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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.
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