Dr Louise Newson: [01:00:00] You're going to really enjoy this episode with Dr. Kelly Casperson, who hopefully many of you will have heard of. She's a great advocate for testosterone in women. She was on the FDA panel recently, and we talk about testosterone, what it is, what it does in our bodies, how it works in a basic physiological way, and also how women feel when they are prescribed the natural testosterone too. So enjoy it.

Dr Louise Newson: [01:00:28] Kelly Casperson, you are here, but you're not here, which is a real shame because I loved, loved being with you in Australia. You are my new friend, best friend forever, because like me, you've got a really inquisitive mind. And I guess like me you're quite happy to talk about things that you've learned, things that might have got wrong in the past, things that you were taught at medical school, which now you know are not right. But also you've got a lot of clinical knowledge and I find with a lot of things, especially in health of women where there seem to be very polarised views is that a lot people that do a lot of the shouting and are really anti-hormones, they never prescribe them.

Dr Kelly Casperson: [01:01:16] That's true.

Dr Louise Newson: [01:01:16] There's two things I think, which I want to unpick because we want to talk a lot about testosterone in this podcast. Is that if I don't know something, I go back to basic physiology and basic science, and then if I feel really down and I want to give it all up and I feel awful, I just do a day in my clinic and I do a good day a week anyway, it's very busy, and I just see the transformational effects of hormones. So you have this dual effect really, you have science supporting what you think, and then you have the art of medicine showing you what you can think and learn is true. So I think we are both in a very privileged position that we can do both, can't we?

Dr Kelly Casperson: [01:01:56] Yes. Yeah, yeah, absolutely.

Dr Kelly Casperson: [01:01:58] But I think, you know, if we'd had this podcast conversation 20 years ago, well, I wouldn't even have it because I didn't know that women had testosterone. Like, that's madness, isn't it?

Dr Kelly Casperson: [01:02:09] Yes, I didn't know it either. And I thought the other thing, I thought osteoporosis was a fixed state.

Dr Louise Newson: [01:02:15] Yeah.

Dr Kelly Casperson: [01:02:16] Like that was another thing of like, your bones are just osteoparotic, you can't do anything about it. Like that's another one that's coming up a lot. People just think it is how it is instead of bones react to the environment.

Dr Louise Newson: [01:02:27] Yeah. So I was really freaked when I first learned that women had testosterone. But rather than thinking that's not true, I did what I always do, I went back to the basics and I learned a lot of physiology about men and women because essentially our cells are pretty much the same and how testosterone works at a molecular level. And when I talk about testosterone, I talk about the hormone that we prescribe, which is the molecular copy of the testosterone we all produce, men and women, because it's the same, right, isn't it, the testosterone for men and woman. But also what I have done, and I know you enjoy it as well, is looking back at the history of hormones, because as soon as they discovered the molecular structure of testosterone, they commercialised it and they made a synthetic version. So when people are worried about testosterone and the risks, they're actually talking about the risks of the synthetic testosterone, aren't they?

Dr Kelly Casperson: [01:03:28] Yes, that's right.

Dr Louise Newson: [01:03:30] So, I want to talk now about pure testosterone, the testosterone we make in our bodies and men make as well. Men make more than us, but we still make it. And it's a biologically active hormone, isn't it?

Dr Kelly Casperson: [01:03:45] Yes.

Dr Louise Newson: [01:03:45] And it is made all over our body. It's made obviously in our ovaries, but our adrenal glands, our brain makes it, our muscles make it, it gets made everywhere, doesn't it?

Dr Kelly Casperson: [01:03:53] It's fun to talk about because so many people, they don't even know ovaries make it, let alone other body parts convert and make it, to use locally. I always say, I always like to go back to the basics and hormones make healthy cells stay healthy, right, that they work in the nucleus, they help the mitochondria as far as the brain goes. The glial cells, nobody knows what a glial cell is, but I have a neuroscience undergrad. Glial cells are the support cells for the neurons. They help the myelin sheath of the neurons, like testosterone's everywhere in the body, but a lot of people start the conversation too high of like, what's it good for, what's it indicated for, it's like, understand what it does first. Then we can talk about what makes sense of what it's good for.

