Ramadan is one of the holiest months in the Islamic calendar and marks four weeks of fasting, prayer, reflection and community.

From the evening of Friday 28 February to the evening of Sunday 30 March 2025, many Muslims will observe the month by not eating or drinking in daylight hours.

Here Dr Hina Shahid, a GP and chair of the Muslim Doctors Association, offers advice on managing the menopause during this special month.

What about my hormone replacement therapy (HRT) medication?

Some medication can be affected by the Ramadan fast, so here is what you may need to change if you take HRT.

If you replace hormone levels using skin patches, skin gels, an intrauterine device such as a Mirena coil, or a vaginal pessary or cream, then you don’t need to make any changes during Ramadan.

‘Continue as normal with these forms of HRT,’ says Dr Shahid. ‘These are absorbed through the skin, they are not ingested and have no nutritional value, so they don’t break your fast.’

However, oral HRT does break your fast, so move them to before or after daylight hours.

‘Most women take their HRT tablets first thing in the morning, so just move it back earlier to your suhur, the predawn meal. If you normally have them in the evening, just wait until the sun goes down.’

These small tweaks shouldn’t disrupt their effectiveness, Dr Shahid says. ‘If you just move it by a short amount of time it won’t have an impact on your hormone levels, and as they tend to be taken once a day they are not hard to move.’

RELATED: HRT doses explained

I’m perimenopausal. What if I’m on my period during Ramadan?

Women on their period do not fast during Ramadan, so if you’re in perimenopause and still having periods, Dr Shahid says the exemption to not fast applies, and you can make it up at a later date.

‘If you’re having irregular bleeding, and you have already seen a doctor about this, then you may still be able to fast and it would be advisable to speak to an Islamic scholar who can give specific advice around this,’ she says.

RELATED: Heavy periods during the perimenopause: what you need to know

Don’t be tempted to skip suhur

Your menopause is unique to you, but many women can find their sleep is poor and they are tired as hormone levels decline.

Dr Shahid says it can be easy, especially when you’re tired, not to get up early and leave time for suhur before dawn.

‘But I would always recommend women, especially those experiencing menopause, to get up and have a good healthy meal,’ she adds.

‘Aim for lean protein, like meat, fish or vegetarian options, wholegrains and fruit and vegetables. These will help give a continuous, steady supply of energy that stabilise your sugar levels. Oatmeal is a good option. Make conscious choices about what will work best for your body and provide the nutrients you need.’

Drink plenty of water at night

Keeping hydrated is important for energy and wellbeing and can be tricky for those observing Ramadan as the fast includes not drinking any liquid.

Ensure you drink two litres of water during non-fasting hours, so you are topped up for the day and eat plenty of hydrating foods, such as fruit and salad vegetables, before dawn and after sunset, Dr Shahid says.

Choose evening foods that won’t aggravate perimenopausal or menopausal symptoms

When breaking the fast after sunset, it can be easy to be drawn to a large, rich options for iftar, which can be geared towards unhealthy food.

‘You might really want a samosa, but try and avoid fried and fatty foods,’ Dr Shahid says. ‘They can disrupt your energy levels, give you heartburn, make it harder to sleep and worsen night sweats. It’s really important to pay attention to your nutrition, especially if you are going through menopause. Again, focus on lean protein, wholegrains and a balanced diet.’

Try to stick to a routine

Find a new routine during Ramadan, keeping your meals at similar times every day and following the steps that usually help you manage your symptoms, like not getting too hot in bed.

Many women will go to the night prayers at a mosque, which are often busy and warm. Wear layers of cool natural fabrics to these sessions to minimise hot flushes, Dr Shahid says.

‘You are not going to be perfect every day of the month, but try and have some structure,’ she says. ‘Ramadan is meant to challenge you but within limits. If you can get a daytime nap, and some people take time off during Ramadan to really concentrate on it, then this can help.’

Focus on the positives and joy that Ramadan brings

A month of fasting can bring emotional up and downs, and when mixed with menopause, when declining levels of hormones can affect your mood, this can be a difficult combination.

While some days will be harder than others, there are many positives to take from Ramadan, says Dr Shadid.

‘For women experiencing fluctuating moods due to perimenopause and menopause, it may become more noticeable during Ramadan when you are hungry and tired,’ she says.

‘This is when lifestyle measures are really important, and Ramadan is a really supportive month with a focus on community and family. A lot of people do extra prayers, it is a spiritual time with an emphasis on gratitude. This can lead to an amazing positive synergy between Ramadan and mood.’

Reaching out into the community and talking to other women who are going through the menopause during this time can be a great source of support, says Dr Shahdid.

And if you are really struggling on some days and break your fast, don’t feel you have failed.

‘There are all sorts of reasons that people need to break their fast, and people are encouraged to stop if they need to,’ says Dr Shahid.

‘You can make it up at another time. It is important for women not to feel bad and beat themselves up, it is absolutely fine.’

The post Managing your menopause during Ramadan appeared first on Balance Menopause & Hormones.

• Hormone replacement therapy (HRT) is usually the first line treatment for the management of perimenopausal and menopausal symptoms
• However, your HRT prescription may need adjusting over time
• Always speak to a healthcare professional if you don’t think your treatment is as effective as it once was, or you are considering stopping treatment

HRT is usually the first-line treatment to improve symptoms of perimenopause and menopause [1].

When it comes to HRT, there is no one size fits all approach. The type and dose of HRT is prescribed according to your symptoms, medical history and personal preference.

In terms of symptom relief, every woman is different: symptoms such as hot flushes and night sweats usually subside within a few weeks of starting HRT, while other symptoms, such as low mood, muscle and joint pains and vaginal dryness, may take longer to improve.

But what should you do if your HRT doesn’t seem to be as effective as it once was?

Is it common to have to change my HRT prescription?

Many women need their HRT treatment regime altered over time.

When you start HRT for the first time, there may be a noticeable improvement initially but then not as much as you were hoping for, or there may be a return of some symptoms. This may be because you own hormone levels are reducing with time so you may need more to replace the amount of hormones that are missing in your body.

My symptoms have returned. What should I do?

Your healthcare professional may have given you a range within which to manage the dose yourself (for example, one to three pumps of oestrogen gel). You can usually alter the dose yourself within the range prescribed for you if you aren’t feeling the benefits of HRT, but just remember it can take a few weeks or months to respond to any changes you make.

RELATED: HRT doses explained

If you are experiencing a recurrence of symptoms, the first step is to talk to the healthcare professional who prescribed your HRT. It may be that you need your dose or type altering: you may need to change from a gel to a patch for example or you might benefit from adding in testosterone, as well as oestrogen (and progestogen if you are taking this). Whatever the reason, discuss it with your health professional if you think your HRT needs changing.

Blood tests may be recommended to determine how well you are absorbing oestrogen through your skin and to look at other causes of your symptoms, such as vitamin deficiencies or an underlying thyroid disorder.

RELATED: Understanding hormones levels in your blood

What about alternatives?

Another option your healthcare professional may discuss with is trying a different method of HRT, or a different brand.

Hayley Berry, pharmacist with Newson Health, says: ‘Remember that we have lots of different types and brands of HRT, so we can usually find a very similar product to the one that you’re using.’

For example, two pumps of Oestrogel is roughly equal to 2-3 sprays of Lenzetto, a 50mcg patch, 1mg oestrogen-only tablet or one sachet of 1mg Sandrena gel.

RELATED: HRT supply: what should I do if I can’t get my usual prescription

If you don’t feel a treatment is working as effectively as you’d like, don’t just come off it, as it could cause a return of symptoms. Always speak to your healthcare professional first.

‘Healthcare professionals will work with you to find a suitable alternative for you,’ says Ms Berry.

References

1. National Institute of Health and Care Excellence (NICE) ‘Menopause: identification and management’

The post What to do if HRT seems to have stopped working for you appeared first on Balance Menopause & Hormones.

On this week’s podcast, Dr Louise is joined by Dr Mohit Khera, a US-based leading urology specialist treating urinary tract disorders, male infertility, and male and female sexual dysfunction.

They discuss the role of testosterone, the most biologically active hormone in the female body, why he believes testosterone is the best barometer of health of all hormones, and testosterone replacement.

For more information about Dr Mohit, click here, and you can follow him on Instagram @ drmohitkhera.

For more information on Newson Health, click here.

Dr Louise Newson’s first-ever live theatre tour, Hormones and Menopause – The Great Debate, takes place 27 September to 12 November. For more information and tickets, click here.

Transcript

Dr Louise Newson: [00:00:00] Hello. I’m Dr Louise Newson. I’m a GP and menopause specialist, and I’m also the founder of the Newson Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. I’m also the founder of the free balance app. Each week on my podcast, join me and my special guests where we discuss all things perimenopause and menopause. We talk about the latest research, bust myths on menopause symptoms and treatments, and often share moving and always inspirational personal stories. This podcast is brought to you by the Newson Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women. So I’m very excited on the podcast today because I have someone here with me remotely because he’s in America, mo Khera. He’s a professor of urology. And I have been reading his work, I’ve been watching his work. I’ve had him in high regard. But also many of you know, my husband’s urologist. And so he’s feeling quite left out that he is not here in this podcast because him and Mo have even danced together at conferences. They enjoy each other’s company. So it’s another connection. And I love connections. So welcome, Mo. So today we’re going to be talking about testosterone. So thank you so much for agreeing to come to the podcast. [00:01:28][87.7]

Dr Mohit Khera: [00:01:28] Thank you so much for having me on the show, Louise. [00:01:30][1.3]

Dr Louise Newson: [00:01:31] So we’ve been talking a lot before we started, and I could talk to you all day and all night because your knowledge is incredible. But I wanted to just talk really basically about testosterone. But before I start, could I just ask you why you urology, why did you get into doing urology? [00:01:47][16.5]

Dr Mohit Khera: [00:01:48] It’s probably the most amazing field in medicine. You know, urologists have the ability to be surgeons. So we get to operate and we also get to make the diagnosis. So we get to do both sides. And if you think about it, the population’s ageing, so more and more people will need a urologist. By the year 2050, 20% of the population globally will be over the age of 80. So think about that. So and I think the best field in urology really is sexual medicine and infertility. It’s what I specialise in, and it’s really been a passion for mine. [00:02:16][27.3]

Dr Louise Newson: [00:02:17] And Paul would also add that urologists are the nicest people, would you agree with that? [00:02:21][3.6]

Dr Mohit Khera: [00:02:21] I would agree, 100%. [00:02:21][0.0]

Dr Louise Newson: [00:02:24] And I actually agree. So I had the pleasure last year of lecturing for the British Association of Urological Surgeons (BAUS). Paul was in the audience, my husband, but actually in the coffee breaks, in the lunch break, everyone’s really friendly. They’re chatting, they’re laughing, they’re shaking hands, they’re sharing anecdotes. There’s none, no competitiveness. Whereas I’ve lectured a lots of other healthcare professionals’ meetings and conferences where people are a bit guarded. They’re always trying to protect, whether it’s their own clinical practice or just their own way that they, I don’t know. But something about urologists is that they’re very different. I don’t know if that’s the same in America? [00:03:08][44.7]

Dr Mohit Khera: [00:03:09] I may be biased, but I completely agree with you. [00:03:11][1.8]

Dr Louise Newson: [00:03:13] Which is great because we all learn from each other every single day. I keep saying to my children, every day is a learning day. There’s so much and medicine doesn’t stop. I wish I could sleep less because there’s so much to read and understand, and I feel really embarrassed doing a podcast about testosterone. Because if I had met you 12 years ago, I didn’t even know women had testosterone in their bodies. So I feel quite cheated as a doctor Mo, that I’ve had so long without knowledge. And now I’m going to say something which not everyone might agree with. But I think testosterone is one of the most important hormones for men and women. [00:03:55][42.4]

Dr Mohit Khera: [00:03:56] I would completely agree. And I would tell you that if you’re going to pick one hormone that’s the best barometer of overall health, it’s testosterone. And we’ll talk about that. There’s so many different body parts that are affected by testosterone in a negative and positive way. And for me it’s the best barometer of overall health. [00:04:15][18.1]

Dr Louise Newson: [00:04:16] And that’s really interesting because for many years, testosterone, certainly for women, has been spoken about just in respect to libido. And we can talk about that a bit later. And for men, it’s about whether they can have an erection or not. So when I started reading about just basic physiology, what does testosterone do in our bodies as human beings, whichever gender or sex we are? I’ve quite quickly realised that we have cells all over our body that respond to testosterone. And testosterone has really important biological process effects in our cells, including getting right down to our mitochondria. So it’s not just there for a laugh, it’s there for a reason, isn’t it? And all these cells and tissues and organs. [00:04:59][42.8]

Dr Mohit Khera: [00:05:01] Completely agree. And if you think about it, you know, we talk about testosterone for women. If you think about testosterone, actually the most commonly biologically active hormone in women, it’s not oestrogen. She has more testosterone than any other hormone in the body, but yet we don’t feel comfortable giving it back to her, which I never understood. [00:05:18][16.9]

Dr Louise Newson: [00:05:20] No. And I think more and more about this, actually, because it’s not really a menopause related decline unless someone is young and they have their ovaries removed because it’s more of an age-related decline. But it’s also not just ovaries that produce it. Of course our brain produces it. We’ve got cells that produce testosterone in our brains, but also our adrenal glands. Our muscles can produce testosterone. You know, it’s not just a gynaecological hormone, is it? [00:05:52][32.2]

Dr Mohit Khera: [00:05:53] And you bring up a good point. You know, so men and women are a little bit different. So men predominantly make their testosterone from the testicles, 90%, 10% from the adrenals. And women, it’s typically, you know, half of the testosterone is from the ovaries and half from the adrenal glands. So it’s slightly different. And, you know, with this concept of testosterone declining with age, I used to think that there was this real concept called male menopause. I used to give lectures on this and say, you know, when men get older, they go through male menopause. As they get older, the testosterone declines. But today we know that’s not true. Actually, it’s that ageing only has a slight decline in testosterone. It’s the acquisition of co-morbid conditions that drops a man’s testosterone over time. So diabetes, obesity, metabolic syndrome, slightly different than women because, as you know, women, they will have a little bit more of a decline in their late 20s and then it’ll kind of steady off over time and then maybe a slight decline during menopause as well. So, you know, I do think that age does contribute, but it’s also acquisition of co-morbid conditions that really bring us down, you know. [00:06:57][64.4]

Dr Louise Newson: [00:06:58] But I think it’s also the more I see, obviously I have a huge clinical experience. I’m very privileged with the number of women that we see through the clinic. But increasingly I see younger women. Like I saw someone today who’s only 32. She’s had awful PMDD premenstrual dysphoric disorder and she spends three or four days a month in bed because she has so exhausted. She’s been diagnosed with depression, fibromyalgia and chronic fatigue. And she had tried some synthetic combination oral contraceptive, but her testosterone level is very low. And she also has something called lichen sclerosus, which I’m sure you are aware of. And increasingly, women with lichen sclerosus respond a lot better with testosterone than oestrogen. And there are a lot more, I think, younger women who are more testosterone deficient than oestrogen deficient. But medicine often is very simplistic and guideline driven. And a lot of people say we have to give oestrogen and progesterone first and then consider testosterone only if people have got reduced libido. And I saw someone else today in my clinic who’s in her late 40s, had periods have nearly stopped. She’s been on oestrogen and progesterone. She has an okay libido. She doesn’t have a partner, but she has muscle and joint pain. She has awful brain fog. She has reduced stamina. She can’t work at the moment. She’s been told she can’t have testosterone because her libido isn’t too bad and her testosterone level is undetectable. [00:08:35][97.4]

