[INTERVIEW]
Ronda Nelson: So your patient comes in, she is tired, she has foggy brain, she’s l- gaining weight, she has low libido, and she’s losing muscle. So she goes to her doctor, and her doctor says, “Oh, I know exactly what to do. I’m gonna order blood labs on you.” And what happens? Those blood labs come back, sure enough, they show low testosterone.
And before you know it, she walks out the door with a prescription. She’s now on testosterone, promised that her libido is gonna come back and she’s gonna feel amazing. But that is not the answer that she needed to hear, nor is it the solution. What she needs is someone like you or me that are willing to ask a different question and tell her the truth about what’s really going on. Let’s talk about it.
Yeah. So I just wanna know, how did testosterone end up becoming the answer for everything in women when it comes to hormones? So many women are now on these compounded hormone creams, and everybody’s including testosterone. And they include it because they’re like, “Oh, it’s gonna take your brain fog away, and it’s gonna help with weight gain and give you more muscle and, you know, better — you’re gonna have way better control over your food, and you’re not gonna be as hungry, and it’s anti-aging.”
If I hear that one more time, I swear. There are so many symptoms that are pinned on this one hormone for women, but all of those symptoms, just like we talked about last week with men, they all can be pinned to a variety of other physiologic signs. I’m not saying that testosterone is not relevant in women. It is, and we need a teeny, tiny, little bit of it. But as I mentioned last week, giving testosterone to a woman would be like giving estradiol to a man. We would never think of it because estradiol is not his dominant hormone. But yet testosterone converts into estradiol just like it does in a woman, and so we give her testosterone, and even though it’s a small dose, we’re still messing with her physiology.
I think that giving a hormone, to think about that it somehow explains away everything that a woman doesn’t like about perimenopause or menopause or stress or aging or whatever it is, or sex life, that is just the wrong approach. It makes me really suspicious of what the ulterior motives are of these drug manufacturers and these, you know, promoters and companies that are doing the low T thing on Instagram, social media, et cetera. It’s like coming back around. It was a thing before, but it kind of got low-key and now it’s sort of starting to come back around.
It’s not that she can’t make testosterone. She brings that testosterone down from androstenedione, and that’s her normal physiology. But it doesn’t stay there. Her priority is to convert that down into estrogens. We don’t want to give her too much testosterone. And, again, like I mentioned last week, FDA has never, ever approved testosterone for women. There is zero clearance to use it for the symptoms that they’re claiming that it solves, like brain fog and weight gain and loss of muscle and all of the things, libido. It’s never been approved for that. Ever, never, never. So it’s completely prescribed to women off-label, even though it’s in a compounded formula of some kind.
And the testosterone patch for women was considered by the FDA in 2004, but it was not confirmed or approved, I mean, because they have inadequate long-term safety data. In 2004 — too bad they don’t apply that now about long-term safety data. Ugh, think COVID. But nonetheless, they disallowed it because they didn’t have enough long-term safety data, but yet somehow this is still being allowed to go on. I think women need to know that there is no testosterone product that has ever been FDA approved for her, and so why would you add it? The marketing makes it sound like it’s, you know, just like the missing female vitality hormone, and it is not. It’s a big, big problem.
So here’s what the evidence says. The strongest evidence shows us that pen- perimenopausal women that have decreased libido or persistent, even, you know, intermittent libido issues, they need to go undergo a full psychosocial assessment, then they can be carefully, carefully — underscore — dosed transdermal, which I don’t love because the transdermal is where we get into the risk with the path of transfer. But nonetheless, and then they say, “You’re gonna monitor it, and then we’re gonna make sure that she doesn’t get too much of it. We’re gonna keep an eye on it.” But we already established that free testosterone is not measured well in blood. So how is it that they’re measuring it?
There are some instances where women might need a little bit, but it’s very, very rare, even more rare than in men. So the long-term safety data is very, very limited. So I don’t like the fact that women are just being given this testosterone willy-nilly. She does not qualify for testosterone therapy just because she has low libido. There’s no reason, so why are we even testing it in women? Why? There’s another underlying issue.