Dr Louise Newson: [01:04:40] Yeah, and I think this is really, really important when we think about why we prescribe testosterone, because we know that there's all the talk about libido, sexual pleasure. Yeah fine, we know that testosterone prescribing can help with that. But if, you've just mentioned the myelin sheath, now some people might not know what the myelin sheath is, but it's like the conducting part, it's the outside part of the nerve that helps our signals to go very, very quickly. So if I put my hand on a hot plate, I want my hand to remove quickly. But I'll only do that if the signal goes to my brain very quickly and then the signal from my brain, which says, 'oh gosh, that's hot', goes back down my arm and tells my arm to lift my hand off. And the myelin has to be very, there's lots of other reasons, but the myelin has to good. As we age, but also some autoimmune conditions, obviously we know multiple sclerosis, the myelin sheath gets damaged. So I put my hand on the hot plate, my myelin's not good, it's going to take longer for that signal, so therefore I'm more likely to burn my hand. So when you read, and there's lots of papers, I know you've read them as well, that shows that testosterone will help keep myelin healthy, build the myelin sheath, repair the myelin sheath. So then you suddenly start thinking, hang on a sec, what about multiple sclerosis then? Is that more common in men or women, because men have more testosterone than women? Oh, no, it's more common in women. And then what about in men? Is it more common in men who have low testosterone and oh, yes, we've got studies showing that men with low testosterone are more likely to have multiple sclerosis. So then you're like, well, why don't all the neurologists know this? Why aren't we giving testosterone or measuring testosterone levels in people with multiple sclerosis?

Dr Kelly Casperson: [01:06:36] Yeah, very good question. Neurologists, why aren't neurologists curious about testosterone levels?

Dr Louise Newson: [01:06:36] Yeah, you see, it's so interesting, isn't it? When you, and this is what you do in medicine. You start with an idea and a concept, then you go back and work it out. And then if it fits the way you're thinking, we should be exploding that and thinking more and teaching it. I don't know why it's been ignored.

Dr Kelly Casperson: [01:06:54]  I get cynical sometimes of like, because you can't make money off testosterone because it's generic, because it's cheap, because you can't patent a hormone. I mean, if you look at how things are, how money moves science, right. Like culture and economics shape science, whether we want to believe that or not. And if there's no money in it, who's going to fund it unless it's a government that's funding it, right. Which, I would say the health of a nation is very important and worth funding. But the other problem with testosterone is we've said only one gender has it, right. We've made it binary. So people are like, we don't have the data in women. Literally, because nobody's studying women for anything.

Dr Louise Newson: [01:07:36] What's really interesting about that, which you're right, because people don't study women because we're too complicated because of our hormones, but there is very little data about the use of, I don't know, statins in women, for example. So the guidelines for women has been written on the evidence from men. And that seems fine, we can do that or blood pressure treatments, or any treatment.

Dr Kelly Casperson: [01:08:00] Sleep medicine.

Dr Louise Newson: [01:08:02] Yeah, so anything is always based on a 70kg man. And so that's fine, we do that and no one argues. Whereas if we say, oh, we're looking at all the data of testosterone in men and we want to equate that with women, you're like, no, no, no, we've got to do the studies in women, which we know full well, we'll never do. So that seems a bit weird, doesn't it?

Dr Kelly Casperson: [01:08:20] And it's a bias that is worth pointing out because once you point it out, it clicks. Like, you know, once you've pointed out, it clicks in people's brains and they're like, wait. The other very interesting thing is Parkinson's disease. Right, so testosterone and estrogen help the dopamine pathway. Parkinson's is a profound lowering of dopamine in a certain portion of the brain. Looking at testosterone in helping Parkinson's and possible prevention. Right, and we know in men, because we have the studies, low testosterone's correlated with depression and dementia. These are all brain things, going back to the role of testosterone in the brain, right. If brain cells work the same, I think the same is true for women. It's just very hard to do a long-term testosterone study for dementia prevention, but like biochemically and extrapolating the male data, it makes sense. And my other question is, when dementia affects two times, two to three times the amount of women than men. Women carry the burden, it's incurable, treatments are awful and expensive. Why aren't we doing everything we can to try to figure this out and to try and preserve brain health? Like that's my big view of like, we don't have any data to show it's dangerous and we have some good knowledge to show its beneficial. Why can't we take that great leap? We're never gonna do a randomised placebo controlled trial looking at exercise versus placebo for dementia prevention. We're not gonna do it, but we always say exercise is dementia prevention.

