Why Women Need Testosterone with Dr. Kelly Casperson

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Testosterone really is a motivation hormone, which it helps dopamine, it helps serotonin, it helps the brain. Like, if you literally Google testosterone, it'll say the male sex hormone, but if you go down in the paragraph on Google, it'll say found in all bodies. So we just have to get women to understand that this is, this is a hormone in all bodies that help all cells function.

What are some symptoms that someone's testosterone low energy, fatigue.

I hit a wall at 3 PM. I go to the gym, but I'm not seeing any gains. It's like as if I wasn't going to the gym. Decreased libido. We know in men, higher risk of depression and dementia. Normal and optimal are two different things in labs, and I just want to break people from thinking like, just get her to a lab and get her to normal. Is like, how does she feel? Does she have any side effects? The definition of evidence-based medicine available evidence, clinician experience, wishes of the patient.

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Kelly Casperson. I'm bringing her back.

She's a crowd favorite. And last time people loved her honesty, her practicality.

So we're going to drive into the questions that a lot of you have been asking privately.

Let me tell you a little bit about her. She is a board-certified urologic surgeon. She is an amazing public speaker. I got to hang out with her at the UCI Women's Wellness day's event. She rocked the crowd. She's a sex educator and host of the top-ranking podcast, You Are Not Broken.

In fact, that is really the through line of her work.

She is dedicated to empowering women, and she is taking like a totally taboo subject and making it fun and adding science into the mix, and also going over to Washington, DC to fight for our rights. Helped get the black box warning off of estrogen, and now she's working on getting testosterone as a prescription. So I am super excited to have her back with me today. Enjoy the episode.

Dr. Kelly Castorson, welcome back.

Thank you.

You were such a crowd favorite last time. Oh, awesome. I wanted to go deeper. And plus, I have you here in person.

I feel like that was forever ago.

It was forever ago. Yeah, it was.

We will link to this. Yeah, you got to go way back.

We'll do JJVirgin.com/DrKelly. But we want to go play on that, but go a little deeper because you've been really out there Talking about testosterone, and I think you're helping now to get this actually recognized as something women need, and maybe that insurance could actually pay for it. That still blows my mind. Yeah. Let's talk about it because it's still, it's still known. In fact, I was interviewing a well-known female doctor who referred to testosterone as the male hormone, and I thought, I don't wanna, don't wanna correct her.

Can I edit this out? Are you kidding me? I mean, I think, you know, that goes to show how little physicians got taught in medical school. Or residency. So when women go to the doctor and they get dismissed about this, which is not okay, but it's coming from a place of lack of education. I went through medical school and didn't know you make testosterone, which then converts to estrogen. There's all these facts that are literally not taught even in medical school. So now women are learning because of social media, because of podcasts, because of reading things, books, and then they go into their doctor's office, and if the doctor hasn't been catching up like she's been catching up. There's this big disconnect in what she knows. And that's what, you know, the menopausie and all of the educators say is like, I'm sorry, at this point in time, you might know more than your doctor does, but that doesn't mean you shouldn't advocate and you shouldn't get a second opinion and you shouldn't try to do things that make you feel better.

And hopefully you have a doctor, if you don't, find one who is either open to learning everything about it or is up on it.

Yeah.

One of the two.

Yeah, and there's—

dirt is not okay.

Exactly. And there's nothing like— this is the boots up, you know, from the, from the dirt up approach to changing women's health is changing the medical system's a big slow ship. Getting 10 women to go into the doctor's office in a week and say, hey, I'm interested in vaginal estrogen, testosterone, hormone replacement therapy, issues with my sexual health, whatever it might be, that doctor's like, they're coming in, I need to respond to this, right? So that's our bottoms up approach to changing the healthcare system.

I'm trying to think of when this was. It was 15 years ago when I first started having some of the symptoms of perimenopause, which my dentist identified, because I didn't realize I had—

I had—

my gums were bleeding and I went in, I go, what the heck is going on?

My male dentist was like, oh, that's estrogen.

Right then, that's impressive.

One of my buddies, Dr. Alan Christianson, who's a naturopathic medical doctor, was like, we can start by doing testosterone. That will bring your estrogen up. I look at now, I go, how lucky was I? You know?

Yes. Yeah, totally. Yeah. And, and the, the other thing is the erasure of what we did know. So if you look at the 1990s, about 40% of women in America were on hormones. And then the Iron Curtain of the WHI fell in 2002. Not a bad study, bad media, bad press, right? So now we have two decades of physicians that didn't get taught in medical school And the doctors who were practicing in the '90s have now retired. So if you look at 2000 to 2010 to 2026, the prescriptions continue to go down because these people retired. Oh, wow.

That's crazy. Well, let's go back to testosterone. So this is the most predominant of these sex hormones with women, correct? What does it do for us?

So the myth— when, when people say estrogen's our biggest sex hormone or our most common, that's actually wrong. Actually, testosterone— the ovary makes testosterone, adrenal gland makes testosterone, and we convert testosterone and estrogen peripherally in some tissues, brain. So testosterone's the most, but when you see those nice graphs of here's your estrogen and then it declines, they always leave out testosterone, or they put testosterone in nanograms per deciliter and don't have it in the same conversion unit, so it looks lower than estrogen. Testosterone's actually the dominant one. And another big myth is all the testosterone just converts to estrogen. That's not true. Premenopausal, you're walking around with 4 times more testosterone than estrogen. Estrogen will go really high during ovulation, but by and large, it's otherwise testosterone. And it doesn't all convert to estrogen because we have androgen receptors, which is what testosterone receptors are called. If it was there just to make estrogen, you wouldn't have the receptors all over your body for the androgens.

So what is it doing?

