unPAUSED with Dr. Mary Claire Haver - Testosterone Is Not a Male Hormone: Levels, Dosing, and What It Does During Menopause

Episode Date: September 1, 2026

In this episode of unPAUSED, Dr. Mary Claire Haver sits down with Dr. Mohit Khera, board-certified urologist and Professor of Urology at Baylor College of Medicine, where he holds the F. Brantley Scott Chair in Urology, to tell women the truth about testosterone — the hormone women actually make more of than estrogen, yet still cannot access in a single FDA-approved formulation.Dr. Khera explains why testosterone is one of the most biologically active hormones in the female body, with receptors in the brain, heart, bone, muscle, and genitalia, and why the research to prove its full benefits for women has simply never been funded. He walks through what low testosterone really looks like, how to get tested properly, why women with low libido are so often handed an SSRI that makes things worse, the truth about pellets, creams, and injections, which side effects are reversible and which are not, and the red flags to watch for when looking for a prescriber. He also shares why sexual dysfunction is a couple's disease, what he calls the "hormonally dangerous decade," and the one intervention he's found that makes women feel even better than hormones.Guest links:Dr. Mohit Khera (Instagram) https://www.instagram.com/drmohitkhera/Dr. Mohit Khera (X) https://twitter.com/DrMohitKheraDr. Mohit Khera (LinkedIn) https://www.linkedin.com/in/drmohitkhera/Dr. Mohit Khera (Website) https://drmohitkhera.com/Dr. Mohit Khera at Baylor College of Medicine https://www.bcm.edu/people-search/mohit-khera-24469Books:"The New Perimenopause," by Dr. Mary Claire Haver https://thepauselife.com/pages/the-new-perimenopause-book"The New Menopause," by Dr. Mary Claire Haver https://www.amazon.com/New-Menopause-Navigating-Through-Hormonal/dp/B0CKBZ4K1Z

It's not a male hormone. We know if you treat women for decades, you'll see it helps with muscle mass, depression, energy, mood, sleep. Just because the data does not show it, does not mean it doesn't happen. Why don't we have the research? It's money. The funding for men is at least 20x or more than in women. Talk to me about levels. What do they mean?

Always start low and go slow. The side effects are related to dose. Acne, facial hair, oily skin. Those are reversible. For many years, I've been treated. treating women with testosterone and giving them hormones, I found one thing that actually makes them feel better than the hormones. The views and opinions expressed on unpaused are those of the talent and guests alone and are

provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. For years, I've watched women come into my office and tell me their libido is gone. They tell me they barely recognize themselves. They tell me their partner is patient, but they can see the toll it takes. They tell me they've tried everything, and nothing works. Their OB-Gen told them it was stress. Their therapist told them it was the relationship. Someone else suggested an antidepressant. Nobody mentioned testosterone. And for years, I didn't either. not because I didn't believe the data, because there was no FDA-approved formulation.

The guidelines were unclear. The field treated female testosterone as French, so I referred out. I hedged, and I watched women suffer with a treatable problem because the research infrastructure was built for men and the regulatory infrastructure had abandoned women. Here is what I know now. Testosterone is one of the most biologically active hormones in the female. male body. The data on safety is stronger than people think. The reason it is not FDA-approved for women is not because it doesn't work. It's because nobody funded the trials. Women have been told

testosterone will give them facial hair in a deep voice. Women have been told it's experimental. Women have been told to wait. And while women have been waiting, men have had access to testosterone replacement therapy with FDA-approved gels, pellets, injections, and patches for decades. Today's guest has spent his career closing that gap. Dr. Mohit-Kara is a board-certified urologist and professor of urology at the Scott Department of Urology at Baylor College of Medicine, where he holds the F. Brantley-Scott Chair in Urology. He earned his MBA and his Masters in Public Health from Boston University and his medical degree from the University of Texas Medical School at San Antonio. He has published more than 160 articles in peer-reviewed journals, written and edited

two books in the field of sexual medicine and men's health. Dr. Kara is one of the few academic voices in this country who has consistently made the case that women deserve the same evidence-based access to testosterone that men have had for decades. He is here today to tell women the truth about testosterone, what the research actually shows, what the risks really look like, and what to ask for in a doctor's office that has never prescribed testosterone to a woman. I'm Dr. Mary Claire Haver, a board certified obstetrician and gynecologist and certified menopause practitioner. I'm also an adjunct professor of obstetrics and gynecology at the University of Texas Medical Branch. Welcome to Unpaused. The podcast will be cut through the silence and talk about what it

really takes for women to thrive in the second half of life. This episode of Unpaused with Dr. Mary Claire Haver is brought to you by Alloy Health. You know, know those moments when you look in the mirror and suddenly think, why does my skin look so different? And you start buying every new serum and moisturizer hoping something will turn it around. But here's what I want you to know. If you're in your 40s and noticing these changes, it may not be your skincare routine. That's the problem. It may be your hormones. As estrogen declines, our skin can become thinner, drier, and less elastic. So instead of just adding another product to your routine, it makes sense to look at what's actually driving those changes.

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Your menopause specialized doctor will tailor your skin care to your needs. Plus, you get a $0 unlimited messaging with your doctor. Head to M-Y-A-L-L-O-Y.com and use the code M-C-H-20 to get $20 off your first order. This podcast is sponsored by Midi Health, the first virtual clinic created for women by women for the treatment of menopause. Don't let anyone tell you menopause is something you have to suffer through alone. Midi can help. Visit join midi.com to learn more. Dr. Kara, welcome to unpause.

Thank you. Thank you for having the show. So you spent your training, learning to take care of mostly men. I know there were female patients in your residence as well. Yes. But when most people think about urology, they think the male plumbing system. But how did you end up becoming one of the world's loudest voices to me in the academic arena on testosterone and women? I got to tell you a story.

So in 2007, I finished my fellowship at Baylor College of Medicine with Dr. Lipscholds. And I was really good at getting men, excellent erections, great libidos. And one day a woman called me, and she was extremely upset. And she said to me, you've ruined our relationship, everything was great until my husband met you, and now we fight every single day. And I couldn't understand what she was talking about. In the sense, she was saying, he wants to have sex with me every day now. We haven't had sex in 10 years. and we fight every single day.

And I thought to myself, she's right, right? It's okay to leave both libido's low, but you never raise one libido high and the other one to keep it low. So that year I flew out to Irwin Goldstein, godfather of female. Yes. And I said, teach me everything you got

about female sexual dysfunction because it's not fair to treat one partner without addressing the other. And since 2007, I've been treating both. Now, if you treat women for female sexual dysfunction, function. You're going to have to learn a lot about testosterone, a lot about hormones, and that's where I got into the business. And so we've been doing it ever since. Wow. In your training, you know, again, I have a urological system. You have a urological system. But like, did you

cover female sexual function at all? Are you just assumed the gynecologists are going to take care of us? Yeah. So we do not get, I did not get any training in my residency or my fellowship in female sexual dysfunction. Let's take it back a step further. If you look at medical school training, There was a survey that just came at medical school training. 50% of medical students said they never got training on sexual dysfunction at all, at all, right? 65% of residents said they never got sexual dysfunction training at all. And of those that got training, 50% said our training was lousy. I learned nothing, right?

So you have to understand that there's very little training that goes on in our academic system. My wife's a family practitioner, and she said to me, look, I see these patients, I have about 18 minutes a patient. I got to go through diabetes, hypertension, OSA. I can't get to sexual dysfunction. And I said, it's extremely important. She goes, if I even could get to it, I wasn't trained on how to do it, right? And what am I going to do if she tells me I have sexual dysfunction?

So it's a big problem. So in my training, nothing for sexual dysfunction, other than some GSM stuff, like dryness. You know, I knew how to treat that with vaginal estrogen. but I graduate from residency and I go out in a private practice for three years. And outside of obstetrics, which I have an A-plus in, you know, in all areas of obstetrics, then I'm doing gynecology, you know, we're doing both. And I can't tell you how many times I get the well woman done, you know, and then as I'm walking out the door, she gathers the courage in her little paper gown

with her, you know, lap sheet on to say one more thing. Right. And I just remember being a deer in the headlights. Like, I didn't know what to say. I didn't know what to tell her. So what do I do? I walk out and go to my, you know, seasoned, you know, co-workers who had been out in 20, 30 years of practice and be like, Ms. Smith is complaining of low libido or whatever she called, however she described it. And their responses were, because they weren't trained, oh, give her some wine, you know, tell her to relax, have some wine.

