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6. Testosterone in Perimenopause & Menopause with Dr. Tami Rowen
122 Plays13 days ago
Is testosterone the "missing piece" of your hormone puzzle, or is it a social media-fueled performance enhancer? In this deep-dive episode, Dr. Rachel Pope is joined by Dr. Tami Rowen, a lead gynecologist at UCSF and expert in sexual and transgender health, to separate data from hype.
They tackle the confusing world of testosterone for women—from its role in desire and energy to the hidden history of how it was once used to protect the uterus.
In This Episode, We Discuss:
- The HSDD Breakthrough: Why the best-known data for testosterone is in treating Hypoactive Sexual Desire Disorder (HSDD), and the surprising truth about the doses used in successful clinical trials.
- The "Menopause Cliff" Myth: Why testosterone doesn't actually crash at menopause, but rather begins a slow, steady decline in your 30s.
- Dosing & Safety: The difference between "physiologic" levels (what you had in your 20s) and "supra-physiologic" doses (performance-enhancing levels) often seen in boutique pellet clinics.
- The Breast Cancer Debate: Is testosterone protective or risky? Dr. Rowen explains the "anti-proliferative" nature of the hormone and the nuances of aromatization into estrogen.
- The "Estratest" History: A look back at why we once used estrogen and testosterone together to protect the uterine lining—long before progesterone became the standard.
- Cognition, Mood, & Muscle: Does it actually help with brain fog or gym gains? We look at why the data is mixed and the power of the "placebo effect."
- The FDA Gap: Why the U.S. still lacks a testosterone product specifically approved for women and what that means for your prescriptions.
Key Resources & Mentions:
- ISSWISH: International Society for the Study of Women’s Sexual Health
- Dr. Tami Rowen: UCSF Health Profile
- Research Study: The Women’s Health Initiative (WHI) and the 300mcg testosterone patch trials.
About Our Guest:
Dr. Tami Rowen is a board-certified OB/GYN and Associate Professor at UCSF. She is a nationally recognized expert in sexual medicine, transgender health, and complex gynecological care for cancer survivors.
If you found this episode helpful, please Rate, Review, and Subscribe on Apple Podcasts or Spotify! Your support helps us bring this vital information to more women.
Follow Dr. Rachel Pope:
- Instagram: @DrRachelPope
- Website: OurWomanity.com
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Transcript
Introduction to Testosterone in Sexual Health
00:00:00
Speaker
I can tell you many of my patients have come to see me because of hypoactive sexual desire disorder. And one of the best treatments for them, one of the best things that's available is testosterone.
00:00:13
Speaker
works great for so many of them. But for some, it doesn't seem to do much at all. And I'm still trying to wrap my head around that. I have some patients who are transgender and the testosterone helps them to feel aligned with who they are. And for that, I'm grateful. But how to prescribe it for cisgender women And what are all the indications? If you look on social media, you'll probably be very confused and think that it's for energy, for mood. And I think for a lot of women, they do get those positive side effects, but is it indicated for that reason?
Expert Insights from Dr. Tammy Rowan
00:00:52
Speaker
Well, I have today on Dr. Tammy Rowan.
00:00:56
Speaker
She's an OBGYN whose care and research focuses on sexual health and transgender health, as well as complex gynecological care for people with cancer. She's a lead gynecologist at UCSF, and she's an expert in laparoscopy. surgery. I know she does a very mean vaginal hysterectomy as well. And she's the medical director of the perioperative services for the OBGYN department.
00:01:18
Speaker
She is a superstar in the society I'm involved in, ISHWISH, the International Society for the Study of Women's Sexual Health. And she is one of my go-to people when I have tough cases that I just need to talk to someone about more theoretically or philosophically, she's someone that I often get insight from because she knows the research inside and out and she cares deeply about patients.
00:01:43
Speaker
So have a listen. So I'm so excited to talk to you about testosterone and you know I know you from the sex medicine world and maybe we could just start there.
Research Findings on Testosterone in Postmenopausal Women
00:01:52
Speaker
Testosterone for hypoactive sexual desire disorder. When do you prescribe it? What do you see its benefits for? And what What do you think about it?
00:01:59
Speaker
So I think that there's a lot in that question. And, you know, what I would say is that where the data on testosterone lives is that it has been shown in several randomized controlled trials to improve low sexual desire, mainly in postmenopausal women. There is one study in perimenopausal women. The thing to understand is that most of the studies were done using a And there were actually three different doses that they were using for the patch. There was 150 micrograms, 300 micrograms, even a 450 microgram. And the data really landed on this 300 microgram patch showing that it did better than placebo for improving sexual desire. Now we don't have a patch available in the United States. So we will use either compounded or male formulations. And we're trying to give people about a 10th of the dose of a cis man is the way to think about it. the way to think about it is to try to restore us to a physiologic level of what we were when we were in our 20s, which is when our testosterone peaks.
