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Hey, everybody! It’s Dr. Trish Murray from Discover Health Functional Medicine Center doing my Discover Health Podcast. Today my focus is to talk to the men, or if women are listening this is all about you helping your man, because we’re going to talk about the almighty testosterone today, specifically testosterone deficiency. What if you have it, or how do you know if you have testosterone deficiency? If you do, what can you do about it? I’m going to share some slides, and we’re going to get right into this.
Here we go. Again, the title of this podcast is “Testosterone Deficiency: How Do You Know If You Have It and How Effective is Treatment?”
Before we can talk about deficiency of testosterone, let’s first of all make sure you understand testosterone production. Testosterone is produced by Leydig cells in the male testicles. There is a circadian rhythm to this, so there’s different times of the day that means the testosterone level is going to be different. So, we know from research and studying this that the highest levels of testosterone occur in the morning, typically between 8 and 11 AM. This is the time, you’ll notice, when you’re going to want to test a man to know whether his testosterone levels are deficient or not.
Testosterone production is signaled by a certain hormone called luteinizing hormone, and this hormone is put out by the pituitary gland in your brain. Remember that hormones are sort of like follow the bouncing ball. One hormone tells another hormone, another organ, when to put out the different hormones. Now, testosterone in men is similar to estrogen in women. The other thing that everybody needs to understand is men and women both have testosterone and estrogen in our bodies, but the balance of them is very different from a man to a woman. The peak levels of testosterone, or estrogen for that matter in women, are going to be highest when we are younger in our reproductive years because these are sex hormones, testosterone and estrogen.
Obviously in men testosterone is going to be at its peak in a male’s reproductive age. When you’re younger. By the time you hit your late 30s into now your 40s when we’re starting to, if you will, at 40 something not really be looking typically to reproduce, testosterone is going to start to decline. It declines by one to three percent on a normal basis every year but causes of testosterone becoming deficient abnormally fast or declining at a rate that is, you know, much more than one to three percent is going to be caused by certain things.
If you take nothing else away from today’s talk, what I want you to understand is that functional medicine, lifestyle medicine is extremely important in all of you guys out there maintaining your virility because look at these causes of deficiency. This is just a few I’m going to list here, and I’m going to talk more about this in detail as I go through more of the slides.
Causes of deficiency include:
- You see, increased fat cells actually cause a decrease in testosterone and an increase in estrogen, which you do not want.
- Type 2 diabetes. Sugar causes inflammation. Inflammation lowers testosterone, and diabetes and increased sugar causes insulin resistance. If your insulin is not productive, if you have too much insulin in your body and you have insulin resistance, insulin also will cause a reduction in testosterone.
- COPD which is chronic obstructive pulmonary disease from smoking. Guys, tobacco and smoking guess what? Decreases testosterone! COPD, the chronic disease that comes primarily from smoking over many years, will deplete your testosterone more quickly than normal.
- Chronic kidney disease which comes, again, from all these other things I’m talking about.
- High blood pressure will cause a depletion more quickly than normal of testosterone.
- HIV infection or other chronic infections may deplete your testosterone.
- Opioid dependence and overuse of opioids for pain or for just recreational use, whether you’re young or you’re old, is depleting your testosterone and destroying your virility.
What are some signs or symptoms that men would have of low testosterone levels? Let’s look at this list together:
- Loss of body hair
- Increased body fat or your basal metabolic index of…now if someone has increased body fat and they have a BMI greater than 30 that is consistent with obesity. Again, that’s going to cause production of increased estrogen, depletion of testosterone, and loss of a male’s virility.
- Sexual dysfunction including low libido, meaning low sex drive, you’re not as interested in sex as you used to be or ED, of course, erectile dysfunction. Now, what truly is erectile dysfunction? Erectile dysfunction could be anywhere from you’re not even having spontaneous erections in the mornings, let’s say, or you can obtain an erection, but you cannot maintain that erection to have intercourse. That is still considered aspects of erectile dysfunction.
- Hot flashes
- Breast enlargement in men (gynecomastia)
- This next one is important to take a minute to talk about depression. If you are feeling down, if you are feeling lack of motivation, if you are feeling more angry, more agitated, more depressed, unable to move on in your life with things, lack of vitality…it actually could be due to the fact that you’re having low testosterone levels. So, remember that. As we talk later about the benefits of testosterone treatment, it could be that if you have low testosterone levels that might be the answer to your depression. That’s important for guys to understand and to have that looked at by your medical provider.
