How estrogen-centered menopause care sidelined testosterone in women

Sharon J. Parish, MD, IF, NCMP, explains that menopause care became dominated by what was then called hormone replacement therapy, now known as menopausal hormone therapy. The prevailing idea was that women were missing something that needed to be replaced. Conjugated equine estrogen, paired with medroxyprogesterone acetate for women with a uterus, became a standard formula, and she believes it shifted attention toward restoring estrogen and progesterone rather than androgens.

Bruce Dorr, MD, FACOG, URPS, IFMCP, gives credit where it is due, noting that Premarin's introduction in 1942 was a major breakthrough for women with menopausal symptoms. He describes how the 1966 book “Feminine Forever” by Robert A. Wilson made estrogen synonymous with women's hormones and framed menopause through an estrogen-deficiency lens. He prescribed a great deal of it himself, he says, but it was never the entire hormonal picture, because women did not stop producing androgens.

Parish adds that wide dissemination, a highly publicized Women's Health Initiative, and a large pharmaceutical company behind the product kept attention on estrogen. Later focus on genitourinary syndrome of menopause and vaginal estrogen, she argues, further obscured the role of androgens.

The discussion then turns to the oral combination of esterified estrogens and methyltestosterone. Parish explains that it was intended for refractory vasomotor symptoms rather than sexual function, although smaller trials suggested a sexual health benefit. Concerns about oral testosterone's adverse effects on lipid profiles and potentially the liver contributed to its disappearance from the US market. Notably, she says, it was never FDA approved, and the United States has never had an FDA-approved testosterone product for women.

Parish describes the resulting variability in practice. Some clinicians prescribe only FDA-approved products, whereas others use evidence-based off-label approaches, including male products at female doses that mirror trials of products designed for women.

In the next episode, Dorr recalls the day the Women's Health Initiative results reached his office, and Parish explains how the trial's design shaped 2 decades of hormone fear.