TESTOSTERONE & ITS ROLE IN MENOPAUSE

introducing claire stuart to our monthly menopause cafe over to you claire thanks benny so hello everyone uh welcome again um so when i did the last meeting a couple of months ago we had a little chat at the end about what people would want to talk about and certainly this is a big uh topic we're getting lots of referrals from gps into my clinic at the minute about testosterone because i know there's lots of social media out there all the celebrities seem to go on testosterone as part of their hrt from their private practices so i think it's really good chance just to run through what it is why we need it and and really is it something that we do need because um it's kind of tilted a little bit as the wonder drug and um it's not necessarily uh quite that exciting i'm afraid um right let's see if i can get this working oh there we go um so what is testosterone i'm gonna just go back a little bit very very uh basic summary of it all but it's a sex hormone made by both women and men um young women actually produce three to four times the amount of testosterone in our bodies compared to our estrogen and half comes from the ovaries and the rest from the adrenal glands but the majority of the testosterone we make actually gets converted into estrogen um and therefore we get the benefit of the estrogen not so much the actual testosterone as uh directly as the test as the ovarian function though starts to fail so as you go into perimenopause the hormone levels start to fluctuate they start to decline and testosterone also drops the same as our estrogen and progesterone so little graph just to give you a little idea um of what we look like so we make obviously more estrogen than anything else progesterone is nearly up there similar and as you can see kind of mid to uh mid 30s 40s we start to get that decline down to around the time of menopause around the age of 50 51 and testosterone starts off at a lower point but declines far less so overall by the time we're through menopause we often have slightly more testosterone than we do estrogen and progesterone and we will convert some of that still to estrogen um but the impact of that level dropping as well as the stream levels dropping is what why we get menopause symptoms that can be related as well to lower testosterone levels and when we think of testosterone the big thing people think about is sex and libido but actually testosterone has quite a role in some of our just general well-being as well um so it can affect your moods and changes in your mood cognition and some of that get up and go can be related to your testosterone some of the strength in your muscles and bones and but the majority of it is around libido sexual arousal ability to orgasm um but again part of this role is because of how it changes estrogen and how the lachine estrogen levels change some of the tissues and how the sensitive they are in response um to stimulation um so why don't we just give it as part of routine hrt if the levels decline and it's so important well purely because most of our testosterone is converted to estrogen so the key is to replace estrogen well and if you replace the eastern levels well for a lot of women that will resolve their symptoms um including libido and and testosterone in itself extra is not necessary um and as you saw from the graph the post post-menopausal lovers continue to produce slightly more testosterone than estrogen um and that's why older women sometimes can end up with some masculinizing features so the additional um coarse hair growth for example the deeper voices and that is because testosterone is the dominant hormone in post-menopause but we do know some women will benefit and how do we know um so anyone who's gone to see their gp in uh practice unless they're a confident menopause gp and there are there are them out there um and they're very happy and confident with uh all areas of management of menopause and often you get referred into secondary care and we talk about symptoms blood tests and then we look at um hrt already so obviously the symptoms we highlighted on one of the previous slides we do some bloods so for blood levels um the basics are the testosterone and free androgen index that tells us how much free floating testosterone there is around in your body that's not already been converted and a normal level for a woman is between one and five percent and post-menopause it can drop below one percent um and that's where you're more likely to benefit from testosterone replacement so it doesn't actually matter what you overall testosterone levels are they can be a little low um but potentially what you've got then floating around is is used as an androgen in your body and we will normally check estrogen levels as well especially if you're already on hrt because the importance is is your estrogen being properly replaced um so it doesn't matter what type of hrt you're on whether you're on oral transdermal continuous sequential and we can still check at eastern levels now obviously for perimenopausal women on sequential hrt um levels do fluctuate because there's some ovarian activity so reading levels can be a little trickier but that is when it's likely that the the um overall hormone levels are going to be better compared to post menopause but we look for a range um and it is slightly tailored from person to person and preparation and age a little bit but generally we we want to see that the eastern levels are within the kind of age we range would expect for a woman in their 40s um and our younger women