00:02:59
Speaker
And we usually are doing that in order to treat low desire. But one caveat, and you may not even know this, is that in those studies of the 300 microgram patch, most of those people had levels higher than you and I would have had when we were in our 20s.
00:03:15
Speaker
I did not know that. What? what Why was that? they So they just included people who had levels? It was the dose that worked. No, that 300 micrograms that worked better than 150 micrograms. and Amazing. And we need to start talking about the fact that yeah we can. keep saying that we need to stay at physiologic level. And I understand why we say that. But the therapeutic benefit, even in HSDD, we can talk about it for the other things people are using it for, but even in hypoactive sexual desire disorder.
The Natural Decline of Testosterone and Its Implications
00:03:49
Speaker
In those trials, we weren't treating to levels. We were giving people a dose and that dose brought them to higher levels than we often are aiming for.
00:03:58
Speaker
Oh, okay. And let's go back a second because I want our listeners who are not necessarily in this world that you are and I are in, why do we try to generally stay in premenopausal levels?
00:04:10
Speaker
right So the idea is that if we're saying that the lowering testosterone levels that really doesn't occur, it's not a menopause issue. I always say that your body from a testosterone perspective doesn't know that it was in menopause yesterday versus today. testosterone actually slowly declines in your 30s. And then it kind of slowly it keeps declining through your 40s. And there's no cliff, it falls off in menopause. And so we oftentimes will see lower sexual desire really peak in perimenopause, right? So if you look at every study, like this is across the world, I was just researching this, this is not just Western countries, it's all over.
00:04:45
Speaker
Sexual dysfunction and low desire really starts to increase in your 40s and 50s. And so it's very easy to say, well, could this just be a testosterone issue? Physiologically, not necessarily because your levels started decreasing in your But we do know that people who have low desire tend to have lower levels. There's no cutoff.
00:05:05
Speaker
But if you look at you know a group of 100 women with normal sexual desire, a group of women with no sexual desire, the lower sexual desire people are going to have less testosterone circulating than the people with normal desire.
00:05:18
Speaker
So physiologically, we know that if you give people testosterone, they seem to get better from a low desire perspective. And we really then say, well, let's give them back their testosterone that they had in their twenty s before they had low desire. So it makes sense where we're like, if we're going to say it was the testosterone that started decreasing in your 30s, let's go back to the level when you had the best in your 20s. Right. So that's why we do it. But actually, if you look at the therapeutic levels that were achieved in those studies, they were even higher than what a lot of those women had in their twenty s
00:05:52
Speaker
Wow. Wow. Okay.
Potential Side Effects and Risks of High Testosterone Levels
00:05:54
Speaker
And what's the worry, right? Why do you and I worry about going too high with testosterone? So there are side effects from going too high. And so the ones that we always think about that we know when people have excess testosterone, right? And those young people, PCOS patients, acne, right? Hair loss on your head, hair growth on your face. So those are just these you know adverse effects we say that people wouldn't want those right And then there's these unknowns, right? And the unknowns are what are the long-term risks of having excess hormone, you know, mainly testosterone. The one we worry about the most is breast cancer risk, because we do know that a lot of breast cancers are hormone sensitive. And so we have no data that shows long-term effects of testosterone supplementation on breast cancer. risk
00:06:40
Speaker
And so that's the main one. That's helpful to think about because I feel like people tell me, okay, well, I'm a breast cancer survivor. I know I can't have estrogen, but can I have testosterone? Ooh, I just had that patient this morning. So here's the thing is that testosterone is aromatized into estrogen. It was in the past. pathway of estrogen production. If you look at the way that testosterone behaves in a breast that does not have breast cancer, it looks like it's actually potentially protective. It's anti-proliferative. That means it doesn't stimulate cell growth.
00:07:12
Speaker
So in some ways you think that maybe it could be beneficial. in someone without a history of breast cancer. And we actually have some epidemiologic data that suggests that if you look at transgender individuals, for example, on high dose testosterone therapy, if they haven't had their breasts removed, they actually have lower risks of breast cancer.
00:07:31
Speaker
We have other studies that show that the way testosterone works on breast cancer cells is it's anti-proliferative. So most anecdotal evidence would suggest that it is not going to increase one's risk of breast cancer.
