by TC Luoma
Testosterone is Just as Important for Women
The evidence is overwhelming that TRT can save women's lives, but most doctors still won't budge in prescribing it. Here's what to do.
There's this now-famous Jimmy Kimmel bit where a reporter asks men on the street to identify female body parts from a chart. They all fail miserably, some claiming that women have two uteri, six ovaries, or one fallopian tube, while most misidentified nearly every one of the seven parts of the female reproductive system.
Most couldn't even identify the vagina, one claiming it was a trick question. Mercifully, they stopped the quiz before some putz misidentified the fallopian tubes as entrance ramps to the Santa Monica Freeway.
Am I wrong in suggesting that guys like that should have to take some sort of government exam before allowing them to fumble around down there? You know, just like going to the Department of Motor Vehicles, they line up at the Department of Vagina Mechanics, show their birth certificate, and take a multiple-choice exam indicating they know the fundamentals of operating a commercial or non-commercial vagina.
Anyhow, given the mass ignorance of many men on the subject and given that T Nation is primarily visited by men, it may seem puzzling to talk about yet another woman's issue, especially a controversial one – testosterone replacement therapy, or TRT.
It shouldn't be puzzling, though. Women do read this site, and at the very least most men have a female or females in their life that they care about, and it's their goddam duty to read this article and, if sufficiently moved, pass it on to them. Here's why:
Despite testosterone being regarded as a male hormone and estrogen being recognized as a female hormone, young women's ovaries produce about 3 or 4 times more testosterone than estrogen. Yep, it's true.
Yet, when women grow older and seek medical help for pre- or postmenopausal symptoms, most of the medical profession completely ignores testosterone, despite most women having, by the age of 40, suffered a reduction of the hormone of almost 50%.
Some docs will temporarily prescribe estrogen and progesterone in an attempt to temporarily ameliorate the daunting symptoms of the "change of life," but too few doctors consider, in their wildest Dr. House fantasies, prescribing testosterone to women.
You don't need to be a medical professional to sense something is wrong with that. How can you expect a hormonal stool to stand if you just replace or repair two of its legs (estrogen and progesterone) and ignore the other(s)?
More precisely, why ignore a hormone that the International Census Group, in 2018, unanimously agreed was the more important hormone for women regardless of decade of life? Why largely ignore a hormone, that when replaced to normal physiologic levels, has strong evidence to show that it reduces occurrences of breast cancer, Alzheimer's, osteoporosis, and other maladies that afflict women?
Why the Stigma Against Female TRT?
This isn't the first time I've banged the Taiko drum on this issue, but a new prospective paper and a recent study have made me think that it was again time to pull this issue out of the closet, put on its Easter hat, and drag it back into the sunshine.
The prospective paper, titled "A Personal Prospective on Testosterone Therapy in Women – What we know in 2022," by Gary Donovitz of the Morehouse School of Medicine, obstetrics and gynecology department, makes a compelling case the medical profession is being a little cowardly and depending too much on the findings/mis-findings of the past.
Donovitz lays out a compelling case for the use of TRT in women, correctly pointing out that testosterone has been used to treat perimenopause and menopause symptoms for over 80 years, albeit in apparently more medically evolved countries than the U.S.
You can blame a few things... a lot of things, really, on why the trend never really caught on here. For one, there's the awful stigma of all those Ludmillas and Helgas that represented the Soviet shot put teams in the Olympics of the early 60's that were as thick as the Kurganskaya cattle that roam Siberia.
Then there's all the myths, that TRT is bad for female hearts, livers, and breasts, and it will make their hair fall out so they look like slightly more coquettish versions of the
Rock.
The Women's Health Initiative of 2002 didn't help, either. The WHI was a study of more than 160,000 postmenopausal women's health issues, among them hormone replacement consisting of estrogen alone, or estrogen in combination with progesterone.
The study was initially said to have blown the doors off traditional hormone replacement by supposedly revealing that the combined use of estrogen and progesterone led to increased risk of breast cancer, deep vein thrombosis, and Alzheimer's (even though the results were far more nuanced than that).
Within months, the number of women using HRT dropped by almost half, and if anything, it made things more confusing. It also, as a side effect, probably made women even more wary of testosterone or anything at all connected with hormones.
Here's the thing, though: It's been known for over 70 years that testosterone is protective against female cancers.
Female TRT May Prevent Breast Cancer
The Testosterone Therapy and Breast Cancer Incidence Study tracked 2,377 pre- and postmenopausal women for 9 years, each of whom had received testosterone or testosterone/estrogen implants. The women demonstrated a 35.5% reduction in breast cancer occurrence compared to age-specific Surveillance Epidemiology and End Results (SEER) incidence rates.