- Decreased strength or loss of muscle mass and atrophy of the muscles
- Decreased sense of vitality
- You see, testosterone causes our bones to put out more red blood cells. If a man is anemic as he’s getting older, it might be due to low testosterone. It’s another thing to be checked.
- Osteoporosis or low bone density or if a man from a fall is having more fractures than “normal” it’s something to be looked into because they may have low testosterone.
So, this is quite a list guys! Look it over and see if you are consistent with any or multiple of these in particular. More than just one is more signs that you might be at risk for testosterone deficiency.
Now, guys there is a questionnaire and there are others than this one, but this is the one I’m going to focus on in this talk. It’s called the ADAM questionnaire. Acronym A.D.A.M. or ADAM, standing for androgen deficiency in aging males, questionnaire. You can see the list of questions that are asked. There are basically 10 questions:
- How do you rate your libido or sex drive?
- How would you rate your energy level?
- How would you rate your strength and endurance?
- How would you rate your enjoyment of life?
- How would you rate your happiness level?
- How strong are your erections?
So, you notice these questions are elucidating that list of symptoms and signs that I talked about on the previous slide. You can find this ADAM questionnaire online, guys, or go from this list I have right here. Answer them. If you have more than three of these questions positive, meaning you answer yes to them or you score them high, that is concerning for a testosterone deficiency.
Now, of all the things I’m going to talk about in this podcast and all the slides I’m going to go over, this I would rate as the most important for all men and the women out there that are listening to this for your man or the men in your life. The clinical findings that are consistent with low testosterone…meaning testosterone is not a test that the primary care doctor is going to do just on a regular basis. You have to ask to have it tested, but if you have these clinical things that I’m about to start talking about and if you have multiple of them, first of all, these could be the why as to why your testosterone is low because these are the root cause of why testosterone gets depleted. You’ll notice and I’ll emphasize this again at the end of this list is all of these that I’m about to go over are preventable and are related to your everyday lifestyle whether you’re 25, 35, 45, or 85.
If you have atherosclerosis, increased plaques in your arteries, if you have heart disease already and you know it, and high cholesterol, that’s leading you down a path of more heart disease and going to lead you down a path of low testosterone.
The next is Type 2 diabetes or way before you ever get diagnosed with diabetes, men and women are told that you have metabolic syndrome or insulin resistance. Your blood sugar is too high, you’re eating far too many grains in your diet, your diet is full of processed foods in boxes and bags, you’re not staying on the perimeters of the grocery store, and you’re filling yourself with processed high sugar foods and you’re developing insulin resistance. Insulin that’s too high, guys, depletes your testosterone, whether… again, I don’t care your age. If you’re 15, 25, 35, or 85, insulin resistance is bad for virility and testosterone.
Next, obesity. Again, if you have increased fat cells due to your diet, lack of exercise, and too much stress and toxins in your body, then you’re producing too much estrogen and you’re depleting your testosterone. If you are not exercising and doing some sort of weight resistance type exercise or tension-related exercise or strenuous exercise and you’re losing muscle mass or you’re not developing any muscle mass as a young man, you are depleting your testosterone.
High blood pressure and high cholesterol are related in clinical findings that are consistent with men with low testosterone. Smoking…guys, tobacco is not your friend. It’s destroying your virility; it’s decreasing your testosterone. Alcohol. Increased alcohol use. It is generally recommended that men should drink no more than two alcoholic beverages per day. If you’re drinking more than that on a daily basis you should realize that you’re depleting your testosterone, you’re depleting your ability to be a virile male.
Next, inflammation. Again, if all this other stuff is going on in your body, if you’re eating too high a sugar diet because sugar causes inflammation, if you’re under too much stress causing inflammation, again inflammation depletes testosterone.
I mentioned earlier opioid use. If you have chronic pain and you’re taking opioids chronically or if you’re using them recreationally it’s going to destroy your testosterone levels. Look at the next one guys – insomnia. If you don’t get enough sleep, if you are burning the candle at all ends, you’re destroying your testosterone too quickly. Finally, OSA is obstructive sleep apnea. Again, all of the list before this is what’s causing your obstructive sleep apnea, so the bottom line is that’s another clinical finding that’s consistent with low testosterone.
As I said at the beginning, guys, if you look at this list it’s all preventable, and it’s all related to lifestyle-related things. So, if you are a man who is not living a healthy lifestyle, to be honest you are causing your own depletion of your virility and you’re going to lose testosterone too quickly. You can reverse all of that! You can improve your testosterone; you can improve your virality; you can feel more vital; you can reduce your depression; you can lose the weight. All of these things are possible.