She'll get over it. Like, that was it. Or take an SSRI. All right. I mean, it's sad. The number one treatment for F. FSD in the United States is vaginal lubrication. That's it. So FSD for our listeners, female sexual dysfunction.

Of the 48% of women who suffer from female sexual dysfunction, only 19% get therapy. 19%. Now, think about this. If I told you there's a condition that affects 48% of women, would I not get your attention? It's a big unmet need. And then I tell you that the physicians are incapable or are very uncomfortable treating the problem. Big problem, not much doing about treating this. So it's a big problem. So when we look at where the bias is, okay, when a man has sexual dysfunction, it's automatically assumed to be a mechanical problem, a plumbing problem, right? Most of the time.

Get more blood flow to do. So that's my assumption, right? But for a woman, it's psychological. Right, which is not true, right? So what is the actual number of say? Yeah, so let's talk about a female sexual sphung because it's a loose term. What is it? if a woman suffers from one of four conditions, low libido, decreased arousal, meaning blood flow

to the genitalia, orgasmic dysfunction or pain, if she has one of those four, and she's bothered by it, she suffers from female sexual dysfunction, right? So if the woman comes in and she says, I have really low libido, but I don't really care. She doesn't have FSD, right? So that's really how you diagnose it. Male sexual dysfunction, we think of it like erectile dysfunction, and that's a predominant condition. but there's other conditions, low libido incriminate incriminate inculmonary, pre-gulation, delayed ejaculation, and orgasmine.

So there are other conditions as well. And the thing is that both of these are unmet needs. The funding for men is at least 20x or more than in women. We'll get into that, right? We have a fraction of what we spend in women. Just a fraction. It's not fair. And if you look at all the data, say, does it work in women?

I have to say, I don't know. We don't have data. Does this work in women? I'm not sure if we don't have data. which is very, very unfair. Wow. So let's talk about testosterone a little bit. It's a really, really hot topic.

Do you do social media at all? A little bit. A little bit. Okay, I think I have a PhD in Instagram right now. So I see a lot of information being served, a lot of misinformation, a lot of misunderstanding, a lot of public debate over this testosterone issue. So one of the things is, you know, how much testosterone does a woman actually have in her body? There's some debate over.

Is it more than estrogen, less than estrogen? Really, walk our listeners through, like, where does it come from? Yes. You know, and how much do we actually? Let's look at the differences in sexes. So in men, we know that 90% of the testosterone comes from the testicles, 10% from the adrenal glands. In women, it's different. We know that roughly 50% of their testosterone comes from either the ovaries or the adrenals.

50% comes from peripheral conversion, right? DHE, and dresed anode. So it's a peripheral conversion in the tissues. So we always were thought, when a woman goes through menopause, she gets a precipitous drop in her estrogen, progesterone, testosterone, everything drops. That's not true. Not for testosterone. Not for testosterone, right? Because the adrenos can continue to produce as well.

And even in the ovaries, even postmenopausal, can still produce some testosterone. So you don't assume she's postmenopausal and the T is low. Check the T. If she's postmenopausal, we assume the estrogen progester low, but not the T. So we check it. A woman makes about 300 micrograms of testosterone every single day, 0.3 million. It's very small. It's typically one-tenth to one-twenty of what a man makes, right? But it's sufficient. She will convert a lot of that testosterone. But we have to understand testosterone is extremely important for

women as well. It's associated with a male hormone. It is so important for women. Let's look at the receptors. That's my next question. Where are the receptors located? They're all over in her brain. They're in her heart. They're in her bone. They're in her muscle. Predominally all over the genitalia as well. Look at where the receptors are located. She has these receptors for a reason. Now, their studies suggesting that there may be benefit in muscle, in depression, in muscle mass, but it's conflicting. And someone says to me, Dr. Kara, well, there's not great data. Remember, a global position statement says we should only use testosterone for HSDD.

That's a very important point. Right now, every position statement out there says testosterone for women should only be used for low libido or hypoactive sexual desire. debate on social media. So that's it. So that's what every consensus statement says. But we know, we know, if you treat women for decades, you'll see it helps with muscle mass, depression, cognition, there's energy, mood, right? Sleep, we've seen these things.

Just because the data does not show it, does not mean it doesn't happen, particularly if you don't spend money on doing the research. Yeah. So this is a lack of a study issue, not that the studies have shown it doesn't help. 100%. Is that, am I correct in saying that? And there is conflicting data. So some studies show if you give a woman testosterone, her mood and depression improves. Other studies say it doesn't.

Some studies say if you give a woman testosterone, her muscle mass will improve. Others say it don't. But you know their muscle mass improves if you give them testosterone. It's abandoned in athletic sports because it gives you a significant advantage. So the reason why we say it's only used for HSDD, I think, is because we don't have the research to say that it's effective in other areas. But that doesn't mean it doesn't work. Why don't we have the research? It's money.

It comes down to money. Look, I was involved in the Traverse trial. Yeah. The Traverse trial was the largest randomized placebo control trial. We were asked in 2015, nine of us to develop this trial. We spent over $500 million to show that testosterone did not cause a heart attack. The largest randomized placebo control trial, 5,246 patients. We will never spend that on a woman trial to look at testosterone.

There's not even close. I don't think we'd even spend $100. million. Who paid for that trial? It was industry. Right. So industry paid. But that was with the FDA had said, look, we have a warning. We have a sense. There was a black box warning. In 2015, they put it on there because of four studies. So 200 studies said that testosterone does not increase the risk of heart attack. 200 studies said that if you give testosterone, it may improve cardiovascular risk. Four non-randomized, non-plicebo control studies, bad studies came out from 2010 to 2014 saying that if you give

testosterone to a man and may increase his risk for heart attack. So in 2015, the FDA said, you know what? We want a large study. We want you to show us that it does not increase the risk of a heart attack. So we did it. We enrolled our first patient in 2018, our last patient in 2022, and we showed that there was no increased risk in cardiovascular events in men taking testosterone. In February 28th, 2025, big day for me, the FDA announced we're taking off the black box morning. It does not cause cardiovascular risk. So that was really important. But, But they're not going to spend that money on women to look at testosterone and their benefits, and that's the problem.

We spell a fraction of what we spend on women as we do in men. You describe testosterone as the most biologically active hormone in the female body. Yes. What makes you say that? Because you look at the receptors. They're everywhere. If you look at the location of the receptors, plus women have a much higher content of testosterone, the nesterdial. Women think that I don't make...

Now, that's a big controversial topic. That's right. someone try to do a takedown of this. So walk me through what that means and how we measure it. We measure it differently. So if you measure estrogen, if you measure testosterone, it's a nanogram per deciliter. Okay. If you measure estrogen, it's picogram per milliliter, right?

So it's different, right? But if you do the conversions, you actually make more, a woman makes more testosterone than estrogen. Right, she makes more testosterone. Right. And then we convert some of that testosterone to estrogen. Right. But she makes more. So to tell me that she doesn't need it, she makes more testosterone than estrogen.

estrogen. That's a really important point. She has receptors all over her body looking for testosterone, right? When she's deficient, why can we not give it back to her? Let's hold this thought for a second. Let's say she's deficient in another hormone. She's deficient in thyroid. Insulin. Cortisol, estrogen, progesterone, any hormone she's deficient in, we're okay in giving it back to her. Why not testosterone? What is the logic by not giving her back a hormone that she already made? makes higher content than even esterdial. What is the logic? If I were to give you another $500 million, but I'm going to ask you to study women this time, what would that study look like? That study would look like looking at depression, bone mineral

density. It would be looking at cardiovascular risk. I think that testosterone is cardiovascular protective, right? You were looking at diabetes, obesity. I would want to look at everything that we looked at in men, which I know, and to look at women. I don't think men and women are that different. like in terms of cardiovascular muscle. I mean, if there's a strong signal that it's going to help men, I think it's going to help women. But I have to show it. Right. So give me the money and I'll show you.

Okay. Yeah. So what does low testosterone really actually look like in a woman? Most commonly, sexual side effects are the most specific, right? So if a woman has low testosterone, she'll say I have low libido. They can typically have low arousal, orgasmic dysfunction as well. So sexual. But there's other symptoms that occur.

