Low Testosterone (Low T)

Podcast Transcript

Dr Scott Steele: Butts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Dr Scott Steele: Hi again, everyone, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. Today, we are going to once again step out of the digestive track and go a little bit under something we haven't talked about before, and that's low testosterone, otherwise known as "low t." And I'm super excited to have Dr. Scott Lundy, who is a Staff Urologist and a Surgical Scientist here at the Cleveland Clinic in Cleveland Clinic's Department of Urology. Scott, welcome to Butts and Guts.

Dr. Scott Lundy: Thanks for having me, Dr. Steele. It's nice to be here.

Dr Scott Steele: So, long-time listeners to this know that I always start off with asking you to tell us a little bit about yourself.

Dr. Scott Lundy: Yeah.

Dr Scott Steele: Tell me a little bit about your background, where you're from, where'd you train, and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Scott Lundy: Great. Yeah, so I was born to an Air Force family. I'm the first person in my family not to go flying. So, I'm a bit of the black sheep, if you will. But, moved around a lot growing up, went to college and became a biomedical engineer, and decided to pursue medicine at that time, and went and did an MD-PhD program in Seattle at the University of Washington. I really enjoyed a lot of my training there, and ultimately settled on the fact that I had to be a surgeon and I had to be a scientist, and so proceeded in that direction and went into urology.

I came to Cleveland for residency at Cleveland Clinic, which is a six-year residency, and then stuck around for one extra year in reproductive urology, which is a field that's dedicated primarily to infertility, vasectomy reversal, microsurgery, low testosterone, and erectile dysfunction. I stayed on here as staff, and I now split my time between time in the research lab, doing basic science research, and also seeing patients and doing surgery. I'm happy to be here and discuss some of these areas that are near and dear to my heart.

Dr Scott Steele: As somebody who spent 17 years of their life in Seattle, welcome into the Midwest from the West side. That place is near and dear to my heart. So, today, we're going to talk a little bit about low testosterone. So, just to start, let's go ahead with a giant overview of that. What is testosterone to our listeners? You can't turn on the television these days and not see some sort of a commercial about it. And what causes someone to experience low levels of testosterone?

Dr. Scott Lundy: Yeah. So, testosterone is actually the primary sex hormone in all men and women. Believe it or not, it's more prevalent in women than estrogen even, but we often think of it as only a male hormone. That being said, it is the primary driver for many of the aspects that make us masculine. It's also important in things like muscle mass, in bone health, supporting mood, and it's really critical in supporting normal erection function and in sex drive. And it does this through a variety of various biochemical pathways.

Testosterone starts off actually quite high. When people are born, there's a "mini puberty" that occurs right after birth, and then that subsides for many years and things go quiet until puberty happens. And then there's another raging storm of testosterone that occurs in young men. As that number goes up, sex drive goes up, erections come about, and then that number stays high for many years. But then as men age and get older, that number dwindles, the testosterone levels fall. Other things can also cause this to fall, things like diabetes, for example, obesity, regular use of opioid pain medications. Chronic stress has a role in decreasing testosterone levels. And there are other things as well, like sleep apnea, or rarely things like brain masses that can cause decreased testosterone. But the things that we see often act in concert together to drop testosterone levels. And in some men, this causes them to have symptoms.

Dr Scott Steele: Yeah. That's a great segue, if you will, into - I know you spoke a little bit about it, about what it does, and I'm assuming it's the opposite. But just kind of clarify a little bit - what are the symptoms of low testosterone and maybe even a little bit more than that? Almost I always think about things in colorectal surgery world. When are these symptoms something that I would say, "Hey, I need to go talk to my doctor about it," versus, "Eh, it's a process of I'm just getting older"?

Dr. Scott Lundy: Yeah, that's a great question. So, many of the symptoms associated with low testosterone are general symptoms. So, things like fatigue, lots of people are tired for a variety of reasons, but low testosterone is one of them. Other things like low sex drive are a really common side effect of having low testosterone, or erection problems. But as we said, many of these symptoms can come from multiple sources, and so it's really a judgment call, or a clinical decision, on whether the testosterone itself is an important aspect of that symptom. Other things like decreased lean muscle mass can come up. Decreased cognition has been reported to be a symptom of low testosterone, and depressed mood or mood swings can also be a role particularly in men who are actually being treated to artificially decrease their testosterone for prostate cancer, for example.

Dr Scott Steele: So, talking about just in general what's considered a low testosterone level, if you could kind of talk about that. And then secondly, let's just say I'm a 50-year-old male, is this a normal lab that people are getting? Or do I need to specifically talk to my doctor about, "Hey, can you check my testosterone," and should they?