Dr Mohit Khera: [00:08:37] Yeah, I think that’s very unfortunate. You know, when patients, women come into my clinic and I speak to them about hormones, I tell them there’s something called the triangle and the triangle is oestrogen, progesterone and testosterone. And unfortunately, most people just focus on the oestrogen, progesterone, but they’re missing the third component of the triangle. And hormone replacement is not rocket science. Essentially what we’re doing is taking someone who’s low and putting them back into the normal range. Nothing fancy. We’re just taking someone’s who low and putting them back into the normal range. Now, there are other hormones we also think about you should think about thyroid, cortisol. We call that outside the triangle, very important but the triangle really is the testosterone, oestrogen and progesterone. Unfortunately, most women are deprived of the testosterone, maybe because of fear prescribing. And right now, most societies will say that testosterone should only be prescribed for HSD, right, so for a low libido. But I do believe that there are other benefits with testosterone besides just HSDD. And even if the literature doesn’t support that yet, I think it’s because we don’t have enough studies. Because clinically, I do see women see improvements in muscle mass. I can see improvements in depression. I can see improvements in brain fog. I mean, I can see a lot of other improvements besides just libido when I treat women with testosterone. [00:09:58][81.6]

Dr Louise Newson: [00:09:59] And it makes sense because we have testosterone receptors all over our brain. And also testosterone works as a neurotransmitter and affects other neurotransmitters in our brain as well. But one of the reasons I take HRT is because I’m very worried about osteoporosis. I have doctored so many women, especially with osteoporosis of their spine, it’s so painful, it’s so uncomfortable, so hard to treat when it’s more advanced. So I know that oestrogen and progesterone help strengthen my bones and my muscles. But we have testosterone receptors in our bones as well. And we know for men, helps strengthen our bones. And it’s very likely common sense will dictate won’t it Mo that it will help strengthen our bones and improve our muscle strength? [00:10:43][44.0]

Dr Mohit Khera: [00:10:45] Yes, absolutely. I mean, you know, some of the, a lot of the data, unfortunately, it comes from the men, from the study of men. But when you give men testosterone, if you look at a graph, you can see increased bone mineral density as early as three months. And a lot of the trials will be statistically significant. Every three months that you give the testosterone, you increase the bone mineral density on the men. In other words, reversing osteopenia and reversing osteoporosis. And really so so men and women are not that different in certain categories. I’d say, for example, bone mineral density. And I’m sure Louise you’re familiar with the studies when you give women oestrogen or testosterone and look at bone mineral density, the group that does the best is the combination when you give them oestrogen and testosterone. But we don’t talk about testosterone for bone mineral density in women. We talk about vitamin C and vitamin D and oestrogen, but we don’t talk about testosterone, which we should. So, again, I think this is a big unmet need. I think there are a lot of women that could benefit from testosterone in terms of bone mineral density. We just need the trials. We need the studies. And unfortunately most of the money is spent on the men, not the women. [00:11:50][65.7]

Dr Louise Newson: [00:11:52] Absolutely. And also, a lot of studies now are funded by pharmaceutical companies who make the bisphosphonates, they make the other drugs that are used. And the new drug came out for osteoporosis treatment and it’s 300 pounds a month as opposed to HRT, which is a few pounds a month. So there is a bit of vested interest for these drugs. But often in medicine it’s using some common sense and some basic knowledge. And people keep talking about we need randomised controlled studies that actually we also need other observational data. But the most important thing for me is patient choice, people being allowed to choose. And often that isn’t happening. And we increasingly see women who’ve just been told they can’t have testosterone because their libido isn’t severe enough or they don’t fulfill the criteria for HSDD which says you have to have at least six months of severe psychological distress. Now, I don’t know about you, but I went into medicine to help people, not watch them for six months have severe psychological distress. Is it is it like that in America that you have to wait six months to be severely psychologically distressed? [00:13:00][68.2]

Dr Mohit Khera: [00:13:01] Yeah. So, I mean, I guess for us, it’s a clinical judgment. And so like in the UK, I assume in the United States, it’s off label, we call it off label. I think all that off license, the same thing. You know, essentially I can’t walk into Walgreen’s and buy a testosterone for women. It doesn’t exist. Right. Which is unfortunate because testosterone has been around since 1935. It’s been a long time. It was used in women in the early 40s. And today we still don’t have an FDA approved testosterone for women both in the US and the UK. If we go to Australia, we could get licensed or FDA approved, but we don’t have in the US. But basically it’s a clinical judgment that if a woman comes in and she complains of low libido and I check her levels and it’s low testosterone, I don’t necessarily wait six months to treat her with testosterone supplementation. I do think that she could benefit now. And what’s the harm of giving her a three month trial to see if it improves her sexual function and libido? I don’t think there’s any. And so typically, I will treat her with supplementation. Now, we because we’re off label, we do it slightly different. I mean, I tell the patients, you can use a gel or a cream from a compounder. I do use a lot of pellets and injections and I know that there have been many guidelines stating to stay away from the injections and the pellets. The main reason why they say to stay away from the injections and the pellets is because of the worry of the super physiologic levels. And you would see that maybe with a pellet, but with injections, you don’t necessarily see that because we get it compounded. We use a much smaller dose and the women will inject once a week and it’s extremely effective. [00:14:37][96.0]

Dr Louise Newson: [00:14:38] And again, it’s about choice. We see some people who don’t absorb the cream very well, but then they absorb the gel better or vice versa, having it through the skin or even as the injection or the pellet is far better, like you wouldn’t give oral testosterone because it gets metabolised through the liver. So that’s something that we wouldn’t do. But it’s very difficult in countries where you haven’t got anything licensed. But the thing is about it, is it is just a natural hormone. So when you’re talking about injecting, you’re injecting pure testosterone. This is quite different Mo, isn’t it, to injections that you might, I don’t know, I’ve not tried and I hope you haven’t either, that you might buy over the internet because you’re going to the gym and you’re wanting to build. They’re not anabolic steroids in the way that these synthetic testosterones are, are they? [00:15:29][50.5]

Dr Mohit Khera: [00:15:30] That’s exactly right. And you mentioned something very important about the gels and the creams. So remember, I tell them my patients a very simple formula. It’s the milligrams times the percent penetrance gives you the level. So let’s say give you 1000 milligrams of testosterone, but you have 0% penetrance. You get nothing. Absolutely nothing. So sometimes if someone has a low percent penetrance, you have to increase the milligram dose to get the level that you want. And so that variability on skin can be an issue. Injections typically don’t have that. You can get it into the body without having to worry about the skin penetration. You bypass the skin pentration. Louise, sometimes patients come to me and say, which one is the best one to take? I say, Look, testosterone is a molecule. It’s a compound. It’s not more magical if it’s in a pellet or a gel or an injection. It’s the same drug. All we’re doing, these are different ways to get the drug into your body. And let’s find the one that works the best. But the testosterone is the same. That’s a very important point. [00:16:32][62.2]

Dr Louise Newson: [00:16:33] Absolutely. And it’s the same with the oestradiol, which is the most anti-inflammatory type of oestrogen, and progesterone. And, you know, I often have conversations with Paul, my husband, as you know, he’s a reconstructive surgeon. And…but he could definitely, well he does prescribe hormones for me, he could definitely do my clinic. It’s very simplistic medicine. It’s three, like you say, basic hormones. It’s not synthetic hormones. I don’t prescribe the contraceptive implant. I don’t prescribe synthetic progestogens or synthetic oestrogen. We we’ve sort of moving away and we’re making it very safe, actually. So safe that it seems a shame, like you say about it, having to be by prescription and see a specialist, because a lot of my patients are buying all sorts of things over the counter to try and help their symptoms that we have zero evidence for. And not everything we buy over the counter is safe. But there’s a reason that we have these hormones, and like you say at the beginning, quite rightly, we are living so much longer. We weren’t designed really to live this long, were we, without our hormones. So it’s not just the symptoms, it’s the effects of not having the testosterone and hormones. That can be a real problem, can’t it? [00:17:51][78.2]

Dr Mohit Khera: [00:17:52] Louise, these hormones improve the quality of life. That’s very important. They improve one’s quality of life. Most of the time, we are spending all our time trying to increase our life span. Our life span now in the United States is 77 years old. Women are 79, men are 75. But the concept of health span, how long live healthy is 67 years old. There is a a ten year gap from when you will die to when you’re healthy that you will live in poor health. And really, what we should be doing is not trying to prolong our lifespan. We should be trying to prolong our health span. And I really believe that these hormones can make a big difference in improving someone’s health span. Not only do they improve someone’s health span, they also improve someone’s sex span. Right. So sex span is the time of life you are able to engage in sexual activity. And most people want their sex span to last as long as their lifespan, using the hormones definitely improves someone’s sex span as well. [00:18:50][57.9]

Dr Louise Newson: [00:18:51] Yeah, and that is crucially important. I found a paper recently from 1984, so when I was at school and it was giving oestrogen to women who’ve had their ovaries removed and a hysterectomy or it was giving oestrogen and testosterone and the results showed that wellbeing was better in people who had testosterone as well as oestrogen, which echoes what you’ve just said. But why is wellbeing not seen as so important? I don’t really understand and it’s a very hard thing I think, to measure. You know, when I started taking testosterone in the first six, eight weeks did nothing. And I thought what what’s the great… I don’t really understand. And then suddenly I realised and this sounds a bit trivial, but I could run up the stairs quicker. I could open the blind in the morning and smile because the sun was shining. I could empty the dishwasher in a second rather than thinking, I’m just too tired. I didn’t have this treacle thinking through treacle feeling in my brain. I just felt the clouds had been lifted. Things were more in colour. And that’s what patients say to me a lot. But I don’t know how you measure that, but I don’t know whether you have to measure it. Can you just ask women, do you feel better because you’re having a natural hormone? Is that a bad thing? [00:20:11][80.1]

Dr Mohit Khera: [00:20:12] At the end of the day, it’s really how she feels, right? It’s not about the number, it’s not about the testosterone value. How do you feel? If you feel better and symptomatic improvement, then we’ve accomplished our goal, right? And I think that’s very important. And one thing that you probably have done that others do as well is that I tell patients, this is a partnership. Okay, I’m going to give you back the triangle. I’m going to fine tune the hormones, but that is only half the story. Your job is to focus on the four pillars of health, diet, exercise, sleep and stress reduction. And if you focus on even one has a profound impact on your life. And if you do those four and I do my side as well. Very powerful together. In fact, giving testosterone makes these four a lot easier. So I do think that it’s a combination. And I do think if you give a patient that’s awesome and they lift weights, it increases the muscle mass. You know, so again, there’s synergy between lifestyle and hormone replacement therapy. [00:21:12][60.3]

Dr Louise Newson: [00:21:13] Yeah. And that’s crucially important. And sometimes I see people who’ve been told by other doctors that you can only have your hormones once you’ve improved your lifestyle. But actually, it can be really difficult. I know when I didn’t have hormones the last thing I wanted to do was to do any exercise at all. And also I couldn’t sleep. I like, Paul can tell you, I was awful. I was tossing and turning and I was awake and I was catastrophising at four in the morning and now Paul’s really annoyed because I can sleep a lot less than him. I go to bed. Later. I get up earlier. But I look on my ring or my device and I just sleep really efficiently because my organs are working. My brain is, and but also I’m exercising more, I’m eating better, I’m happier. I’m, you know, and those things as a doctor, we have to take into account. And like you say, it’s it’s a partnership with our patients. We work together. But the other thing I think people don’t realise is that, all our hormones are derived from cholesterol and cholesterol then obviously goes down to progesterone. But the other, the fourth bit, if you’re going to make a square, is cortisone and cortisol, which is our stress hormone. So as you’re saying, quite rightly Mo, if we improve our wellbeing, we improve our mental health our physical health, then that cortisol is going to improve as well. But often when people don’t have the hormones, they’re sort of, our body produces more cortisol, stress hormone and adrenaline and everything else because they’re trying is trying to compensate for what we don’t have. And it’s all about doing the right dose and the right choice of treatment for the right patient. And that’s what we do in everything we do in medicine. But somehow there’s sort of politics and personalities that get in the way of women being able to receive hormones and men actually, because there are a lot of men who would benefit from testosterone instead of other treatments for other conditions. But it seems always like, sex hormones, that maybe because they’re called sex hormones and I don’t think they are, I think they’re health hormones. And it seems a bit like a trivial form of medicine. And I do think it is at all. [00:23:27][133.3]

Dr Mohit Khera: [00:23:27] It’s not trivial at all. I, as I mentioned earlier, the best barometer of, particularly a man and I think also about a man’s overall health, is his testosterone level. So did you know if a man has low testosterone, it significantly increases the risk for having a cardiovascular event. Nonnegotiable. Low testosterone increases risk for heart attack, low testosterone increases risk for breaking a bone, osteopenia, oesteoporosis. Low testosterone increases a man’s risk for diabetes and metabolic syndrome. It’s non debatable. Low testosterone can be associated with depression. And low testosterone can be associated with prostate cancer. So, so I think, you know, it’s not just about sex Louise. It’s about his overall health. And if you don’t have the same amount of studies we have in men as we do on women. But I can assume also that women with low testosterone should be at increased risk for depression, low testosterone, women should be increased risk for osteopenia, oesteoporosis, cardiovascular risk. We just don’t have the trials. But again, I do think that those trials need to be done. And men and women in many cases are not that different. [00:24:30][62.2]

Dr Louise Newson: [00:24:30] Yeah, absolutely. Of course, we’re not different as much as people expect us to. Of course we’re not. And we learning all the time. But in the meantime and we don’t have the studies, we can act on common sense. We can share decision making. We can allow women to make choices. And as I say to people every day in my clinic, everything is reversible. You can choose. We give therapeutic trials of all sorts of medication, and hormones are no different. People take it, don’t like it, that’s fine. They don’t have to continue. And I think that’s really important as well, isn’t it? [00:25:02][31.6]

Dr Mohit Khera: [00:25:03] Yep. But again, and you nailed it. So I tell my patients, male and female, that if you take this medication and you don’t see symptomatic improvement, there’s no point continuing because because I’m not here to treat your number so much. I’m here to treat you. And if you don’t see the improvement, we can consider stopping. So in men in our guidelines, typically about three months, a lot of the other guidelines like ISSWSH up to six months. So I would say for three to six months for a trial is very reasonable to see if there’s any benefit. You know, the side effect profile is not as bad as people think, particularly in women. A lot of women say, if I take it, am I going to get a beard and am I going to? Well, you know, the difference in women is we start low. We started a low dose and we go up and, you know, you can get acne. You cant get facial hair. I have not yet to see a patient who has a deepening of the voice or clitoromegaly in my practice. I think those typically happen at super physiologic level, but acne and facial hair can happen. And quite honestly, many women who do develop that will say, Look, I can deal with it on the back end. I love my testosterone. I’m not going to stop. I say, okay, then we’ll look at you. But the side effect profile, we do check for erythrocytosis. So I do think that’s important to check. We just presented one of our big papers, so I have a long history of treating women on pellets for many years, and we presented our data last year at the, in San Diego at the SMSNA meeting . And what’s interesting about women when I put them on pellets is that they have a much lower rate of erythrocytosis and hypertension than I see in men. [00:26:31][88.5]

Dr Louise Newson: [00:26:32] So just before we end, though, I’m very grateful for your time, but I always I’m just going to spring this on you because I always do three take home tips. So for people who are listening, just three things. So if they’re men or women and they’re thinking about testosterone, whatever age they are, whatever symptoms they have, what are the three things that you think they should take home and really learn about testosterone for their future health? [00:26:56][24.6]

Dr Mohit Khera: [00:26:57] First and foremost, if you have signs and symptoms of low testosterone, meaning low libido, low energy, sexual dysfunction, increased fat deposition and decreased muscle mass, maybe even some depression, check your testosterone level. It’s a simple, simple blood test which can make a significant difference in your quality of life. I would also say that one of the best barometers I think, of a person’s overall health is their testosterone level. It’s a marker. It’s a marker of other underlying conditions that could be existing. And so take the low testosterone seriously if you do have a low T level. And finally, I would say that our our knowledge about the safety of testosterone is getting better and better. And I do think that testosterone, if prescribed appropriately, is a safe medication to prescribe, but it should be monitored. But it is a safe medication. So this dogma, this conception that it’s dangerous, it’s putting fuel on the fire. It really is not true. I do think that it’s a safe medication, particularly if it’s monitored and prescribed appropriately. [00:28:00][63.1]

Dr Louise Newson: [00:28:01] I totally agree. So thank you so much for your time and hopefully I will meet you in real life at some stage. So thank you. [00:28:07][6.0]

Dr Mohit Khera: [00:28:08] I appreciate it. Thank you so much for the invitation, Louise. [00:28:09][1.3]

Dr Louise Newson: [00:28:12] You can find out more about Newson Health Group by visiting www.newsonhealth.co.uk and you can download the free balance app on the App Store or Google Play. [00:28:12][0.0]

The post Testosterone and the hormone triangle, with Dr Mohit Khera appeared first on Balance Menopause & Hormones.

