Testosterone Hormone Therapy in Perimenopause: How to Match Symptoms, Labs, and Treatment Correctly

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0:44No ID, prescription or age requirement. It's the number one OBGYN recommended brand of emergency contraception and it won't impact your future fertility. That's freedom to be. Use as directed. We can have some real talk because if you've been told your testosterone is only about your libido, you have been given an incomplete and frankly misleading story. And the perpetrators of that tend to be the medical community. And FDA, I'm looking at you. So the symptoms that suggest that women may benefit from testosterone are often misattributed. They're dismissed and they're labeled as things like burnout, depression, just getting older.

1:23Have you tried losing weight? These ridiculous things that we are told as women instead of somebody just digging deep and figure out what's going on with our hormones. So today we're talking about the patterns that actually raise my clinical eyebrows when a patient presents with these symptoms. But I want you to stick around because I am going to go through the types of hormone therapy that are available to women, what you should know, pros and cons, and we're going to these symptoms I'm about to list, then this episode is for you. If you feel emotionally flat or have a persistent low mood, I'm not talking about cyclical.

2:04We're not talking about a PMDD picture. We're talking about most days out of the month. You just feel kind of bluesy, a bit sad, less motivated. If you're also having fatigue, despite doing everything right, you're taking your B vitamins, you're exercising, you're getting eight to nine hours of sleep if you are, good job. but everything right is still not giving you the energy that you need. When it comes to your muscle mass, check in right now. Are your muscle gains matching the effort you're putting in? If you're losing muscle or you're unable to build muscle despite consistent strength training, not just like every now and again we go to the gym, okay, consistent, then we start thinking about testosterone.

2:49And that's not to put you down if you're not being consistent. It's just to say, if you're not consistent and you're not building muscle mass, that would make sense. If you feel you have a loss of drive, motivation, follow through, you don't want to start a project. And if you do muster the energy to start a project, you cannot follow through on the project. So that difficulty initiating or completing tasks. This is because testosterone affects our executive function. Again, testosterone is far more than our libido and our ability to please men, which is kind of the view and the take that the FDA has.

3:27Now, if you're having low sexual desire, so you're not interested, you're less responsive to stimuli, so whether that be mental or physical stimuli, that can be related to your testosterone, as can reduce genital sensation. inability to achieve an orgasm can be related to our hormones as well. Now, libido and women's sexual health is far more than just hormones. It's far more complicated than that, but these hormones do play a role. For example, difficulty getting aroused and the achieving of an orgasm, that can be hormonally related. So anytime somebody says, hey, I've got these sexual concerns, I'm going to look at their hormones, but I'm going to look at a full picture as well.

4:12Now, if you find that you don't have the drive, the ambition, the ability to set boundaries like you used to, that can be another sign that testosterone is getting low. If you feel like your nervous system is on edge all the time, you're always panicking, every little thing is perceived as a threat, that is your body's way of keeping you safe because if testosterone's low and we are weaker, then we better be hypervigilant about our environment. So if any of these sound like you, I definitely want you to stick around because I think it's so important that women understand testosterone in their own body.

4:45Testosterone plays a crucial role in our genital blood flow. It's not just estrogen involved there. Sensory responsiveness, motivation and drive, not just sexual, like drive all together, that ambition, that like wake up, kick ass, repeat kind of drive. And before we get into labs and testosterone hormone therapy in women. Quickly, if this show has helped you think differently about your hormones, please consider subscribing, dropping a comment, leaving a review, sharing this with someone who needs this information. This can seem like such a small act, but it is tremendous in supporting this show.

5:25And if you're new here, welcome to the Dr. Brighton Show. I'm Dr. Jolene Brighton. I'm board certified in naturopathic endocrinology. I have been supporting women and prescribing hormone therapy for about 15 years now. And in addition to that, I'm a nutrition scientist, I'm a sex counselor, and I'm certified menopause practitioner. So when we talk testosterone therapy, that is totally my wheelhouse. And I brought notes today. If you are a woman and you're paying attention, you know testosterone is having a moment right now. And women are finally in masses hearing that it's not just a male hormone, that ovaries make it, and that it affects your energy, your muscles, your libido, and your brain function.