So what could it be? It’s very much similar to men. Could it be that sleep is impacting maybe the way that she’s feeling, her brain fog? Yes. Maybe it’s impacting her libido. And I say libido, too, because there’s the relationship, you know, piece. I mean, you could have a bad relationship and poor libido. Okay, that makes sense the way that women are wired, um, sexually wired, but testosterone is not the answer. What we don’t need to do is make her hypersexual, then we’re gonna get into some other kind of different problems that we don’t wanna have.
Now, if she’s got testosterone, they say, “Oh, well, that will improve, like, you know, vaginal dryness or the other genitourinary symptoms that we see in menopause.” Okay, well, maybe, but I’ve never, ever had a patient come in with those symptoms and not been able to resolve them using other methods. So why are we throwing a monkey wrench into her hormone system? Why are we adding something that we know is gonna disrupt that HP axis for her, the feedback loop? The endogenous testosterone’s gonna get interrupted without looking at the underlying factors.
So maybe it’s iron, iron status. Anemia can be a player here with some of these symptoms that she’s got, that she thinks, or her medical doctor thinks, testosterone’s gonna fix. Could be that she has some depression and anxiety, and they wanna give her a medication. She’s like, “I don’t wanna take an antidepressant.” They say, “Okay, well great. No problem then. Let’s just go ahead and give you some testosterone. That’ll fix everything.” No. We have to say no to this every day. So insulin resistance, metabolic health, sleep, her hormones are a big player here. The thyroid, iron status. There’s so many things that we could be looking at to help try and solve this problem.
She can still have a woman that has completely normal testosterone, can still have no interest in sex. This is not the symptom that we wanna hang the testosterone hat on. I don’t think that’s a fair evaluation or assessment. If she’s not sleeping or if it hurts, that’s one thing, and we can fix that. But just because those things are happening does not mean we need to give the other.
So let’s talk about how this testosterone gets produced. It gets produced — the androgens, which is androstenedione and testosterone, and then subsequently she does even have a little bit of DHT. So they get produced in the ovaries, the adrenals, and then peripheral conversion out in the tissues. So the precursors for her, just like men, are DHEA and DHEAS, and then, of course, androstenedione. So testosterone acts at that same androgen receptor the same as men, and it converts to DHT, the same mechanism, converts to estradiol, same — everything is the same. The physiology is the same across the board. It’s just men retain that testosterone, and we do not. It’s just metabolized differently in either sex.
So in females, we need those precursors the same way that men do, but we need the precursors so that they’ll go drop down into the estradiol side rather than dropping down in the testosterone/DHT side. So I don’t know that testosterone suddenly, like, has a collapse moment. Like, she’s fine, fine, fine, and then she’s not. It’s perfectly normal for androgen levels in women to decline as she ages, throughout adulthood. It just goes down, down, down, down. Most of that decline, interestingly, happens during her reproductive years.
So just because she goes into menopause does not mean that all of a sudden there’s just this one big, you know, cataclysmic, like, fall off the cliff testosterone decline. That’s not how it works. Now, surgical menopause, if she did have surgical menopause — abrupt menopause is different because now we have had abrupt removal of the ovaries, which means we’ve had an abrupt removal of all of those hormones, including testosterone, because it is synthesized in the ovaries. So there may be short-term reason to provide that in the interim until her body adjusts to being in menopause, even though it was surgical. So we want to make sure that we’re considering all of this. Just because she’s going through menopause does not mean that her testosterone just all of a sudden took a big dig.
The pattern is a lot more complicated than that. So her age and her adrenals and her ovarian capacity — like how healthy are those ovaries? What is her metabolic health? Again, binding proteins, same as with men. How well is the tissue converting? What kind of nutrients are missing that would enhance that local tissue conversion? And then, of course, her surgical history, as we just talked about. I think it’s a lot more simple. I think that we don’t need the testosterone in order to make her work well.
