Can Women Have Low Testosterone? with Talia Crawford, MD

Podcast Transcript

John Horton:

Hello, and welcome to another Health Essentials Podcast. I'm John Horton, your host.

When it comes to sex hormones, testosterone is typically talked about as being a guy thing. But the fellas do not have exclusive rights to it. Women also produce testosterone, and the hormone plays a critical role in their health and overall well-being. It's important for bone and muscle, mood and energy, fertility and libido.

Today, we're going to talk with Dr. Talia Crawford about what options women have if their testosterone levels dip too low. Dr. Crawford is one of the many experts at Cleveland Clinic who join us weekly to unravel the mysteries of the human body.

So with that, let's dive into a topic that is a bit controversial and still being explored.

Welcome to the podcast, Dr. Crawford. We're so glad you could join us today.

Dr. Talia Crawford:

Thank you so much for having me, John. I'm very glad to be here.

John Horton:

So you're with us to talk about women and testosterone, which just sounds like an unusual pairing, as testosterone is usually connected to men's health. So tell us, what's it doing hanging out in women's bodies?

Dr. Talia Crawford:

Yeah, so I think part of the confusion with testosterone and estrogen is that we genderize them and call them sex hormones. But in reality, they have important biologic functions in both men and women. For women, testosterone is naturally produced in the adrenal glands and the ovaries and some peripheral tissues, and it has lots of important roles in our bodies, including maintenance of bone and muscle mass, cognition. It influences mood, energy, and then also libido.

John Horton:

Wow. Yeah, so it really does play a pretty critical role. Now as far as levels go, women have less testosterone than men, correct?

Dr. Talia Crawford:

Correct. Yeah, that's absolutely right. Typical levels, or what we would consider a physiologic range in a woman, is between 15 and 70 nanograms per deciliter. That varies a little bit by lab, but that's kind of a general standard. However, it is important to keep in mind that if someone is below that, we don't truly have a cutoff level that defines a deficiency in women.

John Horton:

If a woman has low testosterone, and it sounds like that's a tough thing to put a number on, but if it is low, where do you see it in daily life? How is it going to affect her?

Dr. Talia Crawford:

So she might experience a lot of symptoms that could be multifactorial. And due to other things, that's why sometimes, it's tough to just blame it on testosterone. But that can include fatigue, low sex drive, mood changes, brain fog, and decrease in muscle and bone mass. Some of those things change as we age, and some of that is mediated by hormones, and some is other factors. However, the only evidence-based indication that we have currently to supplement testosterone is for low libido. The fancy term for that in medicine is “hypoactive sexual desire disorder.” So the only evidence-based indication that we have currently is for use of testosterone is to augment libido in peri and postmenopausal women. We do generally try to avoid using it in reproductive-age women because of the risk that it poses to pregnancy, if someone were to conceive while on it. However, we do have other medications that we can use for low libido in premenopausal women.

John Horton:

All right. Now, a lot of those symptoms that you mentioned, like you said, they are multifactorial. I mean, there's a lot of reasons why you could be fatigued or have some of those other issues that you talked about. So how does a woman typically learn that she has low testosterone?

Dr. Talia Crawford:

That is a complicated topic because we don't have, like I mentioned, any clinical criteria for diagnosing androgen deficiency in women. So data correlating androgen levels with specific signs and symptoms aren't necessarily available. So we typically are only checking testosterone levels if we're having a conversation with a patient about low libido, and we want to make sure that her levels aren't outside the physiologic range before we offer her that therapy, specifically.

Testosterone is a complicated hormone because it has its own biologic effects on tissue, and also, it can be aromatized or turned into other hormones. And so, those other hormones can have their own effects on tissue. So it's really tough to pinpoint what action testosterone is taking versus what is the action of a hormone that it's being aromatized into.

Additionally, hormones fluctuate throughout the menstrual cycle, and are also influenced by some supplements that people take, especially herbal supplements. So it's difficult when we're just checking a blood level at one particular day, in one particular clip in time, to say that it's representative of someone's hormone levels across the course of a month.

John Horton:

Yeah, so if you are testing because maybe you think there might be an issue with low testosterone, is that something where you might have multiple tests then, just to gauge where it's at over a stretch of time, or can one test give you a little picture as to where we're at?

Dr. Talia Crawford:

For the indication that we're testing, it's usually just one test to make sure that somebody's level isn't above 70 before we're offering that patient testosterone therapy. It's not typically something that we check multiple times to determine that it's in a safe range. Now, the exception to that would be after we start testosterone therapy, then we do need to measure the level multiple times to ensure that we're not getting outside a safe range.

