What You Need to Know About Testosterone Therapy in Menopause

In part three of five transcripts from Dr.Rebecca Dunsmoor-Su’s interview with David Stewart on the SuperAge podcast, “HRT, Estrogen and Menopause, New Scientific Findings with Dr. Rebecca Dunsmoor-Su”, she reviews the need for quality sleep, and what you need to know about testosterone therapy in menopause.  Please listen to the full podcast by visiting SuperAge.com.  

The need for quality sleep  

David: I know that if you're not getting deep sleep, your brain's not being cleared out, and your chances of Alzheimer's dementia goes through the roof.  So, how are you addressing that?

Dr.Rebecca: Sleep is really key for women, especially, as we age. It's not just the Alzheimer's dementia risk, which is higher in women as we know. But it's also the fact that if you're not getting deep sleep, you're reducing your basal metabolic rate. All women tend to start gaining weight during this time in this transition. It probably has a lot to do with their lack of sleep. You can lose about 400 kilocalories a day in your basal metabolic rate if you're not sleeping well. It tends to generate a little bit of an insulin resistance from that lack of deep sleep. Your cortisol never really goes all the way down. You don't get to that really restful place. So, sleep is really key.

How do we address it? Well, I address it in a couple of different ways. I address it with the one proven therapy for sleep that's been shown in studies to actually work which is cognitive behavioral therapy for insomnia, either using an app, or an online system, or they can even work in person with someone. But the apps in the online versions are actually quite good, and can really help people track their sleep habits, and make changes that helps them to sleep more deeply. Then, sometimes, I address it with hormone therapy, if that's one of their big symptoms, and they want to try hormone therapy for it.

David: What is cognitive behavioral sleep therapy?

Dr.Rebecca: Cognitive behavioral therapy is a style of therapy that works on behaviors-recognizing behaviors, and changing them is basically the tenant of cognitive behavioral therapy. There's a specific subset called cognitive behavioral therapy for insomnia. And what that does is, it very specifically tracks behaviors around sleep, about when you go to bed, what you do when you wake in the middle of the night, what things you include in your bedtime ritual, what do you do when you wake in the morning, all these types of things. And then, it works with you on how to adjust those to improve your sleep.  And there's a great app that people can get for free called CBT-I trainer, I believe. It was made at the VA for veterans with PTSD. So, it's free to everybody. It's in your app store. You can just download it and give it a try.

 David: In my world, I would call this good sleep hygiene.

Dr. Rebecca: It’s a bit more structured than good sleep hygiene. They're actually things that it recommends in terms of like, if you wake in the middle of the night, you actually get out of bed, don't check the time, go to a quiet place and actually sit up. It's a little bit more, but yeah, it starts with good sleep hygiene. 

About testosterone therapy

David: So, let's talk about this other hormone that you mentioned, testosterone. Is it ever a good idea for a woman to be supplementing testosterone?

Dr.Rebecca: I'm glad you're bringing it up because there's a lot of what I like to call predatory practice out there - when people are selling women testosterone as a fountain of youth. Testosterone is anabolic steroid. It will make you feel great - and then, it'll wear off, and you'll need more, and then, you'll feel great for a little while, and it'll wear off, and you need more. So, we end up seeing as women getting into really high levels of testosterone, basically male levels of testosterone, and getting all the joy that comes with that including facial hair and acne. Their voices can deepen, they can grow an Adam's apple, they can actually grow a small penis from their clitoris. But also on the inside, they're getting cardiovascular disease on the level of men.

Testosterone is an important female hormone. As I mentioned before, it doesn't really go down with menopause. It goes at a slow drift throughout our lifetimes, but you haven't suddenly lost it. People assume as we go through menopause, and there's often a change in libido, that its testosterone causing that change. In fact, it's probably a much more complex thing that has to do with psychological factors, how we feel about our bodies, how we feel about our aging, how we feel about our relationships and all those things that are causing that drift down in libido. But there are some small studies that have shown that replacing testosterone at very low female physiologic levels can give a slight boost to libido in women. So, you can increase their sexual satisfying events by about two per month over time. 

David: I know you don't like to say numbers, but can we put a number on that? What's the dosage?

Dr.Rebecca: We're having to use male-dosed products at female levels. Because there is no female-dosed testosterone product available in the US that's FDA approved. So, we're just struggling with that as physicians. A lot of people are given like compounds or pellets, these are dangerous, very hard to manage, and you can get really high testosterone levels. Those of us who practice in this space typically take a male-dosed product - it comes in little packets of five milligrams each, and for a man, that five milligrams would be a one daily dose. We have women use 1/10th of that a day. So, about 1/10th of five milligrams, 500 micrograms. We're taking it down and trying to keep it in the female physiologic range. It's hard for us to do. It's something that those of us who work in the sexual function space really struggle with because we think there's some decent data for this, but it's really hard to safely replace in women. This is not something that should be routinely replaced in women because it is hard to manage, you have to get blood tests regularly to make sure we're not bumping you too high to the male range, and it's just something that has a role, but a very restricted role. 

Whether you suffer from sleep issues, hot flashes or changes in sexual function, finding the therapies that fit your needs can seem daunting.  Skip the endless searches for information, and tap into the proven therapies of our integrated care team.  You will access both evidence-based lifestyle strategies and treatments approved by our CBT-trained health coaches and physicians who specialize in menopause.

Continue to part 4 to learn about the three typical usage patterns of HRT, the risks of HRT, plus why the risk of Alzheimer’s disease is so much higher for women.

Did you miss part 1 of this series? Learn about the hormonal journey and why hormone testing is not always helpful.

‍In part 2, you'll learn about the benefits of estrogen, and why some women are not good candidates for HRT.

And be sure to listen to the full podcast episode at SuperAge.com.