The Dr Louise Newson Podcast - 116 - Testosterone: the forgotten hormone with Professor Isaac Manyonda

Episode Date: September 14, 2021

Professor Isaac Manyonda, professor of obstetrics and gynaecology at St George's Hospital in London, makes a welcome return to the podcast to discuss the important hormone, testosterone, with Dr Louise Newson.  The experts discuss why awareness of testosterone in women is usually overshadowed by estrogen and they describe what type of symptoms can be greatly improved by replacing testosterone, as well as the different preparations available, licensing issues and challenges of accessing the medication on the NHS.   Isaac’s top 3 tips if you’re considering testosterone:  Understand that testosterone isn’t just a male hormone, it is a key female hormone, and tell your doctor this if they are unaware!  Be clear (with your doctor) about what symptoms testosterone can help specifically that estrogen alone may not fully alleviate, such as brain fog, sleep disturbances, lack of energy, and low libido.  If your usual doctor will not prescribe testosterone for you, look into what other NHS clinics in your region will, it can take a bit of finding out how to receive it. It should be something you can access via the NHS, but change is slow.

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsome, a GP and menopause specialist, and I'm also the founder of the Menopause charity. In addition, I run the Newsome Health Menopause and Well-Being clinic here in Stratford-upon-Avon. So today I'm very happy and privileged to be introducing to you for the second time, actually, Professor Isaac Menyander, who some of you might have heard us talk before about the benefits of HRT. So this time I've requested him to come back to talk about testosterone and the role this important hormone has for women. So thanks so much for your time today, Isaac, and joining me in the podcast. My pleasure. So I'm a menopause specialist. I ran a very busy menopause clinic. I do some research in menopause. I've set up a

menopause charity. All I do is think and breathe and spend my time thinking about the menopause. get 10 years ago, if I'd had this conversation with you, I don't think I even thought women produced testosterone. So I feel a bit of a fraud, but actually I feel a very frustrated fraud because since I've learned about testosterone and since I've understood what an important hormone it is for a lot of women, I'm absolutely outraged that we're not allowed to prescribe it in the UK as a licensed product. So there's a lot we need to unpick in the next half an hour. And so perhaps, Isaac, you could just start by explaining. why women have testosterone and do we all have it and where is it produced and you know what's it all

about yes i think in years to come people will laugh at us as doctors physicians insofar as we seem to refuse to deal with things that are so obvious that we know about but we know that although we talk about estrogen as the cardinal female hormone and testosterone as the cardinal male hormone. In reality, the female body, certainly in the reproductive phase of life, produces a lot of testosterone. So the female ovary produces three times in terms of testosterone as it does, estrogen. Not many people know this, but this is a biological fact.

And if you are to examine a woman's eyes or her brain or her bones or her breast or the gentle organs, you will find receptors for testosterone. In other words, it's not an accident. It's not a fluke. It's not just there by chance. This sort of quantity of hormone and the fact that a lot of the body parts do contain, the receptors that recognize testosterone would imply that testosterone has an important role in women as it does in men. It's just that the difference is largely in quantity and what it subserves.

But to answer your question directly, testosterone in women is produced by ovaries and by the adrenal glance. And they produce measurable quantity. of this hormone. And this hormone is produced during the reproductive phase in women's lives, and after the menopause, the levels decline. Not exactly the same way as the estrogen does, but they do. Yeah. So if the whole idea of hormone replacement is to try and mimic or replace the hormones that are not being produced, we must think in terms of, not only estrogen, but also in terms of testosterone. Yeah, and I think that's so important.

And just to reiterate, it's exactly the same testosterone as men produce, but it's lower doses. But actually, what you said at the beginning is very interesting, and a lot of people might not realize, is that women produce three times more testosterone than estrogen, and we have cells that respond to testosterone all over our bodies. So actually, maybe we could argue that testosterone is more important than estrogen. But we always say that estrogen is the female hormone and testosterone is the male hormone. And that's too simplistic, isn't it, to say that? I think it is too simplistic.

I think, though, it's not possible for us to say one is more important than the other. No. They're different, aren't they? They're different. And I think they work together to optimize the well-being of women. And this is true in the premenopausal phase as it is when women have gone through the menopause. And they are certainly very clearly defined things that testosterone does in women that perhaps are not so focused upon on an everyday basis in hormone replacement.

