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10. Why Testosterone Matters for Women with Dr. Mohit Khera
79 Plays4 days ago
There is an undeniable buzz around testosterone for women right now. While many patients report feeling more energized, happier, and clearer of mind after adding it to their hormone therapy regimen, clinical questions and nuances still remain. In this episode, Dr. Rachel Pope sits down with world-renowned urologist Dr. Mohit Khera, Professor and Director of the Laboratory for Andrology Research at the Baylor College of Medicine, to demystify testosterone's role in midlife optimization, the safety data behind it, and why sexual health is the ultimate check-engine light for your overall well-being.
Key Takeaways:
- The Hormonal Triangle (Triple Therapy): Modern midlife medicine must evolve past dual hormone therapy (estrogen and progesterone). True optimization requires Triple Therapy—adding systemic testosterone to balance the triangle—alongside localized vaginal estrogen therapy for complete quality of life restoration.
- Women naturally produce nearly five times more testosterone than estradiol. When testosterone declines, replacing it can significantly augment bone mineral density, lean muscle mass, cognitive focus (brain fog), mood stability, and all four domains of sexual function (desire, arousal, orgasm, and pain mitigation).
- The Clinical Safety Reality: Historical fears that testosterone causes breast cancer or cardiovascular events are not backed by data. Large-scale charts and transgender health studies (using ten times the standard female dose) demonstrate excellent safety profiles. In fact, emerging data suggests testosterone may even help decrease breast cancer risk.
- The "Sex Factor" & Overall Health: Sexual health is a bidirectional barometer for physical and mental health. Rather than just a recreational activity, sexual function acts as a "check engine light." Dysfunction is often an early clinical indicator of undiagnosed depression, diabetes, or future cardiovascular events.
- The 50/50 Rule: Hormones are not a standalone holy grail; they are synergistic with lifestyle modification. Clinical optimization requires medical therapy (50%) to meet lifestyle modifications (50%) halfway through intentional diet, exercise, sleep, and chronic stress reduction.
Upcoming Frontiers in Healthcare:
The landscape of hormone therapy regulation is rapidly shifting. Dr. Khera shares recent monumental policy wins, including the FDA's removal of major historical warnings on local estrogens and male testosterone labels. For women, clinical discussions are currently underway with the FDA to bring regulatory approval for female-specific testosterone gels and oral formats to the US market within the next two to three years.
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Transcript
Introduction to Testosterone and Its Benefits
00:00:00
Speaker
Have you had friends tell you that they just started testosterone and they've never felt more energized, happy, more clear of mind than before? Has it just been a game changer after starting menopause hormone therapy and then testosterone made things even better? You feel like yourself again?
00:00:17
Speaker
There's so much buzz about testosterone that I'm doing another podcast episode about the topic.
Guest Introduction: Dr. Mohi Kira
00:00:22
Speaker
I love testosterone for my patients as well, but there's a lot of nuances and there's still a lot of questions about it. And so that's why I have on today, Dr. Mohi Kira. So Dr. Kira is a professor in the Scott Department of Urology at Baylor College of Medicine, and he holds the F. Brantley Scott Chair in Urology.
00:00:42
Speaker
So yes, he's a urologist. He also serves as the director of the Laboratory for Andrology Research. So he does a lot of research. He's the medical director of the Baylor Executive Health Program and the medical director of the Scott Department of Urology.
00:00:54
Speaker
He also serves as the past president of the Sexual Medicine Society of North America. There's a ton of accolades that I could list out for you, but you could also look that up yourself. And I want to cut to the chase. All right. So I'm so excited to have you here, Dr. Kara, to talk about you know your experience because as a urologist, you treat both men and women.
00:01:14
Speaker
And so I'm assuming you probably started treating men with testosterone before you started treating
Impact of Testosterone Therapy on Couples
00:01:20
Speaker
women. but can you tell us a little bit about that? Like, how did you start treating women too? Sure. So first of all, thank you so much for having me on your show. Yeah. And I have to tell you a story and it's very important. So back in 2007, I finished my fellowship and the fellowship was in male sexual dysfunction.
00:01:37
Speaker
And I was really good at getting men excellent erections, great libido. And one day a woman called me and she was extremely upset. And she said to me that everything was great until I met her husband. Oh, no.
