Testosterone & Women
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These statements have not been evaluated by the Food & Drug Administration. These products are not intended to diagnose, cure, treat or prevent any disease. If pregnant or lactating, consult a physician before using.
This page is zeroing in on a long misunderstood hormone, Testosterone and it's function and need in the human female. Although we do not sell testosterone we do sell two products that stimulate the production of testosterone. The first product is Tribuplex and the second product is called hGH-PH Complex. All women (and their mates should read the info on Tribuplex, since it is exclusively addresses the hormone testosterone and it's benefits.
Many Doctors are apprehensive about prescribing anything that is not in The Physicians Desk Reference, (The PDR). To help them in prescribing all natural estrogens, progesterone and testosterone you might want to set up a conference call to a "Compounding Pharmacy" like Stark Pharmacy in Kansas City (telephone: 913-345 3800). The Pharmacist can help with the writing of the prescription, then fill it and send it to you.
Hope this helps.
--------------Norman Rose, Editor.
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The following information on "Testosterone
Testosterone For Women
"Testosterone is also a female sex hormone "SUSAN RAKO, M.D., AUTHOR OF "The Hormone of Desire".
FULFILLING THE SUPERHORMONE promise means restoring the natural balance of hormones that we enjoyed when we were at our physical and mental peaks. It means following the entire blueprint that nature wrote for us, not just a fragment of it. Let me explain what I mean and why this concept is so very important.
If you are a woman, at twenty years old your body produces peak levels of estrogen, progesterone, and testosterone. At fifty your body produces far less of each. If you receive standard treatment, however, chances are you will take estrogen and perhaps progesterone. As a result, like many women who take only estrogen or estrogen with progesterone, you may find yourself thinking, "I don't feel like myself." And you may not feel like yourself for a good reason: You're not yourself. The reason is that by ignoring the superhormone testosterone, doctors who prescribe conventional estrogen replacement therapy are heeding only part of nature's superhormone command, only part of the superhormone promise. In other words, for many women who feel they are not quite themselves, the ingredient missing from the blueprint is testosterone.
Although testosterone is widely known as the male hormone, it is less well known that it is also a critically important hormone for women. There is a great deal of misunderstanding and confusion about the role that testosterone plays in the physical and emotional health of women. As a result there is also great confusion as to whether testosterone should be routinely included with the estrogen/ progesterone given to menopausal women. Today, fewer than 5 percent of menopausal women who are using estrogen are taking testosterone along with other hormones. This omission is due, I believe, to the fact that there is a definite (and I believe irrational) resistance to giving women what is mistakenly regarded as a purely male hormone. This resistance is based on groundless fears that testosterone will somehow masculinize women, causing them to grow facial hair, become overly aggressive, and, in sum, look and behave too much like the stereotypical male. As one of my male colleagues admitted to me rather sheepishly, "I know that I'm not being fair, but I don't like the idea of giving male hormones to women." If, as suggested earlier, male researchers had difficulty accepting the reality that men experience a decline in testosterone as they age, a similar resistance seems to be in force when it comes to acknowledging that women produce testosterone in the first place!
Candidly, I think this resistance is not rooted merely in the perceived close association between testosterone and male development and behavior. I think this resistance also has to do with the fact that testosterone is so closely identified with sexuality and lust. Well, it's true. The ebb and flow of testosterone does control sex drive for both men and women. It may be hard to believe, but many physicians still sincerely feel that it is unseemly to give women (especially menopausal women) anything that will enhance their libido.
It is time to shatter the myth that testosterone is exclusively a male hormone. It is not. Testosterone is produced in both the ovaries and adrenal glands of women, just as a small amount of estrogen, the so-called female hormone, is produced in men. Although women make only about one-tenth of the testosterone that men do, it is nevertheless an important hormone for normal female sexual development. In fact, puberty and the onset of menstruation in girls is triggered by the revving up of the production of testosterone and DHEA by the adrenal glands. This process is known as adrenarche. In women, testosterone levels fluctuate throughout the menstrual cycle, rising just before ovulation, creating a surge in libido. Mother Nature knew what she was doing! That is the point in the cycle when a woman is most fertile and most likely to conceive!
Testosterone For Women
As women age, there is a dramatic drop in the production of testosterone. By age forty, a woman has half the amount of testosterone that she had at age twenty. One factor contributing to this decline is that at this age a woman's adrenal glands are pumping out less DHEA. DHEA is broken down into a small amount of testosterone when it is metabolized, and for women this is a main source of testosterone. By the time they reach menopause, many women are testosterone deficient.
In women, as in men, the extent of the drop in testosterone varies from individual to individual, and while some women may not experience adverse symptoms from the decline in testosterone, others will feel the loss more acutely. In most cases if a woman feels that she needs testosterone after menopause, she will have to raise the subject with her doctor.
I want to assure you that there is nothing unseemly, unnatural, or otherwise unsound about giving women testosterone if they need it. Just as boosting testosterone levels can reinvigorate men, it can be a boon to women, provided it is given to the right women in the right fashion. Restoring testosterone to youthful levels may not be appropriate for every woman, but it is certainly the right treatment for women who are testosterone deficient and who are suffering the effects of this deficiency.
