaneous medicine like myself started thinking, well, let's start treating women physiologically as if their ovaries were still there, which occurs when you're 30. And this for us it was 20 years ago. We started doing this 22 years ago. And we replaced primary testosterone, estrogen, progesterone with actual bioidentical copies of testosterone, estrogen and progesterone. And this led to our modern approach. Now there's many ways to do this and they sort of all work. I'm going to talk about the way we do it, but this is not the only way. And if you're on doing something else and it's working for you, that's your choice, you should continue it. I would agree with it. I'm not a fan of the synthetic progestins or synthetic estrogens, but I am a fan of the bioidentical ones, which in some cases are prescriptions. There's a prescription progesterone called Prometrium. There's many prescription estradiols. Anything besides prometrium is a fake progestin. I would stay away from it. And there's no FDA approved testosterone for women. Commercially available product. Right now testosterone is FDA approved for women for metastatic breast cancer. Actually is approved for women before men. And it's been approved for, you know, 70 years for women. But we get it. Our testosterone is made in a FDA approved manufacturing facility. So this is an FDA scrutinized product and we use it as a pellet that's put under the skin along with a little bit of estrogen. And then we recommend progesterone orally because there's not a good pellet therapy for progesterone and progesterone pellets wouldn't make sense. So right now we use a weight based Testosterone, typically a milligram per pound of testosterone. And then you typically about 6 milligrams or 1 20th that amount of estrogen. And this gives a physiologic response. And that's typically progesterone, one or 200 milligrams at night. The reason you take it at night is, can create a little bit of sleepiness and a lot of women like that for the, for their sleep. And that is the current pathway that we're. And things change over time as more information comes available, we may alter it. But I'm not going to say if your doctor's got you on a patch and some progesterone orally and so maybe some topical testosterone. I just don't see the therapeutic levels with topical testosterone. There's problems with it. It's not a good injectable form of testosterone for women, so we prefer.