So we want to ask, like, what’s happening upstream? Well, number one, her upstream hormone is going to be DHEA. So how do we make sure her DHEA is working well and she’s got enough? So the hormones that produce in the peripheral tissues — DHEA, a lot of it is made in the adrenal glands. So by the time she reaches the age where maybe testosterone is assumed to be needed, is it plausible or even likely that she has had some stress in her life? I mean, these women do not go through life and not have stress. So it’s probably likely that she’s had some stress. And those little adrenal glands — I don’t believe in adrenal fatigue, as it were, like that’s Addison’s. So I don’t think it’s that, but I think that they’ve become pretty dysregulated, that HP signaling to the adrenals has become dysregulated. And when that happens, the DHEA may not get the signal to get produced. I don’t know. I mean, it’s gonna be different in every single woman.
So we know that depending on the tissue-specific enzyme expression, that influences the way that DHEA is produced. So that doesn’t mean, though, that I’m gonna give DHEA. Again, it’s a hormone, and I’m really against this. I am against it. Over the years, my clinical experience — 20 years doing this — my experience is that women’s hormones can balance out just fine. It just gets a little turbulent in the middle sometimes. And sometimes we have to work a little bit harder to bring that nice baseline back. Sometimes we have to just work at it a little bit more. But that does not mean that we need to be reaching for a pill or a hormone in order to bring her to that baseline. You know, perimenopause is kind of a crazy period of time anyway. The time to prepare is beforehand, not after the fact.
So if testosterone is low, so to speak, I’m definitely gonna just look upstream, but I wanna think, “How do I support her? How do I support the normal things that I would do with every single other patient?” — and that is not giving DHEA. So you can ask, like, “What’s happening with her stress? Is there an HPA dysregulation? What about progesterone?” Progesterone’s another upstream hormone with women. But this progesterone is not converted directly into testosterone in every single tissue. The whole process of creating and synthesizing these hormones requires a lot of different enzymes, intermediate hormones. There’s organs, there’s regulatory signals, there’s lots of things happening in the body that causes these hormones to be synthesized.
So if there’s low progesterone and if she’s in her reproductive years, that means we have a luteal phase or a corpus luteal dysfunction, which means that we probably have a follicle dysfunction, and the low progesterone could be part of a bigger picture of what’s dysregulated in her sex hormone cycle.
I have so much training on this inside Clinical Academy. This is my wheelhouse. I love this interplay in these female hormones. I love them. Male hormones, I love it, too. It’s just a lot more boring. Women — up, down, up, down, up, down, different cycles, different phases, different up, down, up, down. The whole thing is so fascinating to me. So I love how these female hormones work. So if you’re not good at it, I’ll teach you how to be good at it, rondanelson.com/clinicalacademy. Go there, sign up, get in, and learn about female hormones. That’s where you’ll learn it, and you’ll know it, and you’ll be really confident.
So if she’s saying that she’s got low T, right, and she’s in her reproductive years, don’t buy it, because that means that there could be a dysregulation in the actual rhythm of her female hormones, which includes estradiol and progesterone. So if she’s not ovulating well, testosterone’s not the answer. It’s to upregulate that whole system so that she can start to ovulate well and then get enough progesterone, which is going to feed downstream into that testosterone.
So now, stress. We talked about stress. We talked about managing stress. We talked about DHEA. We talked about the HPA, about ovarian physiology, like making sure that her ovaries are really, really working. Yes, she could have been put into surgical menopause for some reason, or, you know, maybe she has primary ovarian insufficiency. You know, a lot of these influencers online now are talking about, like, “Oh, you’re in your 30s, you have low libido, you must be in perimenopause. You need hormones.” Ugh. I talked about that a while ago, too. Makes me mad. What is happening? No, you do not have premature ovarian insufficiency. You do not. That has to be diagnosed — ultrasound, like the full deal.
If you are not eating well and you’re picking off your toddler’s plate and your blood sugar’s all screwed up and you’re at the gym every single day of the week, hardcore working out, CrossFit, plus lift, plus, plus, plus, of course you’re gonna have low hormones. You’re gonna have screwed up hormones. You have no body fat to speak of. Your cycle is dysregulated. Your blood sugar’s all screwed up. Of course. So it’s not perimenopause. It’s that you’re not caring for yourself, my dear. That’s the conversation that we have to have with more kindness than that. I’m being saucy with you guys, but you get my point. We have to educate them.
Then don’t forget, like, these women, often they’re undereating. They’re not eating three times a day. They’re going too far, skipping meals. They’re too busy. They’re working out. They’re burning calories, but they’re not taking care of their metabolism. That’s a big one.
