Testosterone for Women and Men: What Providers Should Order

Testosterone is the hormone nobody checks in women. Nico Misleh, MSN, FNP-C sat in an OB-GYN office with his wife not long ago and watched it play out. Nobody ordered it. It did not come up. He checks it on every female patient he has, his students all check it, and inside that bubble it starts to feel like standard practice. It isn't. So the first half of this episode is women. Testosterone isn't a male hormone that women happen to carry a little of. They have it by design. It's doing work on lean body mass, on body composition, on cognition and mental clarity, on drive through a dopaminergic pathway, on libido. Bone too. It has effects on bone mineral density that don't run through estrogen, and progesterone does the same thing to bone, so this isn't a testosterone-only story. The woman on estradiol and progesterone can be a lot better and still not be all the way there. Her hot flashes eased and her sleep improved. Her libido is still flat, and she can't hold muscle no matter how hard she trains. That's frequently a testosterone story, and it stays unnamed. Testosterone did not come up once in his own NP program. Not for women, not for men. Androgenic side effects come up. They're real at supraphysiologic doses and uncommon at replacement doses handled carefully. The reference range is the harder problem. It was built on a population that includes symptomatic women, so it can tell you what's typical and it can't tell you what's optimal. His line: we're the cardiologists who never got taught how to use an EKG. Men get the second half. His position is that testosterone is still under-prescribed in men, and that where it does get prescribed, it's often done badly. Total testosterone is probably the least useful number on the panel. Free testosterone is what the cell can actually use. SHBG is the little protein he calls a Pac-Man, binding testosterone up and holding it hostage where tissue can't reach it, and in his opinion you can't interpret a testosterone level without it. He walks a case. Total of 5 or 600, SHBG north of 100, free testosterone nobody ordered. That man has low testosterone and it will never show up on paper, because the value that would have caught it was never drawn. Nico is plain about not having known what SHBG was either. In his words, we're all in this boat together. Then the hands-on stretch. Intramuscular versus subcutaneous and what the head-to-head data actually showed, needle gauge and length, post-injection pain and how to settle it, compounded creams and gels, why he isn't a fan of pellets in either sex, and the dosing philosophy he teaches. You aim for the maximum effective dose, not the smallest one that moves a lab value, because you're restoring a molecule the body already makes. Male testosterone therapy is module two of the HRT University® Master Course. Testosterone in women is the testosterone section of module three, the female module. SHBG runs through both. The Master Course is jointly accredited through Pinnacle Conference, LLC (ACCME, ACPE, ANCC). Earn 30 CE hours, including 12 hours of pharmacology. Master Course: https://hrtuniversity.com/hrtcourse/ More episodes: https://hrtuniversity.com/hrtu-podcast/ The Second Opinion Newsletter: https://nicomislehnp.kit.com/8050eeea5f Provider community: https://www.facebook.com/groups/1179376819949373/