6:09And all of that is progress. And as someone who has been in this arena long enough to have been criticized because the Women's Health Initiative was out there telling everyone that hormones would hurt us and I was prescribing them at the time, I, for one, am so happy to see this. Now, the problem that's happening at the same time that I need to put you onto is that testosterone is being oversimplified. There are providers who are like, cool, hormones are great. Women need hormones. Let's put everybody on hormones. And in some instances, testosterone is being oversold, overprescribed, and it's being done poorly.

6:47And that comes with risks and that does cause harm. And so as exciting as it is, I want to give you some guidance today so that you don't fall into the trap of being given super physiological levels of testosterone. Some providers do that, but hairlines start to disappear. They start receding. Voices start to drop. There's a masculinization of the face. Like your body becomes very, very muscular. I love that. I love seeing muscles on women, but it's the type of muscles that you don't get without having hormonal influence to push you there. And listen, if you are someone who has low testosterone, I want you to know I'm not a gatekeeper, okay?

7:26I'm not talking about this from a perspective of like, we should not be giving women testosterone, hell yes, we should give every woman who needs testosterone the option to choose for herself if she wants to use testosterone. We're going to talk about who benefits from testosterone, who needs to be cautious, and how testosterone fits into the larger hormone system. But first, I want to get into labs. And before we go through labs that should be tested before prescribing testosterone, I want to remind you, I have a plan for you that guides you through how to eat, how to move, how to sleep, how to reduce stress, how to do everything your body needs to optimize your hormones through midlife.

8:05If you go to drbrighton.com slash plan, D-R-B-R-I-G-H-T-E-N.com slash plan, you can grab that. Meal plan, recipes that don't require too much cooking, helps you hit your protein and your fiber requirements to have optimal hormones every day and gives you guidance on how to work out. Okay, labs. First thing we got to do is be very clear that labs alone do not diagnose a testosterone deficiency in women. You cannot look at labs alone and not also ask the patient questions and understand how it feels to live in their body. And keep in mind, you know, we've got to do a whole panel with testosterone, but total testosterone does not equal tissue level testosterone.

8:48Normal doesn't mean that you feel great in your body, okay? I really hate when people have symptoms and then they're like, but my doctor said all my labs are normal. And I'm like, is it normal based on the reference range that's based on elderly people and sick people? Because that's the majority who get labs drawn. That may not be normal. It's also important to understand, as we talked about in the last episode, that receptor sensitivity matters. So when it comes to lab testing, there's a lot of nuance. And often I will see that doctors are just ordering a total testosterone, hanging their hat on that and saying, okay, that's it.

9:25end all be all your total testosterone looks fine but I do things differently and I get a full panel and I definitely would recommend that you do the same and if you are someone who has been told your labs are normal therefore your symptoms don't matter wrong when it comes to hormones symptoms matter more than just a single number we have to look at an entire picture so when it comes to testosterone testing the panel that I order for patients is a total testosterone that's going to tell me how much you're making. A free testosterone that's going to tell me how much is bioavailable. A sex hormone binding globulin, that's going to tell me, are you binding up that testosterone?

10:04And is that the reason why your free testosterone is low, is that we've got a protein problem there? I also look at DHA sulfate, that tells me how much the adrenal glands are contributing and doing their role right. Remember from our last episode, we women primarily make testosterone from our ovaries and our adrenal glands. And then I also like to look at dihydrotestosterone or DHT. Now you can do all of this in a serum lab. You can also do a Dutch test and then do blood work for the sex hormone binding globulin. The DHT tells me how active is your 5-alpha-reductase activity. That's an enzyme that takes your testosterone to a very potent form that leads to hair loss, sometimes oily skin, acne, and then next to hair loss being the worst is hirsutism, and that is growing hair where you do not want it.

10:55So I want to know that ahead of time because if I'm going to prescribe testosterone, I want to get ahead of things in that pathway and make sure that I don't push someone into losing their hair because then they would hate me forever, and I don't want that. By the way, if you are losing your hair, I have a whole hair loss protocol episode that I will link to in the show notes. They'll be at drbrayton.com or they will be below this episode in YouTube so that you can get some solutions and grow your hair back. Now, something else that's like really, really important to understand is that there's no defined testosterone deficiency syndrome in women that's just based on labs, that we can just look at the labs and say, oh yeah, absolutely, like this is what's true for you.