Let's add some digestible numbers to that 35.5% reduction rate. Every year, in the United States, about 240,000 women develop breast cancer. Approximately 40,000 will die from it. However, the Testosterone and Breast Cancer Incidence suggests that implanting women with testosterone or testosterone/estrogen implants could prevent over 85,000 breast cancer cases every year and, ipso facto, several thousand breast cancer deaths.
Another study, known as the Dayton Study, was conducted almost concurrently with the Testosterone and Breast Cancer Incidence Study. It also found significantly lower (39%) incidence of breast cancer in testosterone implant users.
How Is This Possible?
It's almost universally accepted that estrogen is stimulatory to breast tissue, provided that breast tissue is hormone-receptor positive, notes Donovitz. However, when testosterone is present, it binds to the testosterone androgen receptor complex (T-AR) and counteracts the stimulatory effects of estrogen.
Furthermore, the T-AR downregulates the receptor for estrogen, is anti-proliferative, and increases apoptosis (a type of cell death) of breast cancer cell lines.
Other Positive Effects of Female TRT
Testosterone has "parking spots" all over the female body – just as it does, of course, in the male body. These parking spots, known more technically as androgen receptors, are found in almost all tissues, including breast tissue, blood vessels, the heart, the gastrointestinal tract, the brain, bladder, uterus, vagina, skin, muscle, joints, and fat.
At the most basic level, this means significantly reduced pre- and postmenopausal symptoms, as confirmed by Menopause Rating Scale questionnaires offered to women receiving TRT. At a more downstream levels, this abundance of androgen receptors in various tissues also means that TRT could lead to improved heart health, improved bladder function, improved brain function, increased mobility, and improved fat mobilization, among other things.
The effects of TRT on libido are also potentially profound. It's estimated that 1 in 10 women suffer from hypoactive sexual desire disorder (HSDD), which simply means that they have no interest in doing the deed and experience stress because of it. Now, experiencing a decline in sexual interest, for a great number of women, might just be common sense given the kind of partners many have chosen, but for those who have no apparent excuse, TRT can significantly increase libido.
TRT may also enlarge the clitoris, which often leads to increased sexual satisfaction (more tissue to stimulate and easier to find for those men who failed at the DVM).
Oh, and one more very important thing. One in 7 women will develop osteoporosis after the age of 50. Of those that experience a significant decline in bone density, approximately 50% will sustain an eventual fracture.
Historically, it was thought that an estrogen deficiency was responsible for osteoporosis in women, while the same condition in men is blamed on a testosterone deficiency. Does that seem strange to you that God/Nature has different biochemistry rules for each sex? It should, because God/Nature don't have separate rules for Tom and Sally.
Almost every study shows that androgen (e.g., testosterone) stimulates the differentiation of bone cells called osteoblasts, and mature osteoblasts increase bone formation and bone density in men and women.
Still, still, countless doctors refrain from treating women with testosterone because of alleged unknown effects.
What Are the Down Sides of Female TRT?
One of the most pervasive myths about female TRT is that it can cause breast and/or uterine cancer. The breast cancer allegation is clearly wrong, as explained by the previous section on the anti-breast cancer proliferative properties of testosterone.
As far as uterine cancer, there's no evidence that testosterone promotes endometrial (a uterine tissue) cancer. However, unopposed estrogen, as is the condition seen in women who don't receive TRT or progesterone in conjunction with estrogen therapy, can promote endometrial hyperplasia (which can lead to cancer) and/or adenocarcinoma (a type of cancer that can occur in various tissues, including uterine).
It's true, though, that TRT can cause undesirable or virilizing effects in women, i.e., characteristics associated with males. These include acne and hair growth. These, however, are easily treatable by adjusting the dosage, and using acne medications and any of various hair-removal systems (waxing, epilation, laser, depilatory creams, etc.).
A deepening of the voice is possible but highly, highly unlikely when using approved TRT dosages that are monitored by a sane and competent physician.
Regardless, these inconveniences seem a small price to pay, though, for all the potential benefits of TRT.
Shots, Creams, Gels, or Pellets?
Here's where you tear your hair out: There are currently no FDA-approved testosterone therapies for women. Men? We've got plenty. Over 30 and counting. As a result, progressive physicians who want to give female patients TRT are forced to call an audible and prescribe a men's medication, making appropriate calculations concerning dosing on the fly.
But let's forget all that for now and pretend that we live in a medical utopia and can get whatever drugs we want. All forms of TRT have their drawbacks. Creams and gels are the easiest to apply, but they require clean skin, the avoidance of excess perspiration, and making sure not to expose children to treated skin (as in a hug). There also appears to be some individual variation as to how well they work (i.e., how well they're absorbed).
