Testosterone For Women: An Overview

I want to go over a book I wrote. This was in 2017's testosterone strong enough for a Man Been Made for a Woman. And some of the updates that have occurred since this was published, which was again 2017. So the history of hormone replacement therapy is explained elsewhere, but I'll just do a brief Overview. In the 80s and 90s we were using a drug called Premarin. Premarin is notably made by Wyeth Laps at the time, and it was the most common drug sold in America. And we knew that women who were in menopause had significant vasomotor symptoms, hot flashes, night sweats, also conditions that occur such as more cancers and more cardiovascular disease and kind of a deceleration in their health. We started using Premarin, which was made from the Premarin stands for pregnant marrier. And Premarin and its estrogens initially was taken from pregnant mare urine. They were about five year old mares. And then it was eventually synthesized from a soy feeding product that appeared to reduce risk of cardiovascular events and all cause mortality. And about late 80s, early 90s, a drug called Provera came out because we knew if we gave women a Premarin by itself, that she could have overgrowth of her uterus and potentially get uterine cancer. We could treat that with progesterone, which was generic. And the same manufacturer Wyeth made Provera, which was a synthetic form of progesterone to block effective estrogen on the uterus. And we were routinely giving women who were in menopause premarin or Premarin. And Proverb we call Prempro, it was based on whether or not they had an intact uterus. So if a woman had no uterus, she'd be given Premarin and if she had a uterus, she'd be given Premarin plus Prover, hence Premapro. And it was routine to start this at the time of menopause and let the woman continue to take it throughout her life. And there was observational studies that women had less all cause mortality, less cardiovascular disease, less dementia, maybe even less breast cancer. In the late 90s they decided to do a large study where they enrolled women, average age was in their 70s who had never been on any kind of hormone replacement therapy. And in general they were many years into menopause and they started them on premarital Provera, Premarin and or premium, which contained Provera. And the initial reports came out in 2002 and then 2004 that these women who had never been on hormone Replacement therapy, they were 10 or more years into menopause had increased risks of breast cancer and or cardiovascular disease, based on which arm of the study. So women that were on the estrogen only actually had little lower rates of breast cancer. Women who were down estrogen and progestin had higher incidence. Breast cancer, it was small increase incidence at 101%, but it's increased. And women on either form had a slightly increased risk of heart disease. So it's led to a cessation of using hormone replacement in women. Even though we were really studying a drug, we were also studying a drug that was not being correctly used. We weren't putting women who were in menopause 10 or 15, 20 years into menopause starting on a strong synthetic sex steroid. But this led to a wide abandonment of the use of hormone replacement therapy in women. And probably one of the biggest, biggest negative consequences in women's health care of the last century was abandoning treatment of menopause for fear of causing disease. Now when we start looking back at the information more intently, because it's been out 20 years, we identify that women who were started on the hormone replacement therapy, even these strong synthetic hormones, within six to 10 years of menopause had about a 40% reduction in cardiovascular events and cardiovascular death. And we look at the all cause mortality, meaning dying of any cause. Women who are on hormone replacement therapy started within about a decade of menopause, which is how we normally did in practice. They live longer. And several studies have been done since then. Some of them aren't in the book because they're newer, but the long term reduction of mortality in women on hormone replacement therapy is right around 10% if you follow a study out for say 15 years. This is something that we as scientists and doctors didn't realize back in 2002 and 2004. How misplaced, how we misinterpreted the results of that study. It was called the Women's Health Initiative study who. So let's fast forward to where we're at now. So during that time between 2002 and 2004, when we were routinely using Prempro, and then doctors pulled it away from their patients and women were kind of thrust back into menopause symptoms, having vasomotor symptoms, weight gain, hot flashes, and ultimately more cardiovascular events, more diabetes, more obesity, and more deaths, we started realizing the advent of, we would call bioidentical hormone replacement, which would be hormones that are pretty much identical to what our bodies were making. So Prempro was a synthetic version of a Hormone and the hormones we're using now are actually, actually hormones. The main ones would be testosterone. That's the main hormone that a woman has. Even though we think of testosterone being a male hormone, woman has about 10 to 20 times more testosterone than estrogen. So testosterone primary, estrogen secondary and progesterone tertiary. And the testosterone replacement wasn't that common. In fact, it was an attempt to get testosterone FDA approved as a, as a drug for women with hypoactive sexual disorder. And the FDA determined that that condition