The Dr Louise Newson Podcast - 250 - Testosterone: the missing piece of the jigsaw?

Episode Date: April 2, 2024

This week we mark 250 episodes of the Dr Louise Newson Podcast! And joining Dr Louise this week is Anita Nicholson, a nurse practitioner and menopause expert at Age Management Center in the US, where she aims to help patients lead the best quality of life for as long as they can. Here, Dr Louise and Anita compare notes on the attitudes towards testosterone in the UK and the US, share their clinical experience of the benefits it can provide women, particularly in restoring their zest for life. Finally, Anita shares three things she thinks could make a huge difference to women's health: Women need to educate themselves. They have to be their own advocate. I would love for hormones to become available and affordable. In the US, we don't even have vaginal oestrogen covered by some insurance here, never mind over-the-counter access. More education of healthcare providers. So have a fellowship in menopause. Let's start very early with med students and nurse practitioner students so they understand that menopause and sexual medicine is very important for our life span and our health span. You can follow Anita on Instagram @menopause_agewellfnp and the Age Management Center on Facebook /AgeManagementCenter and YouTube /@agemanagementcenter. Click here for more information about Newson Health    

Hello, I'm Dr Louise Newsom. I'm a GP and menopause specialist and I'm also the founder of the Newsom Health Menopause and Wellbeing Centre here in Stratford-Pon-Avon. I'm also the founder of the free balance app. Each week on my podcast, join me and my special guests where we discuss all things perimenopause and menopause. We talk about the latest research,

bust myths on menopause symptoms and treatments, and often share moving and always inspirational personal stories. This podcast is brought to you by the News and Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women. So today on the podcast, I've got someone from America who I have met in real life, some of my American guests I haven't met in real life, but I've got with me Anita Nicholson,

who's a nurse practitioner from Portland, Maine, in America. and I met her at a conference. We were both at a conference recently, a menopause conference, and I was presenting some of my work from our clinic about testosterone and benefits. And we met at coffee and the coffee break wasn't long enough actually because we were chatting and sharing our experiences of the patients we see and the journeys that they have had before they come and see us and the transformational way that we can help them. And it was just lovely to. speak to a kindred spirit, actually, who understood what we're trying to do and try and improve the lives of so many people. So thanks for joining me today, Anita. It's very exciting to

see you again. Yes, Louise. Thank you for inviting me. So you're a nurse practitioner, and you've had a really interesting background, actually, haven't you, looking at, you know, I think things change, don't they, with time, how you want to reduce diseases and improve longevity. And it's a journey to that age, not the age that we die necessarily. And certainly how I practice medicine or think about medicine, about prevention, rather than waiting for the disease to come, is quite different than if you'd met me 30 years ago when I had just trained in medicine. And so what's your journey been like?

Similar. I spent probably 20 years in hospital-paced medicine, ICU, cardiac surgery, cardiology, and found I really wanted to get ahead of people having heart attacks. And through my own journey through menopause, which was related to chemotherapy, so I went right off the deep end in a menopause, really struggled to navigate that. And I thought, if I'm struggling, other women must be struggling. And I'd really like to get ahead of all of this disease that will happen to us later in life. So I started to shift my career to real primary prevention and focusing on women's health only.

So now I only see women in my clinic. Nothing wrong with the men. There's plenty of men here to take care of them. Absolutely. It's interesting, isn't it? Because, like, you know, I'm not a gynecologist. I'm not an OBGYN. And I've done a lot of hospital medicine.

And actually, even as a medical student, we did an elective. And I did it with a cardiothrassic unit. And it was very interesting. And I love cardiology. I love treating diseases and I really enjoyed hospital medicine. And I never once thought that I would set up and run a clinic that was just for women. Like you, I love women. But I also love helping men and children and all sorts.