So by that I mean, if you imagine a woman who presents to a doctor saying, I just can't sleep because I've got these night sweats. I'm checking away my blankets and then I'm taking them back. During the daytime, I'm really troubled by hot flashes and my moods are terrible. And the doctor gives them estrogen. Well, some of these symptoms will get better. So the hot flashes will go, the nightswets will go, her moods may improve. But there are other symptoms within the menopausal complex that she may not necessarily have focused upon when she spoke to the doctor,

or certainly they may not get better when she takes the estrogen on his own. So things like having a foggy brain or not having sufficient energy as she used to her, or not just using muscles, muscle mask compared to what she was before. These things, but even more importantly, loss of libido. Now, when the women get better because the hot flashes have gone and they can sleep better, they may think they have done well. But the other things, they may say, well, I'm getting old and what do I expect, and perhaps they don't matter so much.

But actually, what that means is that we are under-treating women if we don't address those issues. And those issues are often not addressed by estrogen-on-neanism. of. That is where testosterone comes in, because testosterone has been shown very clearly to be good for some of the things that I've already mentioned, such as clear thinking, eradication of a foggy brain, such as mass and mass, increasing a woman's sense of strength, a sense of well-being, better libidivit, and so forth. It is important to recognize that when we are using just this to determine this one for a good

proportion of women we are under treating them. Yes. And this is something that is going to be shown very clearly when people do the relevant pieces of research, which I hope you want to do. I absolutely want to do. And it's interesting actually, so I'm sure you know we do a menopause symptom questionnaire on every patient who comes to CERMI clinic and we look at the psychological symptoms, the physical symptoms and the vasor motor symptoms, hot flushes and sweats.

We did it a couple of years ago on women who take estrogen and testosterone, and we found that women who took testosterone significantly improved on everything, actually, including vasor motor symptoms. And these were women that were on estrogen, and then we added testosterone. And we tried to write it up. And someone who's a very learned professor who knows testosterone very well actually said, I think this is a placebo effect. I don't think testosterone has this effect at all, and they refuse to publish it.

And I felt very sad by this actually because I don't think women expect their well-being to improve, their brain fog to improve, their sleep to improve by hormone. So I don't think it is placebo, especially when it's statistically significant. So we're going to repeat it on bigger numbers because when you've got bigger numbers, it's harder to push back.

But this is one of the big problems with female health, especially hormonal health, is that we haven't got loads of really good studies. So people try and pick apart whatever there is. And then that makes it very difficult. So when you look at, if you like, how we're allowed to prescribe testosterone, if you look at the nice menopause guidance, they'll say we're allowed to consider it as an option for treatment

if women have reduced sexual desire despite being on HRT. And it's very difficult, isn't it? Because libido obviously and a woman is not just about a hormone, own, but women who have brain fog, who have poor memory, who have low feelings of self-worth and even just body shape changes, they've got less stamina, like you say, they've got less muscle strength. Of course their libido is going to be reduced. So it's very difficult, I think, and it's underserving women, to just focus on libido as the only reason to consider testosterone, actually. I don't know what you think. Absolutely. I mean, the International Menopor Society

published a concessal statement in September 2019, in which they said exactly what you've said, which is to say testosterone should only be given to women who have sexual dysfunction, hyperactive sexual desire dysfunction of the HSDD. And I think that's profoundly misguided. And the challenge is for people to conduct these studies that you yourself have done, but in a way that makes it impossible for reviewers to turn

these studies down. In other words, if the design of any of these studies is such that one group of women would have had estrogen and testosterone, and in a reverse manner, they would have this. In other words, crossover studies are done. It will be impossible to refute the evidence that And I mean, you know, and I know that testosterone makes a huge difference, not just for libido issues, but for all the other issues that we've talked about, such as energy, such as a sense of well-being, such as foggy brain, such as sleep, and so forth. And even on its own, it also does alleviate things like hot flashes and night sweats. And it's interesting because we used to have testosterone licences as a patch. And I've spoken to quite a few people who have. And I've spoken to quite a few

