Testosterone Therapy in Women-The Debate Continues...

A review of the recent buzz in the journal," Obstetrics and Gynecology"

My Friends, 
I have dedicated my career to studying hormones in women - it’s one of my favorite subjects (along with fitness!). So let’s continue the conversation with a review of this very provocative article in Obstetrics and Gynecology.
Cheers!
-Carla

The use of Testosterone (T) therapy in mid-life women has been the subject of great debate in recent years. Off-label use of T therapy targeting pre-menopausal physiologic blood levels has been studied for the treatment of hypoactive sexual desire disorder in menopausal women with good evidence for safety and efficacy. However, there are no FDA-approved testosterone products dosed for use in women. As a result of this and many other factors, women are resorting to alternative sources to obtain testosterone and other types of hormone therapy.

This article published in the November 2021 issue of Obstetrics and Gynecology provides a provocative but well-accounted, evidence-based review of the current landscape of the use of T in mid-life women. After their publication, there were rebuttals and re-rebuttals further fueling this heated debate.

Testosterone Therapy in Women

A Clinical Challenge

Rebecca Dunsmoor-Su, MD MSCE, Ashley Fuller, MD, NCMP, and Amy Voedisch, MD, MS

Obstetrics and Gynecology VOL. 138, NO. 5, NOVEMBER 2021

This article is an editorial from the Swedish OBGYN Specialists—First Hill, Seattle, Washington; and the Division of Family Planning, Department of Gynecologic Specialties, Stanford University, Stanford, California with no significant disclosed conflicts of interest.

The authors summarize the current clinical landscape surrounding the use of T therapy in mid-life women with the following main points:

• There is great variability in the evaluation and prescribing practices outside the clinical guidelines published in the peer-reviewed literature for allopathic menopausal medical practice.

• The prevalence of permanent adverse reactions and uterine malignancies is often understated and unaccounted for.

• Hormone preparations are often obtained through compounding pharmacies at doses and formulations that have not been thoroughly studied for safety or efficacy.

• There is evidence of safe and effective use of pre-menopausal, physiologic T therapy in postmenopausal women with hypoactive sexual desire disorder. However, longer-term safety studies are needed with the longest trials to date extending only 4 years.

• Adverse events are most often seen when testosterone blood levels exceed the pre-menopausal physiologic ranges and can include acne, hair growth, weight gain, alterations in high-density lipoprotein (HDL) and low density-lipoprotein (LDL) levels, irreversible deepening of the voice, temporal balding, development of an “Adam’s Apple”, clitoromegaly and potentially uterine malignancy.

The authors go on to describe “where the blame lies” for this “current crisis”:

• Inadequate medical education

• Failure of the FDA to approve testosterone products dosed for women despite peer-reviewed evidence supporting safety and efficacy at doses targeting physiologic, pre-menopausal blood levels.

• Deceptive marketing practices by those groups that promote these formulations as safer and more effective than FDA-approved products without supporting peer-reviewed evidence.

• Inconsistent insurance coverage for FDA-approved products for female use.

In My Humble Opinion…

The authors present a compelling case supported by evidence and do so very methodically. Their positions are supported by consensus from the various respected medical societies and the peer-reviewed medical literature.

What I take issue with is the provocative, authoritarian tone of this article, which chastises (and in some cases, maybe justifiably so) other providers who are practicing outside the consensus for the safe and effective use of T.

Although the authors do an excellent job of stating the problem and providing supporting evidence, they do very little to put forth solutions to these problems thus creating more division in the totality of the mainstream and alternative medical community.

Although I agree that there are indeed predatory practices of some medical providers, the mainstream medical community isn’t much better when they either shrug off the symptoms that women present or refuse to consider thinking “outside the box” to find reasonable solutions and interventions. Surely there is something in between predatory, unsafe medical practices and suggesting a cup of Ashwagandha tea to calm anxiety even if there isn’t a double-blind placebo-controlled randomized control trial to support it.

I also take issue with the portrayal of the mid-life woman as a victim. Predatory marketing practices are apparent in every industry. We’re big girls... this isn’t our first rodeo. So while the “ruling” medical bodies, FDA, and insurance companies throw grenades at one another, let’s try empowerment as a strategy and take matters into our own hands.

Here’s what you can do to make the most informed decisions you can about your health and wellness:

• Speak to your health care providers. As faulty as the system is, most providers do care about your health and well-being, even if the tools and sometimes the knowledge are incomplete. Get second opinions and different perspectives.

• Research your health care providers! Investigate if they receive direct monetary gain from the therapies they prescribe. This conflict of interest incentivizes the provider to prescribe their therapy... not the most appropriate therapy.

• Evaluate “studies'“ critically. A study showing the benefits of a therapy that is funded by the same company producing the therapy presents a financial conflict of interest. The most reliable studies are those where the authors have no financial interest in the results of the study. So before you look at the data, look at who funded the study.

• Research your compounding pharmacy. Although they are not overseen by the FDA, there is oversight from the global pharmacy community that has clear standards of best practice. Ideally, seek PCAB-certified pharmacies.

• Be wary of the dreaded “Google” search. There is a lot of unhelpful information out there. A great “go-to” for reliable information for mid-life women is the North American Menopause Society. It is a great start for learning about health and wellness issues important for mid-life women.

• Find your tribe. You are not alone. There is lots of support out there. For fitness-minded women, check out Feisty Menopause. This is my tribe. The work they do and the community of women they serve are second to none!

So remember... you are your own best advocate. You’re smart, you’re resilient and you are not alone! ..and most of all you are NOT DEFICIENT! All the tools you need are out there to help you live your best years ever from mid-life and beyond!

For more great talk about hormones and hormone therapy, check out my latest appearance on Hit Play Not Pause and register for the FREE 10-day Master Class Series, Perimenopausal Athletes and Beyond with former pro triathlete Tenille Hoogland.

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