But actually life just has, you know, takes it sort of different directions and you go with a direction if it feels right. And, you know, we're only talking about something that affects 51% of the population directly. But every woman knows a man, whether they live with them or they're related to them or they work with them. So it has an indirect effect on the rest. So there's nothing else in medicine that affects every single person other than hormonal health, is there? That's true. Yeah. If women live long enough, it will happen to them and everyone in their life is affected as well. Yes. And it's really interesting because the conversation changes all the time. But for, and I was going to say decades, but it's centuries actually. Women have been ignored. And people have been very scared of hormones

because hormones affect for many women, their emotions as well and the way their brains work and their personalities and the way they function. And people have been scared of that. And then even when they realize there's been all sorts of weird treatments over the decades, hasn't there, to try and calm women down or to suppress them or to help them with their depressive symptoms or reduce their anxiety, all sorts of often quite barbaric treatments. And now we've moved on. We know that a lot of symptoms are related to hormonal deficiencies or fluctuations, depending whether someone's menopausal or perimenopausal.

And we have really safe natural hormones to replace that deficit. But over in the UK, only about 14% of it. of women who are menopaus or take hormones. Over in the US, I think it's even less, isn't it? Maybe 10, maybe less, yes. It's still quite low. Yeah, which there's nothing else in medicine, in my knowledge, correct me if I'm wrong, where we have an evidence-based treatment that is not given to the majority of people

that are suffering from the condition. It's true, yes. You can look at the percentages from many different, you know, data that's collected, which is hard to do when you don't have an FDA-approved testosterone, for instance. So where is prescribing happening? And it's, you know, how many prescriptions of male testosterone was built for a female? And what about the compounding pharmacies and whatnot? But even if you look at the, there was a research query 2010 to 2021, like 190,000 women, 40,000 of who had diagnosed hypoactive sexual desire and 3.9% treated.

3.9%. 3.9. So I think that would be considered rarely prescribed. You know, and that wouldn't be the case if it was we found that they had high cholesterol or we found that they had hypertension or they just pick one. I know. You know, it wouldn't be 3.9 percent. Which is quite shocking because if we sort of think about HSDD, as you said, hyperactive of sexual desire disorder. It's very common in menopausal women and actually perimenopausal women and even younger women as well. Yes. But even if you look at the way it's defined, it's quite barbaric for women, isn't it? Yes. I don't love that it's a desired disorder. It's not a desired disorder. And I also don't love the wording around, but you really have to be

suffering. Yes. I really don't like that either. And you have to be suffering for the minimum of, at least three months. So you can't just have a month or six weeks of suffering. You have to wait until you had three months. And whose judgment is that? Well, this is really interesting. Suffering enough. Yes. I don't love that. Yeah. I feel like in life, many of us suffer for all sorts of reasons. There's all sorts of reasons why our libido can change. And it often is situational, of course. But there are still other reasons, including low hormones. that can affect our desire. But it's a desire for what?

And that's what I find really difficult because if you look at Freud's interpretation of libido, it's not just about sexual pleasure. It's about pleasure of life and enjoyment of life. And is it really wrong for us as clinicians to want to enable our patients to have better quality of life and enjoy life more? And I don't think it is actually. But it seems like we have to prove that we're suffering a lot before we can get any enjoyment.

And that doesn't seem right either. No, and how do you even ask that? But are you suffering enough? And is there any domestic situation that could be affecting? This is not a conversation that men have. No, not still. With male patients, you know, who may present and say the same array of symptoms, you know, maybe there's anxiety, maybe there's some mood change. sex drive is gone, you know, cannot maintain an erection, cannot achieve orgasm.

They're not going to dive into what's your home life, how much are you suffering. That conversation doesn't happen. They get to treatment and that's the end of it. And I think we need to treat our women patients like that. We don't need to make a judgment on are you suffering enough? And I do like your point about inviting pleasure into our lives, especially at this stage of our life. We have enough experience and wisdom and knowledge of our own self to be able to cultivate pleasure everywhere in our life, not just intimately. You know, find the joy, feel the joy with our intimate partners, any other place in our life.

