Nurse practitioner, clinic owner, and founder of HRT University. I teach providers the physiology behind hormone therapy, so they’re not piecing it together on their own.
So we stop testosterone in women now?
|
Well, I guess we ought to stop prescribing TRT to women. Didn't you hear the news? According to a recent study that will be presented sometime this week via The Menopause Society, testosterone therapy has been linked to postmenopausal women with a higher risk of incident cardiovascular disease. Hmmm... I don't yet have the full study, but I'll be waiting with baited breath that's for sure. However, anytime I see headlines like these floating around, almost always when you dig into it, it's far less scary than it sounds. Here's what we know so far: Researchers from Drexel pulled electronic health records from TriNetX, a massive network of hospital and health system data. They matched 3,164 postmenopausal women (45+) who started testosterone against 3,164 women who didn’t, and followed them for roughly 3 years. Again, the new cardiovascular diagnoses was the scary thing they found: 3.8% in the testosterone group vs 0.5% in controls. Hazard ratio of 8.08. Yikes! But here's what the headlines missed... To the researchers credit, the authors called their own findings hypothesis-generating. The headlines skipped that part (they always do). So this isn't "testosterone causes cardiovascular events" by any stretch. And this is clear when you run these types of studies... Because the database doesn’t know what “testosterone” means. TriNetX captures that a testosterone order exists. That’s about it - seriously. No dose. No route. No formulation. No indication. No confirmation it was ever filled or used. So a woman on a few milligrams of transdermal cream and a woman on a whopping pellet dose land in the same exposure bucket. No serum levels. No dose-response. But here's the real killer: Look at the control group. They had a CV risk of 0.5% over about 3 years works out to roughly 1.7 to 1.9 events per 1,000 person-years. For context, ARIC put coronary heart disease incidence in white women aged 45 to 64 at about 4.0 per 1,000 person-years. In the subgroup not on hormone therapy, the controls had 0% events. Zero. Which is practically impossible. It's zero because we have a missing data pattern. And that's a huge red flag. And, by the way, the rest of the existing evidence says otherwise... A 2024 study in the Journal of Sexual Medicine used a different TriNetX network that includes claims and pharmacy data: 16,783 women with at least three testosterone prescriptions. It found lower MACE risk in testosterone users (RR 0.64), and no difference in women 56 and older. Interesting Same study data platform, yet moving in the opposite direction. A 2023 JCEM analysis of 25,796 women found a hazard ratio of 1.24, with no increase in MI or heart failure. Something worth watching, sure, but nowhere near 8! Don't forget, the women who choose to get testosterone, and who gets looked at also matters. Most women don’t land on testosterone at random, and they're certainly not being offered by every PCP. The women who land on TRT oftentimes have low libido and fatigue, right? And these overlap with early heart failure, metabolic syndrome, and even depression. Some of these women may have been on a cardiovascular trajectory before TRT was ever prescribed or considered. What this does NOT mean. It doesn’t mean testosterone is proven cardiovascular-safe long term in women. What RCTs we have are short, mostly under two years, and they excluded higher-risk women. So the data is technically still inadequate to assess long-term cardiovascular risk. But it also doesn’t mean you should pull every woman off testosterone this week. In fact, what this all means to me is that more and more people are paying attention. I believe women, and men for that matter, will begin to have more access and more opportunity to discuss this type of incredible therapy with their provider. And that provider ought to be you :) Hope this helps -Nico PS I got a killer podcast episode for those of you ever wondering why you feel more confused the more you learn about HRT... In this episode I make the case that prescribing uncertainty comes from the quality of what providers were taught. Information without a framework has nowhere to go, so another conference or course adds to the confusion. A physiology-first framework found in the HRTU Master Course you the opportunity to truly master HRT and become confident so your patients keep coming back for more. Agrawal, P., Singh, S. M., Hsueh, J., Grutman, A., An, C., Able, C., Choi, U., Kohn, J., Clifton, M., & Kohn, T. (2024). Testosterone therapy in females is not associated with increased cardiovascular or breast cancer risk: A claims database analysis. The Journal of Sexual Medicine, 21(5), 414–419. https://doi.org/10.1093/jsxmed/qdae032 Jones, D. W., Chambless, L. E., Folsom, A. R., Heiss, G., Hutchinson, R. G., Sharrett, A. R., Szklo, M., & Taylor, H. A., Jr. (2002). Risk factors for coronary heart disease in African Americans: The Atherosclerosis Risk in Communities Study, 1987–1997. Archives of Internal Medicine, 162(22), 2565–2571. https://doi.org/10.1001/archinte.162.22.2565 Lopez, D. S., Mulla, J. S., El Haddad, D., Tahashilder, M. I., Polychronopolou, E., Baillargeon, J., Kuo, Y. F., Gilani, S., & Khalife, W. I. (2023). Testosterone replacement therapy in relation with cardiovascular disease in cisgender women and transgender people. The Journal of Clinical Endocrinology & Metabolism, 108(12), e1515–e1523. https://doi.org/10.1210/clinem/dgad388 The Menopause Society. (2026, October 20). Testosterone therapy may increase risk of cardiovascular disease in postmenopausal women [Press release]. https://menopause.org/press-releases/testosterone-therapy-may-increase-risk-of-cardiovascular-disease-in-postmenopausal-women |
HRT University
Nurse practitioner, clinic owner, and founder of HRT University. I teach providers the physiology behind hormone therapy, so they’re not piecing it together on their own.
Have you heard some version of this in your office? “I’d like to feel better, but I’m scared of progesterone. Doesn’t it cause breast cancer?” It’s a fair question, and it's one that used to make me stumble early on. A lot of women were taught to fear it for many MANY years. But a 2017 paper by Zhou and colleagues found something many providers like you haven’t seen. When progesterone met one of the most aggressive breast cancers we know of, it slowed it down... See, triple-negative breast...
I want to run some startling numbers by you this morning. Mind you, I'm no Einstein when it comes to stats etc., but these will probably take your breath away... In the USA 6,000 women enter menopause every day. Menopause symptoms cost U.S. women an estimated $2 billion a year in lost work time. Fewer than 4% of women aged 50–60 use hormone therapy. Less than 1 in 10 OB-GYN residents (about 7%) felt adequately prepared to manage menopause. Nearly 4 in 10 men over 45 in primary care have low...
Your wish is my command. Many of you have asked, so this morning, I bring to you the case for checking ferritin levels. And yes, I believe based on the literature, that it's on of the most underrated and helpful markers when it comes to discovering iron deficiency. Let me make the case here. First of all, most iron-deficient young women aren’t anemic. In US females aged 12 to 21, 38.6% were iron deficient at ferritin <25. So only 6.3% had iron deficiency anemia. Put another way, just 16.4% of...