people who are older than me. And actually it's quite sad because when I reflect on what they say about how, oh, we used to give testosterone, especially women who'd had their ovaries removed, and my goodness, they felt good. My goodness, they felt wonderful. My goodness, their libido was back. And then it was withdrawn. And then they said, oh, but women didn't really need it. And it was, it's always struck me that, why is it bad that women can feel good? And it's a very sort of disparaging thing because it's so hard to measure. It's not like, measuring a blood test that we can say the sugar level goes from one to another or blood pressure reading goes from one valley to another. So when people say goodness, it's really hard to get women

off testosterone because they feel so great on it. Well, of course they do because it's their own hormone. Why should we be denied it? And I think it's very interesting actually because it does seem to decline at different rates and different women. And so there are some women who are perimenopausal and have very few symptoms of estrogen deficiency, so they might have the odd night sweat. But their brain is gone, their memory's gone, their concentration has gone, their muscle strength is going, they're putting on a bit of weight. And I generally find that these women are more testosterone deficient than estrogen deficient. And you can't predict, can you, which woman's going to decline first and which one the woman misses more. And like you say,

it's often a combination. And some women you give estrogen to, and they feel amazing very quickly, you give them some testosterone. Well, I don't really know if I've made any difference. Whereas other people, you give estrogen to. I remember when I started HRT, the estrogen helped with my night sweats, but I felt exhausted. I felt like a zombie.

And then once testosterone started to kick in, I thought, my goodness, I wish I'd started this 10 years ago. My brain has come back. I can multitask. I can, and I sleep really well, which I hadn't done for quite a long time. and I'm sure it's a testosterone. So it's difficult sometimes, isn't it, to know which women at which stage? And I think there's a lot of women who are perimenopausal

who would benefit from testosterone probably before estrogen. I don't know what you think. I think that is the case. But given the environment in which we function, we cannot escape from the fact that estrogen will be the dominant hormone to replace. My view truly is that we should be considering stepwise replacement. In other words, since the vast majority of women will present weight, pot flashes or nightsworts or mood changes,

it's not a problem to start with estrogen and review their symptoms and add testosterone as time progress and then assess whether they feel that the testosterone has made it. difference. In my experience, the vast majority of women do say, ah, yes, I did feel well on estrogen, but the testosterone has made a difference. And you cannot then say to them, stop with the testosterone when the combination makes them feel so well. So I think in the environment in which we function, it probably may not be the common thing to start with testosterone and not is. No, I mean, I always start on estrogen first because certainly I work out of the Nice Guidance, because as people know, listening, the NICE is the National Institute of Health and Care Excellence,

and their menopause guidelines, the only one they've ever developed, actually, came out in 2015. And so I work out of those, so we give estrogen first and then add in, like you say, testosterone. And that way, actually, I think it's important for women to know how the different hormones are feeling and affecting them. But it's very difficult for women to access testosterone, actually, because it's not licensed. We don't have a licensed female product. So the only way of women actually obtaining it in the NHS

is the male version. And that's fine. It's safe because you give it at low doses. But I think it's quite horrific that the only way women can have their own hormone is having a men's licensed product. There's this big gender inequality that I really quite battle with. that it doesn't seem fair, does it?

Well, not only does it not seem fair, but let me just, my personal experience, no, not personally in the sense of taking, but personal in the sense of giving it to women, is that a lot of the male preparations actually are nowhere near as effective at the other preparations that we will talk about in a minute, in part because you can never really get it. right. You'll say, well, we're going to need this little sachet should last seven days or it should last 10 days and you use a smidgen of this male preparation for them. What is this midgeon? How much are

you really taking in and so forth? So my experience is that women do not really benefit much for the male preparations. And fortunately, there are available unlicensed products that are specific for women. And by the way, in all the patch that you were referring to, do you know why the manufacturer stopped making it? It was something about the patch, wasn't it? It wasn't about the testosterone. It wasn't about the testosterone. It wasn't about this efficacy. It was money. They were not making enough money. But also, it was, I found out the other day, it was eye-washedingly expensive. It's about 120 pounds a month for the cost of this patch. But they still, because it wasn't widely used, I suppose. They weren't making the money that they had hoped.

