Testosterone for women and the FDA workshop

Philip Pape 0:00

If you've heard that testosterone is the missing hormone for women in menopause, for your muscle, for your energy, even your belly fat, this episode is for you. Today I'm evaluating the testosterone claims. You'll learn the one thing that it is proven to help with how high the dose has to go before it adds any muscle in women, according to the research, and what builds muscle in menopause without a prescription at all. Welcome to Wits & Weights, the show that puts a popular piece of fitness advice under the microscope, finds a hidden reason it doesn't work, and gives you the deceptively simple fix that does. I'm your host, certified nutrition coach Philip Pape, and testosterone for women is everywhere right now. It is a trending topic. Prescriptions for women have more than doubled in the last few years. Menopause telehealth companies are offering it, clinics, doctors with big followings on social media, on podcasts. And recently, just last month in September, the FDA held a full-day public workshop on testosterone and said that it wants manufacturers to bring it better data. So if you are over 40, especially if you're in peri or postmenopause and you lift weights, as of course you should be lifting weights, somebody's probably said, hey, your testosterone's low. Maybe they've said it, maybe they've implied it, maybe you've heard it online and said, hey, I got to check this. Maybe a functional doctor, maybe blood work panel, I don't know. But I hear it a lot now, let's just say. And of course, fixing your testosterone's got to be a direct correlation to helping you get strong and building muscle, right? And I get why that's appealing. I'm a dude, okay, I'm not a woman. And for men, of course, it it's always been a topic of concern. And if you're training, you're eating your protein, if your progress is feeling slower, there's always something we want to grasp to at this age, you know, 40s, 50s. And testosterone is definitely one of those shiny objects today. So today's episode is focused on that, and it builds on some recent episodes. So in 501, you can find the episode number, by the way, in your podcast app. I don't put them in the title anymore, but in episode 501, we looked at how perimenopause affects your weight. You know, we talked about how it's not necessarily the root cause of weight loss resistance or weight gain. There are other reasons for it during perimenopause based on the evidence. Then in 505, we covered creatine for women in perimenopause in menopause. And then 511, we talked about hormone therapy and belly fat. So today we're gonna look at testosterone. So it's kind of like a nice cluster of episodes recently around peri-impostmenopause because I want to bust all the silly myths that are out there about this time of life because life, because ladies, I care about you being successful and not being chilled and taken for all you're worth with nonsense out there, right? We want to do this the right way based on what really works. Then I want you to stick around to the end of this episode. I'm gonna share an inexpensive supplement that across 22 trials in older adults who lift weights added more lean mass, about three pounds of lean mass, on top of what they would have had otherwise. So here's the plan for today's episode.

Who's promoting testosterone to women

Philip Pape 3:17

First, where are these claims coming from about testosterone and who is making them? Always important to look at that. Then, what does the research say testosterone can help with for women? Which there's one specific thing it does, but there's also a thing that is claimed to do that's not the main thing. Teaser. And then a study related to muscle gain that a lot of people are talking about and the dose involved with testosterone. So we'll get to that if you're like, what is he talking about? Maybe the people I follow are talking about it. I don't know. Then of course, we're gonna talk about what are the, what's the approach here? What is the fix? Or maybe not so much the fix as the you know, the simple approach and how to talk to your doctor about testosterone, if you do want to try it, without getting pushed into pellets, which caveat, not a big fan, not a fan. Okay, so let's start with the claim itself, which is kind of like the story goes like this testosterone is the most abundant hormone in a woman's body. True, actually. It tends to crash or decline at menopause. And if you replace it, it's gonna bring back your muscle tone, your energy, your motivation, help with your brain, help with fat loss. You'll hear it called the hormone that nobody tells women about. In fact, we've talked about it on the show. We had Karen Martell on talking about it, and you know, all that stuff actually does hold up, you know, what we were discussing. I feel like there's one or two other experts I had on as well where we talked about testosterone. So it's it's taken on a new level of insanity today because you have menopause telehealth companies, and I hear them all the time. I don't know why they haven't reached out to advertise on my show, maybe because they know I'll probably say no. Depends, depends. But like MIDI Health, they're not a sponsor, but they are one of the largest. They announced testosterone for women about a year ago with a big press release about how explosive the demand for it was among patients. And when you go to their webpage, it lists energy, mood, muscle tone, cognition as possible benefits. And then to their credit, it says, Oh, the evidence is still emerging. Okay, fair. And I'm not knocking MIDI, I'm just they're huge and you hear them everywhere on podcasts, whatever. And they're selling stuff too. So you got to keep that in mind, but it's understandable. Then you have physicians, physicians who are like the Dr. Ozas of our time, the books, the clinics, the podcasts, the supplement lines, just goes on and on. And they talk about testosterone as a motivation hormone or a longevity hormone. And you've got the compounding pharmacies and pellet clinics, which it the list goes on, is what I'm saying. So you guys gotta be careful. We gotta be careful. There's just so much junk on social media today. And a tiny sliver of these are probably real doctors who see real patients. A lot of them are sincere, but almost everyone, and I hate to say almost everyone, but a vast majority of these folks promoting this the hardest tend to get paid in some way related to the prescription or going to their clinic or something like that. And and you just have to understand that conflict, right? It doesn't make them wrong. It just means we have to go look at the evidence and say, is this really the case? Now, the demand side, if we're looking at the economics, the demand side is is is there. There was a data analysis for Reuters this fall that found the rate of women getting testosterone prescription went up two and a half times in about three and a half years. So 250%. Now, most insurance doesn't cover it for women. Pharmacies have started rejecting some of those prescriptions because there is no testosterone product approved for women in the US. The last I checked. Women are using men's testosterone gel and just fractionalizing it to a tiny amount of the dose, or they're using compounded creams or pellets. So a lot of you are right now thinking like of making that decision, or your friends are doing it. Everyone's doing it, like GLP wants, right? And I don't mean that as a well, no, I do mean that in a snarky way. Let me just be honest. So let's talk about the reality of what testosterone does for women. Okay.