Dr Louise Newson: [01:09:55] It's so true and it's so obvious as well. And I know Professor John Studd, who's now died, but he was a great advocate for hormones and did some really great research in the 1980s and 90s. And I remember him saying to me ages ago when I sat in his clinic once, he said, Louise, you don't always need a randomised controlled study. Like sometimes it's so obvious that we just don't need to do it. When they discovered that smoking was associated with lung cancer they didn't do a randomised control study to prove the harm. When they discovered penicillin and they knew how it worked in the body, they didn't do a randomised controlled study. And that's the same with natural hormones. The problem is the only randomised control study we have with HRT is with the synthetic progestogens which we know have risks and medroxyprogesterone acetate, which is a synthetic progestogen. But with testosterone, there are smaller studies. There are a few randomised control studies. There's lots of observational studies. You know, even in 1940, they were doing some studies on women and men with testosterone.

Dr Kelly Casperson: [01:11:03] I think the other thing is because testosterone is so integral, it's myelin sheath, glial cells, mitochondria. It's not specific like for a shoulder problem. And the problem with that is when you give women and men testosterone, they say, I feel more like myself, I have more motivation. The things they say because that's an integral part of your being and your functioning, those things are almost too soft for medicine. Right, like I can measure your blood pressure. I can X-ray your spine. I can't say Louise feels more like Louise. Right, but these hormones are so integral. That's the things they help with. I feel like more like myself. I'm more interested in the world. These are brain things that were very hard to study and so I think it gets dismissed of like, you can't use hormones for quality of life. And I'm like, brain health is quality of life.

Dr Louise Newson: [01:12:01] I totally agree.

Dr Kelly Casperson: [01:12:02] Does that make sense? Like it gets dismissed because it's so integral and it acts in everything.

Dr Louise Newson: [01:12:05] This has happened with a lot of hormone research, and this is why it went back to just looking at flushes and sweats. Because if you had a hot flush in front of me, and I was the researcher, I could see your hot flush. I could, you know, see. But I can't see you smile in the same way. I can't see that internal thing. And even now, I see people talking about the testosterone research and say, well, it's just a placebo effect. Now firstly, you know, so many women benefit from testosterone. I don't think it's just a placebo. And also there are lots of symptoms that improve with testosterone that people aren't expecting. So a lot of people say to me, gosh, my muscle and joint pain's improved. My sleep's improved, my migraines have improved. They weren't expecting that.

Dr Kelly Casperson: [01:12:52] I can think quicker, which is very hard to measure. How do you measure somebody thinking quicker, right?

Dr Louise Newson: [01:12:57] I totally agree and it's little things like I just find that life's easier. I'm not overwhelmed as much.

Dr Kelly Casperson: [01:13:07] I don't hit a wall at 3pm is what a lot of people say. How do you study that? How do you study not hitting a wall at 3pm? And my point is, these hormones are so integral to how the body functions that it's almost hard to study it because the human just feels better. And let's go into that placebo. Number one, statins have a placebo effect. Nobody knows that. Number two, SSRIs [selective serotonin reuptake inhibitors]. The big studies say they probably don't work much more than placebo. And 25% of American women are on an SSRI. So that dismissing testosterone because it's a placebo effect makes no logical sense when we've got 25% of American women on something that doesn't work much better than placebo and we don't blink an eye. We also don't have much long-term studies on SSRIs. And you give people a statin and or a placebo statin and their cholesterol actually goes down. Why aren't we looking into that? Right, like, so the placebo argument to me falls apart so quickly.

