Dr Louise Newson: [00:00:01] So Susan, it's very exciting to have you here. Usually with guests in the US, I've never met them before, but I have had the pleasure of meeting you, having lunch with you, spending time with you recently at a conference in Los Angeles. So it's great, Mo Khera, who's been on my podcast twice, Mo is a great friend of my husband who's also a urologist has been on my podcast talking about testosterone, and everyone wants to know about testosterone.  [00:00:31][29.4]
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Dr Susan Hardwick-Smith: [00:00:32] Absolutely.  [00:00:32][0.0]

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Dr Louise Newson: [00:00:32] And it feels like testosterone is almost like a naughty word for some people and it's the best thing ever for others. So I'm really keen to just talk to you about testosterone but also about how we can individualise care for women and personalise care and just a bit about your approach really. So you're a doctor, you've got a really interesting background and you ended up being in America even though you're originally from New Zealand so even that's a great story. So can you just say a bit about your background before we start talking about testosterone? [00:01:09][36.5]
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Dr Susan Hardwick-Smith: [00:01:10] Yeah, well, that's such a nice introduction. Thank you. It's so lovely to be with you. And I've been following you for ages and had this amazing opportunity to meet you in LA at a meeting and we hit it off. And we've got connections, as you said, through Dr. Khera, who I just saw on your podcast a few weeks ago. So yes, I was born in New Zealand, moved here when I was 18, trained as a traditional MD, went through the traditional OB-GYN training. And I practised traditional OB-GYN for 20 years, delivered 7,000 babies, did all the surgeries, all the wonderful things that we can do in that specialty. But as your listeners know, we learned nothing about menopause, like absolutely nothing. And so when I reached my mid-40s and started having those symptoms myself, I was absolutely clueless about what to do to help myself. I went through about a year of being untreated, I didn't think I was old enough to go through menopause. I was a gynaecologist, because I thought I'm 45, that can't be happening. Completely clueless. And then when I finally figured out how to replace my hormones safely, and I felt amazing, I retired from that traditional OB-GYN practice went into a menopause specific practice in 2020, not the best time to start a business in the middle of COVID, but I just had to do it. I'm like, I need to do this. Honestly, I thought I would just have a quiet little life with just me and my nurse practitioner. And that didn't work because it was so popular. Now we've got three offices in Texas and growing and 12 providers and the virtual programme and all the things. And really, I think that we learn how to be menopause doctors by going through menopause frequently, not always, but it becomes much more urgent when it's happening to you and all these symptoms that you've been taught are just hormonal or she'll get over it or whatever or like, holy crap, this is really serious. So just to give hope to your listeners, I know they've heard it from you too. I felt absolutely horrible, like deadly awful and now I feel better than ever. And the difference is just replacing those hormones and all of them, yes, estradiol, progesterone and testosterone. Absolutely so important.  [00:03:13][123.5]
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Dr Louise Newson: [00:03:14] Yeah and so one of the things about testosterone, I'm learning every day is a new day and every day is a learning day I always tell my children but I'm learning more and more about testosterone from my clinical experience so we have thousands of women who use testosterone and I very much like to talk about testosterone deficiency like I would progesterone deficiency or estradiol deficiency it's irrelevant what the label is whether I'm giving them the label of PMDD or perimenopause or menopause, it's irrelevant actually. But I realise more and more that testosterone deficiency occurs quite young for some women. There's quite a few women who are, they've probably always been testosterone deficient.  [00:03:56][41.5]
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Dr Susan Hardwick-Smith: [00:03:57] I couldn't agree more, and I knew nothing about this, so what I was taught, which was sort of nothing, it was less I was taught than it was just sort of this assumption that we go through our menstrual lives and then all of a sudden we go through menopause and all three hormones drop or maybe didn't even hear about the third one, testosterone. But what happened in my case is I was still perimenopausal. I was ovulating and still making estrogen and progesterone, but my testosterone was almost zero and all of the symptoms that I had initially, or many of them, were related to that particular hormone being low. And I can't tell you the number of times I wish I could go back and apologise to the women that I misdiagnosed before this happened to me, and I probably told them, you're fine. You're still having periods, so maybe you just need an antidepressant, or maybe you need some marriage counselling, or all the other stupid stuff we say when we don't know. But in my case, a little bit of testosterone replacement, it changed my life. I don't want to overstate it, but it literally turned me back into somebody that I recognised as myself again.  [00:05:00][63.2]