And then when you’re evaluating them, very often the medical doctor’s gonna order — and this is insurance regulated, too — they’re just gonna order kind of the baseline tests. I would really encourage you to, like, look at the thyroid, look at liver enzymes, look at sex hormone binding globulin, look at FSH and LH. Ask whether they’re on any kind of hormones already. You know, are they on oral progesterone? Or do they have the estrogen patch? Are they on insulin? What’s happening? What’s their HOMA-IR score, right? That is fasting insulin and fasting glucose calculated. What kind of medications are they on? These are the questions that you have to ask.
And in your mind, what is happening with the signaling? Is there an issue with — are we getting too much DHT? I almost always test DHT in a woman who has supposedly low testosterone, and the reason that I do that is because I wanna see if the testosterone has disappeared down into DHT. If that happens, she very often has hair loss. And it’s female pattern balding, the kind that’s up here on the top of the head, not male pattern here. But it’s a diffuse — it’s usually diffuse up on the top of the head. That’s female pattern balding. So that’s another sign for you that there’s something going on, something’s not right within this ecosystem of the endocrine system, the sex hormone endocrine system.
So if you’re looking at, or a doctor’s looking at, testosterone and there’s, quote, “altered production” or “reduced production,” that just means that there could be so many other things going on. So how do we test? Well, aside from all the tests that I just told you about, I would definitely do a saliva test. I wanna see what is happening in that saliva. What can it give me information about? The free hormones that are happening. Because what if she might be getting a hormone exogenously from her skincare or her body care or something that she’s eating? I mean, our food is full of hormones.
What about, like, the Glade plugins or scented candles? All of those things are estrogen or endocrine disruptors. We call them xenoestrogens. And, uh, cash register receipts are one of the worst places. Tin or lined cans have a lot of, like, the BPAs, BPHs. Maybe that’s what’s messing up her hormones. But we quick go — no one wants to look at any of those things. We just go, “Oh, let’s just give testosterone. It’ll just be fine.” But we have to ask, there’s so many different questions that you wanna ask. And again, I teach all of this in Clinical Academy. If you want the deep dive, you wanna know how to fix it, that’s where you need to go.
So you can order a bunch of different tests. I would stick with the ones that are going to be good on a blood test, like fasting insulin, fasting glucose, et cetera. But for her sex hormones, I really would encourage you to do probably two tests. I like to order from Diagnostechs. I’ve been using that lab for a long, long time. I like their lab. So Diagnostechs, and then I would use the ASI, which is called Adrenal Stress Index. And the second one that I would order would be, um, wherever stage of her hormones she’s in. So if she’s reproductive, then you would use the female hormone panel expanded. And then if she’s in menopause, you just use the expanded menopause panel. They do have a perimenopause panel, but I don’t recommend it because it’s kind of hard to test perimenopause women in general. So just use one of those two depending on what stage of her reproductive life she’s in. But the saliva test is gonna give you a lot of really great information. It’s gonna help you see if there might be excess hormone anywhere or deficiency in hormone that will let you address it and then support that local tissue.
So I’m not gonna use the testosterone level just at its base to diagnose whether she’s low or not. I’m always going to look and turn over the other rocks. So when you use saliva, it’s gonna be very, very, very useful for you. You’re gonna get a lot more information.
All right. So as I said last week when I was talking about men, I have had hundreds and hundreds of women that I get their saliva test back, and testosterone’s off the hook, super high. I’ve also seen it where their estradiol is really high, and if it’s extremely high, I know for a fact — well, I mean, I can’t say a fact. There’s always gonna be, you know, some random one outlier, but the largest majority of the time, it’s because of exogenous exposure. And so what I want to do is rule out all those exogenous exposures. So the first place I’m gonna look if her testosterone is high, is I’m gonna look at her husband. Or I’m gonna look at her work environment. If she works with a bunch of men, and all those men are on testosterone — there’s doorknobs, there’s desks, there’s places where those oils are gonna collect. No matter how clean you are, you know, you hug somebody, “Hey, nice to meet you, nice to see you,” whatever, there’s gonna be exposure.
