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[rosie17]

I have a question about testosterone and hope someone here can explain it to me:

I've read many, many times, including here on this forum, that a woman produces more testosterone than estrogen during their reproductive years. If this is true, why is estrogen (and progesterone, if needed) the main focus of HRT? And why does estrogen have to be at optimal levels before adding testosterone?

In two of Dr. Vliet's books (Screaming to be Heard and The Savvy Woman's Guide to Testosterone), she states that estrogen levels need to be optimal before considering testosterone. However, she seems to contradict herself in the 2nd book mentioned above when describing a case study:

“Both her estradiol and testosterone levels were quite low, so I wasn't surprised that she felt so miserable, or that she had so many problems with her sexual response. I started her on a compounded bioidentical micronized testosterone 1 mg tablet every morning. Since she still had her uterus and would need progesterone as well as estrogen, I suggested using Nuvaring, a vaginal ring combination of ethinyl estradiol and progestin,……”

It seems she started testosterone, estrogen and progesterone at the same time, but later in the book she again states that estrogen levels need to be optimal before adding testosterone.

Below is a brochure from Dr. Vliet's practice:

http://www.herplace.com/pdf/testosterone-brochure.pdf

Under “Cautions” it states “Women should not take testosterone without estrogen.” Nothing about raising estrogen to adequate levels before adding testosterone. Has she changed her mind since she wrote her books? Is there new scientific evidence that contradicts this recommendation? Very confusing if you ask me.

The following brochure, though very positive, is equally confusing (to me at least). Under “Myth #2” this brochure states that estrogen and testosterone are BOTH crucial for normal sexual function; however, then goes on to say that it is recommended to reach adequate estrogen levels BEFORE adding testosterone – it says “recommended” and not “imperative.” My question is why? (I'm a ‘why' kind of person)

https://menopausedoctor.co.uk/wp-content/uploads/2017/06/testosterone-ten-tips.pdf

I have to admit I have quite a bit of brain fog since menopause knocked me to my knees, and I may have missed something in all my research. Can anyone clarify this for me?

[Hurdity]

I do have a copy of Vliet's first book but not the second.

It is important to understand the role of the main two sex hormones.  I haven't time to look it all up right now - but basically  oestrogen is the main hormone which makes us female and testosterone is the main hormone which makes men male. It is not the absolute amounts which are important to our gender and sexuality, but the relative amounts - so - we have more testosterone than we have oestrogen (maybe 3 x ?), but we have 1/10 ( approx?) the amount that men have. They will have therefore approx 10 x the amount of testosterone that we have and presumably a fraction of the oestrogen.

In women particularly who are replacing hormones - it is the balance between oestrogen and testosterone which is crucial as well as (?rather than) the absolute amounts. Testosterone declines from around age 30 (maybe a bit out there?), and continues to decline throughout life, but not particularly quickly at menopause (except in surgical meno) - after menopause some is produced by ovaries still and also adrenals. At menopause oestrogen production declines very dramatically so women become relatively richer in testosterone ie more testosterone domninant  - women change in fat distribution after menopause towards more male shape, also more hairs on face, and slightly deeper voices - in effect losing some of our natural oestrogen-like female-ness. We don't turn into men obvs but our oestrogen has taken a dive. Even so testosterone is also decreasing so for many women replacing both is necessary.

I think some gynaes suggest replacing oestrogen first because a high(er) dose may be sufficient to improve symptoms so think it best to get settled on that before introducing testosterone.

Sorry I can't comment on Vliet's views but also to say that one reason for confusion is that there is just so little research on testosterone in women and especially testosterone replacement long term ( and with different oestrogen regimes) - because there have only been two licensed products - pellets ( maybe they are still produced?) and patches (which were withdrawn) and there were no long term data on these anyway (possibly 3 years was the most?).

Hopefully this doesn't add to your cofusion because I just typed it as it came to me!!!

Hurdity x

[rosie17]

Thanks for the reply, Hurdity. It seems to me that the consensus is that if we can muddle along with estrogen, we may not need testosterone? Don't we have testosterone receptors throughout the body? And doesn't testosterone help reduce our chances of getting heart disease, breast cancer, osteoporosis and dementia, among other things? Our bodies wouldn't produce it if we didn't need it.

All I know for sure is that I started testosterone along with estrogen and progesterone about a month ago and the symptoms I've had for nearly 20 years are getting better, especially the monthly 'cycle' I get even though I'm almost 10 years into menopause. I've never had results like this when I used estrogen and progesterone only. Not even close! I guess I'll stick with what I'm doing and keep a close eye on my blood levels and symptoms. There definitely need to be more studies - I just get the feeling that science/medicine aren't interested.

Thanks again!

[Hurdity]

There just isn't enough research as I said - I don't think we know what the long term health consequences are of testosterone decline in women - but it declines gradually. There are metabolic effects (of T) I gather and effects on our lipid profile/cholesterol?  If there was enough research it could turn out that all HRT should contain a small component of testosterone?  As it (T) is still produced throughout life (as is oestrogen) - some women will continue to produce more than others so presumably may not experience negative symptoms of testosterone deficiency. However as oestrogen is the hormone that makes us female and declines dramatically at menopause - if you are going to replace a hormone then it is important to replace this one at least, whether or not you replace testosterone.

Sounds like it is the missing link for you - as it was for me too! I agree that there seems to be a lack of interest and knowledge...

Hurdity x