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Melanie Cole (Host): Men naturally lose testosterone as they age, but there are ways to increase declining levels. My guest to tell us about this today is Dr. Charles Walker. He’s a board-certified urologist with Montefiore St. Luke’s Cornwall. Dr. Walker, I’m so glad to have you on today. This is something that so many men and their partners deal with every single day. Before we talk about it, tell us what is testosterone and what is it’s role in the body?

Charles Walker, MD (Guest): So, it’s a simple question and an extremely complex question as well. Testosterone is essentially the major androgen steroid hormone in men. And it’s something that – the production of testosterone and the effects of testosterone begin even in utero. Essentially what it does is it’s responsible for – at the beginning of life, in utero for the development of male organ systems so we call that virilization. And so, right from really the first four to six weeks of development, we start to see the development of the male organs internally as well as externally under the influence of testosterone.

And throughout your life, it has many different roles. So, it’s responsible for development of secondary characteristics, sex characteristics in men as they go through puberty and later on in life, in adulthood it maintains fertility, it’s responsible for lean muscle mass development, it’s responsible for bone density and there are many parameters of health that we now believe are either directly or indirectly impacted by testosterone. We can talk about that in a little while.

So, that’s essentially what it is. It’s extremely important as a hormone for men and for their health and wellbeing.

Host: As I said in my intro, Dr. Walker, that men lose testosterone as they age; so, is this a natural part of aging and how come if it is, some men get low T and other men don’t?

Dr. Walker: Great question. So, it is a natural part of aging. We see this in men as they get older. And I think the question is why does that happen and it’s not clear why some men are more likely to have lower testosterone levels while others maintain testosterone levels but a lot of it probably has to do with the comorbidity of other chronic diseases as men get older. And so, other factors, other conditions, health conditions, can affect testosterone production, like obesity, whether men have been treated for cancer in their life, whether they have chronic illnesses of any kind. And so, those can affect testosterone levels.

And so, it’s not always clear which men are going to fall I guess develop low testosterone, but it clearly is something that develops as men get older and it is a natural part of aging. The other I think question is, are they going to be symptomatic from low testosterone or not and I think that’s something that is really the important issue when it comes to treating testosterone.

Host: Well then, let’s talk about that. What are some of the signs and symptoms that they themselves or their partner might notice and based on those symptoms, when is it time to see a doctor?

Dr. Walker: So, some of the most common symptoms are related to sexual function and sexual health. So, we see erectile dysfunction, particularly in younger men as well as decreased sex drive or decreased libido. Testosterone can affect your lean muscle mass and so men may notice that they are having a harder time maintaining lean muscle mass. They may notice that they’ve started to gain weight as they get into their 40s and 50s. Symptoms of depression, or feelings of depression can be related to low testosterone. And also a little bit more controversial but feelings of low energy or symptoms of low energy and fatigue have also been associated with low testosterone but the issue there is that there’s a lot of other things that can also cause those symptoms in men particularly as they get older and so not always clear if that’s directly related to testosterone but that would be a sign that should prompt men to ask their doctors about testosterone testing and possibly even a referral to a urologist or men’s health specialist.

Host: That’s great advice. So, tell us a little bit about diagnosis and some of the treatment options. Dr. Walker, we see these commercials and for any number of treatments for low T, tell us about those that we are hearing about. Are they actual? Are they pushing medications? What are those commercials that we see and tell us how you diagnose it.

Dr. Walker: So, that’s a great question. I was reading a statistic recently that testosterone prescriptions had risen to such a high level in the last five years that it’s now recognized as one of the top 150 medications prescribed which is pretty significant. So, testosterone has become I think, a subject of a lot of interest and we see a lot of prescriptions, we see a lot of advertising, marketing for testosterone products and I think there’s a lot of misinformation out there.

