The Truth About Testosterone in Women

0:00We have a steroid language problem. We are going to build an environment full of frail, sick people. The problem is not that GLP-1 medications destroy muscle.

0:14Dr. Gabrielle Lyon:The problem is that fast weight loss with too little protein with no resistance training will cost you lean mass at any age by any method. We are moving into a new era of body composition, one in which obesity is not the primary issue anymore. And if we do not get ahead of the conversation that people are very divided on testosterone, then we are going to be in an even more dangerous spot than we were when the obesity epidemic hit.

0:54Dr. Gabrielle Lyon:I recently got interviewed for a woman's magazine about steroid use in women. And they were good questions, they were reasonable questions, and they were asked in good faith. But somewhere around the fourth one, it struck me that my job in that room wasn't to just answer the question in front of me, but it was to translate the science, to clear up the confusion that was underlying every single question. Before I could say anything useful, I had to get us all on the same page. Can you imagine a woman telling her sister that she's going on testosterone and her sister says, oh my gosh, you're going to take steroids.

1:33Dr. Gabrielle Lyon:Now that reaction, as you know, is unfair. And that is the reaction that we're going to fix today. Because here's what worries me. If we keep telling the same old story, if we keep saying that testosterone and anabolic agents are going to get lumped into one dirty word right at the same moment that GLP-1 medications are everywhere, we are going to build an environment full of frail, sick people. So in medicine, a shared vocabulary is a necessity. It is mission critical. Think about the phrase, quote, this patient looks sick. Now, sick to a surgeon and sick to a family medicine doctor like myself are two completely different, quote, sicks.

2:14Dr. Gabrielle Lyon:So we can't rely on that. We have to build standard language instead. Now, if I say a patient has three plus pitting edema, there's a defined standard for exactly what that means. There's no guessing. We have that kind of standard language for medications as well. But somehow steroids, and even when I say that, I'm sure you're cringing, got exempt from that standard. And what do I mean by this? When I say steroids, people don't picture a molecule, which is exactly what it is. They picture a baseball field, jacked guys, manly looking women, a bad spray tan, and probably a skinny tank top. That picture is doing a lot of damage in both directions.

2:55Dr. Gabrielle Lyon:And today we're going to fix the word and the science. What you're going to leave with today? Three things. First, what a steroid is, because right now that one word is covering your asthma inhaler, the cream you put on poison ivy, the cholesterol in your blood, and a vial somebody's cousin sold at the back of the gym. These things, they are barely related. Second, the difference between restoring a hormone level and pushing a supra-physiologic one. This is the whole game, and it comes down to a range. Third, what these drugs do inside a cell, and probably my favorite part, I'm going to fold in a little bit of history along the way.

3:38Dr. Gabrielle Lyon:Are you ready to get your mind blown? A steroid is not a drug. Yeah, it's a shape. Four rings of carbon stuck together. Three of them six-sided, one of them five-sided. That's the steroid part. What the molecule does depends on the little pieces hanging off that frame. So what counts as a steroid? Cholesterol. I feel like I'm on the prices right. Cortisol, the hormone your adrenal glands make, estrogen, yes, estrogen is considered a steroid, progesterone, your bile acids, vitamin D is built on a steroid backbone, and prednisone, hydrocortisone cream, and the inhaler that maybe if you have asthma, you have used.

4:20Dr. Gabrielle Lyon:All of these are steroids. And no one has ever lowered their voice and said, oh my gosh, you're using hydrocortisone cream. No, nobody in the history of ever, which means the word as a whole carries more than just information. It carries also a reputation and a stigma. And unfortunately, that reputation is from one branch of a very large family. And this branch is called anabolic androgenic steroids. The family is testosterone, plus all the synthetic molecules someone built by modifying testosterone. Now you notice how I'm just stating this simply. There is no judgment. Anabolic means tissue building, not muscle, specifically tissue.

5:09Dr. Gabrielle Lyon:Androgenic means masculinizing. And those two effects, they ride together to varying degrees because they're both triggered through the same doorway. And that is the androgen receptor. I've talked a lot about this and I will continue talking about the androgen receptor. Let's talk about androgenic anabolic steroids or anabolic agents. There is a spectrum. For example, testosterone is more androgenic, meaning it has masculinizing qualities, whereas something like nandrolone is more anabolic, meaning it builds tissues. Both the androgenic and anabolic activities both work through the same androgen receptor.