And what I have found very consistently with women that that feeling of being able to connect with joy and pleasure drains. out of their body when they go through perimenopause and menopause. And it's hard for them to really pinpoint when it happened, but they know that it has happened. They know that they're in an experience where this, I used to feel joyful right now in this circumstance, whatever it is, but I can't connect with that anymore. And that touches every part of their life, not just their intimate life. And it can be devastating. And it's not that they're depressed, but being in that stayed for a prolonged period of time can be depressing. I absolutely agree. And it's really hard to sort of put down on a questionnaire or on a research tool or whatever. But it is that

people often say, I just feel joyless. I feel flat. My zest for life has gone. It's quite sort of subtle changes that often come on quite gradually. And the more we learn and know about physiology of our hormones, so the more how our hormones, estrogen, progesterone and testosterone can light up our brains, it's no surprise. And when we talk about HSDD, it's talked a lot in the context of testosterone. And so we've talked on many podcasts before about the role of estrogen and progesterone, which are sort of the building blocks almost. We've always been the go-to parts of HRT. But testosterone is an independent hormone. It's produced by our ovaries, our adrenal glands, but our brain produces testosterone as well, doesn't it? And we have receptors for

testosterone all over our body, including our brain. And it actually blew my brain when I first realized this because I was felt really cheated as a woman who has had this biologically active hormone in my body at higher levels when I was younger than when I was older, but also as a clinician, why didn't anyone tell me that women had testosterone and it has this effect? And then as a medical specialist, I've also felt cheated because whenever we have, or I've gone to presentations about testosterone or educational events, it's always been testosterone, HSDD, severely psychologically distressed with their reduced libido and then consider testosterone. No one's been saying about all the other biological effects that testosterone has. So it's, I don't know about you,

were you given much education over the years about testosterone? No, that was not covered in any of my training, this menopause care right now is an independent education. I mean, certainly prepare for and get certified by the menopause society. Yes, do that. Sometimes the guidelines aren't up to date. So you write a test that you have to, you know, bear in mind what you're the test is. But otherwise, it's an independent study on your own dime. Yes. Right. So if you want to become specialized in menopause care, doing a lot of self-study on your own dime. Absolutely. And many of us are really motivated because the more you do perimenopals and menopause care, the more you realize it's transformational

medicine. There's nothing else I've ever managed in medicine where I've had patients who feel better, but also their future health is better as well. And when I first started learning about testosterone, in fact, the conference we met at, I'd gone to similar conference actually seven years ago was my first menopause conference. It was in Amsterdam and I had just started taking testosterone about four months before. And I was experiencing this joy that I hadn't had for like 10 years I thought a lot of my sort of soundness and ineptness and just loss of self-esteem and low self-worth was just because I'd had my third child when I was 40. I thought I'm just a bit old to be a mother again. I was trying to change my career.

I was trying to set up a clinic. I was doing all these things. And then suddenly my brain literally felt like it was opening up and alight again. It's all I can say really. And I could jump out of bed rather than thinking I'm going to hit snooze 28 times before I get out of bed. But I went to a lecture by an Italian professor. And he was talking about the benefits of testosterone beyond libido or sexual, you know, libido. And he was said, I remember going to the opera with my wife.

And it's the most wonderful opera with their, you know, listening. And I look at her and she's crying. She's got tears of enjoyment because the music is just so wonderful. And I think to myself, that's testosterone that's done that. It's given her this tingling sensation's enjoyment. And I came out of the lecture theatre thinking, yes, that's what I'm getting. Really, you know, I was really invigorated. And I turned to two of my colleagues and said,

that testosterone is amazing and I stupidly said to them oh do you take testosterone and they both look poker face and said no I don't need it and I thought okay I've really just overstep probably all professional and personal boundaries here and then I realized that actually maybe I was oversharing telling people that I was on the hormone I don't know why but and then I got told off actually for talking about it in public but actually like lots of things in any experience you learn more from yourself, but then it makes you understand, like, why is my brain feeling like this? Let me go back and look at some neuroanatomy, neurophysiology text.

