James K. Rone, MD, FACP, FACE

Fatigued, moody, poor libido after childbirth

October 17, 2013

Tags: testosterone in women, thyroid, fatigue

THIS PATIENT EMAILED ME ABOUT FEELING FATIGUED, MOODY, AND UNINTERESTED IN SEX 2 YEARS AFTER HER DAUGHTER WAS BORN. SHE MENTIONED HER MARRIAGE WAS ON “THIN ICE” AS WELL.

Let me start with a few general caveats and a few comments upon some of your statements, then I’ll try to provide you some helpful guidance. And please try not to take offense at anything I say—I wouldn’t be doing my best for you if I weren’t honest.

1. If there is a role for testosterone replacement in women—and there probably is, we just haven’t worked out the safety questions, the proper reasons to use it, how to dose it, and there is no practical FDA-approved product that can be adapted easily to the lower doses that would be appropriate in women compared to men—that role would not be in premenopausal menstruating women, but rather in postmenopausal women, especially those who have had a total hysterectomy (taking the ovaries, which still produce testosterone after menopause), and who are disturbed by a lack of libido, which is the main testosterone effect in women, though there may also be some role with respect to fatigue and maintenance of lean body mass (as opposed to fat mass).
2. My reason for excluding premenopausal menstruating women from this potential role for female testosterone replacement, is because the existence of mostly regular monthly menses proves the proper functioning of the brain, pituitary, and ovaries with respect to sex-steroid production—it doesn’t take much to interrupt regular menses, so if you are regular, chances are everything is running as it was physiologically intended to, and if you are not, it is extremely doubtful taking testosterone would be the solution (the opposite might even be the case).
3. By the way, the presence of underarm and pubic hair proves the presence of testosterone and/or DHEAS, the largely similar adrenal hormone, and speaks against the need for replacement of either.
4. Now, giving supplemental testosterone to a premenopausal menstruating woman, is profitable to the clinic doing it, and may well improve energy and libido, but none of that means it’s safe, especially over the long run. Cocaine makes people feel good, but most of us would agree using it is a bad idea, right? Potential side effects of testosterone replacement in young women would include acne, facial and body hair growth, clitoris enlargement, and potentially cancer promotion and potentially birth defects in a female fetus should pregnancy occur. In short, no matter how beneficial it might seem, it’s a bad idea, at least given the current state of our knowledge.
5. With regard to your situation, obviously the best outcome would be for some relatively simple to treat medical condition to turn out to be responsible for your symptoms. I’m forced to point out though that it is not at all unusual—for all kinds of reasons—for young mothers to be fatigued, irritable, distracted, and to have a low sex drive. I don’t need to tell you that having an infant or toddler in the house adds stresses, changes established lifestyles, can be exhausting (especially if you’re working outside the home as well—you don’t say), and not unusually alters the marital relationship, not always for the better. My point being: your friends who say it is “just motherhood” aren’t necessarily wrong—and you finding the answer “unacceptable” doesn’t change that, nor does the fact that your “marriage is on thin ice.” Don’t misunderstand—I’m not unsympathetic to your plight, but the acceptability of the answer is irrelevant. I’m sure many patients with cancer find that unacceptable too.
6. Along the same lines, I will freely admit that depression is diagnosed and treated in situations such as this, excessively, and often wrongly. That fact alone, however, does not automatically make the diagnosis wrong. Food for thought.
7. You mention “hormone balancing.” I don’t know what that means. It’s not a concept any real endocrinologist embraces. It is hype, a catch phrase that alternative-medicine providers—who don’t really know what they are talking about—use. To the extent that hormones need to be “balanced,” our bodies are generally much better at it than you or I or the compounding pharmacist are. (I’m not attacking you, I’m attacking practitioners who throw cool-sounding terms like that around like they mean something.)
8. Don’t be taken in by saliva hormone testing that is used and promoted by many purveyors of bio-identical hormones. Most such testing is unvalidated with respect to accurately diagnosing endocrine disorders. For the most part, real endocrine disorders are only confirmed by carefully done and timed serum testing.

Now, on to the, hopefully, helpful part of this:
1. I’ve treated a great number of patients for hypothyroidism in recent years, whose other doctors said their thyroid levels were “normal,” and it was life changing for some, not all of course. Suffice it to say—I never accept a report of “normal” thyroid functions without looking at the numbers myself. So please send me whatever thyroid test results you can get ahold of and I’ll let you know what I think—send the result and the normal range as they differ from lab to lab. Bare minimum I need a Free T4 and TSH to make a reasonable assessment—but send me whatever you have.
2. Did you experience any peripartum hemorrhage/serious delivery complications? Sometimes that damages the thyroid and other endocrine control mechanisms in ways that are not always easily discernable.
3. Did you breast feed successfully?—if so, that rules out what I was getting at in #2.
4. You mention exercising regularly and that it is mostly “cardio.” I strongly suggest adding resistance training to the mix. Endurance training as you are doing is important and valuable, but resistance training (i.e., weightlifting, and, yes, yoga and stretching to engage muscles we don’t even think about) builds muscle, improves ability to manage activities of daily living, helps weight management more so than endurance training does—and, most relevant for this discussion, the more muscle you have the less fat you have and the enzyme aromatase in fat converts testosterone to estrogen, depleting your body of testosterone.
5. And by the way, dovetailing with my earlier points, it is in fact physiologically normal for the female body to try to rid itself of testosterone, enhancing “estrogen effect” and, frankly maximizing fat deposition (within reason) to assure available caloric resources to maintain a pregnancy and nourish the infant. In other words, to repeat, this notion of supplementing testosterone in young women is just plain wrongheaded. Focusing on profit and “feeling good” over normality.
6. Also, you say you eat healthy, and perhaps you do, but I believe much of what is popularly labeled “healthy” is in fact not, or at least not the best diet for all. Consider increasing protein and fat intake, and limiting carbs, especially breads, and I have virtually eliminated high-fructose corn syrup from my diet. Hydrate well with water, and frankly black coffee is a pretty healthful drink and the caffeine may help your energy.
7. To summarize—send me your thyroid levels and I’ll advise you accordingly. No to testosterone. Yes to resistance training, perhaps yoga. Try changing up your diet since you feel lousy doing whatever it is you are doing. Don’t just assume what everybody says is healthy really is for you. And, frankly, if your marriage is on “thin ice,” regardless of the cause, I’d advise couples counseling. Can’t hurt.

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