Really, it was largely the money issue. And so if they had been making enough money, perhaps they would have continued. And in the same, the story actually is very similar with Organum. Remember, well, you may not know. Years ago, Organon used to make the estrogen and testosterone pellets, and then they stopped. So now, if you want estrogen and testosterone pellets, you have to buy them from a company that buys them from America. And maybe this is just as good a time to move into what sort of preparations are available to women that work.

And the good news, I mean, you are very familiar with the Androfam. So do you want to talk about that? Yeah, so Andifam is a cream that many people might have heard of. It's actually made for women. So it comes in a pink tube. And it's made in Western Australia. It's actually recently become licensed for women in Australian, which is great. And it's a white cream, and there is a syringe so people can measure the amount.

It is next year in 2022 going to change to a little pump so people can have an actual amount that's easier for them to administer, and it's rubbed onto the thigh every day. There is a big move to get this AndroFem licensed by the MHRA in the UK, and I had another meeting today about it, actually, because it's the best preparation, really, for women. and it's safe. It works out about 80p a day, so it's a lot cheaper than the intrams of patches that we mentioned. So that's the only topical, as in, goes through the skin. You shouldn't have testosterone as a tablet. There are some private clinics that offer it as a tablet or a lozinger, which are not licensed, not regulated, shouldn't be given. The male testosterone equivalents are

the gels, but like you say, Isaac, you have to guess the amount, and the one that's most widely given is actually one that's a sash and it's quite hard measuring from a sash. There is a little tube as well, something called testing. There are others that are male preparations. There's a couple of pumps, one called testogen and one called testosterone in the UK. But we've seen people with really high levels of testosterone and side effects because they're not sure how much to give and they're often giving a lot more than they should. And then there are the implants as well, aren't there, that some people have in clinics.

Yes, implants have been used since as long ago as 1938. So for a large extent, there is, in fact, a lot of data out there on their efficacy, if you like. I'm very much a fan of implants, I have to confess. And you and I have had this discussion before in passing about the benefits or otherwise of implants versus a cream that you administer. to the skin. The implants are very standard doses. They're not licensed, but they are wide, relatively widely used. And they are specific for use in women. The implant is put just underneath the skin under local anesthetic. And they are implants of estrogen and implants of testosterone. Right now, we're talking about testosterone. And they last anywhere between four and six months.

they are very effective in terms of the benefits that we've already talked about. And I think it's important whenever you have treatments for this sort of thing to have alternatives. So I very much welcome the fact that Androfam may well be licensed in the not too distant future in the UK. I think it's good to have the Androfem which will suit some women, but not all. and it's important to have the availability of implants which will suit other women but not all. I have to say, I have yet to come across a woman that said I had unacceptable side effects from the implant. Yes. But I have had the occasional woman who has had some problems with the antifer.

Now, in the side, you know, you can, potentially you can see problems on both sides. So issue of absorption depends to some extent on where you apply the antrofoam. The implant does not have that problem of how much is absorbed because you really just place it in one area and the releases from that particular area. So it's very easy to, there are those advantages of not having to apply it on a daily basis. Once you put it there, four to six months, you forget all about it. Now, of course, you could argue that as it is wearing out, then you have the problems of when do you replace it and so forth. I don't think that's quite as big a problem, but you know, you could argue that at that stage,

women begin to feel the return of their symptoms, but then that's the time to replace. Yeah, I think it's useful having a choice. I mean, some people can't access the implants or it depends on where they live and whether there's a menopause clinic and whether they're administrating them. So sometimes the cream or the gel can be easier. But whatever way that people have, actually it's very safe. You mention some side effects. And people who are more anti-testosterone in women will talk about the side effects,

such as facial hair or voice changes or skin changes. But actually, they're very unusual to have side effects when they are given in normal female range doses. So you can measure testosterone levels and see. And also I think it's important to know that any side effects are reversible as well, aren't they? They're not going to last forever. Yes. I think let's tackle the side effects or potential complications head on. Because it is important that people do know that they are,

but they need to understand also how frequent these side effects happen. So if we talk about voice change, I'm now in my early 60s, I have never come across a woman that has had. voice change as a result of testosterone. It is an exceptionally rare complication of testosterone therapy. Herstitism or facial hair, a lot of women without being on HRT will develop unwanted facial hair with the onset of the menopause. The actual amount of hair growth is actually very small and very easy to.

