Menopause Hormone Levels: Do Lab Values Inform Therapy?

[Dr. Mark Hoffman]
Do the ovaries still make a physiologic amount of testosterone that's of value after menopause? I know that there was this whole push, I think, like when we were in training, I'm a little bit older than you, but it was, "If you're going to get a hysterectomy, leave the ovaries out." In the last 10 or 15 years or so, I've been like, "Leave them in no matter what, unless there's something wrong with them." Now the pendulum has swung back, saying, "Probably can take them out at 50," or, "If you take them out earlier, you can probably just give them HRT and they're fine."

What do we know about postmenopausal ovaries, what they do, whether it's estrogen, progesterone, testosterone, and how are you counseling patients on that?

[Dr. Jessica Ritch]
Generally the first thing that drops off is the progesterone. That's typically because not really ovulating regularly anymore. If you're not having that ovulation trigger, you're not getting that same rise in progesterone that you usually get after ovulation. That tends to drop off first. I think that's why I have so many patients who come in to see me who are just on progesterone. They've gotten some labs that show that they're low, I don't see much value in that. Progesterone, there's some evidence that it can help with sleep for people with sleep apnea, but in general, nobody should just be on progesterone.

Then, of course, the estrogen starts to drop off as the ovaries aren't responding more to the FSH. Even though FSH is going up and up, the ovaries are going to stop responding at some point so the estrogen is going to drop off as well. Then testosterone is a little bit of a lag. It's a couple of years behind the estrogen and progesterone in terms of the drop-off because it's not really the same cyclic stimulation that we see in the ovaries for the menstrual cycle. The ovaries are still producing some testosterone even when the estrogen and progesterone are dropping. Then of course we have steroid hormone production in the adrenal glands, although much less so than we were getting from the ovaries. It is a little bit of a slow drop.

Like I said, the majority of symptoms that we're seeing in perimenopause and menopause are due to, first of all, the erratic fluctuations of estrogen that are happening in perimenopause. I will have some of those patients that come to me that are monitoring their labs all the time. I have a nurse who I see, and she's always like, "But the estrogen was so high." Then we go through the pattern. We're like, "Yes, it went high because the FSH was so high. Then it stimulated the estrogen." We're not going to treat the numbers. We're going to treat how people feel, stabilize things along the way, and then see what we need to add back in to get you feeling better.

[Dr. Mark Hoffman]
Good. The other big thing I want to ask, though, about this in terms of hormones is testosterone. A lot of testosterone questions, and I feel like I don't know anything helpful to tell patients about testosterone. I know that ovaries do produce testosterone, and I understand that when you go into menopause, your ovarian hormone production goes down. That includes testosterone. You're nodding, so I'm hoping that I'm somewhat right here. Tell me what you know about testosterone in the menopausal patient and what we can be telling our patients.

[Dr. Jessica Ritch]
That is true. Definitely, the ovaries are producing testosterone. The testosterone seems to drop off a little bit later than the estrogen does. We tend to lose estrogen a little bit sooner and progesterone. The testosterone drops off a little bit later. I will tell you that my opinion on testosterone has been evolving, and it's still evolving, but here's what we know.

We do know that women who are getting testosterone supplementation do feel better in terms of less fatigue, more energy. They have improvements in libido and muscle mass, so it can be helpful in those ways. We do know there can be side effects to testosterone, so abnormal hair growth, acne, virilization things like voice deepening, clitoromegaly, things like that, that people don't necessarily want.

We don't know a whole lot about risks. These are not really well studied in women. The studies that we do have typically are followed for six months or less. They're usually using a topical patch that's not available in the United States. It looks like, at least from those small studies, that things are fairly safe in women. When we look at men, of course, the concerns in men are always things like cancers; prostate and testicular cancers, and cardiovascular disease. Some of the newer evidence suggests that it may be safer in men than we had originally thought, but there's really still not a lot of data on women.

