The Testosterone Conversation with Dr. Kelly Casperson: Beyond Libido Description

In this episode of unPAUSED, Dr. Mary Claire Haver continues her conversation with Dr. Kelly Casperson, urologist, author, and host of the podcast "You Are Not Broken." Part 2 goes deep on testosterone therapy for women, the most misunderstood hormone in women's health, and covers the full range of what it actually does in the female body, why every woman will experience declining levels over time, and why there are still zero FDA approved testosterone products for women while men have more than a dozen.

Dr. Casperson opens with the basics: ovaries make testosterone, the hormone pathway runs one way from cholesterol through progesterone to testosterone to estradiol, and women in normal cycling years carry four times more testosterone than estrogen in their bodies. She explains where testosterone receptors are found, which is everywhere from the brain to bone to muscle to the clitoris to the tear ducts, and why reducing testosterone in women to a libido drug misses the full picture entirely.

The conversation covers what testosterone actually helps with across every domain of female sexual health including desire, arousal, orgasm, and blood flow to the clitoris, as well as its role in energy, motivation, mood, nerve function, and mitochondrial health. Dr. Casperson explains why women and testosterone research is lagging decades behind male data, why women on estrogen who add testosterone are able to reduce antidepressant use at significantly higher rates, and why she describes it not as a libido medication but as a motivation medication that supports the dopamine and serotonin pathways.

They address the safety data directly. Decades of data exist on testosterone use in trans men at ten times the female physiologic dose with no increased risk of death, cancer, or breast cancer over 50 years. Dr. Casperson also walks through the emerging research on testosterone and breast cancer risk reduction, the cadaver data showing higher brain testosterone levels correlating with lower rates of dementia, and why she would spend a blank check on a randomized placebo controlled trial studying testosterone and dementia prevention.

Dr. Casperson walks through how to prescribe testosterone responsibly without FDA approved products, why pellets tend to run supraphysiologic and what that means for hair loss and side effects, and how to evaluate whether a patient is a candidate. Dr. Casperson also walks through what labs she runs on every woman who presents with hypoactive sexual desire disorder or who simply does not feel like herself, from a full thyroid panel to fasting insulin to B12 to omega-3 levels.

The episode also covers genital urinary syndrome of menopause, the Medicare data showing only 7% of women who received a GSM diagnosis were given vaginal estrogen within 18 months, how to apply vaginal estrogen cream correctly and why a loading dose is often counterproductive, and the data showing vaginal estrogen decreases urinary tract infections, reduces ICU admissions and death from sepsis, does not increase breast cancer recurrence, and may be associated with decreased risk of rectal cancer.

Also covered are vaginismus, pelvic floor dysfunction, the role of vibration and blood flow in restoring sexual function, the sexual side effects of birth control pills, antidepressants, and GLP one medications, and why moisture during sex is not a reliable indicator of desire or arousal.

The episode closes with Dr. Casperson's message to every woman listening: you are not broken.

Guest links:

• Kelly Casperson, MD
  
• Kelly Casperson (Instagram)
  
• Kelly Casperson (YouTube)
  
• You Are Not Broken (Apple Podcasts)

Books:

• “You Are Not Broken,” by Kelly Casperson, MD
  
• "The Menopause Moment," by Kelly Casperson, MD 
  
• “The New Perimenopause,” by Dr. Mary Claire Haver
  
• “The New Menopause,” by Dr. Mary Claire Haver
• "Sexual Behavior in the Human Female," by Alfred Kinsey
  

Articles:

• Oral Sildenafil in the Treatment of Erectile Dysfunction (New England Journal of Medicine)
  
• Primary Orgasmic Dysfunction: Diagnostic Considerations and Review of Treatment (Psychological Bulletin)
  
• Genital vibration for sexual function and enhancement: a review of evidence (Sexual and Relationship Therapy)
  
• The Role of Vibrators in Women’s Pelvic Health: An Alluring Tool to Improve Physical, Sexual, and Mental Health (International Urogynecology Journal)
  
• Differences in Orgasm Frequency Among Gay, Lesbian, Bisexual, and Heterosexual Men and Women in a U.S. National Sample (Archives of Sexual Behavior)
  
• Variation in Orgasm Occurrence by Sexual Orientation in a Sample of U.S. Singles (Journal of Sexual Medicine)
  
• Men versus women on sexual brain function (Human Brain Mapping)
  
• Menopause & Masturbation Clinical Study (Womanizer x Kinsey Institute)
  
• Effects of testosterone treatment on clitoral haemodynamics in women with sexual dysfunction (Journal of Endocrinological Investigation)
  
• Role of Estrogens and Estrogen-Like Compounds in Female Sexual Function and Dysfunction (Journal of Sexual Medicine)
  
• Testosterone for Treating Female Sexual Dysfunction (Clinical Obstetrics & Gynecology)
  
• Mortality trends over five decades in adult transgender people receiving hormone treatment: a report from the Amsterdam cohort of gender dysphoria (The Lancet)
  
• A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones (European Journal of Endocrinology)
  
• Testosterone and pre-androgens by age and menopausal stage at midlife: findings from a cross-sectional study (eBio Medicine)
  
• Predicting low testosterone in aging men: a systematic review (CMAJ)
  
• The effects of transdermal testosterone and oestrogen therapy on dry eye in postmenopausal women: a randomised, placebo-controlled, pilot study (British Journal of Ophthalmology)
  
• Testosterone, cognitive decline and dementia in ageing men (Reviews in Endocrine and Metabolic Disorders)
  
• Testosterone for Low Libido in Postmenopausal Women Not Taking Estrogen (New England Journal of Medicine)
  
• Global Consensus Position Statement on the Use of Testosterone Therapy for Women (The Journal of Clinical Endocrinology & Metabolism)
  
• A Retrospective Case Series on Patient Satisfaction and Efficacy of Non-Surgical Lysis of Clitoral Adhesions (Journal of Sexual Medicine)
  
• Vaginal Estrogen Utilization Among Medicare Beneficiaries With Genitourinary Syndrome of Menopause (JAMA Network)
  
• Management of Antidepressant-Induced Sexual Dysfunction: A Literature Review (Cureus)
  
• Effect of GLP-1 agonists on testosterone levels: a systematic review and meta-analysis (BMC Urology)
  
• Treatment Gaps in the Management of Genitourinary Syndrome of Menopause (JOGC)
  
• Vaginal use of estradiol is associated with a reduced risk of rectal cancer in postmenopausal women: A Finnish nationwide case-control study (Maturitas)
  
• Reduced breast cancer incidence in women treated with subcutaneous testosterone, or testosterone with anastrozole: A prospective, observational study (Maturitas)

Other Resources:

• PHIL Rx
  
• HRT may help women stop antidepressants, study suggests
  
• Antidepressant Use Among Adults: United States, 2015-2018 (CDC)
  
• Impact of Vaginal Estrogen on Serious Adverse Outcomes in Postmenopausal Women with Recurrent Urinary Tract Infections: A Retrospective Study (ICS-EUS 2025)
  
• Dr. Mary Claire Haver (Substack)
  
• 2023 ISSWSH Slide Deck (ISSWSH)