Search for tag: "testosterone"

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Scot: You guys want to hear an epic tale?

Mitch: How epic?

Troy: I'm ready.

Scot: Should I tell it in my epic tale voice?

Troy: Please.

Scot: There are other people around though and I think they can hear me, so I'm feeling a little shy about it right now.

Dr. Smith: Let it go.

Scot: The office I . . . Listen and you shall hear the tale of two guys and testosterone therapy. One guy got amazing life-changing results, the other none, nothing, nada, zip, zero, bupkis. In the telling of this tale of T, we hope we can help all men learn why T works for some guys and not others. Was that epic?

Troy: That's epic. Who uses the word bupkis anymore, though? Bupkis?

Scot: This is "Who Cares About Men's Health," providing information, inspiration, and a different interpretation of men's health. And today, to tell the tale of T are the "Who Cares About Men's Health" players. I am Scot and, obviously, I bring the BS. Balancing my BS with his MD is Dr. Troy Madsen.

Troy: I'm not part of the tale of T, but I'm excited to learn more about it.

Scot: But your name begins with T.

Troy: Oh, that's right.

Scot: Producer Mitch is also in the mix.

Mitch: Hey, there. I didn't know we were players. I kind of like that.

Scot: And Dr. John Smith is from the Division of Urology at University Utah Health. And he's going to talk us through testosterone therapy in our tale of two different guys with two very different experiences with testosterone. Dr. Smith, as always, it's great having you on the show.

Dr. Smith: Gentlemen, thank you for having me.

Scot: By the way, your shows that you do with us are quite often the most listened to shows. And I don't know if it's because the topics you talk about are just really that interesting to people, or if it's because you have lots of family members. But I don't care. It doesn't matter to me.

Dr. Smith: We Smiths are a large clan.

Scot: There's kind of this implied thing and . . . I don't know. Maybe it's just me, but I think it's a lot of guys, that testosterone is kind of a cure-all for men who are suffering from fatigue, or struggling to lose weight, or struggling to put on muscle mass, or their sex drive is reduced. So it's kind of like, "All guys should be on it," right?

But we've talked about testosterone on the show before and testosterone therapy, and it's not a magic bullet. It works for some guys, and some guys, it doesn't necessarily work for. The only time it's a magic bullet apparently is if you're Mitch. We're going to hear about his pretty amazing story with testosterone.

And then, on the other hand, we're going to hear about my experience that I had with it that I haven't really talked about on the show, because I had a hard time putting it into words and figuring out what that story was. But after hearing Mitch's story, I figured out what my story is.

And I think in this process, we could kind of learn a little something about testosterone therapy, that it's not this universal cure-all. And Dr. Smith would back that up, right? It's not a universal cure-all like the ads would have you believe.

Dr. Smith: Well, I think a lot of it depends too on your patient selection. A lot of guys come in because they hear about a guy like Mitch where it changes things for them, their life is great, they have a lot of benefit from it. And they go get their testosterone checked, and they may not even have low testosterone. It may be something else. And so you do see a relative benefit for some and not others based on lab results and other things.

Scot: So, back in Episode 102, Dr. Smith talked about how maybe some guys with low testosterone might slip through the cracks because their doctors aren't necessarily familiar with hormone therapies or they're not comfortable with them as opposed to Dr. Smith, who's studied this and has put in more time as an expert. Not saying anything bad about anybody else. It's just that he's had a lot more experience with it.

So that conversation made Mitch seek a second opinion that's made a huge difference in all aspects of his health. And I think this is a great chance to hear Mitch's story, what he was struggling with, and then the process that he went through to finally get on testosterone therapy and find out how that's impacted his life.

And I think it's a great story of how testosterone therapy can help some men, and how you also kind of need to be an advocate for your own health sometimes. You have to kind of work through the system. So, Mitch, tell us your story.

Mitch: It was very interesting. The recording of that particular episode was like smack dab in the middle of a yearlong struggle with some really, really severe fatigue, right? And we're talking physical, mental. Every day I was just tired. I was dragging myself, and I felt it in my joints. I felt it in my brain. And it just kind of kept getting worse and worse.

And we talk about on the show, "Oh, yeah, get more physical activity. Change your diet." If you're so tired all the time, the idea of getting up and running for 30 minutes, I'd be completely worn out for the rest of the day. I would just be that physically exhausted.

And it was even my therapist, my mental health person, who was saying, "Hey, you're obviously not doing the work that we're doing every week because you're so tired. You're so out of it. We can't help pull you out of whatever's going on if you're this out of it."

So after kind of talking through it and just struggling with all of this, I decided to go to my PCP. And I told him, "Hey, I'm dealing with some severe fatigue. It's been going for a very long time," blah, blah, blah. But I was like, "Hey, what could be wrong?" And so he did a whole bunch of panels. We ruled out things like diabetes and all these other conditions. He took tons of vials of blood out of me, and they all came back normal.

And he kind of said, "Well, why don't we try some lifestyle changes?" So I tried. For months, I was doing healthy meals every day. I was going to bed at a certain time. I was trying to drag myself out of bed every morning just to go on a little jog or working out. I was doing everything I possibly could, but I still was tired and I was putting on weight.

And even when I went back and I said, "Hey, I've tried the things and I don't mean to backseat doctor, I'm just a podcaster, but I have a feeling that something else is going on. I'm not lying to you. I really am doing all the things I think I'm supposed to." And the response was to prescribe me antidepressants. There was such a confidence in my doctor that it must be something mental that's causing my exhaustion.

And I took him at face value, so I went and I took the antidepressants. I tried it out and had kind of weird motional swings for a week or two. And I don't know, it still wasn't going away.

And about that time is when we recorded the episode. If there's any love letter to the show and the idea that talking about health can be a huge change for people, we had a conversation about this very thing where it's like, "Hey, sometimes your PCP might not feel super comfortable giving you hormone therapy because they're not super trained in it."

And after hearing that, I decided to reach out to Dr. John Smith because what better men's health person to talk to you than someone I've already interviewed? We got the test done, and sure enough, my levels were pretty low. They were under 300. We took both of them in the morning to make sure we were minimizing any other potential things that were going on. But I had really low testosterone.

Dr. Smith: Mitch, I love your story because your PCP is awesome. The fact that he took the time to go through all of those things with you and make sure that it's not something else. I have a lot of people's PCPs who won't take that time. Not that they don't have the time, but sometimes PCPs are overwhelmed.

But bless his heart, or her, for going through the time to get the blood work and make sure all those things are normal. Because I've found plenty of folks who come in who have thyroid issues or other issues that are causing their fatigue. So I just wanted to put a plug in for your PCP and some kudos and a pat on the back for taking the time to really make sure that they covered all their bases.

Troy: I'm curious too, John, hearing this, what do you think happened with that blood test with the testosterone level with his PCP? Because it sounds like it was above 300 and then when you tested it was well under 300. Do you think that was testosterone levels dropping over time, or maybe just the way the PCP did the test? What's your take there?

Dr. Smith: So I've had patients who've had three or four testosterone levels done. They'll have one that's in the low 300s, and then the next one will be like 240. And then they'll have one that's like 380. And so it does vary based on diet, exercise, and some of those things that are going on. We don't fully know 100% why, but it is variable. But most of the time, those people who are lower tend to be lower on average.

And so insurance requires two morning draw testosterones. And the AUA, or the American Urologic Association, has also kind of backed that up of two morning draw testosterones that show a low level.

Scot: And what if a patient is at, like, 320? Three hundred is the lower limit. Is it up to a doctor's discretion at that point based on symptoms, or how does that work?

Dr. Smith: Patients who are symptomatic in the low 300s, sometimes they do benefit from testosterone where their body does need to be a little bit higher in that normal range. And so taking the opportunity to try it. Like you said, some people it's great and it works, and some people don't notice a huge benefit when they are supplemented in that range.

But sometimes it's worth a try, especially if you've tried other things, you've got other lab work, and everything looks normal. Well, let's try it and see if we can benefit you and help your fatigue and those other things.

So it is kind of doctor discretion and having that conversation with your patient of, "Hey, this is may be very helpful and it may not. Let's find out and just see."

Troy: You mentioned also insurance coverage. Does insurance require levels less than 300 to pay for the treatment?

Dr. Smith: Usually they do want to see low levels of testosterone before they'll pay for treatment. A lot of them aren't sticklers. If you're like 330, 320 and you have a second level that's like 289 or 301, they're usually pretty good about making sure that things are taken care of.

However, that being said, certain forms of testosterone replacement are fairly inexpensive with discount programs like GoodRx, and SingleCare, some of these websites online that have kind of created relationships with pharmacies to give people discounts. So it's not this cost burden if insurance did ever balk it and your doctor was like, "Hey, I think you'd really benefit."

Troy: So I have to ask you this just because you kind of went that direction too. If someone's paying out of pocket, what does it cost?