So I’m gonna be looking at every possible angle to see where that exogenous testosterone might be coming from. So it could be — probably not primary for her, ’cause if she’s not on it yet. Excuse me, too much talking today. Um, but I am gonna be looking at secondary exposure, like from a spouse or a workplace. So it could be even like towels and bedding, clothing. Um, massage therapists are especially at risk, chiropractors even, acupuncturists, people that have a lot of, like, hands to skin time. Sometimes you don’t know if they’re on any kind of a hormone and if it’s coming through the skin. So you have to just know that you have to be aware of that, and that it could be that. I’ve had several massage therapists — when I find out what they do, and then their hormone levels are, like, all screwed up on a female hormone test, I go, “Oh, okay. This is all exposure.” And you can’t massage with gloves on, so then we just have to support the detoxification pathways in the body to help her kind of get that out.
Let me see. What else can I think of? I have a whole bunch of notes here, but I don’t wanna belabor this, ’cause so much of this I covered last week in the show. So make sure that you’re looking, though — ask about other people in her home. So if she is getting it, like, investigate, ask questions about the kids, and then look in women for that hair loss, possibly scalp hair loss. Another sign you can look for in women where they may be getting testosterone exposure, which can drive the free testosterone down because it’s taking up all the sex hormone binding proteins. But ask about — well, listen for, I mean, voice changes. Sometimes you’ll see that, like, their voice will get, um, real low. Um, hypersexual, sometimes that can happen, and even disruptions in their cycle, you know, that can happen too. Ask about kids, like precocious puberty, accelerated growth, premature hair growth, um, armpit hair, pubic hair, et cetera, or behavior changes, that kind of thing.
So when a woman gets testosterone, it changes more than just her testosterone, just like it does in men. It’s going to go downstream. It’s gonna bind to those androgen receptors. It’s gonna convert to DHT — DHT or to estradiol. It’s gonna affect those sebaceous glands, the hair follicles. It could cause hair loss. It’s going to definitely gum up the liver. There’s no way around that, and it can even affect lipid physiology, so you might start to see changes in her cholesterol. Tissue enzymes are altered because the tissue, the gland, is like, “Hmm, I thought we were supposed to be regulating testosterone, but there’s some extra hanging around here, so I guess we’re not gonna do it.” Then that impacts the way that the feedback is to the HP axis.
So, you know, when you add a hormone, it doesn’t stay neatly packaged inside that hormone lane, whether it’s testosterone or estradiol or progesterone. I’m just a big no on all of them. All of these hormones, I’m a big no on. When you add a substrate, it can become a more potent androgen. It can convert into estrogen, and that can mess up — it’s like throwing a stick in the spokes of a wheel. It just causes all kinds of chaos, and women need lower testosterone, so adding even the tiniest little bit can really mess her up.
And then there are people that are using pellets. Pellets are such a huge problem. I almost forgot about this. You put a pellet in, she is screwed for three or four months. There’s no — you can’t reduce the dose. It’s just gonna slowly leak into the system for months, and the secondary effects can happen long after the pellet is either removed or replaced. There’s dosing inconsistency problems with them, product variability, manufacturer variability, and, again, the FDA has never approved any of this. So this is such a racket. I just think it’s such a racket. If she accidentally gets a pellet put in and you can’t just get it out easily, it just doesn’t work. So then she doesn’t feel good, and she has to suffer through those consequences for three or four months until the pellet gets removed.
So currently, testosterone is not supported — none of these hormones, estrogen, progesterone, testosterone, none of them, but we’re talking about testosterone today — none of them are supported for the symptoms that she’s coming in for. The evidence shows that it supports a limited — underscore, underscore, underscore — sexual-related dysfunction, but it does not establish benefits for broad use for cognition, mood, memory, body composition, weight, or general health. It’s just not there.
So just like with these men, it’s the same thing. You have to first define what is her complaint and then trace it back. Trace it back. What could this be related to? Could it be related to insulin or metabolic health? Could it be related to the adrenals? Could it be related to sleep? Could it be related to diet? Maybe it’s where she’s living. It’s possible — what if it’s mold? What if it’s some kind of a stealth pathogen? What if it’s an allergy that’s causing inflammation? What if it’s gut dysbiosis and she’s recycling her hormones through that enterohepatic recycling system that we so conveniently have? What if that’s what’s going on? You just have to investigate.