Dr Louise Newson: [01:14:15] You're absolutely right and I think it just feels like people are scared of testosterone. And I don't know whether they're scared because women are stronger and better and happier, or the other thing is this confusion about the synthetic testosterones, because we know that the chemical testosterones that are made in a very different structure, do have risks associated with them, of heart disease and clots. But when they made them, and like going back to your point about money, as soon as they found the structure of testosterone in the late 1930s, they wanted to make chemical estrogen, a chemical progesterone, chemical testosterone. And as you probably know, they were trying to make a chemical progesterone and they were testing it on the womb because of course with women, it's always about the womb and bleeding. And they saw it didn't have the same effect as progesterone on the womb. But it had other effects on muscles and various things. And then they thought, gosh, this is very similar to testosterone. So they forgot about progesterone and went straight to the testosterone substances that they made and pushed them to market very quickly. And now there's hundreds of different testosterones and some of them are anabolic steroids, of course, and a lot of them have side effects. And once certain communities got hold of them, it had a really bad rap for the whole of testosterone and that's a real problem, isn't it?  [01:15:50][95.4]
Dr Kelly Casperson: [01:15:50] I joke now because it's so silly at this point, but I'm like, the American political community did not like East Germany winning gold medals in the 1980s at the Olympics. And so an act of Congress, truly an act Congress passed the anti-doping act of 1991. And that's why testosterone is on because of doping swimmers in the Olympics and there's a lot of doping in sport. Nobody wants that. I get that they're trying to control it. But what happened is they took a hormone your body naturally makes and they put it on our DEA list along with ketamine, Tylenol with codeine, and now you need a DEA licence. And that's where the reputation of this is dangerous, because why else would it be on this list, it's on the list because of sport doping. And Lord knows I always joke, I can't make you an Olympic gold metal pole jumper on female dose testosterone. There's going to be other anabolics in there, right, and so there, and there was with the Olympics, lots of anabolics, but this one natural hormone got thrown on the list. I do believe we are working to get it off the list to destigmatise the fact that this is not a threat to life at normal physiologic doses. And that's all we're talking about. Keeping the doses from going low in life, not doping, not trying to make you win a gold medal.

Dr Louise Newson: [01:17:15] So I'm super excited to announce to you that my next book is now available for pre-order. It's coming out on May 21st. It's called The Power of Hormones: break free from fear and misinformation about hormones and harness them for a healthier, happier life. It's very historical, it's very factual, it talks about how hormones work in our body and the mess that we're in actually when we don't have them. There's a lot of information, it's taken a lot of work and I really hope you enjoy it when it comes. So you can find out more about it on my website, on my social media and pre-order it.

Dr Louise Newson: [01:17:57] We've been doing quite a lot of campaigning over here to try and get it changed. And I have a few patients who, and some of them have been on my podcast, who are now having to make the really difficult decision to either give up their sport or take testosterone because they're very testosterone deficient and they're having lots of symptoms. But even if you take it at a really high level, just looking at the randomised control studies, we know that testosterone can improve libido. The women who I've been speaking to with very low testosterone have a myriad of symptoms, but they also have reduced libido. And so in my mind, it seems absolutely outrageous that an organisation is saying that women who are professional sports players with low testosterone are not allowed to have an orgasm and not allowed have sexual pleasure. Because that's basically, isn't it, what it boils down to if they're only looking, so we forget the feeling better in yourself, forget the joint pain, forget migraines, forget all the other symptoms. Just let's look at libido and orgasm. So how can a committee say that women are not able to have an orgasm because we can't give you the treatment that will improve?

Dr Kelly Casperson: [01:19:12] They can take estrogen is my understanding.

Dr Louise Newson: [01:19:13] Yeah, of course they can.

Dr Kelly Casperson: [01:19:15] There's a bias, there's a bias in what hormone you're allowed to replace.

Dr Louise Newson: [01:19:18] And so this is wrong, and I feel sorry for the committee because I think they've been mis-educated by the wrong people, having this confusion between the anabolic steroids, which of course we don't even prescribe and we wouldn't recommend for people to take whether they're athletes or not, with the natural testosterone where we're just replacing a hormone deficiency.

Dr Kelly Casperson: [01:19:38]To my understanding, no natural testosterone has showed increased risk in breast and in fact, Rebecca Glaser's work shows decreased risk of breast cancer. So whenever people say, it was just like estrogen, right, are you talking about oral synthetics or are you talking about, you know, natural transdermal because they're very different mechanisms.