Testosterone levels across menopause

Philip Pape 7:18

The there is a thought that testosterone declines precipitously at menopause. Well, guess what? It does not. It does not, at least not at natural menopause. Again, on average in the population. There was a research team at Monash University in Australia, and they measured testosterone in over a thousand women in their 40s, 50s, and 60s. What they found is that testosterone drifts down with age, starting way back in your 20s. And by around the age of 60, it's roughly half of what it was. But going through menopause itself didn't change it. So that's the distinction I'm trying to make. It just gradually declines over a long time. The levels bottomed out at around age 58, 59. And then after that, they actually ticked back up back up a little, which is interesting. The ovaries keep making some testosterone after menopause, which is also why women who've had their ovaries surgically removed are in a different category, right? For them, they really do get a sudden drop. That's no surprise. They don't have ovaries anymore. And by the way, ovaries are a whole fascinating topic because you know we're finding more and more how they are active in more ways than we used to think into later age. And this is one example of those. So the idea that your testosterone falls off a cliff at menopause and has to be replaced, always want to question these claims, especially when you're having issues, let's say losing weight or building muscle, and you immediately go to like it must be hormones or I need HRT for that. What we find is a lot of people have multifactorial reasons for the struggles they go through. And a lot of times they're not doing the boring basics, which we're going to talk about the boring basics, of course, as we always do on the show, because that moves the needle the most. And if you're not doing the boring basics, how do you know it's that something else is a really a problem until you take care of that? Anyway, this testosterone slowly declines starting in your 20s, and it happens everyone, men and women. So it's hard to like pin the blame on that as a variable if something has changed dramatically. Makes sense, right? Now, what does testosterone do for women when you give women testosterone?

What 36 trials show testosterone does

Philip Pape 9:24

Well, there was actually a really big review that pooled together 36 randomized trials of over 8,000 women. And the answer points at one single thing that it does, one benefit. In postmenopausal women, it improved sexual desire, arousal, and satisfaction. So that is a real thing. That happens. For women who have low sex drive, and especially if it's noticeable and it bothers them and it's affecting their life, that is a very powerful, important thing. Men and women want to have their sex drive, obviously. The size of the effect was about one extra satisfying sexual experience a month compared with placebo, once they started taking the testosterone. So whether that's a helpful enough to move the needle for you or not, or you know, life-changing, let's say, maybe, maybe not. And I know there's a lot of jokes about, not jokes, there's a lot of, gosh, I don't know, I don't know if I want to call it sex maxine or testosterone maxine, but like the whole TikTok culture around pushing any one of these things for some reason. So people will glom onto that in the marketing and be like, oh my gosh, it's gonna completely change your life. I've actually heard this talked about on recent news podcasts, talking about how you know it tends to be overhyped, like many of these things are. Now, in that same review, that large review of 36 trials, 8,000 women, testosterone did not improve body composition or muscle or thinking or memory. Although not many women were measured on those across all the studies, right? Like some studies did, and this is the challenge with a meta-analysis is trying to have enough of like a sample size of studies with measuring the same thing. It did increase acne, it did increase unwanted hair growth. And there's a global consensus statement backed by menopause and endocrine societies, including the menopause society, which I very much respect, that says the only evidence-based use of testosterone for women is low sexual desire that causes distress in postmenopausal women. It found no benefit at normal female doses for muscle strength and well-being. The medical director of the Menopause Society, Dr. Stephanie Fabian at Mayo Clinic, Mayo Clinic, told Reuters that there is no evidence it improves muscle, bone, or mood in women, and that what it's being promoted for on social media isn't what the data support. So it's not just me being skeptical and like getting tired of, you know, the youngsters doing their thing on the TikToks. No, it is what the experts in the field, the ones I respect who really know this stuff, who follow the evidence, and are putting it in the guidelines, are saying. All