are a little bit more likely if you've gone through menopause in your late 30s 40s whether that's naturally or certainly after surgical menopause um then testosterone replacement can be really helpful so if you have had a hysterectomy in your 40s and you have no ovaries there to really say any tiny last little bit of hormones around then you are more likely to replace all your hormones and compared to someone who's gone through a natural menopause late 40s early 50s when your ovaries will release still a little bit of hormones and um and the testosterone levels may actually be quite adequate for the um for giving you uh replacements basically um so let's say as we check each string levels especially if you're already on um hrt we don't see quite so many women on oral hrt anymore gps are getting better at commencing people on transdermal although i know a lot are still getting offered oral um but certainly what i'm seeing in my clinic is a lot of women are very clued up and have done their research and are requesting transdermal which is brilliant um and the only issue with transdermal is absorption is the different preparations people will absorb slightly differently and which is why if you get to certainly a maximum dose of estrogen and your um symptoms are still persistent um it's worth knowing whether or not you've been adequately replaced um if we are looking at a full range of symptoms so obviously with menopause um if anyone's gone through the symptom checkers that there are available on some apps and on the websites there's a really large range of symptoms out there and the majority are due to low estrogen levels so if you have gone on to hrt and a lot of your symptoms have improved but certain ones are persistent so this is where the cognition mood changes libido um anxiety levels um are still a problem despite maybe hot flush is improving sleep's generally better and urinary and vaginal symptoms are improved and then this is where testosterone can have its place um we also look at the from the eurogenital hiv site so that was obviously my last talk and we we went through that in quite a lot of detail um because a um the vulva and vagina are very estrogen sensitive and when the estrogen levels drop um obviously atrophy starts to kick in and it will affect everyone in slightly different levels so some women will be really effective compared to others um but it does affect the um volvo tissue so the fat pad decreases the tissues get quite tough and dry and it can actually affect nerve endings and that ability to get aroused so one of the key parts of um managing with libido is to make sure that the vulva and vagina are very well estrogenized so even if we don't think peop people are telling us that they don't have any particular dryness that's bothering them um i will always recommend that if libido is an issue that um vaginal estrogens are really helpful especially as potentially sex has been put off for a while because you've not found the mood and um the dryness you just might not be that noticeable um but when you come to uh improving libido and and try to have sex then it can be quite painful and then we end up with the situation that there's um some essentially some vaginal tears or um the stretching is not as good and so it's always worth commencing on vaginal estrogen really quite nice and early and the other thing that we always explore is is the low sex drive something that's actually causing a personal concern or is it more that there's pressure or um feeling to need to please a partner and it's quite a tricky and sensitive subject um so we do have psychosexual support within the trust um and gps and i um secondary care we can all refer into the psychosexual team and they've got a very strong interest in um postmenopause and perimenopause changes and actually our physios also um do an awful lot of work especially with anyone who's maybe not been sexually active for a while and having difficulty with vaginismus or pain with sex um because it's all about um looking at it not just from that desire but the ability and why um because the the um the head often has a very uh strong control on vaginal muscles um so you know always worth it we always explore whether or not this is actually a very important part of um ongoing menopause management or not and um you know don't be afraid to talk to us about it um gps sometimes we'll ask um they're a little bit more focused occasionally on the general symptoms of menopause but um yeah we're definitely getting more referrals through because women are coming forward so when do we add testosterone so we add it when we are happy you are adequately estrogenized and the symptoms settle but big things such as libido sexual function are an ongoing concern and certainly with some consideration if that general fatigue up and go is an ongoing issue and the free androgen index is less than one percent um because if you've already got a very good testosterone levels if we add it in it's not going to make much difference and potentially increase the risk of side effects and we make sure the vagina has been given some hrt too like we just mentioned and we do occasionally consider it and it's not um i've never looked after anyone yet but i'm still relatively new to all of this and there is a syndrome where it's just low sexual desire and testosterone levels are low and it generally affects women in perimenopause but they've got no other menopause um symptoms then it can be used as a trial so is there anyone who can't have it well in all honesty the most people can obviously during