Contrarian Endocrinology Part I: Testosterone for Women

by Karlis Ullis, MD with Josh Shackman, MA

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• Part I: Testosterone for Women
• Part II: Estrogen and Progesterone for Men

In this series of articles, I will attempt to bring clarity to two common myths about endocrinology. The first myth is the notion of the exclusivity of "male" and "female" sex hormones. While it is true that men have higher concentrations of testosterone and lower concentrations of estrogen and progesterone than women, all of these sex hormones play vital roles in both sexes. The second myth I will dispense with is the notion of "good" and "bad" hormones. Some hormones such as DHT and testosterone have been demonized and blamed for all sorts of health problems, but the fact is that every hormone plays a vital balancing role in the body. Rather than be labeled as "good" or "bad", each hormone has an optimal equilibrium level in the body with respect to the other sex hormones. It is when your sex hormones are out of balance—out of their proper ratios then you may manifest health problem, not just because of any one solitary "villain" hormone.

Testosterone is widely known as being the male hormone, yet it has been so villainized by society that even its medical use in men has been made into a social taboo for many years. However, now not only has testosterone replacement therapy became more accepted for use in men, more and more doctors are now also prescribing testosterone for women. In this article I will outline the benefits for testosterone use in women for increasing libido, mood, energy, skin quality, and most importantly to Mesomorphosis readers – body composition.

Testosterone and Female Body Composition

A women in her late twenties, came to see me complaining about her difficulty in losing weight. After taking a medical history , it was very difficult to tell what the basis of her problem was. She was working out daily, with a balance of aerobic exercise and weight training under the guidance of a qualified personal trainer. Her diet was a basic low carbohydrate/ high protein diet. Even more perplexing, she had been taking a caffeine/ephedrine thermogenic stack and had previously experimented with some diet drugs as well. Something was obviously wrong. I did blood tests to check all of her hormone levels. When the results came back, all of her hormones were in the normal range except for, you guessed it, testosterone! She had very low free testosterone level. It was equal to that seen in a postmenopausal women. This was an obvious source of her fat loss problem .

While the role of testosterone in maintaining muscle mass and losing body fat may be obvious to bodybuilders and athletes, it is a basic hormonal fact that is often absent in the medical community. It is known that many women begin to gain fat rapidly about ten to fifteen years before the menopause and also after. The connection between low to absent testosterone production and the deterioration of a healthy body composition is rarely made. Most women are often only given estrogens and progestins as hormone replacement therapy, but not testosterone. I have found in my medical practice that giving women estrogen and progesterone and not testosterone makes it almost impossible for them to lose weight/fat. With the scourge of increasing obesity in the USA, one would expect the medical community to pay closer attention to these issues. Yet the connection between sex hormones, and body composition is highly controversial.

Why is there such a controversy? Why is a hormone commonly used by farmers to fatten up livestock given to postmenopausal women at risk for obesity? Many doctors point to a recent study showing that when postmenopausal women given estrogen actually gained less weight than those not given estrogen (Espeland, et al, 1997). In this study 875 women were either put on .625 mg of oral estrogen a day or a placebo for three years. So does this mean that estrogen is actually a good fat-loss agent? Hardly! In this study, in spite of the publicity it was given, the authors note that when you control for lifestyle factors such as physical activity the effects of estrogen replacement therapy were insignificant.

From my clinical experience I have found that on the average when a young woman goes on birth control pills a 3-5 pound gain in fat mass can be expected, and at menopause with oral estrogens 4-8 pounds of fat mass gain can be anticipated - especially when oral estrogens are used. A recent controlled study showed that oral estrogens caused a gain in fat mass and loss in muscle, with a decrease in IGF-1 levels (O'Sullivan et al, 1998). This study is more consistent with my clinical observations.

So why isn’t testosterone more commonly given for weight loss in women? The medical community actually commonly believes testosterone causes obesity. This is due to a number of studies linking upper body obesity /abdominal obesity in women to elevated testosterone levels. Once again, this is a case of blaming one hormone as a "villain". In these women, they do in fact have higher than normal testosterone levels but their whole hormonal system is out of balance. Not only do they have high testosterone levels, but they also have poor insulin sensitivity as well as high insulin levels. Often these women have a metabolic problem of insulin resistance—which is associated with obesity. There is no serious evidence that testosterone replacement therapy for women will result in greater body fat – in fact the opposite is true.

With the social stigma against testosterone and anabolic steroids in general, and it is difficult enough to get a study approved on testosterone in men. Imagine how difficult it is to get a human use committee to approve a study on testosterone in women! However, there is one study that helped to illuminate the potential for androgens to help women lose fat. Lovejoy et al, in 1996, compared the effects of nandrolone decanoate and the anti-androgen drug spironolactone on body composition in obese, postmenopausal women. The dose given the nandrolone group was low – 30 mg every other week. All women in the study were put on a calorie restricted diet (500 calories below lean mass maintenance), and were told not to change their exercise habits. After nine months, the women receiving nandrolone lost an average of 3.6 percent of their bodyfat while the placebo group lost only 1.8 percent and the spirolactone (an anti-androgen) only .5 percent. Nandrolone doubled the rate of fat loss over the placebo and the anti-androgen group barely lost any fat at all – the role of androgens in fat loss is clearly demonstrated. Even more impressive, the nandrolone group actually gained an average of roughly four pounds of lean mass in spite of the calorie restriction while the placebo and anti-androgen groups lost over two pounds of lean mass. Nandrolone also did not produce insulin resistance as androgens have been previously believed to do.