did not exist. And all male panel on the FDA did not allow testosterone to be approved for women, but it is generally approved for women for, not for sexual disorder. It was approved actually in the 1950s for the treatment of metastatic breast cancer. So testosterone was originally approved for metastatic breast cancer and still have to be approved for women, just not for sexuality. It was approved for women before it was approved for men, which is, which is interesting. So testosterone started getting attention during the bioidentical hormone years and studies started linking it to a marked reduction in breast cancer. And there's a whole chapter in the book, the book about breast cancer and testosterone. But tamoxifen, the drug tamoxifen is commonly used in breast cancer, is actually made to copy some aspects of testosterone. And testosterone is better at inhibiting breast cancer growth and better at prevents upregulation of estrogen receptors on the cancer cells. So testosterone can be effectively used to treat breast cancer. That's what was FDA approved for. Then there's a doctor Laser in Dayton, Ohio who's done a series of published papers showing that her patients on testosterone she used testosterone, only had a marked reduction in breast cancer rates compared to the general population or the WHO trial. And her study was as much as 70% reduction. Other studies that have emerged since I wrote the book have been using combinations of testosterone and estrogen. And again, we give a bigger dose of testosterone than estrogen. The testosterone dose is usually about a milligram per pound and the estrogen dose is usually about 3 to 6 milligrams, a much lower dose because again, there's more testosterone in your body than estrogen. What they found was about a 40% reduction in breast cancer events when we use testosterone in addition to estrogen versus taking nothing. And I said briefly before that the Premarin only trial of the WHO had decreased incidence of breast cancer. It's not clear why that is, but the Premarin is not estradiol, which is the main estrogen women have. So perhaps the Premarin Was actually blocking estradiol on those receptors and still getting relief of vasomotor symptoms. It's not really, that's not really clear. Estrogen only does have some risk of breast cancer involved. It's not substantial, but it's a risk. Or if we combine it with testosterone, we can mitigate that risk and actually reduce the overall risk of breast cancer. Doesn't mean you can't get it. One in eight women get breast cancer. But if we reduce that by 40%, that's substantial. Studies have shown testosterone is cardioprotective, means protects the heart. Studies have shown women with the lowest testosterone levels have the most cardiovascular events, particularly in diabetics or overweight women. Studies have shown that testosterone helps protect against weight gain, obesity in women. So the study performed, that study is in the book. But the put women on testosterone 100 milligrams or placebo, women in their 50s, and they monitored their weight over a six month period. And these are women that were perimenopausal that were already gaining weight. This was common. This is one of the most common things we hear about menopause is the weight gain concern. And women on placebo gain additional weight. During the six month period. Women on testosterone lost a little bit of weight. So it's not like you take, you put a testosterone pill, the weight falls off, but it does favor, does favor weight loss. Look at the breast cancer concerns. Breast cancer is obviously a big concern for women for, for righteous reasons and we need to survey for it. But the fear of using hormones because of the cause of breast cancer is actually very misplaced. Again, the study, the women's health study, showed women on estrogen only the premarin had less breast cancers. And combining testosterone with estrogen markedly reduces breast cancer risk. According to studies over the last, say, 15 years. Cardiovascular risk is protected from. Estrogen does protect against cardiovascular risk. Testosterone does to some degree. But estrogen is more cardioprotective. We do a test called a cimt, which is a crowded intima media thickness test. We scan the arteries of the crowded arteries, the thickness of the artery wall and look at plaques. That's a good, say, window into your heart and the rest of your circulation system. We can see it very easily. And it's a mirror. So you don't typically get plaque in one artery, but not another area getting diffusely. There's some arteries that are prone to them. So there's an area right here high that's kind of prone to it. And there's one called the lad in Our heart that's prone to early plaque developments. We scan those arteries and we can guess, we can actually predict if they're going to have somebody going to have a heart attack in the next 10 or 15 or 20 years. If the woman's heart age is older than her age, we should probably do some intervention. If it's younger, whatever she's doing, the working good. Studies have shown that adding estrogen in during menopause, not 10 years later. Adding estrogen to women in menopause regresses atherosclerotic plaques, very cardio protective. So right now, a good approach for women in menopause, typically within six to ten years of menopause. Different studies suggest different numbers. To start these things is to get informed, learn, talk to your doctor. 