Ashlee Williams, MD (Host): Testosterone plays a big role in men's health, affecting muscle mass, bone health, mood, energy, and more. So, how do you know when changes you're experiencing might be related to low testosterone or something else?

Welcome to the Healthier You podcast. I'm Dr. Ashlee Williams. And today, I'm talking with Dr. Joseph Monye, a board-certified endocrinologist here at Kaiser Permanente, about common symptoms of low testosterone, how and when doctors know when to test testosterone levels, what can cause testosterone to drop, and what treatment options are available. Dr. Monye, thanks so much for being here today.

Joseph Monye, MD: Thank you so much for having me, Dr. Williams. It's a pleasure to be on with you.

Host: Thank you. Okay. So, let's start with the basics. What does testosterone do in the body, and why is it so important for men's health?

Joseph Monye, MD: Great start. So in terms of testosterone, I would say to start, let's kind of talk about where testosterone may come from. So, it's produced primarily in the testes from signals from the brain. And as far as its function, it primarily helps to promote a lot of the changes we see in males, especially as males reach puberty.

So, a lot of the secondary characteristics when it comes to hair growth, body hair, facial hair in terms of promoting musculature, bone strength in terms of things like sperm production and sexual interest, in terms of just overall vitality, energy, that's some of the things we kind of think of and associate with testosterone production and function.

Host: Okay. So, what causes testosterone levels to decrease, and what are some of the common symptoms?

Joseph Monye, MD: In terms of testosterone levels decreasing, levels primarily tend to start decreasing naturally as we get older. So, a lot of times males, once they hit age of 30 to 40, typically, we'll see a gradual decline in testosterone levels. Now, there are some other things that pathologically, you know, just from a medical standpoint can go wrong and affect testosterone production.

But I would say naturally through the course of a man's life, we will see testosterone levels decrease almost akin to what you would see when, when a woman with, you know, uh, estrogen in terms of menopause. So, those are kind of fairly similar.

Host: Who exactly should be tested for low testosterone, and how is low testosterone diagnosed?

Joseph Monye, MD: In terms of who should be tested, that can vary. But primarily, you want to see somebody that has symptoms, right? So, a male should be complaining of certain types of symptoms, and these may include, but not necessarily limited to just low energy, a sudden loss of you know, musculature. Primarily, you will see males come in and they'll complain about a decrease in sexual interest and desire, and things of that sort.

So, a lot of the time when males come in with these type of symptoms, that may be a clue that, hey, this is somebody that we need to do further testing and to evaluate if they have low testosterone. And testosterone level, it's a very, very simple blood test. We can check via lab work, and we just send a patient in for some morning labs. We always like to collect testosterone levels first thing in the morning, primarily because this is when testosterone production is usually the highest in males. And it kind of wanes over the span of the day. So, we check first thing in the morning. And like any other test, we want to make sure that we check levels not just once. You know, we don't use just one single time point to determine if testosterone levels are truly low. We want to repeat that test to confirm that the patient does truly have low testosterone levels.

Host: Okay. So, the person has come in, they've gotten the multiple tests that have confirmed that they have low testosterone levels. Can you talk a little bit about the treatment options for low testosterone?

Joseph Monye, MD: Absolutely. Absolutely. So, in terms of treatments, there are several things. And we want to, first of all, isolate that the patient does truly have low testosterone levels. Once we do that, the reason why testosterone levels are low, and that's a very important point to make sure we don't miss.

And so, if testosterone levels are low due to, let's say, metabolic reasons, obesity, sleep apnea, you know, dietary habits, maybe medications, things such as steroids and opioid medications, these things can all affect testosterone. So, we want to make sure we address what might be causing the levels to be low.

Sometimes, unfortunately, it might be because of signals in the brain that are not being produced the way they should be from a tumor in the brain. It could be a testicular issue, a testicular condition, a tumor in the testicle. So, we want to make sure that we kind of go through systematically and verify exactly why the testosterone levels are low before we kind of address the treatment.