It is working on cellular health. So I like to define what a hormone is, right? Because otherwise it's this big scary thing with all these myths. Hormones travel around the body and they help healthy cells stay healthy. That's very important because hormones don't work so well at treating disease. They work better at maintaining cellular function, cellular health, mitochondrial health, changes in the DNA, changes in the function of the cell, and that's in every single tissue. So when people say things that are very vague sounding, like it helps energy, and you're like, that sounds so vague. How do, how do we know? I can't test your energy. I can't x-ray it. It sounds so vague. Mitochondrial health is energy. It's the energy-producing part of the cell, and that's what hormones work on.

What are some symptoms that someone's testosterone is low?

Energy fatigue. I hit a wall at 3 PM. I've just gotta chug coffee to get through the rest of the day. I go to the gym, but I'm not seeing any gains. It's like as if I didn't— wasn't going to the gym. Decreased libido. Libido is a mood, right? So change in mood. We know in men, higher risk of depression and dementia with low testosterone in men. Now, we don't have the data on women like I wish we with men, but cells function the same no matter who you are. So there are some, I think, strong signals that this is really important for brain, for mood, for energy.

Yeah, you wonder, because we know estrogen is, so it would make sense that testosterone would likely be too. And I would think overall drive.

Yeah. So testosterone helps motivation, right? And libido is a specific motivation. It's a motivation towards sex. But when women come back after I've started them on testosterone, it's not just sex that got better, or motivation towards sex. It's motivation to get this job done. It's motivation to start this business. It's motivation to finish this project. Testosterone really is a motivation hormone, which it helps dopamine, it helps serotonin, it helps the brain. It makes sense once you break down kind of these vague things like energy and motivation.

This helps a lot because when you start with, okay, well, it's energy, I'm like going, all right, well, gosh, there's so many things. Well, it's like, okay, which thing is it? You know, when you, you look at all these symptoms of all these different things, you're like going this could be any of these things. But then when you pull in the motivation card, that really helps differentiate it. So I know that this declines very differently than estrogen and progesterone decline, which may be why people don't recognize the symptoms, because it's not like it just fell off a cliff.

Well, and we don't even think it's in our body.

Yeah, that's right.

We didn't know. We didn't even know about it in the first place. And now we're like, this might be the problem. And you're like, hold on. Like, if you literally Google testosterone, it'll say the male sex hormone. But if you go down the paragraph on Google, it'll say found in all bodies. You're like, can you— can you move that up in the definition? So we just have to get women to understand that this is, this is a hormone in all bodies that help all cells function. But unlike estrogen and progesterone, testosterone will start declining after our 20s.

After our 20s. So when we think about replacing it back, are we replacing it back to what an optimal level would be in our 20s?

I mean, I, I joke, but I'm like, in a perfect world, when you were feeling awesome, when you were 28 or 32, check your labs. I wish I had this record.

I wish I had, like, why don't we have the time, you know, that blip in time when you really could look at all of your hormones and go, this was my optimal for estrogen, for progesterone, for testosterone. Who the heck knows?

Who the heck knows?

Well, so in the absence of knowing, how would someone know where they'd want their levels to be when they're now postmenopausal?

Yeah, well, I think even taking a step back on how, how do hormones work in the body— they fluctuate, they go up and they go down. We make our testosterone while we sleep, it goes up after we work out. It's a very fluctuating system, hormones. But how our brains work is we think about lab values like we think about kidney function, right? Kidney function, your creatine, your creatinine, very narrow window. Outside that window, bad news bears. That's not how hormones are. I mean, look at estrogen, for example. It like plummets when you have a period, it goes up to 300 to 500 when you ovulate. When you get pregnant, it's 3,000, 10,000, right? So hormones are always fluctuating and changing. And where we always want to go, because we don't understand this, is what's the right lab? All the time on the internet, people are like, what should my testosterone be? Where should it be? Especially when you get into dosing testosterone, that if you're going to take a testosterone product, did you check your lab 2 hours after you applied it? Did you check it 3 days after you applied it? Right? There's all this nuance in it. And that's why it's so hard on the internet to be like, what's the optimal range? Right. It's like, okay, well, that's on what testosterone product, how many hours after you dosed it, right? There's so much nuance to it. So I've simplified it down into my 3 steps for women.

Amen. You were just giving me a little insight.

I'm like, yeah, okay, no, yeah, it gets very complicated, right? Let alone, like, let's just make it worse. Uh, how sensitive are your androgen receptors? How many androgen receptors do you have in your brain? We know that brain androgen testosterone level is different than serum testosterone level. We can't measure your brain, right? So it gets very, I guess, out of how we like to measure it. Very like, it's very complex. And what we're seeing is female athletes, they tend to naturally have a higher testosterone. I ask my patients, I'm like, were you very— and they'll be like, oh yeah, I was like Division 1, blah, blah, blah, blah, blah. And I'm like, I know you're probably going to feel better at a higher testosterone, not because I checked you when you were 28, but female athletes tend to naturally have a higher testosterone.

Okay, here's my question. —did their higher testosterone make them select for sports, or did they do sports and that helped raise their testosterone?

We don't know, but it's probably the first. Yeah, because there are people who are actually studying this. Okay, so 3-point thing for women. I'll let you do this.

3 things. How does she feel?

Does she have any side effects that she doesn't like? What are her lab values? In that order. Okay. And what people are doing is they're focusing on the lab values and not caring about the woman. She should feel— I noticed that I feel different. Maybe I have more energy, my libido's back, maybe I'm sleeping better, maybe I'm seeing gains at the gym, right? So she's noticing an improvement. Mm-hmm. Side effects that she doesn't like: way more hair than I wanted, hair loss.

Are these reversible? Not all of them. I know that's the biggest scary part. Yeah.

And we can talk about that and we can talk about how to mitigate that.

Okay.