There are a handful of researchers who have investigated the role of testosterone in postmenopausal women. Dr. Barbara Sherwin, a professor of psychology at McGill University in Montreal, is one of them. She began research on testosterone in women more than a decade ago and is the undisputed leader in the field. In one innovative study, Dr. Sherwin investigated the effect of using either estrogen alone or small amounts of testosterone in combination with estrogen in young women who had undergone hysterectomies and as a result suffered premature menopause. Since one-third of the testosterone produced by women is made in the ovaries, these women experienced a dramatic decline in testosterone when their ovaries were removed. Dr. Sherwin's study showed clearly that the women taking testosterone and estrogen were more interested in sex, enjoyed intercourse more, and even had more orgasms.
"There was a dramatic effect on libido," says Dr. Sherwin, who feels that testosterone can be beneficial for many women who experience a decrease in sexual desire around menopause. According to Dr. Sherwin, the length of time needed to be on testosterone varies from woman to woman. "Each woman is different. Some may need to stay on testosterone for a long time, while others may only need it for short-term therapy."
What about the fears that testosterone will masculinize women by, for example, encouraging the growth of excess body hair? If correct doses of testosterone are given, there will be no such negative side effects. As long as the dose is the lowest possible, there should be no problems.
Questions have been raised about whether testosterone might actually increase the risk of heart disease in women or at least negate the positive effects of estrogen. Oral testosterone does appear, however, to lower levels of cholesterol and LDL, the so-called bad cholesterol, which is good. But oral testosterone also appears to lower levels of HDL as well, the so-called good cholesterol. This is bad because low HDL is a major risk factor for heart disease in women. The effect of testosterone on cholesterol depends, however, on the way the hormone is administered. The good news is that if it is given by injection instead of orally, testosterone does not appear to lower HDL or cause any negative effects. A recent study conducted at the Bowman-Gray School of Medicine at Wake Forest University suggests that women have little to fear. In this study, researchers performed hysterectomies on female macaque monkeys, which made them menopausal. Macaques are a good model from which to study humans because, similar to humans, they can develop heart disease. The postmenopausal macaques were then given estrogen alone, estrogen/testosterone together, or no treatment at all. The researchers found that the monkeys receiving either form of hormonal therapy had significantly lower levels of LDL (the "bad cholesterol") than did monkeys in the control group. What was most striking to the researchers was that there was no difference in cholesterol levels that could be attributed to using estrogen alone or in combination with testosterone.
Despite these positive findings, I still believe that any woman who is taking testosterone should have her cholesterol levels checked every six months, just to make sure that she is not losing too much HDL. If a woman is at particular risk of developing heart disease (it she has high blood pressure, diabetes, atherosclerosis, or a parent who died from a heart attack at a young age), I would think twice about putting her on testosterone unless she absolutely needed it. I would then recommend monitoring her cholesterol even more closely, but I would not altogether rule out using testosterone. A woman's emotional well-being-feeling good about herself and, more important, feeling "like herself" is critical for good mental and physical health. If a woman finds that a lack of libido due to low testosterone is ruining her sex life, adding testosterone to her superhormone cocktail for even a short period may make a real difference in helping to restore her interest in sex and her ability to enjoy it. (For more information on other things that need to be monitored when you are taking testosterone, see chapter 10, How to Take Superhormones)
Throughout this book I have shown how one superhormone complements the action of another, and how the cocktail approach customized to the individual can work wonders in terms of maintaining health and strength. Studies of women and testosterone are few and far between, but so far the ones that have been done have yielded some surprisingly good news in this regard. They have shown that testosterone combined with estrogen has a more potent bone-sparing effect than estrogen alone. In one study, researchers gave postmenopausal women either a combination of estrogen and testosterone or estrogen alone for nine weeks. Estrogen has a particular effect on bone; although it can slow down the rate of bone loss, it has no effect on the formation of new bone. Therefore, although it can slow the progress of osteoporosis, estrogen is not a cure for this leading cause of death among older women. The good news is that women who took the combination estrogen/testosterone cocktail not only showed signs of a slowdown in bone loss (the estrogen effect) but, more important, also showed signs that new bone was being formed, an effect that could only be due to the addition of testosterone. I believe that the "cure" for osteoporosis may exist in simply following nature's blueprint by restoring the natural youthful balance of estrogen and testosterone that women lose after menopause.,
Finally, there is another compelling argument for including testosterone as part of a woman's superhormone cocktail. It makes many women feel better and better able to tolerate the other hormones in their cocktail. Although some women swear by their estrogen/ progesterone replacement therapy, many women do not like the effect of estrogen and progesterone, and often say they cause them to experience a lack of energy and zest for life. I think this unintended consequence occurs because their cocktail, which consists of only estrogen and progesterone, does not duplicate the normal hormonal state that existed prior to menopause. Some testosterone is necessary to help restore youthful levels. For many women, a small amount of testosterone can make a big difference."
The following is an excerpt from the book,
Hormone Of Desire"
TESTOSTERONE DEFICIENCY AND MENOPAUSE
"By the time we begin to have signs that our ovaries are shutting down, we have had a significant part of our adult lives to get to know ourselves and the way we function sexually and energetically. If we're lucky, we will have made peace with our sexual rhythms, our patterns of intimacy with our partners, and our psychosexual complexity-or, in other words, what works for us sexually.