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Dr Louise Newson: [00:05:01] Yeah, I remember about six or seven years ago, I was called up from NHS England with someone quite senior, and he did a Zoom call with me and he said, Louise, I thought in medicine, you were taught first do no harm. And I said, yes, of course. What are you talking about? He said, well, I've heard that you prescribe testosterone to women with regular periods, and we've all had a meeting about this and discussed it and we've agreed that this is a dangerous practice. And I said, well, I beg to differ actually, because I have seen firsthand a lot of women who have improved and they said, he said, we've all agreed that's placebo and it's dangerous what you're doing. And I didn't have the confidence that I do now. I didn't publish like I do now and I didn't have the number of patients that I do now and I went away from that meeting and got very upset and actually cried because I was crying for all those women that have been denied a very safe hormone and it's a shame it's called testosterone because everyone thinks it's male hormone and like you, I feel very different when I use testosterone and I wish I'd started it about 10 maybe 20 years before I did. I had my third daughter when I was 40, but I know I was struggling from about the age of 35. And looking back, I feel sharper and brighter and more mentally able now than I was probably 20 years ago. It's not such an effort to think.  [00:06:33][91.9]
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Dr Susan Hardwick-Smith: [00:06:35] So interesting, and I've heard many of your guests talk about this before, but it does just lead one to be kind of upset about how men are treated when their testosterone drops. Say for example, it might drop by 50% between age 30 and 50 for the average man. And he very rightly so is going to get replacement if he's symptomatic. And ours has dropped by close to 100%, yet we're not offered treatment. And the international consensus that you're well aware of from 2019 is six years old now, basically says testosterone is only appropriate for post-menopausal women, which makes no sense at all. But if you're somebody who isn't quite as experienced as you and I in seeing patients and are just referring to the guidelines, you know, doctors, it's very wonderful that we have these great groups to make consensus statements to guide us. However, they're, you know, not always so, right. If you're in practice, like you and I are seeing thousands of patients, we're going to learn things that are not in a consensus statement because it takes decades for 25 physicians to agree on anything and then publish it. So if we waited for that to happen, we would all be suffering for decades. So sometimes it's just common sense. Okay, this patient's presenting with multiple low testosterone symptoms. Her blood level shows her testosterone is low. We replace it appropriately for a woman and lo and behold, she feels better. What on earth could be wrong with that? No matter how old she is.  [00:08:05][90.3]
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Dr Louise Newson: [00:08:06] Yeah, I totally agree. And one of the things I've written a lot in my book, The Power of Hormones, is about how all three hormones, progesterone, estradiol, and testosterone, work in the body. And I've spent quite a lot of time writing about how it works in the brain. So testosterone is very important as you know in every cell in our body and brain, but it helps the communication with those neurons and it helps build that myelin sheath. Which is like the conduction part really, isn't it, of the nerves. So it helps everything fire very quickly and effectively, but it also helps with metabolism. It helps with glucose metabolism in the brain as well and helps all the cells to work better. And if you go within the cell, it helps all our mitochondria, which is the powerhouse of all our cells, to function better and reduce inflammation throughout our brain and body. So it has really important physiological actions everywhere. So this obsession about libido is just weird in some ways. It's quite degrading actually for women. And don't get me wrong, like you, I'm very happy talking about sex. And I think it's important that people should have libido and great orgasms. But I don't think that's the only thing we should be thinking of when we're talking about a hormone that has these effects everywhere in the body. It just seems weird.  [00:09:33][86.7]
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Dr Susan Hardwick-Smith: [00:09:34] The idea, right, of course, the idea that this very powerful hormone that we're now potentially lacking in perimenopause or menopause, or even younger, could only have one benefit, it makes no sense. It doesn't target one thing. And so currently in the United States, and I think in the UK as well, we're instructed if we read these consensus statements, we can only say that testosterone is beneficial for HSDD or low sex drive and not all the other things, which obviously it's great for many things. I absolutely love the paper that you published recently about cognition and testosterone because I hear from my patients, I'll tell you the same happened to me, words like optimism and motivation and getting my pep back and just saying yes to social invitations instead of