What happens to testosterone during the menopause?

Testosterone is an important hormone that’s made by your ovaries, as well as your adrenal glands and brain. It’s the most biologically active steroid in women throughout the lifespan – you produce three times as much testosterone than oestrogen when you are younger [1, 2]. Levels of testosterone decline as you get older production, and this this fall can lead to symptoms such as a lack of energy, brain fog and low libido.

Does testosterone cause hair thinning and loss?

In the UK, over 20% of women under fifty experience hair thinning, and this number rises to about 65% during and after menopause.

Hair thinning can be genetic and is caused by a sensitivity to a form of testosterone called dihydrotestosterone (DHT). If you have an inherited follicle sensitivity to DHT, thinning is most likely to begin around the time of menopause.

Oestrogen can support hair growth but as levels decline during menopause so can hair growth, and there can be shrinkage in hair follicles. For some women, the decline in oestrogen means the balance between oestrogen and androgen (a group of sex hormones including testosterone and DHT) is altered, which can worsen female pattern hair loss.

DHT, not testosterone, is thought to be the active androgen in hair loss.

Jane Martins, a trichologist at Philip Kingsley, says: ‘Although it has been well established that DHT plays a significant role in male pattern hair loss, the role of DHT in female pattern hair loss remains unclear.’

What about hair gain?

Unlike DHT, testosterone can play a role in stimulating hair growth, and a study has shown testosterone therapy has a beneficial effect on scalp hair growth in female patients treated for symptoms of androgen deficiency [3].

While testosterone replacement can support hair growth, the dose and subsequent monitoring of levels is important as higher levels can have the opposite effect, as Jane explains: ‘In my experience, I find that in females with elevated testosterone levels, for example PCOS, this will exacerbate female pattern hair loss. A similar effect is seen in some women taking testosterone as part of their HRT. In the latter situation it is important to find a balance between the benefits and the potential negative effects.’

Can HRT affect hair?

It can but it’s complicated. A small number of women notice that synthetic types of HRT can worsen hair loss whereas body identical HRT is usually beneficial for hair growth.

HRT isn’t usually prescribed for symptoms of hair loss alone but some women who take testosterone as part of their HRT for menopausal symptoms have reported scalp hair growth as a side effect. One paper found two thirds of women treated with subcutaneous testosterone implants have scalp hair re-growth on therapy [4].

Jane adds: ‘In our clinic we have not seen a positive impact as a result of taking testosterone in terms of scalp hair growth. The impact of testosterone will differ depending on the individual, with some not experiencing a deterioration in hair density.  However, unfortunately in others, hair thinning may be exacerbated. 

‘From a hair perspective, choice of progestogen as part of an HRT regime is important since some can have an androgenic-like action, which may adversely affect hair loss.’

Will taking testosterone give me a beard or moustache?

Testosterone is usually given as a gel or cream on your skin or sometimes an implant. Some women  experience hair growth on the site of application (which is usually the skin of your upper thigh) – in this case it’s advised to rotate the site of application and to spread thinly. The dose of testosterone is very low so it will not usually cause facial hair growth. It is usually advised to have initial blood tests taken before starting testosterone and then three to six months after or following any dose change, with bloods then monitored annually to ensure levels remain in the female range.

Jane Martins is a trichologist at Philip Kingsley, philipkingsley.co.uk 

References

1, 2 Rebecca Glaser, Constantine Dimitrakakis. (2013), ‘Testosterone therapy in women: Myths and misconceptions,’ Maturitas, 74 (3), pp 230-234, https://doi.org/10.1016/j.maturitas.2013.01.003

Panay, N., & Fenton, A. (2009), ‘The role of testosterone in women,’ Climacteric, 12(3), pp185–187. https://doi.org/10.1080/13697130902973227

3, 4. Glaser RL, Dimitrakakis C, Messenger AG. Improvement in scalp hair growth in androgen-deficient women treated with testosterone: a questionnaire study. Br J Dermatol. 2012 Feb;166(2):274-8. doi: 10.1111/j.1365-2133.2011.10655.x

The post Testosterone and hair during the menopause appeared first on Balance Menopause & Hormones.

This week on the podcast, Dr Louise is once again joined by her friend, retired consultant urologist Steve Payne.

Together they look at the similarities and differences in women and men’s experiences of menopause and andropause, and the effect of low testosterone levels, including loss of libido and lust for life, lethargy, mood changes, depression and muscular weakness.

They address the issues surrounding testosterone replacement and Steve questions if medical professionals can learn from the treatment of men with prostrate cancer with testosterone supplementations when treating women with breast cancer with hormones.

Steve has written a factsheet about making informed decisions during cancer care. You can also read more about his and his wife Jan’s experience, plus practical advice, here, and listen to the podcast  Making decisions about cancer treatment and the importance of quality of life with Steve Payne.

Click here for more about Newson Health.

Transcript

Dr Louise: Hello, I’m Doctor Louise Newson, I’m a GP and menopause specialist, and I’m also the founder of the Newson Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. I’m also the founder of the free balance app. Each week on my podcast, join me and my special guests where we discuss all things perimenopause and menopause. We talk about the latest research, bust myths on menopause symptoms and treatments, and often share moving and always inspirational personal stories. This podcast is brought to you by the Newson Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women. So today on my podcast, I’m really delighted to introduce to you someone I’ve known for many years, who has been a real inspiration, not just to me, but especially to my husband. He still manages to be a great mentor, friend and colleague often when Paul goes abroad to Africa to do charity operating. So I’ve got with me Steve Payne, who’s a urologist, who was working at Manchester Royal Infirmary when I did my medical training. So I’ve known you, Steve, for many years.

Steve: [00:01:32] Indeed.

Dr Louise: So welcome to the podcast. It’s great having you here. So I speak a lot about Paul and I’ve even had him on my podcast actually. But urologist, sometimes people don’t know what it means. So do you mind just talking about what a urologist is and why you decided to be a urologist? [00:01:50][16.9]

Steve: Let’s start with that first. I mean, I decided to be a urologist because I liked the people who were in urology. And I think that that’s a really common reason for people wanting to go into the speciality. But a urologist is somebody who deals with the urinary tract, and that is from the top of the kidneys down to the very tip of your water pipe and all of the points in between. But there are a group of urologists who are also work as andrologists and they’re people who deal with predominantly male reproductive and sexual issues. Some of those are medical, some of those are surgical. And I was a urologist and an andrologist. So I did a lot of stuff related to male sexual dysfunction and infertility.

Dr Louise: Really interesting, and really important. And actually, you’re absolutely right about working with people who you respect and enjoy working with, because many of us see more of our work colleagues than we do of our partners or families when we work long hours. And it’s certainly one of the reasons that Paul went into urology as well. And you still, I was lecturing recently at part of the British Association of Urological Surgeons, and I said to Paul, I cannot believe how chatty people are on the coffee breaks. They’re just really cohesive and just really supportive of the lecturers as well. Whereas I’ve been to many conferences where people don’t talk, they’re not supportive. They wouldn’t go up to a lecturer and say, well done. And it’s really interesting how people in medicine, you think all doctors are the same, but they really vary, don’t they?

Dr Louise: [00:03:25] They do, they do. And interestingly, I’ve been talking this week at a conference which has involved an awful lot of trainees. So there are 150 urological trainees at this meeting. And they wanted to hear what somebody at the end of their career had to say about the various bits and pieces that they were going to face along the way. So, yes, I think it’s really interesting. I think it’s a great speciality. And I would wouldn’t I?

Dr Louise: Course you would. So I was a junior doctor in the 90s and obviously Viagra had come out, Cialis, which is a sort of a purer, well, not purer form. It’s just slightly better, isn’t it, it just acts…

Steve: Different.

Dr Louise: in a different way. Came out and but when I was a GP, we could only prescribe it as an NHS script for people who had comorbidities. So if they had diabetes and they really had to prove that they were really struggling with their impotence and sexual desire, and it was quite a big thing. We could do it privately. We were allowed to. The computers were set up so we could prescribe Viagra privately. And it was really interesting because it was the first time, actually, that I’d seen so many men coming to see me, because men often don’t come to the surgery quite as often as women. But I also felt quite sad that they had to sort of, especially to me as a woman, prove how difficult something that is so important but they’d never spoken to a medical person about. But they really wanted this treatment. And now now obviously Viagra is over the counter. You know, I haven’t seen people for many years actually, who who need Viagra. But when we talk about sexual desire or libido, often it’s not just about… Libido isn’t just sexual desire. When we think about Freud’s definition of libido, it’s more pleasure of life as well. We’re having this conversation increasingly in our clinics and academically as well, because we’re talking about the role of testosterone. But also with men, it’s not just Viagra as well, is it? I mean, you’re, well you said you’re an andrologist as well, so interested in the role of male hormones, which obviously include testosterone to a large extent, don’t they?

Steve: They do. They do. I mean, obviously testosterone is much more important than anything else. And the biggest issue, of course, if men are suffering from low testosterone, then the biggest issue that comes to the fore is libido. Because, you know, that is the thing which decreases most in men who have a low testosterone over 90%. But they also suffer from lethargy, which is almost as prevalent as reduction in libido, reduction in their erectile function, loss of strangely pubic rather than facial hair. They also get mood changes and over half of them get significant depression. And then something which they also notice, which obviously becomes more of an issue to men as they get older anyway is muscular weakness. So testosterone clearly is very important in maintaining an awful lot of those functions.

Dr Louise: Yeah. And it’s interesting. I only knew, I started to read more about testosterone in women about eight, nine years ago, because before that time, Steve, I can admit I didn’t know women had testosterone in their bodies because no one taught me. But it’s actually the most biologically active hormone in women. So I presume it’s up there as being one of the most biologically active hormones in men as well, because we have cells that respond to testosterone all over our body to help with various biological processes. And men do, too, don’t they?

Steve: [00:07:05] They do. They do. I mean, the really interesting thing about testosterone is that it’s only the free testosterone which is majorly active in men. That’s only 1 to 3% of the testosterone that a man produces, because the vast majority of it is bound to a couple of proteins, one’s albumin, and the other one’s something called sex hormone binding globulin, which is produced in the liver. So it’s only that very, very small percentage of circulating testosterone which is biologically active and creates all of the positive effects that a man sees.

Dr Louise: Yes. Which is the same in women, isn’t it? We have bound testosterone. We have sex hormone binding globulin, which can be increased or reduced with various factors. So it’s only the freely available testosterone that’s going to have these biological active processes working in our bodies.

Steve: Yeah. No I think it’s really important that people understand that a relatively small amount of the hormone can have such dramatic effects on various different bodily systems.

Dr Louise: Yeah. So I mean, testosterone in men and women actually was sort of first spoken about really in 1940 and they were doing experiments on both sexes, which obviously they then stopped looking at it in women and carried on with men. But actually, we know it’s produced via sexual organs. It’s produced by our ovaries and the testes, but it’s also produced in the brain as well as, you know, oestrogen and progesterone are produced in our brains as well. So testosterone does work as a neurotransmitter. And it also can be produced in our muscles as well, and probably… and our adrenal glands and probably other places that we we don’t even know. But the effects that it can have, like you say on our energy, on our mood and our concentration is really important. But I’m also interested in diseases as well, because I’m quite keen to prevent diseases, not just treat them as a doctor. And when I read about the effects of testosterone on our nervous system and also can help obviously reduce inflammation, but it helps improve mitochondrial function as well, which is like the powerhouse of all our cells, but also on the nerves. It can help rebuild the myelin sheath, and the myelin sheath is the, well you can explain, even as a urologist, you know what a myelin sheath is, don’t you, Steve? Putting you on the spot here.

Steve: Well, it just, helps increase the efficiency of the neural transmission, in other words…

Dr Louise: Yes. It’s like the conductor bit isn’t it?

Steve: …Stimuli go quicker.

Dr Louise: Yeah. And that’s very interesting, so I was doing a talk recently for, it was a debate actually, for a society about multiple sclerosis and whether menopause care should be better for women with multiple sclerosis. And actually the person that was saying against it, didn’t win and she still agreed with me. But actually, if we’ve got a hormonal deficiency, especially testosterone, and we’ve got a condition affecting our nerves, it’s a double whammy. But also, I’m very interested in diseases that are more common in women than men. So there are a lot more autoimmune diseases that become more prevalent in women in their late 40s. Multiple sclerosis, for example, is far more common in women than men. And for many years I’ve been thinking, well is it something about oestrogen? Because although men have oestrogen, we have a lot more oestrogen when we’re having our periods. But more recently I’ve been thinking, is it because of testosterone deficiency? And those men that have some of these, you know, men can have multiple sclerosis, is some of that going to be related to testosterone deficiency in men as well? And we don’t really know the answer do we?

Steve: No, certainly not. I mean, if one just concentrates on multiple sclerosis, it’s always been said that the further north you go and the further west you go, the higher the incidence of multiple sclerosis. Maybe we ought to be looking at the hormonal levels in people in those locations.

Dr Louise: Yeah. And the more I see and speak to women and treat them and also speak to other experts, not just in the UK but worldwide, there’s a lot of us who are picking up a lot more women who are testosterone deficient before they come oestrogen deficient, and they often have various symptoms affecting their mood, their energy, their concentration. But like you say, their muscle strength, their stamina, sometimes they do have flushes that are related to their testosterone. And men can have flushes and sweats, can’t they when their testosterone levels low?

Steve: They can. I mean, interestingly, although testosterone levels may be significantly reduced in men, it’s only about 40% of them who actually get what we would call an andropause.

Dr Louise: Yes.

Steve: So not by any manner of means to all men who have a low circulating testosterone actually get significant symptoms as a consequence of it. So they’re obviously, it’s obviously an important co-factor in a generation with a lot of other symptoms, but it’s probably not the whole answer. But it’s an important co-factor.

Dr Louise: Yeah. And it’s interesting because we often don’t know, like, you know, when I see people in the clinic, as you know there’s no diagnostic test for the menopause and if someone has low testosterone, I’ll say to them, your testosterone is low. You may benefit from having testosterone, but I don’t know how many of your symptoms are related to the low testosterone, because there’s often lots of reasons why people are tired or they don’t sleep well or whatever. But sometimes, as you know, in medicine things are multifactorial. So it’s sometimes the missing piece of the jigsaw. And many years ago, it must’ve been about 20 odd years ago, we were… In general practice you have these sort of QOF where people have to ask certain things, and it actually goes to the way many GP practices are paid. I’ve always been salaried, so nothing affected my pay. But the QOF was added for asking people with type 2 diabetes, men with type 2 diabetes, if they had erectile dysfunction, and then we were doing testosterone levels on those people. But what we found was that nearly everyone had erectile dysfunction, but they didn’t talk about it. But then when we did testosterone levels, they were always low. And then that was a whole can of worms because they didn’t want us to treat with testosterone. So they withdrew that. So then we didn’t have to ask. And then it’s almost like, if you don’t test for it, you won’t know.