Subcutaneous or intra-muscular injections, most likely given once a week by a doctor or the patient herself, are a quick, efficient way to assure adequate levels of testosterone, but this method also causes elevated, unnatural spikes in testosterone (they don't mimic the natural ebbs and flows) that could increase the risks of side effects.
There is also a testosterone capsule available in the U.S. It's called Tlando and, you guessed it, it was formulated for men. Each capsule contains 112.5 mg. of testosterone undecanoate (TU). This is a potentially wonderful alternative to all the other routes of TRT administration, but the dosages aren't woman-friendly. Given its short half-life, men need to take two of the 112.5 mg capsules, twice a day. Taking even half that would constitute an overly large dose for most women.
The drug is available at different, possibly female-friendly doses in other countries, but unless you want to travel to Thailand and swallow a balloon-full of TU capsules, you're out of luck.
That brings us to pellet implants. They're very small – about the size of a grain of rice – and are implanted, usually in the fatty tissue on the side of the hip. This involves making a tiny incision and inserting the implant via a small plastic applicator with a plunger. The usual "dosage" is 2 or 3 pellets.
The downside of pellets is that the patient has to undergo the procedure in the doctor's office every four months or so. The upside? It's the only method that's been extensively studied in women, most notably in a 7-year retrospective study in which 1,200,000 pellet procedures were performed in over 400,000 patients. The complication rate was less than 1 percent. Most surprisingly, despite the hurdles imposed by this type of procedure, the continuation rate after two insertions was 93%.
What Dosage of Testosterone is Right for Women?
A study ("Low complication rates of testosterone and estradiol implants for androgen and estrogen replacement therapy in over 1 million procedures") used a proprietary dosing algorithm to determine that the optimal blood levels for adult females fall between 150 and 250 ng/dl.
However, as men who receive TRT have likely found out, dosing is highly individual. Doctors should probably strive for a level of testosterone that's high enough to resolve symptoms, but low enough to avoid undesirable side effects.
Even the North American Menopause Society believes that hormone testing has very limited use in women. They don't believe it's diagnostic and should only be used to establish a baseline.
What About Younger Women?
It's quite possible for younger women to experience a testosterone deficiency, too. Causes often include birth control pills, stress, being overweight, and less commonly, pituitary problems.
Symptoms are generally the same as they would be for men in the same predicament:
- Muscle weakness
- Fatigue
- Weight gain
- Decreased libido
Other female-specific complaints include vaginal dryness and changes in breast tissue. Of course, if most doctors find that TRT in pre- and postmenopausal women is risky and controversial, their feelings about its merits in younger women are probably even more intractable.
Still, where there's a will, there's a way. Women, as well as men, have to be militant when it comes to their medical care, and they always have the option of "voting" with their feet when it comes to finding proper medical care (i.e., walk out the door and find someone more sympathetic to your needs).
My Recommendations for Women in General
The best TRT method – the most tested and best for keeping levels stable – is the use of implanted pellets. However, the fact that you need to go to a doctor for an undignified procedure every four months or so may be a deterrent.
Cost-wise, pellets work out to about 3 dollars a day, but insurance may cover the procedure itself, in certain cases.
So, given the effort needed to get pellet-based TRT, my recommendation would be to go the injectable route. Tiny insulin needles can be used to make the procedure painless, and women would only need to inject once a week or even once every two weeks in the abdomen or outer thigh.
Side effects can be kept non-existent or to a minimum by starting with a very small dosage and monitoring its effects. While no one has definitively established precise dosing protocols for women, the following provides a good framework:
- Up to 175 pounds: 4 mg. every week, or 10 mg. every two weeks
- 176-200 pounds: 6-7 mg. every week, or 15 mg. every two weeks
- Over 200 pounds: 8 mg. every week, or 20 mg. every two weeks
Still, I'm acutely aware that no science is ever incontrovertible. While the research seems to overwhelmingly show that TRT in women, especially pre- and postmenopausal woman, can be a health-saver and a lifesaver, we could sure use some more research, at the very least to put the minds of fearful practitioners at ease.
References
- Gary S. Donovitz, A Personal Prospective on Testosterone Therapy in Women---What We Know in 2022, Journal of Personalized Medicine, 2022, 12, 1194.
- Reuthairat Tungmunsakulchai, et al, Effectiveness of a low dose testosterone undecanoate to improve sexual function in postmenopausal women, BMC Women's Health, 2015, Dec. 2.
- Gary Donovitz, Breast Cancer Incidence Reduction in Women Treated with Subcutaneous Testosterone: Testosterone Therapy and Breast Cancer Incidence Study, Eur J Breast Health, 2021 Mar. 31.
- Rebecca Glaser, et al, Incidence of invasive breast cancer in women treated with testosterone implants: a prospective 10-year cohort study, BMC Cancer, 2019, Dec. 30.