How does she feel? Does she have side effects that she doesn't like? And then what are her lab values? Meaning, is she absorbing it? Is it hitting a peak where I say over time, that's going to do some changes that might be irreversible, right? But what we know is in America, our lab values, the Quest Labs, LabQuest, those are based on two old studies. So for— again, so hormonal lab values are not like kidney function lab values are. And if you look at— Sue Davis published an amazing paper in 2025 looking at over 3,000 normal women in Australia. And if you convert it to American values, Below 10 is like, uh, your lowest 10th percentile. And Quest Labs in America, normal goes down to 2. So normal and optimal are very different things, but men have it the same way. Men's testosterone, 300 to 1,000, roughly. At 300, at 305, he's in the lowest 5th percentile. He's 2 standard deviations below the mean, and he will get told by his doctors, your testosterone's normal. It's like, but probably not for you had we checked it when you were 28, and also not for your average 55-year-old man. Right. So normal and optimal are two different things in labs. And I just want to break people from thinking like, just get her to a lab and get her to normal is like, how does she feel? Does she have any side effects? Use the labs as a guide. Okay.

So a couple of things there. Number one, the labs, because again, I know there's all sorts of lab testing out there. There's saliva, there's urine, there's blood. One of the most confusing things I ever sat through. I was doing a hormone course and all the doctors disagreed on the type of lab testing. I thought, what is someone in the audience supposed to think? Yeah, yeah, yeah. It was like urine or saliva or blood, and it depended on what you were taking. And it's like, okay, what's the best type of lab testing? And is there a certain amount of time lapse after you've had whatever type of testosterone dose you're doing?

Yeah. So I use serum. You need to get the testosterone female mass spectrometry lab test because it's sensitive under values of 100. If you order a total male testosterone, it's worthless at lower female physiologic values.

Is that what would happen?

Well, if you go to somebody who knows what they're doing, they're going to order the proper test, right? But left to your own devices, you might just be like, pick the first testosterone that comes up. And that was designed for testosterone in the 600s. Okay, so testosterone, it'll say testosterone, female, and it'll say mass spectrometry as the type because it's good, it's sensitive at lower testosterone levels. So I use serum, urine, saliva, expensive, some more expensive. Usually insurance doesn't usually cover it. And, and then we don't always know. Again, a lot of testosterone products haven't been tested using those things. So if you're trying to interpret, is your product good using things that the product was never tested upon? It maybe is not ideal.

Okay. Side effects. Way back in the day, I used to train people out of Gold's Gym in Venice. And one of the things I loved most about being there was I was really petite compared to all the women. And literally these women from the back, you're like, is that a guy or a girl? And you could hear their voice and still not know. And that is the big concern. I'm like, uh-oh. You know, they had big jaws, they had big acne, they had deep voices.

Yep.

What in— what of these things are not reversible, and how would you be able to watch this to make sure this doesn't happen to you?

Yeah, good question. So first of all, those women, I don't know them personally, but you likely— anabolic steroids. Yeah, I'm sure that's synthetic, just for the people, because I think the— our lack of knowledge of how hormones in our bodies work, we just think it's just like quick, fast, steep slope to like normal, then irreversible damage, right? It's like, no, this is all a big spectrum. But likely when you're seeing really big people, really bulky— and men too— there there is a level that natural hormones will not get you. You would then have to do anabolic, off-label, you know, other stuff. So we're just talking about the testosterone your ovaries make and giving you back that amount. Hormones are a spectrum, right? The more you give, the more likely you're going to get androgenic side effects. I tend to not see really you sliding into that more masculine irreversible until you're hitting 200, 250. Oh wow, really high. I think some women are very, very happy, and a lot of studies support this, in the high double digits and in the 100s. But Everybody's different. I'll get a woman to 60 or even to 40, and she's like, I've got hair and I've got acne and I've got everything else. Because again, what don't we know? How many androgen receptors do you have? How sensitive are they? We don't know any of that. What would make someone have more androgen receptors?

Like, is this genetics? Born? Yeah. What your parents gave you. And then for sensitivity, and I'll just share this, this story. We were in Korea a couple of years ago and we bought up this really amazing Korean ginseng you can only get there. And the way that they sold it to Tim was they went, it will help your sex drive and it will help your erections. And I'm like, going, we're gonna— we walked out with $4,000 of—

oh my God. Well, remember, remember in the Viagra studies, placebo, the sugar pill, gave men an erection 40% of the time.

Well, here's what happened that was interesting, and I'm all for it, but hey, all the stuff—

if placebos work, yeah, great, enjoy your erection whatever way you got it.

But what was interesting about it was actually his testosterone started go higher. I realized that I needed less of some of my, like, less thyroid, less— I forget one of the other ones, maybe it was testosterone.

But I didn't pay attention to it for a couple months.

I was like, man, this is interesting, my lab values are going up. And then I was at a lecture and they were talking about ginseng and how it was— it could sensitize the, you know, some of the hormone receptors. Did that just happen? Right? No. Yeah. You know, so it couldn't have been placebo. I wasn't planning on this. So interesting. But I just wonder if You know, because there would be two things: how many receptors you have and how sensitive they are. Yeah. And I would assume as we age, it would be like every type of resistance we get from anabolic resistance, insulin resistance, to hormone resistance.

Right.

And I'm guessing that exercise would be one thing that could help here. Yeah. But I just wonder if things like ginseng could too. Not a lot of data.