Steve: All of these things are so multifactorial aren’t they. I mean, it’s definitely been found that men who suffer from an andropause often have an increase of visceral fat. So there seems to be a significant association between obesity and what we would call hypogonadism, in other words, not producing enough testosterone. And if you take a man with a BMI so there’s a body mass index above 30, which is moderately obese, then they will have a testosterone which is approximately 30% lower than and with a normal BMI of less than 25. So you know, as with oestrogen and various other hormones, obesity can have a significant effect on their circulating levels and therefore their bioavailability.

Dr Louise: Absolutely. So and it’s so important that people are, well all our patients we look at holistically and we often find actually when people have their hormones replaced they find it easier to exercise, they have more stamina. They’re sleeping better, which obviously can help with weight as well, but also the metabolic changes that occur. And low oestrogen in the menopause and low testosterone can drive a metabolic state. So we know people with low testosterone, men and women, can increase their risk of type 2 diabetes and obesity. So it’s a sort of chicken and egg thing, really. So addressing both of them can make quite a difference. And some people who have testosterone or some men who have testosterone and are overweight or obese, when their weight reduces, their exercise improves. If they’ve started on testosterone, they might find that they don’t have to continue on testosterone as well, didn’t they?

Steve: Yeah, absolutely. Absolutely. I mean, as I said, it’s really complicated. But no doubt, you know, lifestyle factors and lifestyle modification, reducing smoking, reducing alcohol consumption, apart from the effects on weight and things from drinking because they say, you’re drinking another bottle of fat don’t they if you drink a bottle of wine?

Dr Louise: Absolutely. So we’re sort of talking about the beneficial effects of a natural hormone that men, women produce. We all produce. But there’s a lot of people that are quite scared of giving testosterone back. And many years ago, again, when I was a GP, about 15 years ago, I saw a man in the clinic who was 62, and I remember him because I knew his wife really well, but she kept bringing him in because she was worried about him and she said, he’s really sweaty. He’s really worse at night, actually. He’s just really vacant. He’s just not himself at all. He’s really just got no interest, no joy. He’s got no energy. We used to go out walking in our retirement. He’s not doing anything of that. He’s quite distant. And because he was getting night sweats, that can be a symptom of lymphoma, as you know. So I had some blood test done. He was a little bit anaemic. He went to the haematologist. Everything was fine. Things went on and on. And I remember coming home one day and saying to Paul, I’ve got this man, this patient, I just, I’m not sure what’s going on. And Paul said, well, what’s his testosterone level? I went oh, I’ve never done that. And I did it. And it was incredibly low. His free testosterone was very, very low. And so I gave him some testosterone to try. And the effect was transformational. It really made such a difference. And then one of the partners said to me you shouldn’t be doing this. You need to refer him to the specialist. It shouldn’t be you that’s giving, you know, a natural hormone back to a patient. So I said oh OK, so I sent him to the local urologist and they stopped it straightaway. And they said, well, he’s got a history of raised blood pressure. And, giving testosterone is going to increase his risk of stroke. He needs to stop it straight away. And I was really upset because his quality of life completely deteriorated and vanished in front of my eyes. And they went from driving down to Cornwall to do nice walks, to him being housebound again. And it really struck me that I was wondering about benefits and risks, shared decision making, but also I couldn’t quite understand how giving a natural hormone could increase risk of stroke because I wasn’t giving him high doses or levels. But there’s always been this thing about people have been scared of testosterone, and I don’t quite know where it’s come from Steve, can you explain?

Steve: Well, I think there are two drivers for this aren’t there. There are a group of individuals who look at all of the adverse effects that you can have from various hormones without looking at the positive aspects. And I think the other thing is, as you say, it’s all about shared decision making. And, you know, we are still very paternalistic in medicine in this country. Not perhaps as paternalistic as they are in other countries, but we are still pretty paternalistic, and we have our beliefs and those beliefs are very largely unshaken, often not based on significant scientific evidence. And they’re perpetuated, dependent upon the speciality that you work in. I mean, I think in urology, we’ve actually been really quite fortunate in as far as urologists have been able to have reasonable conversations with GPs about somebody being started on testosterone. And I think the evidence that is out there now about the downsides of testosterone are really quite small. There was a recent paper in the Journal of the American Medical Association which showed, for example, that men who were treated with the testosterone had no higher incidence in the development of prostate cancer than a placebo group. And I think that that is something which is really, really important. You know, people were worried and are worried, continue to be worried about whether giving more testosterone causes more prostate cancer. But interestingly, the American Urological Association in its guidelines in 2018, has actually said that hypogonadal patients, in other words, ones who haven’t got a significant amount of testosterone circulating, should make an informed consent before starting testosterone replacement therapy. And that was basically designed for treating hypogonadal men who’ve already been treated for prostate cancer. So I think that there’s quite a lot of acceptance in the urological field that testosterone replacement therapy isn’t necessarily a bad thing. And interestingly, I was at a recent meeting where the use of drugs for the treatment of prostate cancer that caused hypogonadism were responsible for a much higher incidence of cardiovascular disease, and that in certain men with cardiovascular risk factors, those drugs should not be used. So there’s a strong association, as I know there is in women between testosterone and cardiovascular disease.

Dr Louise: Yes. Yeah. We know that women who have low levels of testosterone have a greater risk of cardiovascular disease. And there seems to be real resistance to replacing testosterone to see if it reduces risk in women of cardiovascular disease. But I’m very interested in this because with prostate cancer, some people listening might know in certain types of prostate, not all types of prostate cancer, but certain types drugs are given to block the effects of testosterone in the body. And it’s the same with oestrogen receptor positive breast cancer. Often they give oestrogen blocking drugs. And you’ve been part of this group that I’ll do another podcast on in the future looking at the effects of these drugs. And I’m very interested in the different types of oestrogen. So we have oestradiol, which is a very good type of oestrogen, and oestrone which is an inflammatory type. And increasingly there’s evidence that it’s the oestrone that is related to the breast cancer, not oestradiol. So if we’re blocking all types of oestrogen, you’re blocking the good oestrogen as well. And there’s an increased risk of heart disease, osteoporosis, diabetes when you’re blocking but also the effect of symptoms as well. So even if we’re “just” and I say just in inverted commas. So we’re ignoring health risks, but we’re just looking at the person in front of us and how they’re suffering. The effects of blocking testosterone in men, blocking oestrogen in women are very similar. So you become menopausal basically. Or andropausal, don’t you?

Steve: You do. And I mean, in fact, my brother has recently been treated with androgen analogues. That is a strange thing. You actually give something which switches off the pituitary gland in your brain, which drives your testicle. So you produce an initial high level of testosterone, which then switches everything off. But he had all of the things that you normally ascribe to a menopause. So lots of hot flushes and this and that and the other. But I mean it’s also been recognised relatively recently that men become osteoporotic if they stay on those drugs for any length of time. And indeed they need to have Dexa scans if they’re on it for more than a couple of years. So, I mean, there’s great similarities between the two hormones.

Dr Louise: Well, there is and for those of you listening that haven’t listened to the podcast I’ve done with Steve before, it’s worth listening because you’ve got very, very close experience of your wife taking oestrogen blocking drugs following her breast cancer diagnosis. And it’s a really, really great podcast to listen to, but it is about quality of life. But the other thing is looking at the prognosis and there are different types, there are different grades, there are different stages of breast cancer as there is in prostate cancer. So this is a very general conversation. But for some people or many people, thankfully the outlook from prostate cancer is very good. And we know there’s a lot of men that die with prostate cancer, but not from it. It’s not their cause of death. Most men, like women, die from cardiovascular disease. And so actually it’s weighing up the quality of life. And if the beneficial effects of blocking those, the testosterone with a relative increased risk of diseases and reduced quality of life. And so it’s very interesting that they even did a study looking at replacing testosterone in men that had had prostate cancer. And very reassuring looking at the results, wasn’t it?

Steve: It was indeed. There is no significant evidence. And in fact, all of the evidence has been put together in guidelines by a number of different urological associations to say that there is no convincing evidence, there needs to be a sensible discussion between whoever is treating that individual and the individual themselves about the pros and the cons of treatment. And as you know, Louise, prostate cancer becomes much commoner as you get older. So that, you know, it is said that 80% of men if they get to the age of 80, will have some evidence of cancer in their prostate. And as you say, most of them die with it rather than of it. But in fact, I mean, the outlook for men who are much younger, who are treated for prostate cancer is much better, with 90% of men surviving ten years.

Dr Louise: Which is wonderful, isn’t it?

Steve: It is. And it’s a dramatic change. And of course, there is the possibility that there are a lot of new treatments out there, biological agents, which are going to change things significantly. So maybe surgery won’t be required, surgery or radiotherapy won’t be required. But then again, we do need to look at the way that those work and the effects that they may have. As you know, Jan had problems with aromatase inhibitors. And whilst they may be very good from an oncological perspective, consequences upon quality of life were really quite significant. We really do need to look at the quality of life aspects of all new treatments and all new medications.

Dr Louise: Yeah, absolutely. And involve patients, you know, in our clinic if women have had breast cancer and they choose to take hormones for quality of life, but also disease preventative effects such as osteoporosis or cardiovascular disease, they often sign a shared decision making document that we have to say that they understand there are benefits, they understand there are potential risks and maybe risks that we don’t know because the studies haven’t been done. But on balance, they’re keen to, you know, go ahead. And they’ve we’ve had a informed decision making consultation. And that often helps when they go and see other doctors. So I’ve got a patient at the moment who’s GP’s refusing to prescribe her HRT for her. And the oncologist had written to the GP last week to say I fully support her having HRT because without it, she will not be able to sleep, she’s at a very high risk of osteoporosis because she’s very slim. And her breast cancer was a really good prognosis. It was very small without any spread. Her lymph nodes were clear, and she’s thinking about taking tamoxifen, which she can have with her HRT. And so to work in the shared sort of care where I’m involving the oncologist, sadly the GP I can’t involve, but the oncologist is helping as well. But putting the patient in the centre and you know, that’s really crucial in everything that we do, even, you know, the way you operate on people, the way you decide which operations or which treatment, it varies between people because it’s what their expectations, what their knowledge, what their beliefs are and any risks they want to take compared to any benefits they might have. And we can’t decide, I don’t think, for patients, can we? We have to just assist them.

Steve: Absolutely not. I mean we are slightly more fortunate in urology as far as we do have a moderately reliable marker of disease progression, which isn’t something that’s present for women with breast cancer. So although PSA gets very bad press, it is a very useful indicator of the efficacy of treatment. And of course, you can utilise that when you are treating men with testosterone supplementation. And indeed, the American Urological Association guidelines say that you basically should just bring their testosterone up to a physiological level. In other words, what would be normal for a man of that age. And as long as it improves their quality of life, then that’s fine. You shouldn’t give them increased levels of testosterone.

Dr Louise: No, which makes perfect sense. And the other thing just before we finish to add is that when people have testosterone, especially if they’re using it as the gel or sometimes in women we use a cream. It doesn’t build up in the body. You know, if they stop using it, it goes out of the body very quickly, which is very reassuring. So often people know they can do a trial, have a therapeutic trial, see if it helps. Like we’ve already said at the beginning, not everybody who’s tired it’s going to be related to low testosterone. So if they don’t feel any better, they don’t have to carry it on either. So it’s a choice of starting and stopping medication, which I think is also really important.

Steve: Yeah, yeah. No, I totally agree with that. I mean, there does seem to be a difference in the culture or the opinion between andrologists, urological oncologists and oncologists and menopause specialists treating women with breast cancer. And maybe there’s something to learn from what has happened in the treatment of men with prostate cancer, with testosterone supplementation for our colleagues who are treating women with breast cancer.

Dr Louise: Absolutely. And a joined-up approach in medicine, joining up patients and various specialists is really crucial. So I’m very grateful for your time, Steve. Before we finish, I always do three take-home tips. So I’m very keen to ask you three things, if people have been listening and think, whether they’re men or women, could any of my symptoms be related to low testosterone? What three things would you recommend for them to do?

Steve: Well, number one is if they’re not feeling how they feel they should be feeling at their age, say they’re over 50, then it’s probably worth seeking your GP’s advice and getting a testosterone done. The second is if you do have urinary symptoms, a very royal problem to have just at this point in time, then do go along and see your GP and get yourself checked out to make sure that those aren’t related to prostate cancer, even though the vast majority of them, greater than 90% of them, will be due to benign disease and not due to cancer. And the third thing is, if you are a man who has been treated for prostate cancer and is having sexual difficulties when none existed prior to the treatment for prostate cancer, then always ask whether you could have a testosterone level checked and if it is low, whether you could be treated with testosterone. So I think those are the three things that I would suggest.

Dr Louise: Ah thanks, Steve. Thanks for sharing some of your phenomenal knowledge and experience, and I’m very grateful for your time today. So thank you.

Steve: Okie doke Louise.

Dr Louise: You can find out more about Newson Health Group by visiting www.newsonhealth.co.uk, and you can download the free balance app on the App Store or Google Play.

ENDS

The post Testosterone supplementation: what can we learn from men’s healthcare? appeared first on Balance Menopause & Hormones.

This week on the podcast, Dr Louise is joined by Elin Sullivan, a young woman who suffered a myriad of symptoms for years before getting the right treatment.

Elin first experienced recurring urinary tract infections at 19 years old, and twice required hospitalisation. She also suffered from sweats, sleep disruption and fatigue, shaking and lichen sclerosus. After a chance encounter with Louise, she tried local hormones, which was transformative, and now takes testosterone to balance her low levels.

Elin talks about how hard it can be to experience perimenopausal symptoms at a young age and shares her tips for other younger women experiencing issues that they think might be down to their hormones:  

1. Although it can feel really hard, don’t stop advocating for yourself. You may have self-doubt or worry that you’re wrong but keep pushing. My doctor was sick of seeing me, I was there probably every week, but don’t give up.
2. Rather than just giving your doctor a list of your symptoms, show them when they were happening as well. Have a log of symptoms and anything that might have affected them on that day. This will help your doctor rule out things but also show if your diet, etc, has an influence.
3. Don’t be scared to try medications or suggestions. It might help but if it doesn’t it can potentially help your doctor decide the next step. I never believed local HRT could make such a big difference but am so glad I tried it.

Click here to find out more about Newson Health.