Okay. She'll say that I have a depressed mood, change in my mood, decrease energy, right? Poor cognition's been seen as well. Decrease muscle mass, increased fat deposition. These are very similar to what we see also in women who go through menopause, right? And sometimes you say some of the menopausal symptoms are very similar to what someone's suffering from low testosterone. And there are many studies showing that if you place a woman with HRT and you put her on estrogen progesterone and she still has symptoms, if you add the testosterone, you can mitigate. those symptoms, right? Why? Because those symptoms were actually T-related, not so much

P-related. We do see that in clinical practice. Yes. You know, we always, you know, I'm a gynecologist, I'm a menopause specialist, so we start with estrogen and plus or minus progestin, depending on, you know, uterus and sleep issues. Sure. And then, you know, testosterone, definitely with HSDD, but we are seeing when we add it, suddenly they're getting better symptom control across the board. Across the board. And Luis News Newsom just published that big study in her group. When she added the tea, those patients saw greater improvements in menopausal symptoms than just estrogen progester alone. How often clinically do you and your team, because you have residents, I mean, you're in a big academic practice. So walk me through what your practice looks like.

I'm at Baylor College of Medicine, and I'm in the division of sexual dysfunction and fertility, and so we have three clinical fellows. We have 20 residents. We have an unbelievable amount of medical students. And every day, it's a lot of fun. You're constantly teaching, you're educating, You're operating with them. I work at the VA every Monday, half day. So I'm working with the vets and I'm operating with the residents there. But it's busy. You know, it's about 150 to 160 patients a week.

Eight surgeries a week. But it's fun. And then we spend a lot of time Friday afternoons. It's my research day. I started a basic science lab in 2007 and still running where it's called the Laboratory for Andrology research where we do a lot of research looking at testosterone for men and women in our lab. Yeah. And so it's busy.

That's awesome. Yeah. So how often in this clinical situation do you have a patient who's come in and she's been worked up for depression fatigue relationship problems who's never had her testosterone drawn? So common because getting her testosterone drawn is something that's last on most clinicians' minds, right? Yeah. So she comes in and she has these symptoms. It wasn't even on the checklist.

It's not on the checklist. TSA is on the checklist. For sure. For sure. Clinical depression is on the checklist and they may check for – We screen for everybody. Right. So depression. But the T is one of the last.

last on the list. And what's unfortunate is that many women, I've seen this, will come in with those symptoms and they'll be given an SSRI. Say, I think you need an SSRI. You've got a lot of stress going on. You're a little bit depressed. I'm going to put you an SSRI. And she's already telling the clinician that she suffers from low libido. What do you think that SSRI is doing to her libido? It's plummeting. It's plummeting. It's plummeting. It's plummeting. So it made it worse, right? She doesn't need an SSRI. She needs to really look at her hormones, right? Evaluate her hormones. Look at her testosterone level. Start with the biodendicals first, normalize her, and then see if you need something else, right, but not the reverse. So what does the blood draw look like? Like, what are you looking

for? Are you doing free? Are you doing total? There's a lot of questions about that. Yeah. So what is the scientific validity of doing a free versus a total? So look, if you look at the global consensus position statement, the statement states that you should only look at total, right? And there's reasons for this, because we know that as you get to T levels below 100, the asses. Yes, female levels, the assays become more inaccurate. So if you really want the most accurate testosterone level, then you want to get LCMS, right? And you want to get something, but it's hard to get LCMS and it's expensive. So we use amino assays as a surrogate.

And for our listeners, what is LCMS? The good comatography mass spec. It's a specific type of way of measuring testosterone women at low levels. It's the most accurate. And you can send it out. So LabCore has it, Quest has it. But most clinicians just order testosterone. Okay, fine.

So it's not as accurate because of lower levels. And remember, women also have diurnal variation, particularly younger women. So just like men, we have the highest levels in the morning of testosterone. Oh, wow. So do women. So just remember that. We also know that. How much is that fluctuation?

It's about 25% from morning to evening on testosterone, but at younger ages. So as she gets older, she loses the dinerial variation just like men. But it's a 25. So she comes in and she's 45 years old and you check a tea in the morning and you check it in the afternoon. It can be a 25% variance on the T level. Okay. in the morning. The second thing is we're getting into a world of fasting. So we do know that if you are

if you have a meal, testosterone levels can also be suppressed in men and women. So they recommend fasting in the morning. She's premenopausal. I'll get the, I want her in the follicular phase, day three to seven roughly to check out of it. But she's post-menopausal. That's fine. So early morning fasting, if you can. But we use LCS. Now the guidelines say don't use free tea. And I don't completely agree with We do know in the male population, free tea is the best predictor of symptoms. It's been shown e-mass study, no measures are shown, that your body doesn't care about the total. Right.

It only cares about the free. It only needs the active. And so it's not that different in women also. It's the active. In certain women, the SHBG can be very elevated. Okay, so walk me through SHBG for our listeners. Sex hormone, binding, globulin. Think of it like something that's bad, not great.

It's made by the liver, and it loves to bind to the testosterone. And if it binds to the testosterone, guess what? You don't have very much to use. So the higher the SHBG, the less free T I have, right? Well, what is notorious for causing elevated SHBG and women? Oral estrogen. Oral estrogen and birth control. Yeah.

That is notorious. Erwin Goldstein did this amazing study out of Boston University several years ago. And he showed that if a woman took oral contraceptive pills greater than five years and then stopped, her SHBG may never normalize. It's permanently elevated, right? So that was an interesting that merely made a hit on me because I thought, okay, that's making her have long-term effects of negative sexual dysfunction because her free tea will permanently low. So I see a woman, she's been, she said, look, I took birth control 20 years.

Yeah, I took it, yeah, it took 20 years ago, but I took it for 10 years. You look at the SHBG, it's still sky high, right? Because it can stay perfectly elevated. So you have to compensate by giving her high T levels as a workaround. Okay. Now, guidelines will say, don't look at the SHBG, just look at the total. But no, there's exceptions. If you have a woman who's in the normal range who has signs and symptoms of low T, check

the SHBG. If it's elevated and the free tea is low, I still think it's important to raise the T to see if she has improvement in symptoms. Are there ways outside of elevating testosterone? Like, how can I get my SHBG down if it's elevated? Yeah. So people ask me that. Some patients are very clever.

They said, look, you know what, don't raise my tea. Lower my SHBG. I said, look, SHBG is due to medical conditions. For example, hyperthyroidism will increase SHBG. Pregnancy will allocate SHBG. So conditions can do it. Serosis decreases it. So if you fix the condition, you can change the SHBG.

There are supplements, but I'm not a big believer, like boron. There's certain ones that can potentially drop the SHBG a little bit. The best way to drop SHBG, testosterone. Testosterone in itself lowers SHB. So it feeds back to the liver somehow. And drops the SHBG level. So you're increasing totality. and you're dropping SHBG, and that helps a lot.

Welcome back to another midi pause. I'm Dr. Mary Claire Haver, host of Unpaused. Let's talk about one of the most frustrating parts of perimenopause and menopause for so many women. Sleep. Why is it that the place we're supposed to feel most at peace can cause so much disruption? If you've ever found yourself wide awake, staring at the ceiling at 2 a.m., convinced something is fundamentally wrong with you, This is for you. Even women who never had trouble sleeping can suddenly find themselves waking up in the middle of the night, tossing and turning, are feeling exhausted no matter how many hours they're technically getting.

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or supporting blood sugar balance. For others, it may involve hormone therapy, targeted supplements, or addressing underlying issues like anxiety or sleep apnea. This is exactly why personalized care matters. Midi Health helps women navigate menopause with a much more comprehensive approach, including sleep health. Midi connects women with clinicians who specialize in midlife and menopause care, So instead of feeling dismissed, you're actually getting support tailored to your symptoms and your lifestyle. What's great is that MIDI looks at the bigger picture. They help women identify why sleep is being disrupted, not just how to temporarily mask it. Whether that means exploring hormone therapy, creating a sleep support plan, or addressing related symptoms like anxiety or night sweats, the care is individualized.