Not a lot of data. We, again, we need— testosterone is the black box, especially in women's health. But this is what I want women to know, going back to I'm afraid of too many side effects. The body hates drastic change. Thyroid storm, rapid weight loss, postpartum, right? The body really reacts strongly to drastic change. So if you go from sea level to Everest Base Camp in one day, it feels really crappy, right? But if you go there slowly over time, your body really doesn't know it's now at 17,000 feet. Same with hormones. So if you don't have any hormones, you don't have many hormones, and then you go to a super high value, your body kind of gets shocked. When your body gets shocked by that, your body's like, uh, let's not make hair anymore. Right? Like, let's do drastic things. So if you look at the testosterone data, testosterone doesn't cause hair loss. And this isn't even in higher dose pellet data. Testosterone doesn't cause hair loss more than placebo, which is interesting because placebo caused hair loss because 50% of women have hair loss in midlife, right? I also believe the women who say, I got a pellet and I lost hair. I believe them. So how do I reconcile this, right? It's like, don't shock your body into doing really drastic things Slow, low, gradual increase is the best thing you can do when you're trying to find a testosterone dose. This makes it—

well, it seems like that with estrogen, progesterone too. Like, that's why these pellets have never made sense to me.

Yeah, it's, it's go— it's sea level to Everest Base Camp. Yeah, in one day. It's, it's a dramatic change, and your body, you'll get a big steroid high from it. That's why some people love it, and some people, it's too shocking to their system, and you can't reverse it. Yeah, it's— I've had friends pull out pellets. It's, it's not something I, I ever want to try to do.

Yeah, it seems— those seem like they could make sense once you knew where your dosing was. Yes. Then to do it, but to just do it to start, it's like, oh, this thing's scary.

The internet's a very pro-pellet, anti-pellet place, and I like to remind— pro, anti, every— it's a pro, anti everything. But I like to remind people, men have pellets for testosterone that are FDA approved that are covered by insurance. So it's not the pellet in and of itself that's crappy. It's the mismanagement and going from 0 to 450 in one day that is a problem. So I agree, if you're like, I know I like testosterone, I know I maybe like a little higher level, I know my pellet is going to be properly dosed not to shoot me up too high, and I'd like something that just lasts for 3 months, you're a great pellet candidate. But it shouldn't be the first thing on the testosterone menu, in my opinion.

That makes sense. Do it— is that a steady release when you have a pellet?

Yeah, you still tend to get a peak and then a slow steady decline, but in general it's supposed to be more steady state.

Is there a preferred way to take testosterone, or does it not?

So I think it's a menu. And again, let's look at men. Men have oral, men have injections, men have pellets, men have gels, right? So for women to be like, there's one right way, it's like, well, the dudes don't have one right way, right? There should be lots of different ways. And ideally, you're going to be with a clinician who's like, I understand that this is a menu. What are your goals? Let's start you out slow. Let's go, you know, were you an athlete? Do we might need to get you higher? There isn't this one best way, but the International Guidelines for Low testosterone in women do suggest starting with a transdermal because it's cheap, starts pretty low dose, reversible because it's only for a day, right? So there are kind of things to suggest that's the best, at least as a place to start.

Ah, so transdermal. It's been so long since I used that. It's a daily thing. Daily thing.

And then shots weekly or twice a week.

I personally do the shots. That's been super helpful for me. But Tim has now become my nurse. He was like, I did not sign up for this, but you like the effects, so yeah, right? I should Okay. And so you would notice any of these symptoms and just back down? Yeah. Yeah.

And so if you go really high, voice changes, clitoral changes, and it can be permanent and it can be severe. So especially if you're a professional singer, you get paid because of your voice. Do not go fast on testosterone. Go slow. Our voice changes anyways in midlife because estrogen goes down, right? So now we've got declining estrogen. We shoot our testosterone way up. Same with clitoral hypertrophy. Now, that's the flip of the other coin, which is clitoral atrophy. And we're trying to figure out how do we get that not to happen. But I have seen profound, bothersome clitoral hypertrophy from pellets. I don't think I've seen it from anything else to the point where she had to go get surgery to have reductions. And you think, oh, no big thing with the swimsuit. If your clitoris is big enough, you can see it through a swimsuit. Wow. And she did not know. She didn't want it. Most people don't want that. Yeah. Who'd want that? Right. And so she had had 2 doses of pellets. I don't know how high her peak got, but 2 doses. Got her to the point where she needed clitoral reduction surgery. Wow. So that's the— like, should we ban them? No, but we should do them appropriately and we should counsel people appropriately and we shouldn't go super high, super fast.

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Cool, that would be great. And DHEA, how it works in the pathway— does it convert to testosterone, or is that only in men?

Like, what's this? It converts to testosterone and estrogen. So we call it a precursor hormone, even though it's a hormone. Call it a precursor.

We can buy it everywhere. These— that what we can buy and not buy over the counter is bizarro to me.

The world's all made up by rules that, that it helps. Testosterone's over the counter in Mexico. You can buy it at the airport.

Yeah, I heard that from you last night. Yeah. Like, I am going to go stock up next time I get over there. Great.

So, you know, I'm like, that's just information to have. Yep. Testosterone's available over the counter in, in Mexico. So yeah, it is all made up. In Canada and in the UK, DHEA is a prescription. Uh-huh. But in the United States of America, it is over the counter.

Wow. Okay. So talk about it. What is it? What does it do? Yeah.

So it's a precursor hormone, can convert into testosterone or estrogen. Data on oral, and again, the, The problem with over-the-counter is it doesn't have the strict dosing regulation requirements. Supplements just don't compared to an FDA-approved product, right? It's like, are you taking a high-quality supplement? Does it actually have DHEA in there? We've got issues with the supplement industry. Labeling isn't always what's in the product. So we've got that problem.

We've got the Amazon compounding it of like fake stuff on there.

Oh yeah, all the gummies, which— Oh yeah, those gummies. Don't tend to have anything in them. Creatine gummies. Yes. Yeah, that was— So that's the problem with supplements. And I think a lot of people don't know that. Of like labeling and what's in there doesn't have to be—

You need third-party tested supplements, people.