Dr. Smith: So injectable testosterone is by far the least expensive. And depending on what your dose is, you can get two or three months for $20, $25.

Mitch: Oh, wow.

Troy: Oh, wow. That's super cheap.

Dr. Smith: So it's not this killer expense. And then other forms of it, if you want to be fertility friendly and things like that, there are some other off-label uses for medications like clomiphene, which we've talked about, or Clomid. And that again is something that you're going to pay $20, $30 for a few months' worth of medication. So the cost burden is there but $20, $30, if it changed your energy level and a lot of those things, is completely worth it.

Troy: That's surprisingly inexpensive. As someone who's purchased over-the-counter omeprazole, I will say that's a whole lot less expensive than treating yourself for heartburn.

Scot: Wow.

Troy: I'm surprised at how inexpensive that is.

Scot: So what was Mitch diagnosed with? Was it just low testosterone or is there a specific name for it or?

Dr. Smith: So the $500 word is hypogonadism. Everyone else just says low T. But it's the exact same thing.

Scot: I'm going to choose low T.

Troy: I know. Hypogonadism just doesn't sound good. Let's go low T.

Dr. Smith: Low T works very well.

Scot: Yeah. So I was surprised when Mitch told me what his particular treatment option was because . . . and I'll get to my story in a bit. I used a rub-on cream, which I think is actually testosterone, right? But it wasn't testosterone that Mitch got. It was something else.

Dr. Smith: So Mitch was put on a drug called Clomid. And this drug stimulates the brain, the pituitary to produce hormones. One is called luteinizing hormone. The other one is called follicle-stimulating hormone. And these two hormones stimulate the testicles to make testosterone and sperm. And in that way, we were able to alter the body's production of sperm and up-regulate it. And so that's what the drug that Mitch had, or has, does.

Now, the creams and the injections are giving exogenous testosterone into the body and actually causes the body to kind of shut down its own production because we're giving the body this exogenous testosterone. And so that's kind of the difference between those two, even though both of them are very beneficial for patients.

Mitch: So with the medication I'm on, my body and my testicles are capable of producing testosterone, but for one reason or another, it wasn't making enough. And so we're now putting a drug into jack those numbers up. Is that how it kind of works?

Dr. Smith: Exactly.

Troy: Talking about the Clomid . . . I don't know that we ever really talked about why Mitch is on Clomid versus exogenous testosterone. Mitch, was that a decision you made kind of hearing side effects and what's involved in each one? Or, John, is that typically first-line treatment? What was that decision process?

Mitch: So Dr. Smith was really, really good. We had a conversation, right? He talked through the different options and he said, "Hey, some patients prefer this over this. Here's why." Here's blah, blah, blah. And so, for me at least, it was a joint decision.

And it sounded like, for me, that Clomid was the easiest entry point, right? See if my body can make this stuff anyway, and if it can, great. If not, we can try something else. And taking half a pill every other day is a whole lot easier for me than getting injections or a magic cream or whatever. So I thought I would start with that first.

Scot: Dr. Smith, does Clomid work for some men and not quite so well for others? Are there kind of some criteria that you would use to have that be the first thing, or is that generally the first thing you try?

Dr. Smith: No. I usually have a conversation, like Mitch said. I like to lay out the options because I feel like the more information the patient has, the better off they are.

And some people prefer to take a pill versus giving themselves an injection versus having a cream. Each one of them has a plus and a minus to them. And so having that conversation, giving them the options, letting them know what is available, and then what fits best for their lifestyle. That's how I like to do it personally.

Clomid may not work for some people because if the testicles of a certain individual are not able to produce sufficient testosterone, then the Clomid isn't going to help. No matter how much we stimulate the testicles, if they're unable to produce what we need them to produce, it's not going to make a difference. And so in certain individuals, that isn't an option that works.

We'll try it and then they'll come back and their labs haven't changed and they're like, "Well, what happened?" And I say, "Well, your testicles just can't produce anymore, so you need to be on exogenous testosterone. We need to give you testosterone because you can't make your own." So those would be the people who Clomid would not work for.

Scot: So is there anything else we need to cover about what Mitch is on? Should we just get to Mitch's results? Is there anything else to that part of the story, Mitch? You went through this.

Mitch: No, not really. I got on a cheap pill and things turned around. It was awesome.

Scot: Yeah, but drastically, the kind of drastic that we make fun of. Like, it's the silver bullet. We spent a lot of time . . . at least I felt like I did. Maybe Dr. Smith didn't. But upon reflection, I wanted to communicate this is not a silver bullet, right? You still have to do these other things, and you should try these other things. But for you, it was kind of a silver bullet.

Mitch: Yeah. It was night and day. It took me about a week to notice anything. So I show up to the pharmacy, I pay my $30, I get this big pile of meds, and I just start taking one. And after about a week, that weekend I woke up feeling like I had had the first full night's rest that I've had in years, right? I just woke up and felt amazing.

And it kept going. I could keep having energy. When I got done with work I actually felt like I could do something in my evening, like I could work out, or go for a walk, or do a hobby, or something, rather than just crash in front of Netflix and order GrubHub.

And it wasn't just that. I was suddenly able to work out without feeling completely wrecked, right? It used to be I'd do a hard set at a gym or something like that and I would just . . . it would drain the last bit of energy I had left in me, and so I just would crash.

And it just felt good mentally. Mentally, I was able to be sharper. I was able to focus on things. This brain fog and overall physical fatigue that was going on completely disappeared. And then on top of that, I lost 25 pounds in a month.

Troy: That was the crazy part.

Mitch: After years of struggling with weight and doing everything I was supposed to and never seeing anything, suddenly a month after getting on this medication, I lost all of . . . It's slowed down now. I'm not continuing to lose all this weight. But it's like something suddenly fell into place and my body worked.

Troy: You lost weight, and you also put on muscle mass too, didn't you?

Mitch: Yeah, I did. But we don't know the exact number.

Scot: He's got to be honest about that.

Troy: You're just downplaying that part. "Yeah, I'm pretty ripped now."

Mitch: I am not ripped, but . . .

Troy: You probably are.

Mitch: No.

Troy: I haven't seen you in a couple months. But this was how long ago? When did you first start the treatment?

Mitch: This summer actually, so a couple months ago.

Troy: So it's been a couple of months. That's what I wondered too with treatment. Is it like there's sort of this honeymoon phase where everything is great and you feel good, and you lose weight, and then after a month, everything kind of levels off or maybe there's a little bit of a rebound? But it sounds like, in your case, everything is still good. Things are going well.

Mitch: I mean, I'm not still losing two or three pounds a week, but I still have my energy. I still feel mentally sharp and good. And they're talking about maybe even minimizing and taking me off of some of my mental health medication I've been on because of how much better I'm doing.

Troy: Wow.

Mitch: Yeah, big change.

Troy: That's great. No, that's huge. John, is that typical? Is Mitch's experience typical?

Dr. Smith: I think Mitch is at the higher end of what people experience. I will say most people within the first year, the testosterone literature will tell you that you'll have a body mass change where you'll lose about 2.5 kilograms of body fat and you'll increase lean muscle mass. So that's something that you see across the board.

Mitch is probably someone who is in better shape than most of my patients. So folks who are a little bit more out of shape may not notice that muscle mass change as much as Mitch did. Because Mitch has done a very nice job of staying in shape and taking care of his body and being in a good body mass to start, and that makes a huge difference for patients.

But I would say Mitch is on the higher end of people who have done very, very well and are very pleased with their treatment.

I would say, overall, most people who get a benefit, they do maintain that energy improvement and things like that.

On a caveat, if you have the desire to go to the gym and you're just too tired, the testosterone isn't going to make you want to go to the gym. But if you had that inherently before and the fatigue was impacting you, once you get that energy back, you're going to want to go back to those things that you enjoyed, if that makes sense.

Scot: Mitch also talked about how mentally he was feeling better. Is that common that the testosterone can help there? What do you think is going on with that, Dr. Smith?

Dr. Smith: So there is some debate on that, but overall, when you have more energy, you feel better, you're able to go and do the things that you like to do, you have the energy to go do the things you like to do, your mental health status changes, and you feel better. And I think that just stands to reason.

People who get a good result from hormone therapy of one reason or another, they tend to be happier. They tend to feel better. Because when you feel better and you're able to go and be active and do things and have energy to do things, overall you do feel better. Overall, things are just better.

Scot: All right, Mitch. Now the dark side. Are there any side effects?

Mitch: But they're all testosterone related. It's not like the medication . . . It's like Dr. Smith was talking about earlier. I used to have to shave maybe once every week and a half. Now I'm shaving twice a week. So we'll see if I can . . .

Scot: Like a regular teen wolf.

Troy: Wait a second. You used to only shave once every week and a half? Was this because you wanted to grow out a beard and then you'd shave it off, or . . .