John Horton:

Now, you had mentioned that it's only used in treatment … now, in cases of low libido — this is going to sound like an odd question — but how is that measured? That seems like a pretty ... it could be all over the board as to what somebody considers low in that realm. So how do you kind of make that determination?

Dr. Talia Crawford:

Yeah, libido is complicated-

John Horton:

…a little bit.

Dr. Talia Crawford:

Yeah, because libido is a mood, so that can change depending on a lot of other factors in life. So usually, we find that out because a patient comes in complaining about it. So some people experience low libido, but it's not distressing to a lot of women. So in that case, we wouldn't pursue therapy at all. So I would only pursue therapy for a patient with low libido if she told me it was distressing. And in that case, we need to have a very thorough conversation about other things that can affect libido, such as interpersonal dynamics with the partner, medications, environmental factors and even some health conditions that can affect libido.

John Horton:

Yeah, there's definitely a lot that goes into that.

Dr. Talia Crawford:

Absolutely.

John Horton:

So if you're doing these tests and you find that a woman's testosterone levels are low, what kind of treatments are out there to give them a boost?

Dr. Talia Crawford:

So I always counsel patients when we're checking testosterone. Again, we're just checking it because we want to make sure it's not too high. So as we start therapy, it's important to keep in mind that we're not treating a lab value. So, for example, some women are going to feel great at 15 nanograms per deciliter, and other women are not going to feel any therapeutic effect until they get to 50. So it varies a little bit for each patient.

There's currently no FDA-approved formulation to treat low testosterone in women, which, unfortunately, means that a lot of women will pursue therapies that are not safe, such as pellets and injectables. However, the Endocrine Society and the American College of Obstetrics and Gynecology do recommend that we use a fractionated dose of a male-approved transdermal product. Usually, that's about a 10th of the dose of a 1% testosterone cream that would be used for males. So on average, as far as number of milligrams, that's 5 milligrams daily, but it can vary between 3 and 10 depending on a patient's response to therapy and what her levels are. As we're monitoring therapy.

At the Cleveland Clinic, we typically compound this to make sure that we are getting the correct amount. However, there are some FDA-approved transdermal male products that can be prescribed with a dosing that's appropriate for women if there is no compounded pharmacy available to the patient.

John Horton:

I want to unpack a few things that you mentioned there. One, the first being that there is no FDA-approved treatment for women. So basically, it sounds like what you have to do is, if you find that maybe a woman's testosterone levels are low, you're taking a treatment method that's been OK’d for use with men, and trying to make it work for a woman?

Dr. Talia Crawford:

Yes, that's right. Yeah, so testosterone, at least in the United States, is not currently approved for use in women, but we do have a lot of data to support its safety and efficacy as long as it's being compounded appropriately at the right dose and also monitored appropriately. So we feel comfortable doing that.

John Horton:

Yeah, and I think this is where we want to make sure to emphasize, just because it isn't an approved FDA thing, there are things where, I think they say, is it “off-label” use, where there's permitted uses kind of around where the official approval is?

Dr. Talia Crawford:

Right. That's exactly what it is. It's an off-label use at this point in time. We have good data on it, great data for safety and efficacy, but it's just not yet FDA-approved in the United States. We hope that we will have a product that is approved here in the future. It is approved for use in Australia and some other European countries that do have FDA-approved products for women to use testosterone, but not here yet.

John Horton:

Yeah. Well, and it seems like there really is a need because I know we were talking about earlier, like I said, when you go into a supplement market, and you start searching online, there are a lot of things out there where the products … where they promise that they can boost your levels or do things like that. I take it any woman who's concerned about her testosterone level just shouldn't kind of dabble in doing that, and kind of just picking something out and trying it to see what works?

Dr. Talia Crawford:

Yeah, I agree with that 100%. I would say that using transdermal testosterone or some of the FDA-approved therapies that we have for low libido in reproductive-age women is much safer than using a supplement that's not regulated, and also a supplement that might be very expensive. And so from that standpoint, much more efficient from a cost standpoint just to come in and speak to your clinician about your other options.

John Horton:

Yeah. And as we've talked about in this podcast before, the supplement world is just very Wild, Wild West. You never really know exactly what you're getting in some of these products.

Dr. Talia Crawford:

Right. Yeah. Supplements are not regulated by the FDA, and so quality and purity are kind of unknown, and the amount even, of a supplement that you're getting can be problematic. A lot of them interact with other medications, too, so that's an important thing for people to keep in mind.