So, I think that the first thing you have to do when there’s a concern for low testosterone is be evaluated by your doctor. And some primary care doctors are comfortable initiating that workup, other times, and they may just do a screening test and we can talk about that in a second. Or they may refer directly to a urologist or men’s health specialist or an endocrinologist. So, wherever you end up once you have identified a possible symptom of low testosterone; the physician is going to do typically a screening for low testosterone by testing your serum testosterone level. And this is best recommended to be done in the morning. Okay, so we like to do this typically before 11 or even 10 in the morning and that’s because testosterone levels fluctuate throughout the day particularly in younger men.

So, we typically will do one screening test and there’s a number of different ways to test for testosterone. You can test the total testosterone. You can also test the free testosterone level and we can talk a little bit more about that as well. But basically, either a total or total and free testosterone is usually the test of choice for screening. And if that comes back abnormally low; then we typically will repeat the test a second time and once we have established and confirmed that there are two measurements that are below the threshold that we recognize to be the lower limit of the normal range; then we say that low testosterone is present and if you haven’t had a referral at that point to a specialist, that would be the time to refer to a specialist for further evaluation.

The question about all the marketing behind testosterone I think in part – I think is part of the reason why it’s become somewhat confusing about how to deal with this condition. And what ends up happening I think, is that there’s a lot of men who are being treated with testosterone without having the appropriate evaluation, without having the appropriate testing and getting the medications from sources, from medical sources that are probably not appropriate. And so, I think that’s the concern and we have to be really careful and really vigilant about making sure that we go through the proper avenues to diagnose and treat low testosterone.

Host: So, what are those proper avenues? Tell us about what you might choose as far as various treatment options and potential side effects, adverse effects of testosterone therapy. So, is this always something you would use? What are some of the different types that you might look at?

Dr. Walker: So, that’s a good question. And I think the first thing that I want to establish is that low testosterone in fact is present. There’s a lot of controversy about that because the lab testing is so varied both in the types of tests that are used, the way it is actually done in the laboratory, there’s a lot of variability. There’s also a lot of variability in terms of what we call the normal range and so, different labs use different reference ranges. And so, some of the organizations in urology and endocrinology and andrology, which is really the study of male sexual health and reproduction; have really made a concerted effort to recognize some universal measurements that we recognize as being cut offs for low testosterone.

So, I think the first thing you have to do is really establish that you are really seeing a patient with low testosterone, you’ve repeated the tests, you have demonstrated that it is present. The second thing is to demonstrate that in fact there are symptoms. And the first thing I want to do is try to rule out potentially treatable causes. And so that could be anything from chronic opioid use, to chronic illness. We can even see low testosterone with daily marijuana use and so there are things that people will come to us and we want to establish is there something that we can change that can improve these levels.

Weightloss for example in our obese patients. So, there are things that I think are correctable without even putting people on treatment. And so once we’ve established and ruled out those types of things; men can also have endocrinological abnormalities such as high prolactin and high prolactin levels are something that we see in people that have certain endocrine diseases. And so we want to make sure that we’ve assessed them for all of these potentially treatable causes for low testosterone.

Once we’ve established that we’ve ruled those things out, we clearly have low testosterone levels present and we have patients with symptoms; then we can have the conversation about how to treat the low testosterone. And there are many, many different ways to do it. There are topical therapies that range from gel-based therapies that are applied to the skin to patches, creams, there are injections, testosterone injections that can be given in the office and also patients can be educated how to do that themselves. We have implants that can be put in underneath the skin. There are formulations that can be put in the mouth that can dissolve into the lining of the mouth and also the nasal passages.

So, there’s many different ways to treat testosterone and I don’t know that there’s one way that’s better than the other. I think it really needs to be individualized to the patient, also the starting levels of testosterone and how far you have to go to get to the goal. And so those sorts of things figure into the treatment that we ultimately recommend. Another consideration is are these men who are at an age where they want to conceive children? And is fertility an important consideration? Because there are other treatments that we can actually give to men with low testosterone that can preserve their fertility.