Mitch: No, I couldn't grow any facial hair. I've always been a little baby face. So yeah, I'm having to learn how to shave all over again and more frequently.

Troy: But to say more frequently, just twice a week, though.

Mitch: Yeah. That's a significant change.

Troy: From every week and a half, yeah.

Mitch: I'm doing that. I got a little bit of acne on the body. I've been like zit-free since I was 18, 19, and now I'm getting little bumps on my body every now and then. But nothing, a little bit of whatever little special acne stuff or whatever won't help.

And after we chitchatted last time, I'm growing my hair out. I've got this awesome mane going these days, and I started to see it coming out in my comb. So went to Dr. Smith and was like, "Hey, I think I might be losing some of my hair." And he's got me on Propecia. Haven't had any side effects with that. And I guess that'll help control any hair loss that might be involved.

But any of those changes, I would not trade for the world. Being a little hairier, a little zittier, and maybe a little thinner in the hair, I am fine. I would much prefer that than just being tired and miserable all the time.

Troy: So you're going to have this killer beard going on and shave your head, but you're going to feel good.

Mitch: Yeah, 100%.

Troy: Take it.

Dr. Smith: Mr. March of the "Who Cares About Men's Health Podcast," Mountain Man Mitch.

Mitch: We'll see.

Scot: I've been looking for a name for you. I think we might have it there. Thanks, Dr. Smith. I like it.

Troy: Triple M.

Scot: Yeah, that's good. Are there other side effects that some guys would experience in addition to what Mitch is talking about?

Dr. Smith: So those are very typical. Increased testosterone can increase male-pattern baldness. You can get some acne, increased body hair, facial hair, those types of things. Kind of like when you're going through puberty, some of those similar things when the testosterone levels kind of raise like that.

We always watch the red blood cell count because it will stimulate that. Testicular size changes in the case of people who are on exogenous testosterone. It doesn't happen with the Clomid like Mitch is on.

Those are the big ones that most people see. The medication that Mitch is on, the Clomid, some people will have a little bit more of a moodiness or mood swings. They feel like they would cry during a Hallmark movie kind of a thing. Their emotions are a little bit closer to the surface.

I had a guy literally tell me that one time. He's like, "I feel great. I feel like I'm going to cry at a Hallmark movie." And I said, "Okay, so your emotions are a little bit closer to the surface." And he's like, "Yeah, that's kind of what's going on." And so that's the biggest thing with Clomid that people tend to see. But that's pretty typical.

Scot: So after hearing Mitch's story, I got curious about testosterone again myself because I feel like I kind of have the same things. I feel like I've been exercising and doing the right things, but losing body fat is difficult. I feel like I kind of have low energy and some of those things.

I had tried testosterone before back around 2010, so 13 years ago. I had just turned 40 and it really didn't work for me. So I thought, "Well, I'll get my levels tested again and see how they look." And my levels came back right in the middle, like at 650.

That's about as average as you can get, right, Dr. Smith? Because I am the most average man on the face of the earth. You ask me my skills and ability in anything, it's going to be average.

Anyway, with that number, I made the assumption that testosterone therapy is really not going to help me. Would that be a good assumption to make, that that's probably not the issue?

Dr. Smith: Yes. If you're asking me the question, I would say yes. Because if you're in the normal range, there's not a lot of benefit to be had. Now, some people may disagree, but I look at you have a certain number of receptors for testosterone. And if you think about it like a parking lot, if you have 600 parking spaces and 1,400 cars, it really doesn't matter how many parking spaces you have, you're not going to be able to fit all the cars.

And so with a normal testosterone in a normal range, you're going to be saturating those parking spaces, aka those receptors, that the testosterone interacts with. And so the benefit ratio of taking someone with low testosterone where there are too many open parking spaces, so to speak, to someone who's got almost all the parking spaces full all the time, you can see how the benefit would be there or wouldn't be there. And so normal testosterone, adding more doesn't necessarily improve things.

Scot: So I'm going to say, first of all, you have the best analogies of any of our guests ever. Every single episode, you just nail it with an analogy. That was awesome.

Troy: Parking spaces. That makes perfect sense.

Scot: That was fantastic. So I'm going to try to keep my story short when I tried testosterone for the first time. I tried it for a couple of years and really didn't notice any benefits, and it was a lot more hassle than it was worth.

So I had just turned 40 and I was working at a place and there was this guy that was really super muscular. He was younger, and he was like, "Oh, man, as soon as I turn 30, I'm going to go to the doctor and get testosterone therapy." Because he is under this impression that you start losing testosterone as you get older, which is true.

And then you see the ads in the media, and there, again, this seems to be recurring in my life, low energy. I've always wanted to put on muscle and I've always found it difficult even when I weight train. Losing the fat is difficult even when I feel as though I'm doing things right.

So I had another friend who started testosterone, had some results like Mitch. It gave him this energy and drive again. So he referred me to this particular doctor. I got the test. They got the levels. They put me on the cream. I did that for a couple years. After a few months, they ended up putting me on some pills to balance the hormones that the testosterone cream was causing.

And I also didn't like the fact that since I was using the cream, I had to be really careful my spouse didn't get near it. And I really wasn't noticing any difference. So I just ultimately kind of ended up quitting that.

Fast forward to the last episode we did, I thought, "Wow, I wonder if I could go back and pull those old labs and see what my testosterone levels were." And even back then, they were around 600 and 650.

So what this physician and I were trying to do is we were trying to optimize, get at that upper level thinking that that's going to make me feel even better.

And after learning from you, Dr. Smith, and your awesome parking space analogy, it makes total sense why that didn't help me. So in that case, testosterone really wasn't the solution for my problems or my perceived problems of energy and whatnot.

So in a way, I'm kind of jealous of Mitch, but also in a way, I'm glad to know that everything is okay. And maybe now I can kind of be a little bit more honest with myself. Am I going to bed at a decent time? Am I eating the way I need to be eating? Am I getting enough calories? Could there be some other reasons why I feel like I'm tired, or is it just my perception?

So that was my story, which is very drastically different from Mitch's, but I think it really illustrates that if you don't need it, getting more is not going to necessarily help.

Mitch: So did you have any response to the treatment? Did you feel anything other than just kind of the same?

Scot: No, not really. I think at first I kind of thought maybe I did, but that could have been the placebo effect. I don't know. Ultimately, I didn't notice a whole lot of difference over the long term. And that, in combination with the downsides, is kind of why I just decided to stop.

Dr. Smith: Scot, that's been a little while ago. Have you had your levels rechecked recently?

Scot: Yeah, I just had them rechecked after Mitch had such success with his treatment and found that they're just dead in the middle.

Troy: They're still . . .

Scot: That's that 650 level.

Troy: Okay. So still 650. Yeah, maybe I missed that. Because you were 650 years ago, and just everything has stayed exactly the same. Clearly no benefit for you to go on testosterone at this point.

Scot: Yeah. So what was the difference there between my experience and Mitch's experience, Dr. Smith? Do you have any more insight to that?

Dr. Smith: So we kind of talked about this a little earlier. Mitch had low testosterone, so adding more cars to the parking lot made sense. For you, you could make the argument that you may have even changed the cars in the parking lot initially because when you start testosterone, your body is going to shut down your production. And so you're really just keeping yourself at that same level.

And I don't know what your labs looked like, if they rechecked your labs and things. But I've had people who've come in to me from other outside places who've said, "I've been on testosterone for about a year and a half." And they bring me their original labs and they're kind of like yours or kind of in the middle of the range, 550, 600. And I look at their numbers on testosterone and they're, like, 720. And so really, they didn't do a whole lot other than shut down their body's native production.

Now, I've had some people come in who were just being dosed up very, very high, who their testosterone levels were off the charts. And some of them said, "Oh, I feel great." And some of that, I'm guessing, is placebo.

But I've had some patients who, at a higher range, they do say they feel better. And I don't know that it's all placebo. And so there could be some benefit to that.

But being in the normal range, you're not going to get a ton of benefit. And so I think that's really where we look at it and we say there's not a whole lot more that you need to do.

And I would say that some of the patients I have that come in, they'll get sent by their primary doctor after they've had a couple of testosterone tests that are in the normal range. And they'll come in and I'll look at them and they may be . . . Their body habitus may be larger.

I'll ask them questions like, "Do you snore?" Because I've diagnosed plenty of folks with sleep apnea where they get that treated and they feel like a million dollars. And it wasn't their testosterone. It's that they were waking up 30 times a night because they were having sleep apnea events during the night. Things like that I've seen.

You have to ask the questions around to get to the answer for some of those folks. Some people may be on extreme diets trying to lose weight and they're like, "I'm just tired." And I'm like, "Yeah, you're eating 500 calories a day. I don't know why you would be tired."

Things like that are going on where you've got to ask the questions because you'll get to the answer. "Hey, well, if you start eating 1,200 calories or 1,500 calories, you'll probably have more energy because your body is not going to try to store everything thinking that it's never going to eat again."

