Peter Attia· MD
um that's one of the big reasons I mean we and and we didn't get back to this with the or contraceptive patient the solution isn't to leave her on her birth control pill and give her testosterone right first of all it's not indicated for premenopausal woman second of all why that's not what do right you try to correct the so you would you would take if this is the woman we're talking about just going back to our hypothetical case yeah let's just say that that's the path we're going down you would remove her from the OC probably switch to an IUD if Testo if shbg levels were still sufficiently high and and free testosterone well let's just say total testosterone was kind of 40th percentile you'd say look we're going to bring that up higher and G given that your shpg is so high it's going to bring your free testosterone right up to about the 50th percentile and again you're using that as a guide post but it's ultimately symptoms that you're treating you're managing symptoms yeah so let's say that's what I decided I look at the biological psychological and social factors in this woman and I decide like that's the thing that's amendable to intervention I'm going to change our contraception right and um so it's not just women who are already on these that I tell I I'm a little you know birth control pills combined contraception I want to make this disclaimer patches and rings are extremely effective and most women don't have a problem right so if you ask me what should I take you know it's you have to talk to your doctor right should I use niud to start with I can tell you how I canel my own daughter but that's my college age daughter but that's that's different than what I would tell patients and people um they they they're incredibly effective worldwide they prevent unre un unwanted pregnancies they Pro protect against birth you know uh birth mut alties Etc worldwide they liberate women all across the world we don't want to like say nobody should take birth and but for this discussion if somebody has a problem that's something you can change and if it's one of the problems we talked about right whether you should what you should tell a 20y old about whether you use bir trills or put in an IUD is like a whole another conversation right to be preventive again this is a small percentage of people who develop these issues most some women aren't sensitive to the everyone gets a change in their shbg some women aren't sensitive to it some women aren't sensitive to the the non-endogenous estradi in their vestibules some aren't so I can't tell you who that's going to happen to um so again the decision about what to use over time is a discussion with your doctor um I think more gynecologists need to offer informed consent so women can choose more carefully at the onset and this is an important campaign that gets missed right like there's no informed consent they just hand people a prescription at 21 right you should give women Choice um but anyway so getting back to testosterone um so I think the challenges then like we weren't going to use it on this page but let's go back to this for a minute is that you're going to then have to do that on Tenth of the male dose but you do have to follow levels because women are all over the place like how well they get on10th how that one also how V how variable the absorption is not all people have the same skin these were not designed for women I can tell you that the data in Australia is very positive for example I worked very closely with the one of the main researchers there a woman named Susan Davis who's done a lot of the work um in this field both in Australia and worldwide and and is a first author on a number of really important testosterone consensus papers she um impresses me but what she tells me about the clinical outcomes and the ability to get kind of steady state good blood levels because it's a controlled product designed for women regulated and formulated we need that that said you do have to follow levels mainly to make sure that you're a achieving safe doses right y so like if you said to me well like let's say someone has a level but it's too low and they're not getting benefit um would you go up and i' say sure because we haven't achieved the physiologic range and I know it's still safe so I am like checking it to make sure they're if they're not having symptoms that are improving to see that we're giving them enough but the most important reason for monitoring blood levels and I monitor for because of what you explained the smartest thing is just to men a total te right it's not a so we we didn't go through this in elaborate detail it's not clear that that's the best marker for knowing whether that's the way to tell whether testosterone is helping a patient in their cells and in their brain right their genital cells their brain and some other body cells too right but that's probably the grossest best measure we have because T fre is calculated and we don't even know if that's the bioactive component yeah testosterone it's a very complex what now is called iny it hits the cells it gets converted into metabolites um Androgen DHT it enters the cell through the Androgen receptor and has both genomic and non- genomic effects non-genomic means direct action genomic means it causes Gene translation other protein development which then has trophic effects right and so all of that's happening