And because it's virtual, women can access. expert support from home, which makes these conversations feel a lot more accessible and less intimidating. Because sleep isn't a luxury, it's foundational to your health. So if perimenopause or menopause has completely changed the way you sleep, know that you're not alone. And more importantly, you're not out of options. The right support can make a huge difference. Go to join midi.com. Join midi.com and connect with one of their clinicians. today. This podcast is sponsored by Midi Health. You've heard me talk about my menopause toolkit. It consists of nutrition, exercise, hormone therapy, and other medications, stress reduction,

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making expert high-quality care accessible and affordable for every woman, all of which is why Mitty should be part of every woman's menopause toolkit. Book your virtual visit today at join midi.com. That's join M-I-D-I-D-I-com. I'm getting my blood drawn. I'm doing it in the morning. I'm doing it fasting. Yes.

And I'm post-menopausal, so time of the month does it. But if I'm Perry, which a lot of our patients are, we have them try to come in in molecular face. Because we're doing a bunch of other labs, too. And, okay, talk to me about levels. What do they mean? Yeah. So let's talk about levels. Guidelines will tell you that we should put them back into the premenopausal range.

And what is that? So some will say 17 to 57. Most will agree that 20 to 80 is the premenopausal range. Some others will say, no, it should be higher. But most guidelines say 20 to 80. So this is where I disagree a little bit. And we look at the male literature as well. If she's 25, that's considered normal.

But to me, that's not considered normal, right? that say, well, she's in the normal range. So normal ranges for thyroid, testosterone, men. If they give you a range, patients tend to do better I've seen in the upper quartile of normal. It varies. If they're symptomatic. Yeah. So I use that as a judgment.

Just like you would treat a woman who had needed estrogen progesterone, the OBG wines do it on symptoms. You don't check levels. I've never seen it. Let me check estrogen. Oh, you need. You come in, she still has vasemotor symptoms. What do you do? Yeah, guidelines don't support.

You just give her more estrogen, right? Checking estrogen. Right. All right. So the fear is that you don't want to get superphysiologic on giving her too much. Many years ago, this is very important. In my lab, I started checking the blood in men and women, and I checked something called the CAG repeat. The CAG repeat is looking at the sensitivity of the androgen receptor. Looking at her DNA. So I showed the DNA, and the men and the women, I looked at the sensitivity of the testosterone receptor. We showed, for example, those men who have more sensitive receptors, they need less tea. those men who have very insensitive receptors, they need more tea. And we published also in women a very similar paper. What does that mean? All of us are different.

Levels don't matter. Well, to somebody, but all of us are different. And all of us have our own set point. So let's say on that range from 20 to 80, you feel great at 60. Yeah. Okay. It doesn't mean that everyone has to feel great at 60. Maybe she feels great at 80 and she feels great at 40.

What if she feels great at 100 or 120? Right. So that's where people will say you need to be. be careful. I have no problem in raising the levels higher, slightly higher, but I want to be very clear. I don't believe in keeping superphysiologic levels at a sustained superphysiological level. If they're transient for a while, I agree. If the woman is in the upper quartile abnormal and she still has symptoms, that's your clue to say, what else is going on? So I will tell the residents, I say, look, we got this patient into the upper quartile abnormal. His or her testosterone level is right

where it needs to be. Well, Dr. Carol, let's raise it. Let's raise it. Let's raise it to superfizance. physiological levels. No. Let's first look and see what else could be causing her symptoms. And then we'll talk about it. Is she depressed? What about her relationship with her partner? What's about her overall health? And we'll talk about that. Health is important. First look at everything else before you tell me you want to raise it to the superficial level. Yeah, that makes sense. So testosterone has been used in women. We looked at the data since 1935 in some ways. And yet here we are. It's 26, and there is no FDA-approved testosterone formulation for women. How is that possible? I want to talk about the history. It's so interesting. Okay.

1935, Boonanerusica actually invented or synthesized testosterone. Back then, it was an oral testosterone in 1935. In 1939, a physician named Alfred Lozier, he was an OB-GYN in London, was the first to start using it in women. And his first was a case report of a woman who had mastitis. He started noticing that women who were breastfeeding during their menstrual periods also have a lot of testosterone in the urine. So he started giving this woman with mastitis of testosterone and reported significant improvements. A year later, he wrote the first pellet study, 1940, giving 10 women testosterone pellets, and he reported significant improvements in sexual function. Greenblatt was an OBJYN in Canada. Yeah, and he was in 1941.

One, same thing. He started giving women pellets, showing significant improvements. And over the course of many years, other studies have come out showing beneficial effects of testosterone and women. But what happened is the United States had three strikes. First strike, we had in 1965, we had ester tests. I don't know if you remember that. Yeah, I mean to describe it. Estro tests, basically was methylated testosterone and estrogen, and it was out in 1965 for women. And it was an oral. It was an oral.

The FDA later on said, you know what, we know we gave you permission to put it out there. But we want you to give us a study showing how this would work with just estrogen alone versus estrogen plus testosterone. The company said, we're not going to spend the money. We're not going to do it. We're done to take it off the market. Strike number two was Intrinza. I don't know if you remember Entrenzo. It was a patch.

And it was a patch that were women. It was by Procter & Gamble, and they were trying to get it for women through the FDA. And a lot of the studies were done at Baylor. And I was working with the guy named John Buster back then. He was doing the clinical trials. And it was a patch. It was 300 micrograms. And they almost made it through the FDA.

They had great data. Like, efficacy was fantastic. They had a large phase four cardiovascular study looked really good. And the year they tried to get it passed was right after the WHI came out. Right after. And the reason why it was turned down, if you read, was the theoretical potential adverse risk. Great data. So we have strike two.

And Libby Jell was our third, I hope, the most recently. Yeah. Yeah, recently. And so Libby Jell tried to get it through. and they had the largest study on cardiovascular. It was a great study. Good money, great well-designed study, but they missed their efficacy endpoint

in terms of improving sexual function, so they took it off the market. So we lost all three, right? And so right now, if you and I went to Australia and we asked for testosterone for women, we could get enderfim. It's available. It's on the market. If you and I go to Walgreens down the street

and say, could you please give us all the testosterone for men, 30 products will show up on the counter. Zero, zero for women. Not one FDA-approved product for women, which is unfortunate, right? Now, it's not illegal to give a woman. No, it's off-label. It's off-label. But that's where the problem is it gets unregulated.

Levels get crazy. You have to do one-tenth a dose and try to squeeze it out. Like, why do you have to do this? And if it's off-label, it's going to cost her more money, right? Because she has to pay the compounded price. The men walk in pay a $10 copay, by the way. $10 co-pay, right? The women pay the $90 for the compounded, or she pays the whack price for the,

commercially available and then has to spread it over time. So it's much easier for men. And so it's very, I have two daughters. So I tell them the story. And my daughters were very upset. They're like, that's unfair. Why do they get to do that? And I said, I agree. Right. Yeah. So how, what are women actually using? I mean, I know in the landscape, we've got compounded versions. When I first started, you know, putting a toe in the water after long, heartfelt conversations with Kelly Casper Center, Russell Rubin and Ishwish, you know, doing an Ishwish, you know, doing an Nish Bush conference, I'm like, okay, I've got enough data in my mind to justify doing this, but I was scared of it.

Sure. Right. I was taught to be scared of testosterone. It was a bad hormone for women. So I couldn't get my patients to be able to afford the, you know, using the men's versions at the time. Sure. We have a workaround for that now.

So I was compounding at a local pharmacy. But then a lot of women were coming in who were already being given certain other forms like pellets and from a certain company. but they were coming in with, to me, astronomical levels of testosterone. And this was weeks out from their implants. So it is the Wild West out there right now. So walk me through how you try to give testosterone to your patients. Sure.

So I think when you look at all the consensus statement guidelines, what is the main concern? The two main concerns are superphysiologic dosing and compounded, meaning unregulated. So if you had something that wasn't superphysiologic and it wasn't compounded, you feel the safest, right? So I tell women, look, testosterone is a compound, it's a molecule. I don't care whether it's a pellet, an injection, a patch, a gel, it's the same drug. It's different ways to get it into your body. So let's talk about the different ways to get into your body. Yes, we do use a lot of compounded creams. We do sometimes commercially available gels, and we try to use one-tenth dose. But quite frankly, my favorite is injectables. Now, if you look at the consensus statements,

they say, well, injectable should be on the lowest. But not necessarily. The reality is, is that Any drug that you use, any formulation you choose, as long as you do it appropriately with the right dose and the right monitoring, you win. Even a pellet. I mean, I have to say, I don't want to demonize pellets. It's a method of delivery. Right. But let's talk about this. I use a lot of pellets in women, and I use the commercially available one, test a pell.