And so some of those things I see in folks where they have symptoms but their testosterone is in that middle of the road, kind of like yours was, Scot.

Troy: Speaking of levels, I know we're talking about you, Scot, but I've got to bring it back to Mitch. Mitch, do you know what your level is now?

Mitch: It's in the 700s.

Dr. Smith: So he's not through the roof, but he's pushing towards the upper end of the normal range.

Troy: Yeah. Nice.

Scot: I mean, I feel completely great with my decision now in retrospect, because I think being on it could cause more problems for me when I didn't have a problem to begin with, right? Because there are downsides. Doesn't your body kind of stop making it if you're putting cream on long enough?

Dr. Smith: Yeah.

Scot: Any take-home messages? What are the take-home messages here, Troy? What do you think? What did you get out of this episode?

Troy: My take-home message from all this is if you're experiencing something like Mitch experienced, it makes sense to get your testosterone level checked. And it also makes sense to pursue treatment when treatment will work. And if the parking spaces are full, there's no point in putting more cars in the parking lot. That's my takeaway.

Mitch: Sure. That's a good one.

Scot: How about you, Mitch?

Mitch: I think the big one for me is to talk to each other about health. I would not have been on this kind of journey, I would not have advocated for myself, I would not have sought out a second opinion had I not talked to other men on this podcast and in my life about testosterone, about their experience with it, etc. I would not be where I am today or thinking about my health the way it was if I did not talk to other men about my health.

Scot: Dr. Smith, do you have something that you'd like to throw out as a take-home message?

Dr. Smith: I love it. I'm super happy for Mitch. And I'm also happy that you were able to kind of find your way. You mentioned it earlier about being an advocate. I tell patients all the time, "I get to see you for 15 minutes and you know your body a heck of a lot better than I do. And so if you think something is wrong . . ." Like Mitch, he was like, "There's just something missing here. What is it?"

Being an advocate for yourself and finding someone to have that conversation with about these things, because it can make the difference. Or it may not make the difference, but at least you'll understand the reason why and you can then make the informed decision of which way to go.

So I think that, for me, was the take-home. You guys both did that in your own way even though you ended up in two different places.

Scot: And those gentlemen are the two tales of T today on "Who Cares About Men's Health." Great conversation. Guys, as always, it's a pleasure to get together and talk about men's health. Dr. Smith, it was great having you on the show. Thank you for listening, and thank you for caring about men's health.

Dr. Smith: Take care.

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Scot: So will testosterone solve all my problems as a man? That's today on "Who Cares About Men's Health," providing information, inspiration, and a different interpretation about men in men's health. He brings the MD to the show. Ladies and gentlemen, Dr. Troy Madsen.

Troy: Yeah. Ready to talk about testosterone. I am curious, very curious. Where do we go with this? What do we do?

Scot: Offsetting the MD, I bring the BS. My name is Scot Singpiel. And Mitch, he's responsible for bringing the microphones. Welcome, Mitch.

Mitch: Hello. Hi.

Scot: I think Mitch needs some testosterone. You know how low key he is.

Mitch: It's low T day. I mean, based on everything I see on the internet, that's got to be what's going on.

Scot: Well, yeah. I mean, you go to the internet . . . I'm going to do my impersonation of the internet. You ready for this?

Mitch: I love it.

Scot: All right. You're, like, "You have low energy? You've got to get some T. You putting on a few pounds of fat? You've got to get some T. You having trouble sleeping? You've got to get some T." That's my impersonation of the internet. It's the answer to everything.

Troy: It is. It cures everything.

Scot: Yeah. So we're going to find out if that is actually true or not with Dr. John Smith.

So, Dr. Smith, what is the common complaint you get when somebody comes to you and they're interested in testosterone treatments? What problem are they trying to solve? What are they trying to cure? All the things I talked about? Something else?

Dr. Smith: Absolutely. I mean, I think the thing about testosterone is the symptoms are so wide-reaching -- fatigue, cognition, erectile issues. They've heard on the internet, or they've talked to a friend who's on testosterone, and they're like, "Man, it just changed my life. It fixed everything." Which in some people's cases that may be true, but for most people, it definitely can play a role in helping them out, but I don't think it's the cure-all that you're talking about, that the internet shows. It's not making Frank Thomas who he is today.

Scot: And that's dangerous, right? Because you can get testosterone without even having a face-to-face conversation with a doctor, right? You can essentially just order it online. Is that true or is that overstated?

Dr. Smith: I think some of the newer companies you've got out there that are making things available . . . hopefully you're getting at least a video conferencing going over your medical history with someone who's a medical provider, whether it be a nurse practitioner, a PA. Hopefully you're talking with a physician. If they're not doing it that way, they're doing it wrong.

But testosterone is one of those things where it can be very helpful. I have quite a few patients that are on it, and I think it is one of those things that can definitely benefit people. But the extent that it benefits them kind of varies between patients.

Scot: Testosterone, I get the impression that it's probably not a do-it-yourself sort of a thing. It's not something you want to, as a layperson, just dive into on your own. Why is that?

Dr. Smith: Well, there are certain . . . everything has a risk and a benefit, and testosterone is no different. For people who have low testosterone, replacing it can really make a difference. It can give you that increased boost of energy, help you with weight loss, help you with metabolism, help with sleep. It can help with erections. I mean, it can help with cognition in people who have low testosterone. However, it's not necessarily the thing that's going to fix all those problems.

And oftentimes I'll go through people's history and say, "Hey, man, your testosterone is normal. Adding more to the mix isn't likely to fix things. We should look at other issues." And so I think really just taking that deep dive and seeing if it's something that is right for you is important.

Troy: I guess, John, I've seen all this stuff Scot mentioned, you see all these things on the internet, you see TV ads, etc. Yeah, I think I wonder myself, "Man, is my testosterone low? Should I be worried about this?" At what point do you tell people, "You should get your testosterone level checked"?

Dr. Smith: I think if you've looked at some of the other . . . if you've talked to your primary doctor and kind of gone over things, the usual suspects of a thyroid issue or vitamin deficiencies, things like that that they check a lot, if those are all normal, I think it's completely reasonable to look at it.

Some people say, "Oh, well, my dad had low testosterone and I got it checked in my 30s." But if you look at the facts of the matter, about 40% of people over the age of 45 have a testosterone level of 300 or less. And so that's a decent amount of the population that's out there. And so I think if you have an interest in it, it's okay to ask to have it checked because it's better to know and to at least know what your options are where it may be a benefit to you.

Scot: And how do you do that, then?

Dr. Smith: So your regular doctor can check it. You can make an appointment with a men's health specialist like we have at the University of Utah. We have a men's health group with multiple different providers. We have nurse practitioners, PAs, and multiple MDs and DOs that can take care of your needs as far as checking the hormones. But that's the first thing that we do.

And hormones, ideally, should be checked before 10:30 in the morning because our bodies spike testosterone between the early hours of the morning. Usually people will say between 4:00 a.m. and 10:00 a.m. in the morning. And so we want to check it to see what your body is actually doing.

If you're low in the morning, the odds are that you're high in the afternoon are going to be really slim to zero because your body spikes it in the morning to give you that boost of the hormones that you need to get you through the day.

Scot: And when you take a look at that test, it's a range, right? So a man gets the test done and you've got some numbers and there's a range. And what does that tell you? Let's pretend I'm at the low end of the range, but I'm still considered normal. Is that somebody that you would suggest testosterone therapy for?

Dr. Smith: I think a lot of it is the discussion that you have with the patient. So the range is huge too. If you look at the range, most labs are between 300 and 1,000. Some are a little less, some are a little more, but just for intents and purposes of this discussion, about 300 to 1,000.

So let's say, Scot, you're at 350. Well, what does that mean? Insurance requirements say that we've got to get two tests that show a low value before 10:30 in the morning. So let's say we've done that. You come in, your first one was 350, your second one was 340 or 338. What do we do from there? Well, then we have a discussion.

And I think in a lot of those folks, it is reasonable to discuss therapy. People outside the normal range, it's obviously okay to discuss that as well, but people tend to feel better in a range around 400 to 700. Sometimes, some people will say 600 or higher. There's a lot of different variability out there between who you talk to about it.

But again, if you're feeling the symptoms of fatigue, decreased libido, decreased erectile quality, some of those things are really hitting you hard, and you're like, "I'd love to try testosterone to see if it would help some of those symptoms," I think it's completely reasonable to do that.

Mitch: But insurance won't cover it unless you are beneath that range?

Dr. Smith: Not necessarily. Insurance wants to see that you're in the low. Really, I think it's reasonable for anybody that's 350, 400, and below. You can talk to them about testosterone replacement therapy. And if there's benefit there, insurance usually won't balk at it. And if they do, and it is helping you, cash pay for this stuff is not obscene.