11:35In fact, studies have looked at testosterone levels in women, in perimenopausal women, in postmenopausal women, women using testosterone therapy, and there's really been no consensus. And in fact, what we see is that the blood markers don't always correlate to how you're feeling, and how you're feeling may not be showing up in the lab work. So it can be a bit tricky. That's why I look at the full panel, because a lot of times these studies, they'll just look at total testosterone or maybe just free testosterone and they're not looking at the full picture. Like, how is the adrenal function? So the choice to use testosterone therapy for clinicians is based on clinical judgment and married with the lab.

12:20So we're going to look at the labs. We're going to look at the patient's symptoms. We're going to understand what is happening for this entire person. Remember in the last episode, I'll link to that too because I'm acting like you heard it, but maybe you didn't hear it. I talked about how inflammation, that can be impacting testosterone levels. So we don't want to go chasing testosterone when the root at all of that is cortisol, HPA dysregulation happening, and we're having inflammation. Like we need to address the inflammation. And maybe testosterone is a part of that, but it may not be. And it may be the wrong mood to try to push testosterone when what we really need to do is drop the inflammation.

13:00Now, in terms of lab values, there are certain parameters I am looking for, but I just don't want any clinician who's listening to only see a patient as their labs. And I also don't want you as the individual to be like, oh, okay, these labs mean I have to get on testosterone. It is much more nuanced than that. Now, when it comes to total testosterone, I like to see a level of at least 15 nanograms per deciliter. These are the lower ends of the range, by the way, that I'm looking for. If you have symptoms, it's going to change things on how I look at it. But if it's less than 15, I'm like, we got a production problem.

13:41If we have a low sex hormone binding globulin, I'm looking for insulin resistance. I'm looking for inflammation. So this is very common in the polycystic ovarian syndrome picture. If I see a high sex hormone binding globulin, then I expect to see a low free testosterone. And that is common on oral estrogen. So hormonal birth control we talked about in last episode, thyroid excess. If you have what is called estrogen dominance, so we have too much estrogen going on, can even be xenoestrogen, sex hormone binding globulin goes up. It's a protective mechanism by the body to keep you from getting overexposed to estrogen.

14:20Also testosterone. So it's protective, but it can really suck when you're like dealing with low testosterone symptoms. Now for free testosterone, if that's below one, and I'm looking at sex hormone binding globulin and that looks normal, but total testosterone is below 15, I'm like, we're not producing testosterone. We are not converting testosterone. Ideally, a free testosterone should be between two and four. So below one with symptoms, eyebrows go up. We need to be thinking about what we want our next step to be. Maybe it'll be working on those adrenal glands, but it's likely going to be GHEA or testosterone therapy if somebody is in perimenopause.

15:06Now, we mentioned DHEA sulfate. That is a very age-dependent number, and it depends on how you're measuring it. Are you doing blood spot? Are you doing blood draw? Are you doing Dutch panel? But DHEA sulfate, that's specifically what we're looking for. It helps distinguish adrenal versus ovarian contribution. And so if total testosterone, free testosterone are low, DHEAS is low, Zax hormone binding globulin is normal, we've got an overall production issue. And testosterone, as I talked about in the last episode, it can decline starting in our late 20s. testosterone is on its way out and sometimes it's going out before estrogen even is and so that's what's kind of lame about perimenopause everybody talks about estrogen but they forget the fact that progesterone and testosterone can go first one thing i hear from women all the time is that they're struggling with symptoms like hot flashes sleep disruptions and brain fog but aren't sure where to turn to for help menopause is inevitable but suffering through it isn't that's why I want to tell you about Alloy.