Lovejoy’s group were impressed by the ability of nandrolone to produce increased muscle mass in spite of overall weight loss. Keep in mind that dose was fairly small and only given every other week, and that these women were put only somewhat extreme calorie restricted diets without being put on a weight training program. Imagine the improvement in body composition had these women been put on a balanced exercise program and were given a high protein diet in addition to their nandrolone!

Despite the positive result, the authors cautioned against using nandrolone decanoate as a weight loss therapy. There was a mild abnormality of blood lipids and a slight increase in abdominal fat in the nandrolone group. While these side effects were minor, I believe that if testosterone was used in this study instead of nandrolone, these effects would be smaller or non-existent. I also think that daily use of a testosterone gel would be more effective than a bi-monthly shot, since the gel would keep testosterone at a more physiological and consistent level whereas injections lead to huge up and down fluctuations.

It is clear to me, both from my clinical practice and from research, that testosterone is vital for women to preserve their lean mass and to prevent obesity. Not only will testosterone help mobilize body fat and negate some of the fat storing effects of estrogen, it is also extremely effective in building lean mass in women - even at small doses. Hormone replacement therapy that only includes estrogen and progesterone but leaves out testosterone is a curse of many a women’s fat loss program. This is not only a concern for postmenopausal women. Young women should think twice about using birth control pills. Birth control pills elevate estrogen and progesterone levels while drastically lowering testosterone levels. This is reason why many women experience large gains in fat as well as a decreased libido when using birth control pills.

Energy, Mood, and Libido

Far from being the cause of irritability and "roid rage" as widely believed, I have found that restoring testosterone levels to normal can tremendously improve energy levels and mood in women. Estrogen is sometimes believed to be energizing, but most women do not feel much of an "energizing effect" from estrogen. Natural progesterone can have a calming, relaxing effect on women, but the nasty synthetic and potent progestins like Provera (medroxyprogesterone acetate) or the more potent, nornorethindrone can actually cause irritability, aggressiveness, and even acne.

Libido is one area of use for testosterone in women that is starting to gain larger acceptability. One pharmaceutical company (Unimed) is close to getting a testosterone gel for women approved for use as a libido enhancing drug. While the thought of horny postmenopausal women may cause you to snicker, I believe that libido is a serious medical issue. The infamous study on sexual dysfunction funded by the Ford Foundation and the U.S. National Institute of Health showed that low interest in sex was the number one cause of sexual dysfunction in women (Laumann, et al, 1999, JAMA , Feb., 10, 199, Vol 281. No 6:pp537-544). Restoring a healthy libido in women can help bring back the spice in marriages, relationships, relieve stress and depression, and even improve body composition through increased sexual interest and activity. Testosterone is the primordial hormone for promoting both a sexy body and a better sex life.

Testosterone and Skin

Do you have dry and thin skin? This may be a sign of lack of oil production from your sebaceous glands. A lack of oil production can be related to a decline in testosterone . Also thinning, atrophy , or inflammation of the the introitus (the vaginal opening) can be from a hormone imbalance. Even painful intercourse can be due to the lack of estrogen and testosterone. I have treated young and older women with testosterone creams to thicken the vaginal entry so that they may be able to enjoy sex without pain. Using small and balanced doses of T gels and creams I have improved the quality of aging skin without the side effects of acne, hair loss or masculinizing effects.

The role of testosterone on skin condition is often ignored, even though this should be of obvious concern to anybody using testosterone to improve overall physical appearance. Normally it is believed that testosterone can only worsen skin by causing breakouts of acne. However, low testosterone levels can only lead to worsening of skin conditions as well. Restoring testosterone to normal levels can make skin look much thicker and smoother than it was before.

Protocols for Female Hormone Replacement Therapy

Many women come to my office complaining of lack of energy, sex drive, and weight gain. They have been to other doctors who have told them that these are inevitable effects of aging and they should just learn to live with them. However, I have found that providing these women with a "hormonal makeover" can have profound effects on their lives. For postmenopausal women, I begin by placing them on "start up" small dose of a testosterone cream or gel (usually at .25 to 1 milligram every other day in the am applied to the neck area behind the jaw for best absorption capacity, or the inner non sun exposed area of the upper arm hangs next to the chest wall). The dose is individualized over time.