For the past twenty-five years, my work as a psychiatrist has taught me to appreciate the differences, substantial and subtle, in the ways we experience and practice the intimate and sexual aspects of life. Sexual desire is influenced by many factors-relational, situational, psychological, and physical. The following comments, written in response to an anonymous questionnaire that was answered by several hundred women at workshops I have taught, are representative of observations women make about the loss of libido.
From a forty-nine-year-old woman who is still having menstrual periods: "I've been wondering if my libido is diminished over the last year or so-but this question has been occurring to me at the same time I'm grieving the loss of my mother, so I'm not sure what is happening right now."
A fifty-five-year-old woman, whose last period occurred at age fifty-two, writes: "I am wondering if my body is telling me that my partner of five years is not 'the one.' "
TESTOSTERONE DEFICIENCY AND MENOPAUSE
A forty-six-year-old woman who is still menstruating comments: "I don't think about having sex. I wonder whether this is hormonally related or psychological, because my husband and I have problems with having sex."
A forty-seven-year-old woman, also premenopausal, notes: "I had/have chronic fatigue syndrome-an extenuating circumstance that makes it hard to evaluate the loss of libido, I am experiencing."
And a fifty-year-old whose last period was a year ago writes: "I've been exhausted, overworked. I'd rather sleepor at least that's my excuse. But really I'm just not interested."
Whatever other factors may be playing a part in a woman's loss of interest in making love, without adequate testosterone, sexual desire simply cannot exist. In other words, we are more at the mercy of our hormones for our experience of sexual desire than we might wish to believe. Particularly for women whose loss of interest in sex makes them (or their partners) wonder "whether this means that the love is gone," knowing that the problem might be testosterone deficiency could prevent a considerable amount of potentially unnecessary anguish.
'Why do some women develop testosterone deficiency
During our mid- to late teens our adrenal glands produce peak amounts of testosterone and other androgens. Even before most of us begin to approach menopause, during our mid- to late thirties our adrenal androgen production decreases by more than half. This is the "adrenopause" I referred to earlier, and reflects the decline in DHEA and DS I previously discussed. Our adrenal glands continue to produce some androgens throughout our lifetime, but the amount produced is greatly reduced-down to 1.8 percent of original production after age seventy. When our ovaries shut down, the amount of testosterone they produce is reduced by one half Since both our adrenal glands and ovaries are the source for the building blocks of testosterone that are produced by other tissues, when the ovaries and adrenals slow their production, the end result is a significant reduction in overall testosterone.
Research has shown that in order for a woman's adrenal glands to produce their maximal amount of androgens, her ovaries have to be well functioning. The fact that the workings of the adrenal cortex is linked to the workings of the ovary may be a consequence of a fascinating fact: In the developing embryo, one original group of cells is the source both for the ovaries (or testes) and for the outer parts of the adrenal glands. As the embryo develops, these cells actually migrate to the two locations, some of them forming the ovaries (or testes) and others forming the outer parts of the adrenal glands.
If a woman of any age-even a nineteen-year-old, whose adrenals are at peak androgen production-should have her ovaries removed surgically (or functionally destroyed by chemotherapy), her adrenal glands will subsequently produce less androgens. She will lose not only all of her ovarian estrogen, progesterone, and testosterone, but also a portion of her adrenal testosterone and other androgens.
The bottom line is that we need fully functioning ovaries in order to maintain fully functioning adrenals.
While men's adrenal glands also show a drop in androgen production with aging, the drop is less precipitous. The difference is probably due to the continued function of the testes, which, unlike the ovaries, do not shut down dramatically at midlife.
Before I did the research, I knew that the average age for a woman at menopause is about fifty. I was surprised to learn that 8 percent of all women have a full, natural menopause before the age of forty. Symptoms of testosterone deficiency can develop for these women as early as their mid- to late thirties.
"I went through menopause at age fifty-one. My mid-to-late
The short answer is that at that time, with this person's particular balance of hormonal factors, she had more available testosterone.
During the years just before menopause, often called the peri-menopause, the ovaries produce estrogen but often fail to mature an egg follicle. This means that the ovaries fail to ovulate, and so fail to produce progesterone, which is made by the follicle cells of the ripening egg.
Another element in this complex tapestry of hormonal interactions is that for 50 percent of women, when the ovaries stop producing eggs, the ovarian tissue (ovarian stroma) that produces testosterone responds to the pituitary gland's attempt to get it to ovulate by producing more testosterone. When this happens, a woman may experience some increase or return of vital energy and libido. How long this level of testosterone effect may last depends on the rate at which testosterone production by the adrenals and ovaries continues to decrease, as well as on the genetically determined receptor and enzyme factors discussed previously.
Researchers have discovered that for about 50 percent of women, the ovaries do not make a major contribution to testosterone production following menopause. These may be the same women who suffer a significant loss of libido following menopause.
Dr. Barbara Sherwin of McGill University in Montreal is a leading researcher in testosterone supplemental therapy for menopausal women, and with regard to the potential increase in the ovaries' production of testosterone at menopause, explains: "When it occurs, this increase in ovarian testosterone production is time limited, so that eventually, testosterone levels decrease in all women."
What is evident is that Margaret Mead, who touted "postmenopausal zest," was conceivably reflecting her own experience and the experience of some but by no means all postmenopausal women.
'When can a woman develop testosterone deficiency?"