5:54Dr. Gabrielle Lyon:It just depends on what the molecule is. All this to say is when somebody says, quote, the word steroids, you have to ask them what they mean. Do they mean the anti-inflammatory kind? Do they mean the tissue building kind? What is it that they mean? And that becomes really important. So before we go any further, I want to share with you a quick history because frankly, that is one of my most favorite parts about these podcasts. Testosterone was first isolated and made in a lab in the 1930s. And the very first thing anybody and everybody wanted it for was for medical purposes. So there was a researcher who showed testosterone made the body hold onto nitrogen and build tissue.

6:39Dr. Gabrielle Lyon:Nitrogen is a part of protein. And the immediate thought was, we can use this to treat people who are wasting away, people whose disease is burning through their body. And that was the original point to fix a deficiency, reverse wasting. And frankly, that use has never gone away. And to this day, nobody argues about the use for testosterone in replacing it for people who genuinely cannot make enough. Here's the twist. And this is the whole reason I think that we're in this mess, is that the performance use showed up almost immediately. It didn't happen decades later. It really was essentially in parallel.

7:20Dr. Gabrielle Lyon:Within about 10 years, by the 1940s, there were reports it made people stronger. And by the early 1950s, weightlifters, they were already on it. But it didn't carry a stigma. Then the Cold War, I don't know, like lit a fuse or something. Soviet weightlifters dominated the 1952 Olympics. An American doctor named John Ziegler helped build a synthetic version and it hit the US market in 1958. This was called Dianabol, the first anabolic steroid you could buy. From there, it was rolled through elite sports and in the 60s and 70s, they stacked multiple compounds, doses that weren't just a little above the medical levels, right?

8:03Dr. Gabrielle Lyon:Sometimes a dose would be a hundred times a replacement dose. And for a long time, it stayed in that world. Then in the 1980s, it crossed over out of elite sport and into the general public. Regular people, mostly young men, using it to look a certain way rather than win anything. It was more for aesthetics rather than sport. And that is basically, I don't know, it's kind of the world that we still live in. This drug class was born out of medicine to treat sick people, deficient people. The abuse was a parallel track that showed up almost the same year. And eventually, I don't know, it's gotten more attention than the medicine ever did.

8:41Dr. Gabrielle Lyon:The word steroid your sister is reacting to has nothing to do with replacing hormones. And testosterone is an anabolic androgenic steroid. It's the OG, the original one. And every synthetic got built by essentially tweaking it. So when someone tells you testosterone is a steroid, they're right about the molecule. But that molecule shouldn't hold a bad reputation because every adult body makes testosterone, women included. A woman is not estrogen with nothing else going on. She runs testosterone too, and at a lower set point than a man. And that set point is a number. You can draw blood, you can measure it.

9:24Dr. Gabrielle Lyon:That number is different for everybody. but there's a defined female reference range. It does sit well underneath the male range and it shifts after menopause. I think we have a lot of room to continue to evaluate and develop data on this. But at the end of the day, there are two situations. There is a molecule. Number one, that molecule is used for restoring, for example, a post-menopausal woman with a diagnosis or with low lab values brought back into a normal female range. Or number two, somebody looking for a synthetic androgen to build a physique with the same drug family. Again, here's the comparison, and I use this in clinic.

10:07Dr. Gabrielle Lyon:Levothyroxine, thyroid hormone. Your body makes it. When you stop making it, you have hypothyroidism. We replace it. We check it against the lab value. We recheck it, and we adjust it. And nobody, not one time, ever has looked at a woman on levothyroxine and said, you're on a thyroid drug. No one implies she's cheating. Same clinical act. There's the same logic. But the difference is one of those hormones got caught up in a sports scandal. I don't know. And the other one didn't. I say this because again, I have concerns about the use of GLP-1s. And if we demonize testosterone, and then we make all androgenic agents that are used, say, for HIV or wasting, if we make all of them bad and we continue to perpetuate a narrative, we're going to be in trouble.

10:54I will say there are guidelines. Ishwish published one in 2021 for systemic testosterone in postmenopausal women. And in 2019, there was a global consensus position statement. It was endorsed by 10 international medical societies. Both support testosterone in women for hyposexual desire disorder, HSDD, which is low sexual desire in postmenopausal women. I think that we're going to begin to see a lot more research on all of this. And that same consensus statement says plainly that the evidence is insufficient for anything else. Again, I do believe that that is going to change. There also is no FDA approved testosterone product for women in the US.

