Testosterone for Women: The Levels Necessary to Achieve Symptom Improvement
Testosterone for Women: The Levels Necessary to Achieve Symptom Improvement
Written by Neal Rouzier, MD
A 45 y/o premenopausal woman presents with the typical perimenopausal symptoms of HSDD, fatigue, weight gain, loss of energy. Your history and w/u do not reveal any relationship issues, medication issues, or any other confounding factor that may be causing the patient’s symptoms. You prescribe testosterone to her, but she reports no improvement in symptoms. After doubling the dose of testosterone, she notices significant improvement in her symptoms and relates improvement in strength, energy, and weight loss. However, her PMD becomes very upset when he tests her hormone levels. The patient becomes alarmed when her TT level approaches 400 ng/ml. You then provide literature support for supraphysiologic levels and advise her to never have her PMD test levels. In addition, she is advised to stop her hormones if the PMD ever insists on testing hormone levels. You now realize the importance of discussing supraphysiologic levels to achieve symptom improvement as well as the consequences of involving her PMD in her hormone program. If the patient is well educated from the beginning on the benefits of testosterone and that the benefits typically require supraphysiologic doses, then they are not so alarmed when supraphysiologic levels are seen in their lab tests. And this applies to all hormones.
In the first course, Testosterone for Women (Part I), I reviewed the current controversy in prescribing testosterone to women. In a separate consensus paper that is different from the one discussed in the first course, the authors recommend testosterone replacement based on symptoms and signs and not on serum levels. In fact, in this second consensus paper from “experts that have experience in the field of testosterone administration,” the authors stressed the importance of replacing testosterone to improve symptoms and not by being guided by numbers or levels. These authors specifically emphasized that testosterone should be supplemented based on symptoms and not just on serum levels alone, as testosterone levels do not correlate with symptoms as per much of the medical literature. The authors also suggested that testosterone should be dosed and adjusted based on symptom improvement, and not by testosterone levels. The authors reiterated that no number (or testosterone level) denotes a deficiency as symptoms denote a deficiency. Furthermore, improvement in symptoms do not correlate with numbers either as all women will respond differently and not based on any number. So, in contrast to men where the guidelines state that we must follow levels and numbers, these guidelines for women recommend that we do not test baseline levels nor treatment levels, rather symptoms should guide treatment initiation.
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Symptoms vs Numbers Adjusting Testosterone in Women
Symptoms, and not numbers, should also be used to adjust and change dosing as symptoms do not correlate with serum levels. (As I commonly explain to patients, I use the numbers or levels as a guide to my therapy and I don’t restrict therapy based on a number). What a concept! This is completely the opposite of the guidelines for men where we are forced to focus on numbers and not symptoms. How can the rules and regs for women be so opposite to that in men? In men, we are forced to adhere to numbers which are intended to restrict therapy in men. In women, it is the opposite whereby we are instructed to treat women based on symptoms, usually sexual dysfunction, and to completely ignore numbers because they don’t predict symptoms or symptom improvement. The treatment in women is completely divergent to that in men. We will review the most recent consensus recommendations on treating and monitoring testosterone in women. Again, we must realize that consensus statements will differ based on the experience and expertise of the clinician, as well as their political and economic agendas. And yes, I’m very biased in my opinion also, but that is based on a review of hundreds of published articles and reviews.
Testosterone Therapy Guided by the Studies
Be aware that there have been multiple papers, guidelines, consensus opinions, expert reviews, as well as randomized clinical trials on the use of testosterone in women. Each and every paper written will be based on a clinician’s clinical experience and understanding of the medical literature. Opinions will also be guided by their confirmation bias, political agendas, pharmaceutical industry affiliations, past medical training in hormone therapy, and their desire to help patients or not help patients. A command of the medical literature is also beneficial in this circumstance as the medical literature and science should guide our therapy as opposed to someone’s biased opinion and who has no command of the medical literature nor any expertise in prescribing testosterone. Some recommendations state that testosterone should only be prescribed to maintain levels within normal limits. Other expert opinions utilizing data and studies suggest that testosterone should be dosed based on symptom improvement which frequently requires supraphysiologic dosing to supraphysiologic levels in order to achieve adequate symptom improvement. Dosing to maintain “physiologic levels” as suggested by some authors does not result in symptomatic improvement as per most RCTs. The foregoing involves two completely different opinions and concepts which can be confusing to patients and practitioners. Nevertheless, our therapy should be guided by studies that demonstrate success of treatment and improvement of symptoms and not by someone’s biased opinion that may not be evidence based.