Dr Louise Newson: [01:20:11] So when you talk about testosterone and the mitochondria, you talk about inflammation, it's very similar actually to a debate that's been going on for many years about testosterone and prostate cancer, because people used to say well one of the treatments is blocking hormones for some people who've had prostate cancer. So therefore testosterone is bad, but now they know that actually if you have low testosterone your prognosis is worse and giving testosterone back will improve the prognosis for prostate cancer.

Dr Kelly Casperson: [01:20:43] Yeah, that's right.

Dr Louise Newson: [01:20:44] Cancer, you know, obviously there are different types and different organs, but Rebecca Glaser's work is amazing, but it makes people think about testosterone for people who've had breast cancer. There are no studies that show that natural testosterone increases incidence of breast cancer or worsens survival if people have it afterwards, or if they've had a diagnosis.

Dr Kelly Casperson: [01:21:08] Yep, that's exactly right and I think, I mean, we know that grassroots can make things move mountains. You know, grassroots helped get the black box warning off estrogen products in America very recently. And so I really think the importance of conversations like this to let people start thinking about what, what we're currently doing. Does it make sense? Is it, does it make sense to be afraid of this? Does it makes sense to not research this? Does it sense to not try it if the risks are so low and your fear of dementia is so great right, like body autonomy and self-advocacy of like, education is the way for people to start thinking their way through this because just accepting the status quo we've learned time and time again especially in medicine, we're wrong a lot, we're wrong a lot that's how we advance and to be humble and curious, to progress this profession forward is what is needed because if we just think we know everything that we know, based upon what's available right now, history has proven us wrong 200 times.

Dr Louise Newson: [01:22:14] Absolutely, and I think we can be humble and we can change and we can learn and we can advance. And, you know, we desperately need studies, but most studies are still funded by pharmaceutical companies. No one is interested in a cheap as chips testosterone. But what we can do and what we're all doing actually is educating women to allow them to have a choice and that's so important. And I just wanted to touch on the FDA, Kelly, because, you know, I felt a bit like your mother. I was so proud of you and Rachel. I was so tingly watching you stand there and represent millions of women because you're as cool as cucumber. You must have been really nervous and you knew what you were doing was so important. And I just want to publicly congratulate you because it's, you know, and also two women. You know, it says a lot when women are representing women.

Dr Kelly Casperson: [01:23:12] It was a great honour, so exciting. I had tears, I was sitting, I was like, I was the last one to speak. And I was, I had to get the tears, get the tears back because you got to speak next. It was very moving for me to be on that stage.

Dr Louise Newson: [01:23:29] And it started a conversation, which is what's been needed for decades, actually. And I think we should be allowed to apologise and move on. And that doesn't happen enough actually in medicine, not just with hormones, but in general. People get greedy, things change, they're doing what they think is right initially, but then science might overtake or knowledge might overtake current practices and that's fine, you know. So I think it's incredible. Amazing to be witnessing something in our lifetime where it's going to make such a difference.

Dr Kelly Casperson: [01:24:07] We're now in the post black box era. This is the next one. Watch out for the patch shortages and the progesterone shortages because the women are coming, wanting to try things to help them feel better. And female dose testosterone. We don't have that in America. You're lucky you have AndroFeme. It's coming. It's on its way. I know it. I don't know have a timeline exactly, but it's coming.

Dr Louise Newson: [01:24:27] Well, it's got to, hasn't it? But you know, yes, we have AndroFeme that's become licensed in the UK, but we don't have any product. So it's just dangling a carrot. We can't prescribe it in the NHS. But it is licensed. Like, how did that help women? It didn't really, did it?

Dr Kelly Casperson: [01:24:45] Wait, you mean it's licensed, but it doesn't exist?

Dr Louise Newson: [01:24:48] Yeah, so at the moment in the UK, we can only prescribe it privately, which we've done for many years, but the MHRA have licensed it, but we don't have any stock, so we can't actually prescribe it in the NHS.

Dr Kelly Casperson: [01:24:59] Wild.

Dr Louise Newson: [01:25:00] I know.

Dr Kelly Casperson: [01:25:01] We have you guys as the beacon of hope, so...

Dr Louise Newson: [01:25:03] Well, I wouldn't because the FDA response, it blew up, everything I saw on my social media was all about the FDA announcement. There was nothing in our media over here, nothing.