00:07:42
Speaker
But I also have to say that estrogen doesn't either. Right. So we know that conjugated equine estrogen decreases your risk of breast cancer. Natural estrogen is probably neutral. But when you get breast cancer, those cells are sensitive to hormones. So you can't use the same logic. Right. Because if we block estrogen in those breast cancer cells, they have lower rates of recurrence.
00:08:05
Speaker
yeah testosterone, then we say, well, maybe testosterone is safe. But my question is, we didn't test the cell for testosterone receptors. You have no idea. you know, it may have progesterone receptors. We know it may have estrogen receptors. And most of your listeners don't realize this.
00:08:21
Speaker
Testosterone is in the pathway from progesterone to estrogen. So when progesterone is metabolized down to estrogen, it stops at testosterone. And so if someone has breast cancer, unless I know that their breast cancer is not androgen receptor positive, yeah I would not feel comfortable giving them testosterone without counseling that it could increase their risk of recurrence.
00:08:47
Speaker
Doesn't mean it will, but informed consent. Yeah. That makes a lot of sense. And what about the uterus? Do we need to be worried about the uterus with testosterone? Yeah. So just like testosterone is anti-proliferative at at the breast, it appears to be anti-proliferative at the level of the uterus. And so in general, we think that it's protective. And your listeners may not realize that before we used to give estrogen and progesterone together, there actually was a pill that had estrogen and testosterone.
00:09:15
Speaker
It's called Estrotest. And it wasn't because we were trying to give people testosterone for libido or energy or muscle or all the reasons we say. It was actually because the testosterone was protecting the uterus. But then once progesterone came in really Provera was the first one. We realized that the progestins did a better job than testosterone did. So we switched over. That said, we have data again in the transgender literature. So this is where as someone who does sexual medicine, I do a lot of transgender care. Patients on high dose testosterone are transgender men. When we look at their uteruses after a hysterectomy, a majority have proliferation, small, small majority, like 51%. So it's like 49%. It blocks the lining of the uterus, yeah but 50% actually have some proliferation. Now that's probably because it's such a high dose that it's being converted into estrogen. Yeah.
00:10:09
Speaker
found But this idea always that testosterone is anti-productive or blocks the effect of estrogen at the uterus, I think is it's really individual.
00:10:20
Speaker
Yeah. Yeah. And I love that you brought up you know providing care for our trans population because I do as well and I give much higher doses of testosterone to people. those individuals.
Individual Responses and Treatment Considerations
00:10:31
Speaker
And when I see women, cisgender women who are coming in on whopping doses of testosterone, like from a pellet or something, you know, that's where I start to see the spectrum of testosterone dosing and then what is happening to the person's body. And I'm generally not going for that middle. like For my patients who are are coming to see me for desire for menopausal symptoms, I'm not looking for the same effect as for my trans men or even in between.
00:11:01
Speaker
but are you getting a lot of patients who come in? I do. I mean, when I see, sometimes I'll see a transgender patient on a low dose of T for a transgender person and their testosterone level is the same. As a cis woman who's taking, you know, a kind of what would even be a typically prescribed dose sometimes for libido, she's just absorbing it very well and happens to have a high level.
00:11:23
Speaker
And I think this is where we see the individual responses, right? Because we talk about testosterone for libido and energy and cognition all the time. But when we see our transgender patients, they're not necessarily reporting these crazy high libidos. right Now, many of them are younger. They're not perimenopausal. They start when they're younger. But I think this is where we can really see this kind of broad range of what testosterone does. yeah And the expectation that it's going to have a specific response really needs to be tempered with the reality of how an individual may actually respond to it
00:11:59
Speaker
Yeah. What do you think for the women that come to see you who are on estrogen, a progestin, they're they're on hormone therapy for menopausal symptoms. And they say, you know, i just keep hearing about testosterone. I feel like it's the missing piece, but they don't necessarily have hypoactive sexual desire disorder. How do you counsel them?
00:12:17
Speaker
Yeah. So I say, you know, the best data we have is on hypoactive sexual desire disorder. But even then, you know, there are people in that group who didn't get a benefit and some who might have had an extreme benefit. So I'm not someone who sticks to, well, the only evidence is for this, because truthfully, the data for HSDD is also not the strongest.