10, 15 years ago, doctors are recommending against hormone replacement therapy because of this one study that was, that we really misinterpreted. Now studies have shown that that was probably the wrong thing to do. A big miscarriage of justice for women. But if you're going into menopause, you're having menopausal symptoms. With menopause comes breast cancer, cardiovascular disease, weight gain, decreased energy, decreased sex drive, mental fogginess, hot flashes. And these can be markedly reduced with hormone replacement. And the approach we're using now is testosterone pellet. It's like a little piece of rice that goes under the skin in your buttocks. It's implanted with a little device, typically 1 milligram per pound, and then a few milligrams of estrogen as a pellet. And then taking oral progesterone, natural progesterone, to protect the uterus. And progesterone has other effects besides protecting the uterus from overexposure to estrogen. Progesterone has positive effects on weight, on mood, on all of your organs, even on your skin. The testosterone, we sometimes think about this as being a male hormone. And men do have about 10 times more testosterone than women do. But women have about 10 to 20 times more testosterone than estrogen. And back when we started picking the hormones for women's hormone replacement, we were actually using ground up sheep ovaries at one time. That would contain estrogen and testosterone. That's where most estrogen and testosterone are made. And again, the first drug was based on this Premarin, the pregnant Mary urine, which is purely an estrogen product and it's not estrogen. Similar to women, there's multiple conjugated estrogens, estrogens. In this formulation, we actually use a pure form of Estrogen. Estradiol, which is the main women estrogen. There's also two other estrogens that women has, Estriol and estrone. Estriol is very high during pregnancy. We might use estriol as a topical to make the skin glow. Estrone is maybe a little bit linked to breast cancer, so don't use that in hormone replacement. I found that over the last 20 years, treating women with menopause, we were using topical cream formulations, predominantly using what we call biased, which was estriol and estradiol, oral progesterone and some testosterone gel. We weren't getting adequate serum levels of the testosterone. With the gel, you really can't apply that much to your body. So we've switched to using the pellets. And with the pellet, it goes in your tissue and it's little incisions made in the skin. And the pellet goes into the skin, usually in the buttocks or someplace you have a scar. If you had a prior C section, you put in the C section scar and it eludes the testosterone over about four months, doesn't need to be removed, it just breaks down. And if we're putting the testosterone in, you could use estrogen cream, but we just put estrogen pellet in along with it. It's very practical to remember to take another cream and then a progesterone orally, typically 200 milligrams at night, because it doesn't make you a little sleepy when it's absorbed, it turns into something called GABA that does help relaxation and sleepiness. So that's the current protocol we're using. And again, the studies that are showing less cardiovascular disease, less breast cancer, less all cause mortality, less weight gain, better quality of life, better longevity. And I think when we think about longevity or anti aging, what's the anti aging practice? We'll find most anti aging practitioners are really focused on hormone replacement. It's really at the base level, you know, you have nothing about longevity. I think about it in four stages. Stage one is general health care and wellness. So if you have hypertension, you don't treat it, you've shortened your lifespan. If you have diabetes, you don't treat it, you shorten your lifespan. If you don't get screened for cancer, you know, your potentially lifespan is shortened. So general health care does help us with longevity to some degree. We can have our criticism against, against American health care system, but it has extended our lives and then wellness, which is right in that same phase. That's where you're eating properly for your body, you're exercising properly. For your metabolic needs, you're maybe doing meditation, maybe doing sauna, maybe fasting periodically. These are all parts of wellness that are stage one. Stage two is more regenerative medicine. And hormone replacement therapy falls right in that regenerative medicine category. Now, we're not regenerating your ovaries as a woman, but we're giving you the same output of testosterone, estrogen, progesterone through these little pellets. So having the pellet installed on your skin is kind of like having your ovaries work again. And when you're young and healthy, you really liked having all that estrogen, testosterone in your body. It made you who you were, made you feel young. Along the same lines of regenerative therapy, I think about things like stem cell therapy or platelet rich plasma for joints. We can think about treatment we do for reversing sleep apnea. Sleep apnea shortens your life. And there's some other things that regenerative medicine as well. And the next step above that, step three would be don't die of anything stupid or preventable. And that'd be more advanced cancer screening. So right now we do cancer screening that would include, you know, do your mammogram and your Pap smear and your colonoscopy and you're over 50 and certain other screening tests. But you also get full body mri. And if you do a full body mri, you'll pick up pancreatic cancer, ovarian cancer, sarcomas, cancer that you can't pick up with screening tests. There's also a blood test called