Healthcast 611 - What is the optimal blood level for testosterone in women?

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Women always ask about my goal for their blood level of free Testosterone after insertion of testosterone pellets. That is a good question, and it is not easily answered. When I was trained by Dr Gino Tutera in 2002, and he taught me that the optimal range for Free T in women who take T pellets to be over 15 pg/ml. He taught me that each woman is an individual and the blood level that they need is specific to their metabolism and genetics. To determine the perfect level of T free for an individual we should follow the resolution of her symptoms after her T pellets are inserted. Today we will talk about the research done by Dr Rebecca Glaser, published in Maturitis 74(2013) that confirms my practice of adjusting the dose of pellets based primarily on the resolution of Low T symptoms. Prescribing pellet Testosterone for woman is not easy and her doctor must find her own ideal blood level.

Testosterone replacement for women has been ignored as an essential hormone replacement for women, and until recently was not considered a major sex hormone in women. Premenopausal women have 15-20 times more testosterone than estradiol circulating in their blood streams. This makes testosterone the most prevalent sex hormone in premenopausal women, yet it is still mislabeled as a strictly male hormone!

After late 30s to mid 40s women develop a deficiency in testosterone and develop a host of symptoms that doctors have sadly called the symptoms of "aging", when the symptoms are directly related to the lack of free T in a woman's circulation.

Both pre- and post-menopausal women over 36 may experience the following symptoms of testosterone deficiency:

• Sexual dysfunction-lack of libido and loss of orgasmic function
• Anxiety, irritability, depression
• Physical fatigue
• Lack of the feeling of well-being
• Poor cognition
• Memory loss
• Insomnia
• Hot flashes
• New autoimmune diseases
• Arthritis
• Weight gain
• Muscle loss and physical weakness
• Pain
• Vaginal Dryness
• Irritable Bladder
• Migraine headaches
• Osteoporosis

One of the reasons that the majority of doctors don't use T pellets is because it takes intense individual training after residency and time and attention to each patient, her symptoms, and time for multiple adjustments of dose before the maintenance dose is determined. This is something a doctor or nurse must do all the time to be good at it and the doctor must have a complete grasp of endocrinology, nutrition, and gynecology to become good at this type of T hormone treatment.

Once the pellet dose is determined it is the most convenient dosing schedule (once q 4 months, only 3 doctor visits a year) with 100% compliance because the T Pellet dose is given in the office, very rare complications, and an amazingly complete resolution of symptoms, which has not been seen in any other T preparations, bio-identical or not, given with a different delivery system.

With the right doctor or Nurse Practitioner, a knowledge of pharmacology, endocrinology, gynecology and nutrition, this form of T delivery to women brings them back to a more youthful body and mind as well as prevents diseases of old age such as Osteoporosis, Heart disease, Sexual Dysfunction, mood disorders and autoimmune diseases to name a few.

In the research paper by Dr Rebecca Glaser: Testosterone implants in women: Maturitis 2013 Dr Glaser explains that there are many problems secondary to following blood levels to determine dosage, and explains why following symptom resolution is the preferred way to provide this type of Testosterone replacement:

Specifically,

1. Blood tests of free T are rarely repeatable and often wrong—it is not a good, repeatable blood test. The only thing less reliable is saliva testing which I don't recommend.
2. No single blood test represents the true daily blood level of free T in pellet patients. How fast your body uses the available T up, varies by number of hours or sleep, stress level, estradiol and estrone levels and amount of exercise engaged in per day.
3. Fat metabolic activity: T pellets are inserted into fat in the hip and as we are now discovering, the ability of fat to dissolve a steroid hormone placed in fat is individual and determines how quickly the pellet is dissolved and needs to be re-dosed. There is no test for this, so trial and error is needed using different dosage to determine ongoing maintenance dose.
4. ARs (Androgen receptors) are distributed throughout the body and the number of Ars plus the "stickiness" of the receptors for free-Testosterone in the blood, is determined both by genetic makeup and age. ARs of people with dominant genetics from the northern latitudes, are relatively resistant to binding, and these receptors must have a higher blood level to respond at an optimal level. Women who have their dominant genetics closer to the equator, require less free T to achieve optimal symptom relief. The genes are not specifically discovered as of yet, it is impossible to test a patient to see if they have strong or weak receptors. This discovery is found through trial and error. Age also causes a loss of the # of receptor sites, therefore more T mgs are needed in the pellets.
5. Estrogen interferes with the free T level from a particular dose: Binding to SHBG decreases the active form of T (T free) per dose of T pellet. The amount of estradiol and estrone a woman has been given or makes, decreases the amount of active T free. The lower the Estrogen levels, the lower the SHBG and the more T free is available.
6. Cortisol Binding Globulin goes up when Cortisol increases secondary to life stress, surgeries and illness. This binding globulin inactivates the testosterone and decreases the percentage of active T.
7. Speed of a woman's Liver metabolism is increased by multiple drugs that go through the P450 system, alcohol intake, fatty food intake, and amount of environmental chemicals that act like estrogens. One patient's liver metabolism of T through the P450 system is individual and is not the same for another woman of the same age, weight, etc. The speed of breakdown of T determines how fast the T pellet is used up.

There are several other dosing issues that are addressed after the first pellet insertion in preparation for the second insertion. Most important is whether their symptoms are completely gone. If they are, we leave the dose the same, if not they usually need more T dose, or they are converting T into E1 and E2 which binds the T free and lowers the effect. For this we exchange one of the T100 mg pellets with one TA 90/10 pellets, which blocks the conversion, and releases the T free and stops increasing the E1 and E2.

There is a small percentage of women of women who do not tolerate TA pellets. They feel like they have no sex drive and don't feel their T free as they should….it is an opposite reaction, because in everyone else the T free is higher, they feel more sex drive and lose belly fat. If the "opposite" patients still need to lose belly fat and lower their T-free, DIM, zinc, and Calcium D glucarate can be used to lower the Estrogen in the circulation.

I agree with Dr Rebecca Glaser MD, who states that dosage should be guided by safety, tolerability and clinical response, rather than a random T or T free levels, yet I always draw blood levels to find out if a woman's ideal blood level specific to her has been reached, and if it is repeatable.