It's not something that I start with. The argument I think a lot of people make who do a lot of testosterone therapy is that we would offer this to men. We care more about men's quality of life, it seems, than we care about women's. I agree, there are a lot of things that we do for men that we don't necessarily do for women, but I do think it's more of a conversation. I do think it shouldn't be a, "Well, your testosterone is low and you need testosterone." It should be a conversation about the risks and benefits. Just because somebody's male partner will take anything at any risk to improve their sex life, does not necessarily mean that the woman wants to do the same. It's really a conversation about risks and benefits.

When I'm starting someone on a hormone replacement therapy, I always start with estrogen, and then, of course, progesterone, if they have a uterus, to protect the uterus. Then even if they've come to me for testosterone, I say, "Well, let's just wait on that. Let's see how you feel first with the estrogen," because a lot of the symptoms that they're having in terms of the fatigue and also the libido and energy, those are going to improve with the estrogen alone, which are much better studied. We know the risks and benefits in women of estrogen and progesterone much better than we know testosterone. Then I say, "If you're still having very bothersome symptoms, then we're going to consider adding a topical testosterone," but that can get a little bit trickier.

[Dr. Mark Hoffman]
Is it trial and error, really? Are you measuring testosterone? I know we talked about labs a minute ago, but do you check testosterone levels in women at all? Is there any value in that?

[Dr. Jessica Ritch]
I do check them initially, but again, the initial is really more to rule out the other things, particularly in the perimenopausal person, to see if it's a PCOS issue or something along those lines. If I'm supplementing testosterone, which again, I don't start with, so it's not the majority of my patients who are on testosterone, but if I'm supplementing testosterone, then I will check the levels mostly to make sure that they're not getting crazy high. There are no set therapeutic levels for what a woman's testosterone should be, so it's not like you're titrating a dose to a specific level. It's more like, "Okay, well, what's the normal range of what a woman should have?"

I do have some patients who are on the pellets and other things, not that I've given them the pellets because I do not do that, but who have come in on pellets. Sometimes their levels are three, four times what a normal female should have in terms of a testosterone level. I don't think that's where anybody needs to be.

[Dr. Mark Hoffman]
What are the kinds of things we should be looking for? You mentioned energy and libido. In terms of response and dosing and things like that, we don't need to go through specific doses, but is it similar to estrogen where it's like, "Let's give you a little more, see how you feel. Let's give you a little more, see how you feel." Then you have a point where "Okay, I don't think any more is going to help," and it's more of a trial-and-error type thing?

[Dr. Jessica Ritch]
A little bit. There are some guidelines. There are basically a couple of different ways that you can do testosterone. Some people will do injections in the pellets. Like you said, I don't do that. The pellets I'm not really that comfortable with. I think they're poorly regulated, not well studied, can be inconsistent. There is, of course, FDA-approved testosterone for men. Topical, a gel product that you can use. Generally, for women, we just start at a 10th of the dose of men. Not super scientific. It's like a pea-sized amount that they rub into their skin. That's one way to do it. They probably won't have that covered by their insurance, but because the tube is going to last them so much longer than it would for a man, it's usually one or two tubes in a year.

The other way is to use a compounding pharmacy, which as I said, I'm not a huge fan of compounded bioidentical hormones. I do use compounding pharmacies when I need to, when I can't get something that's commercially available. I have a few in my area that I feel comfortable with, but it's sort of the same thing. We just start at a low dose and then we build up from there. I will talk with the pharmacist specifically about how they make that and how we can dose each patient.

Really then, I'm checking the levels to see, "Okay, are we getting too high?" Then for the effectiveness to see, basically it's always, "How do you feel? How do you feel with that?" Some people feel great with it. I would say the majority feel great. They have more energy. They have their sex lives back, but I do have a lot of people too who are just like, "Whoa, that was too much. I don't want to be on that anymore." It's always trial and error. You have to see how each person is going to respond to it, just like with anything else.