Testosterone and Menopause

By Suzanne Fenske, MD, FACOG, ABOIM, MSCP

Testosterone and Menopause

Testosterone isn’t just for men; all humans need it for life and health. Yet, there are so many questions about testosterone for women, especially in midlife. There’s a lot of discussion about estrogen and progesterone replacement in menopause, but do women benefit from testosterone, too?

Today’s article will answer your testosterone questions, specifically low testosterone related to menopause, libido, and optimal health. Keep reading as we take a deep dive and cover these topics:

• What is testosterone?
• Testosterone and women’s health
• Does testosterone decline in menopause?
• Testosterone and libido – what the research says
• Do women need testosterone replacement in menopause?
• How to support optimal testosterone levels with age

What is Testosterone?

Testosterone is a steroid hormone made by the body from cholesterol. It’s in a group of androgen hormones that all humans produce. They include:

• Dehydroepiandrosterone sulfate DHEA-S
• Dehydroepiandrosterone DHEA
• Androstenedione
• Testosterone
• Dihydrotestosterone

Fun fact: All estrogen is made from androgens! The body converts testosterone into dihydrotestosterone (DHT, a more potent androgen) with an enzyme called 5-alpha reductase. Then, DHT converts into estradiol (the primary estrogen during the reproductive years) through a process called aromatization.

During the premenopausal years the ovaries produce a quarter of the testosterone in a woman’s body, the adrenal glands another quarter, and other tissues the rest.

Testosterone is essential for total body wellness; specifically, it plays a role in these systems:

• Reproductive tissues
• Brain health - mood and cognition
• Breast health
• Musculoskeletal health (bones and muscles)
• Skin and hair
• Cardiovascular system
• Metabolic health

Testosterone circulates free or bound to a protein, albumin or sex hormone-binding globulin (SHBG). High SHBG can contribute to low testosterone levels in women. When looking at blood labs, we order free testosterone, total testosterone, and SHBG.

Does Testosterone Decline in Menopause?

Androgen levels peak during the reproductive years and start declining in a woman’s mid-30s. Interestingly, menopause is not associated with a rapid decline in testosterone like it is with estrogen and progesterone. After menopause, the ovaries still make some testosterone.

The decline in testosterone is more linear, but by the time a woman is 10 years post-menopause, her testosterone levels are half of what they were in perimenopause.

Testosterone and Libido

Women’s libido and sexual health post-menopause is one area where testosterone gets lots of attention. Low libido is a common symptom during perimenopause and post-menopause, and testosterone is one piece of the puzzle.

Hypoactive sexual desire disorder (HSDD) is the clinical term for low libido. It includes decreased sexual desire, often along with painful intercourse or diminished arousal and orgasm. The condition is multifactor, stemming from emotional, relational, psychological, and physical root causes, including low testosterone. However, a diagnosis is not dependent upon androgen levels in blood tests.

Another contributing factor to low libido is genitourinary syndrome of menopause (GSM). Vaginal dryness, thinning skin, tearing, and discomfort make sex less pleasurable or even impossible in some cases. Cells in the genitourinary system contain not only estrogen receptors but also androgen receptors.

Do Women Need Testosterone Replacement in Menopause?

We know the benefits of using hormone replacement therapy (HRT), including estrogen and progesterone, for menopausal symptoms and long-term health, but where does testosterone fit in?

(If you need to catch up on the HRT conversation, please read The Women’s Health Initiative and HRT and Bioidentical Hormone Therapy Misinformation).

Unfortunately, there isn’t an FDA-approved testosterone prescription available for women. However, your provider can prescribe you testosterone through a compounding pharmacy or prescribe a male formula off-label and give you specific instructions about dosing. And it’s something you may want to discuss with them, especially if you have libido or HSDD concerns.

A 2019 review of 36 randomized controlled trials found transdermal testosterone to be an effective treatment for postmenopausal women with low sexual desire. Other research supports this conclusion and finds its way into a global consensus statement for testosterone in women and HSDD practice guidelines. It’s important to note that these studies conclude that more evidence is needed to prescribe testosterone for other concerns, such as musculoskeletal or cognitive health.

Intravaginal DHEA is approved for genitourinary symptoms in menopause, so this is another option to consider discussing with your provider.

Typically, it’s important to optimize estrogen and progesterone levels first before adding testosterone. Restoring estrogen levels may have a beneficial effect on libido and other menopausal symptoms independently. Further, estrogen and progesterone protect the system against high androgens. Everything needs to be in balance.

Please work with TārāMD or another menopause specialist to help personalize your hormonal care and provide follow-up monitoring. Too much testosterone can cause insulin resistance, weight gain, or unwanted facial hair. It’s one reason we don’t recommend testosterone pellets, which can cause very high levels in women.

How to Support Healthy Testosterone for Menopausal Women

From an integrative and functional medicine perspective, testosterone replacement isn’t the only tool in our tool kit for testosterone support. Here are some other helpful ideas:

• Optimize nutrition – Nutrition is foundational for hormone balance and production. Be sure to get enough protein, omega-3 fats, zinc, magnesium, and antioxidants, as these nutrients support testosterone production and pathways. For a more specific and personalized nutrition plan, work with a TārāMD nutritionist.

• Lift weights – While testosterone can help improve muscle mass, working to build muscle mass can also stimulate testosterone. Strength training is an integral part of a menopause exercise plan and supports lean body mass, bone density, metabolic health, and longevity.

• Try supplements – Specific supplements may help support low testosterone symptoms. These include: maca, ginseng, gingko, tribulus, fenugreek, zinc, or a combination formula. It’s important to choose a supplement designed for women, and note that some formulas will be geared towards lowering androgens (in PCOS, for example) instead of raising them. Please work with the TārāMD for guidance.

• Support adrenal health – After menopause, the ovaries still produce some testosterone, but the hormonal system relies more heavily on the adrenal glands. Support adrenal health by managing stress (easier said than done!), getting good sleep, listening to your body, and being gentle with yourself. Read more here.

• Work with a menopause specialist – You deserve comprehensive menopause care and ongoing conversations about the pros and cons of different treatment approaches. At TārāMD, we won’t tell you that your low libido or other symptoms are “just part of getting older,” as you might hear from other practices. We will take the time to understand your history and goals and put together a safe, evidence-based approach so you can feel your best. Bioidentical testosterone may be part of that plan if it’s a good fit and makes you feel better.

Testosterone isn’t always front and center in women’s health, but it’s an important hormone and one to be aware of as it declines in midlife. A healthy lifestyle, including nutrition, exercise, and stress management is foundational, and you may benefit from additional support from supplements or testosterone replacement. The most important takeaway is that if you are suffering, there are options, and we can help!

References

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