Testosterone For Men: An Overview

Foreign. Talk about some highlights in the book. If your testosterone is low, you're going to get fat. And 17 other things the FDA doesn't want you to know about testosterone. You could buy these or you can actually download them free from our website. If you Google Allure medical books, it's free download. I'd like you to read that if you have any interest. Let's go over some highlights why, why I wrote the book and things you might might want to learn about it. So right now a big topic is this weight loss with these new drugs called GLP1 agonists such as semaglutide might know it as Ozempic or Wegovy or Mongerno. They're really effective for helping with weight loss. And then we have to look at why did people get weight in the first place. It's obviously related to our lifestyle, diet and exercise, but also some external factors, some, maybe some environmental factors. And we're seeing low testosterone in men at young ages than before. Now, testosterone replacement has been FDA approved since 1950s. There's three major form forms of testosterone replacement. One is injectable. That's probably the most common where somebody gives themselves a shot. Used to be once every two months, but now it's actually once a week or maybe twice a week. And there's form formulas for that. And that's a common option for people to give themselves a shot at home. Another one is a gel testosterone gel. I don't condone those because there's not good safety studies on. I'm not saying they're not safe, but the all the safety data and the data robot book is really related to injectable or pellets. So I don't have much of an opinion on the gels. And then there's pellets which are in our practice. We do a lot of that mainly because we offer the pellets. We see men that don't want to give them themselves a shot every week or that they are in a situation where they like to set and forget it. They don't like poking themselves in the needle. So the shot that. I'm sorry, the pellets last about five months and there's about 10 little pieces of rice that go in the skin, usually the buttocks. We put in the skin of the buttocks and after a couple of days you can't feel them. It gives you a nice steady level over five months. Then you just do it again. So let's talk about the title of the book is if your testosterone is low you're going to get fat. And I, you know, I just wrote it as a catchy title, but we see is that there's a clear relationship between low testosterone and obesity, low testosterone and type 2 diabetes, and then low testosterone and cardiovascular disease and cardiovascular mortality. So what happened first, the chicken or the egg is not really known. It's probably a little bit bi directional. So obesity does lead to low testosterone and low testosterone leads to obesity. Now in the book I wrote, you can look at the references for how we, we walk through this scientifically. But men with low testosterone that are obese, they might get a little bit of bump in their testosterone levels if they, you know, lose weight and start exercising. But it usually won't get back to materially, say comfortable levels in testosterone replacement. Once we start taking, putting people on testosterone, the weight doesn't just start falling off. In fact, sometimes the weight goes up a little bit because the first thing that happens is the bones get a little more den and the muscle mass goes up a little bit. So people commonly would tell me I've gained about five pounds, but my clothes are fitting better. I just know I've gained a little bit of weight. What's happening is that even if they're not exercising, they do get a little bit more dense bones and more dense muscles. Now we recommend you diet and exercise. That's what we should be doing as humans. But if, but if you're not doing that, you'll still see that this is more favorable towards weight loss. In a long term study over 10 years, there was a linear drop in weight of body fat every year over the 10 year study. So if you do have issues where you're trying to lose weight, I recommend first off you start dressing lifestyle. Maybe you would go on a GLP1 agonist. These medications are very effective, but lifestyle is number one. And then we should check your testosterone level. And if we look at other conditions, how often is low testosterone checked? So let's talk about body composition briefly. So we think about testosterone for bodybuilders and anabolic steroids for bodybuilders. And that's where it's commonly abused. And they use synthetic testosterone to really work heavily on the muscles. We're not talking about that, we're talking about men who start developing low testosterone over time, usually related to age. But there may be other factors. In fact, the FDA approval for testosterone replacement is for men that have low testosterone due to a brain damage, missing testicles or having an extra female chromosome. And the FDA specifically said that testosterone is not FDA approved for men have, that have low testosterone for no reason reason other than