pregnancy and breastfeeding but unlikely to see anyone in that situation um that's menopausal if there's active liver disease um now uh for women we give it transdermally and we don't have a feminized and testosterone available on the nhs in this country um you can't get it privately it comes from australia and whether anything will change here i don't know so we give the stuff that is designed for men and they do have implants and oral medication as well um but it needs to be transdermal for us so it bypasses the liver so it will be safe for most people even if they've got active liver disease and got to be very careful with anyone with hormone-sensitive breast cancers as we've said testosterone can convert to estrogen and cells um it's potentially okay if you're on um the androgen blocker so letters all and astrozole but there's actually very limited data out there and obviously our competitive athletes know i know a lot of competitive athletes um you know by the time you're getting to mary perry menopause they're probably not competing anymore but we've got to keep within the female physiological range um for them or as it will look as a performance enhancing drug so when we give it like i said it's we don't have andre available on the nhs which is what you'll hear and that's what our celebrities in the social media are generally taking um we give fractions of the dosage we give to men and there are a few ways of giving it thankfully in our trust and we have actually got two or three options available um but these are the two most common uh ways of giving it so there's testim which is a sachet look anyone who's on sandrina it's a bit similar um and you give a tenth of a sachet every day so as you can imagine that's quite fun trying to work out your dosage of that and as long as you make this actually last 10 days you're not going to overdose um and it is just a case of squeezing out a fraction and rubbing it on and usually to your arm and moving the site around so that it doesn't affect hair growth if you use the same site again and again and tostron which is the one i tend to prescribe because personally i think it's a bit easier it's a pump delivered testosterone and um for men they do six pumps a day so but we use one pump two to three times a week and so we tend to start off at two pumps and increase it to three depending on symptoms and and um and blood results so that's what they look like uh so you can see there's your testimony the tostran and the pump and the android's the lovely pink one because it's for women and everything for women's pink um so what do you expect so with the correct dose symptoms should improve within uh three months so we give it as a trial for three to six months and if you don't see an improvement in symptoms then it is not worth it um now we do give it fairly small doses so the side effects are pretty rare um there's a nice list of them as you can see there's lots of them with the big ones being things like increased hair growth which is the hirsutism voice deepening um headaches and alopecia so it's more women will describe that actually their hair doesn't thin that's that's often a side effect of menopause and low eastern levels but potentially things like residual hair lines um to a certain extent or bold patches appearing um and um you know obviously significant far less common ones but um they're very similar to most medications that we give you for anything in terms of blood pressure changes fluid tensions um i mean there's no particular increased risk of blood clots and strokes with the dosage that we use um similar to us using the transdermal hrt and so we check the um free engine index after three months we check that we're replacing correctly that we've got our levels between one and five percent um and if the levels are high it depends a little bit on whether or not you've got any side effects um and how much you're using as to whether or not we do reduce or stop um or just continue as we're going um it can only be initiated with someone with an interest in menopause um in the u in england we're not so bad at cat it's um greyless a drug in scotland um but it can be initiated by anyone really in this country as long as they've got an interest they don't have to be a specialist they just have to be confident um so a lot of gps won't prescribe it because they haven't done the training um we're hoping to set up some women's health hubs in the region with our gps who are interested to help improve primary and care and the prescribing from the primary side um but um you know at the minute anyone who wants testosterone i'm seeing in our area is often getting sent in um to see me um bar a few gps and there's a good leaflet for anyone who's interested on the women's health concern all about testosterone um it's not got lots and lots of stuff in it but it gives you a basic rundown of what we do and what side effects and how to take it and that's it fairly short and sweet for today because it's not a big subject but it's certainly a very um poignant one at the moment and uh i know lots of people are very interested in um testosterone and it's definitely increasing in terms of referrals into my clinic at the minute so i'll open it up to any questions i'll just stop sharing my screen there we go thank you claire i will just stop the recording then we can take some questions one second

Channel: Mersey and West Lancashire NHS Trust

Views: 19,535

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Id: ZEwwVonZK60

Length: 19min 20sec (1160 seconds)

Published: Mon Mar 14 2022