11:34This I think is a bummer and it's its own episode. But Susan Davis ran a two-year trial published in 1995, 34 postmenopausal women randomized to estradiol implants alone or estradiol plus testosterone. Bone density went up in both groups and faster at every site in the testosterone group. Fat-free mass went up, but only in the testosterone group. All of this is interesting. And I think that it tells us something about the androgen effect to bone and lean tissue on top of estrogen. As a physician, I just want to pause and say, I'm keeping this very broad. You know, we're not talking about the difference between pellets, transdermal, but we are talking about this in broad ranges.

12:19The point is the female testosterone range needs monitoring. And with monitoring, there is good medical choices. Now, we have to understand what do these molecules do? These are molecules that are fat soluble. They pass straight into the cell membrane. Once inside, they bind to the androgen receptor. The pair travels into the nucleus. It sits down on the DNA and changes which genes get read. What follows, according to the literature, pushes all in one direction. Muscle protein synthesis goes up. Breakdown appears to go down. These drugs, they work.

12:59Dr. Gabrielle Lyon:The foundational trial is by Bashan, and it was in the New England Journal of Medicine in 1996, another OG. Men were randomized to testosterone or placebo with or without supervised lifting. The group that got both gained considerably more lean tissue than lifting alone. This was a real effect, and it was measured in men in super physiological exposures under supervision. Beyond muscle, there are receptors, androgen receptors in bone, in brain. the oil glands in your skin, hair follicles, vocal cords, clitoral tissue, which has a same tissue as its male counterpart. Now, there are oral compounds in this family and they carry a structural change that lets them survive a first pass through the liver.

13:47That's what makes a pill possible. All of this outside of say chisotrex. You change the ring structure and you change what the compound turns into downstream. For example, testosterone given as testosterone converts into estradiol and DHT. And a lot of what people like about it, bone and blood vessel signaling include, it all runs through these conversions. There are several synthetics which are built to skip these steps and that gets marketed as fewer estrogen side effects. What is also true is that it skips estrogen's contribution to your skeleton. Again, this isn't chemistry at all. There's drug checking work out of Australia showing that what gets sold to women, say for example, oxandrolone especially, is frequently mislabeled, underdosed, or something totally different.

14:37And oxandrolone, again, is an anabolic steroid. So a woman who thinks she's picking up, say a mild option, define that as you will, swallows something and it's considerably more masculinizing than she was planning it to be. And this is why we have to stop shaming women and shaming this conversation. We just have to understand it more. So oxandrolone does have FDA approved indications in catabolic states, recovery from severe burns, and approval describes a labeled use in a patient. We're not talking about the moral character of a molecule. So why women and why now? Again, I was doing this interview for this magazine and this conversation used to live almost entirely in men's sports and it doesn't anymore.

15:26And the numbers are frankly getting handled badly. So what do I mean by that? You'll hear that female steroid use was 1.6 % 10 years ago and now it's 4%. Those two figures set side by side as proof of a surge in some kind of anabolic abuse. This is not necessarily true because the 1.6 number comes from a 2014 meta analysis, which was 187 studies of lifetime prevalence of use. The 4 % comes from a 2024 for systematic review in addiction. That one pooled 18 studies. Confidence intervals running from two all the way to nine and heterogeneity at 95%, which is very high. So what does all that mean?

16:16The 4 % isn't a general population figure. You break that same review into groups and you get 16.8 % among bodybuilders and 4.4 % among athletes and gym goers and 1.4 % in the general population. So the number that compares to 1.6 is actually 1.4. So that's not doubling and that's not a rise. What the 2024 data does show is concentration. Use is dramatically higher inside bodybuilding and gym populations than among women generally and in the general population, which obviously that makes sense. That's a real and important finding. It just isn't the finding that people are talking about. And then we will continue to shame anabolics.

17:07And we don't have good longitudinal data in women to make the rising claim either way, right? Longitudinal data is not randomized controlled trials. Now, I'm spending time on this because when you inflate a number to make a point, you hand the other side a reason to throw out everything else that you've said, including the parts that were true. But at the end of the day, we have a steroid language problem. But what has actually changed is culture. Women have started lifting, which is a total win. And I've spent my whole career on the sidelines encouraging women that they should be training. So I think that this is a good thing.

17:46But with that, there's now different critiquing of physiques and there are non-achievable and achievable body physiques, but we have to just be really clear. Are we utilizing testosterone and or anabolic agents for medical purposes or are we using testosterone and or other anabolic agents for physique? At the end of the day, these are two separate conversations. in the last few years, we've really normalized two things. Number one, we've normalized that medication can change body composition, and this has become ordinary. And also a gray market has taught us a lot that people are ordering compounds and taking it like it's, I don't know, just another Tuesday.