John Horton:

Yeah, definitely why it's always good to work with your healthcare provider if you are going to seek out this sort of treatment to boost testosterone levels.

Dr. Talia Crawford:

Absolutely.

John Horton:

You had mentioned, too, a couple different age ranges or times when a woman might seek this sort of treatment. Is there a certain age or whatever where it's more likely that you might see this, or does it span the whole gamut?

Dr. Talia Crawford:

I really see this in women across all age groups. Our testosterone specifically starts to decline in our 30s, and that progresses through to the postmenopausal state. And that doesn't always cause problems for people. So low libido can present even in the context of normal testosterone levels for a variety of reasons in life. For middle-aged women, sometimes, it's because they have other stressors, which are young children, stress from work, they're not sleeping well. Certainly, in postmenopausal women, we can see that there is some hormonal influence from low testosterone, and even sometimes menopause, and the symptoms that menopause can cause will cause people to feel like their sex drive has decreased.

John Horton:

Now, what are the risks or potential side effects of low testosterone treatment for women, and how can they be managed?

Dr. Talia Crawford:

So generally, if we supplement testosterone as recommended, which is about one-tenth of the dose that's used in males, and we monitor it appropriately, it's kept in the physiologic range, it's a pretty safe product. So you might get a little bit of hair growth at the site of application. Typical site of application that we'd recommend is the lower abdomen or the buttock. You may also experience some acne.

Where we run into trouble with bad side effects is if it's outside the physiologic range or it's in a supratherapeutic range. So side effects that can occur with that include deepening of the voice, enlargement of the clitoris and male pattern balding. Voice changes, specifically deepening of the voice, and enlargement of the clitoris are, unfortunately, not reversible side effects. So I always emphasize that to patients when I'm counseling about them, about the importance of monitoring testosterone therapy with blood draws because we really need to be careful to make sure that it does not get outside the therapeutic range. This is another reason why pellets and injectables are so dangerous because these often do result in supratherapeutic, very high testosterone levels, and we can't reverse that quickly. So it just takes a while for the body to bring that level down. Sometimes, that's weeks to months even, and so those products are more likely to cause those adverse side effects.

Additionally, oral testosterone therapy is not recommended because it does have adverse side effects on blood lipids. So specifically, it will decrease HDL and increase LDL or bad cholesterol. Short-term use of transdermal testosterone therapy we know does not impact breast cancer risk. However, we don't have data on use of testosterone therapy, or at least we don't have robust data on use of testosterone therapy in breast cancer patients. So we generally recommend that anyone with a hormone-sensitive cancer, including breast cancer patients, not use testosterone therapy. We only have data to support about two years of safety for testosterone therapy. So beyond that, we don't really know what the risks are. There may be risk of cardiovascular disease, and maybe higher cancer risk with more prolonged use. So I typically counsel my patients not to use it more than about two years.

John Horton:

Yeah, it sounds like everything you just said is the reason why you don't want to go experimenting with this on your own and trying supplements you get online or things like that, and really work with your healthcare provider to get the proper medication, which it sounds like, for the most part then, you're talking creams and patches, right?

Dr. Talia Crawford:

Just creams. In the United States, we don't have access to patches. So for the purpose of compounding or even using … like Testim® is a product that's typically used on men, which we can write that prescription so that it would be equivalent to one-tenth the dose, but we can't really do that with a patch.

John Horton:

And it sounds like if you are a woman, and you do go on this treatment route, it's something where you're going to be tested somewhat regularly to make sure that your levels don't surge too high?

Dr. Talia Crawford:

Yeah, that's right, John. We would test the level four to six weeks after a woman starts testosterone therapy, and then after that every six months, unless, of course, new side effects develop, then we might test sooner than that. But that's kind of the general monitoring frequency that would be recommended.

John Horton:

Yeah. So overall, when should a woman talk to their doctor about low testosterone treatment? What should set off that conversation?

Dr. Talia Crawford:

So currently, the only evidence-based medication that we have is for low libido and sexual dysfunction in peri and postmenopausal women. Testosterone has lots of different beneficial effects for women in general, but unfortunately, we are just not there with the data to be able to say we should be supplementing testosterone for any of the other things that we talked about, like energy or cognition, or maintenance of bone and muscle mass. I think we have a long way to go with the data, and we have a lot to learn about testosterone therapy in women. So I hope that a lot more research will be done in that realm.

John Horton:

And it sounds like there's a lot to look at here. And I know we've talked, that there's a little bit of controversy about when to use it, how to use it and all that. And it sounds like this is still being worked out as to the best application, because it is important. I mean, it needs to be addressed, but it's just a matter of figuring out how and how to do it safely.