Yeah, absolutely. So there is a decent amount of data on oral DHEA. It doesn't seem to help the majority of people in a measurable way, but people with, especially with adrenal issues, certain medical conditions where both ovaries and adrenals aren't producing it because DHEA is more adrenal driven, they can show benefit. So there is a signal that it can help some people. I'm talking oral. A signal that it can help some people, but universally, by and large, we're like, it's not something we're just recommending to everybody because a lot of people are like, it's probably not doing much. I had crazy sexual dreams on oral DHEA. Really? So that was nice. Good ones? It was Tom Cruise. So depending, depending upon your opinion. Yeah, but so that was fun. But like, that's all I really— some people will notice like greasy, greasy skin. Not things you'd want. I mean, it's like, I mean, Tom Cruise is not bad, but it's, you know, is it going to be effective? Maybe, maybe not. Is it safe? Yes, it's been around forever. It's pretty well tested. It seems to be quite safe. The question is, is it going to add value to you? And again, that we're talking about oral DHEA in this scenario.

So probably more if someone did an adrenal test and found out that their DHEA was low, maybe it may, but it's still, it's like very poor. Or is that happening because of lifestyle stuff? Yeah, it's very poorly tested. Okay. All right. Well then if the oral is like, eh, Talk to me now about vulvar, vaginal.

Yeah, so there is a, uh, we have this beauty right here. We have this amazing product, which is our DHEA Vulvar Serum. So the vulva and the vagina, just to back it up for people, vulva is the external genitalia of the women, the entrance to the vagina, the clitoris, the labia minora. That's vulva. And the vagina is the part you can't see that tampons go in and babies come out, right? So that's the inner part. So both the vulva and the vagina have androgen receptors and estrogen receptors. And as we get older, all of our hormones go down and things change because of low hormones. Bones get more weak, hair gets more brittle, vulva atrophies, vagina loses its elasticity, we lose collagen, blood flow. It's called genital urinary syndrome of menopause. It's incredibly common, up to 80% of women, and it's progressive, meaning if you don't think it's bad right now, it'll get worse if you don't do anything.

Is it reversible?

Yes, but But if it's severe or it's been a long time since menopause, it's trickier to treat. You would probably have to throw more hormones on the pile. Amazing paper just came out about this. The body's like, I'm not getting any hormones, I'm going to downgrade my receptors, right? So you're trying to treat this years past menopause when it's severe and we're like, we're throwing these products at it. It's just not— the plant's not blooming, right? It downgraded all its receptors.

I wonder, so once you've downgraded those receptors, can you get them back? Can you wake them back up again? Or— Yeah, I mean, we're probably—

and this is expert opinion, this is not published, but this is us trying to figure out how do you reverse severe atrophy when we've neglected it for so long? Probably have to have a component of systemic hormones on board. Not always. Again, a trained clinician is the hardest thing to find, but the most important thing to find. But that's where we're like, if we're throwing estrogen at the problem topically, locally, and it's not getting better, Don't forget the androgens. Androgens are important. Bladder health, vulvar health, vaginal health. So that's where DHEA comes in. That's where even you can compound a local testosterone to come in. And what do we need to do to reverse atrophy? We don't know. There's no published data on reversing like severe clitoral atrophy. How do you make a labia come back again? That's kind of where we're headed in clinical care is like what combination? And it's probably going to be different for everybody, but DHEA topically, locally, pelvic, wonderful for the tissue. Absolutely wonderful. A recent paper just came out showing basic equivalency between the DHEA and estrogen, but for sexual function, DHEA came ahead. Really? Yeah. Wow.

I feel so sad for the women 60-plus that were the victims of this whole Women's Health Initiative. It's just so frustrating because Well, I know that you can start hormones at this point. You've also like, what have you lost? Yeah. You know, in terms of bone mineral density, in terms of this atrophy, it's just, it's just so awful.

It's awful. I call them the piss boomers. They should be.

Yeah. I'm right on the tail end of them. And I just was lucky that I had amazing—

You were in like a time and a place where you got access.

This woman early on in my career, I met her. We had a, we shared, we had a mutual friend. And she was Suzanne Somers' doctor. She was an endocrinologist in Santa Barbara who got in trouble for prescribing hormones as an endocrinologist. Like, what the hell? But I helped her put on this certification program for practitioners. And so I sat and listened to everything she did and how she taught for years. Yeah. So I knew all of this stuff before, as things started to shift. Yeah. You know, I didn't know the, like, things now we're learning about carrying menopause symptoms, like the bloody gums. I had no clue what that was going on. Yeah, but all the rest of it, I was like, I knew immediately when my thyroid went down. I—

well, I think there's so much work to be done because if you ask even the average woman, what does menopause mean? What does it mean? They can't answer you, or they'll give you an answer that's like, oh, no more periods, can't get pregnant. And you're like, that's a symptom of what it actually is. What is it actually? They don't know. I'm like, it's you outliving your ovarian function. They have no idea. But once you say hormones affect every single cell, then you're like, oh, that's why everything can be affected by low hormones. Yes, that's why.

And here's the other one. This, this one gets me. I was speaking at a lecture and this one came up. She goes, okay, I'm doing everything you're talking about, like I'm lifting weights, I'm eating protein, I'm doing fiber, I'm sleeping. I cannot shake this weight. And I said, are you on hormone replacement therapy. She goes, no, I want to do everything naturally. What would you say to someone like that?

I would say, what's on your feet? You have socks and shoes on. That's not natural, right? Like, the— I can pick apart natural so fast. Like, we're in an air-conditioned building, we drove a car here, we brush our teeth and floss. None of that's natural, right? And actually, outliving ovarian function for 40 years is not natural. Average life expectancy in America in 1900 1947, went down after that because of a flu epidemic. And before that, from all the research they can find, average life expectancy about 37 for all of human existence. Now, yes, there's outliers, of course, but society having an average age of death of 80, that is brand new. And I think this myth of natural is a very good way of controlling women, of like, let's make you believe that this is natural. Okay. All right. Well, suffering is natural too, but it's optional.

