Balancing Testosterone

Testosterone is, ideally, the second or third hormone added and balanced in HRT. We've said this before but we'll repeat it because we think it's important and we don't want you to miss it by reading skipping around. The statement in the American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Menopause (free signup required to read) that we cannot determine our need for other hormones until our estrogen is as fine-tuned as possible makes simple, physiological sense of the kind it's hard to argue with once stated. This means that the current chic of adding testosterone to compensate for ill-fitting estrogen hrt is pretty much unjustifiable given the risks both testosterone and progesterone pose.

If, however, you don't get what you're looking for from estrogen, then it is time to look into supplementing this other important ovarian hormone.

At this point in previous versions of this article, we would suggest that supplementing progesterone before testosterone provides a safer overall hormonal profile of risks. Now that we know more about progestogen risks, especially their links to cancer, we feel that picture is much less clear. Still, all we can do is point out the dangers: it's up to you to weigh what you hope to accomplish and how you choose to get there. If you're thinking about using testosterone to boost libido, we'd like to point out that there are other areas to evaluate in the libido troubleshooting decision tree before you get to that; you might find it useful to have a look at the Sexuality and surgical menopause article to review those steps.

Okay, disclaimers about risk and benefit aside, let's look more closely at supplementing testosterone.

Testosterone supplementation for women is fairly new. Only a decade or two ago, researchers were trumpeting the astonishing news that women produced and had receptors for testosterone. Predictably, a few books were written that claimed everything a woman had wrong with her could be cured with a little testosterone, and if a little was good, a lot was better. Our stance is a lot less glamorous, but may be more survivable.

We feel that since our ovaries averaged an output of around 0.3 mg a day of testosterone, that's probably all we need of the stuff. Guys, obviously, have a lot more. Because a lot of testosterone supplements were designed for them and the experience of doctors and pharmacists is primarily with them, you may need to rein in the dose enthusiasm of the professionals. Doctors seem fairly willing to write prescriptions for testosterone, but you may need to convince them that you only want a smidgeon. For this reason, even though there is a tendency to write prescriptions for 2% or even 10% creams, a 1% or even 0.5% preparation makes a more reasonably-measureable strength for a prudent woman's dose range.

A lot of women come home from the pharmacy with their new tube of testosterone cream only to find the directions say "take as directed" and their doctor's office says something like "measure out an inch a day" when they call and ask them how they're directed to take it. The right way to approach this situation if the label doesn't show the cream strength is to call the pharmacy, speak to a pharmacist, and ask what is the strength of your cream in milligrams/unit volume and how many miligrams is in each prescribed volume dose.

Why do the numbers matter? All other things being equal, a good place to start is replacing what your body made normally: roughly 0.2-0.5 mg/day. Or even less if you are also using progesterone. By working around a normative amount, you can be both consistent and reasonable. If you need to add more later, fine—but at least you aren't going to start out at disaster level. And if you only need a very small volume every day, ask your pharmacist for a small, needle-less syringe so you can measure accurately. Your body will appreciate consistent dosing.

Beginning testosterone

When you begin testosterone, it's not uncommon to feel a quick zing from it and then not much. Response time to testosterone is generally slower than with the other two hormones. It usually takes a full month or three (yes, we really just said three months) for it to take effect, and that can be a long time to wait (especially if you have a partner slavering over the prospect of a new, interested you). In addition, because it affects the balance and supply of both estrogen and progesterone, it is not unusual to get a few hot flashes in the first week or so you're taking it in human-identical form. This transitional effect does settle down as things shake out, but it can be distressing if you think you've gone after a little sexual boost without realizing you've altered your overall hormone balance.

It not unheard of to need to adjust the other hormone doses to accommodate the addition of testosterone. Some testosterone is converted to estradiol, so it's important to understand that may act as an estrogen supplement if you're not fully meeting your estrogen needs on your estrogen hrt. According to some manufacturers, men using testosterone see a 10% or more increase in their estrogen levels when beginning testosterone supplementation. This has important implications for both typical hrt balance as well as for those who cannot or choose not to supplement their estrogen levels, since as a priority, estrogen needs will be met with the testosterone before our bodies use any leftover testosterone as itself.

If you have been on testosterone a month and don't feel that you are terribly thrilled with the results, you might also explore whether you need every bit of the estrogen you are taking. Remember, estrogen in excess tends to suppress arousal and orgasm, so in that respect it counteracts testosterone; it also raises the level of a protein that inactivates testosterone.

If this seems like a confusing situation, it is. Or at least, it is from the standpoint of our trying to drive what our body does with the supplements we give it. In fact, our body prioritizes hormone needs and scalps from everything lower down on the priority list to meet higher-priority needs. Estrogen will always trump progesterone or testosterone. Which, coming full circle, is exactly why the Endocrinologists' guidelines specify estrogen adequacy as the starting point for other hormone supplementation.

The other caution that we'd like to urge on women beginning testosterone supplementation is to be sure of their cardiovascular heath beforehand. The male profile of CV risk is higher than a woman's, and much of that is conveyed through the actions of testosterone. Many careful doctors today check a woman's lipid levels (cholesterol, HDL, LDL) and blood pressure before she starts taking it, so that if they are elevated or become elevated after she has been on testosterone awhile, other interventions can be put into place to control them. Since our risks of CV disease are elevated by menopause anyway, we think that's such a sound measure that we'd urge women whose doctors haven't thought of this to request it themselves. We think sex is just swell, but for all that taking testosterone might improve it, having a stroke surely won't.

Using testosterone

Testosterone cream and gels prescriptions tend to be written in terms such as "take as directed" or "a pea-sized amount". In fact, as we mentioned above, there's quite a bit of flexibility in dosing and the ultimate goal should be, as with any hrt, using only as much as provides the desired effect

One thing that's easier with testosterone balancing than either estrogen or progesterone is that it doesn't have to be used on a daily basis. We respond more slowly to both a dose and a dose wearing off, so it's fine to use testosterone on a weekly or few-days-a-week basis. We have to feel our way to the frequency and dose, both, that provide just the support we're looking for. But unless we're using testosterone as a major contributor to our estrogen balance, intermittent use should not cause symptoms of estrogen fluctuation. In fact, if it does, that's a good indication that we should revisit our primary estrogen hrt rather than relying upon testosterone to make up its shortfall. 

Another thing prescriptions tend to be skimpy in the details on is where we should apply testosterone creams or gels or ointments. Basically they can be used anyplace away from breast tissue where we don't mind stimulating a little hair growth (no, this does not mean that if we're showing signs of balding we should apply it to our scalp: it doesn't work that way). Some women report good results using the inner thigh. Other women apply it to their labia or even clitoral tissues, and that seems to work as well. In any application, be sure to keep in mind that we really don't want to share our topical hrts with partners or children, so we should limit their direct contact with the skin to which it's applied and wash our hands properly after application. 

In essence, then, the process is one of beginning with a very small amount and working upward until we fid steady support at the level we desire. If we get to the full daily amount without hitting that point, adding another day of use per week, all of them at a somewhat lower level, will give us a gradual stairstep up without overloading ourselves on a less frequent basis. This is truly a feel-your-way-along process.