Oh, okay, I can understand now why it's working. So it's unlikely to be just a placebo, isn't it? Oh, it absolutely is not a placebo. And we should be talking about it. We should, like, make everyone very comfortable talking about women's health and women's hormones and what it means and what the change is, I have patients who consistently tell me I have saved their life. And they mean it. I have other women who have said, you know, I feel incredibly better. You know, I'm back to my life again. I feel reengaged with my friends. I started my hobbies

again. I'm motivated to go to the gym. I feel excitement for things. And none of those are sexual. none of those are sexual they're back into enjoying their lives again and getting stronger and feeling more confident and i would say there's consistently a message of somewhere along the way when your hormones go down and i think estrogen plays a role in this and a lot of different things do too but we lose the sensation or the understanding or the connection of our feminine energy of our sensuality our sexuality This is a personal feeling, and you don't need to have a partner to feel that way in your body and your life and your mind and your spirit. And it disappears. And women struggle to feel, I don't feel attractive. I don't feel sexual. I don't feel that in my body. I don't feel it when I look at myself when I'm talking, all of those things. And that's not made up. That's a consistent message that I get from women. And when they start on hormone replacement therapy, and some I've only ever started on testosterone, that comes back. And they can feel that again. They can feel their sexual identity again. They can feel their feminine energy and that sensuality. And they then go

forth in their life and connect and do the things that they've loved to do or find new things to do, relate to their partner in a different way. That is a consistent message. Yes. And it's interesting, isn't it? Because a lot of the guidelines, well all the guidelines actually that I can think of, say that we have to give HRT first if women still have reduced libido despite being on HRT considered testosterone. But actually the more work I do and I learn every day from patients that we see is that I think, and I'm really keen to hear what you think, there's a lot more women out there who are testosterone deficient before they become estrogen deficient. Yes. Do you see that in your practice? Yeah. I do. I have women. I have women. I have

women in their late 30s and on who are in perimenopause. I know we don't have the data on this. This is just my clinical observation. Many of them have been on oral birth control for a very long time, right up until their 30s when they decided to have babies. And most of them say, I just didn't bounce back after my last child. Those women have very low testosterone and have all the symptoms of testosterone depletion. And I start them on testosterone. On its own. before. On its own. Yeah. And that makes a difference. And then we talk about perimenopause and what will happen next when progesterone goes, when estrogen leaves the building. You know, I think of estrogen as the queen of everything lubricated eyeballs to vagina. You know, you're going to notice it and, you know,

certainly talk about it right away when it starts to happen. So I definitely have, I have a cohort of women on the young side and my older ladies who are maybe, you know, know, 68 to 75, and they're keenly feeling the lack of stamina and ability to maintain their muscle mass. And just their sort of mojo, their get up and go. This is what they tell me. Only testosterone for them, game changer. And it's interesting because some clinicians get quite scared of giving testosterone without estrogen. And people talk about this aromatization of testosterone to estrogen. But actually, our hormones come from the same pathway anyway, don't they?

That's right. They're very similar. When you look at their chemical structure, estrogen, testosterone are very similar. And some might convert to estrogen, but it's very low, and it's not enough to really have an effect. And we have to remember that people have estrogen endogenously anyway in their bodies. That's right.

And even when people are post-menopausal, there's still some estrogen production anyway. And so testosterone is an independent hormone. And I often say to people, if you had a patient who was hypothyroid and had type 1 diabetes, would you say to them, right, I'm going to give you thyroxin today and then I'm going to give you insulin in three months time? It just doesn't make sense. Yeah, you're exactly right. I tell people that estrogen and progesterone are a couple and testosterone plays in his own sandbox. Completely different. They work well together, but they can be given separately.