If she’s in her reproductive years, look at her whole cycle. Don’t negate that. You’ve got to test the full 11 sample test from Diagnostechs that gives you the graph of what’s happening at those free hormones at every phase throughout the cycle. And then DHEA, be sure that you test that, although the saliva tests all have DHEA on them. Look at her iron status, look at her thyroid, look at glucose, fasting insulin, her liver, her sex hormone binding globulin. And then you’re gonna wanna investigate her environment. What’s her sleep like? Is she overtraining? Is she undereating? What’s her relationship like? What’s her stress like? Is she in chronic pain? Is she on opioids or other pain medications? Was her partner using hormones? Um, was she on hormones at one time and now she’s off? Was she on birth control and now she’s off? Does she have an IUD? These are all things that can influence this.
And then you wanna look at precursors, certainly. You know, is there evidence — are her ovaries working? Are her adrenals working? Those are gonna — you’re gonna find those when you do the saliva testing. And then you ultimately get to decide, do you think that this is a testosterone — does she really truly need it? I would argue no. I would argue no. It’s just such a huge no for me.
There are ways that you can support the underlying issue. It’s not about testosterone. Her lack of libido is not a testosterone deficiency. I’m telling you, it’s not. It’s related to something else in the body that’s awry. Her body did not wake up one morning and just go, “Gosh, I think I’m just gonna screw things up today, and we’re gonna make this body fat, unhealthy, unwell, inflamed, tired, and with poor body image and emotional psychological anxiety problems. I think that’s a great time. Let’s just do that.” It’s never going to do that. It doesn’t want to be out of sync, doesn’t wanna be out of a state of homeostasis. So what do we need to do to bring the body back to that state? Exogenous hormones are not the way we do that.
I’m sorry. I know this is not a popular opinion. I always say, “I am not very fun at parties.” I am not fun, because I will tell the truth, what I believe to be the truth. And listen, if you are listening and you are a hormone lover — good, good on you, friend. You do you. You stay in your lane. But don’t come at me sideways with hate, hate comments, and all the things, because last I checked, it’s a free country. Last I checked, everybody gets to have an opinion, and this is mine. And this is my clinical opinion based on my own clinical experience, and if you’ve had a different clinical experience, I’m so happy for you. You keep doing what you’re doing if that’s your clinical experience, ’cause we can each have a different experience. We each have a different experience of all kinds of things every single day.
I just wanna advocate for the women who may not know, and I say, how about we give all these other things a try? You are never, ever gonna be wrong to support her stress handling system. Never, ever. You’re never, ever going to miss it if you get her metabolic health straightened out. You’re never, ever going to be wrong when you’re working on gut dysbiosis or reducing inflammation or her thyroid or restoring iron. Or even making sure that her hormones are good. Like, we could use things like Black Cohosh. We can use things like flaxseed. We can use — make sure the liver is working. You’re never wrong. All of those things are fine.
So I don’t know. Before you decide that she needs testosterone, maybe do the due diligence and let’s look at some of the underlying issues. That’s all I’m saying. That’s all I’m saying. So there you go. That’s it. I definitely need to take a chill pill after these past two weeks, ’cause this one always gets me pretty fired up. You can tell I’m very passionate about this.
[CLOSING]
Ronda Nelson: So if you, like me, love to know the physiology, you wanna know how things work, but you also don’t quite know what to do with what you know in order to translate that into what to do with a patient, that’s why I created Clinical Academy. So go to rondanelson.com/clinicalacademy. You will not regret it. I am telling you, it keeps you from chasing symptoms. It keeps you from giving wrong protocols. I’ll teach you exactly what’s going on, how to fix it, and what that looks like with your patient. I’ll give you lots of options, how to test all the things. Lots of cheat notes, cliff notes, guides, resources. I got it all for you.
So go join me, rondanelson.com/clinicalacademy. We have two live calls a month. They’re fun. You’ll love them. Can’t wait to see you there. All right, friends, take care. I’ll see you next week.
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