During the two or three years preceding menopause and through the five years following, a significant number (roughly 50 percent) of women who approach menopause naturally that is, with their uterus and ovaries intact-notice some symptoms of testosterone deficiency. For some women the onset of symptoms of diminished sexual interest and response may be rather sudden-over a period of a few months. For others, the change may be more gradual-over a period of several years.
A gradual development of testosterone deficiency is a function of aging for all women, as a consequence of several factors: loss of ovarian testosterone, diminished production of adrenal androgens, aging testosterone receptors, and reduced enzyme function. just as there is a wide spectrum of ages at which women experience menopause, there is a wide spectrum of ages at which women develop critical reductions in adrenal androgens and in testosterone receptor and enzymatic failure. Some women have the genetic predisposition to maintain androgen production and receptor and enzyme functions adequate to keep them vital for decades longer than others.
Nearly one-half of the women who have their ovaries removed (most often accompanying hysterectomy), no matter what their age, are likely to develop testosterone deficiency precipitously, due to the total loss of ovarian testosterone together with the reduction in adrenal androgens that follows the total loss of ovarian function. In spite of increasing awareness that most hysterectomies are avoidable, hysterectomy continues to be the second most frequently performed major surgical procedure in the United States (surpassed only by cesarean section-another often-avoidable procedure). To me, the statistics are horrifying. A recent Gallup survey confirmed that one-third of American women have their uterus (and too often, their ovaries) removed-most often before the age of fifty.
Dr. Vicki Hufnagel, gynecological surgeon and author of the 1988 book with the optimistic title No More Hysterectomies, describes in detail the miserable consequences of having one's ovaries removed. She writes about the outrage that "physicians blithely told their patients that the uterus and ovaries had nothing to do with sex" and goes on to affirm that, following hysterectomy, "indeed, the loss of sexuality can be very real." Acknowledging the ovaries as a major source of testosterone, she recognizes that "androgens, in the form of testosterone, enhance women's libido ... by increasing susceptibility to psychosexual stimulation, heightening sensitivity of the external genitals, and creating greater intensity in sexual gratification."
My experience with women who have had a hysterectomy and have consulted me after developing testosterone deficiency has been heartbreaking. I received an impassioned letter from a forty-nine-year-old woman who had her uterus and ovaries removed because of ovarian cysts and endometriosis when she was tbirty-five. She wrote of "utter rage at discovering that [she had] been denied the benefits, or even the mention, of testosterone information ... by more than thirty gynecologists, endocrinologists, internists, psychiatrists, psychopharmacologists, dermatologists, and a few holistic gurus." During the fourteen years since the removal of her ovaries, she has suffered "dramatic emotional/physical changes." She described a profound loss of sexual desire, thinning and loss of pubic hair, skin rashes and dryness, "little muscle tone and inability to control [her] weight."
Before the surgery, she was an energetic and focused person, was never late, and read at least two books a week." She wrote that, following the removal of her ovaries (and while receiving continuous estrogen replacement therapy), "the only way I can describe how I feel about almost everything is that: I either don't care, or I'm too tired to care. It's no longer clear to me which is which. This is a drastic change from how I used to function, and it's difficult to distinguish whether it is from diminished sense of well-being, or having no energy." She goes on to describe herself as "constantly late, disorganized, taking forever to get ready, taking three hours to read a newspaper."
This unhappy woman has consulted many doctors over the years, and at various times has been treated with a total of seven different antidepressants and even with lithium (a drug most commonly used to treat manic-depressive illness). "I have constantly been on some drug to get me going since the hysterectomy, but most were a nightmare."
Unfortunately, her story is far from unique. Even today, most women who undergo a hysterectomy with removal of their ovaries are offered estrogen alone, if indeed they are offered any hormonal supplements at all after surgery. Too few women are given the option of using supplementary testosterone, even though research conducted over a period of several decades by Drs. Barbara Sherwin and Morrie Gelfand of Montreal has shown that women who are treated with both estrogen and testosterone following a hysterectomy achieve an optimal balance of sexual energy and vital energy, as compared with women given either no hormones or estrogen alone.
Research has shown that women who have had a hysterectomy leaving their ovaries intact can expect to go through menopause four years earlier, on the average, than they would have had they not had their uterus removed. The exact cause of this earlier menopause is not
known for certain, though Dr. Hufriagel explains that removal of the uterus can lead to ovarian failure as a result of interference with the blood supply to the ovaries. (The uterine artery may be the source for up to two-thirds of the ovaries' blood supply, and surgical removal of the uterus disrupts this source.)
The uterus also produces chemicals, known as prostaglandins, that provide hormonal cyclic stimulation to the ovaries. If the uterus is removed, this rhythm is disrupted, which may be another factor contributing to an earlier menopause. This, in turn, can result in the earlier development oftestosterone deficiency.
Women who have been treated with chemotherapy and subsequently experience a "chemical menopause" suffer the same onset of symptoms as women who have had their ovaries removed. In her article in the spring 1992 issue of theJoumal of Sex and Marital Therapy entitled "A Neglected Issue: The Sexual Side Effects of Current Treatments for Breast Cancer," the late Dr. Helen Singer Kaplan, noted New York sexologist, pointed out that women whose ovaries are functionally wiped out by chemotherapy develop testosterone deficiency, usually without any acknowledgment of the problem, much less any warning beforehand that it could happen.