Now, to just give an example to show you that the research that has been done shows, for example, obese teenage boys…when you test lean boys and you compare it to teenage obese boys, the obese boys were shown to have fifty percent less testosterone than the lean boys did. So, there’s your example of how some of these lifestyle-related things are the main reason for loss or lowering testosterone.
Now, if you’ve heard all this and you’re like, “Oh! Well, I would like to get tested to find out if I do have low testosterone, if I have testosterone deficiency.” What’s the lab testing that you need to have done that you should ask your medical provider for?
Well, first of all, in order to diagnose any man with low testosterone or testosterone deficiency they have to have their total testosterone tested on at least two occasions. So, you can’t just do it once; you need to do it twice, and the level that is the line in the sand for whether someone has low testosterone or not is 300. And you also want to get your blood drawn for your total testosterone, again, in the morning between 8 and 11 AM to assess for your optimal levels.
So, that’s first – total testosterone on two occasions between 8 AM and 11 AM in the morning. Besides that, you also want to ask to get tested for your free testosterone. You see, testosterone gets bound in your blood to proteins. There are a couple different proteins, one called albumin and another one called sex hormone binding globulin.
Globulins are proteins, and sex hormone binding is a globulin, a protein, that binds sex hormones such as testosterone. Sixty percent of your total testosterone is bound to sex hormone binding globulin on a regular basis. So, you notice you need to have your sex hormone binding globulin stay low. If it goes up too high, it’s going to bind all of your testosterone and not allow you to have much free testosterone. It’s the free testosterone, guys, that’s biologically active, meaning it can be activated and functioning in your body to give you your virility. So, you don’t want too much of your testosterone bound to proteins. You want to know – how much of my testosterone is free and bioavailable? So, the total testosterone, the free testosterone, and the sex hormone binding globulin are the first three things you want to make sure you ask to be tested for by any medical provider if you’re concerned about your testosterone levels.
You also may want to get tested for the hormones that cause testosterone to be produced, luteinizing hormone and follicle stimulating hormone as well as something called prolactin. These are labs that usually would be done later if you are found to have low testosterone. They wouldn’t necessarily be the first line tests. The other ones I’ve listed – total testosterone, free testosterone, and sex hormone binding globulin – would be the first tests.
Also, to finish the list, you want to ask for a complete blood count, meaning they’re going to look at your red blood cells. Because testosterone increases the production of red blood cells, you need to be looked at first to see if you’re anemic. Also, if testosterone is going to increase your red blood cells more, you don’t want to already have a problem with too many red blood cells. So, your hemoglobin and your hematocrit should be checked. If your hematocrit is greater than 50 percent, that’s going to require more evaluation to make sure it might be safe if your testosterone is low to consider you for any testosterone therapy.
Your PSA or your prostate specific antigen should also be tested because, of course, we’re going to talk later about the fact that if someone already has prostate cancer or is at increased risk for prostate cancer should not be considered as a treatment. Guys, yes, this is where you would need a digital rectal exam if you are considering going on testosterone therapy because, again, that is a test to test your prostate to see if there are any tumors on it or any concerns that there might be a tumor. That is the main reason for doing that test of digital rectal exams. You are going to need one if you’re considering going on testosterone therapy.
Now, how do you determine if someone truly is diagnosed with testosterone deficiency? Well, guys, the endocrine society guidelines state the following, “Only if there are signs and symptoms of hypogonadism and total serum testosterone levels are low [meaning less than 100] on at least two occasions,” would you be considered diagnosed with testosterone deficiency. So, you have to fit all of that statement.
Now, if you do go on testosterone therapy, the goal of testosterone therapy, of course, is to increase your testosterone level, but how high? Well, the goal in the recommendation is to increase your total testosterone level to a mid-normal range of between 400 to 700 nanograms per deciliter. Remember the line in the sand of being too low is less than 300 nanograms per deciliter.
So, what are the benefits and what are the risks of testosterone replacement? Well, first of all, obviously one of the main reasons that any man would want to consider it would be erectile dysfunction. What’s interesting though, guys, is that there is no definitive evidence in all the studies that have been done so far that testosterone definitively black and white improves erectile dysfunction in men with particularly normal testosterone levels. Now, if you are found to be testosterone deficient, it may be an excellent therapy for you, but if you are not deficient in testosterone, less than 300 nanograms per deciliter, then it’s not very effective.
