GLP-1 surprise pregnancies, female hormones, and sex after 40 for both of you

A full hour on sex and hormones, and we barely got through the list.

What we covered

GLP-1s and unexpected pregnancy. A warning from the OB/GYN chair: women who've been overweight often don't ovulate regularly because of estrogen made in fat tissue. Lose the fat, get insulin sensitive, and ovulation comes back. We're seeing pregnancies in women who thought they couldn't conceive. If you're prescribing GLP-1s to a woman of childbearing age, have the birth control conversation, and if she wants to conceive, start the prenatal vitamin before she knows she's pregnant, because the neural tube closes before a missed period. Same rule as testosterone in men: it is not contraception.

Nobody asks women about sex. About one in four women report a desire or arousal problem, and we think the real number is higher, because "are you sexually active?" is a useless question and women don't bring it up with male doctors. Better openers: "how's your libido?" and, for anyone, "how is it on vacation, with no kids?" If the answer is "much better," the problem isn't a hormone.

How female hormones decline. The three-minute version: progesterone falls away from estrogen in the 40s, women get put on an SSRI for it, and the SSRI kills libido. Testosterone matters in women too and is usually ignored. The 2002 Women's Health Initiative study scared a generation of doctors off hormone therapy; the data has since been reread. One tell for ovarian decline: a woman who is intensely emotional in the days before her period.

Forms of hormone therapy. We all agree compliance beats everything: whatever form the patient will use consistently. Where we differ is on the details.

• Estradiol: patches for consistency, topical for lower clot risk than oral, or intramuscular injection for the steadiest levels. Patches fall off; creams absorb unevenly and transfer to kids and pets.
• Progesterone: oral micronized, nightly, not cyclically. If a woman can't tolerate a full dose and has to go lower, she needs periodic pelvic ultrasound to check the endometrium. For breakthrough bleeding on injectable estradiol, a low-dose levonorgestrel IUD stabilizes the lining locally with almost no systemic effect. This one changed one of our practices on air.
• Testosterone in women: two of us have moved from creams to weekly or twice-weekly low-dose injections of compounded testosterone. Women feel the difference even when blood levels look the same on cream. Why: skin absorption converts more to DHT (hair loss, acne), and the lymphatic route is unreliable.

Labs. Estradiol has to be the high-sensitivity LC/MS assay or the number is useless. On a cycling woman, draw on day 19 to 21. In perimenopause, draw the morning after a bad night of hot flashes, when FSH and LH are most likely to show it. What FSH, LH, E1, E2 and E3 are. On estriol face creams: holy water.

Perimenopause. Two descriptions from the table: an old truck that runs some days and not others, and ovaries with early dementia. Labs are a snapshot; menopause is defined by a year without periods, not by a number. Educated patients can titrate their own estrogen by symptoms, with progesterone every night.

How to bring it up with your doctor. Not at the 15-minute annual. Book a separate visit and say it's about your sex life. Searching for a BHRT physician is one route, with a caveat: we see 25-year-olds on testosterone and premenopausal women on high-dose estrogen pellets, so credentials and physiology matter. Expect to pay out of pocket for the time.

Men. The ones whose hormones and PDE5 inhibitors are dialed in but "it still isn't working" usually have a stress problem no drug fixes. Sleep apnea is the most common thing under a dead sex drive, and testosterone makes apnea worse. Arterial plaque shows up in erections before it shows up as heart disease; what shockwave therapy does and why getting a morning erection back fixes the psychological half. The tech and founder patients who are on every peptide and still not sleeping.

Receptor fatigue and pellets. The package-in-the-foyer analogy: a steady hormone level stops working as receptors down-regulate. Drop the testosterone dose for a few weeks, then back up, and libido returns. Only one of us uses pellets, and only in women: men need 9 to 15 pellets through three tracks, with bruising and scarring, and once they're in you can't lower the dose. Bodybuilders as the natural experiment: more isn't better, more is more side effects. Use a major lab like Quest or Labcorp; most independent labs' assays aren't trustworthy.

Timestamps

• 00:00 Intro
• 01:19 GLP-1s and surprise pregnancies
• 06:25 The question nobody asks women
• 15:21 Female hormone decline and the WHI study
• 18:35 Patches, creams, pills, injections: what each of us uses
• 28:33 Progesterone dosing, endometrial protection, and the IUD trick
• 35:49 Perimenopause: when to draw labs
• 40:30 FSH, LH, and the three estrogens
• 43:16 How to bring this up with your doctor
• 46:41 Men: libido, ED, and stress
• 48:40 Sleep apnea
• 50:30 Blood flow, PDE5 inhibitors, shockwave therapy
• 53:32 Receptor fatigue and the case against pellets
• 58:43 Injectable testosterone for women
• 1:00:57 Not medical advice, and why the first visit takes two hours

Sources

1. Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women. JAMA. 2002;288(3):321-333.
2. Manson JE, et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women's Health Initiative randomized trials. JAMA. 2013;310(13):1353-1368.