For Women

Hormone replacement therapy (HRT) provides women with, or replaces, hormones that their ovaries stop making. The ovaries make estrogen and progesterone as part of the menstrual cycle. The ovaries also make androgens, including testosterone. Hormone levels usually start to change during perimenopause, the years just before menopause. In perimenopause, many women begin to have symptoms such as hot flashes, vaginal dryness, irregular periods, and insomnia. The reason for the symptoms is usually fluctuating and declining hormone levels.

These hormonal changes are due to aging ovaries that are losing their ability to produce eggs and hormones. Women may have widely varying estrogen levels during their monthly cycles as the ovaries keep trying to produce eggs. Often there will be cycles in which no ovulation occurs (called anovulatory cycles) and therefore no progesterone is produced. This can lead to irregular cycles with heavy or abnormal bleeding as a woman approaches menopause. ANY ABNORMAL BLEEDING, PAINFUL OR IRREGULAR MENSES, TENDER BREASTS, PMS SYMPTOMS ARE A RESULT OF LOW PROGESTERONE.

At menopause, the ovaries stop producing and releasing eggs (ovulating) each month, and monthly periods stop completely. The ovaries are no longer producing estradiol and progesterone (although they continue to produce androgens). Menopause does not mean, however, that you have no estrogen in your body anymore. Women with more body fat usually have more estrogen than thinner women do, because estrogen is aromatized in fatty tissue.

After menopause, there is much less estrogen and testosterone in the body than before menopause, and very little progesterone. This drop in hormone levels can have various effects, including the familiar symptoms of menopause such as hot flashes, night sweats, vaginal dryness, and loss of libido.

A woman who has a surgical menopause, in which her ovaries are removed (usually along with her uterus and fallopian tubes), will have a much more sudden drop in all sex hormone levels than a woman going through natural menopause. This sudden loss of hormones can cause severe symptoms and health problems, especially in younger women, unless adequate hormone replacement is provided.

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Testosterone and Its Benefits to Women

If you have your ovaries removed or you are in natural menopause, your testosterone levels drop by 1/3 or more, and it is definitely advisable to replace it along with estrogen. As one author, Dr. Susan Rako, MD, stated, “It is the Hormone of Desire.” Besides the bone and sexual benefits, it also acts on the brain, muscles, liver and blood vessels, as it enhances cognitive functions.

The negatives of too high a dose of testosterone include susceptibility to baldness, facial hair, acne or deepening of the voice. Dr. Elizabeth Barrett-Connor, MD in San Diego says, “Definitely, one size does not fit all and the testosterone should be tailored to each individual according to needs.” In therapy the goal is to reinstate what the woman had before menopause, to bring her back to what she was and how she felt.

Testosterone can be administered as a cream, sublingual tablets, as a single testosterone dose or in combination with progesterone and estradiol. Forms and dosages of testosterone supplementation include:

  • The sublingual tablet dissolves under the tongue 2 hours prior to bedtime.
  • A topical gel that gives a 24-hour even release capability is applied to clean dry skin as 2. ml. per day.
  • A testosterone 2% thick gel is available to apply a small amount (lentil pea size) to vulva area about 1 hour prior to bedtime every day.

Testosterone’s Impact on Postmenopausal Women and Breast Cancer

Loss of libido, fatigue, and anorgasmia are common testosterone related symptoms women experience as their natural production of hormones starts to decline during perimenopause and menopause. The loss of testosterone is often a concern for patients and their physicians, and many are asking, “Should testosterone be used as supplementation in postmenopausal patients?” Additionally, there is worry with the effects of testosterone on women with breast cancer.

Testosterone is an androgen or male hormone found in low levels in the female body. It is a steroid produced in the ovaries, the adrenal gland, and from conversion of other steroid hormones, such as androstenedione and dehydroepiandrosterone (DHEA).1,2,3.

Testosterone’s role in the body is to build muscle and promote muscle tone, increase libido, strengthen bone and in some will improve mood and metabolism. Testosterone levels typically decline as we age due to declining ovarian and adrenal function, Another possible driver of decreased testosterone is an elevated level of a binding protein called sex hormone-binding globulin (SHBG). SHBG binds to both estradiol and testosterone and inactivates the function of these hormones while they are bound to it. An elevated level of SHBG lowers the bioavailability of testosterone and can be an issue for patients on hormone replacement therapy because oral estrogen therapy has been associated with increases in SHBG.

