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Brooke Faught is a nurse practitioner and director of the Women's Institute for Sexual Health, a division of Urology Associates in Nashville, Tennessee. She knows a lot about the vital role testosterone plays in women’s sexual health because she uses it in her practice daily – something her own male colleagues don’t always take seriously. I first came across Brooke ahead of a presentation on her work she made to the North American Menopause Society 2020 Virtual Annual Meeting, and then spoke to her again in 2022 for an update on advances in treatment and guidance as part of the Menopause Shift Summit. Here is some of what I’ve learned from those conversations.
Testosterone is an overlooked but super-important in peri/menopause
Brooke says testosterone doesn’t play as much of a role for women of childbearing years when it comes to libido and sexual functioning, but by the time we get to peri-to-post-menopause, it’s one of the top options. Brooke has been using it for 15 years to treat a range of symptoms including dryness, pain, lack of arousal and orgasm, urethra, bladder and general pelvic floor health.
“There is such a plethora of evidence to show that testosterone is equally as important for preventing those symptoms, treating those symptoms and just maintaining overall tissue,” she says.
Off-label means getting creative with dosing
Although there are countries where testosterone is approved for women, such as Australia, and other countries where it’s prescribed, like the UK, in the US testosterone prescriptions are off-label – meaning practitioners alter them for women from a supply of products intended for men. This also means insurance plans won’t cover it.
“We can use creams, we can use inserts,” Brooke explains. “Again, oftentimes we have to turn to compounding because there's not a ton of options, the way that we have estrogen options for the vulva and vaginal tissue, but we can definitely get creative with products that are currently available that might be used off label or turning to compounding.”
It’s all about the receptors
“This is how I explain it to my patients: a circulating hormone must have a receptor or a house that it must fit into, so this molecule fits into this house before it actually functions and activates,” Brooke says. “This hormone that's floating through the system is essentially a useless particle in the system until it finds that receptor. Now, not every hormone has the same location or number of receptors, but for testosterone, there are quite a few in the clitoris, in the urethra, in the vestibule, which is that ridge of the vaginal opening, so all of the really critical structures for proper sexual functioning, but also just comfort, and just daily urogenital functioning.”
Brooke says estrogen and testosterone are “equally important”, which is why she usually uses them at the same time.
“Estrogen receptors tend to be more the labia, the vaginal canal, and certainly some of the other structures where testosterone receptors are located, but they work really well together.”
Orgasms are an easy fix
Brooke was the first person to introduce me to the term “muted orgasms”, when she told me that a lot of her patients don’t even really think about how their orgasms have changed until she starts asking about it.
“It's one of those things where we just brush it off and think, ‘well, this is just how it's going to be. This must just be that time of my life’. I always hear this, ‘that ship has sailed’, and I'm like, ‘No, there's things that can be done about it’. It's so frustrating because it's so easy to fix. It really is.”
Testosterone is pretty safe
When Brooke hears of a patient with a low sex drive or has diminished arousal and orgasm, she runs blood work. If their testosterone levels are low and coincide with their symptom profile, they are potentially candidates for testosterone replacement.
Brooke says you would have to use a “really excessive amount” of testosterone to ever get close to the side effects everyone fears, including mood swings, aggression, hair loss or growth, acne.
There is enough data to show that testosterone, however it's delivered, is safe, she says, provided each individual patient is monitored closely to minimize any potential risks.
If you have a doctor who is hesitant, you could print out the International Society for the Study of Women's Sexual Health’s 2021 guidelines for use. Brooke carries a copy in her purse to persuade anyone she needs to.
“The short-term and long-term side-effect profile and risk factors was really nominal, it was really surprising,” says Brooke. “And we all kind of felt that, knew that, but to have that from such a highly recognized organization from all these international experts, pulling all the literature that's available, and pulling all this together and reviewing it and coming to this conclusion, was really comforting.”
There is a problem with pellets though
One of the most radioactive subjects on menopause social media is testosterone pellets: they are either amazing or terrible, depending on who you ask. Brooke is a moderate, and believes there needs to be a lot more research on the topic – along with more approved testosterone products produced specifically for women.
“Unfortunately, there are providers across the globe that use inappropriate dosages of testosterone and other hormones that lead to side effects and unwanted outcomes,” she says. “That's where off-label use of products of this nature gets a really bad rap. I think we need a lot more research.”