If a woman has had chemotherapy as a treatment for a non-hormone-sensitive cancer, such as lymphoma, the use of supplemental testosterone for symptoms of deficiency could safely restore vital energy and libido. If the cancer was potentially hormone-sensitive (breast, ovarian, uterine), the decision about supplemental use of estrogen and/or testosterone is a tougher call to make. Definitive risk/benefit data is not available, and cancer specialists are not of one mind as to what to recommend.
It concerns me that several of the best papers published on the subject of testosterone deficiency focus on women who have no ovarian function, either as a result of the surgical removal of their ovaries or as a result of the loss of ovarian function due to chemotherapy for cancer. This narrow pathologizing of testosterone deficiency has a distorting effect. To be sure, women who have developed testosterone deficiency as a result of surgery or of chemotherapy need attention to their problems, but many women who develop testosterone deficiency are women with intact ovaries, who have never had chemotherapy and who develop this deficiency-sometimes even before rnenopause--as a result of their constitutional predisposition.
In the same way that estrogen deficiency is an aspect of normal menopause, we could say that testosterone deficiency is an aspect of normal menopause and aging. The fact that it is a "normal" part of the aging process, however, does not mean that it should be ignored any more than should the gradual onset of osteoporosis or any other treatable condition.
Just as estrogen deficiency can be treated with supplemental estrogen, testosterone deficiency can be treated with supplemental testosterone. Physicians are learning to recognize the signs and symptoms of estrogen deficiency, as well as the considerations for treating it. That is all to the good.
Physicians must learn to ask about symptoms, look for signs, learn about potential treatment of testosterone deficiency in pen-menopausal and aging women, and get that information out to those who need it.
"How do I know if I have enough testosterone?"
The most obvious signs of testosterone deficiency are:
Certainly, each woman must evaluate her sexual arousability
2. Am I suffering a significant loss in this familiar level of energy, well-being,
3. Do I particularly notice a lack of arousability in my nipples and clitoris?
5. In even the most conducive-to-me circumstances,
6. If I do have an orgasm, is it diminished in intensity?
7. Have I noticed (if this has a been part of your sexual life) a lack of sexual dreams or sexual fantasies?
Each of us has her own particular adjustment to the sexual aspect of life, with her own familiar rhythms of sexual feelings, fantasies, dreams, and activities. The answers to these questions must be considered in the full context of your personal sexual history and your present circumstances.
We all know that life circumstances can certainly disrupt sexual rhythms, but the "wipeout" of sexual desire that results from a critical reduction in testosterone is different from the fluctuations we experience with the various ups and downs of life and relationships. If your level of testosterone drops below a critical point, which may occur several years before menopause, your familiar levels and expressions of sexual desire may drop off notably, sometimes over a period of only a few months. This occurrence is most apparent for women whose other life circumstances remain stable.
A common concern among women who have been previously satisfied with their intimate relationships, in the face of the radical loss of sexual desire, is expressed in the question "Can this mean that I really don't love my partner?" And the partners of women who suffer a hormonal loss of sexual desire express their anguish as well. As one husband said, "I felt she was no longer in love with me We made love occasionally, but it was not the same at all. As I got the cold shoulder, I got less and less likely to even try."
Referring to her experience prior to using supplementary testosterone, one woman who consulted me said, "I had absolutely no libido. In fact, I had not had a climax for a year, and I was becoming very depressed. I started to wonder if something was seriously wrong, like did I have cancer."
On a workshop questionnaire, a woman wrote: "I used to be easily aroused, and had frequent ejaculatory orgasms. Now I am not easily aroused by either thoughts (as before) or my lover. Orgasms are rarely wet, and intercourse is painful."
Another woman wrote: "I always considered myself to have a very strong libido. Now it seems that sex does not matter."
Another: "I just don't feel like myself. I never knew I could feel so 'dead' sexually."
And another: "I feel like an incomplete woman, because I have no libido anymore."
These expressions are echoed, with variations on a theme, by too many women-women going through or past natural menopause, women who have had their ovaries removed surgically, women who have lost ovarian function due to chemotherapy, and even women who have had an illness, or have taken medication, that has affected brain chemistry or hormonal balance.
Several women who contacted me after reading my letter to the New York Times reported symptoms of testosterone deficiency triggered by unusual circumstances. One woman was poisoned by exposure to phenol in her workplace when she was forty years old. Before, this devastating misfortune, she had been healthy, was still menstruating regularly, and was enjoying "a great sex life." Three years later, she was struggling with slowly resolving residual neurological effects, including problems with her vision and visual memory. These symptoms troubled her, but she complained even more bitterly about her lack of general vital energy and sexual libido. She was still menstruating, but had noticed a substantial loss of pubic hair. She contacted me, complaining, "I just don't feel like myself."
It was not surprising, given all of her symptoms, that her blood testosterone levels proved to be very low. She opted to use supplementary testosterone, and has kept in touch to let me know that it has restored her to a level of energy, desire, and pleasure that has helped her feel more like herself again.
While it is possible that the hormonal changes that this woman experienced might have occurred even without the disaster of the phenol poisoning, it is also possible that the testosterone deficiency may have developed as a consequence of disruption of the balance and production of pituitary, adrenal, and ovarian hormones and of brain chemical messengers (neurotransmitters) that resulted from the poisoning. Whatever the cause, she has shown much improvement as a result of using supplementary testosterone.