And sometimes I start women only on estrogen and progesterone to begin and then add in testosterone. Other times I start testosterone first. It depends on, you know, each woman is, their care is so individual. Who it is. It's so individual. And what I think the complaint or the thing that is highest on their suffering scale, if you will, is what I tend to go with first if they only want to do one hormone at a time. And so that could be estrogen or it could be testosterone.

I do have a few patients who have a contraindication to estrogen, unusual cancers, not breast cancers. And I've worked with their oncology team to get the approval to just start testosterone. And this woman, and I have a few of them that were really suffering. and the testosterone made a significant difference in their hot flashes, their night sweats, their brain function. Most women will comment more clarity in their brain and their mood and their motivation. They're sort of like mojo. Their zest for life is back again. And it did mitigate most of their symptoms. I don't get the benefit of having estrogen for the rest of their life, but their quality of life is significantly improved. Absolutely. Absolutely.

And it's really interesting because we've looked at our data of adding testosterone in. In fact, you were there when I was presenting it. And half of our patients, we increased estrogen because we thought they had symptoms of estrogen deficiency. In the other half, we didn't. But the benefits with testosterone were the same across the domain of all symptoms, suggesting that we don't always need to be giving more and more estrogen. It's an independent hormone. And so there are people that will probably benefit from testosterone earlier or, you know, maybe to start.

And it is so individual. one of the things that really frustrates me, lots of things frustrate me as you know, is that we're talking about a natural hormone. So when we give testosterone, it's exactly the same chemical structure. It's not being modified in any way compared to what we produce by our ovaries when we're younger. Yet you and me, so you in America, me and UK, we don't have a licensed product of testosterone, do we? So when we say it's licensed, you know, there are lots of drugs that are licensed, Obviously, all the antidepressants are licensed, pain killers are licensed, all sorts of things.

But testosterone also is licensed for men in the UK. Is it licensed for men in the US? It is. Yeah, of course it is. Like, why wouldn't it be? Yes. So women who are slightly, as I said at the beginning, slightly over 50% of the population and produce this natural hormone, which is actually the most biologically active hormone we have,

that we produce in higher quantities than estrogen when we're younger, and it depletes with time. The deficiency causes all sorts of symptoms and probable health risks as well, yet we don't have a licensed product. Doesn't quite add up, does it? No, the gender disparity there is glaring. And at this point, I don't know how close or far away we are

because it would take a considerable amount of money for, you know, a company to decide to do the research and then bring it to the FDA, or the FDA to run a study and then they would easily come up with a product, say like a patch like the UK has or like Australia has. We don't have the patch anymore. That was withdrawn when the drug companies stop making them,

but we use the Australian cream. So that's what they have, which is licensed in Australia. Yes. And they're trying, I think, to get it licensed over here, but it's not really a priority. So we haven't got a licensed product for women. So we can still prescribe androfen. We're allowed to prescribe it privately.

So it's a regulated product. We can prescribe it, but women have to pay for it. On the NHS, the National Health Service, we can prescribe the male testosterone, of course, off licence, because it will be for women, just in lower doses. Because it's exactly the same hormone, of course, isn't it? So we can just do that. So we're more fortunate than you are in the US, actually.

Yes, and here, I fear what would happen if somebody does pick this up and does, you know, the double-blind, randomized placebo-controlled study, that they'll end up coming up with a product that will be terribly expensive. Yes. To pay for the, you know, so they'll kind of put the pink tax on it, and it'll be very expensive, and women won't buy it, you know, because they're going to just get the male generic stuff that's not too expensive. Yes. So I feel a little bit discouraged about if that's going to happen or not. but we can prescribe. Yes. And the other thing is it comes under in the UK as a control drug because it's an

