Ashwagandha, Protein, and the Testosterone Insurance Nightmare

Episode Script

Thanks Toni. We've got a good one to close out the week.

Three things today — a supplement study worth taking seriously, a reason to rethink your protein intake, and a story about testosterone prescriptions that is going to frustrate you in a very specific way. Let's get into it.

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Ashwagandha has been floating around wellness circles for a long time. It's in stress supplements, sleep gummies, adaptogen blends — you name it. And for a while, the evidence behind it for menopause specifically was pretty thin. Interesting animal data, some small human studies, a lot of enthusiastic marketing. The usual.

This week, something more substantial landed in the NAMS journal — that's the journal of the North American Menopause Society, so this is peer-reviewed, not a brand press release.

The study was a randomized, double-blind, placebo-controlled trial. That's the design you actually want. One group got ashwagandha root extract, the other got a placebo, and neither the participants nor the researchers tracking outcomes knew who got what until the end. That setup matters because it's the best way we have to filter out the placebo effect, which is real and strong in sleep research especially.

They ran it for 12 weeks with postmenopausal women. The results: the ashwagandha group had significantly better sleep quality, improved menopausal symptoms — hot flashes, mood, that kind of thing — and better body composition compared to the placebo group. Safety looked clean across the board.

Now, I want to be careful here, because "significantly better" in a study doesn't always mean "you will feel dramatically different." It means the difference was real enough statistically that it probably wasn't just chance. That's meaningful, but it's not the same as a guarantee.

A few things I'd want to know before recommending someone run out and buy any ashwagandha product off a shelf: What was the dose? What was the specific extract formulation? Because ashwagandha supplements are not all the same. Some are standardized root extracts with a known concentration of the active compounds. Some are basically just dried root powder in a capsule that may or may not do much. The study used a specific standardized extract, and that detail matters.

My honest take: this is the kind of evidence that moves ashwagandha out of the "maybe, who knows" category and into "worth a conversation with your doctor" territory. It's one trial, not twenty, so I wouldn't overweight it. But it was done properly, it was published in a serious journal, and the safety profile was good. That's not nothing. If you're already curious about it, this gives you something real to bring to that conversation.

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Protein. I talk about this a lot, and I'm going to keep talking about it because the evidence keeps building and most women are still not eating enough of it.

A new systematic review and meta-analysis — that's a study that pools data across multiple studies to look for patterns — published this week, also in the NAMS journal, looked at protein intake and handgrip strength in postmenopausal women.

Handgrip strength might sound like a weird thing to measure, but it's actually one of the better proxies we have for overall muscle health and even longevity. If your grip is weak, it tends to reflect what's going on throughout your body in terms of muscle mass and function. Researchers use it a lot because it's easy to measure consistently.

The finding: women with higher protein intake had significantly greater handgrip strength and lower BMI than women eating less protein. Across multiple studies. That's a pattern, not a fluke.

After menopause, you lose the hormonal support that helped you build and hold onto muscle more easily. Estrogen plays a role in how your muscles respond to exercise and protein. When estrogen drops, your body becomes less efficient at using the protein you eat to build muscle — so you actually need more of it to get the same effect.

Most dietary guidelines were set based on data from younger adults, often men. The amount of protein they suggest is probably enough to avoid deficiency. It may not be enough to actually maintain muscle mass through menopause and beyond. There's a difference between "not losing muscle fast" and "holding onto strength as you age," and the research keeps pointing toward higher protein being important for the second one.

What does higher protein actually look like? Research in this space tends to point toward somewhere around 1.2 to 1.6 grams of protein per kilogram of body weight per day for older adults trying to preserve muscle. That's a meaningful step up from the standard recommendation of 0.8 grams per kilogram. It's not an extreme amount — it's roughly the equivalent of making sure you have a solid protein source at every meal, not just dinner.

Good sources: eggs, Greek yogurt, cottage cheese, chicken, fish, legumes if you're plant-based, edamame. The weekend is actually a good time to pay attention to this. A lot of people eat less intentionally on weekends, snacking more, skipping structured meals, and protein intake tends to drop without noticing.

If you want to try something concrete this weekend: just check whether you have a meaningful protein source at breakfast and lunch, not just dinner. That one shift makes a bigger difference than most people expect.

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Okay. The testosterone story.

CNN ran a piece this week on a trend that's been building for a couple of years: more doctors are prescribing testosterone for women — for low libido, energy, brain fog, things that estrogen alone doesn't always address — and more insurance companies are denying those prescriptions.

At the same time. The prescriptions are going up. The denials are going up.

Here's the part that matters for understanding why this is happening. There are no FDA-approved testosterone products specifically for women in the US. Zero. The ones being prescribed are either male formulations at lower doses, or compounded versions made by a pharmacy specifically for that patient. Both of those options give insurance companies an easy way out. They can call it off-label, unproven, experimental — and deny the claim.

The thing is, there's actually a reasonable body of evidence supporting testosterone for certain symptoms in postmenopausal women, particularly low libido. The International Society for Menopause and other major bodies have position statements on it. It's not fringe medicine. But because no pharmaceutical company has gone through the FDA approval process to get a women's formulation approved — that process costs hundreds of millions of dollars and companies have made the calculation that the market isn't big enough to justify it — women are stuck.

Their doctor says: this could help you. Their insurance says: we don't cover that. And then the woman is looking at a compounded prescription that costs anywhere from forty to over a hundred dollars a month out of pocket, depending on the pharmacy and the dose.

This is a structural problem. It's not a rogue insurance agent making a bad call. The system has no approved product to point to, so it has no obligation to cover it, and it won't. The fix would require either a pharmaceutical company investing in the approval process, or a regulatory pathway that actually catches up with how women's hormonal health is being treated in clinical practice. Neither of those things is happening quickly.

What I'd say to anyone who's been denied: ask your doctor specifically about the evidence and whether an appeal is worth attempting. Some insurance companies will cover it under a different diagnostic code. Some will approve it with a letter of medical necessity. It's not guaranteed, but it's not always a dead end either. A menopause-informed provider — someone who actually knows this space — is going to be more useful here than a general practitioner who's never prescribed testosterone for a woman before.

The broader point is that this is one of the cleaner examples of a gap between what good menopause care looks like in 2026 and what the insurance and regulatory infrastructure is actually built to support. Women are getting better care from better-informed doctors, and the systems around them haven't caught up. That gap has a real cost — not just financial, though that's real — but in terms of women going without something that might genuinely help them because the paperwork didn't work out.

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Thanks for spending the week with us. If you're enjoying Hot Flasher, hit subscribe wherever you listen so you don't miss an episode — new episodes drop every weekday. Have a great weekend, and I'll see you Monday.

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Sources curated automatically by the Hot Flasher pipeline.