Testosterone: Overregulated, Undertreated, and Misunderstood

Johanna is sharing a conversation from the You Are Not Broken podcast — Dr. Kelly Casperson sitting down with urologist and hormone health advocate Dr. Helen Bernie. They cover why testosterone remains one of the most misunderstood, over-regulated, and under-prescribed hormones in modern medicine — for both men and women — what the FDA's regulatory history has to do with that, and why getting this right is a public health issue, not just a personal one.

🤩 You Are Not Broken

https://podcasts.apple.com/us/podcast/you-are-not-broken/id1495710329?i=1000771524848

Transcript

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Hello my friends, and welcome back to Not Your Mother's Midlife. I am your host, Joanna, and today we're talking about testosterone. Why it's one of the most misunderstood hormones in medicine and why it's being undertreated in both men and women, and why the biggest barrier to fixing this isn't the science, it's the politics. I'm sharing an episode from You Are Not Broken Podcast with Dr. Kelly Kasperson. And she's sitting down with Dr. Helen Burney. Dr. Bernie is also a urologist, director of sexual and reproductive medicine at Indiana University. And the conversation covers both men's and women's health. And I think that's actually what makes it worth sharing because the value of the system around testosterone are not a woman's problem or a men's problem. They are a medicine problem. Let's start with the basics. Testosterone is not just a men's hormone, it is a human hormone. Both men and women produce it, and in both, it plays a role in energy, mood, muscle maintenance, bone density, cognitive function, and libido. Everyone always just thinks it's about the libido. Nope, it's about much more. And when levels drop, which happens gradually in men from around their 30s and more abruptly in women during perimenopause and menopause, the effects show up across multiple body systems. And Dr. Burney makes the case that low testosterone should be part of a routine health screening for everyone. Not because it's a quality of life issue, although it is, but because the research links testosterone's deficiency to early mortality. Diabetes, osteoporosis, and cardiovascular disease. These are serious downstream outcomes. And yet it rarely gets screened for routinely in either sex. On the men's side, she covers something that reframes how we think about sexual health entirely. Erectile dysfunction is not just a bedroom problem. It is frequently the first visible sign of underlying vascular disease because the blood vessels involved are smaller and show damage earlier than the larger vessels around the heart. She describes it as a cardiovascular biomarker, hiding in plain sight. When it's treated as an embarrassing inconvenience rather than a clinical signal, the opportunity to catch serious disease early gets missed. And for women, the picture is different, but the gap in care is just as wide. There is currently no FDA-approved testosterone product specifically indicated for women in the United States. Women who are prescribed it receive it off label, often through compounding pharmacies, with all the inconsistency in dosing and quality that comes with that. Meanwhile, the evidence base for testosterone in postmenopause women for bone density, cognitive function, energy, and muscle mass continue to grow. The science is moving, the regulation is not keeping up with it. Dr. Burney goes into the policy history that created this situation, and it is worth understanding. Testosterone is a Schedule 3 controlled substance. The classification shapes everything. How cautious doctors are about prescribing it, how little incentive pharmaceutical companies have to fund the long-term trials that would generate proper approved indications for women, and how difficult it is for patients to access evidence-based care without navigating a system that was not designed with them in mind. She has been in front of the FDA arguing for reform. The data, she says, is there. The regulatory will is lagging. She also talks about the rise of unregulated men's health clinics, the kind that have proliferated online and offer testosterone without proper baseline workup or monitoring. Her concern is not testosterone therapy, it is testosterone therapy done carelessly without the labs, clinical picture, the follow-up. Because done well with proper oversight and combined with lifestyle changes, and in some cases GLP1 medications, hormone therapy can reverse metabolic disease. Done badly, it creates a different set of problems. New research on testosterone administration roots and clot risk also gets a mention. The root of administration matters, similar to what we know about oral versus transdermal options for women's hormone replacement therapy, and the science here is still developing. The frame Dr. Bernie keeps coming back to is that healthy hormones are not a personal preference. They are a public health issue. When large numbers of people, men and women, are walking around with undiposed testosterone deficiency, with all the downstream effects on metabolic health, bone density, cardiovascular risk, and cognitive function, and the medical system is not screening for it or treating it effectively, that is a policy failure with real consequences. I will link the full you are not broken episode in the show notes. But for now, thank you so much for listening. If you enjoyed this episode, like always, share with a friend or share with your significant other for this one. Share on your socials. You never know who needs to hear this. This is for the girls and the guys. Subscribe to this podcast and to my YouTube. There's lots of fun videos over there. You'll never miss an episode. And until next week, I'm Joanna, and this is not your mother's midlife. Bye bye.