Yeah, that one gets me. So how often should someone use DHEA? For vulva? Yeah, yeah.

Probably daily. The available products now are daily. And again, it's like sunscreen, right? Like, how often do you use sunscreen? Every time you go out in the sun, ideally, right? So like, your body doesn't make these hormones anymore. How often should you use it? Well, for a topical transdermal product, the way those are made, it's a daily. Product.

Okay, so DHEA daily, but estrogen, topical estrogen, so vaginal, vaginal, yeah, twice a week.

So standard is twice a week. That's not really based on any science. I was just gonna ask. It's an old— yeah, it's an old product. And where did the loading dose come from, right? So vaginal estrogen product is loading dose for 2 weeks. Yeah, exactly, loading dose times 2 weeks and then twice a week for the rest of your life. There's no data on why, and I actually think it's not ideal, especially in the really atrophic people, because you're— you have really thin skin and you're going to get systemic absorption from from your product because your skin's not a good barrier. Now these women have headaches and they have breast tenderness and they're like, you told me this was local and I feel awful and I know I don't trust you or this product. So I, in my practice, twice a week till you're dead. Keep it simple. But if 6 to 8 weeks have gone by and you're still having burning, pain with sex, irritation, dryness, recurrent UTIs— because it takes about 6 to 8 weeks to notice benefit— if you're still noticing that, get an exam. Maybe we need androgens. And there's a good amount of people who need more than twice a week estrogen dose. Twice a week is baseline maintenance. What you have to do now to maintain your arms is different than what you had to do to get your arms right. So it's like twice a week is maintenance. That might not be optimal for people, especially if they're trying to reverse or come out of an atrophy situation.

And would it be different if they were also not taking hormone replacement therapy?

Maybe. I mean, the big myth is since you're taking systemic, meaning full body, you're taking systemic, you don't need vaginal. That's not true. Systemic hormones are actually quite low dose. I say the pelvis is the last stop on the train, right? So it really does need that local—

kind of like eye cream. Yeah. You know, we use face cream, we use eye cream. Speaking of face, what about face? Yeah. I mean, there was—

you want to break the internet? You know, talk about putting estrogen on.

I did not use vaginal estrogen on my face. I got facial estrogen. Yeah, but I mean, would it actually even be different?

Not really. But the vaginal estrogen product, the prescription product, is— it's kind of greasy. Yeah, like it's meant to like stay on there and not be quick absorbing in. And we might not want a greasy product on our face. Maybe we do for nighttime, right? So it's just not made for face, but lots of people like it, especially for as an eye cream because it's kind of thicker product. Didn't do that. Egypt sold out. I learned this from an Egyptian dermatology friend. Egypt sold out of vaginal estrogen because the women were putting on their face so much. So again, why does it work, right? Hormones make cells stay healthy. So blood flow, collagen, thickness of the dermis. And we've got multiple meta-analyses in the dermatology literature to say this— we— this is how estrogen works on the skin and that this is safe. And, you know, you'll break the internet with it because people will be like, we don't know, we've not studied it. And I'm like, multiple meta-analyses is actually a lot of research.

So there's no reason then you couldn't put on your face, on your chest, on your— like, I'm looking at now going, I've been using on my face, but I need to put on my chest. Right, on your hands.

At some point, using enough to skin products, slathering it all over the place. At some point you might increase your systemic estrogen like that, putting that much product on skin. For some people that might be a problem. For some people that's not a problem. Just know what you're working with and ideally do it safely.

And what about cycling hormones? Yep. That is it. I actually don't hear that talked about at all. When I talked about Diana Schwartzbein, that was her big thing with cycling hormones. Yeah, that's the only way I ever knew how to do it since I felt like such crap on progesterone. I was happy about that.

Yeah, yeah, yeah, totally. So it's very interesting. There is a subset of people, and this might not be her, I'm just saying the way people think is they think having a period is healthy and normal. And then if you go, we were actually just pregnant our entire lives for evolution. We weren't having 40 years of cycling, right? Right. So to tell people you should do it because it's natural. No, because we were dead. And before we were dead, we were just pregnant.

Right.

And so I want to break that. Like, we don't know cycling cycling and having a period until you're 82. So like, I like to break that argument down for people. I don't think anyone wants to have a period anyway. A lot of people don't like bleeding. Some people do like bleeding. It makes them feel like a woman. Detox, right? So, but to say this is how women's bodies are made— no, we were just pregnant. We didn't have birth control. We were just pregnant until we died. So to say in 80 we should be cycling and having a period until we're 82, it doesn't math very well. Right. Is there a role? You know, people are talking about the body needs a break from this, maybe, but the body lived— but pregnant, you lived at an estrogen of 5,000, right? So all of these arguments have a little bit of truth in them and a little bit of not truth in them. The current standard is you don't need to give a break. You can be steady state. We'll see where it goes. I mean, I truly think 50 years from now we're going to— we're going to look at now and be like, wow, we were just starting to come out of like bloodletting with leeches with hormones. Yeah, but to say that there's only one— and that's like a true expert is going to be like, let's work with you. What I tell my women is like, my job's to keep you safe. Within that container, we get to play. We are trying to find the best you that you can be, and I have the knowledge to keep us safe in that, and we're gonna play. I have one woman, she came to see me, and she was instructed that she needed a 4-day break from her hormones. She's in her 70s.

I remember hearing this at some lecture.