aging. Now when they make these stance, and this was the 1950s, they don't really change it. Okay, so even if there's an overwhelming body of evidence suggesting that men with low testosterone because of aging should get testosterone, they don't reapprove it or change their stance because they don't have to. They were, it has to be a drug company that takes a novel drug to the FDA and says hey, we got this new drug and it's for this or this indication. And that hasn't happened because it's been out for you know, 70 years. So the, your doctor can prescribe testosterone even if you had both your testicles and you don't have brain damage and you don't have an extra female chromosome, it just makes it not FDA approved. Your insurance may cover it, but typically it does not because they will generally cover it only if you have extremely low testosterone on two sequential blood tests before 10am and usually level below 280. By the time it's down to 280, you've already got diabetes. So we're seeing patients that want to kind of catch it earlier than that, in which case it's something that you have to pay for on your own. It's not that expensive. Let's talk about some clinical endpoints. Cardiovascular disease. Back in 2013, the FDA put a label on testosterone saying that it could cause heart attacks. And they did it based on a study out of the new, out of the journal American Medical association that was subsequently essentially retracted. But there was a, there was a thought that, well, men get more heart attacks than women and men have more testosterone than women, therefore maybe testosterone causes heart attacks. Well, there's definitely a link to testosterone heart attacks, but it's not what the FDA would lead you to believe based on their black box morning, which again this is something that they did ill advised. There's been over 127 studies refuting that that statement by the FDA and all major medical associations have come out against the FDA for making that statement, which really harmed men's health. So largest study to date was done by the VA, again government sponsored and it was about 83,000 men, average age about 60, that maybe 66, but it was in their 60s and they followed them for six years. So when we look at studies we talk about people years. So 83,000 men for six years, that's 40, 480,000, almost 500,000 man years, which would be one of the biggest studies Ever done. And they looked at men that had low testosterone, diagnosing the VA system. So the Veterans Administration system, they had medical records and they've really been advanced in the VA at emr. So they were able to pull data pretty cleanly. What they found that men that were diagnosed with low testosterone, they divided into three groups. Those who sought treatment, those who did not seek treatment, maybe because her doctor didn't recommend it or the guy didn't want to go through either of the shots. And those who were partially treated mean they did it. Occasionally they'd take some, some period during the six years they take testosterone placement. But at the end of the six years, they found that the men that had low testosterone, that did not treat the low testosterone, were twice as likely to be dead. They had double the death rate. They had. It was predominantly from cardiovascular disease, heart attacks and strokes. Again, these were men in their 60s, so they're less likely to die of cancer and neurocognitive decline. You're more likely to die at that age, cardiovascular disease. So we know that men with low testosterone are more likely to have heart attacks, more likely to die of a heart attack or stroke, double, double the risk than men, men that are untreated versus men that are treated. So why don't we routinely check the testosterone level and treat these men? Well, it's partly the system. So the system suggests that perhaps low testosterone shouldn't be treated because this is just part of aging. And I've heard that argument a lot. It's like, well, I mean, we're going to get old and die and we're kind of in sort of an anti aging business. So accepting that outcome that you're going to die because you're getting older is maybe, you know, I want to take another crack and have another option. So the establishment has not really been open to the idea of extending life because there is this idea that, you know, as you get old, you should just probably, you know, check out. Another aspect is that, you know, 2013, 10 years ago, doctors, you know, heard that testosterone might cause heart disease. The FDA proposed that. They didn't say did. They said it might. And there was a big splash. So that that happened. And if, if doctors did not read the literature or did not go to conferences, they wouldn't know that that was bs. And another biggie was that a company called Abovy, which had a testosterone product, was very big in the 90s and promoting testosterone use. They had these low t. Do you have, do you have low teeth at a big campaign because they're trying to bring awareness that there's a lot of men, millions of men that have low