So, that, I think covers that issue of treatment. You asked also about side effects. And so, one of the major side effects of low testosterone treatment is infertility. And so, in men that are at an age where they are interested in fertility; we have to advise them importantly that testosterone treatment can actually lead to infertility. Other side effects range from liver affects of therapies that are injected and so we talk about liver toxicity. That’s a fairly rare side effect, one that typically only happens in men that have fairly significant liver disease but it’s one that we have to talk about as well.

We clearly recognize that the blood count can go up when we give men testosterone and so we have to carefully monitor their red blood cell count which we call the hematocrit and that’s something that is a clearly established side effect of testosterone therapy. Men can develop acne or kind of have increased oil production in the skin glands. And so that’s something that is a side effect that we recognize as well. If men have sleep apnea, prior to starting treatment; and actually they should be screened for that before you start treatment; you can see worsening of sleep apnea. And there’s a number of other things that certainly have been identified but remain controversial.

And so, those things would include cardiovascular risk and so that’s something that has been identified. It seems to be at this point, while it’s still inconclusive; the overwhelming evidence on this which seems to suggest that there’s a very low cardiovascular risk associated with testosterone therapy. And the other issue that’s somewhat controversial, is the issue of prostate cancer. And that’s actually – I mean that’s a whole interview and conversation unto itself. But the one thing I’ll say about prostate cancer is that the one place where we really need to be concerned, I think is in men who have prostate cancer who either have not been treated for prostate cancer or whose cancer has come back and has potentially spread to distant sites. Those are men who would be at greatest risk for worsening of prostate cancer with testosterone therapy.

So, those are a number of the common side effects that we see and there are more but that’s just to list some of the big ones.

Host: Wow, so much great information to think about. As we wrap up, give us your best advice for when you want men and their partners to think about getting in to see you, what you want them to know about this naturally occurring process that does happen in many men as they age and if there are any ways to naturally boost their testosterone level, what you would like them to know in the last few minutes here.

Dr. Walker: Okay so, and I chuckle only because it’s one of these things that you can speak to patients about for a long time. So, I’ll try to boil it down. So, the main thing is, I think that men should be aware that if they are having symptoms of sexual dysfunction of any kind whether it be erectile dysfunction or decreased libido; if they are having difficulty maintaining lean muscle mass, if they experience low energy or symptoms of depression, any of those, and certainly if they are found to be a risk for low bone density, so any of those things would be things that I think should prompt men that they need to be screened.

So, I think screening is important. I think doctors need to screen men who come in with any of these conditions. Once you’ve been established to have low testosterone; it’s really important to have – to see a specialist whether it be a men’s health specialist, urologist or endocrinologist and really have an important discussion about whether or not treatment is indicated and what your options are.

So, that’s all extremely important. And I think that men have to careful about going outside of the recommended avenues for diagnosis and treatment of testosterone deficiency because they can get into trouble there if they do that. And in terms of how do we boost a testosterone naturally? I think the most important thing is we have to really try to maintain good overall health through diet and exercise. Obesity is related to low testosterone and is a cause for low testosterone. Chronic opioid use is a risk factor. So, and that’s obviously a major epidemic in the country right now.

But certainly reducing the incidence of things that have been shown to reduce testosterone has to be first and foremost in terms of how men can help themselves. And so, staying healthy, exercising and maintaining a healthy diet are all things that are extremely important for being able to actually maintain higher natural levels of testosterone. And I encourage men not to overlook the importance of that.

Host: It’s great information. So, important for men to hear. Dr. Walker, thank you so much for joining us and that wraps up this episode of Doc Talk presented by Montefiore St. Luke’s Cornwall. Head on over to our website at www.montefioreslc.org for more information and to get connected with one of our providers. If you found this podcast informative as I did, and I’m going to have my husband listen to it; please share with your friends and family and share on your social media and be sure to check out all the other interesting podcasts in our library. I’m Melanie Cole.