00:01:52
Speaker
We had not sex in 10 years, and they had not had sex in 10 years. Okay. Now, you gave him testosterone. You gave him Viagra. He wants to, and he can, have sex every day, and I don't want to have sex with him.
00:02:04
Speaker
You've ruined our marriage. Oh, no. And I thought to myself, First, I thought, this is crazy. This doesn't make any sense. But then I thought about more deeply and I thought, she's right. Like the reality is, is that what is the point of giving him great erections, great libido, if he has no one to have sex with or he's going to fight with her every day? So can leave both libidos low. That is fine.
00:02:25
Speaker
That's really fine. You're not going to fight. But if you raise one on either side without the other, you're in trouble. So in 2010 years had gone by, right? yeah So like they kind of had a new normal. Yeah. She's postmenopausal, dyspareunia, low
Addressing Female Sexual Dysfunction (FSD)
00:02:40
Speaker
libido. I mean, why would she want to, you know, she she said she loves her husband. She doesn't want to have sex with him.
00:02:45
Speaker
Right. And so you put her in this awkward with this position where now he's constantly asking for sex. Right. yeah And so that year I flew out to Erwin Goldstein, who's considered the godfather of female sexual dysfunction. And I went to numerous Ishwish courses. Yeah, he's amazing. And numerous – the Ishwish is probably one of the best organizations when it comes to female sexual dysfunction.
00:03:06
Speaker
went to four of their classes every year. It was amazing. And so since 2009, I've been treating women. And I think it is a disservice if you treat a man or a woman for sexual dysfunction.
00:03:19
Speaker
Don't at least acknowledge or ask about the partner, right? at What are you doing? It doesn't make any sense. So so we've been treating FSD now since 2009. And I can tell you, it has significantly augmented the total treatment package. Because the reality is when you treat both of them, it's synergistic.
History and Benefits of Testosterone Use in Women
00:03:40
Speaker
It's very synergistic. Yeah, everybody's happy. Right. So that's why we do it. So what have you noticed that's different for your female patients compared to young male patients? Like, are they hesitant to try testosterone? Is there any other things that you feel like the conversation is different? Yeah.
00:03:56
Speaker
Yeah, let's think about this realistically. So most clinicians do not treat women for testosterone. Most OBGYNs will not prescribe testosterone. right So women are told, first of all very rarely will this, many of them give them just HRT. Very rarely will they get estrogen and progesterone. But then to give them testosterone on top, you're asking for a way too much because most of them will say it's not FDA approved. It's dangerous. It can cause a heart attack. it can cause breast cancer, which is all not true. Right. And so let's look at history.
00:04:29
Speaker
Testosterone was first synthesized in 1935. And by in women. we were using it in women Lozier was the first describing as an OBGYN in London. He was using it numerous sports, uh, people using testosterone. They were first were actually pellets. That's what they use early on. were pal I didn't know that. Yeah. In women. And they reported significant improvements. If you read the early literature in libido, of well-being women reported improvements in wellbeing. And so we know that right now testosterone is only FDA approved, not even
Broader Benefits of Testosterone for Women
00:05:04
Speaker
FDA approved. It's not FDA approved. It's only, yeah. on recommended for HSDD, meaning low libido. Right. But there are numerous other benefits with testosterone in women.
00:05:13
Speaker
Just because we don't have a study doesn't mean it doesn't benefit. That's what I want to dig in with you because I i am a member of Ishwish also. I kind of follow all of that literature for sexual function. So that's what I'm most familiar with is hypoactive sexual desire disorders, benefit of testosterone. But anecdotally, some of my patients tell me they feel more energy, they feel better mood, but I would love to know sort of what you're seeing too of the other benefits. Yeah. So when it comes to sexual function, there are other areas of sexual function. There's arousal, orgasmic function, pain.
00:05:48
Speaker
It's been shown to significantly improve all areas of sexual function. Remember that we use androgens locally in the vagina. Enterosa, very effective. in helping with dyspareunia and GSM. So it helped all four of those domains, but let's take it a step further. I call it it's quality of life and I call it overall health. Overall health means significant improvement in bone mineral density, right right? If you give women testosterone, and there've been studies giving testosterone plus estrogen, estrogen alone, the T and the E will give you a better benefit in bone mineral density.