While currently there is not a commercially available testosterone supplement for women, supplementing a women’s testosterone level into a normal range has been shown to improve their sexual enjoyment and libido. Numerous women will also testify to the positive effects they experience once their testosterone and other hormone levels are returned to a normal range with hormone supplementation.

When evaluating testosterone’s impact on breast cancer, it is unclear if testosterone is a singular causative agent or if breast cancer is a result of other hormonal stimulation such as estrogens or synthetic progestins. Several clinical studies have attempted to answer this question with results suggesting that there is more to the equation than testosterone. A study that followed 508 postmenopausal women receiving testosterone in addition to usual hormone therapy, evaluated the role of testosterone in hormone replacement therapy. The observations began in 1987 and ended in 1999. Participants received testosterone implants 50-150mg, with a common dose of 100mg, every 5 months in addition to estrogen or estrogen and progestin treatment. The testosterone dose was titrated to relieve symptoms, improve bone mineral density, and decrease possible adverse effects. Seven invasive cases of breast cancer were seen throughout the study. Six out of the seven cases were seen in the estrogen/progestin/testosterone arm. In contrast, only one case was seen in the estrogen/testosterone arm of this study.3 In comparison, the incidence of breast cancer was 2-3 times higher among the estrogen/progestin arm of The Women’s Health Initiative study (WHI). One might possibly surmise that the common thread in these results was the progestin therapy, not the estrogen/testosterone therapy, although this has not been clinically proven.

It has been shown that estrogen therapy may disrupt the balance between estrogen and androgens; therefore, lead to estrogenic stimulation of the breast cells.3 The increased stimulation may lead to cell proliferation, differentiation and ultimately to breast cancer. Estrogen therapy has been shown in an animal study to decrease ovarian production of testosterone by inducing a negative feedback loop in the ovary where luteinizing hormone levels are decreased, leading to decreased production of testosterone and ultimately estradiol; therefore, changing the balance of estrogen and testosterone.5 Experimental data from rodents and monkeys suggest that conventional estrogen treatment may upset the normal estrogen/androgen balance and stimulate estrogen in the mammary epithelium.3 Therefore, increasing a patient’s chance of developing breast cancer.

Clinical studies have provided conflicting results when looking for a clear correlation between testosterone blood levels and breast cancer in postmenopausal women.6,8 As of to date, there aren’t any unbiased trials of sufficient size and duration to evaluate the effect of testosterone in breast cancer. A review of published studies did not find an adverse effect from estrogen/testosterone therapy when evaluating testosterone’s effect on breast cancer. In addition, one study concluded that testosterone may decrease the risk of breast cancer when conventional hormone therapy (i.e. estrogen and progesterone) includes testosterone.3 Another study looked at androgen receptor antagonist in primates and concluded that endogenous androgens (such as testosterone) inhibit mammary proliferation, thus potentially decreasing its impact on breast cancer.

There is an abundant amount of information supporting and rejecting the supplemental use of testosterone in hormone replacement therapy for postmenopausal women. Theoretically it makes sense that replacing all hormones that are decreased during menopause, including testosterone, would have some benefit. Data has suggested that adding testosterone to conventional hormone therapy in postmenopausal women might reduce the hormone therapy-induced breast cancer risk in this population.

Further evaluation is needed to clearly determine the role of testosterone in postmenopausal women. Testosterone supplementation has not been conventionally recommended if there’s a family history of breast cancer, although some physicians believe that there may be a benefit in maintaining normal levels through supplementation. In addition, testosterone supplementation is generally warranted in women complaining of low libido and sexual problems.

Testosterone is referred to as the “Other Hormone,” and it can add zest to menopause. Monthly surges of this androgen boost your well-being, sense of personal power and sex drive. Other benefits derived from testosterone are that it helps promote bone growth, and it can help relieve mild depression, some vasomotor symptoms, and vaginal atrophy and dryness.

Testosterone can be the “Impulsive Hormone,” and there is a parallel of information about it in men and women. Those with higher levels are usually single, aggressive, and dominate and take risks, but these impulses can be channeled and controlled in order to avoid problems. In women a little bit can go a long way, as it enhances sexual desires and fantasies, helps make women more easily sexually aroused, to enjoy intercourse better and have more frequent orgasms.