Now, young men with low testosterone and erectile dysfunction do tend to benefit, but older men don’t tend to benefit. Actually, thus far, studies have shown that phosphodiesterase-5 inhibitors, which that’s the big term or description of medicines like Viagra, guys, work best in men with normal testosterone levels. So, again, until you get your total testosterone level checked, you don’t know where you stand. But, Viagra versus testosterone? That is going to need to be an individual assessment for you between you and your medical provider.
If you have more symptoms such as bone and muscle density problems, testosterone is shown to work very well in increasing bone density and muscle density and improve muscle mass in older men. But, if an older man has balance problems, for example, or is not exercising to improve their strength as well…I mean just to take the medicine, guys, is not going to solve the problem. It’s not going to decrease falls or fractures and it may not improve strength or physical function, particularly more than you exercising and doing more.
How about, you know, cognition? Men that are concerned about dementia or cognitive decline. Guys, I hate to tell you, but testosterone has not shown any improvement in cognitive function in men with or without pre-existing cognitive impairment. The studies have just not panned out that testosterone is the answer for dementia or cognitive decline.
However, as I brought up earlier for depression and mood issues testosterone might be an excellent answer for. So, if an older gentleman is having issues with depression and other signs and symptoms related to low testosterone, this might very well be the answer for you to get your total testosterone, your sex hormone binding globulin, and your free testosterone tested and see if you are deficient in testosterone. Maybe it will help you with your mood instability.
Finally, here, again, that discussion of anemia. If an older man has anemia it might be due to low testosterone. Also, if a man has a normal red blood cell count or particularly a high red blood cell count, you may not be able to tolerate or you may have to go on a very low dose of testosterone because it may cause polycythemia, meaning too many red blood cells. So, again, testosterone stimulates what’s called erythropoiesis or production of red blood cells. But in men with normal or high levels to begin with, this can also lead to a complication of testosterone therapy called polycythemia. So, again, it depends on where the individual is, and this is why you want to be tested for your CBC, your complete blood count, in the beginning when you do your lab work.
Let’s talk about some contraindications to testosterone therapy, meaning why absolutely you would not even ever consider treating a man with testosterone:
- If they were ever diagnosed with breast cancer. Guys, breast cancer obviously is much more common in women, but it does not mean it doesn’t happen in men. If a man has ever been diagnosed with breast cancer, then testosterone therapy is not going to be something…that’s an absolute contraindication to not ever do testosterone therapy.
- If a man already has polycythemia, meaning a hematocrit greater than 54 percent, that’s too dangerous for them to be put on testosterone.
- If a man has active prostate cancer, then testosterone is absolutely a contraindication.
- If you have a PSA, a prostate specific antigen, level greater than four nanograms per milliliter or the presence of a nodule or even an induration like, you know, when a medical provider does your digital rectal exam, again, that’s why it’s done. To test your prostate and feel your prostate gland to see if it has any nodules, tumors, or indurations meaning like a divot in it which could be related to a tumor. If that is found on your exam you need to be referred to a urologist immediately for further evaluation.
Now, folks, in the contraindications world there are absolute contraindications which I just went over and there are relative contraindications, meaning they’re concerning but it doesn’t mean you absolutely could not go on testosterone therapy. You could negotiate and determine whether, you know, your individual situation is okay for testosterone or not.
- The first one, as I’ve talked about previously, is a baseline hematocrit of greater than fifty percent. Again, you need that CBC, that complete blood count, done.
- The next one is really important for all of the guys listening to this to hear. If you still have any desire to have children, if you truly desire your fertility, you want to maintain it. You have to understand that your sperm production is going to go way down if you supplement testosterone therapy. If you take exogenous (outside the body, not natural, not produced by your body) testosterone and you put it in your body with injections, you are going to suppress your body’s ability to produce sperm so that you will be way less likely to be fertile and be able to impregnate anyone if you were still having an interest in doing that and having children
- The third relative contraindication is severe lower urinary tract symptoms, meaning if you already have a history of prostate problems, if you have a history of enlarged prostate that is concerning and, again, it has to be individually evaluated with your medical provider if you would consider going on testosterone therapy. But, it may make those symptoms worse.
- Uncontrolled congestive heart failure. Testosterone, again, may make heart-related conditions worse, so that’s something to be looked at.
- Untreated obstructive sleep apnea. Again, obstructive sleep apnea puts people at risk for heart disease, pulmonary disease, stroke, and if you’re going to go on testosterone that may increase your risks.
These are relative contraindications.