Unfortunately, numbers and serum levels can be confusing to patients. This becomes more problematic when patients discuss their therapy and blood tests with their PMDs. As I have stressed throughout the Hormone Optimization Workshop Series, once a patient involves their PMD in their treatment for HRT replacement, then I will suggest that their PMD prescribe their hormone therapy. Never will the PMD understand hormone optimization, optimal levels into supraphysiologic ranges, or treatment goals to improve symptoms. Nowhere in the medical literature does it dictate or suggest when or how serum levels be tested. As a result, I have changed my thinking as I now recommend that serum levels be tested in a trough level to document/demonstrate lower levels of testosterone as opposed to showing patients optimal levels. High supraphysiologic levels tend to upset and confuse patients and their PMDs. However, experienced clinicians often advise patients in advance of the need to attain supraphysiologic levels in order to achieve symptomatic improvement. In keeping with this concept, I have provided 2 papers in Testosterone for Women (Part 2) that can be given to patients demonstrating that only supraphysiologic levels result in symptom improvement. Hopefully, this will alleviate any patient concern when they see their testosterone levels in the supraphysiologic range. In this course, we will review the levels necessary to achieve symptom improvement, the levels that were measured when symptoms returned, and the time frame from symptom resolution and the subsequent return of symptoms.
“Supraphysiologic” vs “Normal” Testosterone Ranges
Lastly, everyone wants to know a number, dose, range, goal, etc., despite all of the foregoing. OK, we will look at appropriate dosing and the numbers achieved. Brace yourself, the numbers achieved are very supra-physiologic which goes against some guidelines, normal ranges, opinions, and peer recommendations. However, guidelines that suggest keeping testosterone levels within the normal range ignore the plethora of data demonstrating that symptom improvement in women requires very high supraphysiologic levels. Maintaining TT levels outside the “normal” range makes some PMDs and our peers very uncomfortable. IMHO, any author or expert that recommends that total testosterone levels be “kept and maintained within the normal range” does not have any experience or expertise in prescribing testosterone for women. Realize that outcome studies demonstrating symptom improvement only with supraphysiologic levels are in stark contrast to some expert opinions where the “expert” authors recommend that testosterone levels must never go above the “normal range.” There is no study that demonstrated maintaining TT levels within the range of “normal” provided any benefit or symptom improvement. If you want to prescribe a dose of testosterone that doesn’t do anything, then use a dose that keeps your measured level within the “normal range.” Any expert or guideline that recommends maintaining testosterone levels within the “normal range” reflects their complete ignorance, misunderstanding, lack of clinical experience, and command of the medical literature demonstrating that supraphysiologic administration of testosterone is safe, efficacious, and necessary in order to achieve symptomatic improvement.
Improvements for Quality of Life with Testosterone for Women
Fortunately, the original consensus guidelines written by biased male members of gynecologic societies have been rebutted and replaced by expert guidelines by clinicians that are familiar and experienced with treating women with testosterone. Again, guidelines are only opinions or suggestions and are subject to bias depending on one’s experience and political agendas. Despite one’s opinions, we should not reject and ignore the overwhelming literature demonstrating safety and efficacy of testosterone to improve symptoms and quality of life. Although most of the literature reviewed during the courses on testosterone in males addressed reversal of diabetes and CVD, this series of testosterone courses in women will address that the goals in women are different and focus more on improvement in quality of life and well-being and not on some unscientific number or lab test. And that is based on multiple studies published by experts with years of experience in prescribing testosterone to women. Symptom improvement requires supra-physiologic levels which is in contrast to some guidelines that dictate testosterone should be kept within a normal physiologic range. As for me, I simply follow the medical literature that I pass on to you in the Hormone Optimization Workshop Series where we teach the prescribing, monitoring, adjusting, and documenting symptom improvement when using testosterone in women.