Dr. Talia Crawford:

Yes, that's right. [inaudible 00:17:14].

John Horton:

All right, so Dr. Crawford, if we're your patient, we're coming in, and this is on the table, how would you go about explaining our options for testosterone treatment, and how it could maybe be the best decision for our health?

Dr. Talia Crawford:

So the first thing is getting a very comprehensive history about why someone is coming in to request testosterone therapy. In most cases, this is going to be for sexual dysfunction. So I would spend a lot of time with this patient, talking to her about other factors that may be influencing or affecting her sexual health in a negative way, including her interpersonal dynamics with partner, any history of sexual abuse or negative sexual experiences, medications, medical history, also herbal supplements that she's using, as we're talking about things that are not FDA-regulated, substance use, and how well she's taking care of herself with exercise, nutrition, et cetera. And then if she is peri or postmenopausal, we may decide, after all those things that have been evaluated, that testosterone is a potential therapy for her. So I would counsel her about the potential risks of testosterone therapy and the contraindications.

Contraindications, we briefly touched on, but that would be a hormone-sensitive cancer, and then active liver disease would be another contraindication, too, use of testosterone therapy. We should also use caution with testosterone therapy in women who have severe cardiovascular disease, just because we don't have great data in patients with severe cardiovascular disease on the safety of testosterone.

And so yeah, we'd have a conversation about that. And then, if she feels comfortable moving forward with testosterone therapy, I would have her check a baseline testosterone level, and then also a lipid panel, liver function test if she didn't have a recent lab panel done for those parameters. Once we make sure all that's normal, we can go ahead and have her start using testosterone at one-tenth the dose. I typically start someone at 5 milligrams daily and then just apply that cream to the lower abdomen or the buttock once daily, and then I'd have her check a level again in about four to six weeks. And if that's still normal, and in the appropriate physiologic range, then she can check it again in six months. And then I'd have her schedule a follow-up appointment with me in six months, because that’s about how long we need to give it to see if it's really going to be effective. If it's not effective by six months, then we need to be looking at other therapies.

John Horton:

It sounds like there's a lot that goes into getting this sort of treatment and kind of starting it up. I'd imagine it's not like a first move sort of thing, that you often try some different things, even if it's lifestyle changes or things like that, just to see if you can maybe help out and address some of those symptoms without going this route?

Dr. Talia Crawford:

Yeah, that's right. And ideally, patients with sexual health concerns will also meet with a sex therapist. We offer that type of multidisciplinary approach here at the Cleveland Clinic, and that's also very beneficial for addressing some of the other interpersonal or environmental factors that may influence libido and sexual health.

John Horton:

Yeah, well, as you mentioned, hormones on their own are just incredibly complicated. There's no easy answers. Whenever we've done these podcasts looking at any hormonal issue, there's always so much you have to take in. When we look at testosterone in women, just to wrap things up, I guess, is this something that folks should be concerned about, should have an eye on, or is it just something that it may come up when you go in for a regular screening or appointment, and it might be something that gets looked at?

Dr. Talia Crawford:

Yeah, it's not something that I would encourage people to seek testing for any reason other than low libido. And even then, we're generally only checking in just to make sure it's not too high. The significance of a particular lab value is just unknown at this point, so we don't have any diagnostic or clinical criteria to say that a woman is androgen-deficient or deficient in testosterone. I hope that, again, we will have more data on how we should use that lab value to help guide us for therapy for things like mood and cognition and bone and muscle health in the future. But right now, we don't have any guidance based on good data to tell us how to manage that.

John Horton:

Yeah. Well, it sounds like that's going to be the sort of thing where we're going to have you back on in a few years, when we get more of this research done and some of this data in, and we might be able to talk about a whole new realm of treatment.

Dr. Talia Crawford:

I sure hope so. I'd love to be able to do a part two.

John Horton:

Well, we'll put that on the books and get that on the calendar for a couple years down the road.

Dr. Crawford, thank you so much for coming in. This is just a really interesting conversation. And like I said, it always amazes me how hormones work in the body in just so many different ways.

Dr. Talia Crawford:

Yes, John, thank you so much for having me. I love discussing this topic, so it's been a pleasure.

John Horton:

Women need testosterone, and if they're not getting enough of the hormone, it can affect day-to-day activities. Talk to your healthcare provider if you're experiencing some of the symptoms we talked about. You do have options for treatment.

If you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, be well.

Speaker 3:

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