The high-dose muscle study

Philip Pape 12:08

right. So if this big review found no benefit for a lot of those things like muscle, for example, why do people keep saying testosterone builds muscle in women? Because I do hear that message a lot. Well, because there is a study that I want to walk through that people like to cherry pick. Okay, very important. Again, a research group in Boston gave women weekly testosterone injections at five different doses from placebo up to a high dose for six months. The women at the highest dose did gain lean mass, they've got gained about four pounds on average, which was more than the placebo group. And their their power on a few of the tests also went up. So you'd look at that and say, okay, builds muscle in women, right? Given the spread, four pounds. Let me explain because the highest dose pushed their blood levels to about five to six times normal for a woman. So that is not hormone replacement, okay? That is super replacement. It's a level that you would not see prescribed. A doctor or functional medicine or practitioner, even a clinic, I imagine, unless you're you're asking for it in terms of like anabolics, you know, performance enhancing, are not going to give you. The lower doses, which are still above the normal female range, did not add a meaningful amount of lean mass. So this is not that surprising, folks. The muscle gain showed up at a dose way, way above what's considered normal for women. And of course, we see the same thing in men. That's why men, if you are looking to get TRT, hopefully you're doing it to replace. That's the whole, that's the R in the acronym is to replace within normal physiological levels, not you know, anabolic steroid, unhinged kind of levels. That's a whole separate thing. That is not my area of expertise. Now, there's two more catches, two more caveats to the study. The women in the study had all had a hysterectomy, and many had had their ovaries removed as well, which is the group that has a true drop in testosterone, as we mentioned earlier, right? Not it's not your average woman going through natural menopause. Lean mass on a DEXA scan, remember, it counts not just muscle, but water as well. You know, it's everything that's not fat. Testosterone makes you hold more fluid. So there's also a very good chance that part of that four pounds of lean mass was not muscle, a decent part of it potentially. So you'd have to take probably an unsafe, unhealthy, super physiological level of testosterone, way above the dose you should be taking anyway, to barely gain a tiny bit of muscle extra. Is that worth it to you? That's your call, but I don't know, it doesn't sound worth it to me. So, what about the rest of the claims of it building muscle? Well, mostly it's from observational studies where women with higher natural testosterone tend to have more muscle and better bone. Well, guess what? Cause and if or cause or not causation, but correlation, right? Correlation versus causation. Always a very important thing to tease apart when we look at study results. Women who already have more muscle and train harder may simply have higher testosterone because they're have more muscle and train harder. So, you know, it could go either direction, is what I'm saying. And I'm I'm guessing which direction it probably goes. It's that way, i.e., you're fitter, you have more muscle, you train harder, airgo, you have more testosterone. You they probably have lower levels of body fat. I don't know. I'm just saying that. I don't know if that's that's accounted for, but likely the case. Now, some of it comes from the fact there are testosterone receptors all over your body, right? But it doesn't mean that adding more testosterone helps build muscle, but having more muscle results in higher testosterone. Okay. Now, there's also the

Pellets, compounded products, and safety

Philip Pape 15:42

safety piece. I briefly alluded to safety in my diatribe a few minutes ago. In those same trials, at doses that keep you in the normal female range, the short-term safety looks fine, but the safety data go only go out about two years. So past that, we don't know enough about things like heart disease or breast cancer. And that's actually a big part of why the FDA is asking for more data. The bigger problem is how a lot of women are getting their testosterone. Now, this consensus statement I mentioned recommends against pellets, injection, injections, and compounded products because of the risk of pushing your levels way beyond the female range. And, you know, the pellets, the reason they're just so horrible is you can't undo them. If you don't like how you feel, the symptoms get worse. I mean, I've heard horror stories. They're in there, they're pumping that testosterone, you can't control it anymore. I don't know. That just doesn't sound right. That sounds like the opposite of the Hippocratic growth of do no harm. So obviously it's personal choice, but if you're doing it to just save a few bucks, for example, I don't know. I'm not a doctor, I'm not giving medical advice, but just take it for what it is and look at the whole picture. Right. And and the side effects, sometimes they don't go away. You know, thinning hair, a deeper voice, a lot of women probably don't want that. All