manage. I'm not one woman saying it doesn't happen because it does. But it's not, certainly with implants, it's not a problem that occurs until after about at least two years or more of years. And dealing with those problems is very easy to do. The third important side effect is the potential for clitoromegaly enlargement of the clitoris. In all my practice, I've only ever seen it in two women. And this is not a huge enlargement, but it is noticeable. At least it was noticeable in those two candidates. What are the side effects were we talking about? Some people who use the cream or the gel can get some hair growth where they rub it. So usually it's rubbed onto the upper thigh, sometimes on the lower abdomen and they can get some hair growth. But actually a lot of

women find that they don't mind that because their brains working and they're feeling better. And I don't you say two women out of however many. Yeah, lifetimes work. I don't even know you could call it a side effect, you know, or really a complication. It's just because actually all we're doing is giving back our own hormone. We had one of our doctors email me yesterday and was very worried because she'd given testosterone to a woman who had a young child and then she found out she was breastfeeding. And she said, oh my goodness, I've read in the BNF, the book that we use,

and testosterone shouldn't be given in women who are breastfeeding. And she was really worried. And we said, but women have testosterone in their bodies naturally. So what's the worry? Oh, of course, I forgot. My common sense had gone out the window. And it's the same as if people are wanting to conceive, because there's a lot of women we see who have an early menopause.

And as you know, women who take HLT can actually improve their fertility sometimes. and we've had a few pregnancies in the clinic, which is lovely, since it's a bit unusual in a men of the clinic, but we have, and the women have been delighted, and the first thing they say, should I stop my HRT? Or should I stop my HRT if I'm trying to conceive? And of course, I mean, it's mad, isn't it? It's called hormone replacement, but it's not replacing anything.

It's just chopping up, and that's the same with testosterone, or just giving the missing hormone, aren't you? So it's actually, there's very few reasons why people can't have testosterone. Yeah, absolutely. there is something that I want to bring up in relation to the use of testosterone and breast cancer, which is not widely known, which I am having conversations with oncologists and breast surgeons here in the UK in the hoop, that we might look at this issue and look at it very seriously from the point of view of perhaps conducting some studies. But there is a group led by a lady called Glazier in the United States

who have been looking at the use of testosterone in women who have had breast cancer. Their studies to date are not massive, but their findings are what is very, very challenging and potentially very exciting. What they have been able to show is that if you give testosterone, are the particular conditions to women with breast cancer who are in remission, then over a period of time, women who are on testosterone are less likely to have a recurrence of their breast cancer when you compare them to women who are not on testosterone.

Now, look, nobody is saying that testosterone prevents a recurrence of breast cancer. But the observation is really tantalizing. Given that breast cancer is the commonest cancer in women, given that it is such a major impact on the quality of life of women, given that it happens around the time when women are going through the menopause and they are denied hormone replacement, and therefore, not only do they have to suffer the idea that they have had breast cancer, but they have to suffer the consequences of hormonal withdrawal.

It is going to be, in my view, a very, very important question to ask, what is the role of testosterone on breast cancer in the light of the American findings? Yeah. And therefore, this is something that we need to really look at very, very seriously. And for somebody like you with the large population following that you have, of men or women. I think you are well placed to participate in a piece of research of that kind. It's so interesting. And actually, I gave a talk this week to some people on behalf of the British Society of Sexual Medicine about management of menopause in women who have had breast cancer

because these women are very neglected actually when it comes to their menopause. And as you know, lots of them have an early menopause because of their cancer treatments. And actually even when you look at the evidence for giving estrogen for women who have breast cancer, the evidence actually is better than people think. But I'm not going to go into that because you have promised to come back for part three at one stage and I'm going to hold you to it because I would like to do a podcast with you, Isaac, specifically about breast cancer. I have done a few that people might have heard already,

but I really would like to grill down with you about the use of HRT, so estrogen and also testosterone in women who have had. had breast cancer and also vagina on estrogen. So can you publicly agree that you're going to come back into it? Actually, that one is very difficult to refuse in any shape of form because I do think that that is the basis on which a lot of women are denied such a very important treatment. A lot of women do not, for example, realize that you are more like,

to get breast cancer if you're obese than if you take HRT, that you can significantly reduce your risk of breast cancer if you exercise just three hours per week and that a lot of alcohol is riskier than HRT, but that at the same time, HRT has a huge number of benefits. Absolutely. All the other things that people talk about every day in life. prevention of redal bones, improvement in your immune system, protecting your cardiovascular system, preventing dementia.