Grail G R A I L that picks up, it's called a liquid biopsy. So it picks up genetic pieces of cancer. So that could be in that same stage. So we have step one, wellness and general care. Step two, regenerative medicine. Step three, don't die of any stupid cancer screen. Advanced brought it into media thickness testing or some kind of a CT angiogram. So looking at the heart age, if your cardiac age is older than you are, you could take action before you have the heart attack. So right now we wait till you have the heart attack and then you do a stress test and it's abnormal, or you go to the hospital with a heart attack. We do angioplasty and stent, put you on medications. That's chasing, chasing the tail. We can actually look ahead and do like a stress test. Will not pick up a heart attack. Just occur in 10 years. Won't do it. But a imaging Study will. Now these aren't paid for by insurance because the US Preventative healthcare task force you decide it's not worth the money. But quite frankly, the CAT scan for calcium score is $100. You can pay for that and a CIMT imaging of your neck is about $300. These are things that can tell you are you at risk for heart disease. You can guess by a cholesterol, guess by your risk factor, but where are you at? Need an imaging study. Then the third one is neurocognitive decline. So as you get older, you're worried about Alzheimer's or dementia. We can actually measure mri. MRI can tell us decades in advance who's going to get Alzheimer's, who's most likely to get Alzheimer's. They even track that along and reverse brain age. So brain age can be reversed if certain intervention occurs. So that's step three and last step for anti aging is really pharmacology therapy that actually reverses our genetic age. And I'll talk about that at some other time. Those are the four steps. And really hormone replacement is really an entry level thing that there is no rationale to why all women who go into menopause in general should not be put on hormone replacement therapy. You know, the ovaries petered out yet a certain number of eggs when you're born in menopause, when you run out of eggs, then you run out of the ability to make these estrogen, testosterone, progesterone. You make a little bit, but very little. So there are organs that make these hormones, but the ovaries are the predominant ones. And once the ovaries, ovaries have failed, which is definition of menopause, those levels drop off and aging starts coming pretty fast. And women notice when they're in menopause that their resilience drops down again. Weight gain, start getting arthritis faster, starting in mental fogginess, faster, starting they start looking a little older than their face and their body. And these can all be slowed down with hormone replacement. The safety concerns were well founded because they did a study showing that if you're 80 years old and you've never been on anything, you should not go on Prempro. I mean that's just a reality that shouldn't be done. But if you're 50 to 60 years old and you're a woman who's not been on the hormone replacement therapy, it will likely extend your lifespan, likely reduce your chance of a heart attack, likely reduce chance of breast cancer, help you maintain your weight a little bit better, up your Sexuality, lubrication, ability to have an orgasm, help your skin, help your mental bogginess, mentation, slow down aging. And these are steps, you know, the first steps. Now, sometimes people want to do things that their insurance covers. Your insurance will not cover testosterone replacement, and it is FDA approved, but there's no formula that is approved by insurance companies. So typically you're paying cash for that. It's not very expensive, especially when we look at living longer. What's that? Living longer and a healthier life. Less heart attacks, less dementia, less breast cancer. What's that really worth? If you love your body more than your money, then you take care of your body. So in summary, you know, if you don't have a copy of this book, you can. We have it online. It's free. You can buy it on Amazon. Testosterone Strong Enough Man Made for women. I'll be periodically putting up updates to the book because I wrote it in 17. I really update. Things haven't changed a whole lot. We're just getting more and more evidence that when I presented the book, you know, a few years ago, there's even more solid evidence for what we're talking about then. Now, a testosterone is primary hormone, estrogen is a secondary one, and progesterone is a tertiary one. But we typically use all three of them. And what I'm kind of doing is that there was a time where I was using testosterone only because there's so much bad press on estrogen. It was misguided, but it was bad press. Now we have ample evidence that estrogen can be used safely and again, significantly reduce cardiovascular events. I mean, reducing Cardiovascular events by 40% is pretty damn strong. So we should be using estrogen. But there was a time we weren't because we didn't really know that, and we were using testosterone. It worked very well. But if a woman's Within 10 years of menopause, I'm typically going to do a CIMT test of our arteries and see her cardiac age. If cardiac age is, you know, at her age or a little bit older, we're just adding estrogen for safety and prevention. And I just do that routinely. But that would be a reason. If somebody's cardiac age is very young, it might not be an additional benefit because testosterone by itself works well. So testosterone strong enough for a man and made for women, thank you very much.