Melanie Cole, MS (Host): Welcome to It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole. And today, we're talking about testosterone therapy what you need to know. Joining me is Dr. Kian Asanad. He's a urologic surgeon with Henry Mayo Newhall Hospital and Keck Medicine of USC.

Dr. Asanad, it's such a pleasure to have you with us today. So, let's start with how would a man know. Why would he come to see a doctor to have his testosterone levels checked? What are some of the indications that someone would need it checked? And then, we'll get into some, you know, supplementation and some of the available therapies.

Kian Asanad, MD: Absolutely. You know, some of the signs and symptoms of low testosterone can include low energy, depressed mood, sexual dysfunction, specific side effects such as low libido, erectile dysfunction. So, it's important to know what testosterone is. And so, what it does and so when it's low, the signs and symptoms make sense, right?

So, testosterone is a vital male hormone. It plays a key role in energy production, sex drive, erectile function, plays a role in mood, muscle function, mass gain, those sorts of things. So when it's low, men can experience a decreased muscle mass. They can experience increased adiposity or fat development.

They could experience just a lack of sexual desire. Their erections can get worse. They can just feel fatigued and have low energy. So usually, men who come in checking their testosterone usually have one of those signs or symptoms. And we wat tt check their testosterone to rule it out as a potential cause.

Melanie Cole, MS: Well, thank you for that. So, Dr. Asanad, before we get into some of those available therapies, what lifestyle factors such as exercise, diet, sleep, can men take to help their testosterone levels before they consider supplementation? And what are some of those lifestyles that might have a negative effect that might be affecting those testosterone levels?

Kian Asanad, MD: Yeah. So, really, really good point. So, diet and lifestyle is a key contribution to natural hormone production, right? There's four pillars. And there's no medicine on the world more important than these four pillars, right? That's getting good sleep, reducing your stress, having a healthy diet, and exercising regularly three to four times per week.

So, men who are obese or have metabolic syndrome have lower testosterone levels. Why? Because testosterone is converted to estrogen in some of the fatty tissue in the body through a process known as aromatization. That in context with increased scrotal temperature that can occur due to adiposity of the thighs around the testicles can have lower testosterone production And the testosterone that they have gets converted to estrogen. So, reducing your weight, maintaining a healthy diet, typically a Mediterranean diet, regular exercise can improve natural testosterone production through weight loss.

Strength training is important, you know, targeting some of the large muscle groups such as the chest, such as the thighs. Those are some of the most key lifestyle factors. Stress reduction is very important, right? When your cortisol levels are high, that can suppress your body's testosterone production, as well as sleep. Lack of sleep can cause issues with the hypothalamic-pituitary-gonadal axis or the HPG axis in short and disrupt normal testosterone production.

Melanie Cole, MS: What about things like smoking and alcohol? Do they affect testosterone and hormone levels?

Kian Asanad, MD: To a degree, I mean, and not directly. But it all goes hand in hand with not maintaining a healthy lifestyle. Men who are smoking or drinking regularly typically have some of these other comorbidities that go along with it. But smoking and drinking in and of itself may not necessarily just absolutely reduce your testosterone.

Melanie Cole, MS: Well then, Dr. Asanad, tell us about some of the available forms of testosterone therapy out there. We hear a lot in the media, people are worried about side effects. Tell us about the safety and efficacy of these various forms of therapy.

Kian Asanad, MD: So, testosterone therapy comes in all shapes and sizes, right? There are many forms of testosterone that could be given to a man to achieve therapeutic or normal levels of testosterone. So, the most common forms include topical gels or creams that are applied to the chest and shoulders on a daily basis or injections. Those are the two most common forms. Injections are actually done at home. Patients do it at home once a week or once every two weeks. Typically, those in the muscle, I recommend men to do it in the muscle of the thigh once a week. But there are other forms of testosterone. I would say those are the two most common because Those are the most common that insurances actually cover on a readily basis.

