Testosterone for Women: The Evidence that the Guidelines Ignore
Treatment Scenario
Recently, a Midwest NP was reported to her nursing board for prescribing excessive doses of testosterone. One of her gynecology-physician peers did not like the NP prescribing testosterone for a shared patient who was not receiving HRT from her gynecologist. Note that the patient was quite pleased with the hormone treatments from the NP and the patient voiced no complaints. Once a licensing board receives a complaint against a clinician, they are obliged to investigate the complaint. Unfortunately, this case was reviewed by an independent endocrinologist who opined that the testosterone treatment was excessive and not necessary. The important concept to appreciate in these and similar cases is that licensing boards, whether it be for an MD, NP, or PA, have no idea or clue when it comes to the BHRT we prescribe. So, it then becomes our job to educate the licensing board.
The NP utilized all of the articles presented in the webinar series on testosterone in women. It is unfortunate that the licensing boards rely on endocrinologists as their experts, however the board does not know who else should be their expert in this scenario. Of course, an endocrinologist would not be expected to have any of the training, expertise, or knowledge of the literature as the NP with respect to testosterone administration. It is the system, and we just have to work around it. The NP was able to educate her nursing board by presenting multiple peer-reviewed studies and literature support demonstrating that she was practicing based on evidence-based medicine. After successfully educating her NP colleagues, the nursing board found no compromise in patient care.
The system that we have to deal with is one in which our peers are not well-informed. Being prepared and having a library of literature support is necessary to provide credence for our medical practice.
Haven’t started the Testosterone for Women series, but interested in learning more about the studies and data demonstration the benefits of testosterone in women that were ignored? Please consider taking Testosterone for Women (Part 1): The Evidence and Benefits No One Talks About.
The Evidence that the Guidelines Ignore
Last month, we reviewed the silver lining in the recent AACE guidelines. The endocrine society recommended testosterone for only one indication, which was hypoactive sexual desire disorder that is diagnosed clinically and not by any lab test or biological parameter. Nevertheless, AACE guidelines are always restrictive and ignore the plethora of data demonstrating multiple other benefits of testosterone in women. It is interesting and fascinating that the guidelines are restrictive in the use of testosterone, but at the same time, the authors list the various studies demonstrating health benefits in protecting against CAD, CVD, Alzheimer’s dementia, osteoporosis, and diabetes. However, the authors of the AACE guidelines do NOT recommend using testosterone in women to treat or prevent these medical problems, which is without reason. If the studies and science demonstrate health benefits without any harm, it is difficult to conceptualize why testosterone is not prescribed and recommended to all women. Leaving women testosterone deprived and subject to more illness seems tantamount to cruel and unusual punishment. Avoiding testosterone when short- and medium-term studies demonstrate no harm, is inappropriate in my opinion. The minor side effects on the integument are easily treated by dosage adjustment and spironolactone. On the other hand, there are other authors that have a different opinion, which we will review this month.
Whenever I read medical society guidelines, I always come away feeling that those who wrote these guidelines seem to have little to no experience in prescribing and optimizing hormones. They write the hormone guidelines for both men and women, yet lack the information, experience, and education to back up their claims. As I have previously stated, AACE guidelines are always restrictive in contrast to other medical academy guidelines that recommend so many different drugs and medications for varying circumstances. This month we will review other authors that perform a literature search further demonstrating the safety and efficacy of testosterone for women. Again, why do we ignore the science and literature demonstrating the many health benefits provided by testosterone in outcome studies? The authors do mention the association studies where high levels of testosterone are associated with an increased risk of DM and CVD. Unfortunately, the authors do not do a good job of explaining the difference between baseline association studies, observation studies, and RCT outcome studies. Fortunately, the authors do make a point of differentiating exogenous administration from control groups.
Multiple association studies have proven that higher levels of testosterone are associated with better sexual function. (Yes, it is an association study, so I want to know what happens when I give testosterone). The authors then go on to explain that measuring levels is not appropriate due to the extreme variation in different laboratory tests. The sensitivity varies, yet there is one test that appears to be the most accurate and most expensive. After much discussion, the conclusion was that numbers do not correlate with symptoms nor predict those that will improve. After much discussion, the authors state the action of testosterone is a result of intracellular metabolism, so serum concentrations alone are not a good index of tissue exposure. Sensitivity at the level of the androgen receptor also determines an individual’s response to a given level of testosterone. In clinical practice, therefore, concentrations of testosterone in serum are somewhat arbitrary and should always be interpreted in accordance with the clinical presentation. The above statements I have used many times to defend clinicians that are criticized or investigated for “excessive dosing” of testosterone. Our endocrinology peers do not read OB/GYN literature that proves safety and efficacy of “high dose” replacement.They don’t read that treatment should be driven by clinical response irrespective of serum testosterone levels or doses. Anyone that criticizes our dosing, serum levels, or treatment modalities lacks the clinical experience, insight, education, and the medical literature support that guides our therapy. Those that possess the knowledge and experience are not the ones that write the guidelines. Those that are deficient in clinical experience and medical literature knowledge are the ones that write the guidelines. As a result, I present this paper to further support our methodology and this paper is another in a series of papers with my theme of, “Here, read this!”
Haven’t started the Testosterone for Women series, but interested in learning more about the studies and data demonstration the benefits of testosterone in women that were ignored? Please consider taking Testosterone for Women (Part 1): The Evidence and Benefits No One Talks About.
