All About Testosterone

It’s ironic that everything Google serves up when I type in “testosterone” is related to male physiology. Testosterone is just as important in women as it is in men. Data supports that androgens, the class of hormones that testosterone falls into, have a measurable impact on sexual desire, bone density, muscle mass and strength, adipose (fat) tissue distribution, mood, energy, and psychological well-being in both men and women. 

Testosterone production occurs predominantly in testes of men and the ovaries of women. The production is regulated by the hypothalamic-pituitary-gonadal/ovarian axis. Simply put, your brain secretes two chemicals that communicate to speak to your testes or ovaries. A negative feedback loop exists when the body sends messages back to the brain updating the circulating levels of these hormones. When circulating levels are high, the stimulatory functions get switched off.  

Our adrenal glands, which make our stress hormones, also make a little bit of testosterone in both sexes. This speaks to the relationship between stress and hormone production. Your adrenals are responsible for cortisol production, too – this is your chronic stress and survival hormone, and the body will always make it preferentially over less survival-dependant sex hormones. Often in our practice, we observe changes in menstrual cycle and testosterone production during periods of very high stress. 

Body fat also influences hormone production. Just losing 5% of your body weight is likely to positively regulate a menstrual cycle or low testosterone reading in those with weight to lose. The other interesting role that adipose tissue plays is that it increases the conversion of testosterone to oestrogen via a process called aromatisation. The more visceral belly fat you have, the higher your estrogen levels. 

Remember, we learned that testosterone can be converted to estrogen, but estrogen is not converted into testosterone. Progesterone however can convert to testosterone. One of the consequences of replacing estrogen and progesterone in the body via the contraceptive pill or HRT (in women) is that the exogenous hormones suppress the body’s HPO axis. The presence of the pill or HRT tell the brain that there are enough circulating hormones, and to stop stimulating the ovaries/adrenals to produce all hormones including testosterone. Another consequence of taking hormones at any age is a possible increase in sex hormone binding globulin (SHBG). SHBG is a hormone transporter that binds and regulates the bioavailability of free active sex hormones. The higher your SHBG, the less bioavailable and bioactive free testosterone there is floating around to give you your mojo. This doesn’t always return to normal after stopping the pill. When we give estrogen through the skin, SHBG is not elevated as much as it is when we give oestrogen orally. Bioidentical progesterone does not impact SHBG levels either. Oral HRT using non-bioidentical hormones has a similar effect to the pill. 

If we understand that testosterone impacts mood, sexual desire and pleasure, muscle health, and more, why has this sex hormone been excluded from hormone preparations since their inception?  When we supplement testosterone in cisgendered people, we are restoring physiologically normal levels. Masculinisation due to Testosterone supplementation only occurs when we exceed these physiological ranges.

With almost half of women reporting sexual dysfunction of some sort and with the high levels of stress that most people are under, could testosterone replacement be a part of the solution to more fulfilling intimacy in relationships, more drive at the gym, and all-round better body composition for men and women in both a young and ageing population? How would we approach this?

It’s clear from decades of data that replacing testosterone to physiological levels in both men and women of all ages is theoretically safe when monitored appropriately. With no adverse effects on liver function or lipid profiles, the more I read, the more I want to start dishing up a dollop a day for everyone and sundry. 

I would say that the majority of men and women suffering from low libido in relationships where there are discordant levels of desire between them and their partners do not raise these issues with their doctor. Unless I ask about libido, it is seldom volunteered in a consultation. Sex is a vital and important part of intimacy, expression, creativity, and connection. 

Are people having enough sex today? Large data samples of populations are reflecting that couples and singles are having much less sex than ever before. It’s impossible to say exactly why this is and it’s likely to be a multifactorial consequence of many of the innovations of modern life, not to forget social media and porn. I find it so interesting that a high percentage of men who watch porn frequently struggle to maintain healthy erections in conventional  sexual relationships with real women or men.

Testosterone can be administered in many different ways, including trans dermally in creams or gels, into muscles or fat via injections, and even orally. Each application has pros and cons and blood monitoring is required to check red blood cell production, liver function, and prostate growth in men. 

With the right practitioner, you can discuss whether there is a role for testosterone therapy in your sexual health or hormone health journey. If you are on a contraceptive that has robbed you of your libido, a conversation about alternative methods of contraception could be considered. We want to avoid using one drug to manage the adverse effects of another as far as possible in medicine. 

This article does not refer to using testosterone above physiological levels, as it might be abused in the context of doping in the sports arena or atypical muscle building in the gym. Also, it’s important to note that replacing testosterone in a man of reproductive age who plans to have children can potentially make him infertile. A difference between men and women to note is that testosterone replacement in men in their reproductive years can cause infertility. A women’s cycle will recover after it has been suppressed by the pill. 

Ways to naturally increase your own body’s testosterone production include weight-bearing exercise, reducing your excess body fat, and avoiding medicines that will affect your levels. Honouring your circadian levels with good sleep and eating a whole food diet high in fibre that results in healthy bowel function will also contribute to hormone health. Cannabis and alcohol have a negative effect on healthy hormone balance. Healthy testosterone levels contribute to energy, mood, libido, bone density, and metabolic health. You can check your levels with an early morning fasting blood sample with your doctor to start this conversation.

ABOUT THE AUTHOR

Dr Skye Scott is a family GP and co-owner of Health with Heart - a holistic wellness solution that includes a warm-hearted practice in Sandton; bespoke corporate wellness programmes; unique retreats and medical travel experiences; an educational podcast and portal; and a community outreach initiative. For more information or to get in touch, follow @drskyescott or @health_w_heart on Instagram or @HealthwithHeartDoctors on Facebook, or visit www.healthwithheart.co.za.