An extraordinary request for consultation came from a Connecticut woman in her early fifties who identified herself as being transsexual. She was born a physically normal male and, at age twenty-eight underwent a sex-change operation with surgical removal of both testes. In order to develop and maintain female bodily attributes (breasts, fat distribution patterns, and higher voice register), she has been taking large doses of estrogen since she was twenty-three. It is inevitable that, without testicles and with the drop in the adrenal hormones that accompanies that loss, she has been experiencing symptoms of testosterone deficiency - lack of energy, sexual desire, and pleasure-for many years.
The options available in this circumstance are tricky. One issue is her concern about the risk that supplementary testosterone might stimulate the growth of facial hair. If she were to take enough testosterone to bring her blood level into the normal male range, this could happen. The hair-forming elements (PSU's, or "pilosebaceous units") in her facial skin are genetically programmed to respond to normal male levels of testosterone by growing stubbly beard hair. Once a beard has been established genetically and hormonally, only electrolysis, which destroys the hair follicles, can permanently do away with it. Women who take physiological doses of testosterone do not have to be concerned about "growing a beard," because our facial PSU's are not genetically programmed to do that. Instead, we grow fine, downy facial hair, which, so long as we maintain a blood level of testosterone in the normal female range, cannot become stubbly beard hair.
With regard to this transsexual woman's dilemma, the question remains as to whether taking a supplemental dose of testosterone that would be enough to raise her blood level to the top of the female range would stimulate any significant improvement in her vital energy or sexual libido and sensation. Since a man has more testosterone receptors in his brain and the rest of his body and needs seven to ten times more testosterone than a woman in order to maintain his energy and sexual libido, a major improvement for this woman who was originally created male is doubtful. Given the fact that her testosterone receptors are profoundly depleted, she might obtain some benefit from a low dose of testosterone, low enough not to re-stimulate a deep voice, male hair-growth patterns, and muscle mass. She is thinking things over, as yet undecided about what may be worth trying.
"Can men develop testosterone deficiency?"
Because most men's testes continue to produce significant levels of testosterone as they age, and their adrenal androgens maintain at substantial levels longer than women's, the majority of healthy men experience only a gradual and moderate decline in vital energy and sexual libido as they grow older. Of course, some men, with the genetic disposition, general health, and life circumstances favoring it, continue to be vigorous energetically and sexually well into older age. Other men's genes, health, and life circumstances lead to earlier failure in testosterone production by the testes and the adrenals, resulting in the loss of libido and vital energy at an earlier age. On the basis of inadequate levels of testosterone, some men become functionally impotent.
Epidemiological studies show that, while most men in their fifties and sixties ~01 notice some reduction in energy and sexual vigor, it is unusual for a man in his forties or fifties to experience the total bottoming-out of testosterone with the loss of vital energy and sexual libido that occurs in many women.
Dr. Edward Klaiber is an endocrinologist in private practice and a research scientist at the Worcester Foundation for Experimental Biology in Shrewsbury, Massachusetts-the labs where Dr. Gregory Pincus developed the Pill. (Coincidentally, in 1959, during the summer between my sophomore and junior years at Wellesley College, I had my first exposure to endocrinological research when I worked at the Worcester Foundation as a research assistant to the late Dr. Harris Rosenkrantz, studying the effects of vitamin E deficiency on the adrenal glands of rabbits.)
Dr. Klaiber's clinical research for the past twenty-five years has been focused on studying the effects of supplementary estrogen and testosterone for both women and men. In talking with Dr. Klaiber, I learned that there has actually been more clinical research conducted over the past forty years in treating women with supplementary testosterone than there has been in treating men!
I have also reviewed a very interesting series of papers published by a group under the direction of John B. McKinlay at the New England Research Institute. A study funded by the National Institutes of Health and Aging, called the Massachusetts Male Aging Study, has completed a survey of seventeen hundred men aged forty to seventy who were recruited at random from the greater Boston community. At the launch of the survey, an early publication by these researchers observed that "methodological problems [rendered] earlier work on women of limited value." Based on my own review of the medical literature, I can confirm that many studies of aging women have been very poorly designed and often reported on too few subjects not chosen at random. The Massachusetts Male Aging Study was determined not to repeat these confounding errors-and certainly did examine "a carefully selected representative sample of normally aging men."
While the research group did succeed in carefully collecting some quite interesting data, it's the way in which they interpreted this data that I find of greater interest. In an initial paper (in 1989), McKinlay and his co-authors emphasize the idea that "considerable controversy exists about steroid hormone levels and aging men, and if such a condition as the 'male climacterium' [male 'menopause'] exists [my emphasis]. " The premise of this early paper is a challenge to the possibility that aging men have reduced hormone levels and may have reduced sexual functioning on that basis.
As the results of the study came in, there could be no doubt that aging men were found both to have reduced testosterone levels and reduced sexual functioning. The final paper reported by that research group in 1994 focused particularly on the incidence of impotence in their aging population, showing that the incidence of complete impotence tripled from 5 percent at age forty to 15 percent at age seventy, and that "moderate impotence" doubled from 17 percent at age forty to 34 percent at age seventy. The authors concluded that "impotence is a major health concern in light of the high prevalence" and that it "is strongly associated with age."