Mitch: I'll just disclose. Now, I had my testosterone levels checked after we did a previous episode, and my number is right around 400. And my primary care provider is like, "Oh, no, you don't need to. We don't need to. There's no need to talk about testosterone therapy." And so I've kind of put it in the back of my mind.

But then at the same time, you have the weird people on the internet that they say you need to be 600 or 1,000 or above to be healthy. And it's just like if I'm right there, I'm at the 400, maybe it would be helpful. What would you say to someone in my situation?

Dr. Smith: I think you've got to look at the whole picture, but I think it's definitely something that you could consider. Again, most primary care doctors don't do a lot of hormone replacement, so they're going to say, "Hey, you're well within normal range. We're not going to touch it. We're not going to do anything," because that's their comfort zone.

This is the thing that I do every single day where I get people sent from their primary care doctor to talk about this stuff. And I think it's an in-depth conversation of, "Hey, let's look at the whole picture. Is there anything else going on that's a problem, or could be seen as a problem? Do you have a thyroid issue? What is your BMI? How does your weight look? What's your exercise routine?" and things like that, because those things can be done before supplementing testosterone.

And there are some interesting numbers out there with diet and exercise. If people will lose weight of 10 pounds or so, you can increase your testosterone by 100 points by losing 25 pounds and getting diet and exercise.

But a lot of times, it's hard to get the motivation to go do diet and exercise when you're overweight and you're really lethargic. And so it's like, "Would testosterone help me get there?" and a lot of those things as well.

And so again, exercise 15 minutes a day for 6 months of moderate intensity exercise will increase your testosterone by 22 points. And then if you're exercising for 30 to 40 minutes a day, you'll increase it by 50 to 60 points. And so again, there are things you can do other than testosterone if you're kind of in that range, and any of those things fit.

Now, Mitch, I know you're super fit, so that doesn't really . . .

Mitch: Yeah, I'm the fittest guy.

Dr. Smith: . . . matter for you. But if those are things that you can do, those are modifiable things you can do in your life to increase your testosterone naturally.

Mitch: Got you.

Troy: You mentioned diet also, John. I mean, it sounded like we're talking more about weight loss here, but are there any kind of dietary changes in terms of foods you're eating or foods you can eat or even supplements that would increase your testosterone levels without actually having to go for any sort of hormone replacement therapy?

Scot: Raw eggs and meat, right?

Dr. Smith: Right. Exactly.

Troy: Well, sure. Yeah.

Dr. Smith: You've seen Gascon in "Beauty and the Beast." That's how he got so huge.

Troy: Exactly.

Dr. Smith: There are no real big things that are out there that are known to necessarily just be super beneficial, other than eating as clean as you can.

Testosterone is a hormone and hormones are built on a backbone of cholesterol, so they're kind of fat. They're built on fat. And so when you have excess fat tissue, sometimes the hormones like to hang out there because they don't love water. And so you'll find that people may have a higher testosterone level when they lose that body weight, because now they don't have as much body fat and that testosterone is able to kind of circulate. Plus, you're in better health and your body is able to just do what it does better.

Troy: Speaking of our concerns . . . obviously, Mitch has thought about it. I've thought about it. I know, Scot, you've told us before you've had your testosterone level checked. I think a lot of men wonder about this, and I think we get concerned and we say, "Hey, maybe I don't have a lot of energy," whatever it might be. Of those who come in to get tested, what percent really have low testosterone?

Dr. Smith: I mean, my practice is kind of skewed, because by the time a lot of these guys get to me, they've already had it checked with their primary doctor who's not going to treat them unless they're outside of the normal range. And then when they are, they get referred to our office. A lot of primary care doctors don't love treating testosterone patients and they know that that's kind of what we do.

And so I get a skewed percentage. Most of the people who come in and are looking for testosterone have already kind of been pre-screened, so they are low. I would say a vast majority, at least three-quarters of the people that I see, already have testosterone levels that come back and are low and they're there to talk about therapy as a referral from their primary doctor.

Troy: Interesting. Yeah, I just wondered if it's one of these things that it's just something else for us to worry about. And if a lot of us are getting tested and it's a small percentage, or maybe it is, like you said, over 45% . . . I think you mentioned 45% of men have levels under 300. So maybe more of us should be getting tested at some point and we're just not getting tested.

Dr. Smith: Yeah. It's around 40% over the age of 45, you'll see low testosterone levels. And again, it's one of those things where you tend to hit that middle age, people tend to not necessarily be as active, and things like that as well. So there are a lot of things that go into it.

But if we're looking at the actual testosterone itself . . . Let's say you come in, you're low or you're low normal, and you want to try testosterone. There are a lot of things you need to have a discussion with the patients about. Are you interested in having children in the future or any more children if you already have children? What are your goals as far as that goes?

There are multiple different ways to treat testosterone these days or to treat low testosterone, I should say. And kind of having that full disclosure discussion with the patient goes a long way, because there are multiple different modalities of treating it from oral medications to topical medications, to injections, to long-term injectables, to subcutaneous pellets. I mean, there's a myriad of different treatment options that we can discuss.

Scot: And of your patients that you start on therapy, you mentioned that the symptoms can be very broad and caused by a lot of different things. Maybe you're not getting enough sleep. Maybe you've got too much stress in your life. That's why you're low energy. Maybe you're not eating the right foods or exercising. That's why you don't feel good. How many after they get testosterone that come in that have low testosterone actually go, "Yeah, that made a difference," versus, "I'm about the same"?

Dr. Smith: Majority of them. But that also varies via the root that they get testosterone. So I'll talk kind of a little bit about each modality. Oral options is . . . there's a medication called Clomid. A lot of people know it as a fertility medication. Women use it for fertility purposes. But what the medication does is it stimulates your body to produce more testosterone and more sperm. This is a very gradual improvement in testosterone. And a lot of times people don't feel that robust boom, that jolt of energy and things, because it's kind of a low-key slow rise of the testosterone back into the normal range. They don't have that big boost.

And most of the time, when people have that boost, it's from the injection because they're injecting a bolus of testosterone that then is being absorbed into the body and they have their levels shoot outside the normal range. So they feel like Superman. It gives them that rush of testosterone, which you don't get with topicals, the lotions, and you don't get with the oral because it's doing what your body normally did before you didn't create enough testosterone. And so you don't get those super highs that you would have before.

So a lot of patients know, "Oh, man, I do have more energy. I do feel good." The ones who do injections tend to come back and have more of a, "Man, that's great. This stuff is great," because they get that boom, that rush, that spike of testosterone very quickly.

Troy: And then how long until that wears off?

Dr. Smith: So usually people inject on a weekly basis, sometimes every other week, depending on their injection tolerance. And I do have a few patients who inject multiple times per week of low doses because they don't like that roller coaster effect. You do really get a high of testosterone and then it kind of fades out over the course until you do your next injection.

And so that's what they notice. They're like, "Man, I just get this high, and I feel it for about two to three days, and then it kind of wears down and I feel pretty good. And then when I do my next injection, I get that high again." I see that a lot more frequently with people who inject testosterone rather than take oral medications or do topical gels.

Scot: And what about side effects or downsides to testosterone therapy?

Dr. Smith: Man, it's almost like you wrote a script for that or something.

Troy: Talked about the good stuff. Let's talk about the bad stuff.

Dr. Smith: I'm going to make you feel like Superman. And now I'm going to tell you the downside.

Scot: Kryptonite is no good for you.

Dr. Smith: Exactly. You really have to monitor things with testosterone. So testosterone can cause an increase in red blood cell mass, and that in and of itself isn't necessarily a bad thing as long as it doesn't get outside of the normal range too far. That puts you at an increased risk of a cardiovascular event, like a heart attack or stroke.

Now, those incidents are rare, but it's something that we definitely keep an eye on. And that's a reason why we follow these folks with labs regardless of the type of replacement that we do.

Other things that we follow is your estrogen levels can rise because testosterone is a precursor to estrogen. There is a molecule called aromatase that actually converts testosterone to estrogen. Their chemical formula is very, very similar.

Your body likes to keep a ratio of about 10-to-1 testosterone to estrogen, and so the higher your testosterone goes, the higher your estrogen level goes.

And some people will develop breast sensitivity, nipple tenderness, or breast growth from elevated estrogen if their bodies are over-converting to estrogen. And so we watch that closely because that can be bothersome to folks.

And then a couple of the other things, we always monitor PSA in folks that are over the age of 40, or at least I do in my practice because . . . There's not an increased risk of prostate cancer, but if you were to develop prostate cancer, testosterone would feed the prostate cancer.

It's kind of like if you have a match and it's lit, nothing happens. But if you have a match and you pour a gasoline on it, you have a problem on your hands. And so the prostate cancer would represent the match and the testosterone would represent the gasoline. It would help it to kind of progress faster in a way.

