When a woman goes through menopause and her ovaries stop producing estrogen and progesterone, the pituitary responds by increasing FSH, a hormone from the pituitary gland that has regulated these hormones throughout her reproductive life. However, when all the eggs have been depleted, no further estrogen or progesterone can be produced. Nonetheless, the pituitary, which is “hard-wired” to respond to low estrogen, continues to make increasingly higher levels of FSH.
An elevated FSH is a diagnostic marker indicating menopause has occurred. Testosterone production occurs not from the eggs, but from different cells in the ovary, which continue to function in the postmenopausal ovary. Such increases in FSH leads to increased testosterone production. Testosterone can also be produced in fat cells and in the adrenal gland.
A postmenopausal woman with even normal testosterone in the presence of deficient estrogen often develops facial hair and acne. This explains why older women without HRT often develop facial hair and a deepening of their voice. Care should be taken to restore therapeutic levels of estradiol and progesterone before giving testosterone. Restoring therapeutic estrogen and progesterone lowers FSH resulting in a decline in testosterone production. However, FSH levels never return to levels seen in premenopausal women. Testosterone replacement is especially important in younger women who undergo surgical menopause. They will often have marked decline in libido and sexual dysfunction and may also develop urinary frequency and incontinence. Some studies suggest testosterone in the presence of estrogen and progesterone has a protective effect on the breast and may decrease breast cancer risk.
On the other hand, studies in premenopausal and postmenopausal women (on no HRT) who had naturally occurring elevated testosterone showed that testosterone is associated with an increased risk of breast cancer. In the Study of Women’s Health Across the Nation (SWAN), a longitudinal 9-year-study of 949 menopausal women on no HRT reported that testosterone predominance increases the incidence of metabolic syndrome. Metabolic syndrome is a name for a group of risk factors that increases your risk of heart disease and diabetes. Typically, people have elevations in blood pressure and fasting blood sugar, increased obesity around their waist and/or low HDL. In another study of 344 menopausal women ages 65-98, those with the highest levels of testosterone were three times more likely to have heart disease and metabolic syndrome than those women with lower testosterone levels.
Such studies point out the importance of respecting the normal physiology of the body. Testosterone is best prescribed after the woman is on adequate estrogen. Since testosterone can be produced by menopausal ovaries and the adrenal glands, deficient levels should be confirmed with an accurate laboratory blood assay that measures free testosterone levels before prescribing testosterone. Excessive testosterone replacement can cause facial hair, acne and loss of scalp hair and such symptoms are easily avoided by subsequent monitoring of blood levels.
Excerpt from “Outliving Your Ovaries” © 2012 by Marina Johnson MD.
Dr. Johnson has no financial conflicts of interest or ties to any pharmaceutical company.
Her only objective is determining the most effective, safest therapy for patients.