Transcript

Dr Louise: [00:00:11] Hello, I’m Doctor Louise Newson, I’m a GP and menopause specialist, and I’m also the founder of the Newson Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. I’m also the founder of the free balance app. Each week on my podcast, join me and my special guests where we discuss all things perimenopause and menopause. We talk about the latest research, bust myths on menopause symptoms and treatments, and often share moving and always inspirational personal stories. This podcast is brought to you by the Newson Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women. So today on my podcast, I’m delighted to introduce to you someone called Elin, who is young actually, she’s only 27 and I recently met her in a weird way. I meet all sorts of people in things that I do, and I’ll explain more in a minute. But firstly, I’m just going to welcome Elin to the podcast. So thanks ever so much for joining me today. [00:01:20][69.2]

Elin: [00:01:21] Ah, thank you for having me. [00:01:22][1.0]

Dr Louise: [00:01:23] So I really believe in connections happen for a reason. And it’s really, really weird actually. So I am very conventional. I’m very traditional. I’m not very artistic at all. And when one of my children a couple of years ago now had some piercings done in her ear, I was really like shocked because she, they had a cartilage. And then my middle daughter’s had all sorts of piercings, and I thought I’d be one of these mums where my children maybe have doubles, and that’s about it. Clearly not. So I shocked them a few, a couple of years ago and had my conch pierced, which they thought I would never do, and I did it as a bit of a rebellious thing so people could realise that I’m not quite as conventional and conformist as maybe I have been in the past. And it was really painful, and it took ages to heal, and the wind blowing in my ear was awful. And then my oldest daughter and I Jess decided to go and get another piercing done, and I wanted to get my cartilage done. So we went to a different place and we met you. I don’t know if you remember, Elin. We both came in… [00:02:20][56.9]

Elin: [00:02:20] Yeah, I do. [00:02:20][0.0]

Dr Louise: [00:02:20] And Jessica went first and we chose and it was such an amazing experience because you were so calm and you explained everything, and you put me at ease. And I didn’t feel like I was far too old to be sitting in a tattoo parlour, like having my ear pierced and like, I walked out and we walked through London, Jess and I, and my ear the wind didn’t hurt on my piercing and it’s just been incredible. I’ve really enjoyed having it. And I remember you saying when you were piercing my ear that you were feeling quite tired and you had some sort of condition. And obviously I think everything’s related to hormones, but it wasn’t appropriate because I was nervous to ask you any questions. And then Jess, my eldest daughter, then had her eyebrow done and something went wrong with it. I think there was a one of the bits came out, so she went back to see you, didn’t she? [00:03:11][50.6]

Elin: [00:03:11] Yeah, she did a couple of days later. [00:03:12][1.3]

Dr Louise: [00:03:13] Yeah. And she came to talk to you and you can explain what you said to her. But then she came out and phoned me and she said, Mummy, I’m really worried about Elin. And I said, who? I’m sorry. And she explained, she said, I’ve just gone in back into the piercer and I think some of it’s related to her hormones. And I told her to listen to your podcast and find out more about what you’re doing. But I feel really sad for her because she’s really struggling. So then I said, just give her my details and I’ll talk to her. And that’s what happened. So what happened with Jess? What did you say to her or what happened for her to think about your hormones? [00:03:48][35.3]

Elin: [00:03:49] We just got chatting quite very organically. Like none of it was forced but just chatting about how our day’s been, turned on to how are week’s been? And then just saying, I’m tired. And it turned into a question of oh, how long have you been tired? Like, gosh, when I think about it, it’s been months. And then it’s like, but doctors don’t seem to find anything wrong. And then I think that piqued Jess’s interest to be like, oh, have you, have you tried this? Have you tried that? Yeah. Nothing’s really flagged anything up with the doctors. And then we both said, oh, I think it might be hormonal. She said funnily enough you should mention that, my mum actually knows all about this and said, have you ever heard of this podcast? Have you ever heard of my mum? And I was like just when I met her when I pierced her a couple of weeks ago. And I went home and well, she came back later on that day and said she’d spoken to and I think we spoke very quickly after that. But she was very, very knowledgeable, explaining she basically reeled off every symptom I had, just like, do you suffer from this, do you suffer from that? And she said that she’d experienced it too. And it was really just refreshing knowing it wasn’t, I’m not the only young person that felt like that. It made me feel like I wasn’t crazy. So she just helped me feel like I wasn’t the crazy one. [00:05:11][82.0]

Dr Louise: [00:05:12] And isn’t that important? You know, in medicine, we don’t always have answers. We absolutely don’t. And I learned as a GP many years ago to deal with uncertainty and share uncertainty with patients. And often I say, I don’t know. Or I say it could be this, but if it’s not this, we can try something else or we can think about something else. So you’re 27 now, but you’ve had years of symptoms in different ways, haven’t you? [00:05:37][25.8]

Elin: [00:05:38] It probably started when I was about 19. It all started with urinary tract infections I just couldn’t shake. And that was going on up until probably about a year ago. And then starting on some steroids and everything seemed to get a little bit easier. Realising my skin was quite dry and everything I’ve read into the doctors they were kind of shocked that they couldn’t figure out what exactly was causing it. They couldn’t figure out why I wasn’t able to shake the infection. I’d be chatting to Harley Street, chatting to my urologist. And I tried everything and every diet, every drink, every tablet, every plant I could have tried and nothing helped. So it just escalated from there to the point where my body just didn’t feel like my body anymore. [00:06:28][50.3]

Dr Louise: [00:06:29] No and did you have sepsis at one stage with your, one of your urinary tract infections? [00:06:33][4.3]

Elin: [00:06:34] Yeah, it turned into a brief trip to A&E, probably twice I’d say I think, if I look back. Once when I was 20, once when I was 23, that would have been in lockdown. [00:06:49][15.1]

Dr Louise: [00:06:51] So very scary. [00:06:51][0.5]

Elin: [00:06:52] Yeah. It almost felt normal by that point, which is sad. And no-one really seemed to take it seriously. When I went back to the doctors and just getting those three days of antibiotics, it almost wasn’t made out to be a big deal. And then you would start reading into it. And sadly that’s how my grandma passed away, was from a result of urosepsis. So you realise the full extent of it then. [00:07:15][22.3]

Dr Louise: [00:07:16] Absolutely. So you had urinary symptoms. You had recurrent urinary tract infections, under urologists for many years, but then you had other symptoms as well, didn’t you? [00:07:26][10.3]

Elin: [00:07:27] The more recent ones where when I couldn’t sleep, I couldn’t sleep through the night, always waking up covered in sweat to the point where you just know it’s not normal. I’ve never had issues with that before, unless I did have like a urinary tract infection that was normal at the time, but constant shaking, like not being able to walk far distances without shaking and feeling like I was going to pass out, or having to lie on the floor with my legs in the air. And doctors just telling you to eat more, to sleep more to, oh if you exercise and push through it it will pass, but it never passed. It just kept getting worse and worse. And I, I loved going to the gym. I loved going on long walks, and I couldn’t even walk up a hill without sitting to try and catch my breath. I mean, the gym was just almost like, I started to think I was getting something like Parkinson’s in the end. I had really got into my own head with it but thankfully it wasn’t. I’m very glad to be… [00:08:23][55.8]

Dr Louise: [00:08:24] But it’s very scary, isn’t it? Because, you know, you want to exercise, you’ve got the motivation, you go, your stamina is not there. And, and you were saying that you were falling asleep on the Tube before going to work or coming back from work. [00:08:35][11.4]

Elin: [00:08:36] And I’m not a napper. I’m not a napper at all. I’m very strict with my bedtime. I wake up and go to sleep the same time every day and night. But yeah, that’s how I knew it was bad is missing my stops on the way to work, or missing my stops on the way home and yeah, it wasn’t good, I was falling asleep on the sofa before I’d even finished my dinner sometimes as well. [00:08:56][19.9]

Dr Louise: [00:08:56] Which is hard. And I know you’ve got a partner, and it’s hard when you’ve got a partner as well, because it involves them too, doesn’t it? [00:09:03][6.9]

Elin: [00:09:03] Yeah, yeah. But he helped me realise there was something wrong as well and kept pushing me to go to the doctors. And as soon as your name came up, it was like, you have to talk to her. Please talk to her. You’re not yourself anymore. [00:09:16][12.9]

Dr Louise: [00:09:17] Yeah, and it’s difficult because you were still having, you’ve still been having periods, haven’t you although they’ve changed and became quite sort of painful and heavy at times hadn’t they? [00:09:26][8.4]

Elin: [00:09:27] Yeah. Sometimes they didn’t even come at all. [00:09:28][1.8]

Dr Louise: [00:09:30] And so, you know, when we talk, and I’ve spoken before in this podcast about premature ovarian insufficiency or POI, it’s called, which is common. It affects at least 1 in 30 women. But that’s when periods have stopped. But we also know that perimenopause can last for ten years or so before periods stop. And so in medicine, I think it’s cruel and wrong to wait for something to happen if, as in the menopause, which is a year since your last period, if you’re getting symptoms. And so there’s no diagnostic test for the perimenopause at all. And then that makes it quite difficult. And obviously I felt quite guilty almost that I’ve hoicked you out of, you know, from piercing my ear to saying, let me try and help you. And I’m sure I said to you when I saw you and I often say to patients, I have no idea how much is related to your hormones. I can take a really thorough history and let’s see, and certainly I was worried because you had recurrent urinary tract infections and you told me you had lichen sclerosus as well, and your skin in your perineum was breaking down. You were using steroid cream, and that was a real problem. So you had these, I hope you don’t mind me saying, these local symptoms that were really and I remember you saying you saw someone and they had never seen someone so young with such severe lichen sclerosus. [00:10:48][78.6]

Elin: [00:10:50] Yeah, just explaining, oh, it’s an older woman’s problem. It’s an older person’s problem, it shouldn’t be affecting you. And they never explained with how I looked, they weren’t sure if I’d gain any colour back or if any of the sort of tearing would heal, and I couldn’t find any information online about it. There were no pictures to compare to, there were no, there was no-one else my age I could find information from. So I found a couple of groups, and was chatting to people on there, trying to get their experiences. But everyone, there’s maybe a couple that are under 30 in there but same. We’re all looking for the same answers. And since starting the local HRT, it was almost like a gamechanger. Like my skin. You wouldn’t even guess now, it looks normal. [00:11:38][48.1]

Dr Louise: [00:11:39] It’s amazing, isn’t it? And so for those people listening, and Elin’s given me full consent to share, but I started just giving you some local hormones. So that’s vaginal hormones. And I decided to give you Intrarosa, which is prasterone, which is DHEA, and it converts to oestrogen and testosterone in the vulva, but it helps all the tissues surrounding. And because you’re young, I didn’t want to just start giving you systemic hormone therapy without thinking what else could be going on, getting to know you more. And we also, I did some blood tests as a guide. We can’t do a blood test to make the diagnosis, but I wanted to see if your testosterone level and oestrogen level was on the low side, because it would help sort of build this picture in my mind that something was going wrong with your hormones. But the first thing I did was give you vaginal hormones. And actually they’re very safe. They’re very safe for everybody. And although people think that they can only be used in the menopause, we can give them in the perimenopause, but we can also give them to younger women. There are a lot of young women who maybe have had a baby or who are using contraception, or who are just prone to urinary tract infections. And so I knew it was safe. And I knew with vaginal hormones, if you stop using them, they wear off so they don’t build up in the system or anything. And your localised symptoms were so severe I just wanted to see because in my mind, also, if your skin and that area of your body improved with local hormones, it was more likely your rest of your body would improve with hormones as well. But I didn’t expect you to respond quite so quickly because your symptoms were so severe. But that area is very forgiving. You know, we know that if people have a baby, sometimes they have tears and awful, you know, just the whole stretching and everything, having a baby. And then, you know, the body heals itself very quickly. But it’s very reassuring. And just for those people listening who might have lichen sclerosus, it often can be a reversible condition with the right treatment. But often people are given steroids, which can reduce inflammation, of course. But one of the side effects of steroids is that it can thin the skin. And if your skin’s thin already, you have to, it’s a really fine balance, isn’t it, when you use local steroids. [00:13:49][130.2]

Elin: [00:13:50] Yeah, thankfully I haven’t experienced issues with that as it was all very quick diagnosis. Only on steroids for about a year and a half, maybe a year, just between a year to a year and a half before we started the local HRT and yeah, it’s so much better because it’s a lot easier. It quicker. You don’t have to wait for it to dry before you get dressed. It gives you all that time in the morning or the evening again that you wouldn’t normally have just sat on the bed just waiting for it to dry. [00:14:17][27.2]

Dr Louise: [00:14:18] It does make a difference. You know, I think as much as possible we want to just be normal. We don’t want to be labelled. We don’t want to sort of think about treatment that we’re using. So anything that’s easy and quick and also we’re more likely to do it. So this is a daily pessary once it’s, you know, been used often people don’t really realise that they’re having it because they feel well. And it’s a long-term treatment. Often people, once they start it, continue it forever and it’s fine, it’s safe to do that. So then you did that and then I did some hormone tests. And your testosterone level was very low. And testosterone levels are only a guide. And a low level doesn’t mean that’s the cause of your symptoms, of course, but you know, you’re otherwise super healthy. You look after yourself, you eat well. You tried, as you say, so many things before so I decided to give you some hormones systemically to try, thinking I’m sure most of it is related to testosterone, maybe oestrogen as well. But I don’t know how you felt, like a stranger from the street giving you hormones. Did it feel strange or did it feel the right thing to do? [00:15:20][61.7]

Elin: [00:15:21] Well, I’d just gotten to a point where I will try anything and after the local HRT reducing all of that tearing, my skin had gone from white to pink. I was able to wear certain clothes again I thought I wouldn’t be able to wear, just because the discomfort of clothing against my skin. So I was like, I’ll try it. I’d say HRT helped me feel about 40-50% better, the local one. And then I just feel like that last little bit was what I needed to get me back to how I felt when I was 17, 18, everything. It did feel a little bit strange, like the first time you’re putting it on, you’re like, I was never taught about this in school. Doctor never mentioned any of, the GP was very much pushing towards the coil route, which I’d already tried and didn’t want to try again. So I was just glad there was something else I could try. But yeah, I did feel a bit weird, but it’s a lot nicer than I’d say what my other options were that I’d been offered. [00:16:18][57.5]

Dr Louise: [00:16:20] Yes. And I think, you know, we were very clear that it might or might not help. It’s completely reversible. It’s worth trying. And having the blood test is reassuring I think as well to know that there was something that was, you know, low and hopefully treatable. And then I remember, usually when we start HRT often I arrange a blood test before someone comes back to the clinic. And again, blood tests are only a guide, but it helps guide sometimes the absorption to see if levels had improved. And I saw your results and they were significantly better. And I emailed you actually before I saw you, because I was so desperate to hear how you were getting on. And it’s just so lovely. I mean, I’m very privileged in my clinical job because the stories that I hear are dreadful initially, but it is the most transformational medicine I’ve ever practiced. You know, I’ve done a lot of diabetes care and asthma care and raised blood pressure care and, you know, I’ve obviously treated people with infections and all sorts, but the difference is incredible. And so you sent me this lovely email and then we had a consultation a few days later. But even if I all I could see were your eyes, I could see there’s such a difference in you. It’s just wonderful. [00:17:29][69.0]

Elin: [00:17:30] Yeah, my bags aren’t down to here anymore, down to my chin. [00:17:33][3.2]

Dr Louise: [00:17:35] But you tell me you’re working longer hours as well, which is good. [00:17:37][2.5]

Elin: [00:17:37] Yeah, I’ve picked up extra days. I’m back into a sleep routine which I hadn’t had for a while. So it’s always bed around midnight, wake up about eight, half eight, which felt impossible before. I’m back in the gym. I’m stronger than I was probably before I even started to get unwell. So everything is complete U-turn to how it was when we first met. [00:18:00][22.5]

Dr Louise: [00:18:01] It’s amazing, isn’t it? And, I, with your permission, told Jessica as well, my daughter, who’s obviously been instrumental in joining us together, and she’s done that a lot for quite a few other people. But she also says, which I feel as well, very sad for two reasons. Firstly, if I’d not had my ear pierced we’d never have met. And you’re only 27, so would you have carried on for 20 years before you reached the average age of the perimenopause, you know, into your 40s? And how would your life have been? [00:18:34][32.1]

Elin: [00:18:34] Yeah, because I would just never have even heard your name. My GP was, although they did what they could have done, they weren’t taking it as seriously as you did. So yeah, I think I’d still be going. [00:18:46][12.0]

Dr Louise: [00:18:47] So yeah and so your individual life would have been affected, but there are still lots of people out there who are affected. And, you know, we can’t reach everybody through our clinic. And globally there’s a lot of people who are really struggling, and there are people in other countries where it’s less easy to talk about the symptoms and they end up not talking about them because they’ll be judged incorrectly and seen as a failure as a woman, which I find really sad. But I know that if I’d met you ten years ago, before I started my menopause clinic and doing as much work as I do, I would have been the same as your GP. I would not have known what to do because no one taught me about menopause. But more importantly, no one really taught me about testosterone and how important it is throughout our body. And even now the guidelines are, you start HRT, you add in testosterone later if people have reduced sexual desire. But actually testosterone is a biologically active hormone that goes throughout our body, affects every single cell. And increasingly we learn through patients. That’s often what we do in medicine anyway. But we learn that stamina improves, strength of muscles improve because we have testosterone receptors in our muscles, in our bones, and even in our joints. But also energy and sleep improve, which are really important to help us function. That mood, motivation can improve, and also urinary symptoms often improve with testosterone in addition to oestrogen and testosterone’s very anti-inflammatory as well. It reduces inflammation. So there’s lots of reasons why it can help. But no one’s really done any research properly in women looking at testosterone deficiency on its own. You know, you’re still having periods, you’re still producing some oestrogen and progesterone, probably less than you would have done compared to other 27 year olds. But actually, for you, a lot of it was the testosterone that was really low. And we don’t know why some women have lower testosterone sooner than others. And that’s something that is really important because it’s an independent hormone, if you like, that is crucially important for many people, but they’re not, it’s not being diagnosed, it’s not been recognised and then the people are not having the treatment. So, you’ve been discharged from your urologist, haven’t you? Which is great. [00:21:11][143.5]