4 basics for building muscle in menopause

Philip Pape 17:02

right. So what do you actually do? So this is the deceptively simple part, the boring basics. I'm gonna keep it to four things. Okay. Number one, of course, lift weights with progressive overload at least two to three days a week, mostly compound lifts. We know that in adults over 50, across dozens of studies, resistance training added about two and a half pounds of lean mass over a few months of training without any prescription or the need for testosterone or anything else, plus a heck of a lot more strength. Really, we care a lot about strength. Strength and muscle are highly correlated anyway. So that is in the same neighborhood as the four pounds from testosterone that are way above what you should have anyway. And we're talking about women, okay? Training gives you strength, bone, function that are other benefits that you're not going to get from testosterone anyway. Now, look, I'm not discouraging you from considering or taking testosterone replacement if that's something you need. Again, I'm not a doctor, I'm not a medical doctor. I'm just saying here's what you can get by focusing on the basics. All right. Older lifters, of course, will gain a little bit less, you know, strength and muscle than younger ones. Now, in relative terms, at any age, you can gain the same rate of muscle. So don't take that, don't misconstrue my statement. I'm mainly talking about like what the studies show in terms of strength. A lot of it has to do with their ability to push hard, the amount of muscle you start with, uh tendons, connective tissue, et cetera, et cetera, right? So your muscle is still going to respond. To the day you die, you can build new muscle. And that doesn't change at menopause. You just have to be consistent. Okay. It's less exciting, but it works. It works tremendously. That's number one. Number two, eat enough protein. Again, the boring basics, guys. I've talked about the 0.7 grams per pound of body weight for quite a few years now. Spread across your meals however it works for you. And we're actually doing a whole episode on how much protein you need this Thursday. And you're like, haven't you talked that to death? Well, there's actually new research, and experts still don't agree on all this stuff. So, teaser, check out the next episode. Hit follow right now to make sure you get that. Number three, if you're on hormone therapy, HRT, you just have to have realistic expectations when it comes to muscle mass. So when we look at trials that are pooled together, again, meta-analysis, estrogen therapy on its own doesn't seem to meaningfully change muscle mass or strength. It can help with a ton of other things, hot flashes, sleep, as we talked about in episode 511, maybe your belly fat. There was a Danish trial, it was a small trial, but it found that women within five years of menopause built more muscle from lifting on an estrogen patch than on a placebo. So I'll give you that. That's one study of 30 women. So now I always wonder, again, what other factors occur that are confounding factors, right? If someone's feeling better, do they train more, et cetera? Do they eat better, et cetera? So, regardless of the way you looked at it, the lifting is doing most of the work here, whether you're on hormones or not. Number four, if you have low sex drive, low sexual desire, and it's bothering you and it's distressing you, and you want to try testosterone, there is a right way to do it. And there are guidelines on this stuff. So if you want to talk to your doctor, what I suggest is to ask them whether you meet the criteria for low sexual desire after other causes are ruled out, like your relationship, your sleep, your medications, vaginal dryness, right? And there's, in other words, there's a lot of reasons for low sexual desire that aren't related to hormones, as we might guess. And then you can ask for a cream or a gel through the skin at about a tenth of a man's dose. I would, again, advise against pellets or ingestion injections. By the way, again, none of this is medical advice. This is just my thoughts if I were doing this, or a woman that I knew asked for, you know, tips on what to talk to their doctor about. You can ask for a blood test before you start, and then again a few weeks in, because that way you can make sure the levels are within the range, the safe range. And then agree on a rule of like when are you going to stop? If it hasn't helped you by, say, six months, you stop. If you go to a clinic and they're super aggressive, they're all about sales, they they want to give you pellets, they promise all these, you know, muscle, fat loss, brain fog relief, or they want to give you jacked up levels. I would see those as red flags. I'd look for a different clinic. Okay.

