Estrogen, Progesterone, and Testosterone: The Science of Hormones, Sexual Function, and Menopause

In this episode of unPAUSED, Dr. Mary Claire Haver sits down with Dr. Tami Rowen, an obstetrician, gynecologist, and leading gynecologic surgeon at the University of California San Francisco, and an internationally recognized expert in sexual health and sexual medicine. Together they get precise about some of the most misunderstood terrain in women's health: estrogen, progesterone, progestins, and testosterone for women, what they actually do in the body, how the confusion around them began, and what becomes possible for women when care is evidence-based and not fear-based.

Dr. Rowen opens with something most women have never been told: that contraceptive estrogen and menopausal estrogen are fundamentally different molecules with different goals, different mechanisms, and different effects on the body. She walks through why ethinyl estradiol, the synthetic estrogen in most birth control pills, binds to the estrogen receptor 300 times more strongly than natural estradiol, why that matters for everything from blood clotting to testosterone levels to bone density, and why modern contraception is still valuable and worth defending even as we get more precise about how it works.

Progesterone and progestins come next, with Dr. Rowen unpacking what they are, how they differ, why they are not interchangeable, and why the progestin component of birth control is actually the primary driver of ovulation suppression, not the estrogen. She explains progesterone intolerance, who is most at risk, how it connects to PMDD, postpartum depression, and perimenopausal symptoms, and what the alternatives are for women who cannot tolerate micronized progesterone. She also addresses how progesterone sensitivity shows up differently across perimenopause and menopause, and why hormone therapy is rarely one size fits all.

On testosterone, Dr. Rowen covers what the evidence actually supports, where the data is strong and where it is not, why dosing matters and what the risks are when testosterone levels are pushed far beyond a woman's natural range, why pellets carry absorption risks, why packets should never be used for women, and what options exist when no FDA approved product for women is available. She also addresses low libido and sexual desire, the FDA approved libido medications Addyi and Vyleesi, how they work in the brain, and who they are most likely to help.

Dr. Rowen also explains why orgasm changes in midlife, how sexual pain, vaginal health, and GSM and genitourinary syndrome of menopause affect sexual function, why recurrent bacterial vaginosis may have a hormonal root, and why the Dutch test, often marketed as a comprehensive hormone assessment, does not measure what many people believe it does.

Guest links:

• Dr. Tami Rowen (UCSF Health)
  
• Dr. Tami Rowen (ISSWSH)
  
• Dr. Tami Rowen (Instagram)

Recommended Books:

• “The New Perimenopause,” by Dr. Mary Claire Haver
  
• “The New Menopause,” by Dr. Mary Claire Haver

Articles:

• Evaluation and management of hypoactive sexual desire disorder in women. Recommendations from the 5th International Consultation on Sexual Medicine (Sexual Medicine Reviews)
  
• Nomegestrol acetate/17-beta estradiol: a review of efficacy, safety, and patient acceptability (Open Access Journal of Contraception)
  
• Hormonal Contraception and Bone Health in Adolescents (Frontiers in Endocrinology)
  
• Estetrol for the Treatment of Moderate to Severe Vasomotor Symptoms in Postmenopausal Women (E4Comfort Study I)
  
• Combined oral contraceptives containing estradiol valerate vs ethinylestradiol on coagulation: A randomized clinical trial (Acta Obstetricia et Gynecologica Scandinavica)
  
• Conjugated equine estrogens and incidence of probable dementia and mild cognitive impairment in postmenopausal women: Women's Health Initiative Memory Study (JAMA)
  
• Neurosteroid replacement therapy for catamenial epilepsy, post-partum depression, and neuroendocrine disorders in women (Journal of Neuroendocrinology)
  
• Estrogen effects in allergy and asthma (Current Opinion in Allergy and Clinical Immunology)
  
• Contraceptive progestins with androgenic properties stimulate breast epithelial cell proliferation (EMBO Molecular Medicine)
  
• The impact of micronized progesterone on breast cancer risk: a systematic review (Climacteric)
  
• Global Consensus Position Statement on the Use of Testosterone Therapy for Women (The Journal of Clinical Endocrinology & Metabolism)
  
• Testosterone patch for low sexual desire in surgically menopausal women: a randomized trial (Obstetrics & Gynecology)
  
• Testosterone Reference Ranges in Normally Cycling Healthy Premenopausal Women (The Journal of Sexual Medicine)
  
• Breast cancer risk in transgender people receiving hormone treatment: nationwide cohort study in the Netherlands (BMJ)
  
• Estrogen plus Progestin and the Risk of Coronary Heart Disease (New England Journal of Medicine)
  
• Levonorgestrel-releasing intrauterine system use is associated with a decreased risk of ovarian and endometrial cancer, without increased risk of breast cancer. Results from the NOWAC Study (Gynecologic Oncology)
  
• Endometriosis (Nature Reviews Disease Primers)
  
• The influence of combined oral contraceptives on female sexual desire: A systematic review (The European Journal of Contraception and Reproductive Health Care)
  
• Testosterone patch for the treatment of hypoactive sexual desire disorder in naturally menopausal women: results from the INTIMATE NM1 Study (Menopause)
  
• Clinically Meaningful Benefit in Women with Hypoactive Sexual Desire Disorder Treated with Flibanserin (Sexual Medicine)
  
• Bremelanotide for the Treatment of Hypoactive Sexual Desire Disorder: Two Randomized Phase 3 Trials (Obstetrics & Gynecology)

Other Resources:

• Women’s Health Initiative
  
• ISSWSH
  
• BioSante reports LibiGel efficacy trials data
  
• Midlife Women Are Clamoring for Testosterone. Does It Work? (The New York Times)
  
• Why are women prescribed different doses of HRT? (Newson Clinic)