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17:03Brighton. now DHT I always I just want to plug that again hair loss and acne we want to avoid those side effects so that should be part of a panel as well if your DHT is elevated like 5-alpha reductase is off the chain that enzyme is just cranking cranking cranking taking your testosterone to DHT DHT is not all bad okay we need it but too much of it and then we're like where is my hair where did my hair go? And I never want that for you. Now, as I mentioned before, we need to have a balance of hormones because when estrogen is unstable, it's rising and crashing in perimenopause, testosterone therapy can be poorly tolerated.

17:45If we don't get your estrogen right before testosterone therapy, testosterone therapy doesn't feel like it works, but also we might see metabolic changes we don't like. We might see more belly fat. So we have to look at your estrogen as well. We got to look at your symptoms and maybe we're going to do blood work. And I will link to other episodes on that. But the takeaway is testosterone is going to work best when estrogen is more stable. And this is why we don't give testosterone in isolation. We don't just look at testosterone only. Okay, we're going to talk about who testosterone is most likely to help.

18:20But before we get there, please stick around to the end because I am going to go through the different forms of testosterone and what you should know before starting testosterone therapy. So the FDA is like, listen, if you've got low libido, you're not in the mood, you know, that like your desire is distressing you. Okay. So it's not just that like, oh, I'm not really in the mood. It's that like I'm in the mood and it's stressing me out. Okay. You can have testosterone. Right now, there is no FDA approval for all of the other ways that women suffer when they don't have enough testosterone. I said we weren't going to do outrage, but I'm like a little bit pissed off about it.

18:58So here's the thing. Your testosterone labs look low and you're feeling depleted. You're in your 40s, okay? So you are likely in perimenopause. You are having executive dysfunction. So that is like your mental drive, your stamina, your starting projects, your following through. None of that's working for you anymore. If you have ADHD and that's happening for you, like definitely testosterone is like a forgotten one for ADHD women. And I can do a whole other episode about the nuance about that because testosterone therapy is way more nuanced in an ADHD and autistic individual than it is in a neurotypical woman.

19:38So far, we have covered the lab testing and who would be a good fit for this. We went over all the symptoms at the top of this. If you're having those, your labs are showing that you're low, you're probably a good candidate for considering testosterone therapy. Now, I want to move into the types of therapy. So please stick around for that. But before we get there, I need you to understand this. The FDA has only approved testosterone therapy if you have low sexual desire and it's stressing you out. Then the FDA is like green light go. A lot of critics will say, if you are using testosterone therapy for anything other than this distressing low libido symptom picture, you are using it off-label and we're not supposed to do that.

20:28Well, I hate to break it to you, but spironolactone is not meant to treat PCOS, cystic acne, oily skin, hair loss, hirsutism, but we do it, right? There are a lot of drugs that we use off-label. And so to gatekeep and say, well, you can't use testosterone because it hasn't been FDA approved. I hate to break it to you, but the majority of ways that we are using drugs these days, they are off-label uses. So they don't always go back and say, okay, we're going to seek FDA approval for this. They will have off-label uses. So as of right now, there's no testosterone product that's actually approved for women, despite the FDA saying, hey, if you're not in the mood and it's freaking you out, you can have it.

21:12Still, we don't actually have any testosterone. So every form of prescribed testosterone is off-label because it was designed and dosed for men. And then we've had to adapt it very carefully for women. Now caveat, I can use a compounding pharmacy and then get the dose exactly the way I want it for a woman, but that's pricey. And not everywhere has a compounding pharmacy. So there are limitations to that. And before anyone comes in and says, oh, compounding pharmacy drugs are not FDA approved, let me just stop you because that's a lie. That is actually willful disinformation to dissuade you from using a compounding pharmacy, usually by clinicians who are not actually trained in hormone therapy.

21:58So I was actually trained in medical school in hormone therapy, unlike other doctors, and they don't know how to compound medications. So because they don't know how to compound medications, they tell you it's dangerous because that protects what they're doing in their practice and helps keep them elevated on a pedestal as the expert and helps draw a line in the sand of us versus them. Compounding pharmacies use hormones that are approved by the FDA. The FDA approves medications that are meant for going out into the general population. When I compound something just for you, I make it just for you, there is no reason to have the FDA approved that.