00:12:35
Speaker
You know, there are plenty of people for whom it doesn't work. So if somebody wants it, I just want to be really clear what the expectations are. Now, if you look at the data, What people are usually coming in for is saying, I want it for cognition purposes. I hear that a lot. And if you look at the data, the data is very mixed. to There are multiple studies. Some show a slight benefit. Some show. No benefits, some show a worsening. Almost all of them cross the confidence interval of one, which means that whatever is happening could absolutely be due to chance. But that is group data. And what I always say is if you take 100 people, you're going to see that some are going to get better, some might not get better, and then it's going average out, right? And so the issue then becomes, do we deny people a treatment because the data shows that if you get better, it could be due to chance, and that may be the placebo effect. Right. When almost every medication we use that even beats placebo in studies has some component of the placebo effect. Right. And so then it's what are we afraid of? Is there a risk? So cognition is the one where I see it all over the place. Mood. You see actually most studies show a trend towards better mood with testosterone, but all of them, the confidence interval crossed one again, saying this could be due to chance.
00:13:47
Speaker
The other one I hear a lot about is muscle mass. And the data is quite clear. And this is, I do believe this. If you want to see an improvement in muscle mass, you have to be at a super physiologic level. There are multiple studies that show that. And so we see that in our trans people. We see that in these high doses. And so then the question is,
00:14:03
Speaker
If we're at a super physiologic level, so again, for your listeners, this is a level above which you would not see in normal population, right? In 120 year old women, we are at the extreme level of what you would see. Then it's what are we afraid of?
00:14:20
Speaker
Right. And it's those side effects that we talked about. It's, is there long-term risk in terms of things like breast cancer? We do know that testosterone actually does stimulate insulin resistance. So it can actually increase your risk of diabetes. So that is seen, especially in animal models, they've seen that. So these are small risks, right? It's not like it's going to give people diabetes, but there are risks. So it's really about informed consent. And so, so that's typically what i tell people is, you know, what is it that your goal is I do think if you tell people they're going to get better, they're oftentimes going to get better. If you tell people that it's due to chance, it probably will be due to chance. But I don't deny people medications unless there truly is a contraindication. I just want to make sure they're making an informed decision.
00:15:04
Speaker
Yeah, that makes sense. So if you have someone who's coming in and they're saying, I don't know, I guess I wonder, I do see patients who say that they feel improved energy.
00:15:14
Speaker
They feel like their mood is better. They feel like their workouts are more effective. And then I'll see the next patient who's a trainer is on all of the, you know, menopausal hormone therapy plus testosterone and is not noticing anything changing. Again, this is individual versus group data. That's what I'm saying, right? And so, you know, the the perfect example I would say with this is something like birth control. Right. If you take 100 women on birth control, there's going to be a group that say their sexual function is better. There's going to be a group that says their sexual function is worse. And then there's a bunch of people that say it doesn't make a difference So it's going average out to no difference. Well, if a woman comes to me and says, my birth control has killed my libido, I'm not going to say, well, the data doesn't show that. Right.
00:15:55
Speaker
Therefore, I'm not going to switch you to something else. We need to start really thinking about listening to people, right? yeah And saying, if someone says, you know, the testosterone gave me energy and gave me muscle mass and my cognition is better, I don't think it's appropriate. And a lot of people are saying that is, well, that's just placebo. It doesn't work. The data doesn't show that. Therefore, we should take you off of it.
00:16:14
Speaker
I don't believe that. You know, like I'm not going to tell her she's not having that experience. yeah The question then becomes, what are the risks, right? And so we just have to be really clear about what we do and don't know about the risks and make sure people are willing to make those informed decisions. And if someone says, I'm a trainer, I'm honest, it hasn't made a difference, or, you know, my sexual function's not better. I'm not going to say, well, the data shows it should be better. so Right? Yeah. there. No, you know, these are individuals, right? Everybody has different response. And that's what I
The Importance of Expert Consultation for Personalized Treatment
00:16:43
Speaker
think is so important. I try to encourage everybody, you know, we can get a lot of information online and you can get a lot of ideas on social media, but nothing will replace your one-on-one consultation with an expert. And so I appreciate that there are people like you out there that
00:16:58
Speaker
that women can go to. And i hope that you keep teaching and keep training more people to do what you do. Also, I was talking to ah a colleague that you know as well, a mutual friend of ours, about just the age guidance for testosterone, because we don't have any guidance or guidelines to say that there's necessarily an age limit. Do you have any feelings about that for testosterone?
00:17:19
Speaker
You know, again, what I keep seeing with testosterone is so many people are coming in saying that, well, now that I'm in perimenopause or menopause, I need testosterone because I'm deficient. And I want us to stop thinking about this idea of deficient, right? Because you and I could have the same testosterone levels and have totally different symptoms related and different responses. So it's really hormones as therapy. You know, we're doing this as therapy. So in terms of age limit, no, there's no age limit, but it's a data-free zone. You know, i mean, most of the HSTD studies are usually in patients, or you know, postmenopausal up to 65. We don't see a lot of patients in their 70s on these medications.