And those are the things that we really kind of keep an eye on, especially people with family history or people who have had prostate cancer that we're treating with testosterone, which yes, we do that quite frequently.

Troy: So now that we've talked about the risks of taking the testosterone supplement, let's just say someone is like, "Okay, I've had my testosterone level checked. It's low. I don't want to assume those risks." What's the downside of that?

Dr. Smith: So the downside is you can develop osteoporosis with time. There are some studies that . . . initially some studies came out with testosterone that said testosterone supplementation caused cardiovascular issues, and now it's become the opposite. That's been debunked, and there is some literature out there, I don't know that it's super robust, that said low testosterone can increase your risk of cardiovascular events. So those are the big things of not having enough.

Long term, it's really difficult to assess a lot of those risks, but those are the risks. if you were to just have low testosterone.

Scot: Do you have anybody ever come in that you just are like, "No, it's not a good idea for you"?

Dr. Smith: Yeah. I mean, people who come in with a testosterone level of 600 from their primary care doctor. It's a bad idea.

Scot: Yeah. But I mean low testosterone. Is there ever a time where it's just like, "No, probably not. The risks are too big"?

Dr. Smith: So I think the one thing that I didn't get to with the risks is testosterone replacement will cause sterilization. It will stop you from being able to have children. When you supplement testosterone . . . not all methods of supplementation will hurt fertility, but injections will. Anything that's injectable topical or the long-term injectables or pellets all will cause sterility to a point. And so those things are things that you've got to have those conversations.

So if someone comes into my office and they have low testosterone and they don't want to take the pill like Clomid and they're like, "I just want to do injections, but I still want to have kids in six months," I would say, "Let's hold off until you're done having kids or until your wife gets pregnant, or go donate some sperm so that you can have children if that's your goal, before we start therapy."

Scot: Mitch, given the information that you just got today, are you going to go in? You're going to get some T?

Mitch: I don't know. I'm in a place where I think that after this conversation, I would like to go talk to a men's health specialist, especially if there is a hesitation from primary care physicians to just be like, "Oh, you're in the normal range. You're good." There is a curiosity there. There is an interest there, knowing where I'm sitting at on the levels, if they think it would be something that could help with some of the situations that I'm dealing with right now.

Scot: I guess I'm afraid that it just sounds like another pill. I don't mean that as I don't want to take drugs. I just mean we're all looking for the quick fix, right? So yeah, maybe I'm a little tired. Would I like to lose some fat? Sure. Would I like to have a little bit more muscle mass? Yeah. If I'm in that normal range and on the low end, I don't know. It just feels like I'm expecting too much. I'm going in for the wrong reasons. Does that make sense to anybody?

Dr. Smith: And I don't think you can necessarily . . . I mean, again, I'm not trying to sell testosterone here. I just think that . . .

Scot: No, that's not the point of this. We're just trying to get some information, for sure.

Dr. Smith: Right. But I think that if you want to feel your best and be able to do your thing to the healthiest you can be, I don't think it's a bad thing to come in with the desire to be healthier, to feel better, to have more energy. Again, when you start testosterone therapy, you do have a change in lean muscle mass by about five kilograms switch over from body fat to lean muscle.

Scot: Hold on a second. Hey, Siri, convert five kilograms to pounds.

Dr. Smith: Right. Exactly.

Troy: That's a lot of pounds.

Dr. Smith: It's 2.2 pounds per kilogram.

Scot: It's 11 pounds there. All right.

Dr. Smith: Actually, I said that incorrectly. It's five pounds of fat or two and a half kilograms. My apologies.

Troy: That's still a lot.

Dr. Smith: But still, a five-pound change in your body mass, it can be substantial. It can really help. And again, those are just the numbers that we have from the literature that's out there. And so it can be beneficial.

I don't think there's a wrong reason to come in to look for it. Most patients aren't coming in to be like, "Hey, man, I saw this magazine with this guy Schwarzenegger on it and he was pretty big. I kind of want to get there. Can you help me?" Those aren't the patients that I see.

People come in, they're like, "I'm really fatigued. I feel tired at night. My libido is down. I want to feel better. And I want to see if testosterone may be helpful in that regard." And they're not looking necessarily as a magic bullet or trying to use it as a substance of abuse where they can go and just change their whole body composition. But I think it is very beneficial for a lot of people.

Scot: Troy, where do you stand on it?

Troy: As we talk about this, I just feel like there are so many other things I need to address. That's way down the list. We talk about energy and everything there. I feel like, wow, I'm still trying to figure out how to sleep and those kinds of things. So I'm kind of hung up on that still. We've talked about this and if we talk about it today, I am still kind of curious about it, but I don't think I will be getting tested any time soon. I'll say that.

Scot: I noticed a parallel from another show that we did. You're talking about using testosterone treatments to kind of get over that hump, right? Let's say that you would like to exercise more, but you don't have the energy and you do find you do have a low testosterone. That was almost kind of like using medication for mental health. If you're having challenges with your mental health, it can be really hard to become motivated to exercise or eat well, or maybe you don't even sleep well. So you can take medications for a short period of time until you kind of get those things working. We talk about that Core Four, how they all interact with each other. And then possibly come off of it. Am I understanding that correctly?

Dr. Smith: Yeah. And I think if that's your plan, you've got to look at a way to keep the testicles producing while you do that. If you went to an injectable or a topical testosterone that's going to shut down the body's production . . .

So let me nerd out a little bit with the physiology of this. Your body has these precursor hormones called FSH and LH. And those are the two hormones. They are in both men and women. In women, they regulate the menstrual cycle, and in men, they stimulate the testicles to make testosterone and sperm.

And when you give testosterone, it's a negative feedback loop. And so your body sees there's enough testosterone in the bloodstream and stops sending FSH and LH to stimulate the testicles. And so you've got to do something to keep those testicles producing if you're going to be on testosterone in the short term. That's where other drugs come in.

There's an injectable called HCG that we use to help stimulate. It's an LH analog, meaning it's not LH, but it will stimulate the LH receptor on the testicle. And it will continue to have the testicle continue to produce at a lower level, even though you're giving yourself exogenous testosterone.

And then if you decide to come off after six months or a year or whatever, after you've gotten in shape and you've gotten that motivation, then you don't have this complete drop-off of testosterone where your body has to start making it again where it hasn't for the last year.

Scot: But it would. If you're using a topical solution that's telling your body then not to produce more testosterone, does that mean you're dedicated to that for the rest of your life?

Dr. Smith: You can. Now, you can come off of it. And the thing I tell people is if your body was already not producing enough and you haven't done a darn thing to change that, your body is not likely going to go back to producing more than it was before you started the drug. But then there's always that kind of window where your body has to catch up and it's not producing hardly anything at all and you just feel like garbage.

Troy: But it would come back over time?

Dr. Smith: Yes. And that's the part where the HCG comes in to help it, where you don't have as big of a drop-off. Scot: All right. So now I need to ask the question that I think everybody is wondering. I've heard that if you're on testosterone treatments, your testicles get smaller. Is that true?

Dr. Smith: Absolutely.

Scot: Okay. How small are we talking? Yeah.

Troy: What are we talking here? Yeah. Like raisin-size?

Scot: I mean, for running marathons, Troy, that might not be a terrible deal. Right?

Troy: Thanks, Scot. Much less chafing. Yeah.

Dr. Smith: He's looking out for you, Troy. He's looking out for you.

Troy: Exactly. It'd just be nice smooth surface down there.

Dr. Smith: You'll shave minutes off your time.

Troy: Exactly. All that extra weight.

Dr. Smith: Yeah, you won't have the metronome like you've got now, but it'll work out.

Troy: That's right.

Dr. Smith: But they do shrink, and over time you'll notice that testicular size loss happens the longer you're on testosterone. So people who've been on, say, long-term injectable testosterone, they'll shrink down and be very, very small when you get down to it, almost to raisin-like size that you'll see, which is something that I always talk to people about. And again, that's where HCG can come in if you want to preserve testicular size.

And to some people, that's important. And to other people, I say, "If you're not looking to have kids and it doesn't really matter to you . . ." I've never, ever in my experience of having this had someone come in with their spouse and had them saying, "Man, you know what? I just wish Troy's balls were bigger."

So I don't know how much it really matters, but I think a lot of times it is kind of the vanity side of it, of, "This is what I know, this is what I've had my whole life, and I don't want it to change."

Troy: Well, I will tell you, John, hearing that, I'm reassured that your patients are not talking about the size of my testicles.

Dr. Smith: Nor their wives, for that matter.

Troy: That's good.

Scot: John, let's wrap this up. I think we all know your bottom line. I think I've got your bottom line on testosterone treatments. If you're experiencing these symptoms and you get a test and you're in that low range or below, it could be a very good option to help you get some energy back, to help you with your sexual function, with few downsides, really.