So, other forms of testosterone is oral. There's some new oral testosterone therapy options, which is great. In the past, oral testosterone was not recommended because it caused liver dysfunction and liver disease. The new forms of testosterone do not target the liver. They're very safe and very effective. There's a few brands that oral testosterone as an option. So, we counsel men on some of those options. There are implantable pellets. So, what is that? That's an office-based procedure. Gentleman comes in the office for 10 to 15-minute appointment. It's a local anesthetic. Make a small opening typically in the buttock, one to two millimeters in size. And I implant pellets or little testosterone pellets that maintain therapeutic levels for the next three to four months. So, it's really designed for folks who want to come in for a visit 15, 20 minutes, and then not think about it for three to four months at a time. That's a good option.

There are some nasal gels actually that you spray in the nares two to three times per day. Less common, but it's also an option. I would say those are the most common forms of testosterone. There's also some newer types of injections still in the brand of injections, but there's a long-acting injection that's done in the office that lasts about eight to 10 weeks. So, patients will come in, get an in-office injection by a nurse, and come back every two months for that, as well as some subcutaneous forms of testosterone injections through an autoinjector pen for men who have maybe some needle phobia and can inject it in the muscle. So, all those are different types of testosterone. They're all very effective.

Some of the side effects of testosterone and the side effects can differ based on the formulation, but some of the side effects can include worsening hair loss, acne, things like transference is important, right? So men who use topical gels need to be careful about rubbing the gel on their partner or any grandkids. So typically, I tell men to, you know, apply a shirt over or cover up, especially within the few first few hours of applying testosterone.

The injectable form has a more common side effect known as polycythemia, meaning the blood in the body thickens, if you will. And it's much more common with injectable forms of testosterone because the injectable form causes the testosterone to go really high and really low pretty rapidly. And that fluctuation can cause something called polycythemia. And if the blood counts for a man are too high over a critical level, it can increase the risk of major adverse cardiac events like a heart attack, stroke, blood clot.

All in all, testosterone is overall very safe, I'll say as a take-home point. We've done a ton of studies looking at testosterone. If it's being treated appropriately, being monitored regularly, such as with a urologist or even a primary care doctor who feels comfortable managing testosterone—I see patients every six months—it does not cause major complications overall.

Melanie Cole, MS: That was a great explanation. So then, Dr. Asanad, how do age and baseline testosterone levels affect what the man can expect as far as outcomes and efficacy and dosing strategies? How do you tie that all together? I know that we mentioned a little bit about fertility off the air before. So when you speak about these outcomes, speak about some of the things that men are concerned about and also, you know, how age and expected fertility will be affected.

Kian Asanad, MD: So, the first step is when a patient comes in and they have low testosterone, let's first define what low testosterone is, right? It's defined as two levels checked in the morning between 8:00 AM to 10:00 AM that are less than 300 on two separate occasions. That with the combination of symptoms that we discussed earlier gives you a diagnosis of low testosterone. So just having signs and symptoms and the testosterone number is actually normal, it's probably another cause related to those symptoms. Some men have low testosterone but really have no symptoms of low testosterone, so we don't, you know, just treat them empirically either. It's the combination of signs and symptoms.

So if a patient comes, they have the signs and symptoms, they have the blood levels to support it, the first question I ask patients is, "Is fertility and maintaining your fertility important to you?" Why? Because if I put a patient on testosterone, they may see a lot of the benefits of testosterone, but testosterone therapy will make men infertile. Why? Why does that happen, right? So, the brain just sees a ton of testosterone in the body, doesn't know where it's coming from, and will stop sending signals to the testicle to make its own testosterone and to make sperm. So, men on testosterone will typically have very little or no sperm.

And so if men are typically younger or want to preserve their ability to father a child or be fertile, we'll stick to alternative forms of testosterone, meaning not testosterone itself, but medications that help stimulate the testicle to improve its natural testosterone production. These are medications commonly referred to as Clomid or clomophine citrate, hCG injections or anastrazole. Those are the three most common medications.

Melanie Cole, MS: So then, what about other things like bone density, muscle mass? You mentioned that a little bit. I think men have this idea that testosterone therapy is going to increase all of that and make them more manly in a way and stronger. Is that true?