00:17:54
Speaker
And so at the end of the day, I would also argue that people who are in their 70s and eighty s are making really appropriate decisions about hormone therapy because they're valuing quality of life. Right. And so if they say that, you know, if their life is better because of something, I'm not going to take them off of it or if they want to try something.
Hormone Therapy in Older Adults: Weighing Quality of Life
00:18:11
Speaker
Certainly with testosterone, I'm not particularly concerned, but I will say that, you know,
00:18:17
Speaker
Again, the question is what's the benefit? I do think that when it comes to cognition and dementia, I am worried that if people already have changes to their brain that predispose them to dementia, if we add hormones to it we know if you take oral conjugated equine estrogen with a progestin, this is very nuanced. It could increase the risk.
00:18:37
Speaker
It's probably null if you take estrogen baseline. And then the question is testosterone. And then if you're taking it transdermally probably won't make a difference. Cardiovascular risk, again, transdermal, I'm a lot less concerned, but we just don't know.
00:18:50
Speaker
Then for younger patients, I want to make sure you know that the one study that looked at perimenopausal women, so before menopause, yeah gave them a 10 milligram dose. Now, listeners don't know this, but 10 milligrams, it's twice the dose that we give postmenopausal women.
00:19:07
Speaker
And so in the study that showed that perimenopausal women got better on testosterone and we say, oh, we have the data showing. I'm like, they were on double the dose that we typically give people. So again, I want us to start getting honest. I want us to be clear that we are giving people a medication that has therapeutic benefit, but it's not yeah hormone replacement. I am not treating a deficiency. Once you are giving people a super physiologic dose, you are giving them a performance enhancing drug. And this isn't to pass judgment on that.
00:19:35
Speaker
But testosterone is a controlled substance because it is a performance enhancing drug. And so if we're giving people levels that are above you know what a physiologic range is, let's just be real. I'm not here to judge it. I just want us to be honest that it's not- That's such a great point.
00:19:51
Speaker
No, that's such a good point. My last question for you, what do you think needs to happen for testosterone to really move forward in our field for women?
The Need for FDA-Approved Testosterone Products for Women
00:19:59
Speaker
I mean we need an FDA approved product. Right now, there's a lot of push for that. It's interesting because I very much understand and respect the advocacy that like we have enough anecdotal data, we have enough data in other places to say that we should have a female product. But I also am a little cautious because we don't just accept and create products for women that haven't been tested, right? And your listeners and most people don't realize that there was actually 1% gel that was studied. This would be our ideal, right? Give us a 1% gel. Well, so it actually was studied. There were multiple trials. And in the early trials, it looked really promising. But the randomized phase three trial, when women got this 1% gel, they had four more satisfying sexual events per month. That is like Viagra level. Like no other medication does that for women in terms of satisfying sexual events. The problem was so did the placebo gel.
00:20:56
Speaker
And that's why, like literally this was the company that said, we're gonna bring this to market, we're gonna get the breast cancer data. And then their phase three trial just showed how dang strong the placebo effect is. So if we're gonna try, we're gonna probably run into the same problem. and i yeah I mean, as soon as we have an FDA approved product, it's gonna be so much more expensive than how we prescribe it now. It's going to see show throughy it's gonna be more expensive. And I think people will not be so scared to do it because what's happening now is because there's no FDA approved product, there's only a handful of us that are comfortable using what's actually out there. sure So everybody is going to like boutique pellet places and people who are giving them medications that I would argue are not necessarily safe, certainly not regulated.
00:21:48
Speaker
And so we could have just some sort of low dose product. I mean, i see this in the men's health space all the time where they have all these different delivery systems. And I'm just like, why can't you create like a low dose delivery system like this for a woman? And they're like, we can't talk to you about this.
00:22:04
Speaker
It's only for men. I think that it would be a benefit. But it's just a little unusual to get a drug approved for women that hasn't actually specifically been studied at that dose.
00:22:15
Speaker
Yeah. You know, and the best data we have showed that it wasn't better than placebo. I'm still going to argue that we should have a drug available, but there's some reasons why we don't. That makes so much sense.
00:22:26
Speaker
Well, thank you so much for your time. You are so much fun to talk to You know the research inside and out. I know I could always ask you my tough questions and I'm excited to see you at Ishwish. I'm excited to see you too. It's great to be here with you. Thanks, Rachel.