18:37And you put those two things together and the distance between the prescription pen and a capsule from group chats on Reddit, I mean, this is a problem and there are legal status problems, there's evidence problems, and there are risks that we cannot track and we don't have any way to address and protect people. The problem is not that GLP-1 medications destroy muscle. The problem is that fast weight loss with too little protein with no resistance training will cost you lean mass at any age by any method. Some women watch their strength, their shape, all of this disappear during weight loss. They panic and they reach for an androgen.

19:20What would have prevented it was a slower utilization of GLP-1, increase in protein, better training program, progressively loading some heavy weights. But the drug is getting asked to fix a problem that food and training would have helped prevented. So in essence, if we do not slow down this rapid weight loss, reorient ourselves to the conversation of androgens, which are, you know, naturally occurring, so there's androgens and anabolic agents, which I've tried to separate the two, we just have to understand that we will perpetuate a narrative that will ultimately affect women. And most androgen effects in women, if a woman were to go on testosterone, we don't want to demonize.

20:13We know that if the dose is too high, she could get masculinizing effects that will go away if you stop it early enough, like acne. Acne can clear. Menstrual cycles can come back. Yes, sometimes they don't. But if we gaslight people and they go to use anabolic agents and they have a deepening of their voice or an enlargement of their clitoral tissue, which gets described over and over in the clinical literature, this can persist after someone stops using these agents. And there's published cases of women whose vocal cords change permanently after about six weeks of use. And there's another, a handful of other papers that have followed women and women's voices for 20 years.

20:55The reality is that an individual, their susceptibility varies. And there's no test to tell you in advance whether this might happen to you or somebody else. And by the time you hear it, if you are getting anabolic agents out of your gym in the back, you're at a disadvantage. And that is exactly why the sloppy words, they're dangerous in both directions. A woman who avoids female range testosterone because she thinks it's steroids gives up a monitored treatment for nothing. And a woman who takes a synthetic androgen because she thinks it's, quote, just hormones accepts a risk she never even had the chance to evaluate.

21:34So there are four questions. One, what is the molecule? Don't reply with hormones. Not, oh, it's a little something mild, which I have seen people talk about. When you ask, what is the hormone? It's, what is the name of the compound? Spell it out. if no one in the room can tell you what it is, what it works, what the dosing is, there is no conversation. And again, I'm not giving medical advice, but I do think it's important that you become aware of the era that we're moving into. So if you've never heard of it, just hard pass or talk to your physician.

22:08Dr. Gabrielle Lyon:Question number two, are we restoring a level of say testosterone or are we exceeding one? And against which range? This is the question that is important to ask. A treatment aims at a range, a super physiological dose aims past it. And you personally, as someone who is taking a medication or not, let's say you are, you are entitled to know which one you're going for. Are you going for something in range or are you being pushed for something that's super physiologic? Number three, who is monitoring this with what labs and how often? For any androgen in a woman, I want a lipid panel with an ApoB, a metabolic panel, a CBC, blood pressure, hormone levels.

22:53Dr. Gabrielle Lyon:If nobody's checking anything, then you don't have a plan. And that's really important to understand. You don't have a plan. This is not advisable. Number four, where did this agent come from? Can this be verified? Something filled at a pharmacy has a chain of custody, which is really important. a vial or a bottle of pills from a group chat doesn't and the drug checking data says that matters more than most people think and this is why i started talking about peptides and this is why i'm having this conversation about anabolic agents is if you do not vet where it comes from and you cannot have a lab analysis then you don't know what it is and if a conversation if you are making the decision is this anabolic agent right for me then it should survive all four of these questions because it would be a medical conversation.

23:42If it doesn't, then this is never about a hormone. This is about something completely different. Remember, hormones, steroids are the following, cortisol, cholesterol, estrogen, a bodybuilding compound like oxandrolone, nandrolone, testosterone, they are all steroids.

24:01Dr. Gabrielle Lyon:And that should tell you how little the word is doing for you or anybody else. We have to be smarter. We have to ask, what is the molecule? What is the safety data? What are the labs being measured? And is this an ordinary medicine? Or is this something that is synthetically made? All of these are important questions rather than the single statement that I'm hearing, which is steroids are bad. We are moving into a new era of body composition, one in which obesity is not the primary issue anymore. We are moving into an era where sarcopenia, which is low muscle mass and strength, will be the primary problem.

24:40Dr. Gabrielle Lyon:And if we do not get ahead of the conversation that people are very divided on testosterone and anabolic agents, for example, that are used for cachexia, HIV, wasting, then we are going to be in an even more dangerous spot than we were when the obesity epidemic hit. Till next time, stay forever strong. .