Right? It's commercially available. So it's not compounded. Yeah. It's commercially available. And it's a 75 milligram pellet. And let's say I decided tomorrow that I decided to cut the pellet in half, which I've done before, and put 333. milligrams or 32.5 milligrams in a woman, okay? I don't think anyone would argue that 32 milligrams

over three to four months and, and it's not compounded. What would be the harm of giving her 32 milligrams non-combounded over three to four months? Nothing. So you're telling me it's not that it, the pellet is the problem. It's the abuse of the pellet is the problem. It's not the Pellet. Because a 32, I can't imagine anyone telling me, Kara, you're not allowed to use a FDA-approved pellet for women at 32 milligrams every three months. No one's going to say that's a problem. Not a single person is going to tell me that, right?

But they say, yeah, if you put 200 milligrams every three months and don't check levels, which happens, that's a problem. Yeah. That's a big problem. And that's not a pellet problem. That's a method of, you know, that is. That's right. It's how you use it.

So first, how you use it, the levels you're achieving. Because many times these pellets are being reinserted at such high trough levels. The trough level is so high. And then she gets another 200 milligrams, right? And many times I ask when these patients come in, the levels are not being checked. Like there's not even checking levels, which makes me very uncomfortable, right? So I think you have to ask yourself, it's not so much the modality. It's the inappropriate dosing and the inappropriate monitoring.

I love injectables. I found we have a paper coming out right now. You know, we have them, we compound it, but it's a testosteronecipionate, and we have them inject 2.5 milligrams, which is 0.1 cc, is 25 milligrams per ML on Sunday and Thursday. We do the same for men. It works great. Different dosing, though. Different dosing, much different dosing, right?

Much different dosing. In fact, it's 20-weekly or twice week. By-weekly, because we showed many times if you microdose it, you don't get the spike, and it decreases the rate of hertisomy, acne, facial hair, also decreases the rate of arthritisisitis in women as well. So if you just do it twice a week, and typically it peaks in 24 hours. So Mondays when she's on, Friday when she's on, she likes those two days. It's very cheap.

It's $30 a month. No insurance. And she simply has to just pinch the fat and do it twice a week. So they like it. They like it a lot. And when we give women choices, I found that that's the one they choose the most. So I always give them choices. I don't say you have to do this.

I say these are all the things I can offer you. What would you like to do? And we give them choices. Some women say there's no way I can inject. I can't put the gel on every day. I forget to do it. I travel all the time. Please let me use the pellet.

Sure, as long as I'm doing it appropriately, I monitor you, I give you the right doses. No problem. Awesome. Right? But you get to choose. Just like I give the men, you get to choose, right? The creams, injections, pellets is dosing a lot different? Like, there's different concentrations.

Yes. Yes. So listen, I wrote this big paper in 2007 called the Switch study. And what we showed was when you use a transdermal, like a topical, like a gel or a cream, Don't get fooled by the milligrams. This is the formula. It's milligrams times percent penetrance. So if I give you a million milligrams of cream and you have zero percent penetrance,

you get nothing. Nothing. You get nothing, right? But you were fooled on the million milligrams. Like, oh, my God, I got a million, you got nothing. So in our paper, we showed this was with aner gel intestine back then, that 20% of men who put the gel on got nothing. It didn't absorb, right? So each one of us, all of us, have a different percent penetrance.

I mean, we just, Louise Newsom showed that with the estrogen patches, you know, or the transidermal estrogen ops and 20 percent variants. Yes, and everyone has a different percentage. So that's why if you give a woman four milligrams of testosterone and a cream, some women need a higher level. How can you give her eight? Because she's not absorbing. She's a partial absorber.

She's absorbing 30 percent. So if I give her higher levels, because remember you multiply, higher milligrams times the same percent. I get a better blood level, right? So it's okay to go higher in order to get the level you want because we're all different. Right. So creams are very important, gels are very important. I have not found it very useful to, look, even though the guidelines recommend, we should not use compounded. We should use one-tenth of a man's dose commercially. That's not what the world does. The world uses compounded, right? That's what we do. So you have to be careful on the compounding

pharmacy that you use, right? That's what we do. So you have to be careful on the compounding pharmacy that you use, Right. That's very important. How do you pick a compounding pharmacy for the clinicians listening? Really important. Let's look at the different grades. The top is a 503B. This is a 503 compounder. These are compounding pharmacies that make bulk, okay, and they're approved by the FDA. If there's a shortage of a medication, they will make the difference. They're regulated like you can't even believe just by the FDA. The majority of the compounders you see around here are called 503As. There's almost 6,000 of the United States, right? But there's different degrees of quality.

There's 503As that are accredited. There's 503As that are not accredited. And if something is not allowed to be made by a 503A, because we can talk about peptides, it's actually very important. If they're not allowed to be made by a 503A, they're made by what I call the underground. They'll come from China. They'll come from different places and be shipped in.

So the 503A's, you want to make sure they're accredited, and they're licensed by their state, which are two basic things. Like, are you accredited? Are you licensed by your state? that helps prevent a little bit of this concern that it's not of good quality. Amazing. What about oral formulations for testosterone?

Yeah, so right now we don't have, now look, the only thing I have against oral slightly is the increase in SHBG. So they will, just like estrogen, the oral teas will increase the SHBG. But the new undecinoid orals don't. But it's only in Australia, right? Well, not yet. It's coming. In the U.S., they're about to come.

The oral undecinoates don't increase SHBG. In fact, they have a slight decrease in SHBG levels, which is nice. But they bypass the liver, and they go into the lymphatic system. And I've tried using the orals that we have for men, for women. And the lowest dose, one of those by Kaiser-Strax, it's 100 milligrams. It's just too high in women. It's just too high. And it's hard to cut it.

But companies are looking at making a 50 milligram dose, which would be great. If we can get an oral that's lower concentration, that would be fantastic. There's a belief that Androfam, which is available in Australia, may be coming to the United States. So that would be great also. This is a big year. I don't know if you know, we did a lot of work with the FDA also. And this administration is very pro hormones and testosterone for men and women. Well, look what they did for the estrogen black box.

Yeah. And for us also on April 16th, they're lifting the indications for men for you. So they're really proactive. And I think that we will see a testosterone for women within the next two years. I do. Okay. I really hope so. I do too.

We just for dosing insurance. standpoint, all of it would make life so much easier. But we also have to provide the education to the clinicians on how to properly dose and monitor. Yeah. Let's talk about why do we worry about superphysiologic dosing? What's the point? So there's a couple things.

We have most of the data in men, but there's some in women, but superphysiologic doses, you can get cardio toxicity. You can actually get what we call remodeling of the heart. Remodeling of the heart means actually get thickening of the ventricle, which in fibrosis, which is not reversible, right? You see in athletes who dope as well that you actually see increased car. cardiovascular events in young ages, right? There's a lot of, I think, misunderstanding, definitely misinformation on social media

about some of the negative side effects of being super physiological of testosterone. Every woman assumes she's going to grow here where she doesn't want it or have a deepened voiced, you know, walk me through what the data actually says about side effects. The most important thing to realize is side effects are related to dose. Okay. Right? That's very important. If I give you a high dose, you're more likely to get side effects.

If I give you a low dose, you're less likely to get side effects. And every woman will have side effects at a different level. So you always start low and go slow. The most common side effects are acne, facial hair, oily skin. That's a reversible. Right? It's reversible. And if you started low and went slow, you would notice if she started developing them.

And I asked the woman, I noticed you're starting to get some, she says, I'm starting to get facial hair. She says, I am, but I love the testosterone so much, I will deal with it. Great. That's fantastic. Right. But you're like a partnership. You're going through this together. but you have to warn them what's going to happen.

At very high levels of testosterone, you start seeing things like Clitor Megley, enlargement of the clitoris. You start seeing deepening of the voice, right? You can actually start saying something about a hair loss as well. The deepening of the voice is not reversible. So let's just be very clear. It's not reversible. So you have to be very careful.