Elin: [00:21:11] I have, I thought that wouldn’t, I’d never see the day. [00:21:14][2.3]

Dr Louise: [00:21:14] And what did your urologist say? Was he. Well, I’m saying he could be she, were they pleased? [00:21:19][4.3]

Elin: [00:21:20] There was a group of students there as well. We’d done my last cystoscopy, and we’d done my last I can’t remember what it was called… the amount of urine that you can hold and pass. [00:21:32][12.5]

Dr Louise: [00:21:32] Was it urodynamics? [00:21:32][0.0]

Elin: [00:21:34] Yeah. That’s the one. They were really shocked to see that I didn’t have a problem with my urodynamics. That’s what they’d had their money on from the start. Even though I’ve had all these tests a few years prior and no-one could find anything wrong. And they said, so what’s changed? You’ve gone eight months now without… What’s changed? And I gave them your name. I told them about your podcast. I explained about the hormone insufficiency and everything and they were just shocked. They were like, oh, we heard it could affect things. But again, not on someone so young. So it just felt a little bit like, well, I’m here and I’m telling you, and I’d already met so many other young people in the waiting areas in the past that I know haven’t had access to information yet. So again, I’m super happy for myself but then it does make me very angry that there are so many people without the knowledge that you’re spreading. [00:22:25][51.6]

Dr Louise: [00:22:28] It’s really important. And certainly my, I don’t know if you know, my husband is a urologist, and last year I lectured at the British Association of Urological Surgeons, and it was really great because they’re a very dynamic group of people, and they really wanted to learn. There’s a lot of sort of scepticism when I talk to some groups of doctors, but actually they see it already, they see that local oestrogen pessaries can make a real difference for some women with urinary tract infections, but they didn’t know about testosterone, and they don’t often give systemic hormones the same. But they’re really keen to learn. And I think that’s the most important thing in medicine. Certainly, I’ve always been taught to have a really open mind and try, you know, as long as something’s safe, like, I would never try, there’s lots of new drugs that come on all the time that I’m really cautious of starting a new drug if we don’t have data. Some people say we don’t have enough data about testosterone. But then if you look how it works physiologically in the body, you know our natural testosterone. And if people have good understanding of how it works in our body, then that’s very easy, because all I’m doing is giving testosterone. I’m not giving you a testosterone-like substance. There’s lots of, young men in various gyms that are taking testosterone analogues and having all sorts of problems because they’re like testosterone, they’ll help build their muscle, but they have problems as well. But I’m not doing any of that. So it’s quite simplistic medicine. But the problem is, is that no-one’s been taught. And then a lot of people say, well, we need to wait for the studies. Well, the studies won’t be done because there’s never or hardly ever any funding for female studies or studies involving women. But in the meantime, what I would hate to do is have said to you, well Elin, we haven’t got any studies, it might help you, but let’s wait for the studies to be done. Come back in 20 years’ time, because that’s not right and not fair, is it to have that approach, I don’t think? [00:24:23][115.4]

Elin: [00:24:24] I think I’d have cried. [00:24:24][0.3]

Dr Louise: [00:24:25] Yeah, yeah. So we’re hoping, testosterone at the moment is only licensed for women in Australia. It’s not licensed in other countries. And we’re not really sure why. I think it’s just because there’s so much misogyny really that goes on. And it’s never been a priority thinking about female hormones in the same way. There’s always a fear that people will abuse and use it wrongly, and I think that’s why it’s actually labelled as an anabolic steroid, because if you use too much, it can build your muscles too much. But actually, I’m not aware of any women that abuse a natural hormone. And they’re so relieved, like you are that you’re feeling better. But as long as it’s been given in the right way and people are monitored. So always in the clinic, we monitor everyone. Every year they have a blood test to make sure the levels within normal ranges and make sure they don’t have any systemic side effects. But very few people have side effects when it’s used in the right way, because you’re just topping up what’s missing, and your testosterone level is probably still lower than other people’s who are 27, and it might be higher than others. But it’s right for you. And everyone’s different. And so that’s the most important thing, is monitoring and making sure that you’re feeling better. And sometimes in medicine it’s very hard to measure feeling better. You know that you can do these studies looking at blood pressure or weight or, you know, sort of objective measurements. But feeling better can be quite hard to quantify. But just being able to increase your hours at work, to not fall asleep on the tube on the way home, to be able to go to the gym, to be able to sleep at night, in my mind are really good measurements that things are going in the right direction for you. [00:26:08][103.0]

Elin: [00:26:08] And there’s lots of other weird symptoms as well, like you’d have like weird reactions to certain things. I’ve not had that since starting and then weird nightmares, weird dreams and things, there’s so much more than just those little top ones that I feel like are really common for everyone. Just those little ones that affect your day-to-day life have all gone. And like you said, it’s such a tiny amount I’m using, when I actually put it on to my leg you think that’s not going do anything. It’s such a tiny amount and, like, such a big difference. [00:26:37][28.5]

Dr Louise: [00:26:37] Yeah. No. It’s amazing. It really is such a joy to listen to you and hear. And I’m really grateful for you sharing your story as well, because we all learn from other people’s stories. And obviously it’s not going to be as transformational for everybody. But certainly it’s something to consider for people who are having similar symptoms. So I’m very grateful. But before we end Elin, I always end with three take-home tips in the end of my podcast so people can just reflect a bit more. So I’m really thinking about younger audiences, you know, people like you who are in their 20s. What are the three things that you would say to women, girls, you know, who are in their teens and 20s, who think they might have some hormonal changes, but they’re either not being listened to or they’re too scared to go and ask for help. [00:27:25][47.3]

Elin: [00:27:26] The top one thing is it’s really hard at times, but just don’t stop advocating for yourself. There are times where you do have a lot of self-doubt, and you do feel like you’re battling yourself. You feel like you’re wrong but you’re not. Keep pushing. My doctor was sick of seeing me, I was there probably every week. Just don’t give up on that side. And I found what was really helpful to finally get the blood tests on the NHS or to start that discussion with a doctor that actually listened to me was to not just list your symptoms but list when they were happening as well. So having a almost like a log of what happened on what days, just to make sure everything they want to quickly rule out so they’re not ruling it out. So for example, if you’ve not eaten very well for that day, you’ll know if it’s affected by food or if it is affected by hormones and things like that. So if they say, you need to eat better you can say no, I’ve eaten really well this week. I think the other one will be, don’t be scared to try medications. Don’t be scared to take suggestions. And whether it’s to just see if it helps or whether it is just to keep the doctor happy to potentially to get to the next step. So if it is potentially try some hormonal contraception and see if that helps. Or try the local HRT because I’m shocked at how much that helped. I thought that would be completely wasted when we discussed it, I was like, I’m happy to try it, but I don’t know how that’s going to help and if I hadn’t have felt it and hadn’t have done it, i wouldn’t have believed you that was such a big difference it made for me. So just don’t be scared to try things as well. [00:29:05][99.5]

Dr Louise: [00:29:06] Brilliant. Great advice and thank you so much for your time tonight because it’s late at night, you’ve had a long day at work, and I hoicked you in to do this, because I just felt your story is so important to share with others, and I’m sure it will resonate either to people directly or people who have children or know people who are young. So thanks again Elin for your time. It’s been great. [00:29:28][22.1]

Elin: [00:29:29] Thank you for having me. [00:29:30][0.8]

Dr Louise: [00:29:35] You can find out more about Newson Health Group by visiting www.newsonhealth.co.uk. And you can download the free balance app on the App Store or Google Play. [00:29:35][0.0]

ENDS

The post I’m 27 and perimenopausal: how testosterone helped my symptoms appeared first on Balance Menopause & Hormones.

Think you might be menopausal and looking for a simple explanation of menopause? This article sets out what you need to know.

What is the menopause?

The menopause is when your ovaries stop producing eggs and levels of hormones oestrogen, progesterone and testosterone fall. The clinical definition of menopause is when you haven’t had a period for 12 consecutive months.

The perimenopause is a time directly before menopause, when hormone levels start to decline and you are still having periods, however you may notice a change in frequency and flow.

RELATED: What is the perimenopause?

When does the menopause happen?

The average age of menopause is 51, and as a general rule, the perimenopause tends to begin in your early to mid-40s. However, it can happen later or earlier for reasons including genetics or due to surgery or treatment. Menopause before the age of 45 is known as an early menopause, while menopause under the age of 40 is known as premature ovarian insufficiency (POI).

What sort of symptoms can I expect?

Falling hormone levels can trigger a range of menopause-related symptoms, which can include symptoms such as

• Mood-related symptoms
• Hot flushes and night sweats
• Fatigue and insomnia
• Poor mental focus and concentration
• Headaches, including more frequent migraines
• Joint and muscle pains
• Reduced sex drive
• Vaginal dryness
• Urinary and bladder problems, including urinary tract infections (UTIs).

It’s important to remember that everyone’s menopause is different: you may have no symptoms at all or you may experience a rang of symptoms.

The balance app has a handy symptom tracker where you can track the type, frequency and severity of menopause-related symptoms.

How can I manage my menopause?

The balance website has a host of resources on helping to manage your menopause, looking at treatments, lifestyle changes and mental health resources. Head to our menopause library to find out more.

The post What is the menopause? A quick guide appeared first on Balance Menopause & Hormones.

This week we mark 250 episodes of the Dr Louise Newson Podcast!

And joining Dr Louise this week is Anita Nicholson, a nurse practitioner and menopause expert at Age Management Center in the US, where she aims to help patients lead the best quality of life for as long as they can.

Here, Dr Louise and Anita compare notes on the attitudes towards testosterone in the UK and the US, share their clinical experience of the benefits it can provide women, particularly in restoring their zest for life.

Finally, Anita sharesthree things she thinks could make a huge difference to women’s health:

1. Women need to educate themselves. They have to be their own advocate.
2. I would love for hormones to become available and affordable. In the US, we don’t even have vaginal oestrogen covered by some insurance here, never mind over-the-counter access.
3. More education of healthcare providers. So have a fellowship in menopause. Let’s start very early with med students and nurse practitioner students so they understand that menopause and sexual medicine is very important for our life span and our health span.

You can follow Anita on Instagram @menopause_agewellfnp

Transcript

Dr Louise: [00:00:11] Hello, I’m Doctor Louise Newson, I’m a GP and menopause specialist, and I’m also the founder of the Newson Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. I’m also the founder of the free balance app. Each week on my podcast, join me and my special guests where we discuss all things perimenopause and menopause. We talk about the latest research, bust myths on menopause symptoms and treatments, and often share moving and always inspirational personal stories. This podcast is brought to you by the Newson Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women. So today on the podcast, I’ve got someone from America who I have met in real life, some of my American guests I haven’t met in real life, but I’ve got with me Anita Nicholson, who’s a nurse practitioner from Portland, Maine in America. And I met her at a conference. We were both at a conference recently, a menopause conference, and I was presenting some of my work from our clinic about testosterone and benefits. And we met at coffee. And the coffee break wasn’t long enough, actually, because we were chatting and sharing our experiences of the patients we see and the journeys that they have had before they come and see us, and the transformational way that we can help them. And it was just lovely to speak to a kindred spirit, actually, who understood what we’re trying to do and try and improve the lives of so many people. So thanks for joining me today, Anita. It’s very exciting to see you again. [00:01:56][105.0]

Anita: [00:01:56] Yes, Louise. Thank you for inviting me. [00:01:58][2.1]

Dr Louise: [00:01:59] So you’re a nurse practitioner and you’ve had a really interesting background actually, haven’t you? Looking at, you know, I think things change don’t they with time, how you want to reduce diseases and improve longevity. And it’s a journey to that age, not the age that we die necessarily. And certainly how I practice medicine or think about medicine, about prevention, rather than waiting for the disease to come, is quite different than if you’d met me 30 years ago when I had just trained in medicine. And so what’s your journey been like? [00:02:32][33.6]

Anita: [00:02:33] Similar. I spent probably 20 years in hospital pace medicine, ICU, cardiac surgery, cardiology and found I really wanted to get ahead of people having heart attacks. And through my own journey through menopause, which was related to chemotherapy, so I went right off the deep end into menopause, really struggled to navigate that. And I thought, if I’m struggling, other women must be struggling. And I’d really like to get ahead of all of this disease that will happen to us later in life. So I started to shift my career to real primary prevention and focusing on women’s health only. So now I only see women in my clinic. Nothing wrong with the men. There’s plenty of men here to take care of them. [00:03:25][51.8]

Dr Louise: [00:03:26] Absolutely. It is interesting, isn’t it? Because, like you, I’m not a gynaecologist. I’m not in OBGN and I’ve done a lot of hospital medicine. And actually, even as a medical student, we had did an elective and I did it with a cardiothoracic unit. And it was very interesting. And I love cardiology, I love treating diseases. And I really enjoyed hospital medicine. And I never once thought that I would set up and run a clinic that was just for women. Like you, I love women, but I also love helping men and children and all sorts. But but actually, life just has, you know, takes it sort of different directions and you go with a direction if it feels right. And, you know, we’re only talking about something that affects 51% of the population directly. But every woman knows a man, whether they live with them or they’re related to them or they work with them. So it has an indirect effect on the rest. So there’s nothing else in medicine that affects every single person other than hormonal health, is there? [00:04:27][60.9]

Anita: [00:04:27] That’s true. Yeah. If women live long enough, it will happen to them and everyone in their life. [00:04:34][7.1]

Dr Louise: [00:04:35] Yes. [00:04:35][0.0]

Anita: [00:04:35] Is affected as well. [00:04:36][0.7]

Dr Louise: [00:04:36] Yes. And it’s really interesting because the conversation changes all the time. But for, well I was going to say decades, but it’s centuries actually, women have been ignored and people have been very scared of hormones because hormones affect for many women their emotions as well, and the way their brains work and their personalities and the way they function. And people have been scared of that. And then even when they realise there’s been all sorts of weird treatments over the decades, hasn’t there, to try and calm women down, or to suppress them, or to help them with their depressive symptoms or reduce their anxiety, all sorts of often quite barbaric treatments. And now we’ve moved on. We know that a lot of symptoms are related to hormonal deficiencies or fluctuations, depending whether someone’s menopausal or perimenopausal, and we have really safe, natural hormones to replace that deficit. But over in the UK, only about 14% of women who are menopausal take hormones. Over in the US, I think it’s even less, isn’t it? [00:05:41][64.7]

Anita: [00:05:42] Maybe ten, maybe less. Yes. It’s still quite low. [00:05:46][4.6]

Dr Louise: [00:05:47] Yeah. Which, there’s nothing else in medicine in my knowledge, correct me if I’m wrong, where we have an evidence-based treatment that is not given to the majority of people that are suffering from the condition. [00:05:59][11.7]

Anita: [00:06:00] It’s true. Yes. You can look at the percentages from many different, you know, data that’s collected, which is hard to do when you don’t have an FDA approved testosterone, for instance. So where is prescribing happening? And it’s, you know, how many prescriptions of male testosterone was filled for a female? And what about the compounding pharmacies and whatnot? But even if you look at the… There was a research query, 2010 to 2021, like 190,000 women, 40,000 of who had diagnosed hypoactive sexual desire. And 3.9% treated. [00:06:39][39.7]