22:42That's not the role of the FDA. The FDA doesn't care about the titrated fine, you know, prescription that's fine-tuned to the individual. They don't care about that. That's not what they do. That's not even in their scope. Their scope is, is the testosterone you're using FDA approved? Yes, that is what's safe. So it is FDA approved, but the way we compound it isn't meant to go out to the whole population that qualifies for that. So it doesn't need to be FDA approved. I think that nuance is really important because the rhetoric I've seen around this, it is willful disinformation. I mean, perhaps maybe they just don't understand how the FDA works.

23:25They certainly, a lot of these people don't understand how hormones work. They received training in the birth control pill, placing an IUD in pregnancy, and then called themselves hormone experts, but never received training in actually working to fine-tune women's hormones naturally. That's why when you have period problems, all they give you is the pill. You have hormone-related problems, you get the pill. You go into perimenopause and they're like, yeah, just take the pill. I just can't with that. Women deserve so much better. Okay, rant over. Let's talk about what you need to know before going into testosterone therapy.

24:03So first thing is women need tiny, tiny physiological amounts, okay? Small dosing errors matter. Absorption variability matters. Reversibility matters. Timing matters. And you need to understand that benefits often take two to three months. I don't ever want to catch any of you, and certainly not my patients. I always warn them of this. It's just because we get you going on like five milligrams a day, and after a couple weeks, you don't fill it. And then you're like, well, I'll just do it twice a day. and then I catch you like two months later and you're like, why am I breaking out and what is happening?

24:37And I'm like, yeah, what is happening? Don't ever decide to dose up yourself, okay? Please don't ever do that because side effects take time to emerge and it may be a couple months before you notice side effects and then it's going to take a couple months for those side effects to resolve and go away. That's why we always start low and we go slow. I'd rather you feel a little bit better and get impatient with me than us like punch through the ceiling of your tolerance and then you hate me because you're like why do I look like a teenage boy but I'm starting to bald like a middle-aged man like what is happening here so we don't ever escalate in a few weeks just because someone doesn't feel it yet it is not uncommon to not feel the effects of testosterone until month three of using it consistently.

25:26And that is so aggravating. I know, right? Because like progesterone, you take it that day and you're like, I'm sleeping better. I'm more calm. Like, oh, I actually like didn't want to like slap my husband for breathing and chewing with his mouth open. So let's talk about the forms of testosterone now. So generally speaking, I start with creams and gels. These are often the most straightforward starting point. And the nice thing, the thing that I like about them, they're really accessible. Small dosing adjustments can be made. It can be tricky. Like when we order these gels, they come in a sachet.

26:04We're like, use a piece size amount. And that's not going to be completely dialed in and accurate every time you squeeze that. And we just have to recognize we're doing the best we can. But the nice thing about those gels is that they are easy to titrate. So gels and creams are easy to titrate up and down. And because comparatively speaking, it's not inside you like some of these other therapies, it's reversible a lot quicker because we can just stop it. Now you're not absorbing it in your skin. So that's the pros of gels and creams. And we can also get these compounded, but the cons are there can be variation in the compounding quality.

26:47So I always make sure that the compounding pharmacies I'm working with, they're very transparent about how they get homogenous mixes. And I have conversations with the pharmacist. Like I want to know everything about you before I work with you. When it comes to absorption, that can be inconsistent for some people. We see the same is true with like estrogen patches versus using estrogen creams. I think the biggest con and risk of having this topical cream or gel of testosterone is the risk of transfer to others, mostly children and pets. And so that is something that I will tell women if you're going to apply it like on your inner arm and your inner thigh, like put clothes on, wash your hands really, really good.

27:31The other thing is that daily adherence is required. You have to apply this every single day. That can be a con for people who can't remember that or who are traveling a lot and you're like, I don't want to travel with this open gel pack of testosterone. So then we might switch to like, oh, well, let's do like a, you know, compounded cream so that travels better. Now, another way that we can deliver testosterone is through subcutaneous injections. These are micro-dosed, literally micro-dosed compared to what we would give men, okay? So these are not bodybuilding doses. And this is something that I think is just really important to understand is that when I say micro-dose, I'm not saying like, oh, this is just like a tiny bit like microdosing that's like, you know, below the therapeutic effect dosing.