Testosterone and libido for women - what can be done to help?

Testosterone is often misunderstood as a male-only hormone but it can actually be the missing piece of the puzzle when it comes to our perimenopause and menopause symptoms.

Katie speaks to menopause clinician, author and podcaster Dr. Heather Hirsch about what we need it for, how and why we lose it, how it can help with boosting libido, brain clarity and energy levels and why it may not be right for everyone.

Listen to the full conversation in The Latte Lounge podcast episode above.

What is the role of testosterone in women?

Testosterone plays a significant role for the human species because without it, we wouldn't get the urge to have sex and without having sex, we wouldn't reproduce.

And so it's very obvious that one of its main roles is in libido.

In fact, testosterone in women spikes right before ovulation, and that is no coincidence.

Most people assume that testosterone is a male hormone, and that’s not the case.

It is true however that men make ten times more than women, and they make it their entire lives while women really only make it for a short amount of time. 

So we know it's good for libido, but there's also limited data to show that it's good for cognition and it does often help with brain fog. It might also help with things that we historically attributed to oestrogen such as bones and vaginal dryness. 

RELATED ARTICLE: Testosterone, that’s the male hormone right?

Where is testosterone made?

Testosterone is made in the ovaries and this is important for women who have early surgical menopause because if you have early surgical menopause, not only are you taking out all the oestrogen you're also taking out all the testosterone.

In that situation, it is worth discussing testosterone replacement, even without low libido.

There is also a small amount of testosterone made in your adrenal glands. 

This is one reason why some women, postmenopausal feel like they get facial hair.

It's actually because your brain is asking your ovaries to produce oestrogen but that’s no longer possible.

So they send an SOS message to your adrenal glands that sit above your kidneys, and your adrenal glands don't have oestrogen but do produce cortisol and testosterone and that can result in facial hair and acne.

If HRT is taken, you'll see that facial hair goes away, and it's because the body starts to feel less stress.

How would women know whether they need testosterone or whether it's just fluctuating?

It's so hard to understand, or have your doctor sometimes prescribe hormone replacement therapy, that going back for the testosterone feels like you're just pushing the envelope so much, but these three hormones; oestrogen, progesterone and testosterone are really, wrapped up in each other. 

It really helps to bounce this off a good menopause expert because they can help you if you need it.

I would say about a quarter or maybe at most, a third of my patients are on testosterone, certainly not all of them, but certainly not just a handful.

The North American Menopause Society, the British Menopause Society, the International Menopause Society and The Endocrine Society, have a global consensus statement position paper on testosterone, which really cites the driving factor as low libido.

And low libido is typically one of the big driving factors for me to talk to my patients about testosterone. 

The next thing I do is check the lab value because if they're one of those women that is making testosterone because of stress, I wouldn't want to add to that because then they could get acne or start losing their hair.

So it really is a combination of symptomatology, and lab work and really sort of seeing that that test strips testosterone is low. 

You do need to make sure that liver function tests and other things are good before you start testosterone and check those numbers frequently.

It’s just as important as replacing it as making sure you're not overdoing it. You also need to make sure that you are responding to it in an appropriate way.

So if we start testosterone and my patient comes back and says that they don't think it is doing anything and the level is not going up then we may increase it a little bit. 

So there are three guiding principles.

Do you have a fundamentally low libido that's not improved with oestrogen, with sleeping better or with therapy?

Is your testosterone low and are you getting benefit if we do replace it?

How do you replace it for those who it's suitable for? And are there any other ways to boost testosterone levels?

There are two forms of testosterone that I use primarily. The first is a topical route, and another way is an oral combination with conjugated equine oestrogen and testosterone called methyltestosterone.

I use the oral testosterone and oral conjugated equine oestrogen, particularly for those younger women who have surgical menopause and really physiologically need that testosterone.

I will sometimes give them an oral combination of oestrogen and testosterone together if their medical history allows it. 

DHEA is both a natural hormone and a popular supplement that can affect the levels of other hormones in your body.

It has been studied for its potential to increase bone density, decrease body fat, improve sexual function and correct some hormonal problems.

Some women will try to take oral DHEA although I will say clinically, it doesn't seem to do the trick as testosterone does.

You could possibly boost testosterone levels through exercise, particularly weight-bearing, like lifting weights as this is actually a stress on your body so you could be releasing testosterone because of the stress response from weightlifting. 

Certainly, there are other things you can do for low libido like reading erotica.

There are neuronal connections in our brains about sex and fantasy and even something as simple as reading erotica might not boost your testosterone per se, but may help your libido.

RELATED ARTICLE: Sex and relationships in the menopause

How often should we be monitored to make sure that we are absorbing it and that there aren't any sort of nasty side effects?

It is important to keep levels within a normal physiologic range for a woman.

So I like to check their levels when they're first starting, every six weeks, and then again, another six weeks, and then every six months, and then maybe once a year.

Once they're on a pretty standard dose, it's not really going to surprise you all that much. 

If we're starting testosterone, the first side effect you will have if we're using a low physiologic dose of testosterone is a pimple or two. If it becomes like a teenage pimple fest, that is the first clinical sign that your levels are getting too high.

You wouldn’t see more side effects than that right away.

You may have read about side effects such as hair loss and voice deepening, that would be the result of having testosterone levels that were much too high, for much too long.

How long is it safe to stay on testosterone?

If women are on a low physiologic dose that they find helpful, just like their hormone therapy, I don't give them a time limit. 

Why is it so hard to get testosterone licensed for use by doctors in the UK and how can we try and get it if we feel we need it and we've done our research?

As hard as it is to replace the female hormones oestrogen, and then progesterone if you need it, it's even harder to then push for that third thing, which is testosterone.

And as much as sometimes it's easy on social media to put the blame on individual clinicians, in actuality, it really goes back to the medical education system. 

Whatever country we're in, it’s the same. Menopause and the decline of female hormones are not a priority in medical education.

We really don't discuss how the loss of these hormones interferes with chronic disease development, mood changes, metabolism shifts, weight gain, sexual function, sexual health, or indeed even how these hormones interact with our brain. 

For many women, menopause is earlier than natural menopause, and the fact that we do not have good research is a public health crisis.

Clinicians know so much about asthma, COPD, childbirth, the risks of obesity and weight gain, because that's what they have been educated in. That's what colleges have decided collectively is important.

Until we get people to collectively decide that understanding midlife, women's health and the loss of hormones is so fundamentally important to overall health, we're stuck, and luckily, we have social media where things like your podcast and your ability to bring women together and raise awareness via The Latte Lounge are what have been pushing this movement for the last probably five to ten years.

RELATED ARTICLE: Do you struggle to get your menopause symptoms taken seriously?

What last thoughts can you leave us with?

It takes a lot of experience to be a good menopause clinician.

Women are complex and each of my patients feels like a little Rubik's cube that I'm like moving and putting and learning all these clues and moving it all around to see because there's just no one size fits all. 

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