like, oh, I don't want to go, I just feel kind of blah. And it's often misdiagnosed as depression, as you know, and it's maybe sometimes depression, but why don't we try replacing the natural hormones first, because more often than not, that resolves the issue for the patient. I can remember myself within two weeks of starting on hormones, going from just kind of feeling something is wrong with me, blah, I don't have any energy, motivation, no sex drive, but also no other types of drive, just motivation, optimism, good feeling about the future, all those feelings. All of that got better. I actually started testosterone by itself because I'm a scientist. I want to do a study. I didn't want to start three things at once. So I started it alone and this is a study with one person in it, but it's certainly been duplicated many times in your clinic, mine and other anecdotal studies, it works and you know, if we're waiting 20, 30 years for a randomised controlled trial that no one's going to pay for. In the meantime, everyone's going to suffer. So yeah, the idea that it's not safe to take a natural hormone that we've had all of our lives makes absolutely no sense. We have to move away from that.  [00:11:34][119.8]
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Dr Louise Newson: [00:11:34] So, I totally agree. And over here, more women, same in the US and globally actually, are understanding, they're reading the same evidence as we are. They're reading basic physiology as well, and they're understanding the importance of this natural hormone. So they're asking for it more. More and more women are being turned away for the wrong reasons for testosterone, but some people are taking it. So testosterone prescribing over here for women has overtaken for men, which I think is wonderful.  [00:12:01][26.3]
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Dr Susan Hardwick-Smith: [00:12:02] Good for you, probably largely due to you.  [00:12:04][1.9]
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Dr Louise Newson: [00:12:04] So, but recently it was written about in one of our local papers or our national papers and the one of the ex-chairs from the British Menopause Society was writing about the harms of testosterone and she said it's abusive that women are being prescribed so much testosterone. Now I think coming from a healthcare professional that's quite a strong language saying it's abusive to prescribe testosterone. I think there are many drugs that may be abusive when they are definitely associated with harms, you know, without informing patients, but testosterone isn't one on my list. I feel it's one of the most safe and transformational medications that I've ever prescribed as a doctor, actually.  [00:12:49][44.9]
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Dr Susan Hardwick-Smith: [00:12:51] It's mind-boggling how that statement could arise, but I can perhaps sort of see an inkling of where that might have come from because there were in the past and still exist certainly in this country clinics where patients are given unsafe drugs that are either not biologically identical testosterone or doses that are way too high for a female. And so, I think because that happens... So we could throw the baby out with the bathwater and say just because, in my opinion, irresponsible practitioners might offer this doesn't mean that there aren't responsible practitioners offering it. So if patients have to be really careful and smart about whom they trust with their... [00:13:40][49.3]
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Dr Louise Newson: [00:13:40] Absolutely,.  [00:13:40][0.0]
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Dr Susan Hardwick-Smith: [00:13:41] ...health. That can happen in any field.  [00:13:42][0.3]
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Dr Louise Newson: [00:13:43] And it's very important, anything that we prescribe, anything we do, if you do it too much or too little, it's not going to have the same effect. So like me, you're very keen in holistic care and you're the most amazing athlete. I'm just like so impressed with all this, yeah, the triathlons that you do is just amazing. But exercise, nutrition is like a no brainer. Everybody should do that. But when we talk about hormones, we both agree that we're individual and personalised hormone balance is crucial. And so, there's been a lot of debate, especially since the Panamama programme that was made about me, about high doses that I prescribe to some women. And it's been very damaging over here in the UK, and I know it's filtrated into other countries because then people think that these high doses somehow are a problem. Now, one of the reasons I prescribe higher doses for a minority of women in follow-ups is because they're not absorbing through the skin very well and so I spend a lot of time with patients optimising doses but also not just the dose, the formulation. So people really vary with how they absorb through the skin whether it's a gel, a cream, a patch and you've got pellets of testosterone. It's sort of the first thing in my mind is making sure that it's the proper hormone so is it progesterone not a synthetic progestergen. Is it estradiol, not ethinyestradiol, is it pure testosterone, like you say, not some sort of anabolic steroid that's been made by goodness knows who. And then it's like a starting dose that's pretty standard for a lot of people. But then on the follow-up, the whole way that it's been absorbed into the body is really important, isn't it? And it varies so much between people.  [00:15:33][110.8]
