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What’s the Big Deal with Testosterone?

There’s more and more conversation about testosterone replacement in women, but understanding its role in women, and knowing whether it’s something you might benefit from, isn’t always easy.

What is testosterone and what does it do?

Testosterone is the third female hormone which decreases with age, from the mid-thirties onwards. The rate at which testosterone declines varies from woman to woman, as does the effect of the reduction.

Testosterone increases dopamine levels in the nervous system – an important type of neurotransmitter that among other things plays a role in how we feel pleasure. Testosterone also contributes towards metabolism, muscle, bone, genital and bladder health.

In women, testosterone production is split between the ovaries and the adrenal glands. Testosterone can act directly on body tissues, but some of it is converted to oestrogen, mainly in fatty cells.

Following surgical or medical menopause, women can experience a sudden drop in testosterone production which can lead to severe low testosterone symptoms. It’s important that women, and their medical teams, are aware of this and know what to look out for.

What are the symptoms of low testosterone?

  • Testosterone is linked to sexual function, which includes libido and sexual experience. When testosterone levels are low women may lose all interest in sex. Sexual satisfaction may also be reduced, with poor quality and reduced frequency of orgasms.
  • Low testosterone levels are also associated with reduced feelings of wellbeing and joy. Women may feel flat or depressed; they may no longer feel the joy in life and in activities they previously did, leading to feelings of guilt. They may even pretend to feel joy and happiness, just to fit in.
  • Blunted motivation and a lack of ‘va-va-voom’ are features of low testosterone. Women may say ‘I can’t be bothered’, when talking about things they used to enjoy, or lack drive for something new.
  • Unexplained persistent fatigue may suggest testosterone is low. This can negatively affect all aspects of a woman’s life.
  • Reduced muscle strength and recovery. Women may find that despite doing the same amount of exercise, or even more than before, they are losing muscle tone. Muscles may also ache more and for longer. This can be disheartening and reduce motivation to exercise.
  • Changes in cognitive functioning and memory can manifest in feelings of ‘brain fog’ with low testosterone. Other associated symptoms include word finding difficulties, poor multi-tasking and organisation, difficulty concentrating and memory loss. Women may notice they struggle to function at work and home in the way they used to. They can be drained, mentally and physically exhausted, and lack the confidence they’ve always had.
  • Low energy levels are often linked with low testosterone in women. This may be the need to sleep in the day; constantly feeling tired; not feeling like you’ve slept well despite having had a good number of hours sleep that night. This can be debilitating.

Where do I start if I think I might need testosterone?

The first step is to talk to a healthcare professional with experience and knowledge of prescribing testosterone for women. They will discuss the symptoms you are experiencing and decide with you if these could be related to low testosterone. This is a really important discussion and shouldn’t be rushed. A doctor with experience in this area will know what questions to ask and be able to assess if testosterone is worth pursuing.

How is deficiency diagnosed?

If it’s possible that testosterone replacement might help your symptoms, the next step would usually be a blood test, though blood levels don’t always correlate to the severity of symptoms a woman is experiencing. The test would check oestradiol, total testosterone and Sex Hormone Binding Globulin (SHBG) levels.

Oestradiol levels help assess whether you are receiving an adequate amount of oestrogen. This is important because there are similarities between symptoms of low oestrogen and low testosterone. If blood oestrogen levels are low, it’s likely the first course of action would be to increase oestrogen as this may be enough to resolve symptoms.

Women’s bodies will tend to want oestrogen over testosterone, not least because oestrogen is a source of energy for the body. As a result, if a woman needs more oestrogen and is given testosterone, the body will convert some of the testosterone into oestrogen through an enzyme called aromatase. So, it’s sort of a waste of any testosterone replacement if you aren’t at an optimal oestrogen level before introducing it.

It’s worth noting that blood oestradiol levels can only be used if a woman is receiving oestrogen through the skin. Blood levels don’t accurately reflect the amount of oestrogen being taken with oral forms of oestrogen.

Total testosterone measures the total amount of testosterone in your blood stream.

SHBG is a protein produced by the liver; it will bind to some testosterone molecules in the body. Any testosterone bound to SHBG is inactive and can’t be used by the body. So it’s important to know how much testosterone is available in the body and importantly, if it can be used.

Using the total testosterone and the SHBG levels a doctor can calculate Free Androgen Index (FAI).

What’s so important about Free Androgen Index (FAI)?

If FAI is low, and a woman has symptoms of testosterone deficiency, then a trial of testosterone might be appropriate. If FAI isn’t low, there is a higher risk of side effects from testosterone replacement and it’s also less likely to lead to any symptomatic benefit.

If a woman starts testosterone replacement, blood tests are needed at regular intervals to check testosterone is being absorbed through the skin and to ensure FAI levels stay within normal the physiological range for woman. Monitoring FAI levels while using testosterone ensures the risks of any significant side effects are very low.

In summary

It can be all too easy to ignore unexplained symptoms in the perimenopause and menopause. However, if symptoms have started in midlife or after, and are associated with a change in periods, then it’s worth discussing the possibility of low testosterone with your doctor or menopause specialist. And while symptoms of testosterone deficiency are not always clear, and it’s important that other possible causes are excluded, testosterone may be the missing piece for you.

Blood tests are usually needed when testosterone replacement is being considered for a woman. There’s always variation in how blood tests are taken and interpreted, and doctors will ultimately decide what is best for a woman’s situation based on symptoms, individual preferences and priorities, past medical history and blood test results.

Dr Emma Ping qualified as a GP over 20 years ago, and is dedicated to providing evidence-based menopause care. She is passionate about offering women holistic, patient-centred, bespoke advice and empowering them to maximise their wellbeing and long-term health at any age. She recognises that every woman’s situation is unique, and understands the difference positive advice and treatment can have on the way you feel and quality of life. She has a special interest in genitourinary syndrome of the menopause.

Dr Emma Ping is part of the team of Menopause Specialist GPs at https://menopausecare.co.uk/

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