Yeah, so she, she would do you know, she'd do what is it, 27 days, 26 days, and then be cold turkey for 4 days. And I'm like, well, how do you feel during that? And she's like, absolutely miserable. I can't get out of bed. I hate it. Like, I dread those 4 days. And I'm like, it's really good information to share with your clinician, right? So it's like, we have to work with people and be like, her body does not like no hormones.

I can tell when I've like, you know, you take your estrogen patch off and you forget to put it back on. I know it. You know, you just know it. Yeah.

So it's like we rely so heavily on data, knowing that data is flawed, and we don't really listen to women and be like, how do you feel on this? The definition of evidence-based medicine: available evidence, clinician experience, wishes of the patient. Like, that's online, you can look it up. But that's what the definition of evidence-based medicine is.

And everything— like, you hear people yelling on the internet about randomized placebo-controlled stuff. Trials, and it's like, so are we just going to wait 20 years?

Right, right. Well, that's the big argument. That's the big argument with hormones and dementia, right?

So, I mean, it's just obvious.

It's obvious. If you look at— well, it's the thing is like, how much cellular data, animal data, male data, how much data do you want to say there's a signal here that hormones help healthy cells stay healthy? Dementia is the end of unhealthy. Right? So throwing hormones on here doesn't work as well as doing it before the unhealthy happens. And yes, there are many, many different ways that dementia enters your life, but one of them is low hormones. Right. Well, it— well, putting people on estrogen patches remove all dementia from our world? Absolutely not. It's insane to think that.

Yeah, we'll still have brain injuries and toxins.

So Australia, number one killer of women in Australia right now just made that in 2026. Dementia, number one killer of women in Australia, above heart disease. Above heart disease. Like, for people to be like, oh, it's not that— like, this is a big problem and it's coming for us.

Wow. Do you know what the rates are here in the States?

It's lower, but not because we're winning, it's because we're dying of other— of other things. Yeah, yeah, yeah. So if we did have the longevity and, and got on top of the heart disease, dementia is going to come get I wonder why that is that way in Australia. They have a big drinking culture. That's why— I mean, to me, I'm like, there's just one thing that would also link to heart disease. Yeah, you think it linked to heart disease too. Huh. Yeah, but it's the UK. The UK is catching— the UK is going to be dementia pretty quick too for women. In men, testosterone helps decrease the risk of depression and dementia. And why do we test all these things on men and apply them to women except for testosterone? We're like, you're taking a sleep medication that was tested on men, you're taking statins that were tested on men, you're taking high blood pressure medications that were tested on men, but we can't extrapolate the testosterone data. But we can.

Why wouldn't we do this? I don't understand this one. Gender bias. Like, but it, it's like it helps the men too, right? Oh yeah, like everybody wins with rising tides.

But if you look at going back to the studies we do have, Lisa Mosconi's meta-analysis basically saying if you start the hormones young likely a 30% decreased risk of dementia, which is huge. If there was a magic pill that decreased your risk of dementia by 30%, right, it would have 5 Super Bowl ads. It's really amazing that I'm not picking on plastic surgeons, but like that they haven't— like, if you want to maintain the work that's been done or have it heal better, or like all the things like hormones, part of this discussion, like wound, we've got great, amazing wound healing data. Older people, like non-healing ulcerative leg wounds. Testosterone helps wound healing. Yeah. Wow. It helps cells. Amazing. Like, it's so basic. It's so basic. Wow.

Okay. That's interesting. Back over to the, the sex part of things. So someone starts with testosterone, and I know there's, you know, part would be hormonally related, but a lot of it's also brain related. But is some of that hormones in the brain? Who the heck knows? Like, what, what types of things could you see? How much could it impact someone's sex life? And when would you know that it's a hormone problem versus you need to go get some counseling? Yeah.

So how's the relationship? Was sex ever amazing? Do you remember good sex? So we want to know, like, where are we coming from, right? Have you never wanted it? Have you never had an orgasm? Versus like, it was so great and the relationship's still amazing, but man, I'm struggling to orgasm now, or I just can't get aroused now, right? So the story actually tells us a lot about what's going on. So for people to come in and to say, I want testosterone for better sex, it's like, whoa, whoa, whoa, whoa, whoa. Like that's one brick in the wall of the house, right? And, and there is an essential brick. It's the foundation. But I can make you have normal testosterone levels. But if you're overworked, underslept, stressed, hate your partner, like love them but hate them and don't want to sleep with them, right? Testosterone won't help all of that. And testosterone helps every domain of female sexual health except for pain. Doesn't do great for pain. You got to treat pain with other ways. Arousal, orgasm, desire, lubrication. Testosterone helps all of that, and we've published studies on this. So when I hear on the internet like it's only for libido, like, it's like, no, no.

I think people don't understand the whole sex piece anyway, so they think it's libido. They don't realize there's so much more to this.

And this is very important, especially for any clinician. When a woman comes in and says, I have low libido, Ask her what that means, because what I think low libido means and what she thinks low libido means are usually two way different things. And that's just helpful off the bat, right? So like, you need to understand these things and have a decent foundation of Sex Ed 101 before you start throwing medications and hormones at people, because then they'll come in and then they'll think they're a medication failure. Medication was never going to help with what their goal was. So what are your goals? What do you mean by low libido? Very often a woman will say, I have low libido and pain with sex. I'm like, good news, you have one problem. You have pain with sex because I can never make you desire something that's painful, right? So you have to fix the pain.

And the pain piece of it, how common is that? Incredibly common.

Incredibly common. And a decent minority of women never tell their partner that they're experiencing pain with sex.

Oh my gosh.