Enlargement of the clitoris is partially reversible. It can reduce, but it's not, in most cases, completely reversible. And hair loss, in some cases, cannot be reversed. Right. So you have to be a very careful understanding, also in men, it's dose-related. So if you don't want her to have bad side effects, start low, go slow. And if she starts getting these side effects, back off. You can use other medication. We use spyrnalactone, other medications to help combat those symptoms. But it's very important to realize it's dose-related. Is this all theoretical or do we have any data? When we look at frailty and our female population, where does testosterone play in that? I've looked at the data when they, I think there were three, when they looked at N. Haynes, N. H.H.I.

And they were looking at endogenous testosterone levels. And the women in the highest quartile had much, well, they had, you know, it was dependent, you know, the higher your testosterone, the lower your risk of frailty. Yes. Do we have any studies looking at exogenous testosterone, giving, you know, therapeutically giving someone testosterone and will that potentially decrease her risk of frailty? Through sarcopenia osteoporosis, you know, as she ages. Yeah, I love that question.

So let's look at frailty in terms of bone mineral density. That's an easy one, right? So there are studies looking at a woman's testosterone level, the higher her testosterone level, the increased bone mineral density she has. That's good. Okay, so higher T levels, higher bone mineral density. There are studies looking at giving testosterone to women, and what it can do is in certain studies, not all, it can increase bone mineral density.

That's great. And most of those studies, actually, some of them are actually showing that T plus E is better than each one alone. So we're fixated on giving estrogen for bone mineral density. Yeah. But the study showed that the combination is better than the independent, right, combination. That's been shown as well. Now, the third question is, if I give testosterone to her, can I decrease bone fracture? That's never been shown.

So we're not there yet. Okay. Same with men. Identical story. Give testosterone, increase the bone mineral density. If I give a man testosterone, can I decrease the risk? to bone fracture, we're not there yet. Right?

So now it doesn't mean it can't. We just haven't shown it. We haven't looked at it. Yeah, but it is interesting. I would assume that if I'm going to increase for bone mineral density, I'm probably going to decrease their risk for fracture, but that's where we are.

But there's no question that testosterone also increases muscle mass, right? Even if you look at the 2019 Global Consensus statement, the last statement said, we only approved this for HSDD, but for muscle mass and cognition, we just don't have enough patients. We don't.

But look at what happens to women, who take large doses of testosterone, if they're bodybuilders, they get significant increases in muscle mass. It's the testosterone that helps. They're also lifting. They're lifting. So that's a great point.

They're taking in protein and they're lifting and they're taking testosterone. So that's very important. So I remember the plane going up. If you want the plane to go up, you want as much muscle mass as you got, as much of bone mineral density. So when you take the hit,

it's not going to be that hard. And so I think that older patients, men and women, need testosterone more, because you want to protect them from sarcompania and build fractures. Okay. I mean, we counsel around the triad, right? Testosterone, lifting, and protein. You have to have the substrate, the stimulus.

Yeah, and then the hormones make it all. Yes, very important. To stack the cards in your favorite. Each one works a little bit on its own, but when you combine, we see magic. Because we do body composition scanning here in the clinic. We do too. And someone says, I'm going to take that testosterone and improve my muscle mass. I say, nod, if you're not lifting weights and eating protein.

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unpaused at checkout. After you purchase, they will ask you where you heard about them. Please support our show and tell them our show sent you. Some clinics are marketing testosterone and it's through pellets usually. as breast cancer preventative. What are your thoughts around this? I've seen a couple of papers. I've seen a couple of papers. I know the authors have done it.

And I say you cannot make that claim at this point. Okay. Right? I think it's too premature. Yes, there are studies showing that. There are studies also showing that higher levels of tea increase the risk for breast cancer. Now, let me be careful.

Converting. Yeah, well, there's a difference between endogenous testosterone and exogenous testosterone. So the UK Biobank is a big study out of the UK, just came out, of higher levels of T had higher levels of breast cancer, just high levels. But when you look at studies giving testosterone, the Tri-Nex study came out just showing that the air reduction in breast cancer. Others have shown the same thing. So giving is very different than just what's floating

around, right? And so in the floating around, I just want to be fair. So there's some controversy, but be honest with you, I think most of it will lean towards no risk for breast cancer. If you look at all the guidelines, the position statements, they say that no increased risk. for breast cancer if it's physiologic range and patch is what they say. And that's level one grade A evidence, no increased risk. In fact, those guidelines will even say if a woman has a history of hormone receptor positive breast cancer use with caution, unless saying it's still able to use it. So I don't think that, you know, testosterone increases the risk for breast cancer, but it is too premature to say it is a cure for best cancer. Okay. What is proper monitoring for a patient on

testosterone? So we get a baseline. when they hit the door. So say we start, like, how often are you monitoring these patients? So typically I tell women it takes at least three months to see benefit. Let's start there. She says, look, I want to come back in a month and check my levels until I say, I always like to check your levels. And it depends on what formulation you're on, right?

If you're an injectable, your gel, all different answers, right? But it depends on what you're on. But we first like to check everyone in four weeks just to see how things are going. Do I need a tight rate? Do I need to change anything? And then we will see them if they're on a gel or a cream. we'll see them every six months for life, every six months for life and make sure that levels are good. I think waiting one year is a little too long, right? If they're on a pellet, we see them every

four to five months. If they're an injectable, then it's really going to be every six months for life. So it really depends. Now, I prefer to know the trough. I want to know how low is your low, right? If your high is too high, your body will tell me, acne, facial hair. In some women, they get erythocytosis, polycythemia. We don't see it more in men. We don't see it that much in women, but they do. And women can also get hypertension with testosterone. It's really important to know that.

She check the blood pressure. Okay. So, but at the end of the day, we typically like to check those levels at the trough. Because if her low is really low, it's no point living great for three months and lousy for one month, just how bad is the low? I do the same for men as well. How bad is the low? Okay.

What constitutes a red flag to you? you know, not everyone has access to you or us or whoever, but they are interested in testosterone. First of all, how would they find someone who would be willing to prescribe it? Yeah. And what are red flags to look for when they're looking for a practitioner? Yeah. I think Ishwish is a great society that has find a provider on their, so is the SMS&A, two great menopause society as well, great societies to help find providers. Red flags, I think, are sometimes false claims, like anti-aging, cardioprotective, not going to make you have a heart attack, just the false claims.

Other ones are not checking levels is a big red flag. They don't check my levels every time I go in. They just give me the palate. That's a red flag. Okay. That's a big red flag, right? So I think that that's another one. Not checking levels at the beginning is even a bigger red flag.

Like how do you know, I've seen that though. You know, like not even checking my symptoms and they gave me the testosterone, right? You know, so monitoring is very important. And then you should be very, I think everyone should just understand what the levels should be. and if your levels are extremely high before the pellets are going in, you should ask why. Say, I understand my levels are 200 and you're about to put another 200 milligrams in, but it's my understanding that the normal range is 20 to 80. Could you explain to me why you're doing this?

It's very important to know where you should be on your troughs. Okay. You mentioned peptide, so let's go there. It's really important. All right. So let's talk. Look, I got into the business because I do a lot of sexual dysfunction, right, for men and women. and testosterone and estrogen and progester really help with sexual dysfunction.

And let's not forget about vaginal estrogen as well. Game changer when it comes to sexual dysfunction dyspronia for women as well. But when you talk about other things, when I talk to women, I say this is my playbook. I look at it like a triangle. I want to get the estrogen, progester, and testosterone back to where you were and local vaginal estrogen. That's it. Very simple. Your postmenopausal, estrogen, testosterone, local vaginal estrogen.

There's an outside circle that's very important to me. It's your thyroid. It's your cortisol. It's your growth hormone. I want to look at everything on the outside. That's really important. And then I draw a line down the middle. And I say that's only 50% of the story.

Here's the other 50%. It's diet, exercise, sleep, and stress reduction. I don't have a pill on the planet stronger than diet, exercise, sleep, and stress reduction. You can take my hormones and eat potato chips all day and watch TV, but you are not going to get where you want to get. you have to meet me halfway. That's the theme. And so I go heavy on diet, exercise, sleep, and stress reduction. I put them on a program. So for many years, I've been treating women with testosterone and giving them hormones. They feel great. I found one thing that actually makes them feel better than the hormones. Weight loss. When a woman loses 50, 60, 70 pounds, you've changed her

entire life. Right. And it's more than the weight. It's how the world sees her, how she moves through the world. Unfortunately, women's body image is so tied to her weight. It's huge. And it gets even better. Her cholesterol goes down. She says, I've stopped my statin. I've stopped my blood pressure medications. My sleep apnea has gone away. You know my joint pain on my right knee is gone. Like, it is a trickle down of tremendously good effects. Now imagine if you did the diet exercise, sleep and stress loss weight, and you did the hormones. It's on fire. I mean, it's unsophable, right? So just giving her the estrogen progesterone and saying goodbye is a disservice.