Dr. Smith: Yeah. The downsides are minimal. If you're one of those people who overproduces red blood cells or something like that, we keep an eye on it, but yeah, that is the bottom line. If you feel like it's going to make a difference for you, there's a lot of good that can come from it. And it doesn't necessarily have to be a long-term thing. However, most of my patients that are on it are long term.

And I think if you do have questions, go talk to someone that knows what they're talking about. I'm happy to sit down with people. Most of my new hypogonadism patients/low testosterone folks, I like to spend time going over the benefits, the risks, and everything that is involved is involved so that they have a clear picture of what options they have.

And I do have plenty of people who come in and say, "You know what, doc? I think I am going to try to lose 25 pounds and recheck my testosterone." And then I have others who say, "You know what, doc? I just know myself and I'm not going to do that. And so I'm going to take the testosterone and try to do it that way." I think there's merit both ways. Absolutely.

Scot: John, thank you very much for having this conversation with us about testosterone. Hopefully, this will be helpful to a lot of guys. And bottom line, it sounds like perhaps guys who have talked to primary care physicians, haven't gotten a lot of conversation, it sounds like if you do go to a men's health expert, you've got a little bit more time to discuss through some of these issues and really come up with the right choice for each individual guy.

Dr. Smith: Absolutely. I'd be happy to see anybody in our men's health department at The U. I think we do a great job at taking care of folks and making sure that we go over the options and making sure that we help you make the right decision for you.

Scot: Dr. Smith, thank you for being on the podcast and thank you for caring about men's health.

Dr. Smith: Gents, thanks for having me. It's always a pleasure.

Interviewer: Four ways to naturally boost testosterone. Dr. Jim Hotaling is a urologist and a men's health expert. What can I do?

Dr. Hotaling: Simple things you can do are work on losing weight. Even a 10- to 15-pound weight loss can make a big difference. Also, exercise, particularly anaerobic exercise, such as lifting weights. Eating a balanced diet, trying to avoid processed foods, particularly sugar. That can result in changing energy levels and also mess with the natural circadian rhythms that reflect your testosterone production. And the other big thing is sleep. A lot of men have sleep apnea and that can make a big difference in their natural testosterone production. Testosterone levels are a reflection of your overall health. And if you work on making these changes, you should notice a significant difference in two to three months.

updated: April 23, 2021
originally published: May 30, 2019

Interviewer: You've been diagnosed with low testosterone. You don't want to do the creams and pills. Are there other things you can do? We'll talk about that next with Dr. Hotaling on The Scope.

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Interviewer: Dr. James Hotaling is a urologist and also an expert in men's health here at University of Utah Health Care. And guys that have been diagnosed with low testosterone, what else can you do, other than the creams and the pills?

Dr. Hotaling: There's really only three things that have been proven to naturally raise testosterone levels, the first of which is just weight loss. A lot of men are overweight and don't take great care of themselves. So trying to have a normal weight can help a lot, even losing as little as 15 to 20 pounds can make a huge difference. So that's one thing.

Interviewer: And for guys, that's a challenge because, as we get older, we tend to put on about a pound of fat a year, I hear.

Dr. Hotaling: That's absolutely correct. We have a Men's Health Center that's based South Jordan, and we actually have a nutritionist who a lot of our patients see because it's not that men don't want to take care of themselves. It's just that I think a lot of men view going to the doctor as a sign of weakness. So they need some help to learn how to take care of themselves. So that's the first thing. The second thing is exercise, particularly weight lifting. That's very clearly been shown to boost testosterone and human growth hormone. It's actually the only thing that can boost human growth hormone, which can then also drive testosterone.

Interviewer: Are we talking about Olympic strength-type training, or just going in and building up a sweat?

Dr. Hotaling: Yeah, just building up a sweat. Even lifting weights as infrequently as twice a week for 30 or 40 minutes can make a significant difference and it can also boost your metabolism for one to two days after you do that. So it can help with weight loss. And then the third thing is just trying to eat a healthy diet, avoiding a lot of excess sugar and that kind of thing, which, again, ties into weight loss. So those are really the three . . . and then, I guess, the fourth thing would be getting adequate sleep.

We know that when men are sleep-deprived, that can make a big difference in their testosterone production. We particularly see problems in people who have shift work, where they work at night and their circadian rhythm gets all flipped around. Typically, testosterone peaks at about 4:00 a.m. along with cortisol. So that's all tied to your body's rhythms. And the amount of testosterone you have varies minute-to-minute and hour-to-hour. So those things are all things that can help. I think it's also really important to outline the things that don't help, or haven't been proven to help, if that makes sense.

Interviewer: I bet you alcohol is on that list, isn't it?

Dr. Hotaling: Yeah, it is. Again, that goes . . . that's what the biggest thing is. No supplement has ever been shown to make any difference. There are all kinds of natural testosterone boosters, DHEA. And Utah actually is the national, and perhaps the international, hub of supplements. I mean, there are companies like Essential Oils, which are billion-dollar companies and there is no data that any of that makes any sort of difference. And some of it may even be harmful for men. So that's one thing.

I think the other thing that men should watch out for, we also see a lot of men who take Propecia, or finasteride for hair loss. And that can actually have effects on your testosterone, your sex drive, and even your fertility. So that's another good thing to avoid if you're concerned with that.

Interviewer: So avoid the bad, do the good, and about how long until men start seeing maybe some changes?

Dr. Hotaling: Unfortunately, weight loss, for most people, is a slow process, especially if you're going to have sustained weight loss. I mean, you could lose at most one to two pounds a week. But I think if men stick to a healthy diet and lift weights, they should see a difference in four to six weeks and start feeling better. And there has been data that that's essentially something that's been proven over and over again in the literature. Those are really the key things for men.

And I think the other really important thing men can do is just regularly see a primary care physician. Most men don't. Men seek health care at a rate that's about 30 or 40% lower than women. And part of the reason I'm in here talking to you today is that most of the things that bring men to see a doctor are urologic conditions because they disproportionally impact quality of life, and, we might say, men functions, if you will. So I think it's just really important to get in and see a doctor regularly.

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Interviewer: Testosterone therapy, generally speaking it's safe, but there are some side effects. What do you need to know? Why is it important to have a doctor part of your treatments and not just buying it off a TV ad? We'll talk about that next on the scope.

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Interviewer: If you're on testosterone treatments, it's important to be regularly monitored by a physician to avoid potential risk. Dr. Jim Hotaling is a neurologist and a men's health expert at University of Utah Health Care.

So let's say I'm a man. I saw the TV ad for testosterone treatments and now I'm taking them. Are there some possible risks?

Dr. Hotaling: I mean I think the biggest thing we see very frequently, and I define frequently as I probably see one to two guys a week with this, is that testosterone will make men sterile. It's actually been trialed as a male birth control. It only works on about 90, 95% of men. So it didn't actually make it as male birth control. But that's the biggest thing. It will drop your sperm count to zero in most instances.

The other issue is that it can raise your red blood cell count in some men to unsafe levels. Particularly the injections can do that. It can also cause fluid retention. Theoretically we used to think that it would increase your risk of prostate cancer. But there really isn't a lot of data to actually support that.

And then there's been a lot of data about cardiovascular disease, testosterone and increasing the risk of stroke or heart attack. That really as it turns out, the major study that sort of showed that, which is a paper in a very prominent medical journal, has been shown to be methodologically flawed in a number of different things. And actually there's a lot of data that shows that men with testosterone actually do better from a cardiovascular disease standpoint.

I think generally speaking it's a very safe drug as long as things are monitored appropriately. We check labs on our patients every three to six months for the first year and then annually thereafter. Generally speaking we have very few, if any, adverse events from men being on it. So that in a nutshell are what the major concerns are.

Interviewer: So the people that are probably the target for the television commercials tend to be older. So they might not be concerned about their child rearing days are done. Are there dangers? I always understood that there just wasn't enough research to say whether or not it's safe at this point. And I hear a lot of comparisons to estrogen treatments in women.

Dr. Hotaling: Yeah, so there have been some huge trials done on estrogen treatments. One of the big issues is with that is increasing the risk of blood clots.

Testosterone treatments actually raises estrogen levels in men as well. And that can be an issue. That can get to an unsafe level especially in overweight men. Their fatty tissue has an enzyme in it that will convert testosterone to estradiol which is a female hormone and that can get to unsafe levels.

I think the big issue with testosterone is that we have patients who have been on testosterone for 5, 10, 15 years and we don't have follow up. We don't have the research to know what the exact effects are for being on it for that long. We think generally speaking it's very safe as long as it's used in a reasonable and measured fashion.

Interviewer: So originally in this conversation I was going to take it in the direction of, somebody saw the ad on TV, they're getting the creams in the mail now and I was thinking it's a dangerous thing. But it sounds like you're saying it's not a dangerous thing.

Dr. Hotaling: I think if it's monitored appropriately and men are on it for the right reasons, I think it can make a big difference in their quality of life.

