A Medical Perspective: Talking testosterone and what it's got to do with women’s health, with Dr. Gidon

Gidon Lieberman is our Chief Medical Officer. He’s a leading consultant gynaecologist and fertility specialist with over 25 years of experience. He’s accredited for laparoscopic and hysteroscopic surgery, gynaecological ultrasound and management of the menopause. He’s especially interested in helping patients combat infertility – and is very well known for his excellent analogies (see below for more).

A lot of people will link the word testosterone to something that involves their muscles, like body building or strength. Or they may think of testosterone as a hormonal imbalance that’s sometimes seen in conditions like polycystic ovary syndrome (PCOS) – with symptoms including irregular periods, weight gain, acne and excess hair. Most people will see testosterone as a ‘male hormone’, but *spoiler alert* we’re about to tell you that that’s not completely true.

Testosterone is made in everyone

And in people who are assigned female at birth, testosterone has an important role to play in making other hormones including oestrogen. It also has a direct impact on wellbeing, body shape and sex drive.

Testosterone is made in both the adrenal glands (which are near your kidneys) and in the ovaries – about half and half in each. After the menopause, testosterone is still made in the ovaries, but the levels will decrease.

In people who are assigned female at birth, most of the testosterone is picked up by a hormone called the sex hormone binding globulin (SHGB). Think of the testosterone being people waiting for a bus, and the SHBG being a bus picking them up. Most of the testosterone is bound to the SHBG – in other words, most of the people are picked up by the bus. The rest of the testosterone will be free to move about the body, like people walking.

Testing for testosterone

Only unbound, or free, testosterone is biologically active – the testosterone that hasn’t been picked up by the SHBG. When you have a blood test for testosterone, it’s important to think about only the free amount of testosterone, rather than the total amount.

People with PCOS often have an increased amount of free testosterone which causes symptoms that you may know about like weight gain and skin problems.  

The combined oral contraceptive will increase SHBG levels, so the free testosterone is decreased. To continue our bus analogy, there are more buses, so more testosterone gets picked up and so there is less free testosterone able to walk about and cause these symptoms.

At menopausal age, we see the levels of testosterone fall (there are too many buses but not enough people walking). While some people won’t notice lower testosterone levels, others will have more obvious symptoms. In my experience those who are most affected by symptoms are people who have gone through an early menopause or a surgically/medically induced menopause.

Testosterone replacement and why it’s sometimes necessary for menopause symptoms

The clearest reason for testosterone replacement is loss of libido, and for some people testosterone replacement for a loss of libido is a ‘total game changer’. Others don’t really notice a difference! It really depends on the individual.  

If a loss in libido is because of decreased testosterone, then replacing the testosterone that’s been lost should help. If decreased sex drive is because of relationship issues or other medical problems, then prescribing testosterone will make no difference.

Testosterone is also prescribed for other reasons and in some of these cases it’s less clear why it makes a difference – but it does! Reasons it may be prescribed include loss of enjoyment in life (called anhedonia), concentration loss and a decrease in focus on everyday tasks.  

These symptoms also cross over with oestrogen deficiency. Lots of menopausal people find they have ongoing concentration issues or ‘brain fog’, even after oestrogen replacement. In these cases, testosterone replacement can be worth considering.

How testosterone replacement works in the UK

Years ago we used to give testosterone as an implant under the skin every six months which was great if it worked, but not so great if didn’t because the implant was very difficult to remove.  

It also left a scar behind, on the tummy area or the bum which lots of people unsurprisingly didn’t like. We now have some gel products that are much nicer and thankfully easy to source.  

In the UK, testosterone is licensed to treat conditions in men, but it isn’t licensed to treat menopause symptoms. That means it’s called an ‘off-label’ medicine for menopause. Some medicines can be, and are, prescribed to be used ‘off-label’ in a different way from the way they are licensed to be given.  

Having said this, we’ve been using testosterone to treat menopause symptoms for a very long time and this has been safe. Testosterone is licensed for this use in other countries, and hopefully this will be the case in the UK in the not-so-distant future.  

One of the reasons that GPs don’t like to prescribe testosterone is because there is no licence for its prescription in women, so each prescription is outside of current regulations. This is mainly to do with the lack of clinical trials. I hope that with time, confidence in prescribing testosterone will increase and it’ll become more available.

Prescribing testosterone and the future

I tend to prescribe Tostran, Androfemme, or Testogel depending on availability and patient choice. They are all equally effective.  

I totally understand the concerns about taking testosterone and possible side effects. As long as the medication is used within the recommended doses then it’s very uncommon to get problems. We recommend putting the testosterone onto skin that doesn’t have dark hair. Some side effects include loss of head hair, skin problems and very rarely voice changes.  

Blood tests for testosterone (both total and free levels) should be checked before starting treatment and again after 3 months. At the moment it can be difficult for GPs to prescribe testosterone because of the licensing regulations, and I totally understand they are reticent to prescribe. However, the tide is changing with prescribing, and I hope that testosterone replacement therapy will become more easily available.