It's a disservice. Focus on all three. Focus on the outside circle and hit her hard on diet, exercise, sleep, and stress. So what's the peptide that I'm talking about? There's many peptides, but GLP1s, right? GL1 is a peptide. It has revolutionized the way we treat women in our practice, right? It's game changer, right?

And so you put her on if she, look, there's, what are the, benefits. It's FDA approved for diabetes. Great. FDA approved for obesity. FD. approved for sleep apnea. FD. approved for secondary prevention of cardiovascular disease. Secondary prevention, right? We know that FDA proof. It helps with anemia. And for our listeners, secondary prevention means you've had a heart attack. Now we're trying to prevent the second one. Right. Right. Think about renal protection on renal disease. Kidney disease. And hypertension. Like one peptide has such a profound effect. Now, most of it could be due to weight loss. Secondary, yeah. Right. But the cardiac benefits have been shown to be irrespective of weight loss, right? So we put them on peptides. There are other peptides

that have been very helpful also in this business. It's also been PT-141. I don't know. Tell me about that one. Okay. Do you use it? Yeah, I use a lot of it. So let's talk about it. So in 2015, if you and I went to Walgreens and said, could you put on the counter all the drugs for men to help them have better sex? They'd put over 30 products on their Viagra, Levitra, Seattle, put all test on. He said, by the way, could you put on the counter all the drugs to help women have better sex? Zero. Zero. Not one. He said, wait a minute. That's not fair. How did this happen? In 2015, the world got Adi, phlebancerin, first FDA-approved drug, daily medication, great medication. We had Cindy on. Yes. Great medication, right? You take that medication every single day,

significantly proves her desire for sex, period. That's the FDA-approved medication, right? And we, at Baylor, said we started noticing women started having improvements in orgasmic function as well. So very quickly, I got an FDA-approved trial to treat men with Adi versus placebo. We show that in men who take Adi also, not only improvements in desire, but they also improve their orgasmic function as well. And we even wrote it up as a paper, right? But then in 2019, another drug came out for women called brimelanatide. It's an injection.

She injects 45 minutes prior to intercourse. And it actually goes into the center of the brain called the medium. Pnecrup nucleus where she increases her desire for sex. It's extremely effective. Now, she can have nausea if she takes it. So typically only can inject eight times a month. It's an injection. It's called brimilinatine.

It's a peptide. And it increases her desire for sex. And we also see it increases her orgasmic function as well. And we use a ton of it in men off-label as well. Oh, I didn't know. I was going to say, yeah. A ton of it. And what we do is we found that if we use it way ahead of time, not 45 minutes before, but six to eight hours ahead of time, it actually works more effective.

more effective than just 45 minutes before. And it has the dopamine pathway? It has dopamine. It would have melanotide. A little bit different. Yeah, melanotide. Yeah, melanotide. It's a little bit different.

Addie has improves dopamine, but this one actually improves melanotide. It goes to the pathway. So it's actually very effective. And so now we have two drugs for women, FDA-approved, to help them with sexual dysfunction. Now, a lot of the peptides, when a woman says, I want, she comes to me, says, I want peptides. She typically is not talking about these. She's talking about that BPC 157, that TB 500.

I mean, there's a lot of peptides out there that you can use. And just a little story. In 2003, the FDA pulled all the peptides off the market. And I used to write a lot of peptides. And once they pulled it off, I stopped for safety concerns. And they put them in something called category two, which means it's dangerous you cannot compound it. The second they put it in dangerous you cannot compound it,

the compounders, those 5 or 3As could not make it. So where did it come from? China overseas, I call it the underground. When you look at those peptides, bacteria, heavy metals, not the right doses, so it's dangerous, right? But they're looking for other peptides like MOTC, all these other different peptides. In July of this year, July 2006, the FDA is going to announce which ones are legal again. So we're kind of on a lookout for those. Okay.

Which ones are you excited about becoming legal? I think BP 157 with TB 500 is excellent. Okay. And unfortunately there's only been animal studies, but talk about. Talk about regenerative, talking about pain, healing, wound injury. Yeah, what's their method of action? Yeah, so BP 157 is a gastric peptides from the gut. But when the patients inject it, we've seen significant improvements in their overall healing

and recovery. Hey, I injured my shoulder. Hey, I've got some joint pain. Now, I don't prescribe it since it was banned. But on July 23rd of this year, I'm going to find out if I can re-prescribe it. MOTSI is another one that helps lose weight. It helps metabolic and obesity. women drop the weight as well.

There's one that a lot of women like. It's GHKCU, which is copper, which is used on the face, and it's injectable as well. That's very popular, and that's going to come up for a vote in February of 2007 if it comes off the ban list. So I think all of you that are using peptides, be careful because you don't know where it's coming from what's in it. It's better to make sure that they are approved by the FDA, and then a 503A can legally make it, and then we have a better chance of getting better quality.

Okay. Yeah. In our clinic, we don't. We're so busy doing pet E.T plus now. GLP ones or terseptitide and hopefully redditry tight. Yeah, redoubt next year, hopefully. So, yeah, we're getting close. That's really big on social media right now.

It's really big. The Reda Reddha Reddits. Yeah. The only thing is that, you know, people get Redditutri Tide illegally. You can get it, but it's not. I heard. We haven't seen it, smelled it, but I know it's out there. Yeah, but the initial, like the triumph trial and all the recent data, it's so impressive.

So they have the greatest amount of weight loss. It's about 27%. You know, we're terseptitis at 21%. And seven glutides like 15%. So greatest amount of weight loss. It has three drugs in it, but has a least side effect. So very excited to see what this drug can do when it comes out. So you touched on women's sexual health research funding.

Yes. And the disparity, which is ridiculous. Yeah. What do you think it's going to take to change that? First of all, I got to tell you something very important. It's not just women and men. Let's kind of... It's both.

And I'll tell you why. Let me tell you why. Let's look at some statistics. A guy named Dr. Fisher in 2005 did a study. And he said, let's take couples and let's look at what happens when a man develops erectile dysfunction in that relationship. Let's look at the women before and after he develops erectile dysfunction. When a man develops erectile dysfunction, a woman has a 33% to 50% chance of developing female sexual dysfunction. It was just his condition caused her FSD.

So if she was really smart, she'd want to do everything she could to make sure he doesn't get ED to protect her FSD. Now flip it. They've also shown that when a woman develops FSD, a man is 3x more likely to get erectile dysfunction. Wow. So if I was really smart, I'd want to make sure my wife does not get FSD to protect my erectile function, right? I mean, the correlation is very tight. Well, now talk about treatments. Goldstein did the best studies on this.

One of them was he gave all these men Lovietra, a drug to help with the reactions. He gave all the women at home an FSFI questionnaire, female sexual function index questionnaire. He said, I don't want to meet your wife. I don't want to talk to her. Just give her the questionnaire. And he gave half the men placebo. The men that took the levita who had a significant improvement in rectal function, the partner's sexual function scores skyrocketed. Her libido, her arousal, her orgasmic function.

The men who got placebo, those partners did not have any improvement at all. What am I telling you? I'm treating the partner just by treating the other partner. And I never even met her, right? It's so tied together that if you treat one partner, you're actually treating the other. So I tell the residents, you want to give that man in Viagra and you're going to help his erections? Guess what? Skyrocket his partner's libido and watch what happens to his erections, right?

They're so tied together. It's very important. So that's why I think when you look at conditions like menopause, when you look at hypogonadism and men, we suffer the same thing, it's not just one person going through it. Like when my wife was going through menopause and she had hot flashes. low libido, she was irritable. It was affecting her, but it was also affecting me, right? And if I was smart, I would do everything I can to improve her menopausal symptoms, not only to help her, but also help myself. Yeah. Right? It's a couple's disease. Everything is menopause is not just about her. Hypogonitis and low testosterone is not just about him. It affects both of them. Do you ever see

couples in clinic? All the time. I insist. Jim Simon does the same thing. Yes, I know, yeah, I insist. I want to see, and don't forget the, I call them the hormonally dangerous decade. Whoa. 50 to 60. That is the hormonally dangerous decade. Why do you say that? Because women are going through menopause, and that's where hypogonadism, low T and men go up.