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Dr Susan Hardwick-Smith: [00:15:35] Oh, so true. So if you're putting something on the skin, one of the interesting things that I honestly did not know until probably a few years ago is that the drug companies that make this stuff, let's just say for example, a standard starting dose for testosterone would be five milligrammes a day. In Australia, that's five or ten, right. So let's say five to be conservative. The understanding is that we're only going to absorb 10% of that. So there's a guess that 90% of it will be lost. Well, that's a pretty wild guess. Is it 95% or is it 82%? Like we have no idea. Everybody's skin's different, like where it's placed, the time of the day, the temperature, whether you exercise, if you've exfoliated, your particular type of skin. So we can use the same dose, just like you said, and we start with a reasonable dose, like say five milligrammes, for example, and then measure it and I'll get quite different results from different patients. Now, no harm will happen in that couple of months. I tell patients, this is a trial for you because you're an individual. It's an experiment with one person in it, but it's a safe experiment because hundreds of thousands of other women have tried before you and this is very safe dose. It might be too low and we may have to increase it. By no means is it gonna be too high, so there's no harm. But I think this idea that it's precision medicine, I mean, if we're putting a gel, especially if we are using something like the, in this country, the male gel and being asked to divide this into 10, and what possible planet is that precision medicine? That is like guest work, at the best. But I mean this is what we have, so I mean no, nothing wrong with doing that, but we have to understand it's a guess, and we don't know how much you're gonna absorb, but it's not harmful to try. Now, men use gel and they have exactly the same issues. They don't know how much they're gonna absorb. The doctor measures it later. There's really no difference. So I get annoyed, to say the least, with the fact that men have all these different options and they are offered these options and counselled by their provider and they get to choose the one that's best for them and everybody's happy about that. For some reason, it's different for women. We're not allowed to use anything, except the male product divided by 10. God forbid we use anything that's a personalised dose, like one of these, that's bad and of course, pellets are even worse, but truly it's the same hormone. So the way we deliver it into our system really doesn't much matter so long as we follow it and we're careful and judicious and start with a reasonable dose. And then listen to the patient, which is ultimately much more important than what the blood test says.  [00:18:19][164.6]
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Dr Louise Newson: [00:18:22] It's so important, you know, having anything made, whether it's like you say made in a pellet made in a cream, made in the gel, as long as it's the proper testosterone at a dose that's suitable for women, it's a lot safer and a few months ago I've used the cream for many years and I decided to try the gel because I wanted to see how easy is it to divide something by eight obviously it's impossible. But I also find that the gel's quite slippery and some of it fell onto the floor when I was using it. But I persevered. But actually, it only took about four or five days and I realised I couldn't think straight at all. We just went down to Oxford, which is only an hour away from here, and I fell asleep in the car like an old woman. I really wasn't concentrating. My husband said to me, have you been playing with your hormones? You're acting like you used to be. I just wasn't absorbing it. Cause I thought maybe I'm tired, you know, I'm very busy and maybe things are catching up. So then I thought I can't carry on like this because I did feel like that cotton wool brain. So, then I went back to the cream and literally within a few days I'm like, wow, I am back. And it's very interesting that the same dose, you know, different vehicle, different way of absorbing makes such a difference. And if you've done my levels, who knows? And I think we do do levels and you're the same and they're a guide. One of the things that I do want to talk about though is the baseline levels. So we do blood tests like I'm sure you do on our new patients for two reasons. One, it's quite interesting to see what their hormone levels are, but secondly, we do other blood tests to make sure they're not low in iron or vitamin D or underactive thyroid because we can't be saying all your symptoms are due to low hormones. As you know, practitioners, we look at everything. So that's important. But when you get the blood results back, often the laboratories will say the results are normal, but the results of very low. So even if your level is next to nothing, I had someone recently had testosterone level was less than 0.4, which basically means they can't find any. It still was marked as normal because they're saying it's normal to not have testosterone if you're in your 50s.  [00:20:40][138.7]
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Dr Susan Hardwick-Smith: [00:20:41] That's right.  [00:20:41][0.4]