testosterone that are not treating it. And as a manufacturer they had a gel product that they got FDA approved. They got it approved as an alternate form of testosterone to a shot. But they didn't get a change in approval vindications. So anyways, for years they were doing these low T commercials and the prescription for testosterone went up, which we would suggest that then the diagnosis of diabetes, obesity and heart disease will go down. Well, the FDA sued them. They sued them, they won a big case that was $150 million. And they sued them on the basis of the fact that they were promoting low testosterone treatments for men that had both their testicles, did not have brain damage and did not have an extra female chromosome. And their position statement was this is only FDA approved for men that have missing a testicle, have a brain damage or have an extra female chromosome. And it is not approved for men to have low testosterone for any other means. Well, that might seem absurd to you, but the fda, they're bureaucracy and they're supposed to, you know, control big pharma. And they didn't want big pharma marketing it for a non FDA approved indication, which they can't, they can't do that. They did the wrong thing. And it really requires doctors to learn how to know. Your doctor does not is not under the guise of the FDA or if we had the FDA dictate medical practice, healthcare would be a freaking disaster. Many drugs that we use, many life saving drugs use are not FDA indicated for the purpose in which we use them. For example, aspirin for a heart attack. We did that for years. FDA never approved of that, which would mean we couldn't do that. We don't follow the FDA as doctors. We follow best practices of medicine guidelines by medical societies and evidence based medicine. So just to be clear, even though the FDA has not approved testosterone treatment for men that have low testosterone because they're aging, doesn't mean that you and your doctor cannot make that decision. In the book I reference a lot of studies regarding the cardiovascular disease. It doesn't matter the age, even in their 70s and 80s are more likely to survive without cardiovascular disease than men. That when they're treated, than men that are not treated. There's a clear link between treating low testosterone and surviving cardiovascular. Doesn't mean you'll live forever obviously, but not immortal. But it will push that time out and make you healthier longer. We look at health span or lifespan they should go hand in hand. So if we want to live longer, we want to have our health in good shape longer. Ideally, you live a nice healthy life and then when it's time to die, you have a short illness or injury, heaven forbid, and you just kind of check out. That would be maybe a nice way to go versus being dependent on somebody for a long time. So these, these things, the studies that we referenced in the book really refer to health span. How long are we healthy for? Once you've had that heart attack and maybe get heart failure, you become a little incapacitated. So we push that off as far as possible. Get back to weight. Weight is related to diabetes, diabetes type 2 and long term studies, a lot of them are out of Germany because they've been using a long acting form, testosterone, longer than we have here in America. And they found that much lower incidence of developing diabetes on men who are taking testosterone, places that have low testosterone, less incidence of obesity in men that have low testosterone, and even reversing obesity some degree with men taking testosterone. Two other things that sometimes doctors cite because of their lack of awareness and not prescribing testosterone. One of them is the possibility of getting a blood clot. So there's a theory that testosterone might cause blood clots because high dose birth control pills cause blood clots in women that are over 35 and smoking. So there's a unique subset of hormone replacement therapy, which would be in the birth control pill, that has clotting effects in women. So doctors maybe have translated this in the men. So large studies done with tens of thousands of men looking at the rate of blood clotting and then with to testosterone or without testosterone, well, it's not protective, it does not increase your risk. So there's not an increased risk of blood clot, at least not scientifically on testosterone placement in most clinical studies. The last one is prostate cancer. So we know when a man has prostate cancer, one of the treatments is a, basically a chemical castration when they give you drugs to markedly suppress the testosterone level. And this has led to some suspicion that, well, if that's the case, maybe testosterone replacement leads to more prostate cancer. This has been studied extensively. There's no link. So men with lowest testosterone have the most aggressive prostate cancers. That's a known. There's even studies treating prostate cancer with high dose testosterone. I'm not recommending that, but these studies do exist. It appears that testosterone placement