In spite of the fact that men's sex hormones decrease as they age and that loss of potency is associated with aging, the authors are reluctant to acknowledge that the loss of potency (in otherwise healthy men) is a function of hormonal decline. At the same time, though, they do recognize that conditions such as vascular disease, hypertension, diabetes, associated medication, cigarette Smoking, and alcohol or drug use can cause impotence.
Dr. Klaiber's experience in treating men who come to him complaining of having lost the capacity for sexual desire and pleasure is that about 8o percent of men up to the age of seventy receive significant benefit for this problem from supplementary testosterone. Men with problems of impotence may recover their capacity for erection. Even those for whom full capacity does not return often report a welcome improvement in their desire for sexual contact and in sexual sensitivity and pleasure. Testosterone affects sexual sensitivity in genital tissue for men just as it does for women.
And yet a few cautions exist with regard to supplemental testosterone for men. While there is no evidence that testosterone can cause cancer of the prostate, it is known that it can stimulate the growth of preexisting cancer of the prostate. Dr. Klaiber cautioned that supplementary testosterone can "ignite" an existing cancer that might be dormant or very slow growing.
For men considering testosterone supplementation, there is a blood test that can measure prostatic specific antigen, or PSA. It is important to understand that PSA is not an indicator of the existence or absence of cancer; it is an indicator of the volume of prostatic tissue. According to Dr. Klaiber, the risk that a very much enlarged prostate (which would produce a larger amount of PSA, in the range of eleven to twenty-two micrograms per liter) might contain an existing cancer is fairly high. Whatever the PSA value, given the fact that the incidence of unsymptomatic cancer of the prostate is very high in older men, the risk of stimulating growth of prostatic cancer in that population must not be disregarded. Still, Dr. Klaiber does not rule out supplementary testosterone for an older man who wants to use it, provided it is carefully prescribed and the man continues to have his PSA monitored. As long as the PSA value remains more or less stable and within safe limits, continued hormone supplementation is a reasonable clinical decision.
'What are the particular benefits and risks of supplementary
Dr. Klaiber and I also discussed the potential use of testosterone as an "anabolic tonic" for aging women and men whose testosterone levels may be very low. Elderly people who complain of feeling "worn out," who have little muscle mass, who are frail and cannot gain weight in spite of a good diet, are often depressed about their lack of zest for life and profound lack of energy. A check of their testosterone levels will most often confirm profoundly low levels of total and free testosterone.
Older people who have had major surgery (for illnesses other than cancer) and have difficulty regaining their prior strength and energy may particularly benefit from supplementary testosterone, as may those with chronic heart or lung conditions. Because of the risk of prostatic cancer, though, the potential use of testosterone as a tonic may be safer for aging women than for aging men. Even so, clinical studies of the use and benefit of supplementary testosterone for men in their sixties are under way. I haven't yet beard of any such studies on the benefits of testosterone for aging women.
One of the "tonic" effects of supplementary testosterone is the stimulation of red blood-cell production in the bone marrow. Since elderly men and women have aging and narrowing blood vessels, if the blood becomes "too thick," it could put them at risk for potential heart attack or stroke. Especially considering the dosage of testosterone needed by men, this potentiality needs to be watched by checking the red blood count adequately.
Testosterone also has some natural anticoagulant effect, and is rumored to be "safer than aspirin" in preventing blood clots, heart attack, or stroke. People taking an anticoagulant (such as Coumadin) need to be aware that adding testosterone can further thin their blood.
Since the 1940s, reports have appeared from time to time in the medical literature noting one or another beneficial effect of maintaining adequate testosterone levels. The common thread through these various reports is the observation that adequate levels of testosterone contribute to the health of blood vessels, assuring a better blood supply to the heart muscle, brain, and even to the retina in diabetic patients. What this suggests is that adequate levels of testosterone can help to prevent heart disease, stroke, and diabetic blindness.
Researchers at Columbia Medical School reported in 1994 that they had found an inverse correlation between testosterone levels and degree of coronary artery disease. They found that men with higher levels of testosterone have a better blood supply to the heart muscle and higher levels of HDL (the "good" cholesterol) than do men with lower levels of testosterone. Men with lower levels of testosterone have higher degrees of blockage of the coronary arteries and lower levels of HDL.
In an early study, published in 1946, Dr. Maurice Lesser of Boston University School of Medicine reported the results of treating a group of patients suffering from angina pectoris (pain due to inadequate blood supply to the muscle of the heart) with injections of testosterone. He discovered that 91 percent of the group experienced gradual and marked improvement in their cardiac pain.
In 1962, a report appeared in the respected British medical journal The Lancet on the benefits of testosterone treatment of patients with occlusive vascular disease-that is, narrowed blood vessels. Serious consequences of this condition can include heart attack, stroke, and, in diabetic patients, severe damage to the retina, possibly leading to blindness. The researchers found that the use of testosterone resulted in significant improvement in this group of patients. They postulated that the beneficial results were the consequence of the blood-thinning properties of testosterone.
In 1964, the New York State journal of Medicine published an article focusing on the complex and vital role of anabolic steroids in regulating blood sugar and insulin requirements in maintaining a healthy metabolic balance. The authors suggested that the benefits of testosterone and of synthetic anabolic steroids in diabetic patients may be due to metabolic improvements at the cellular level, as well as to the blood-tbinning effects.