Kian Asanad, MD: Yeah. So, in addition to some of these signs of low testosterone, like the subjective signs, right, like low energy, depressed mood, low sex drive, there are some objective signs of low testosterone as well, right? So, men can be anemic. So, we talked about earlier, if you're on high doses of testosterone, your blood counts can be too high. But men who chronically have low testosterone, they just don't make as much blood, and they could have low energy because of anemia. That's an objective sign of low testosterone. So putting that patient on testosterone will improve that objectively as well.

Bone density is very important actually. So, testosterone and estrogen is very important for your overall bone health. So, men can have osteopenia, osteoporosis if they have chronically low levels of testosterone. And I discussed that in consultation and do order bone density scans, especially for older men who may have very low testosterone levels for a long period of time. And putting those patients on testosterone can definitely improve their bone density in addition to bone protective strategies that are typically done by, you know, bone density experts such as family care physicians, vitamin D, exercise, weightlifting exercise, calcium supplementation, those sorts of things.

Melanie Cole, MS: How long are they on it, Doctor?

Kian Asanad, MD: Testosterone therapy is not a cure. It is a lifelong form of treatment. So men who are on testosterone, again, they suppress their body's natural testosterone production. So as soon as they stop testosterone, their levels will go back down to lower or even lower, depending on how long they've been on it. So, it's important for patients to understand it does not boost their body's natural ability to make testosterone. But rather, men on testosterone who are on it for a few years typically do require it for the rest of their lives in order to maintain those levels.

Melanie Cole, MS: So Dr. Asanad, you're always just such a great guest. I mean, you give us so much quality information we can trust. As we wrap up here, what would you like the main messages to be for men about testosterone therapy, what they can expect, why it's important to discuss all of these different options? Gosh, you gave us so many different available therapies, so to discuss that with their urologist and find out about all those options.

Kian Asanad, MD: Yeah. You know, so I think the take-home point is testosterone therapy is one of the most highly abused, forms of therapy and treatment in men. It's readily available. You don't even need to see a urologist, a primary care physician. There are so many direct to consumer platforms available. Just through filling out forms online, you can get medications like Clomid and testosterone shipped to your door whether you have low testosterone or not.

And so, that makes kind of a discrepancy between patients who may actually have medical indications for testosterone. So, I see a lot of patients who come in with maybe signs and symptoms of low testosterone. They have the low energy. They have the fatigue. Their sex drive isn't the same. We do the evaluation and their testosterone levels are normal. They're excellent, they may be better than average. And so, there's a little bit of a discrepancy in really counseling patients on, "Your testosterone levels are actually normal. The symptoms you're feeling are unrelated to low testosterone." You know, and they come in and say, "Well, my friends are on testosterone. They feel great on it." There's medical indications for testosterone. And then, there's kind of cosmetic or supplementation that may not be actually indicated. So, really caution men about that and really know about that fertility approach, right? I see so many men come into the office and are wanting to conceive they're on testosterone and have no idea that they're infertile because of testosterone therapy. It's typically not permanent. I do need to reboot the system, if you will, with certain medications. But it can take some time to get sperm back and optimize their fertility.

So, I would say a take-home, it's the signs and symptoms with low levels that really make that diagnosis. Number two, is fertility preservation important for you? If it is, then we should not be on testosterone, but consider other forms of alternative testosterone therapy. And number three, just really look out for what works from your lifestyle standpoint, whether they're injections, gels, oral testosterone. Really, there's a lot of different options available.

Melanie Cole, MS: Thank you so much. And I'm so glad you brought up all of those options that are out there to your door without a prescription. Because like you say, it's highly abused and this can be something that really changes what a man thinks he's going to get from these types of therapy. So, it's so important that he speaks to a urologist such as yourself to get the real information that he can trust.

Thank you so much, Dr. Asanad, for clearing all of that up for us and giving us great information. Thank you again. And to learn more about testosterone therapy, please visit the free Henry Mayo Newhall Hospital online health information library at library.henrymayo.com.

That concludes this episode of It's Your Health Radio with Henry Mayo Newhall Hospital. Please remember to subscribe, rate, and review It's Your Health Radio on Apple Podcast, Spotify, iHeart and Pandora. Until next time, I'm Melanie Cole.