does not increase the risk of getting prostate cancer. Does not increase the risk. It might decrease the risk, but there's not strong evidence to suggest that. So I'm not going to make that a point on this saying it does not increase your risk of prostate cancer. And in 2023, 24 we should not be missing. Prostate cancer under the right circumstance can be detected fairly easy with more advanced techniques such as 3D MRI and some blood testing. The blood testing kind of getting a little bit of bad rap because there's some misinterpretation of it. But currently the prostate, the PSA test in the right setting can be very accurate for screening for prostate cancer and so can a 3D MRI of the prostate. I've done both of those myself to make sure I don't have prostate cancer. So testosterone replacement does not increase your risk of prostate cancer. A man gets prostate cancer we're typically going to take them off their testosterone replacement, treat the prostate and then generally wait about four years of remission before resuming testosterone. Because once your prostate cancer is treated you're more likely to die of a heart attack or something else than a recurrence of prostate cancer. So that's the prostate cancer. So let's go back and sum this up. There's also some evidence that testosterone replacement is good for depression clinical depression. It does appear to have some improvement of outcomes in people with cardio congestive heart failure. There's numerous other conditions where testosterone replacement therapy is beneficial. We've even used it for patients with ms, both men and women. It's beneficial for them. Testosterone replacement again there's three forms we most commonly use the pellets. Injectables are second to that. We don't prescribe the creams in our practice. Not bad mouthing in the same there's not good data to support it so so we're not using it for that reason. There's plenty of data on the injectables in longer forms such as the pellets and the injectables are done either once a week or twice a week. That's probably the best timing. Once a week is adequate. Some men prefer twice a week he's levels a little bit more even it could be given intramuscular or subcutaneous. Most men get intramuscular but subcutaneous. If you have enough subcutaneous fat that's that's a hurts less and the pellets are putting in subcutaneous and you typically into the fat of your of your buttocks Every five months we have to monitor hemoglobin. So when you take testosterone placement there's a risk of what's Called polyurethema. We call it polycythemia. But it's really not just the red blood cells go up, not all cells. And when that happens, you know, you go give blood at the, at the red Cross every, every, you know, eight, or do what we call a therapeutic phlebectomy or phlebotomy. And I don't see that too much in practice. It happens once in a while, but it does is something that can be managed. And basically you do a blood count at six months and then a year, and then once a year if it's normal. Most men never have elevated red blood cell counts from testosterone, at least not clinically elevated ones. Monitoring the testosterone level, you know, it's very confusing. So when we look at the insurance basis for low testosterone treatment, the testosterone levels typically got to be below 280. And so theoretically, if you were 265 and you took testosterone placement and got yourself up to 285, technically you are now normal. You're still going to feel like you're still going to be tired. You're not going to help you with your weight loss. It's not going to help you with your cardiovascular production. But, but then technically you're in the normal range. Your doctor reads say, well, labs are normal, so you're good there. So we don't use that as a basis for determining levels of testosterone replacement. You can check it because if, let's say you're not feeling better, we check your level, it's like 900. Well, there's something else going on. We should look for it. Or we check your level and it's 300, you're not taking enough. But we don't necessarily watch that carefully because it's not particularly helpful. Just like if you had high blood pressure and you're taking an ACE inhibitor, we're not checking the level of the drug, we're checking your blood pressure. Okay, so that's kind of the concept behind not being really aggressive on checking a blood test for testosterone. It's also very misleading because let's say you take your shot and your level goes up to 12, 1300, which is higher than normal. Your doctor may freak out, you may freak out thinking bad things are happening, nothing happens. It could be, it could be high. And also there's difference between the physiologic and pharmacologic blood levels. So the physiologic level for a man, let's say, is 280 to 1100. That's where if you took a hundred men between 18 and 80. 