So what is hypogonism? It means men have low testosterone. What do they suffer from? Low energy, low libido, erectile dysfunction, increased fat deposition, decreased muscle mass, depression, poor sleep. Well, if I was going through that, you don't think it's going to affect my wife, right? And she at the same time is going through. metapause, mood changes, poor sleep, hot flashes. It's a setup for disaster 50 to 60, right? It's a hormonal. It's a hormonally dangerous decade. And if you don't understand that it's your

hormones, if people sometimes don't even realize to check my hormones, they just live with it, check the hormones. It's a dangerous decade. Wow. Sometimes in our clinic, treating someone's hormones will give them clarity to realize they want to leave a relationship. Sure. You know, that they've been kind of just limping along and then we kind of give them their resilience back and they're like, you know what? I got 30, 40 more years left. This is not my person. Yeah. So I see it go both ways. Yeah. I see it men also, but more of that is libido. So his libido goes up. She's not interested in gaining sexual activity and then he may look elsewhere. So it can be a problem too. That's why it's really important. Counseling. The couple. If I'm treating the couple and I elevate both, I'm less likely to have a problem. Yeah, no, that's great. So what do you say to a woman who walks into a doctor's office and wants to be evaluated for testosterone? Like, she's not coming to you, she's not coming to me, and she's been dismissed. Yeah.

You know, and in menopause, the average, you know, when you look at the data, women will go six to ten times to a doctor before they were able to connect the dots, especially if she has multiple kind of vague. You know, most of us know hot flashes, but, you know, if she's coming in with her. with palpitations, anxiety, weight gain, you know, irritability, a lot of clinicians just because of lack of training, aren't connecting the dots. Yeah. And same with testosterone. You know, testosterone, I feel like for women is where menopause was 10 years ago. Yeah. And so how do you counsel her?

Like, you know, find an Ishwish or you said ASRM. SMS and A. Eshwish, Menopause Society. And we'll put the links in the show notes for everyone. Three phenomenal societies that are really proactive in helping women get therapy and treatment. They're phenomenal. But you have to insist. The best way I'm noticing is social media.

I've watched your social. It's amazing. So women are learning from the social media and you're telling them, get your levels checked. Insist to get your levels checked. In fact, you don't even have to have a prescription or a doctor's appointment to get the level set. Yeah, you can go direct through Quest and Lab Corps. And you can get your own levels checked. So I tell patients, be proactive about your health.

You have to be the best advocate for your health. Not your doctor. You have to be the best advocate. if you know something's wrong, check your levels. There's no harm. Insist on asking your provider, can you please check my testosterone level? Be open, be frank. Can you please check my hormones, right?

If they say no, then I think you need to find someone else who will. Okay. Very fair. So any other labs they should request besides testosterone? Look at the great mimickers. The great mimicers of low tea, there's two big ones, hypothyroidism and depression. If someone who's depressed will have very similar symptoms, Someone who has hypothythor, check the T-3-4, T-3 and T-4, check those levels.

But I check a lot of other things. Check wellness. Like, check her lipids, check her hemoglobin A-1C, check her cholesterol. Like, check the overall health of the patient. We didn't talk about that. We talked a little bit of weight. But exercise, diet, sleep, sleep is like critical. Critical.

And stress reduction. Each one independently has a profound effect on our overall health. And so we absolutely want to check all the other variables. What are you working on right now, research-wise? Well, I just finished my book. It's coming up March, 2027. Oh, amazing. It took me a year and a half.

We're good. I'm getting in. Yeah. So it's coming out in March, and so we're very excited. We're doing a lot of work right now. What is it about? It's about sexual health span. So you know how we all have our lifespan?

Yeah. Okay. So you'll live, well, live until 90, hopefully. And we have our health span, right? Right. Years you live healthy. Healthy. without chronic disease.

And all of us want our health span to last as long as our lifespan. That's it. That's all I'm asking for. But there's different types of health span, right? There's your mental health span. I don't want to mention Alzheimer's. Yeah. Right.

I was there my physical health span. I want to be physically. And there's my sexual health span, right? And the issue is all of us, you tell most men, I want my sex span to last as long as my lifespan. If you tell a man or a woman, you're going to live till a 90, but you can only have sex to 50. They'll say that's unacceptable.

But I'll say you'll be healthy. You'll be healthy. your health span will last as long as your lifespan. No, I want my sex span to last as long as my lifespan also. So the book is about sex span, prolonging your sex span, right? And how do you do that? And there's many ways to do it. And hormones is a big part of it for men and women. The other part is keeping your partner healthy. So let's say tomorrow my partner and my wife says to me, I'm never having sex with you again. Guess what? I'm never having sex again. Your partner controls your sex ban, right? And if your partner says, I'm never having sex with you again,

that's it. So what do you want to do to prolong your sex span? Keep your partner healthy. Because your partners are healthy is a problem and keep your partner engaged. If you want to prolong your sex ban,

keep your partner healthy and keep your partner engaged to prolong your sex ban. So it's very important. And the whole book goes into everything about diet, exercise, sleep, and stress. And how it affects sexual function

and how to prolong your sex span. I've been really big into wellness lately. I think it's really important. And I give this analogy and I just want to share it with you. I think as we exercise and we stay healthy and we do things, I look at it like a plane, and the plane starts getting altitude.

We get higher and higher altitude. But all of us one day, at some age, the engine turns off. When the engine turns off, no matter how hard you work out and how well you eat, you will not gain any more altitude. But at that point, you're going to start coasting. If your altitude's high, you're set. If your altitude's low, you're in trouble, right? So you want to make sure that when your engine turns off, your altitude is. as high as you can get, but you can't make that decision at 72. You've got to do it at 52,

right? At 72, I want my altitude to be high. Too bad. And you only get one shot. There's no redo. So we start now. That's a great analogy. Yeah, because that's it. We're always going to have one day where we're the healthiest we're ever going to be and you're going to coast and decline from there. Right. So you want that altitude as high as you can be. And once it coasts, you want the slope to be light. You don't want a deep slope. Now you can control the slope at that age. You won't be able to go higher, you can control the slope with diet exercise and sleep, right? Yeah. But wouldn't it be great if you had a high altitude?

To start. Then your lifespan and health span will be the same. That's all you care about. That's amazing. Any new trials you're watching or excited about? Yeah, we're doing a lot of work on GOP-1s and fertility. So we're using GOP-1s to see if it makes fertility. We're using a lot of oral testosterone.

We found that oral testosterone doesn't suppress sperm production immense. We're doing that as well. We have a due ultrasound machine that actually can look inside the testicle and fine sperm. And so in the old days, you have to open it and keep looking. Now we can have a much better picture of where it's located and grab it before. No one else is doing this. So we have a lot of clinical trials going on right now.

That's amazing. If you could tell every woman over 40, three things about testosterone, what would they be? It's not a male hormone. It's a human hormone. Women make more testosterone than any other hormone in the body, including estrogen. And if you have signs and symptoms, check your heart. levels. It's a simple blood test. That's all I'm asking, check your levels. And if it's low, get therapy. It can make a profound impact on your quality of life and your partner's quality

of life. Amazing. Yeah. Anything else you want to leave with our audience? No, I just, I think it's really important that everyone understands the importance of this hormone. How can our listeners find you? I'm at Baylor College of Medicine. I'm on Instagram, not as much as you, but at Dr. Mohit, Kira. Okay. And are you taking patients? Is your clinic still taking patience? Yeah. That's amazing. Well, thank you so much for coming on on pause. This has been invaluable for our audience. I appreciate. Thank you so much. You can watch full episodes of this podcast on YouTube at Dr. Mary Claire. You can also find me on Instagram at Dr. Mary Claire and get honest and accurate information on health, fitness, and navigating

midlife at the pause.com. Un paused is presented by Odyssey. in conjunction with good roommate media and longwave digital. This episode was sponsored by Midi Health. The first virtual clinic created for women, by women, for the treatment of menopause. Don't let anyone tell you menopause is something you have to suffer through alone. Middy can help.

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