00:06:19
Speaker
That's awesome. To be fair, there hasn't been a study in men or women showing that giving testosterone, even though it increases bone mineral density, decreases bone fracture. But maybe we have enough studies in men or women. We know that the giving testosterone women has been shown to actually help with cognition. It's been shown in certain studies. We know that it's actually helped to help with muscle mass. No question. and You can't tell me if it doesn't help with muscle mass when you look at the It's banned in all sports. You look at athletes, they use these medications. It does make a difference. Many women will report that they actually have an improvement. Obviously, I said in libido, which goes up significantly. And so these are other things that we're noticing. Mood stability has also been noted as well. That's interesting. and so
00:07:02
Speaker
Remember, Rachel, I have to say that, you know, women make more testosterone than they do estradiol. It's almost 5x. And I can't think of another hormone that a woman would make that we would not feel comfortable giving it back to her, whether it be insulin or thyroid or cortisol. That's such a good point.
00:07:22
Speaker
We give every hormone back to her. We say that if you are deficient, we will give you any hormone you want, but we just don't feel comfortable giving you back testosterone, which doesn't make sense to me. It just doesn't make sense. Oh, that's a really good point. And you mentioned cognition. Some of my patients do say that they feel like brain fog has improved with testosterone. And you're right. i We're just kind of missing that the research to document those things. But I I do think people, and I'm trying to document that as myself, I know you're doing some of that work too. so What do we need to do to get things to change, to get an FDA approved prescription, to get the average OBGYN to feel comfortable prescribing testosterone?
Safety and Efficacy of Testosterone Therapy
00:08:03
Speaker
What do you think? Yeah, I think first we have to show it's safe.
00:08:07
Speaker
If you can show that it's safe, then people will be more likely to look at the efficacy endpoints. If look at the safety endpoints, there has been one study, it was by Dr. David Lopez, friend of mine, that was just a retrospective study looking at a big chart review showing that if you give testosterone, it may increase cardiovascular risk. Then there another study by Taylor Cohn, who's my current, my partner, who big studies showing that it did not increase cardiovascular risk. so Dr. Cohn's study also showed that it decreases breast cancer risk. What's interesting is other studies have also shown a decrease in breast cancer risk in women taking testosterone. And some of the best data we have on cardiovascular and breast cancer is actually the transgender data. If you look at transgender data, ten x of what we give a woman, and we don't see significant increases in cardiovascular events.
00:08:51
Speaker
and And that data is a little mixed and we don't have a large studies, but some studies suggest that that's what you may be seeing. But I would say that, you know, I still think you should be careful on giving super physiologic doses and it needs to be more. Right. You know, it's not something that you want to do, but yeah we have some data to suggest it.
00:09:06
Speaker
So I would say that we should take that with a grain of salt. I do think that it's very safe. I think that there have many studies showing that. Now, in terms of efficacy, the problem is that it's very heterogeneous.
00:09:18
Speaker
Everyone's using different modalities of treatment at different levels. If I define normal testosterone in women as 20 to 80 and a woman is 25, some would say that's fine. Leave her alone. She's normal. Right.
00:09:30
Speaker
I would say that's not normal. And I would raise her up to the upper quartile. And we see that in the male literature as well. You can see a man in the lower quartile and they respond many times very different than the upper quartile. We saw that for diabetes between the T4DM and the Traverse trial, higher levels, a better response.
00:09:46
Speaker
So I think that could be another issue as well. And yeah let's be very fair. Disostrone doesn't have this amazing improvement in every woman. right Every woman gets a different response. Some may not get a response. That's okay.
00:09:59
Speaker
Some may get a response because symptoms are multifactorial. Maybe she's depressed. Maybe she's suffering from other conditions. Maybe you know it's sleep, diet. Maybe there's so many things that can be affecting her. And you can't say, oh, testosterone is the holy grail for her. It'll solve all her problems.