80, that's where they fall. And we would know the guys at the 280 are really kind of, they're usually heavy and they've got low sex drive and other issues associated with low testosterone. That's the physiologic level. But the pharmacologic, pharmacologic level is usually on the higher end because your body makes special things like albumin and sex hormone binding globule to kind of gobble up the testosterone sees coming from the outside. So you gotta run a little higher than normal physiologic levels. So we're gonna be in the upper end of physiologic or even a little bit over. And then that's, that's perfectly safe. There's a measurement called a free testosterone level that's really can't be directly measured by something in the laboratory tries to calculate how much testosterone is free and available for you. But that's never been really ironed out on, you know, what we really do with that number. So we base it more on symptoms. Last thing is sex drive. So erectile dysfunction, urinary, I'm sorry, let's say not just sex drive, say genital urinary health. So studies with testosterone replacement in men that had minor urologic symptoms like frequent urination at night, things that happen with age, they typically get better over time. With testosterone replacement, sometimes the volume of the prostate will go up on MRI dry. But the symptoms get better. It's not clear why that is, but that's been shown in numerous studies. Sex drive usually gets a little better. So if a man has lost some sex drive, it usually gets better. If a man has erectile dysfunction, not a sure thing. You know, there's other drugs that we use for erectile dysfunction and even techniques, but if your testosterone is low, the likelihood of erectile function goes up. If you treat it, good chance it'll get, it'll get better, but it's not the end. All for rectal dysfunction. A lot of times there's circulation problems that affect that. But something we should think about when a man's being evaluated for erectile dysfunction is check your testosterone level. Man's being evaluated for fatigue. You know, go and take a nap in the afternoon. Less energy, not as much strength. I should take check, check testosterone level. Man is a heart attack or being evaluated for say an executive physical where they're checking their heart with a stress test, which is testosterone level. We know if it's low. Your risk of having a heart attack in the next six years is double. You know, then if a guy, if you, if you don't treat it. So we can easily check that, that. So I really advocate doing a screening testosterone level. I mean, even if your insurance will pay for, it's pretty cheap, costs $20 or so. So it's easy to get done. And when we check testosterone levels for screening, we're usually just doing a total testosterone, not the calculated free because that's. You're not on the testosterone replacement at that time. So. And then again, we still, you still do routine screening for prostate cancer even though it does not increase your risk. So in summary, testosterone replacement, if your testosterone is low, you're going to get fat. I wrote the book, you're going to kind of read up on it. I put in the studies at the end, the studies are all listed that I reviewed. This was written a few years ago, but it's still so valid. The biggie I think about is cardiovascular risk. That's my biggest genetic risk. I've got what's called the heart attack gene. So I would be wanting to make sure my testosterone is optimized and I'm eating properly and exercising properly and doing all the things possible to reduce risk of heart disease. Knock on wood. So far, doing great. Obesity, you know, a lot of interest in these GLP1 agonists. We need to check these patients for low testosterone and replace that if appropriate. You know, if it decided between you and your doctor. Cardiovascular disease, again, is a big one, does not cause prostate cancer increased risk and does not cause blood clots increased risk. So this is a safe medication. And I, you know, I think that the fact that there's no drug company pushing it, a lot of doctors just aren't aware of it. And it's not criticism of the doctors, but they're always getting hit with new drug reps bringing, you know, donuts in and a new drug for whatever condition and that's sort of the direction their brain turns to. And since the government has advised the manufacturer that if your testosterone is low just because you're older, it's not necessary to treat it, that is, nothing really could be further from the truth. You know, if we, Unless you're just trying to figure out how to cut healthcare costs by letting people die prematurely and that's, I know that cuts costs because they're, you know, if you have a heart attack, that's very expensive. So promoting screening for your testosterone, not being afraid to restore it. And this is something that you can, you know, see a doctor, get a blood test. Even nurse practitioners and PAs are allowed to prescribe testosterone. Most states, it's considered controlled substance, just like a narcotic is. So not all states allow all providers to prescribe this and then really kind of limited monitoring and this goes along with lifestyle to extend lifespan. So thank you very much. It.