Interviewer: So if I was on it because of a TV ad, it's a good idea at some point to go to a urologist and have some labs done.

Dr. Hotaling: Yeah, definitely. We see a lot of people who are not really appropriately managed. There's a lot of these testosterone clinics that never see the patient and maybe have a phone interview and I think if men are on testosterone they need to see a physician regularly, have appropriate labs monitored, and know that it can make them sterile.

I would say no man of reproductive age who is planning on having children in the future should be on testosterone. There are alternatives that we can use that men have low testosterone and symptoms that are of reproductive age and can boost their testosterone and actually improve, not hurt their fertility.

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Interviewer: Andropause is the male version of menopause. We'll find out more about that next on The Scope.

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Interviewer: Dr. Jim Hotaling is a urologist and also a men's health expert here at University of Utah Health Care. Andropause, what is it?

Dr. Hotaling: There is a natural decline in testosterone in men after the age of about 30 or 35, testosterone goes down significantly. One of the things that's really tricky is we don't know what the normal testosterone is in a 20 year old, 30 year old, 40 year old, 50 year old. We know maybe in a 50 year old and above what an abnormal testosterone is, which is usually a total testosterone, depending on who you look at, below 350 or below 300.

But again this is a lab test that varies minute to minute and hour to hour and it has to be checked before about 10 in the morning to be accurate. So if a man goes to get their testosterone checked at 4 pm it's almost always going to be low. One thing that's difficult is the testosterone industry has had the most successful marketing campaign in the history of medicine.

So it literally took testosterone from in 2000 being about a $100 million a year industry, I think this year it will clear 2 or 3 billion. It's actually taught at Harvard Business School, the whole concept of low T as exactly how you should do marketing. And a lot of men come in because they're concerned with that. In summary andropause is real, but and this is the big but, you don't treat a number.

You really only treat patients if they have symptoms of low testosterone and have low testosterone. Ideally on one to two measurements in our opinion and everybody's bias, but urologist are great people to do that because they understand a lot of the issues that impact men's health.

Interviewer: So what exactly is it? Is it just a natural lowering of testosterone? Is that all andropause is?

Dr. Hotaling: Essentially, yes. The testosterone will decline in a man every year past the age of 30 or 35.

Interviewer: And is it the male version of menopause?

Dr. Hotaling: It is in the sense that it's a decrease in hormone levels and everything else. But for women it's a different issue because at some point they stop ovulating. Men really never stop producing sperm. There are people who've produced children in their 90s, which that's a topic for a different day, but men never stop producing sperm.

And it's not as severe as it is in woman. It's a very gradual decline and at some point, in some men, it declines to a point where it does cause symptoms and that is where I think there is some resemblance to menopause.

Interviewer: And that's where you as a urologist or a men's health expert would perhaps then consider doing some sort of therapy?

Dr. Hotaling: Yeah, that's correct and typically the therapy is testosterone replacement. There are other medications we can use. The downside to testosterone replacement is it will make men sterile, some men permanently. Most men not. But we can use other medications to actually boost testosterone and keep men's' fertility intact.

There are also some surgical procedures, one in particular we can do to actually help increase a man's testosterone.

Interviewer: So decreasing testosterone or going through andropause is just normal?

Dr. Hotaling: Yeah, it is normal and I think that's the key thing to understand. The testosterone companies would have you believe that you should treat a number. And what's tricky about testosterone is anyone, no matter what their testosterone starts at, will feel better when you put them on testosterone. That doesn't mean that everybody should be on testosterone and I think that's the real challenge.

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Interviewer: If you watch any TV at all you can't escape the ads, ads for you need testosterone therapy. It looks like it's pretty easy to get, but should you get it? That's the question. Right now I've got with Dr. Tom Miller, University of Utah health care.

Dr. Tom, for a guy that's over 30 years old, it's been scientifically proven that testosterone levels start dropping at that point. Should I be ordering some of this testosterone online? I mean after all, I want to look like that guy.

Dr. Tom: I think the question, Scot, is why do you think you need it? What's different?

Scot: So, the ads tell me my energy levels have dropped, which they have, that I start putting on more body weight, that my mood is affected, and my sex drive is decreased. Testosterone is going to cure it. It's kind of cure-all is what they're telling me.

Dr. Tom: That's a great concern. That's a concern of many men, and women, throughout the country, but the real question is are there different causes for those things you mentioned? There are many causes for people being a little overweight, feeling a little fatigued. It isn't just testosterone; it's a whole basket full of causes.

Scot: So, if I came into your office, and I gave you those symptoms, and I said that I want testosterone what would you say to me? Where would you start looking?

Dr. Tom: I would ask a few questions. One I'd ask, "What's your sex drive like? Has it dropped off? Are you interested in sex? Do you have the same drive that you had five years ago?" And if the answer to that is no and that you were concerned about it, I'd then go ahead and measure your testosterone level.

Scot: Okay.

Dr. Tom: But I'd also ask you a number of other questions. If the testosterone levels came back low, then we might do a trial of testosterone replacement, and we would then monitor how you felt. Did it make you feel better over the course of time that we try the medicine? If not, it might be wise to stop it.

Scot: So, let's back up for a second, these ads that I'm seeing on TV, I can just order without a doctor's prescription?

Dr. Tom: No, you have to have a doctor's prescription. There's a doctor on the other end that's asking a set of questions.

Scot: So, when I make that call, there is a doctor?

Dr. Tom: There's somebody that has to write the prescription.

Scot: Got you. How do they know how much I need, because it sounds like you would do tests to find out what the actual level is? It sounds like they're just asking me some questions and if I pass they're going to write me the prescription.

Dr. Tom: That's probably true. I can't attest what other things that they do, I'm not sure that's the best way to get health care. Basically you're telling them that you need testosterone, and they're saying, "Fine. Answer these questions. Here's your prescription." I'm not sure that's the best way to try to define what your problem is. As I mentioned before, the causes of fatigue and weight gain there are multiple issues related to that not just testosterone.

Scot: So, let's pretend that I come into you because I want to be a little smarter about it. You ask me some questions; you decide to run some tests. You find I'm in the normal range, on the low end of the normal range. Would you do anything at that point?

Dr. Tom: I probably would counsel you about your lack of sexual drive. Well, I'd seek more information about that, and it might me that there are other reasons for that aside from the fact that the testosterone is in the borderline range. I suppose if you really wanted to try it we could do a trial.

Scot: Sure.

Dr. Tom: I'm not opposed to that if the patient thinks that's right, but I try to give them a realistic expectation. Also tell them that, "Look, it's not a wise thing to take medicine if we do this for several months and you find there's no difference, and you're honest with yourself about it." Just as with any medicine, in my mind, it doesn't make sense to take it if you really aren't getting a benefit from it.

Scot: So, let's take a look at these ads; they promise me so many things. Let's talk about the benefits of testosterone therapy, just from a strict benefit. Why would I, as a man, even come to you and talk to you about it?

Dr. Tom: Certainly, if you had low levels, it might be affecting your sexual drive, you might have some fatigue, you might have less muscle mass then you were used to. In that instance, if you were replacing testosterone, it might help you quite a bit; you might have a great improvement. The problem though, long term, is we don't really know if the side effect . . . we don't know what the side effects are of testosterone replacement over the long haul greater than five years. We just don't know that yet.

Scot: So, this is kind of the risks part right now, is we don't know what the risk are.

Dr. Tom: We don't really know what long-term risks of testosterone use might be, replacement. There are a number of men that I know who have low testosterone and they don't notice any difference. So, do you replace testosterone by testing for it in men who are low? The answer is I don't think we really know. We don't have enough information. We do know that testosterone helps maintain bone integrity and strength but we're not at the point where we say screening for testosterone is a thing to do.

Scot: So, it falls off as I turn 30, and as I get older. When you're testing, are you testing for the normal range for, say, a 55-year-old man, if I'm 55, or were you...?

Dr. Tom: I want to back you up a little bit; testosterone may decrease variably in men so it's not the same as menopause in women.

Scot: Okay.

Dr. Tom: So, when women enter menopause their levels of estrogen drop precipitously. The same is not uniformly true in men. Some men have lower levels of testosterone over time, but not all. So, it's unclear which men would have low testosterone and others have normal testosterone; we just don't know yet. There's not a recommendation to screen all men for testosterone levels.

Scot: So, you really can't say how much should a 50 year old man have?

Dr. Tom: Well that's correct, I mean because we don't screen.

Scot: Got you.

Dr. Tom: We don't test for testosterone as part of an annual exam in the same way that we test blood pressure or test cholesterol or test blood sugar.

Scot: So, your advice is don't order the stuff on TV because you're playing with something that...?

Dr. Tom: My advice is that if you have questions about the way you feel, whether you have fatigue or decrease in energy level or a decrease in your sexual drive, then you should probably talk to your physician about that and decide if testing your testosterone level is right for you. Nothing wrong with that.

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