It is estimated that every day 6000 women enter menopause in the U.S. and receive care from a vast pool of OB/GYNs and primary care providers, many of whom have not been equipped to identify, diagnose, or treat common menopausal symptoms. Menopause is a life stage that can impact all areas of a woman’s health. Ideally, healthcare providers should be viewing all female patients over 40 through the lens of their perimenopause or menopause status since symptoms can be unpredictable in onset and frequency, subtle yet pervasive, and can exacerbate existing conditions. However, the most recent numbers show that only 31% of OB/GYN residency program directors include menopause training in their curriculum; only a modest increase from 20% in 2018 with 84% agreeing that their program needs more menopause educational resources.
While conversations about menopause have become more prominent in the media in recent years, the field of menopause health education has been slow to follow.
I am a senior medical advisor of one of the largest hormone optimization education companies in the country and as such we are constantly building our knowledge in the field of hormone health and wellness. Every month hundreds of new providers seek to increase their knowledge and separate fact from misinformation, and one of the key areas that consistently elicits surprise is the role testosterone plays in women’s health and menopause. Misconceptions about testosterone still linger from flawed studies conducted decades past, but real-life patient results have demonstrated the role of testosterone in optimal menopause care. You, like so many providers, may find these areas surprising.
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Testosterone is not a “male” hormone and has a significant role in a woman’s sexual health
One of the most widespread myths that endures even among medical professionals is that testosterone is a “male” hormone. Testosterone is the most abundantly produced hormone in women, surpassing estrogen levels by three to four times. Summarized concisely in a 2019 study, both estrogen and testosterone play key roles in the development and function of the reproductive organs, bones, heart, brain and liver.
During menopause, the production of estrogen and progesterone decreases significantly but by the time a woman reaches 40, testosterone blood levels have also declined significantly. Since testosterone plays a key role in a woman’s sexual response by increasing blood flow to the genitals as well as nerve sensitivity, this decline negatively impacts libido, responsiveness, and orgasm. While over half of menopausal women experience some form of sexual dysfunction, most providers fail to discuss this issue with their patients, much less examine the root cause and recommend appropriate treatment despite recommendations from the American College of Obstetricians and Gynecologists (ACOG) practice bulletin. Instead of considering the patient’s estrogen and testosterone levels through a simple blood test, many providers are more apt to prescribe antidepressants, recommend a marriage counselor, or avoid treating this symptom altogether.
Testosterone mitigates most of the symptoms of menopause
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The root cause of menopause symptoms is the hormone imbalance caused by a sudden drop off in production of estrogen and progesterone. However, testosterone production in women begins to decline during reproduction years and the majority of hormone replacement therapy does not address this reduction of testosterone in post-menopausal women. The addition of testosterone therapy to hormone replacement therapy may improve urogenital, psychological, and somatic symptoms, may improve bone density, and may enhance cognitive performance. Additionally, many patients report improvements in their mood, concentration, motivation, and energy levels.
For women who have been diagnosed with breast cancer in the past, estrogen and progesterone HRT may increase the risk of cancer recurring depending on the cancer’s hormone responsiveness. However, some breast cancer survivors suffering from menopause symptoms have been safely and effectively treated with testosterone therapy for decades.
Nevertheless, despite observational data demonstrating the safety and efficacy of testosterone in female patients, there are no standard FDA-approved testosterone therapies for women in the U.S. This lack of standardization and of clear guidance for providers to follow highlights the importance of education and training since patient treatment should ideally be based on the effectiveness in treating patient’s symptoms, not solely on lab values.
Testosterone extends preventive benefits for women
Data supporting the preventive benefits of testosterone promises to be only the tip of the iceberg as we learn more about the potential of hormone optimization on disease and aging. Testosterone, along with estradiol, has long been a key to osteoporosis prevention in men. There are also a growing number of studies demonstrating a positive correlation when testosterone has been added to estradiol and bone mineral density outcomes in females ages 40 to 60 years where traditional treatments like bisphosphonates fall short.
Testosterone has also been recognized for its role in men with chronic pain, and some suggest there may be a similar beneficial impact in women.
Preventive benefits may extend even further. A ten-year retrospective study of women who took testosterone via hormone pellets as part of bioidentical hormone replacement therapy had a 35.5% lower incidence of invasive breast cancer compared to an age-adjusted peer rate.
The relationship between testosterone and cardiovascular events in women is another area of investigation as a recent study showed that low testosterone in women over 70 doubled the risk of cardiac events. Testosterone therapy also improved functional capacity and muscle strength and seemed a safe and effective treatment for women with advanced chronic heart failure.
Constant education is needed to keep up with an evolving landscape
Women’s health, and menopause in particular, has long been under-researched but the intricacies of menopause care make it particularly challenging for healthcare providers to offer effective treatment. The balancing of hormones and the role of testosterone involves evaluating hormone levels through blood tests, with treatment plans ideally based on a patient’s symptoms as opposed to serial lab values or measurements.
Furthermore, while new research is constantly revealing advances in the field, only the most assiduous healthcare providers can keep up. Our goal as researchers, educators, and providers is twofold: to ensure our network can access, understand, and utilize the most up-to-date knowledge in the field of hormone health, and to constantly add to the repository of knowledge with the goal of improving the standard of health for women worldwide.
Photo: Peter Dazeley, Getty Images
Dr. Bruce Dorr is boarded in Obstetrics and Gynecology and subspecialty boarded Urogynecology and Reconstructive Pelvic Surgery (URPS) and is also a senior medical advisor for Biote. For the last decade, he has directed his practice towards a functional medicine practice of hormone health and wellness.
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