Now there are many different formulations of testosterone, and there’s no formulation that really has a superior clinical effect over another. If you if you are planning after your work up and you and your medical provider feel that testosterone therapy is an answer for you to trial, you can do different kinds of testosterone. You can do injectable or into the muscles. You can do intranasal. You can do pellets that are actually…you go to the medical provider, they do an incision, and they use a trocar to put pellets under your skin in your body and they stay there, and they slowly get give off testosterone over time.
The last two are dermal meaning on the skin: transdermal gel or a transdermal patch. What you need to realize from this list is none of them are oral. Testosterone should not be taken orally because it is toxic to the liver and it’s not usable that way. The other thing that you need to realize guys is that topicals, the gel and the patch, can be transferred to other people that touch you and interact with you such as the women in your life and the children in your life. That would be a problem possibly, so you have to think about that and which formulation you would consider for testosterone therapy.
Now, let’s say you found that you go through the lab tests, you have multiple symptoms, you work with your medical provider, you decide to initiate testosterone therapy, you decide on one of the formulations, and you’re taking it. Well, what do you need to do to follow up and recheck levels? The re-evaluations for therapeutic response and adverse effects:
- Within the first three to six months of going on the therapy, you need to get retested for your bloodwork. You need to do the total testosterone; you need to do the CBC again, that complete blood count, to see what’s happening with your red blood cells; you need to check your PSA, your prostate specific antigen, and see what’s going on with your prostate; and I hate to tell you but, yes, this is where if you are concerned and the medical provider needs to test you to see if your prostate might be developing any problems related to going on the therapy you do need to do a digital rectal exam at that follow-up. If all of that work up at somewhere between three and six months is completely normal, then you can go to annual reevaluations with the same level of testing.
- If your hematocrit rises at that follow-up to greater than 54 percent, you either need to stop the therapy or you need to lower the dose and retest the CBC within probably a couple months or at least a month or so and see if it keeps rising.
- If your PSA rises greater than 1.4 nanogram per milliliter with the use of testosterone over the first three to six months or even in the first twelve months or you have an abnormal digital rectal exam at any time in those rechecks you need to actually stop therapy and be referred to a urologist for a full evaluation for the risks of prostate cancer.
- Free testosterone and sex hormone blinding globulin should be retested to see where they are and whether they’ve improved and if they’re involved in why you have a low free testosterone level.
I mentioned this before, but I want to make sure you realize this again, guys. Endogenous versus exogenous testosterone. Exogenous, meaning if you take testosterone synthetically from outside your body and you’re not naturally producing it and you put it in your body by the nasals or the pellets or the injections or even the gels that exogenous testosterone triggers a negative feedback which diminishes your natural ability to produce testosterone more than normal. Therefore, decline in testosterone is further intensified by the testosterone therapy. You’ve got to realize that’s what’s going to happen normally, typically with testosterone therapy, guys.
That pretty much covers everything I wanted to go over today. I hope this has helped you understand testosterone deficiency. Whether you have it or not, remember, needs for you to have multiple symptoms. The ADAM questionnaire is where you would want to go to answer questions to see if you do have multiple symptoms that could be consistent with testosterone deficiency.
We also reviewed in this what labs need to be done to diagnose you with low testosterone or normal testosterone or do you have normal total testosterone but low free testosterone with high sex hormone binding globulin? You see, that’s why we want to do all three of those tests. Again, that’s total testosterone, free testosterone, and sex hormone binding globulin.
For the diagnosis of testosterone deficiency, you must have multiple symptoms and low total testosterone level on two different lab tests. We also discussed together the contraindications to testosterone treatment.
Finally, guys, the most important point I wanted to make in all of this is you can go over all of this and some of you out there, yes, are going to have testosterone deficiency as an older man and testosterone therapy may be the answer for you, absolutely. But what if you’re someone that is a couch potato, if you’re someone who is overweight, if you know your diet is bad, if you’re a smoker, and you drink too much…guys, your overall understanding that your day-to-day lifestyle habits throughout your life – your diet, exercise, exposure to toxins, and stress levels end up being the root cause to chronic disease and steal you of your vitality and your virility.
So, if you take nothing else from this talk, I sure hope you take that to heart and start listening to more of my Discover Health Podcasts which will help you improve your lifestyle so you can lose the weight, decrease your fat cells, get away from alcohol, get away from tobacco, decrease your stress, avoid toxins, and improve your testosterone levels and your virility and live the life you want to live and take control of your health.
With that, guys, I hope this has helped and we’ll talk to you on the next episode of Discover Health Podcast.
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