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Chapter 1: Why are so many women denied testosterone treatment?
So, Susan, it's very exciting to have you here, usually with guests in the US. I've never met them before, but I have had the pleasure of meeting you, having lunch with you, spending time with you recently at a conference in Los Angeles. So it's great.
Mo Kirher, who's been on my podcast twice, Mo is a great friend of my husband, who's also a urologist, has been on my podcast talking about testosterone and everyone wants to know about testosterone. And it feels like...
testosterone is almost like a naughty word for some people and it's the best thing ever for others so i'm really keen to like just talk to you about testosterone but also about how we can individualize care for women and personalized care and and just a bit about your approach really so you're you're a doctor you've got a really interesting background and um you ended up
Being in America, even though you're originally from New Zealand, so even that's a great story. So can you just say a bit about your background before we start talking about testosterone?
Yeah, well, that's such a nice introduction. Thank you. It's so lovely to be with you. And I've been following you for ages and had this amazing opportunity to meet you in LA at a meeting and we hit it off. And we've got connections, as you said, through Dr. Kira, who I just saw on your podcast a few weeks ago.
So yes, I was born in New Zealand, moved here when I was 18, trained as a traditional MD, went through the traditional OB-GYN training. And I practiced traditional OB-GYN for 20 years, delivered 7,000 babies, did all the surgeries, all the wonderful things that we can do in that specialty. But as your listeners know, we learned nothing about menopause, like absolutely nothing.
And so when I reached my mid-40s and started having those symptoms myself, I was absolutely clueless about what to do to help myself. I went through About a year of being untreated, I didn't think I was old enough to go through menopause. I was a gynecologist because I thought, I'm 45. That can't be happening. Completely clueless.
And then when I finally figured out how to replace my hormones safely and I felt amazing... I retired from that traditional OB-GYN practice, went into a menopause specific practice in 2020, not the best time to start a business in the middle of COVID, but I just had to do it. I'm like, I need to do this.
Honestly, I thought I would just have a quiet little life with just me and my nurse practitioner. And that didn't work because it was so popular. Now we've got three offices in Texas and growing and 12 providers and the virtual program and all the things.
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Chapter 2: How does testosterone impact women's health beyond libido?
Yeah. And so one of the things about testosterone, I'm learning every day is a new day and every day is a learning day. I always tell my children, but I'm learning more and more about testosterone from my clinical experience. So we have thousands of women who use testosterone and I very much like to talk about testosterone deficiency, like I would progesterone deficiency or estradiol deficiency.
It's irrelevant what the label is, whether I'm giving them the label of PMDD or perimenopause or menopause. It's irrelevant, actually. But I realize more and more that testosterone deficiency occurs quite young for some women. There's quite a few women who have probably always been testosterone deficient.
I couldn't agree more and I knew nothing about this. So what I was taught, which was sort of nothing, it was less I was taught than it was just sort of this assumption that we go through our menstrual lives and then all of a sudden we go through menopause and all three hormones drop or maybe didn't even hear about the third one, testosterone.
But what happened in my case is I was still perimenopausal. I was still ovulating and still making estrogen and progesterone, but my testosterone was almost zero. And All of the symptoms that I had initially or many of them were related to that particular hormone being low.
And I can't tell you the number of times I wish I could go back and apologize to the women that I misdiagnosed before this happened to me. And I probably told them, you're fine. You know, you're still having periods. So maybe you just need an antidepressant or maybe you need some, you know, marriage counseling or all the other things. Stupid stuff we say when we don't know.
But in my case, a little bit of testosterone replacement changed my life. I don't want to overstate it, but it literally turned me back into somebody that I recognized as myself again.
Yeah, I remember about six or seven years ago, I was called up from NHS England with someone quite senior and he did a Zoom call with me and he said, Louisa, I thought in medicine you were taught first do no harm. And I said, yes, of course. What are you talking about?
He said, well, I've heard that you prescribe testosterone to women with regular periods and we've all had a beating about this and discussed it and we've agreed that this is a dangerous practice. And I said, well, I beg to differ, actually, because I have seen firsthand a lot of women who have improved. And he said, well, we've all agreed that's placebo and it's dangerous what you're doing.
And I didn't have the confidence that I do now. I didn't publish like I do now.
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Chapter 3: What are the common misconceptions about testosterone in women?
And I didn't have the number of patients that I do now. And I went away from that meeting and got very upset and actually cried because I was crying for all those women that are being denied a very safe hormone. And it's a shame it's called testosterone because everyone thinks it's a male hormone. And like you, I feel very different when I use testosterone and I wish I'd started it earlier.
About 10, maybe 20 years before I did, I had my third daughter when I was 40, but I know I was struggling from about the age of 35 and looking back, like I feel sharper and brighter and more mentally able now than I was probably 20 years ago. You know, it's not such an effort to think, you know.
So interesting. I've heard many of your guests talk about this before, but it does just lead one to be kind of upset about how men are treated when their testosterone drops. So, for example, it might drop by 50% between age 30 and 50 for the average man. And he, very rightly so, is going to get replacement if he's symptomatic. And ounces drop by close to 100% yet we're not offered treatment.
And the international consensus that you're well aware of from 2019 is six years old now basically says testosterone is only appropriate for postmenopausal women. which makes no sense at all.
But if you're somebody who isn't quite as experienced as you and I in seeing patients and are just referring to the guidelines, you know, doctors, it's very wonderful that we have these great groups to make consensus statements to guide us. However, they're, you know, not always so, right?