00:10:14
Speaker
I say it could help. That's an important point. It could help. That's a really interesting point. And, you know, I take care of a lot of trans patients, too. And I have to say that people who I see the most sort of depressed mood after they, you know, they feel great. They're so excited because they've just they've had this life changing vaginoplasty, but they've also had an orchiectomy and their tea is rock bottom. And yeah we have to give them testosterone back and then oftentimes they feel better. And same thing for my postmenopausal patients. I just feel like these two groups of people who have low testosterone and otherwise we wouldn't be looking for that. You do really see low mood and i I don't see it in every patient, but like you said, I see enough that it makes me realize, okay, we we need to be talking to people about it, that at least if you're feeling like your mood is low and it could be for multiple different reasons, like you said, at least we should be looking into testosterone. especially for postmenopausal women or anyone who's had, you know, absolute organs or middle death, create testosterone.
00:11:17
Speaker
Yeah.
Triple Therapy Approach for Postmenopausal Women
00:11:18
Speaker
This is very important. If you look at women and I call it a triangle and the yeah triangle, particularly for a postmenopausal woman is progesterone, estrogen, and testosterone. It's a triangle.
00:11:30
Speaker
Unfortunately, most only get two of the three. Yeah. Lisa Newsome just published yeah a beautiful article showing that those women who had the addition of testosterone to their HRT had a significant greater improvement in symptoms than those that just had estrogen progesterone alone, meaning that the addition of testosterone can significantly improve symptoms or greater than estrogen progesterone and a beautiful Cochrane database study demonstrating that it took women getting just estrogen, estrogen plus testosterone,
00:12:01
Speaker
and sexual benefits yeah far greater with the combination of the two. Adding estrogen to testosterone significantly improves her sexual function than just estrogen alone. And we see that in the male literature also. Estrogen is a huge driver for men, for libido, and I don't think it would be any different than it would be for women. So I do think that Really, the paradigm has to shift. It's no more just dual therapy, estrogen, progesterone. It has to be triple therapy for women. And I want to just make another important point. is It's not only triple therapy, but it also is in addition to local vaginal estrogen therapy. Absolutely. In fact, that to me is probably the most important drug out of the four. So really, some women come in and say, do I really need all four? I say, you need all four.
00:12:46
Speaker
yeah You need all four. You do. It's totally different in your quality of life. Yeah, I agree with you. i also wonder, you know, my patients ask me this too, like, when should they be starting? Like, for example, say they don't have low drive, and then you're automatically kind of thinking testosterone, when should a woman consider testosterone for their well being or for any other symptoms? Like, is there an age? Should it be when they're thinking about hormone therapy? Or what are your thoughts on that? So listen, so the key is is that the testosterone does not have a precipitous drop at menopause.
00:13:19
Speaker
So at menopause, you see that drop in estrogen progesterone, but T is not dependent on that. So it may continue to go. In fact, the fecal cells with the ovaries can even continue to make testosterone well after menopause, but it's on a decline. So it's not a cliff.
00:13:34
Speaker
It's on a slow decline. So it doesn't hurt to check your testosterone when someone goes to menopause, but it may not be low. And many clinicians say, oh, you're in menopause. Let's start you on testosterone. No, you should check those levels. You don't have to check the estrogen progesterone, but you definitely need to check the testosterone because she's still going make it. In fact, even during menopause, there's a slight uptake, a little bit in testosterone, then it comes back down again. So check the levels and see if they're low. And I personally think that we should be monitoring and checking estrogen progesterone levels too. There are optimal ranges. And a lot of my colleagues, you know, OBGYN, they'll go on symptoms. i say oh, you have low energy. I mean, basal motor symptoms, let's start you on E. And I do think that there's certain levels I'm trying to shoot for on the estrogen, progesterone, and the testosterone. Yeah, that makes sense, especially if you're correlating it with your symptoms, right? Do you feel like there's any sort of limit to how long people should consider being on it? Should they...
00:14:27
Speaker
you know, I feel like we don't have any guidance yeah in terms of anything to be worried about from what I understand. But is there anything that you've found in your practice? You're like, oh, maybe you should try coming off or or just continue. So I think think of it differently than the way you think of HRT. Because as a woman gets older and in her 60s, greater than you five years, you start talking about maybe we may want to potentially decrease or stop. But I'm not fully convinced on that either. I do find that I have women who are 89 and they will not stop. And they feel very happy. You know, think that there is a key point on when you start it We do know that if you start HRT earlier, there's a huge benefit than starting it later. Cardioprotective, cognition, dementia. So starting it early is important.