Now, in terms of treatment, if we isolate that testosterone levels are truly low, and it's not due to some of these alternative factors, then we typically do treatment via testosterone injections, which can be given over the span of one to two weeks. We can do testosterone gel, and that's typically just applied on the skin. And then, we can also do testosterone pellets. And this is more of a long-acting kind of formulation where it's dispensed slowly and released over the span of several months.

Host: Okay. Wow. A lot of information. I think it is important to try to figure out the underlying cause of low testosterone before you try to treat it. Are there any risk of testosterone therapy?

Joseph Monye, MD: That's a very good question because, historically, testosterone use has been associated with things such as increased cardiovascular disease, strokes, heart attacks, blood clots. And more so of late, in terms of the data that we have regarding testosterone, what it shows is some of those previous things we thought testosterone may contribute to, it doesn't. And some of that actually includes a prostate cancer and, I guess, exacerbation of prostate cancer.

So, what we do know now from more recent studies is that testosterone does not necessarily increase the risk of prostate cancer. And what it can do in patients with metastatic prostate cancer, we try to take a more advisable approach in terms of discussing with urology, and that might not be the best treatment for a patient, as far as testosterone therapy.

But patients with, you know, just prostate cancer that's not metastasized, that may be somebody that we could consider testosterone therapy. And of course, we want to have a very open discussion with the patient to evaluate and let them know what the risks are and kind of proceed there. Sometimes we see testosterone may increase the red blood cell count.

This is paramount most especially in patients that have sleep apnea. Because what's happening is during periods of sleep, patient isn't breathing properly, there's an increased production of red blood cells. And testosterone, of course, also increase red blood cells. So in having those things together, you can have a increase in red blood cells, which can be pathologic and lead to blood clots.

Now, we want to make sure that when we talk to patients, we screen out for patients that may have sleep apnea, and we advise them accordingly that this can raise the red blood cell count. Testosterone historically also has been associated with lower urinary tract symptoms, patients that have enlarged prostates and suffer from urinary symptoms as a result of that.

And what a lot of the recent data shows that there isn't actually a strong association with testosterone causing lower urinary tract symptoms. What it can do is in patients with lower urinary tract symptoms, if there's a severity of the symptoms, we kind of assess if patients, you know, should be on testosterone treatment or not. But those are some of the typical things that testosterone has usually been associated with.

And like I mentioned, because testosterone increases red blood cell count, it can lead to elevated blood pressure. So, everything we do as far as management of a patient on testosterone therapy, we just make sure, you know, we look for these things, and have an honest discussion with the patient and, you know, kind of talk about what could possibly happen. But a lot of what we thought prior is actually not the case from the recent data.

Host: Yes, I love that. It's very important to make sure that patients are informed of the benefits and the risk of taking any kind of treatment or medication

Thank you so much, Dr. Monye, for helping us better understand low testosterone and when treatment may be beneficial. Here are a few of the top takeaways:

One, low testosterone can impact your energy, mood, muscle strength, bone health, and your overall sense of vitality.

Two, some decline in testosterone is expected with aging, and a normal testosterone level varies widely depending on the individual.

Three, persistent fatigue, decreased libido, low motivation, depressed mood, or loss of muscle mass and strength can all be signs that it's worth talking to your doctor about your testosterone levels.

Four, low testosterone can affect libido, but erectile dysfunction is often related to blood flow and underlying conditions like diabetes, high blood pressure, or heart disease.

And five, for men who have diagnosed low testosterone, treatment may help, but healthy sleep, regular exercise, and managing conditions like obesity, diabetes, and sleep apnea are important too. And remember that there are risks with testosterone replacement therapy, including significantly reduced sperm production, prostate enlargement, and increased risk of blood clot, stroke, or heart attack.

For more expert insights, visit kp.org/doctor and explore more episodes of Healthier You wherever you get your podcast. If you found this episode helpful, be sure to subscribe so you don't miss what's next, and leave a comment with topics you'd like for us to cover in future episodes. Thank you. And from all of us at Kaiser Permanente, be well.