Dr Louise: [00:06:40] 3.9%. [00:06:40][0.0]

Anita: [00:06:42] 3.9. So I think that would be considered rarely prescribed. You know, and that wouldn’t be the case if it was we found that they had high cholesterol or we found that they had hypertension or they just pick one. You know it wouldn’t be 3.9%. [00:06:56][14.8]

Dr Louise: [00:06:58] Which is quite shocking because if we sort of think about HSDD, as you said, hypoactive sexual desire disorder, it’s very common in menopausal women and actually perimenopausal women and even younger women as well. But even if you look at the way it’s defined, it’s quite barbaric for women, isn’t it? [00:07:15][17.5]

Anita: [00:07:16] Yes. I don’t love that it’s a desire disorder. It’s not a desire disorder. And I also don’t love the wording around “but should really have to be suffering”. I really don’t like that either. [00:07:30][14.0]

Dr Louise: [00:07:30] And you have to be suffering for the minimum of at least three months. So you can’t just have a month or six weeks of suffering. You have to wait until you had three months. [00:07:39][9.0]

Anita: [00:07:39] And whose judgment is that? [00:07:41][1.6]

Dr Louise: [00:07:41] Well, this is really interesting. [00:07:42][1.1]

Anita: [00:07:43] Suffering enough. Yes. I don’t love that. [00:07:45][2.3]

Dr Louise: [00:07:45] Yeah. I feel like in life many of us suffer for all sorts of reasons. There’s all sorts of reasons why our libido can change. And it often is situational, of course, but there is still other reasons, including low hormones that can affect our desire. But it’s a desire for what? And that’s what I find really difficult. Because if you look at Freud’s interpretation of libido, it’s not just about sexual pleasure, it’s about pleasure of life and enjoyment of life. And is it really wrong for us as clinicians to want to enable our patients to have better quality of life and enjoy life more? And I don’t think it is, actually, but it seems like, we have to prove that we’re suffering a lot before we can get any enjoyment. And that doesn’t seem right either. [00:08:39][54.2]

Anita: [00:08:40] No. And how do you even ask that? But are you suffering enough? And is there any domestic situation that could be affecting this? This is not a conversation that men have. [00:08:50][10.1]

Dr Louise: [00:08:51] No, not at all. [00:08:51][0.5]

Anita: [00:08:51] With male patients, you know, who may present and say the same array of symptoms. You know, maybe there’s anxiety, maybe there’s some mood change. Sex drive is gone, you know, cannot maintain an erection, cannot achieve orgasm. They’re not going to dive into what’s your home life? How much are you suffering? That conversation doesn’t happen. They get to treatment and that’s the end of it. And I, I think we need to treat our women patients like that. We don’t need to make a judgment on, are you suffering enough? And I do like your point about inviting pleasure into our lives, especially at this stage of our life. We have enough experience and wisdom and knowledge of our own self to be able to cultivate pleasure everywhere in our life, not just intimately, you know, find the joy, feel the joy with our intimate partners, any other place in our life and what I have found very consistently with women that, that feeling of being able to connect with joy and pleasure drains out of their body when they go through perimenopause and menopause, and it’s hard for them to really pinpoint when it happened. But they know that it has happened. They know that they’re in an experience where this, I used to feel joyful right now in this circumstance, whatever it is. But I can’t connect with that anymore. And that that touches every part of their life, not just their intimate life. And it can be devastating. And it’s not that they’re depressed, but being in that state for a prolonged period of time can be depressing. [00:10:34][102.4]

Dr Louise: [00:10:34] I absolutely agree, and it’s really hard to sort of put down in a, on a questionnaire or in a research tool or whatever, but it is that people often say, I just feel joyless, I feel flat. My zest for life has gone. It’s quite sort of subtle changes that often come on quite gradually. And the more we learn and know about physiology of our hormones, the more how our hormones oestrogen, progesterone and testosterone can light up our brains, it’s no surprise. And when we talk about HSDD, it’s talked a lot in the context of testosterone. And so we’ve talked on many podcasts before about the role of oestrogen and progesterone, which are sort of the building blocks almost, we’ve always been the go-to parts of HRT, but testosterone is an independent hormone. It’s produced by our ovaries, our adrenal glands. But our brain produces testosterone as well, doesn’t it? And we have receptors for testosterone all over our body, including our brain. And it actually blew my brain when I first realised this, because I felt really cheated. As a woman who has had this biologically active hormone in my body at higher levels when I was younger than when I was older, but also as a clinician, why didn’t anyone tell me that women had testosterone and it has this effect? And then as a menopause specialist, I’ve also felt cheated because whenever we have or I’ve gone to presentations about testosterone or educational events, it’s always been testosterone, HSSD, severely psychologically distress with a reduced libido and then considered testosterone. No one’s been saying about all the other biological effects that testosterone has. So it’s I don’t know about you, were you given much education over the years about testosterone? [00:12:24][109.6]

Anita: [00:12:25] No, that was not covered in any of my training. This menopause care right now is an independent education. I mean, it’s certainly prepare for and get certified by the Menopause Society. Yes. Do that. Sometimes the guidelines aren’t up to date. So you write a test that you have to, you know, bear in mind what year the test is, but otherwise it’s an independent study on your own time. [00:12:52][27.3]

Dr Louise: [00:12:53] Yes. [00:12:53][0.0]

Anita: [00:12:54] Right. So if you want to become specialised in menopause care, you’re doing a lot of self-study on your own time. [00:12:59][5.4]

Dr Louise: [00:13:00] Absolutely. And many of us are really motivated because the more you do perimenopause and menopause care, the more you realise it’s transformational medicine. There’s nothing else I’ve ever managed in medicine where I’ve had patients who feel better, but also their future health is better as well. And when I first started learning about testosterone, in fact the conference we met at I’d gone to a similar conference actually seven years ago was, my first menopause conference. It was in Amsterdam, and I had just started taking testosterone about four months before, and I was experiencing this joy that I hadn’t had for like ten years. I thought a lot of my sort of sadness and ineptness and just loss of self-esteem and low self-worth was just because I’d had my third child when I was 40. I thought, I’m just a bit old to be a mother again. I was trying to change my career. I was trying to set up a clinic. I was doing all these things. And then suddenly my brain literally felt like it was opening up and alight again is all I can say, really. And I was I could jump out of bed rather than thinking, I’m going to hit snooze 28 times before I get out of bed. But I went to a lecture by an Italian professor, and he was talking about the benefits of testosterone beyond libido or the sexual, you know, libido. And he said, I remember going to the opera with my wife, and it’s the most wonderful opera, we’re there you know, listening, and I look at her and she’s crying. She’s got tears of enjoyment because the music is just so wonderful. And I think to myself, that’s testosterone that’s done that. It’s given her this tingling sensation. And I came out of the lecture theatre thinking, yes, that’s what I’m getting, really you know, I was really invigorated and I turned to two of my colleagues and said, that’s testosterone, it’s amazing. And I stupidly said to them, oh, do you take testosterone? And they both looked poker face and said, no, I don’t need it. And I thought, okay, I’ve really just overstepped, probably all professional and personal boundaries. And, then I realised that actually, maybe I was oversharing, telling people that I was on the hormone. I don’t know why, but and then I got told off, actually, for talking about it in public, but actually like lots of things in any experience you learn more from yourself, but then it makes you understand like why is my brain feeling like this? Let me go back and look at some neuroanatomy, neurophysiology texts. Oh, okay. I can understand now why it’s working. So it’s unlikely to be just a placebo, isn’t it? [00:15:33][153.1]

Anita: [00:15:33] Oh, it absolutely is not a placebo. And we should be talking about it. We should, like, make everyone very comfortable talking about women’s health and women’s hormones and what it means and what the change is. I have patients who consistently tell me I have saved their life, and they mean it. And I have other women who have said, you know, I feel incredibly better. You know, I’m back to my life again. I feel re-engaged with my friends. I started my hobbies again. I am motivated to go to the gym. I feel excitement for things and none of those are sexual. None of those are sexual. They’re back into enjoying their lives again and getting stronger and feeling more confident. And I would say there’s consistently a message of somewhere along the way when your hormones go down, and I think oestrogen plays a role in this and a lot of different things do, too, but we lose the sensation or the understanding or the connection of our feminine energy, of our sensuality, our sexuality. This is a personal feeling, and you don’t need to have a partner to feel that way in your body and your life and your mind and your spirit, and it disappears. And women struggle to feel. I don’t feel attractive. I don’t feel sexual. I don’t feel that in my body. I don’t feel it when I look at myself, when I’m talking all of those things. And that’s not made up. That’s a consistent message that I get from women. And when they start on hormone replacement therapy and some I’ve only ever started on testosterone, that comes back, and they can feel that again. They can feel their sexual identity again. They can feel their feminine energy and that sensuality, and they then go forth in their life and connect and do the things that they’ve loved to do or find new things to do, relate to their partner in a different way. That is a consistent message. [00:17:37][124.3]

Dr Louise: [00:17:38] Yes. And it’s interesting, isn’t it, because a lot of the guidelines well, all the guidelines actually, that I can think of say that we have to give HRT first if women still have reduced libido despite being on HRT, consider testosterone. But actually the more work I do and I learn every day from patients that we see is that I think, and I’m really keen to hear what you think, there’s a lot more women out there who are testosterone deficient before they become oestrogen deficient. [00:18:05][27.0]

Anita: [00:18:06] Yes. [00:18:06][0.0]

Dr Louise: [00:18:06] Do you see that in your practice? [00:18:07][0.9]

Anita: [00:18:08] I do, I have women in their late 30s and on, who are in perimenopause. I know we don’t have the data on this. This is just my clinical observation. Many of them have been on oral birth control for a very long time, right up until their 30s when they decided to have babies. And most of them say, I just didn’t bounce back after my last child. Those women have very low testosterone and have all the symptoms of testosterone depletion, and I start them on testosterone. [00:18:38][29.7]

Dr Louise: [00:18:39] On its own before. [00:18:40][0.8]

Anita: [00:18:40] On its own. [00:18:41][0.4]

Dr Louise: [00:18:41] Yeah. And that makes a difference? [00:18:42][1.1]

Anita: [00:18:42] And then we talk about perimenopause and what will happen next when progesterone goes when oestrogen leaves the building. You know, I think of oestrogen as the queen of everything lubricated eyeballs to vagina. You know, you’re going to notice it and, you know, certainly talk about it right away when it starts to happen. So I, I definitely have, I have a cohort of women on the young side and my older ladies who are maybe, you know, 68 to 75, and they’re keenly feeling the lack of stamina and ability to maintain their muscle mass and just their sort of mojo, their get up and go, this is what they tell me. Only testosterone for them. Game changer. [00:19:27][44.7]

Dr Louise: [00:19:28] And it’s interesting because some clinicians get quite scared of giving testosterone without oestrogen. And people talk about this aromatisation of testosterone to oestrogen, but actually our hormones come from the same pathway anyway, don’t they? They’re very similar when you look at their chemical structure, oestrogen, progesterone, testosterone, very similar. And some might convert to oestrogen, but it’s very low and it’s not enough to really have an effect. And we have to remember that people have oestrogen endogenously anyway in their bodies. [00:19:58][29.5]

Anita: [00:19:58] That’s right. [00:19:59][0.2]

Dr Louise: [00:19:59] And even when people are postmenopausal, there’s still some oestrogen production anyway. And so testosterone is an independent hormone. And I often say to people, if you had a patient who was hypothyroid and had type 1 diabetes, would you say to them, right, I’m going to give you thyroxine today and then I’m going to give you insulin in three months’ time. It just doesn’t make sense. [00:20:23][23.9]

Anita: [00:20:23] Yeah, you’re exactly right. I tell people that oestrogen and progesterone are a couple. And testosterone plays in his own sandbox. Completely different. They work well together, but they can be given separately. And sometimes I start women only on oestrogen and progesterone to begin and then add in testosterone. Other times I start testosterone first. It depends on, you know, each woman is, their care is so individual. [00:20:51][28.0]

Dr Louise: [00:20:53] Course it is. [00:20:53][0.3]

Anita: [00:20:53] It’s so individual. And what I think the complaint or the thing that is highest on their suffering scale, if you will, is what I tend to go with first if they only want to do one hormone at a time. And so that could be oestrogen or it could be testosterone. I do have a few patients who have a contraindication to oestrogen, unusual cancers, not breast cancers. And I’ve worked with their oncology team to get the approval to just start testosterone. And this woman, and I have a few of them that were really suffering. And the testosterone made a significant difference in their hot flashes, their night sweats, their brain function. Most women will comment more clarity in their brain and their mood and their motivation, their sort of like mojo, their zest for life is back again. And it did mitigate most of their symptoms. They don’t get the benefit of having oestrogen for the rest of their life, but their quality of life is significantly improved. [00:21:59][66.2]

Dr Louise: [00:21:59] Absolutely. And it’s really interesting because we’ve looked at our data of adding testosterone, and in fact, you were there when I was presenting it, so half of our patients, we increased oestrogen because we thought they had symptoms of oestrogen deficiency. And the other half, we didn’t. But the benefits of testosterone were the same across the domain of all symptoms, suggesting that we don’t always need to be giving more and more oestrogen. It’s an independent hormone. And so there are people that will probably benefit from testosterone earlier or, you know, maybe to start. And it is so individual. One of the things that really frustrates me, lots of things frustrate me as you know Anita, is that we’re talking about a natural hormone. So when we give testosterone, it’s exactly the same chemical structure. It’s not been modified in any way compared to what we produce by our ovaries when we’re younger. Yet you and me, so you in America, me in UK, we don’t have a licensed product of testosterone, do we? So when we say it’s licensed, you know, there are lots of drugs that are licensed. Obviously all the anti-depressants are licensed, painkillers are licensed, all sorts of things. But testosterone also is licensed for men in the UK. Is it licensed for men in the US? [00:23:10][70.8]

Anita: [00:23:11] It is. [00:23:11][0.2]

Dr Louise: [00:23:12] Yeah of course it is, like why wouldn’t it be? So women who are slightly, as I said at the beginning, slightly over 50% of the population and produce this natural hormone, which is actually the most biologically active hormone we have, that we produce in higher quantities than oestrogen when we’re younger and it depletes with time. The deficiency causes all sorts of symptoms and probable health risks as well. Yet we don’t have a licensed product. Doesn’t quite add up, does it? [00:23:39][27.3]

Anita: [00:23:40] No. The gender disparity there is glaring. And at this point I, I don’t know how close or far away we are because it would take a considerable amount of money for, you know, a company to decide to do the research and then bring it to the FDA or the FDA to run a study, and then they would easily come up with a product, say, like a patch like the UK has or like Australia has. [00:24:09][29.5]

Dr Louise: [00:24:09] We don’t have the patch anymore, that was withdrawn when the drug companies stopped making them. But we use the Australian cream. So it’s the cream so that’s what they have which is licensed in Australia. And they’re trying I think to get it licensed over here but it’s not really a priority. So we haven’t got a licensed product for women. So we can still prescribe Androfeme. We’re allowed to prescribe it privately. So it’s a regulated product, we can prescribe it. But women have to pay for it. On the NHS, the National Health Service, we can prescribe the male testosterone of course off license because it will be for women in just in lower doses because it’s exactly the same hormone, of course isn’t it. So we can just do that. So we’re more fortunate than you are in the US actually. [00:24:54][44.3]

Anita: [00:24:55] Yes and here I fear what would happen if somebody does pick this up and does, you know, the double blind, randomised, placebo controlled study, that they’ll end up coming up with a product that will be terribly expensive, to pay for their, you know, so they’ll kind of put the pink tax on it and it’ll be very expensive. And women won’t buy it, you know, because they’re going to just get the male generic stuff that’s not too expensive. So I feel a little bit discouraged about if that’s going to happen or not. But we can prescribe. [00:25:25][30.3]