Tracking how you feel to use in your training

Philip Pape 21:21

Now, having said all that, the boring stuff, a lot of you need help on like what to do. And you know what people are really into right now is my app, Fitness Lab, in some surprising ways, because it is an AI coaching app, but it's completely trained on my philosophy, on the evidence. It is not Chat GBT. It is a very narrowly focused app on exactly the stuff we talk about on the show, primarily for older adults over their in their 40s, 50s, and beyond. It can build your strength sessions for you or help you with a program you're already following. It can give you advice based on whether you are progressing, how hard your lifts feel. Of how you're recovering based on all of your data. Every evening it asks you to do a quick little check-in to rate things like your sleep, your energy, your stress, recovery, and even if you are opt into it, your libido, your sex drive, which ties into this episode. So if you and your doctor ever decide to try something like testosterone, the cool about thing about Fitness Lab is you're gonna have weeks of data and a way to analyze everything and compare it to all this stuff we talked about. Is it actually helping you? One of our members who uses or users of Fitness Lab, you know, I asked him, How are you building muscle? And he's like, Well, let me ask Philip AI, that's what he calls it, let me ask him to give me a report of how things have changed, my lifts and my measurements over the past few months. And he was able to, you know, the chat in the app was able to take all his data and spit out a quick little report said, Hey, look, here's what's happened to your waist, your biceps, your lifts, and your body weight. And we can go from there and say, have you actually made progress? Anyway, really cool. I'm kind of getting off on a tangent. Go to wit'sways.com slash app to learn about the Fitness Lab app, but don't purchase through that link. I want you to use the link in the show notes to get 20% off. This is exclusive to podcast listeners. You don't have to wait for the next sale or promotion. All right. If you're looking for a coach in your pocket for your training, for your eating, for your stress, for your sleep, for all of it, check out Fitness Lab, go to winsawaites.com slash app and use the link in the show notes for 20% off. All right, so let's wrap up this episode on testosterone with some quick caveats. Just so you know what I'm what I'm not saying here, because nuance gets lost with hormones really quickly. I'm not saying testosterone is useless for women. I think hopefully you've got the message by now that you can have that conversation with your doctor, especially if you have low sex drive. That's the main thing that it works for. And it's totally reasonable to try it the right way if you need it, of course, like with any hormone therapy. I also think the science is out on a lot of this stuff, right? Some clinicians honestly believe that testosterone helps women with energy, with motivation, things like that, based on what they see in their patients. And there's a lot of anecdotal stories by women who take testosterone that things have improved. And the FDA is pushing for better trials, whatever you think of the FDA. And so if better evidence comes in, I'll be, I'll gladly share it on this episode. And of course, surprise, surprise, there's almost no trial data in perimenopausal women at all. So if people are like, this is exactly what's gonna happen for perimenopausal women, it's a very specious argument based on limited evidence. So right now, the evidence for testosterone building muscle in women is just doesn't look like it's supported, other than super, super, super high levels. And I would rather you just lift weights. Lift weights, each of protein, do the boring basics. Use my lab, use my app fitness lab if it's helpful if you want. Reach out, go to witsuweights.com slash question anytime. If you want to ask me something personally, I will respond to you every time.

Bonus: creatine and lean mass after 50

Philip Pape 25:01

And there we go. Now, before we wrap up, I did promise you a supplement that added three pounds of lean mass in older adults who lift. Interesting. Interesting. But again, if if you have a question about hormones, training, anything you're stuck on, you can always send it to me at witts and weights.com slash question. And next Monday's episode is actually built entirely from questions. It's a listener QA, including one about gaining weight on hormone therapy. So I'm trying to answer the things that you guys ask. Now, if you're over 50 and you lift weights, even if you're over 40, actually any age, but this is what the study showed. Guess what? Creatine, of course, good old creatine, is one of the few supplements shown to add muscle on top of your training. I know you've heard a lot about creatine on plenty of podcasts. You've been told to take it. I've suggested it all the time. But I wanted to point out a study to you, okay? Researchers pulled together 22 trials in adults with average age from the late 50s to the 70s who lifted two or three days a week. People who added creatine, so they had a control group without creatine and a group with the people with creatine gained three more pounds of lean mass than the people who did the same lifting with a placebo. And they got a little stronger on the chest press and leg press. Now, if it was just the lean mass, I'd be a little skeptical because we know that creatine draws in more water, excuse me, and water is part of your lean mass, and maybe that's that accounts for it. You know, you gain a pound or two of weight on the scale, but they actually got stronger as well. And they took the normal dose, three to five grams a day, which is always what I recommend. Creatine monohydrate, daily, any meal, anytime, doesn't matter. Keep lifting your weights. Like I said, some of that early gain in is is water in the muscle, but you want to judge it based on your strength. So if you see that it really boosts your ability to get a few more reps and get stronger, that's what we're going for. All right, until next time, keep using your wits, lifting those weights. And remember that testosterone for women is proven to help one thing: low sexual desire after menopause. If you want to get strong and build muscle, you just gotta lift weights and eat enough protein, get your sleep, get recovered. That's still gonna do way, way more than any dose of testosterone that a woman really should be on. I'm Philip Pape, and I'll talk to you next time here on the Wits & Weights Podcast.