Oh, FFS. you don't treat depression with testosterone cream...
Summer was nice. I'm back. Mostly because I'm furious about the medical care my friend Grace recently received.
Grace is obviously not her real name--but it's appropriate because she is giving the provider much more grace than I think that they deserve.
Notice my use of provider. Grace has a doctor that she really likes, but couldn't get in to see her when her mood took a turn for the worse.
She's perimenopausal, and lives in an affluent area. She's been on proven, effective treatment for her perimenopausal symptoms with continuous progesterone and an estrogen patch. Both tested, approved, prescribed. Been around for most of her lifetime and regulated to have the right components at the correct doses. Fantastic. More women should get this when they struggle with the shit show tossed at them in mid-life.
Here's where I stopped giving grace...
Her doctor has been sending the estrogen patch prescription to a compounding pharmacy, where she has been paying out of pocket for these. This is despite her selecting her regular, national pharmacy as her preferred one. She recently discovered that her insurance would fully cover her estrogen patch if it had been sent to her regular pharmacy instead.
She asked if I thought that her provider was sending the prescription to the compounding pharmacy to help them profit. They were not compounding anything, just slapping a label on a box. Of estradiol patches. Which have been widely available and inexpensive for years.
I have no filter. I said yes. It isn't ethical for a provider or doctor to send a prescription to a pharmacy that they have a relationship with over the patient's preferred pharmacy, provided that medication is available at the patient's preferred pharmacy.
Back to compounding pharmacies in general--compounded substances are considered supplements. As such, they are not subject to regulation by the FDA or anyone else. It's one thing to have to pay out of pocket for a box of patches there. At least you know somewhere along the line, they have been tested and approved, that they contain the medications they are supposed to, in the amounts that are listed, with minimal variation batch to batch. Nobody is looking at what's in the compounded substances and testing them. They can contain varying amounts of hormone or medication at best; impurities or contaminants at worst. You can market literal snake oil and slap a label on it that says "all natural", provided you can squeeze the oil from the snake.
Remember the fungal infections from steroid injections in 2012?
https://www.nejm.org/doi/full/10.1056/NEJMoa1212972 (To be clear, Grace did not suffer from one of these injections.)
I wish I could say Grace's saga ended here.
When her mood swings worsened recently, she scheduled an appointment with the mid-level provider with the chief complaint "moodiness". The clinic labeled her appointment a "hormone consult" due to the fact that she was on estrogen.
The nurse took her blood pressure, and on the way out the door, with the door open and the receptionist looking at her, asked "In the last week, have you had feelings of being down, or uninterested in doing things?" She said, "well, yes, that's why I'm here."
That was the extent of her mood evaluation. For the entire visit.
In a week where all anyone can talk about is Lindsay Clancy's trial, how mood disorders can rarely become deadly or psychotic or both, and how the system failed to help her when she repeatedly reached out.
When I see my doctor, and when I was practicing, standard of care is a depression screen. It can start with a single question, like Grace's did. Generally asked in private, and not on the way out the door. When the main reason for the visit is a change in mood, it is generally a simple questionnaire like a PHQ-9. Yes, it's nine questions instead of one. You can search it online and fill it out and score it yourself here. The biggie question is the last one, have you thought of harming yourself or others?
Nobody wants an answer to that other than "never". Everyone deserves to be asked the right questions.
For her mood, Grace was given a prescription for testosterone lotion from the compounding pharmacy. She paid for this out of pocket. She sent me a photo, asking "What does it mean, one pump? How much hormone is in that?" That is the million dollar question--nobody actually knows.
She was also told to "find a functional medicine doctor, and fine tune her gut health".
She's not opposed to modern medicine. She doesn't drink unpasteurized milk. She's not MAHA. She wanted someone to address her depressed mood, to listen to her.
The problem is, how was she supposed to know? She trusts this clinic. She likes her doctor.
Acknowledging that I haven't practiced nor prescribed in five years, I did my own searches for data on this off label use of testosterone. Off label doesn't mean it doesn't work, it means that it's not approved for treatment of this condition.
My search history will now be tainted with functional medicine searches and clinics that promote using testosterone for any number of random concerns. I'm already getting ads.
It appears that I, too, could become a functional medicine provider, as long as I don't claim to be practicing as an MD. Because, you know, brain tumor, loss of memory, unsafe to practice, giving up my medical licence. I wouldn't go to me--but I could charge you cash for my opinion. I could also be a lay midwife and supervise home births. Not gonna happen.
Searches are fraught with errors. We see what we want to in the results, and the more we look, the more the algorithm feeds us results that support this position.
Adding a trusted resource to your search makes it more reliable.
If you search "testosterone menopause", the first result I get is a clinic selling something, a sponsored result. With an attractive doctor or provider photo, a finely tuned website. Designed for clicks and searches. Whatever they say, they are selling a product. This clinic's ads have now infiltrated my social media feed. I prefer links to Bombas and Birkenstocks.
Adding some key search words can sift out what's being sold from what's fact. So can looking for sources cited. Try .edu, NAMS (North American Menopause Society, now just known as Menopause Society, but NAMS is shorter and works), ACOG (American College of Obstetrics and Gynecology. NEJM (New England Journal of Medicine), BMJ (British Medical Journal--although they can link to medications not approved in the US), JAMA (Journal of the American Medical Association). Peer reviewed sources. (I used to say NIH and CDC, but now one must be cautious, since the departments have been gutted and filled with yes men and women...see below.)
Avoid clinics with their own pay out of pocket lab testing and pharmacy.
I have not accepted AI fully into my life, and never will with my writing. (rest assured, the ramblings are all mine).
BUT--even the AI response to "acog testosterone menopause" was spot on. And different from the first search.
AI Overview
According to the American College of Obstetricians and Gynecologists (ACOG), testosterone therapy is only recommended during menopause for the management of hypoactive sexual desire disorder (HSDD)—characterized by a low sexual interest that causes personal distress. [1, 2]
Key ACOG and Medical Consensus Details
No FDA Approval: There are no FDA-approved testosterone formulations specifically indicated or marketed for women. When used, clinicians typically prescribe male-approved formulations at a significantly reduced dose (about one-tenth of a male dose) or utilize specialized compounding. [1, 2, 3]
Not for General Symptoms: ACOG does not support using testosterone for fatigue, cognitive decline, mood changes, muscle mass building, or generalized bone protection due to a lack of robust safety and efficacy data. [1, 2]
Delivery Methods: ACOG recommends avoiding testosterone pellet therapy because of a lack of safety data and the inability to remove the pellet if adverse effects occur. Transdermal options (like low-dose gels or creams) are preferred. [1, 2]
Monitoring: Baseline evaluations and follow-up blood tests at 3 to 6 weeks, then every 6 months, are used to ensure testosterone levels stay within a safe physiological female range (20–80 ng/dL). Treatment should be discontinued if no improvement is seen after 6 months. [1]
"Supplements are also held to no purity or quality standards—so you don’t know what active ingredient you’re getting or how much of it. Some unregulated products can contain dangerous levels of estrogen, progesterone, or even testosterone." from above ACOG patient information by Dr. Nanette Santoro.
One last thought, since you now can't trust everything (anything?) from CDC :
Measles vaccines work.
CIDRAP is an extention of the infectious disease department at the University of Minnesota.
https://www.bmj.com/content/394/bmj-2026-100744 If you prefer to get the news from the Brits. Hell, even AI has the correct response when I search "measles deaths in the US in 2026"
By the way, there are antidepressants, like Effexor (venlafaxine) that have been studied and shown to improve both depression and perimenopausal symptoms. Give us grace.
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