Next, I may redo their previous hormone replacement program. If they are currently on Provera, I immediately switch them to natural progesterone which I believe is far safer. Most postmenopausal women are on Premarin, which is an odd blend of estrogens derived form pregnant horse urine (pregnant mare urine). I reduce the dose of estrogen, and change them over to a natural bi-estrogen or a natural transdermal estradiol compounded formula.  This change is significant, as one study showed that Premarin caused an increase in fat mass and loss of muscle in postmenopausal women while transdermal estradiol had no significant effects on body composition (O'Sullivan, 1998). I also encourage women to increase their intake of fiber, and phytoestrogens by taking a black cohosh containing formula and other plants that have estrogen like effects. Soy products are a must.

The goal of this program is to give women back an optimal balance of sex hormones similar to the one they had in their youthful days. Testosterone levels and sometimes progesterone levels can be restored with natural hormone replacement therapy. Balanced and safe estrogen levels can be obtained from a combination of estrogen production from the aromatization of the testosterone they are using , from phytoestrogens such as soy, black cohosh, and a small dose of natural estrogen. Once this natural balance is restored, women can often break the weight loss plateaus they previously reached and can reverse the loss of muscle and bone mass that occurs with age.

For younger women I am more hesitant to give any hormonal therapies, especially if they wish to someday have children. This is not to say that pre-menopausal women cannot benefit from higher testosterone levels. I have been using the prohormone 4-androstenediol (4-adiol) in selected women who are not wanting to have babies. It has a high conversion rate to testosterone and does not directly convert to estrogen. Since 4-adiol is short acting, I believe it can be used safely in women without causing much side effects or shut down pituitary production of the gonadotropins, if used infrequently. The only problem is that most 4-adiol products are made for men with 100 mg capsules, whereas doses for women should be anywhere form 10 to 50 mg. There are now available 12.5 mg lozenges of 4-adiol in the sublingual cyclodextrin form. Women could take 1/4 to 1/3 of a lozenge intermittently to raise their T levels.

Conclusion

While traditional "female" hormones progesterone and estrogen may have a role in preventing heart disease, Alzheimer’s disease, and osteoporosis, I believe testosterone replacement therapy in the near future will have a much larger effect on women’s lives. In fact testosterone replacement therapy may soon become more widely practiced by women than men.

I also believe that testosterone and other androgens may have a critical role treating some types of female obesity - the estrogen dominant type. Precious little research has been done in this controversial area, but it is obvious that a major reason why women have more difficulty losing fat than men is due to their lower levels of testosterone. Since testosterone can not only help mobilize fat but also build muscle, women can attain higher resting metabolic rates. This is in stark comparison to most diet drugs that result in loss of muscle and usually the return of lost body fat once drug use is ceased. While androgens will obviously have some side effects in women, hence the controversy, however these side effects are likely less than the often life threatening effects of Phen-Fen and other diet drugs. Testosterone as a treatment for obesity is probably much safer and actually more effective in the long term than liposuction. I really hope more research is done in this area, as I believe androgens are crucial in the war against the rapidly evolving plague of obesity in this country.

I hope the medical establishment can soon move away from the concept of the ancient and antiquated model of male hormones are for men and female hormones only for women into a universal concept of optimum hormonal balance of all the sex hormones in both sexes. I really hope to see more studies on testosterone replacement therapy as testosterone becomes more accepted. As controversial as this is, the medical establishment is just as rigid in its approach to male hormone replacement therapy. I hope to help change this with my next article, which will deal with the controversial area of progesterone and estrogen replacement therapy for men.

References

Espeland MA, et al. , Effect of postmenopausal hormone therapy on body weight and waist and hip girths., J Clin Endocrinol Metab. 1997 May;82(5):1549-56.

Kaye SA, et al, Associations of body mass and fat distribution with sex hormone concentrations in postmenopausal women., J Epidemiol 1991 Mar;20(1):151-6

Laumann EO, et al, Sexual dysfunction in the United States: prevalence and predictors., JAMA 1999 Feb 10;281(6):537-44

Lovejoy, et al, Exogenous androgens influence body composition and regional body fat distribution in obese postmenopausal women—a clinical research center study, J Clin Endocrinol Metab. 1996 Jun;81(6):2198-203

O'Sullivan AJ, et al.,The route of estrogen replacement therapy confers divergent effects on substrate oxidation and body composition in postmenopausal women. , J Clin Invest. 1998 Sep 1;102(5):1035-40.

Pasquali R, et al., The relative contribution of androgens and insulin in determining abdominal body fat distribution in premenopausal women., J Endocrinol Invest. 1991 Nov;14(10):839-46.

Stoll BA, Perimenopausal weight gain and progression of breast cancer precursors., Cancer Detect Prev 1999;23(1):31-6

Ullis,Karlis and Ptacek, Greg, Age Right, New York: Simon and Schuster,1999

Ullis, Karlis, Ptacek, Greg, and Shackman, Joshua, Super "T", New York: Fireside Books a division of Simon and Schuster. 1999

Yoo KY, et al, Female sex hormones and body mass in adolescent and postmenopausal Korean women., Korean Med Sci 1998 Jun;13(3):241-6