Ten Common Myths About Testosterone Treatment For Women

There’s a growing interest in testosterone hormone replacement for treating symptoms related to aging. You’ve probably seen advertisements of virile, muscle bound men in their 60’s and 70’s. Along with the growing interest there’s also a growing amount of information. But much of it is anecdotal stories, misleading data and flat out, unproven myths. Especially as it relates to testosterone replacement therapy for women.

The fact is that medically administered, testosterone therapy is also used to successfully treat symptoms of hormone deficiency in pre and postmenopausal women. And two physicians—Dr. Rebecca Glaser and Dr. Constantine Dimitrakakis—are dispelling the misinformation about it through scientific research.

Dr. Glaser and Dr. Dimitrakakis focus on subcutaneously implanted, bio-identical hormones (human identical molecule) and not oral, synthetic androgens or anabolic steroids.

With that in mind, here are the 10 myths of testosterone replacement therapy for women.

Myth #1: Testosterone is a “male” hormone

Although men have a higher circulating level of testosterone than women, from a biological perspective, men and women are genetically similar. Both sexes include functional estrogen and androgen (testosterone) receptors. And while estrogen is popularly considered the primary female hormone, throughout a woman’s lifespan, testosterone is actually the most abundant, biologically active hormone with significantly higher levels than estradiol. And as early as 1937, testosterone therapy was reported to effectively treat symptoms of the menopause.

Myth #2: Testosterone’s only role in women is sex drive and libido

There’s a lot of hype about testosterone’s role in sexual function. But in reality, it’s a fraction of the overall physiologic effect testosterone plays in women. That’s because testosterone governs the health of almost all tissues including the breast, heart, blood vessels, gastrointestinal tract, lung, brain, spinal cord, peripheral nerves, bladder, uterus, ovaries, endocrine glands, vaginal tissue, skin, bone, bone marrow, synovium, muscle and adipose tissue.

The function of these tissues declines as testosterone declines. The result of this deficiency in both men and women includes dysphoric mood (anxiety, irritability, depression), lack of well-being, physical fatigue, bone loss, muscle loss, changes in cognition, memory loss, insomnia, hot flashes, rheumatoid complaints, pain, breast pain, urinary complaints, incontinence as well as sexual dysfunction. And just like for men, these symptoms are successfully treated in women through testosterone therapy.

Myth #3: Testosterone masculinizes females

Testosterone therapy has been safely and successfully administered in women for over 76 years. Rather than decrease a woman’s femininity it increases it. Testosterone stimulates ovulation, increases fertility and safely treats the nausea of early pregnancy without adverse effects.

Sure, large doses of supra-pharmacological synthetic testosterone are used to treat female to male transgender patients to increase male traits like body hair. But this requires high doses over an extended period of time. Even then, true masculinization is still not possible. And these effects are reversible by simply lowering the dosage.

Myth #4: Testosterone causes hoarseness and voice changes

Hoarseness is most commonly caused by inflammation due to allergies, infectious or chemical laryngitis, reflux esophagitis, voice over-use, mucosal tears, medications and vocal cord polyps. Testosterone possesses anti-inflammatory properties. There is no evidence that testosterone causes hoarseness and there is no physiological mechanism that allows testosterone to do so.

Although a few anecdotal case reports and small questionnaire studies have reported an association between 400 and 800 mg/d of danazol and self-reported, subjective voice ‘changes’ an objective study demonstrated the opposite.

Twenty-four patients received 600 mg of danazol (synthetic testosterone) therapy daily and were studied for 3 and 6 months. There were no vocal changes that could be attributed to the androgenic properties of danazol. These conclusions are consistent with a one year study examining voice changes on pharmaco-logic doses of subcutaneous testosterone implant therapy in women by Glaser and Dimitrakakis.

Myth #5: Testosterone causes hair loss

Hair loss is a complicated, genetically determined process and there is no evidence that either testosterone or testosterone therapy cause it. In fact, from a medical perspective, dihy-drotestosterone (DHT), not testosterone, is considered the active androgen in male pattern balding.

There are many factors associated with hair loss. For example, it’s common in both women and men with insulin resistance. Insulin resistance increases 5-alpha reductase, which increases conversion of testosterone to dihy-drotestosterone in the hair follicle.

In addition, obesity, age, alcohol, medications and sedentary lifestyle increase aromatase activity, which lowers testosterone and raises estradiol. Increased DHT, lowered testosterone, and elevated estradiol levels can contribute to hair loss in genetically predisposed men and women. But so can medications, stress and nutritional deficiencies. 