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Dr Louise Newson: [00:20:42] It's bonkers, isn't it?  [00:20:44][1.7]
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Dr Susan Hardwick-Smith: [00:20:45] Yeah, so, that's a whole another thing. When I was in traditional medicine, this is truly the way most doctors practise in this country, probably it's the same there. I was so busy that I had a nurse practitioner and I said, just scan down the labs and tell me the ones that are abnormal. I wasn't looking at every line by line. I didn't understand that the reference range that labs use is just simply saying this is what most people have. It's not in any way saying this is optimal. So a woman who's 50, As you know, if she has an estradiol of zero, that's gonna be in the normal column or a testosterone of almost zero. It's in the normally column. What they mean by normal is common, not optimal. So if we're looking at labs, and I totally agree with you, we wanna look at the number, not the reference range, and develop an idea of what's optimal. Now, there's a lot of disagreement about what optimal levels are, but it's one of the pieces of the pictures. How do you feel? Everybody feels. Well, almost everybody does not feel well when her estradiol and testosterone are zero. So how does the patient feel? We replace it, get it up to reasonable levels based on reasonable common sense. And then if she feels better, that's great. But it gets missed so often, I can tell you, back in the bucket of things I missed when I was in traditional medicine, I would have done the same thing. We just were trained to look for stuff that turned red.  [00:22:06][80.9]
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Dr Louise Newson: [00:22:07] Exactly, if it's got an asterisk in red, then you pick it out, in the other ways you don't. And that's really important, because so many people over here now are asking for their blood test, and then they're told it's normal, and it's not normal.  [00:22:19][12.3]
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Dr Susan Hardwick-Smith: [00:22:20] Same here all the time.  [00:22:21][0.5]
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Dr Louise Newson: [00:22:21] Yeah. And then when we review patients, when they're on hormones, we do repeat levels. But again, they're a guide. And I know you have done this like I've done it, is measured your own hormone blood test over the course of a day. And it really fluctuates and changes. Yeah. And so, but the other thing I was taught as quite a young doctor many years ago was that you look at the patient before you look the blood results.  [00:22:45][23.3]
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Dr Susan Hardwick-Smith: [00:22:45] Absolutely.  [00:22:45][0.0]
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Dr Louise Newson: [00:22:46] We've had patients and I know you have that have had raised levels and it's caused panic, you know alarm bells ring in other people's surgeries but then I look at the patient and she's telling me she feels well, she has no side effects. So what I usually do is say, well just continue as you're doing, let's repeat your blood test in two or three months time, let me know if you have any side effects or problems and then usually when they repeat it the levels absolutely fine. Because it's only a snapshot. It's like a little window, isn't it, to what's going on? It doesn't reflect. Yeah, totally.  [00:23:18][31.3]
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Dr Susan Hardwick-Smith: [00:23:19] Yeah, so obvious things like what time of day you go to your blood drawn. I have some patients who use their testosterone morning and night. So we wanna measure it in the middle of the day. Well, not every doctor's gonna say that. If you measure it an hour after you put it on, it's gonna look a little higher. On the other hand, if you missed a dose, it's going to look a lower. So I mean, there's so many factors that can affect. We've got to, like you said, look at how the patient's feeling. If it's a little bit higher than the consensus suggests it should be in the patient's feeling well and not having any side effects. There are so many things that can affect that. In the United States, we're still instructed, and the consensus paper says, measure of total testosterone, not free testosterone, and that's a whole other conversation. The total testosterone doesn't really represent what's available for use, but there's no consensus about what free testosterone should be. So we're really having to use our common sense, and God forbid doctors should use their common sense. You know, my dad was a doctor and I mean, his whole clinical practice was based on common sense because they didn't have all of these tools. I think we've somewhat lost our common sense.  [00:24:24][65.2]
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Dr Louise Newson: [00:24:25] I totally agree. I think we've lost confidence as well, actually, somehow, as doctors. We're so worried that something awful is going to happen. And we're just writing up some data with Mo Khera, actually looking at nearly 2,000 women who have been on testosterone to see if they have side effects. So none of my clinicians can save the record unless they mark any side effects with testosterone. The clinicians get a bit annoyed because they have to go and answer these templates, but it's really important actually. And we're finding vanishingly rare side effects. The commonest, as we know, is you can get some hair growth where you rub on the cream or gel because it can stimulate the hair follicles. But most women can deal with a slight hair growth on their thigh if their brain's working. But the hair on the face, the voice changes, skin changes, are vanishingly the rare. And actually, the few people that have had side effects have still carried on with their testosterone. It hasn't been enough for them to change. testosterone and I think that's really reassuring actually because if it's prescribed at the right dose to the right person at the right time it's very unusual to get side effects isn't it?  [00:25:34][69.3]