Are there just, I can go on, apart from it being best treatment against symptoms of the menacle. So I publicly declare that I shouldn't be awaiting your invitation. Brilliant, excellent. So I look forward to that. In the meantime, just before we end, I would just like to. ask you for three take-home tips for people thinking about testosterone. What are the three things that women should find out and ask their doctor about? Because a lot of women, I know are going to listen to this thinking, right, I'd like testosterone, but how am I going to get it? So what are the three things women can do to really empower them to try and get testosterone prescribed

to them? Well, first of all, I think they themselves need to understand that testosterone is not predominantly a male hormone. It's a cardinal female hormone. That needs to be understood by the women themselves, and then in conversations with their doctors, they need to point this out if their doctors are against it. So the next thing is that they need to be clear about what testosterone does, and therefore in conversation with their GP,

especially if they have been given, estrogen, but they don't feel as well as they should. So they should understand that the most important areas that testosterone addresses are a foggy brain, better sleep, better energy levels, and libido, better libido. Those four things I've deliberately put them in that order, because I don't want to give the impression that libido is the only thing that is important here. And then the third thing is to point out to their doctors that if they do not know where to access the testosterone, there are clinics that have access to testosterone.

And it may be useful for women to look into where their nearest source could be. So if they were in London, for example, there are many clinics that, would be able to give them testosterone. I'm not trying to advertise our clinic, it's in Georgia's, but we do have testosterone. The problem is if they live in Wales or Birmingham or someplace in the north, it's very, very difficult. But if we live in Wales, the sort of setup that you have established would mean that some women would access some of your clinics.

Yeah, I mean, it's hard. But I think things are, for those people listening who might be frustrated, there are things changing. And I think some of the work that we're doing with NHS England is really going to address this at a big scale, because it's very important that women can access it for free on the NHS. It shouldn't be something that they have to pay for privately. When they want their own hormone back, I strongly feel that they shouldn't be coming to a private clinic. But the more that we understand and the more that women understand, then I think the sooner change can happen. So let me throw the question at you then.

How would you be saying they should get it if the GP says, well, I don't have access to it? What should they be saying the women who are in Wales? I think there should be a bit of campaigning almost. I think we should be being more vocal, actually. I think we should be writing to our local CCG or even if it was in general practice to actually write and ask why and even approach Royal College of GPs to find out why GPs aren't me. trained in testosterone because actually when GPs are refusing it's not because they're being belligerent or they're being arrogant it's because they actually don't know I wouldn't have

known if someone came to me 10 years ago and said I would like some testosterone and I would have thought my goodness what are they going on about I don't know how to prescribe it I don't know what to do and my local menopause clinic is two year weight so it's very difficult actually so I think we just need to keep thinking about the evidence thinking about how we can try and make it available and certainly there's some great work being done behind the scenes on addressing this and I think the sooner it can be the better. So I'm a lot more hopeful than I was six months ago that women will be able to reclaim their own hormones soon. But the woman in Wales has not been given a solution to an immediate problem. There is no immediate, I wish there was.

It's so frustrating and it saddens me every night that women are struggling to just get their own hormones and all we can do is try and work together. And I think, you know, you coming here on this podcast, giving up your time, has been invaluable actually just for letting people assimilate the knowledge and think about it. There's a booklet about testosterone freely available on my website as well and some other information. So I think for people just to understand and to keep their eyes open and eyes open to changes that are happening will be great. So thank you so much for coming today. And I'm looking forward already to part three when we talk about breast cancer.

So thanks ever so much, Isaac. It's been really great. My pleasure. My pleasure. Thank you. For more information about the perimenopause and menopause, you can go to my website, menopausedoctor.com. Or you can download our free app called Balance, available through the app store and Google Play.