00:15:09
Speaker
Now, when I look at testosterone, I think about it the same way when a man asked me, how long do I got to take this? I said, if you are not making it and you are finding the benefit. In fact, I find it more important for the men who are older, preventing sharp lopenia, muscle mass.
00:15:24
Speaker
I mean, these are really important things. As we get older, it's all about muscle and bone mineral density. yeah and it's like yeah And that hormone, testosterone, is so helpful. for bone mineral density and muscle, right? And so with my female patients also, I say, look, I feel the same way as you get older. This is one hormone that I do not want you to stop. Yeah. What do you think are sort of like the next frontiers? Do you have ideas for where we're moving in this world?
Regulatory Changes and Future Expectations
00:15:50
Speaker
Yes. So, you know, this administration has been very pro hormones for men and women.
00:15:55
Speaker
And on November 10th of last year, they removed the black box warning from estrogen, local vaginal estrogen, estrogen products. That was a great win. On December 10th, I led ah a group of experts to for the male testosterone panel. And yesterday they announced that they would remove prostate cancer for the label. wow was yesterday Yesterday, they announced that they're going to remove the BPH warning. Yesterday, they announced that they're going to move the limitations of use in terms of aging, which is a huge win.
00:16:24
Speaker
and And so this FDA is really progressive. And I also think, and I know right now that there is discussion with this FDA, multiple discussions with women experts on testosterone and using testosterone through the FDA. Those discussions are going on. And they've had group panels just learning more. They just, the FDA wants to learn. And I do think it will. Androfemme. Is FDA approved in the their version of FDA in Australia? It's not coming to the UK. And I think, yeah, we'll come into the US. It's the ah gel form of testosterone for women, which is used.
00:16:55
Speaker
And I do think that you will see oral testosterone come through in the US within the next two to three years at a 50 milligram dose, which I think will be fantastic. you know Yeah. That's awesome. So you have a lot of great ideas. And I feel like I learned so much when you came to Cleveland and you were sharing about just your philosophy of health for men and women and seeing a larger framework. You had mentioned something about the sex factor. Could you tell us about that? Yeah. So look, it got really boring when all these people used to come in and I'd give them a Viagra and a testosterone and they would go home.
Integrating Hormone Therapy with Lifestyle Changes
00:17:28
Speaker
Then I'd give him another Viagra. And it was just like, this there's got to be more to this. I mean, it it wasn't feeling right. And so what I realized is that I dropped that paragraph, it could be progesterone, estrogen, testosterone, local vaginal estrogen. I talk about other hormones like cortisol, thyroid, and I say, now we're to draw a line down the middle.
00:17:45
Speaker
And that's only half the story. The other half of the story is diet, exercise, sleep, and stress reduction. I don't have the pill on the planet stronger than diet, exercise, sleep, and stress reduction. And you have to meet me halfway if you want to do this. You have to meet me halfway. And when I started doing that, it just got so much more fulfilling. I mean, people came in, they looked better, they felt better, they're sleeping better, they're eating better, they're using the hormones.
00:18:12
Speaker
Hormones are synergistic with lifestyle modification. You should not just treat hormones like taking care of everything. It's synergistic with your lifestyle modification. And so we've pushed that very hard. We put everyone on the diet, exercise, sleep, stress reduction program, men and women. But the sex factor is important. It's not just about sex.
00:18:31
Speaker
When you think about sexuality, it is the best barometer of a man and a woman's overall health because there's a high directional relationship between sexual health, mental health, and physical health.
00:18:43
Speaker
Right. And sexual health is probably one of the strongest because if someone has poor mental health, they can have significant sexual dysfunction. If someone has poor physical health, they can significant sexual dysfunction. Right. So the sex factor is probably one of the most key factors, you know, your overall health.
00:18:59
Speaker
It goes further. The sex factor also a barometer of your future condition. So men who have sexual dysfunction are 15% of them will have a heart attack or stroke within seven years. Emerging data just also show women with arousal disorder today are more likely to have cardiovascular events in the future. And if you improve sexual dysfunction in men and women, you decrease cardiovascular risk because decreasing sexual dysfunction involves lifestyle modification, eating healthy.