Dr. Scott Lundy: So, a testosterone check is never a bad idea. It's typically done in the morning before 10:00 AM so that we can maintain consistent checks at consistent times because the value does fluctuate throughout the day. Normal men have testosterone levels between 400 to 1,000, is what's considered the typical normal range. And for our guidelines, we follow anything below 300 as considered to be abnormal. And that needs to be documented on two separate tests or blood tests, which can be done in almost any major lab. It doesn't have to be a specialized lab, and it's a fairly fast and easy to run test.

There is some data that suggests that as we age, testosterone drops and we should be using, as a result, an age discriminatory number for testosterone levels. But at present, the guidelines simply state 300 is the correct number, and any men below 300 on repeat labs can be considered for testosterone. But men above that, even with symptoms, are typically not good candidates because the degree of low testosterone is not commensurate with their symptoms, and we need to be looking at other causes.

Now, as far as age, what you mentioned, there are cutoffs that depend on how old you are. But also as managed, the levels simply do drop, and that is almost unavoidable to a degree.

Dr Scott Steele: Truth or myth: Less than 10 percent of people assigned male at birth that are aged 50 to 79 years old have low testosterone.

Dr. Scott Lundy: Myth. The number is actually much higher. So, men over the age of 45, about one-third are considered to be hypogonadal according to this definition, and that number increases to almost half of men over age 75.

Dr Scott Steele: So, as we know, being overweight has a lot of different health impacts. So can weight loss or many other lifestyle changes, diet changes, exercise, help address low testosterone?

Dr. Scott Lundy: Absolutely. Weight loss and vigorous exercise both have a significant impact on testosterone levels, and there's many reasons for that. But one of the primary reasons is that the extra body mass that we often have is adipose tissue, and this contains an enzyme called aromatase. And aromatase turns testosterone into estrogen, and so it decreases the testosterone levels. So, if you decrease the amount of that tissue, you actually decrease the loss of testosterone to estrogen, and your testosterone levels will go up. And similarly, if you lose weight and vigorously exercise, this promotes increased testosterone through other pathways, as well.

Other things like sleep apnea for example, play a large role in these processes, and men who have sleep apnea have decreased testosterone, and that's often related to their weight. Increasing their exercise and improving their diet can improve sleep apnea, which can improve their overall sleep, their overall health, and their testosterone levels.

Dr Scott Steele: You mentioned earlier that some of the symptoms are a little bit vague. So, with that in mind, when should - I'm a listener to this podcast, I'm listening to you, I'm like, "I got low T, I'm telling you I do." But realistically, when should they go ahead and see my health care provider about this?

Dr. Scott Lundy: Yeah. I think it's an individualized decision. But if you're a man who's experiencing erectile problems and that's bothersome to you, or if you're having low sex drive, to me, those are two pretty specific things that would suggest a testosterone level should be checked. Other things like fatigue, it's perfectly appropriate to check, but it does need to be checked by someone who has some knowledge about what time of day to check it and how to interpret it. Because if your levels are 350 to 375, that may look like it's on the lower end of the spectrum, but it's probably not causing your problems. And that's where the trained health care professionals that you trust can come in and provide guidance.

Dr Scott Steele: So, as we talked about before, there's a lot of different advertisements and things on the radio and TV everywhere that talk about you got Low T, there's clinics for it that you can kind of be able to go to. But let's switch gears and talk about actual hormones or testosterone replacement therapy. So, can you talk a little bit about that? What's the goal of it? What are the risks? And who is eligible to receive it?

Dr. Scott Lundy: Sure. So, testosterone therapy in general is a group of treatments that we can offer to men who have documented low testosterone. And the goal of that treatment, present, is to improve the symptoms and their quality of life. There is some evidence to suggest that low testosterone can cause long-term health problems, but we still don't know well enough to use that as evidence to suggest that any man with low testosterone should be treated. But rather, if a man is symptomatic and has low levels, we should consider therapy. And then, by proxy, if the therapy doesn't help those symptoms, then we're obligated to stop the treatment, as well, because it didn't improve the symptoms that we were targeting.

Some men are good candidates for testosterone therapy, and some men are not. Men with advanced prostate cancer, for example, should probably not be treated with testosterone as this can worsen their prostate cancer. Men with a recent heart attack or stroke may not be good candidates in the short term for treatment as well.