If you're in practice, like you and I are seeing thousands of patients, we're going to learn things that are not in a consensus statement because it takes decades for 25 physicians to agree on anything and then publish it. So if we waited for that to happen, we would all be suffering for decades. So sometimes it's just common sense. Okay, this patient's
presenting with multiple low testosterone symptoms. Her blood level shows her testosterone is low. We replace it appropriately for a woman and lo and behold, she feels better. What on earth could be wrong with that? No matter how old she is.
Yeah, I totally agree. And one of the things I've written a lot in my book, The Power of Hormones, is about how all three hormones, progesterone and testosterone, work in the body. And I've spent quite a lot of time writing about how it works in the brain.
So testosterone is very important, as you know, in every cell in our body and brain, but it helps the communication with those neurons and it helps build that myelin sheath, which is like the conduction part, really, isn't it, of the nerves. So it helps everything fire very quickly and effectively. But it also helps with metabolism.
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Chapter 4: How do current guidelines fail women seeking testosterone?
And one of the ex-chairs from the British Menopause Society was writing about the harms of testosterone. And she said it's abusive that women are being prescribed so much testosterone. Now, I think coming from a healthcare professional, that's quite a strong language saying it's abusive to prescribe testosterone.
And I think there are many drugs that may be abusive when they are definitely associated with harms, you know, without informing patients. But testosterone isn't one of my list. I feel it's one of the most safe and transformational medications that I've ever prescribed as a doctor, actually.
It's mind boggling how that statement could arise, but I can perhaps sort of see an inkling of where that might've come from because there were in the past and still exist, certainly in this country, clinics where patients are given unsafe drugs that are either not biologically identical testosterone or doses that are way too high for a female.
And so I think because that happens, we could throw the baby out with the bathwater. Just because, in my opinion, irresponsible practitioners might offer this doesn't mean that there are responsible practitioners offering it. So patients have to be really careful and smart about whom they give. trust with their healthcare, just like in any field.
And it's very important, anything that we prescribe, anything we do, if you do it too much or too little, it's not going to have the same effect. So like me, you're very keen in holistic care and you're the most amazing athlete. I'm just so impressed with all the triathlons that you do. It's just amazing. But exercise, nutrition is like a no-brainer. Everybody should do that.
But when we talk about hormones, we both agree that we're individual and personalized hormone balance is crucial. And so there's been a lot of debate, especially since the Panorama program that was made about me, about high doses that I prescribe to some women. And it's been very damaging over here in the UK.
And I know it's filtrated into other countries because then people think that these high doses somehow are a problem. And one of the reasons I prescribe higher doses for a minority of women in follow-ups is because they're not absorbing through the skin very well. And so I spend a lot of time with patients optimizing doses, but also not just the dose, the formulation.
So people really vary with how they absorb through the skin, whether it's a gel, a cream, a patch. You've got pellets of testosterone. The first thing in my mind is making sure that it's the proper hormone. So is it progesterone, not a synthetic progesterone? Is it estradiol, not ethanol estradiol?
Is it pure testosterone, like you say, not some sort of anabolic steroid that's been made by goodness knows who? And then it's like a starting dose is pretty standard for a lot of people. But then on the follow up, the whole way that it's been absorbed into the body is really important, isn't it? And it varies so much between people.
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Chapter 5: What personal experiences highlight the importance of testosterone?
In Australia, that's five or a ton, right? So let's just say five to be conservative. The understanding is that we're only going to absorb... 10% of that. So there's a guess that 90% of it will be lost. Well, that's a pretty wild guess. Is it 95% or 82%? Like we have no idea.
Everybody's skin's different, like where it's placed at the time of the day, the temperature, whether you exercise, if you've exfoliated your particular type of skin. So we can use the same dose, just like you said. And we start with a reasonable dose, like say five milligrams, for example. and then measure it, and I'll get quite different results from different patients.
Now, no harm will happen in that couple of months of, I tell patients, this is a trial for you because you're an individual. It's an experiment with one person in it, but it's a safe experiment because Hundreds of thousands of other women have tried before you, and this is a very safe dose. It might be too low, and we may have to increase it.
By no means is it going to be too high, so there's no harm. But I think this idea that it's precision medicine, I mean, if we're putting a gel, especially if we're using something like in this country, the male gel and being asked to divide this into a ton, and what possible planet is that precision medicine? That is like guesswork. That's the best. But I mean, this is what we have.
So, I mean, no, nothing wrong with doing that, but we have to understand it's a guess and we don't know how much you're going to absorb, but it's not harmful to try. Now, men use gel and they have exactly the same issues. They don't know how much they're going to absorb. The doctor measures it later. There's really no difference.
So I get annoyed, to say the least, with the fact that men have all these different options and they are offered these options and counseled by their provider and they get to choose the one that's best for them and everybody's happy about that. For some reason, it's different for women. We're not allowed to use anything except the male product divided by ton.
God forbid we use anything that's a personalized dose, like one of these, that's bad. And of course, pellets are even worse, but truly it's the same hormone. So the way we deliver it into our system really doesn't much matter so long as we follow it and we're careful and judicious and start with a reasonable dose.
And then listen to the patient, which is ultimately much more important than what the blood test says.
It's so important. Having anything made... whether it's like you say, made in a pellet, made in a cream, made in a gel, as long as it's a proper testosterone at a dose that's suitable for women, it's a lot safer. And a few months ago, I've used the cream for many years and I decided to try the gel because I wanted to see how easy is it to divide something by eight? And obviously it's impossible.
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