And how easy is it to fix? It can be very easy. Do we just need hormones? Do you have a tight muscle, right? You had hip issues, you got a low back issue, it's affecting the muscles around the vagina. Is it that? Endometriosis, you know, bladder infection, skin infection, lichen sclerosus, like atrophy is huge. So there's many, many different reasons for pain with sex. And that's why, again, in this age of digital health and online, which has expanded access so beautifully for so many people— I still haven't figured out how to do a pelvic exam over Zoom, nor do I want to— but really, a trained clinician— like, the amount of women I've seen who've said, I've been to 4 gynecologists— not to throw gynecologists under the bus, but this is the story— to 4 gynecologists, they've all told me my exam is normal. And I'm like, there's nothing normal about this. We have significant atrophy. You have no labia minora. Like putting anything in there would be massively, massively painful. Right. And so it's like a trained clinician who can be like, tell me where the owie is. Let's look. Here's a mirror. I want you to see. I want you to show me where it hurts. That takes time. It takes training and it takes attention and it's invaluable and it's actually pretty rare.

And it seems like a gynecologist should also be able to do a good pelvic floor exam as well.

People don't even know what a pelvic floor physical therapist is. They're amazing. They are incredible.

They're incredible. I'm just going to bring it— like, anytime I can ever preach about them.

And they love it. Every time we vouch for them, they're always like, thank you so much for bringing us up. So they're physical therapists who are trained specifically in pelvic health. We need a million more of them because we all have pelvises. And men have pelvic floor issues too. And from what I've heard—

well, I was trying to get Tim to the pelvic floor therapist, and I thought, he is not going to be on board for how they have to do his pelvic floor exam.

So yes, we access the male pelvic floor through the anus.

Yes. Yes. He's not going to— he's not going to be happy with this one. Let's go into a little speed round here. You ready? Yep. Okay. Is testosterone safe long term? Yes. Like long term till the day we die?

We have 50-year published safety data on trans men. When what that means for people is that's 10 times the female dose. How about brain fog?

Does it help with that? Yes. Why won't many doctors prescribe this right now?

Lack of education, difficulty in access. DEA restricted because the Olympic doping scandals of the 1980s. Literal Act of Congress, 1991 Anti-Doping Act put all these synthetic sport-enhancing chemicals on the list and one hormone our body naturally makes, which is testosterone. FDA didn't want it, DEA didn't want it, but the Act of Congress did it because we don't like losing. So, so that's not a speed round, but a lack of knowledge about—

I always suck at the speed round. I like how to take street rounds, and then it's like become—

I always want to back up. I'm like, it's not because Dr. Caspersen said so, it's because like everything I say is coming from deep, deep research and knowledge on this, right? So what I'm like, yes, it helps brain fog. It's like, can I— can show you all the papers, right? But yes, it helps.

At what age? Because you said we start— our testosterone starts going down 30s, what you said. I just wonder, you know how we talk about muscle mass starting to decline in your 30s? And bone. And bone. Yes. So I wonder how much of a player testosterone is there. I mean, what point do you think a woman should start?

I think if she doesn't feel right, she should go in because, again, like, not feeling like yourself is incredibly common. It's one of those very vague things. But perimenopause, the most common sign in perimenopause is not feeling like myself. And FLM, it's researched, right? So if you're not feeling like yourself, go in. But that's for a comprehensive exam. Right? What's your glucose? What's your cholesterol? What's your blood pressure? Screen for depression, hormones, right? It's a part of a comprehensive— and I think again, the internet loves to simplify stuff of like, we can't go around just saying this is your testosterone. Like, our body is holistic, right? Everything plays off of each other, right? Are you sleeping? Are you vaping? All of these things that play into your health.

One thing women need to stop being ashamed of Their body. Better investment, hormones or strength training?

There is nothing better than exercise. There just isn't.

Amen to you on that. Most underrated sexy trait in midlife? Confidence. Testosterone, fear too much or prescribed too little? No, same thing. One thing every partner should understand about female desire? It matters. Boom. Thank you for that. All right.

Things you're working on now.

We're going to put everything at jjvirgin.com/drkelly. What do you got going on?

Female Dose Testosterone, DHEA product. Just put in a new book pitch. We'll see where that goes. Just education. I love the stage. I love educating. I love making people laugh and learning. So that's really, really fun for me.

So we have your podcast.

You are not broken.

You're on social at Kelly Casperson, MD. Yes. You've got your You Are Not Broken book.

Yep. And then the second book is The Menopause Moment. The Menopause Moment.

I think that's what we interviewed you on. Maybe that was the Menopause Moment.

Pretty sure. I think it was longer ago than that.

Was it?

I don't know. Well, this will become a more regular— I think we're getting to be around 100 lives.

Yes. We will do more.

Maybe we'll even go to the gym. So fun. Anyhow, it's been fantastic.

Thank you so much.

Thank you for having me. I appreciate you. I appreciate everything that you are doing. We need way more of you, and hopefully you'll start training more and more practitioners on all of this as well.

My pleasure. Thank you.

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Be sure to join me next time for more tools, tips, and techniques you can use to look and feel your and be built to last. Also, I'd love to connect with you and hear your thoughts on the podcast. Here's how. First, subscribe to the podcast and leave an honest review. Second, take a screenshot of your review. And third, text it to 813-565-2627. That's 813-565-2627. 2627. When you do, I'll reply using my brand new Virtual JJ. It's my on-demand virtual self built from my books, talks, and years of experience so I can interact with you directly. You'll make my day and I can't wait to hear from you. Thanks for tuning in and I'll catch you on the next episode. Hey, JJ Virgin here. And just a reminder that the Well Beyond 40 Podcast offers health, wellness, fitness and nutritional information that's designed for educational and entertainment purposes only. You should not rely on this information as a substitute for, nor does it replace professional medical advice, diagnosis, or treatment. If you have any concerns or questions about your health, you should always consult with a physician or other healthcare professional. Make sure that you do not disregard, avoid, or delay obtaining medical or health-related advice from your healthcare professional because of something you may have heard on the show or read in our show notes. The use of any information provided on the show is solely at your own risk.