Dr Kelly Casperson: [01:25:19] That's wild.

Dr Louise Newson: [01:25:19] I think it was firstly because it was good news for women. So if you were all standing on that stage to say, we've got new data that HRT is more dangerous than we think, it would probably be on the front page of our papers. I think media is very selective, we know that. But I think what for me is really disappointing is that the menopause societies, in general, have not come out with a really good statement. Some of them have been completely quiet and some of them have put out some very confusing messages. You know, we should be just reminding ourselves that all guidelines globally, doesn't matter who's written them, say that first line treatment for menopause is HRT. And they all mention testosterone and say, reduced sexual desire. Some say this stupid hyposexual, hypoactive sexual desire disorder, HSDD, which is just barbaric.

Dr Kelly Casperson: [01:26:21] It's just made up. It's all made up.

Dr Louise Newson: [01:26:21] It is but I think, you know...

Dr Kelly Casperson: [01:26:22] Not to dismiss female sexual dysfunction at all. No, but to require a woman to have nothing else in her life going on to affect her desire before she can try testosterone. We don't say that with Viagra and we don't say that with male testosterone.

Dr Louise Newson: [01:26:37] No, but also, it's not just that, they also say women have to be severely psychologically distressed for at least six months.

Dr Kelly Casperson: [01:26:44] Distressed, yeah. I mean, nobody wants to admit to that.

Dr Louise Newson: [01:26:46] Like, you know, we went into medicine to help people. So thinking about testosterone can improve quality of life isn't a bad thing, really, is it, Kelly?

Dr Kelly Casperson: [01:26:56] Sometimes I wonder why I love testosterone advocacy so much, because there's so many barriers to it. So like, I'm just, I like, I'm picking the most like forlorn hormone to try to advocate for, because it has so many barriers against women getting its use. But once you, once you fully understand it, you're like, we can overcome all of this, because this is all just myth, oppression, fear. Like, it's an incredibly safe medication. I come back to that, I'm like, doctors prescribe unsafe medications all the time because they perceive their benefits to outweigh their risks. That's what at the end of the day, benefit, risk, benefit, risk. And with our natural hormones, the risk is so low and the benefit is so great that a woman really should have the opportunity to advocate and have that if she wants.

Dr Louise Newson: [01:27:51] Absolutely. It's a brilliant way to end the podcast thinking about that. So the three take-home tips I'm going to ask you, are what three ways do you think we can enable more women to access testosterone if they want it?

Dr Kelly Casperson: [01:28:07] Learn about their bodies. Learn how it works. Learn how to talk to doctors, and learn how find a doctor that is, you know, already does it, right. We need to enable women to go to a warm audience, right, and then train more doctors and clinicians. And we're doing that, but doctors and clinicians, at least in America, are getting trained on hormones at an unprecedented rate right now. And I'm not just talking OBs. Like, I had a GI doctor text me yesterday, being like, nobody else is doing this. I see the need, I need to learn. So more and more doctors are getting trained. So I think that's it, like education, advocacy, and then physician and clinician knowledge and education, the know-how. And we need an FDA-approved product because, not that it's going to be absolutely superior, but it's gonna blow open the conversation. It's gonna give it a permission slip which we don't have right now.

Dr Louise Newson: [01:29:08] So let's hope we can all work together and keep this conversation getting busier and louder and help more women at the end of the day. So thank you so much for all your work, Kelly.

Dr Kelly Casperson: [01:29:19] Thank you. Pleasure to talk.

Dr Louise Newson: [01:29:21] And all your support and look forward to seeing you in the US sometime soon.

Dr Kelly Casperson: [01:29:26] Sounds good. Cheers.

Dr Louise Newson: [01:29:27] Thank you, bye.

Dr Louise Newson: [01:29:30] I've got something really exciting to share with you. Every Thursday, I'm going to be releasing an extra episode for those of you that sign up. It's an opportunity that I can have more guests share more information, dig deeper into the research that I can share with you. And when you subscribe, this money is going to used to help with research, much-needed research that's away from pharmaceutical companies. So information is down in the show notes. So have a look and subscribe and enjoy.

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