anabolic steroid, which is absolutely ridiculous for women, actually. So men is a different conversation. There are men that can overuse testosterone and it can be an anabolic. All our hormones steroids, actually. But the amount that we need is women is very low. And all we do is replace what's missing. So I don't know about you, but we just don't see the side effects that have been reported in our patients. The biggest or commonest side effect is some hair growth way the cream

is applied on the thigh. But we don't see women with beards. We don't see women with hairy arms. We don't see voice changes. We don't see hair loss. We don't see clitoral megaly. Some people find their clitoris returns because it's shrunk without the hormones. But that's not the same as clitorial megates. So we don't see these awful side effects. So I can't really see that it's working as an anabolic steroid. Women often say that they've got more muscle strength. they've got more muscle definition because when they exercise it's more efficient. But when we're thinking about long-term health and reducing sarcopenia, this sort of loss of muscle mass, it's really important, actually.

But I didn't see women with abnormal muscles who are masculized. It's just not in the doses that we give. I don't see that either. The side effects are very rare. And they're dose dependent, I find. Yes, yeah. You know, so you can easily back off on the dose, the teeny tiny baby almost home. apathic dose that we give. We hardly need any. You know, you can certainly back off on the dose.

But I do echo your point about sarcopenia. For instance, I have patients who fall under categories of chronic illness like multiple sclerosis and Parkinson's. I have some other demilininating neurological disorders, even traumatic brain injury. But especially for the MS patients, the patients who need to stay strong and have their balance. That's very important for them. Yes. Testosterone very much helps with that. It also helps with their brain function and their nervous system. It's sort of a win-win across the board for those patients and they notice a difference. Yeah. And it is that I've got quite a few patients with Parkinson's disease with musculosis at you and also increasingly with lupus actually. And a lot of someone said to me the other day that she can't have a shower with her eyes,

closed because she'll fall over. So this proprioception and she's been told it's her lupus. I'm there. I think I'm sure it's related to testosterone. And a lot of people have this pot syndrome where they stand up quickly and they feel really dizzy. And that can often really improve with testosterone as well. Because testosterone gets everywhere. So there's a huge amount that we need to do. But in the meantime, we haven't got the studies. We act on clinical, well, what we learn in our clinics, but also, basic science as well. And putting the two together is a great privilege and honor being a clinical practitioner like you and I am and helping patients and listening and learning and knowing that what we're

doing is safe. So I'm very grateful for your time, Anita. And we haven't really touched on all the other area of longevity and what else to do because it's not just about hormones. So I might get you back in a few months' time to talk about once we have our hormones balanced, how we optimize our future health because I know you're really amazing and passionate on that like we all are as well. So but before I finish, I always ask for three take home tips. So I'm going to ask you if it's okay, three things that you would love to say had happened to improve the health of women. So if we met in 20 years' time, what are the three things that you think could make a huge difference for women's house? I think the education piece. So women need to educate themselves.

they will have to be their own advocate. Yes. I think your book is a great place to start. Oh, thank you. The definitive guide. Yes, it's very good. I would recommend it to anyone at all. So women have educated themselves.

They've become their own advocates. I would love to know that hormones have become available and are affordable. Like, we don't even have vaginal estrogen covered by some insurance here, never mind over the counter. So the accessibility to the treatment, to the providers. And then the third thing is the education of the providers. So even a fellowship in menopause, let's do that. Yes.

You know, let's like start at, you know, med students, start at nurse practitioner students, start very, very early. So they understand that menopause and sexual medicine is, very important for our lifespan, our health span, really more so. I totally agree. I couldn't agree more. And it's changing the narrative as to what our hormones are, not being scared, embracing them, you know the beneficial effects that we have when we have our hormones. So thank you so much. I've really enjoyed it today. So thanks, Anita. Thanks for having me, Louise. It was really nice to see you again. You can find out more about Newsome Health Group by visiting www.newsonhealth.com.

And you can download the free balance app on the App Store or Google Play.