In 1977, the British Heart Journal published a report of the work of Dr. Martin Jaffe, who demonstrated that men whose electrocardiogram showed evidence of poorer blood supply to the heart muscle after exercise showed significant improvement after being treated with testosterone.
What is most evident to me from all I have learned in my research is that testosterone is a hormone whose role in the maintenance of health has yet to be fully understood and appreciated. In using supplementary testosterone to maintain our vital energy, sexual energy, and quality of life, we may well be making a significant contribution to our health as well.
"Is there a way to measure your level of testosterone?"
Yes. There are two methods of measuring your level of testosterone: One tests blood, the other saliva. The best-known and most commonly used method is a blood test, which can measure both total testosterone and unbound, or "free," testosterone (that portion of testosterone that can attach to receptors in the cells and exert its actions). Different methods may be used by different laboratories for these measurements, some more accurate and dependable than others.
My own experience with testosterone determinations has been with tests performed on blood samples. The laboratory I use, Corning Bioran (in Cambridge, Massachusetts), reports the normal range of total testosterone to be ten to one hundred nanograms per deciliter. For some perspective on these incredibly tiny amounts: One gram is one-thirtieth of an ounce, one nanogram is one-billionth of a gram, and one deciliter equals about half a cup.
I find it confusing that Coming Bioran claims the lower end of the normal range to be ten nanograms per deciliter, while, in practical terms, their method for determining total testosterone is not sensitive to amounts less than twenty nanograms per deciliter. At the other end of the spectrum, it is not common for a woman to have a baseline level of total testosterone of more than fifty nanograms per deciliter. The normal range of total testosterone, as reported by Corning Bioran, works out to be something more like twenty to fifty nanograms per deciliter.
Free testosterone is that small percentage (1 to 3 percent) of the total testosterone that is not bound to the carrier protein. The normal range for free testosterone is listed by Coming Bioran labs as "one-half to five picograms per milliliter." (One picogram is one-trillionth of a gram and one milliliter is one-thirtieth of an ounce, or approximately twenty drops.) Corresponding salivary measurements of free testosterone work out to be about one-tenth the amount found in a matching blood sample-same person, same time.
When a woman reports symptoms of testosterone deficiency, a blood test to measure her total testosterone very frequently shows that she has no measurable testosterone. In spite of this, the laboratory data regularly will yield a determination, always very low, for free testosterone. I puzzled over these values before consulting with Dr. Gerald Sheys, technical director of the Corning Bioran laboratory. I could not understand how the laboratory could come up with a value for free testosterone in a sample reported to have "no measurable total testosterone" in the first place. Dr. Sheys explained that since Corning Bioran's test for total testosterone cannot measure amounts less than twenty nanograms per deciliter, a woman may indeed have an immeasurable but existent, very small amount of total testosterone. He noted that the blood test used by his laboratory for the free testosterone is a more sensitive test, designed to measure trace amounts, and therefore can detect and measure that tiny percentage of the unmeasurable total testosterone not bound to protein.
Another laboratory mystery presented itself when I was contacted by a woman who was taking Estratest H.S., the most commonly prescribed pharmaceutical combination of methyltestosterone and estrogen. Even though natural testosterone has been available for many years, no preparation of plain testosterone---a natural substance which cannot be patented-is marketed by any drug company. Doctors have remarkable resistance to prescribing anything that is not listed in the Physicians' Desk Reference (often referred to as the PDR). A major drawback of Estratest H.S. is that, since it exists in the form of a "caplet" containing two hormones in fixed dosage, it does not allow for flexible dosing of one without affecting the dose of the other. I discovered another drawback when this patient's reported testosterone levels proved uninterpretable.
After this woman began taking the Estratest H.S., she experienced improvement in energy, sexual libido, sensation, and orgasm. However, she also developed unpleasant symptoms of agitation and irritability. I suspected that her blood levels of testosterone might be higher than necessary or advisable and suggested a blood test to check this out, but the laboratory results reported "no measurable total testosterone"! The same sample tested for free testosterone reported a value Of 4.6 picograms per milliliter-the higher end of the normal range. This simply made no sense. Since the woman was taking a significant dose of supplementary methyltestosterone, her blood should certainly have registered some measurable total testosterone. I had no idea how to interpret the free testosterone value. These results were very puzzling. We repeated the tests, which yielded similar results, and I called Dr. Sheys, the lab director. Upon reviewing the laboratory methodology, and in joint consultation with Dr. Richard Reitz, medical director of the Corning Nichols Laboratory in San Juan Capistrano, California, we discovered that methyltestosterone cannot be measured by the standard assay that measures total unmethylated testosterone. A blood test to measure total and free testosterone can yield accurate data only when the person is not taking methyltestosterone.
Upon contacting Solvay Pharmaceuticals, the manufacturer of Estratest, I spoke several times to investigators in the Women's Health Clinical Endocrinology Operations section, who acknowledged that Solvay does have a method of measuring methyltestosterone blood levels, but that this method is both highly specialized and "proprietary."
I have learned some important facts about the way the body uses methyltestosterone, leading me to conclude that even if we had a readily available laboratory method of measuring methyltestosterone blood levels, the meaning of these test results would be of somewhat limited use.
What we know for sure is there is no way to obtain an accurate measurement of the level of testosterone activity a person may have when he or she is taking methyltestosterone.
"Is the saliva test a better way to measure
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