00:19:26
Speaker
It's the same things that you would do to improve your heart. And we also know that if you have sexual dysfunction today and nothing else is going on, it's telling you that something's about to happen. Like you may be fine because sexual dysfunction is not a disease. It is literally a barometer to say something wrong is going on. It's not the disease. It's yeah like a check engine light. Like something's going on. You should not be having sexual dysfunction. Someone who's 80 should be perfectly fine. Why do you have, is it occult diabetes, occult depression?
00:19:55
Speaker
Is occult cardiomyopathy? What is it? And so I think the sex factor really it's not just sex. We should be thinking about the sex factor. And the most important thing I think about the sex factors is talk about a quality of a relationship.
00:20:09
Speaker
Yeah. It improves when the couple is able to engage in sexual activity. It doesn't have to penetrative sex. It's just anything that involves pleasure to two partners. that can in Intimacy really. Right. Yeah. Yeah.
00:20:22
Speaker
It skyrockets the of the relationship. Others have shown people who are engaging with regular sex activity say they have a better quality of life, overall happiness. Some say about immune system. Some recent study came out yesterday on cognition in women who are more likely to be sexually active. I mean, it releases dopamine and orphans. So there's a lot more than it's just yeah sex.
00:20:42
Speaker
Right. And that's why I call it the sex factor. It's really important. That's so interesting. That is really, really interesting because like I've been familiar about the correlation for erectile dysfunction and cardiovascular disease, but I haven't quite pinpointed what similar factor would be for women that I see in my office. you know, it is multifactorial, but you're right. It is kind of a symptom of something larger going on. Symptom.
00:21:05
Speaker
And sometimes sometimes it's a symptom of depression. If someone's clinically depressed, they'll have sexual dysfunction. Right. And so what we do is it was the biggest mistake. i used to just hand him Viagra or maybe hand her a couple of hormones, say goodbye. But now I scream, everyone gets a PHQ-9. I want to see, are they clinically depressed? Might just, you know, I'm not going to the problem. I check hemoglobin A1C on everyone just to make sure. I check an ApoB for lipids, right? Just to make sure that I'm not missing a cardiovascular. The big three are cardiovascular, diabetes, clinical depression. Those are the big three. Now it could be thyroid because thyroid is a great mimicry, hypothyroid. But those big three, you got to check. Otherwise, just handing them the pill and saying goodbye is a mistake. Yeah, oh that's so interesting. I'm just thinking a lot about the menopausal transition for women because we know that their risks for cardiovascular health just, you know, exponentially increased during that transition, especially if they're not on hormone therapy yes and that we can mitigate quite a bit on hormone therapy. And now I just, I just really want to understand more where's, where's testosterone coming in that we could see even more either further risks reduced or specific aspects of health improved. I i mean, I'm excited for the next decade. We're doing a lot of work and you and I are working with Dr. Newsome and her database. 7,000 patients that take testosterone, women, and we're going to see where this takes us. But I do think that, you know, putting a woman on the triangle, progesterone, stentisosterone, local vaginal, looking all the other hormones, thyroid, cortisol, looking at everything else, optimizing your health, then drawing a line and saying, that's 50%. Now let's talk about your 50%. and you put on a program, I don't know what more you can do. just don't know what more- Exercise, just wanna repeat it for everybody. It was exercise, diet, exercise, sleep, stress. And stress mean, that is such a big one. Right, but sometimes diet, exercise, and sleep helps with stress reduction.
00:22:59
Speaker
yeah So, so number one thing, when you think something that looks really stressful, fatigue is the worst contributor. Try looking at it with you after taking a nap and waking up. It's a little different.
00:23:10
Speaker
Do you mean like what like chronic fatigue, chronic cortisol so increase chronic, some stress is good. Like some stress gets you going. That's really good.
00:23:20
Speaker
Right. High stress is dangerous. You know, it's dangerous. Right. Well, thank you so much. I really appreciate you allowing me to pick your brain. And thanks for sharing everything with my listeners. And I know that everybody's taking something away. Thank you, Rachel. Thank you for having me. Thank you.