In studies conducted by Glaser and Dimitrakakis, two thirds of women treated with subcutaneous testosterone implants have scalp hair re-growth on therapy. Women who did not re-grow hair were more likely to be hypo or hyperthyroid, iron deficient or have elevated body mass index. And none of the 285 patients treated for up to 56 months with subcutaneous T therapy complained of hair loss.

Myth #6: Testosterone has adverse effects on the heart

On the contrary, there is overwhelming biological and clinical evidence that testosterone promotes a healthy heart. Testosterone has a beneficial effect on lean body mass, glucose metabolism and lipid profiles in men and women. It is successfully used to treat and prevent cardiovascular disease and diabetes.

Testosterone also widens blood vessels in both sexes, has immune-modulating properties that inhibit plaque and strengthens the cardiac muscle. It improves functional capacity, insulin resistance and muscle strength in both men and women with congestive heart failure.

Myth #7: Testosterone causes liver damage

High doses of oral, synthetic androgens (e.g., methyl-testosterone) pass through the digestive system, are absorbed into the entero-hepatic circulation and can adversely affect the liver. But subcutaneous implants and topical patches avoid the entero-hepatic circulation and bypass the liver. So there is no adverse effect on the liver, liver enzymes or clotting factors.

Furthermore, non-oral testosterone does not increase the risk of deep venous thrombosis or pulmonary embolism like oral estrogens, androgens and synthetic progestins. And despite the concern over liver toxicities with anabolic steroids and oral synthetic androgens, there are only 3 reports of hepa-tocellular carcinoma in men treated with high doses of oral synthetic methyl testosterone. Even the report of benign tumors (adenomas) with oral androgen therapy is exceedingly rare.

Myth #8: Testosterone causes aggression

Although anabolic steroids can increase aggression and rage, this does not occur with testosterone therapy. Even supra-pharmacologic doses of intramuscular testosterone undecanoate do not increase aggressive behavior. But as stated before, testosterone can aromatize to estradiol. And there is considerable evidence among species, that estrogens, not testosterone, play a major role in aggression and hostility.

However, in studies conducted by Glaser and Dimitrakakis, over 90% of women treated with subcutaneous testosterone therapy have documented decreased aggression, irritability and anxiety. And this is not a new finding. Androgen therapy has been used to treat PMS for over 60 years.

Myth #9: Testosterone may increase the risk of breast cancer

It was recognized as early as 1937 that breast cancer was an estrogen sensitive cancer and that testosterone acted as a counter balance to estrogen. Clinical trials in primates and humans have confirmed that testosterone has a beneficial effect on breast tissue by decreasing breast proliferation and preventing stimulation from estradiol.

However, some epidemiological studies have reported an association between elevated androgens and breast cancer. But these studies suffer from methodological limitations, and more importantly, do not account for associated elevated estradiol levels and increased body mass index. And the cause and effect interpretation of these studies conflicts with the known biological effect of testosterone.  

Although testosterone is breast protective, it can aromatize to estradiol and have a secondary, stimulatory effect on the estrogen receptor. But when testosterone is combined with an aromatase inhibitor in a subcutaneous implant, it blocks testosterone from aromatizing. This form of treatment has been shown to effectively treat androgen deficiency symptoms in breast cancer survivors and is currently being evaluated in a U.S. national cancer study. In addition, Dimitrakakis and Glaser see a reduced incidence of breast cancer in women treated with testosterone or testosterone with anastrozole implants.

Myth #10: the safety of testosterone use in women has not been established

Testosterone implants have been used safely in women since 1938. Any real concerns would be well established by now.

Long-term data exists on the successful and safe use of testosterone in doses of up to 225 mg in up to 40 years of therapy. In addition, long term follow up studies on supra-pharmacologic doses used to ‘female to male’ transgender patients report no increase in mortality, breast cancer, vascular disease or other major health problems.

Many of the side effects and safety concerns attributed to testosterone are from oral formulations, or are secondary to increased aromatase activity due to elevated estradiol. This effect increases with age, obesity, alcohol intake, insulin resistance, breast cancer, medications, drugs, processed diet and sedentary lifestyle. Although often overlooked or not addressed in clinical studies, monitoring aromatase activity and symptoms of elevated estradiol is critical to the safe use of testosterone in both sexes. 

Adequate testosterone is essential for physical, mental and emotional health in both sexes. Abandoning myths, misconceptions and unfounded concerns about testosterone and testosterone therapy in women allows physicians to provide evidence based recommendations and appropriate therapy.