Dr Louise: [00:25:26] Yes. And the other thing is it comes under in the UK as a controlled drug because it’s an anabolic steroid. Which is absolutely ridiculous for women actually. So men is a different conversation. There are men that can overuse testosterone and it can be an anabolic, all our hormones are steroids actually. But the amount that we need as women is very low. And all we do is replace what’s missing. So I don’t know about you, but we just don’t see the side effects that have been reported in our patients. The biggest or commonest side effect is some hair growth where the cream is applied on the thigh. But we don’t see women with beards. We don’t see women with hairy arms. We don’t see voice changes. We don’t see hair loss. We don’t see clitoromegaly. Some people find their clitoris returns because it’s shunk without the hormones. But that’s not the same as coclitoromegaly. So we don’t see these awful side effects. So I can’t really see that it’s working as an anabolic steroid. Women often say that they’ve got more muscle strength. They’ve got more muscle definition, because when they exercise, it’s more efficient. But when we’re thinking about long term health and reducing sarcopenia, this sort of loss of muscle mass, it’s really important actually. I don’t see women with abnormal muscles who are masculinsed, just not in the doses that we give. [00:26:42][76.1]

Anita: [00:26:43] I don’t see that either. The side effects are very rare and they’re dose dependent, I find. [00:26:48][4.8]

Dr Louise: [00:26:48] Yeah. [00:26:48][0.0]

Anita: [00:26:49] You know, so you can easily back off on the dose. The teeny tiny baby, almost homeopathic dose that we give. We hardly need any. You know you can certainly back off on the dose. But I do echo your point about sarcopenia. For instance, I have patients who fall under categories of chronic illness like multiple sclerosis and Parkinson’s and have some other demyelinating neurological disorders, even traumatic brain injury. But especially for the MS patients, the patients who need to stay strong and have their balance, that’s very important for them. Testosterone very much helps with that. It also helps with their brain function and their nervous system. It’s sort of a win-win across the board for those patients. And they notice a difference. [00:27:40][51.1]

Dr Louise: [00:27:40] Yeah. And it is I’ve got quite a few patients with Parkinson’s disease with multiple sclerosis like you and also increasingly with lupus actually. And a lot of, someone said to me the other day that she can’t have a shower with her eyes closed because she’ll fall over, so this proprioception, and she’s been told it’s her lupus, and I’m there thinking I’m sure it’s related to testosterone. And a lot of people have this PoTS syndrome where they stand up quickly and they feel really dizzy and that can often really improve with testosterone as well. That’s because testosterone gets everywhere. So there’s a huge amount that we need to do. But in the meantime we haven’t got the studies. We act on clinical well, what we learn in our clinics, but also basic science as well, and putting the two together is a great privilege and honour of being a clinical practitioner like you and I am, and helping patients and listening and learning and knowing that what we’re doing is safe. So I’m very grateful for your time, Anita. And we haven’t really touched on all the other area of longevity and what else to do, because it’s not just about hormones. So I might get you back in a few months’ time to talk about once we have our hormones balanced how we optimise our future health. Because I know you’re really amazing and passionate on that, like we all are as well. So but before I finish, I always ask for three take home tips. So I’m going to ask you if it’s okay, three things that you would love to say had happened to improve the health of women. So if we met in 20 years’ time, what are the three things that you think could make a huge difference to women’s health? [00:29:14][93.8]

Anita: [00:29:15] I think the education piece. So women need to educate themselves. They will have to be their own advocate. I think your book is a great place to start. [00:29:24][9.8]

Dr Louise: [00:29:25] Ah thank you. [00:29:25][0.3]

Anita: [00:29:26] The definitive guide. Yes. It’s very good. I would recommend it to anyone at all. So women have educated themselves. They’ve become their own advocates. I would love to know that hormones have become available and are affordable. Like we don’t even have vaginal oestrogen covered by some insurance here, never mind over-the-counter. So the accessibility to the treatment, to the providers. And then the third thing is the education of the providers. So even a fellowship in menopause, let’s do that. You know let’s like start at you know, med students, start at nurse practitioner students, start very, very early. So they understand that menopause and sexual medicine is very important for our life span. Our health span really more so. [00:30:24][58.4]

Dr Louise: [00:30:24] I totally agree, I couldn’t agree more. And it’s changing the narrative as to what our hormones are, not being scared, embracing them. You know, the beneficial effects that we have when we have our hormones. So thank you so much. I really enjoyed it today. So thanks, Anita. [00:30:38][14.1]

Anita: [00:30:39] Thanks for having me Louise. It was really nice to see you again. [00:30:41][2.2]

Dr Louise: [00:30:46] You can find out more about Newson Health Group by visiting www.newsonhealthcare.co.uk, and you can download the free balance app on the App Store or Google Play. [00:30:46][0.0]

ENDS

The post Testosterone: the missing piece of the jigsaw? appeared first on Balance Menopause & Hormones.

• Testosterone has a significant influence on libido but also brain processing
• Levels of this hormone drop during the perimenopause and menopause
• Some women find testosterone replacement can help to alleviate their symptoms

Testosterone is an important hormone. It’s often referred to as the “male hormone” but while men have higher circulating levels of testosterone than women, it’s the most abundant biologically active hormone in women.

Testosterone is produced by your ovaries, adrenal glands and the brain but, like with oestrogen, levels decline around the time of the perimenopause and menopause and stay low thereafter. This fall in testosterone can lead to a lack of energy, brain fog and reduced libido (sex drive).

RELATED: How does menopause affect my sex drive?

What does testosterone do?

The hormone is perhaps best known for influencing libido – the level of interest in sex, and the amount of pleasure felt from it. But testosterone has a significant impact beyond this – you have testosterone receptors all over your body so its effects can be felt all over.

Testosterone plays a substantial role in a number of physiological processes in the brain. It strengthens nerves in the brain, and contributes to mental sharpness and clarity. It strengthens arteries that supply blood flow to the brain, which protects against loss of memory. It regulates serotonin levels and plays a role in its uptake in your brain, which helps improve overall mood. Testosterone also stimulates the release of dopamine, another neurotransmitter responsible for your feelings of pleasure.

Testosterone also helps with muscle mass and bone strength, cardiovascular health, and overall energy levels and quality of sleep.

What happens if I have low testosterone?

Levels of testosterone in women gradually decline as you enter your 30s but drop around the time of the perimenopause and menopause. If you have a surgical menopause (if you have your ovaries removed, or an operation or treatment that impacts ovarian function), you can experience a more sudden drop in hormones than women who go through naturally.

When your levels of testosterone reduce, you may find that you desire sex less often and when you do have sex, it’s not as enjoyable as it used to be (even when you still desire and love your partner). It’s normal to go through phases of less interest in sex but if you have a total lack of interest, lasting for more than 6 months that has consequences on your relationship and/or self-esteem, you might be diagnosed with Hypoactive Sexual Desire Disorder (HSDD).

RELATED: hypoactive sexual desire disorder: what you need to know

Other symptoms of lower testosterone include dysphoric mood (anxiety, irritability, depression), lack of wellbeing, physical fatigue, bone loss, muscle loss, changes in cognition, memory loss, insomnia, hot flashes, joint pains and urinary complaints including incontinence.

Do I need to replace my testosterone?

A low testosterone level alone does not necessarily mean replacement testosterone is needed.

The 2024 NICE Menopause guidelines say that testosterone can be considered for menopausal women with low sexual desire – if HRT alone has not been effective [1]. The guidance does not mention or support the use of testosterone in any other circumstances yet there is good evidence to show that the benefits of testosterone could help many more women in their perimenopause and menopause.

One paper, Testosterone therapy in women: Myths and misconceptions, said “to assume that androgen deficiency does not exist in women, or that T therapy should not be considered in women, is unscientific and implausible.” [2]

Menopause specialists and, increasingly, GPs are realising the widespread benefits of testosterone replacement for most women. NHS data suggests that 4,675 women aged 50 and over obtained testosterone gel using an NHS prescription in November 2022, a sharp increase from 429 women in November 2015, and this has been largely attributed to a rise in demand from female patients [3].

Testosterone can be considered soon after the onset of perimenopausal or menopausal symptoms, when you go to seek help for your symptoms. You do not usually need to have a blood test before treatment is started; your symptoms are enough of a guide for your doctor to agree to prescribe testosterone. Testosterone can be taken alongside oestrogen and progesterone.

Blood tests are needed a few months after starting testosterone treatment to ensure your levels are within the ‘female’ range. The dosage will be adjusted accordingly, depending on both your levels and whether you have ongoing symptoms of low testosterone. The blood tests can look at both the total testosterone levels in your body, and also the amount which is freely available by adding a SHBG level (sex hormone binding globulin) to calculate your FAI (free androgen index).

How is testosterone treatment given?

Testosterone is usually given as a cream or gel, which you rub into your skin like a moisturiser. It is then absorbed directly into your bloodstream.

AndroFeme®1 cream is made for women. It is licensed in Australia but can be prescribed here and is a regulated preparation.

Testogel, Testim and Tostran are gels that are made for men but can be prescribed off licence and safely used in lower doses for women.

Your clinician will tell you how much testosterone to use. It should be rubbed onto clean, dry skin on your upper outer thigh or buttocks, it usually takes about 30 seconds to dry. You should wash your hands thoroughly after using it. Applying the cream or gel at the same time each day will have the best effect and help you remember to apply it. Avoid swimming or showering until around 30 minutes after application and initially avoid using perfume, deodorant or moisturising creams on the area.

Some menopause specialists give testosterone as an implant, which is a tiny pellet inserted under the skin that usually stays there for six months.

It can sometimes take a few months for the full effects of testosterone to work in your body, whether this is using the cream, gel or the implant.

Benefits of testosterone replacement

Many women find that taking testosterone as part of their HRT provides further improvements than taking oestrogen alone (with or without a progesterone). Benefits you might experience include:

• Increased libido and sexual arousal levels
• Improved energy and stamina
• Improved muscle mass and strength
• Improved concentration, clarity of thought and memory
• Improved sleep

Newson Health carried out an audit in its clinics of 1,200 perimenopausal and postmenopausal women prescribed transdermal testosterone for at least three months. The audit found an improvement in symptoms associated with low libido, but the biggest symptom improvement was seen in mood and anxiety-related symptoms.

A further study of 510 women – who had already been using HRT (transdermal oestrogen with or without a progestogen) – who were treated with transdermal body-identical testosterone for four months, found significant improvements in cognition and mood [4].

The study looked at 10 individual symptoms, all of which significantly improved. The three symptoms most likely to improve were ‘loss of interest in most things’ (56% of women reported an improvement), ‘crying spells’ (55%), and ‘loss of interest in sex’ (52%). Mood and libido improved to a similar degree, suggesting that testosterone may have benefits beyond the treatment of Hypoactive Sexual Desire Disorder in postmenopausal women.

More research is needed and the National Institute of Health Research is currently funding a study to determine the effects of testosterone on women in menopause with the aim of increasing the evidence base for testosterone as a treatment for symptoms beyond altered sexual function.

Risks of testosterone replacement

There are usually no side effects with testosterone treatment as it is given to replace the testosterone that you are otherwise lacking. Very rarely women notice some increased hair growth in the area in which they have rubbed the cream, this can be avoided by rubbing it into places with few hair follicles (upper outer thighs and buttocks are the recommended sites) and regularly changing the area of skin on which you rub it in.

As the dose is so low, testosterone used in this way does not usually increase your risk of developing facial hair, voice deepening or skin changes.

You should have a blood test to check your testosterone levels after around three months of starting treatment and then have regular (usually annual) blood monitoring to reduce the risk of any side effects occurring.

If you use AndroFeme®1, this contains almond oil so should not be used if you have an allergy to almonds. 

Long-term use of safely prescribed testosterone replacement is not associated with any adverse health risks and is shown to be beneficial for the health and strength of your muscles, bones, cardiovascular health and brain health.

References

1. NICE Guidance
2. Glaser R., Dimitrakakis C. (2013), ‘Testosterone therapy in women: myths and misconceptions’, Maturitas. 74(3):230-4. doi: 10.1016/j.maturitas.2013.01.003
3. Pharmaceutical Journal
4. Glynne S., Kamal A., Kamel A.M. et al. (2024), ‘Effect of transdermal testosterone therapy on mood and cognitive symptoms in peri- and postmenopausal women: a pilot study‘, Arch Womens Ment Health. https://doi.org/10.1007/s00737-024-01513-6

The post The importance of testosterone for women appeared first on Balance Menopause & Hormones.

It’s completely normal to go through phases of being less interested in sex. During the menopause, tiredness, stress, life and bodily changes like weight gain, night sweats or aches and pains can put even the most physical relationships under strain.

RELATED: How does menopause affect my sex drive?

But there is a key difference between ‘not tonight’ and ‘no, never’. When that disinterest becomes more than a phase and a permanent state of being, then you may have Hypoactive Sexual Desire Disorder (HSDD). This is deemed to be a total lack of interest, lasting for more than six months, that has consequences on your relationship and/or self-esteem.

Other signs of HSDD include no interest in any type of sexual activity, no sexual thoughts or fantasies, no interest in initiating sex, and difficulty getting pleasure from it, including masturbation.

Who gets HSDD?

HSDD is the most common female sexual dysfunction. One review paper found HSDD is present in about 8.9% of women aged 18-44, 12.3% of 45-64 year olds, and 7.4% in women over 65 [1].

While this shows HSDD peaks during the menopausal years, a lack of libido doesn’t have to be an inevitable consequence of getting older.

How is HSDD diagnosed?

There’s no one test for HSDD but the International Society for the Study of Women’s Sexual Health has issued guidelines for its diagnosis and management so it is well worth speaking to a healthcare professional [2]. Explain how your low sex drive is impacting you and any relationships you have. They will want to explore the root cause, which can often be a combination of factors. You will be asked some questions when a diagnosis of HSDD is being considered, including:

1. In the past, was your level of sexual desire or interest good and satisfying to you? 

2. Has there been a decrease in your level of sexual desire or interest? 

3. Are you bothered by your decreased level of sexual desire or interest? 

4. Would you like your level of sexual desire or interest to increase?

5. What are the factors that you feel contribute to your current decrease in sexual desire or interest: a. An operation, depression,  injuries, or other medical  condition 

b. Medications, drugs, or alcohol you are currently taking

c. Pregnancy, recent childbirth, or menopausal symptoms

d. Other sexual issues you may be having (pain, decreased arousal, or orgasm) 

e. Your partner’s sexual problems 

f. Dissatisfaction with your relationship or partner 

g. Stress or fatigue

How is HSDD treated?

Treatment will depend on the cause and your preferences, and will likely take a well-rounded approach.

You might look to make some changes to relieve stress and improve intimacy, such as exercising regularly to boost self-esteem, taking part in activities you both find relaxing, planning times for connection and intimacy, and sexual experimentation (this could include different positions, places, role play or sex toys). Specialist counselling for yourself, or as a couple, can help.

You might look to avoid substances like tobacco and alcohol, which can reduce sexual desire and performance, or change medications you might be on that are lowering your libido. Sometime medications are suggested to boost your libido.

If sex is uncomfortable, vaginal oestrogen can help relieve symptoms. Finally, systemic transdermal testosterone (through a gel or cream) is recommended for women with HSDD who do not have any modifiable factors or contributory conditions, such as relationship or mental-health problems.

RELATED: the importance of testosterone

References

1. Parish, S. J., Hahn, S. R. (2016), ‘Hypoactive sexual desire disorder: A review of epidemiology, biopsychology, diagnosis, and treatment’, Sex Medicine Reviews, 4 (2) pp. 103–20. doi: 10.1016 / j.sxmr.2015.11.009
2. ISSWSH Process of Care for Management of Hypoactive Sexual Desire Disorder in Women

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