When we actually talk about types of treatments, there are many that are available, but the three most common that we talk about are either injections that are administered by the patient, themselves, once a week or every other week. Patients can also apply gel to their shoulders and chest once a day to improve the levels of testosterone, or they can go to their providers and have pellets placed under their skin every few months. And that's called TESTOPEL, which is a third option for men to have testosterone therapy.

There are even other medications that we can use that are oral pills, that are designed to increase testosterone through other means. And those are appropriate for men who, for example, want to have a child and don't want to have infertility because the traditional testosterone therapies will block sperm production. So, any men who meets those criteria and is interested is a good candidate to discuss this therapy with their provider.

Dr Scott Steele: So, I got to ask, you'll see a lot of these advertisements about low testosterone and some of these precursors that will boost testosterone levels available to your local nutrition store. Do these things really work?

Dr. Scott Lundy: So, unfortunately, many of these supplements that are available contain compounds that are not safe, and that may raise testosterone levels in unsafe ways, even by containing testosterone itself. Many of them also contain small levels of medications like Viagra or sildenafil. So, for the most part, we shy away from using these supplements that are obtained from sources that can't be verified or validated. This is also even more complicated when we include some of the specialized men's health clinics that are available in some markets or online providers. And I think it's important for patients to do their due diligence and make sure that whoever is prescribing these medications for them is doing so in a safe way. And safe means regular monitoring, safe means physical exam, safe means following the guidelines, and sometimes that happens and sometimes it doesn't.

Dr Scott Steele: So, are there any advancements on the horizon when it comes to treatment for low T?

Dr. Scott Lundy: Yeah, there's actually a number of things coming soon. We're really excited because there's a big trial coming that should be reported this year or next year that really delves into whether or not there's an increased risk for heart attack and stroke on men who receive testosterone therapy. Because to present, we don't actually know the answer to that question to the fullest extent. So that trial is concluding now, and we should have results soon, and we're really excited about that.

In terms of the nuts and bolts of actual therapy, there are two things that are now on the horizon or newly available that are useful. The first is called Natesto, which is an intranasal spray that you can use up to three times a day to increase testosterone. And this does so without needles or pokes or anything like that. And it can, in some cases, actually preserve fertility and sperm production, too. So, it's a good option for younger men who want to have a family in the near future.

We also have oral testosterone therapy coming. There was an oral testosterone therapy many years ago, but it caused liver damage. So, we're excited about the new formulation that doesn't seem to have that as a side effect, although this is still in the early stages and we're awaiting more results about its safety and efficacy. So, stay tuned.

Dr Scott Steele: So now it's time for our quick hitters, where we get to know you a little bit better. So, first of all, what's your favorite sport to either watch or play?

Dr. Scott Lundy: My favorite sport to watch is Formula 1 racing, and my favorite sport to participate in is skiing.

Dr Scott Steele: Fantastic. Downhill, or cross-country, or water?

Dr. Scott Lundy: Downhill. And then I'll piggyback on that and say my favorite semi-sport is underwater diving and underwater photography.

Dr Scott Steele: Fantastic. We've had a couple of people like that. So, what is your favorite meal?

Dr. Scott Lundy: I love a good authentic Neapolitan pizza.

Dr Scott Steele: And give me a place that you've either been to or you want to go to that you like to the audience.

Dr. Scott Lundy: Yeah. So, I lived in Florence, Italy for a while during my PhD, and there's a restaurant there called Il Purgatorio. “It's Purgatory.” So, Purgatory I would say is my favorite place.

Dr Scott Steele: Fantastic. And finally, tell us something that you like about here in Northeast Ohio.

Dr. Scott Lundy: I absolutely love that I can walk out my house, hop in my car, and within five minutes be in a national park with my kids, hiking around, seeing nature. It's just an incredibly fantastic place to raise a family.

Dr Scott Steele: That's great. So, give us a final take-home message for our listeners.

Dr. Scott Lundy: Yeah. I think testosterone carries with it a lot of connotations, both good and bad. I think it's a necessary part of what makes us humans and men. And I think treatment for low testosterone in the appropriate patient has a lot of benefits if done safely, but it really does need to be prescribed by someone who has expertise and prescribed to a patient who has the willingness to follow the regimen and stay safe.

Dr Scott Steele: Well, that's super. So, for more information about men's health here at the Cleveland Clinic, please visit clevelandclinic.org/menshealth. That's clevelandclinic.org/menshealth. You can also call the Department of Urology on 216-444-5600. That's 216-444-5600. Scott, you got a great first name, and thanks so much for joining us on Butts and Guts.

Dr. Scott Lundy: Thanks. I appreciate your time.

Dr Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.