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Dr Susan Hardwick-Smith: [00:25:34] Well, absolutely, and I'll just, this is not, I do not believe this is true, but if I play the devil's advocate and I said that, okay, certain patient is going to have oily skin, acne, maybe a few black hairs on her chin, she's not gonna have cancer, heart disease, never been shown to increase death from anything. Apart from these, what I call nuisance symptoms, if it's given at a reasonable level, ask the patient what she wants to do. I mean, this is a patient-centred conversation, like you said, I, if I had those symptoms, which I do not, would completely keep taking it because I feel so much better. I would just do what I needed to do to take care of those symptoms. But if somebody told me I had to stop it because of benign symptoms that are really my choice if I want to absorb them or not. I mean, every drug in the world has side effects, potentially, and we choose if we want to... [00:26:28][53.5]
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Dr Louise Newson: [00:26:28] Totally.  [00:26:28][0.0]
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Dr Susan Hardwick-Smith: [00:26:29] ...absorb those side effects or not, and it should be a patient's choice. Now, I will say we don't really have those side effects if its dosed appropriately. And then another point to remember is we've got enormous amounts of data on giving extremely high doses of testosterone to transgender people who want to have masculinising side effects. So this is a wanted and intended result for those patients. So we know what happens when we give women male doses of testosterone because that community, that's their choice. And yes, they have masculinising effects. However, they do not have cancer. They don't have heart disease. They don't have any other problems. So when people say it's dangerous, it's not, and it's been studied very well in that community and in the bodybuilding community, it's not dangerous. It just causes nuisance symptoms occasionally. [00:27:15][45.8]
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Dr Louise Newson: [00:27:16]  And that's really reassuring. We just had a paper published today actually with Mo Khera's team as well but looking at our data and it's over 11,000 women on testosterone looking at clot risk and we followed people for a year and asked them about clots on testosterone as well as estradiol and progesterone and the incidence was lower than background actually and the few people that had had a clot they had predisposing factors. So again it's really reassuring for testosterone because there hasn't been much data about testosterone and clot. We know how safe it is. So it's Incredibly frustrating. I know you're frustrated and I'm frustrated because we are here as very privileged women who are able to access testosterone and it's kept our physical health and our mental health as good as it can be. And I think that's crucially important but very frustrating that the majority of women who have low testosterone globally cannot access testosterone and if they want it, so many are denied it. So I'm doing a lot of work and you're helping as well with Balance app to really allow women to advocate for themselves and be stronger and have a voice. So as I end the podcast, I always ask for three take-home tips. So what three things do you think women should say to their healthcare practitioner if they want testosterone but they've been refused it? [00:28:42][86.4]
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Dr Susan Hardwick-Smith: [00:28:43] Well I will struggle to narrow it down to three. I think the first thing I might say is that I might be looking for another physician. But if that's not possible, reminding the physician, I heard, I learned that I've had this hormone in my body all of my life. So how could it be harmful to replace it? Secondly, might have to bring them some of the very good studies that we have about the safety and efficacy of testosterone or refer them to your site. If I were cheeky, I might say, if he's a man, isn't it true that men can have their testosterone replaced? So what is the difference with replacing it for women? Now, advocating in that way is not what we were taught. I was taught to be very polite, to believe everything my doctor or my attorney or the priest said. But sometimes we have to understand that not all doctors are educated the same, and we might have to seek out someone else who's on the same page.  [00:29:39][56.4]
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Dr Louise Newson: [00:29:40] Yeah, it's great advice and we have to I think as healthcare professionals and educators, we have to help other people that aren't our patients to advocate for themselves as well. So this conversation is so important and I'm I'm very grateful for your time Susan and thank you. [00:29:40]