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Understanding Male Hypogonadism

Male hypogonadism (testosterone deficiency) affects nearly 5 million men—or more, since symptoms are frequently ignored.

Joshua Halpern MD, MS tells us how The Northwestern Medicine Department of Urology is committed to conducting innovative research to help advance men’s health in the field of male sexual medicine, allowing us to provide specialized urological care to patients with hypogonadism and other conditions. Our research program ranks second nationally among all urology departments for National Institutes of Health funding, with amounts totaling more than $6.8 million.
Understanding Male Hypogonadism
Featured Speaker:
Joshua Halpern, MD, MS
Joshua Halpern, MD, MS is an Assistant Professor of Urology at Northwestern University Feinberg School of Medicine. 

Learn more about Joshua Halpern, MD, MS 

Melanie Cole, MS (Host): Male hypogonadism effects nearly 5 million men or more since symptoms are frequently ignored. My guest today is Dr. Joshua Halpern. He’s an assistant professor of urology at Northwestern Memorial Hospital and Feinberg School of Medicine. Dr. Halpern, thank you so much for joining us today. Please tell us a little bit about yourself and your subspecialty at Northwestern Medicine.

Joshua Halpern MD, MS (Guest): My name is Josh Halpern and I'm a urologist at Northwestern Medicine. I specialize in treating men who struggle with fertility, sexual function, or hypogonadism which we’ll get into today also known at low t.

Host:   We hear about that in the media a lot. You hear commercials about it. So before we get into your research and some of the advances made to treat it, why does it often go undiagnosed as I said in my intro.

Dr. Halpern: You know, a lot of men don’t know the signs and symptoms of hypogonadism or low testosterone despite all the commercials and all that we hear about it. We know that men with low testosterone can suffer from symptoms like low energy, low sex drive, erectile dysfunction. It can even impair their ability to build muscle mass. There are men out there who are struggling with these symptoms, but they don’t know that it can be connected to their testosterone levels. I think this happens especially as men get older because they tend to think that changes in their sexual function or their energy are just part of the natural aging process. So they don’t talk to us, their doctors, about these changes when, in fact, we know that this could be a function of their testosterone. Testosterone levels do tend to decline as we get older. So we as doctors need to be thinking about that as one potential reason why a man could have a change in symptoms when they do present to us with some of these findings.

Host:   If they’ve gone to their primary care provider and they’ve described some of these symptoms and then they are referred to you, what's involved in the general workup or evaluation?

Dr. Halpern:  Anybody who is presenting to us or their primary care physician for the signs and symptoms should undergo a pretty detailed history as far as what’s been going on in their medical history. We know that a lot of chronic conditions can predispose to low testosterone. They should get a good physical exam, particularly a genital exam. Then we’ll do some lab work to send off testosterone levels and usually a number of other hormone levels to try to get to the bottom of what might be going on.

Host:   It’s such an interesting topic and so many men as you say—Men are not always the first to pipe up about these kinds of things, especially when it involved maybe erectile dysfunction or low testosterone. So speak to us a little bit about some of the treatment options that you can offer and what Northwestern Medicine is doing different. While you're talking about that Dr. Halpern, what about men who still want to preserve fertility? Is that effected in this case?

Dr. Halpern:  Yeah. These are all really great points. So for men who do have a diagnosis of testosterone deficiency, which is a combination or a low testosterone test on their blood work in combination with symptoms of low testosterone—such as erectile dysfunction, low libido, or low energy—the standard treatment is to give them testosterone therapy. That usually means taking testosterone in one of a few forms. There are topical formulations, most commonly gels, that a man can put on once a day. There are injectable forms that we can teach our patients to inject into the muscle once every couple weeks or so depending on the dose and the individual. There are long acting pellets that we actually can implant just underneath the skin of the buttock, which is usually performed every three to four months. There are advantages and disadvantages to each of these particular formulations, but what they all have in common is that they're testosterone. Actually what we anticipate early next year is the first FDA approved oral form of testosterone, which I think will be a really good option for very certain types of men with low testosterone. We at Northwestern are offering all of these treatments, and we hope to be offering that oral testosterone as soon as it hits the market.

But I'm glad you mentioned fertility because it’s really important for doctors and patients to understand that testosterone treatment can impair fertility. When men take testosterone, there's negative feedback to the pituitary. In other words, it sends the signal to a man’s brain to shut down the body’s natural production of endogenous testosterone. That basically lowers the level of the testosterone in the testicle itself even though levels in the blood are actually pretty high and normal. The thing that matters most for sperm production is the level of testosterone in the testicle. So giving a man testosterone therapy is actually so bad for fertility that some researchers have looked at this as possibly a form of male contraception. So if anyone is thinking about starting testosterone therapy, it’s really important that we talk to them about their plans for future fertility. Any man that is interested in preserving their fertility, interested in children in the future, then we have to think about some alternative therapies. There are medications such as clomiphene citrate or HGC, both of which could be appropriate in the right patient. They're technically off label, but they can be very effective when they're used for the right person.

Host:   Wow. What a great point that you make Dr. Halpern. So important for other providers so that they can council their patients on this before they do start those kinds of treatments. While we’re talking about possible impaired fertility, speak about the relationship between testosterone and other chronic medical conditions such as cardiovascular disease and cancer. I mean we know as we age certain of these we become an increased risk for, but where does this fit into the picture?

Dr. Halpern:  There's a lot of research on this topic. We know that testosterone deficiency or hypogonadism is associated with a lot of chronic medical conditions whether that’s diabetes, obesity, HIV, even chronic narcotic use. A lot of others can predispose patients to having low testosterone. So anyone who comes to the office with some of these comorbidities with a history of these conditions, we should be thinking about screening them for low testosterone.  On the flipside, what about treating men with testosterone with respect to conditions such as cancer and cardiovascular disease that you mentioned? We know that when it comes to cancer, men with a history of testicular cancer are going to be at risk for having low testosterone especially with certain treatments. So we should be thinking about testosterone for them.

The issue that really comes up a lot when I talk to patients is prostate cancer. So testosterone actually feeds and fuels prostate cancer cells. So in men with untreated prostate cancer, testosterone therapy can be quite dangerous. In fact, a lot of the treatments for prostate cancer are androgen deprivation therapies or essentially aimed towards knocking down the activity of testosterone. Testosterone itself doesn’t cause prostate cancer, which is an important distinction. So there's a growing body of evidence that men who have had prostate cancer in the past, as long as it’s completely treated and they're cancer free, are safe to begin testosterone therapy. Certainly men who have never had prostate cancer are safe to begin therapy from that standpoint as well.

Then the other thing that we talk to patients a lot about is cardiovascular disease and testosterone, which you mentioned. Now, the relationship here is pretty complex and there's a lot of research that’s still going on. What we know for sure is that men with low testosterone are at high risk for having cardiovascular disease. That seems pretty clear. Where it gets tricky is trying to understand what happens to men who start testosterone therapy. There was some early evidence that these men starting testosterone therapy would develop a higher risk of cardiovascular disease compared to men who weren’t on therapy, but now we have some more recent studies suggesting that may not be the case. So for now the jury is still out on the harms of testosterone replacement therapy with respect to cardiovascular disease. There’s actually a large randomized trial that is already in progress. We probably won't have the answer for another couple years, but eventually our hope is that we will have a little bit more clarity on this issue.

Host:   Thank you for clearing that up and I know there is a lot of research going on in that department. Another interesting area is diet. Is there any relationship there between testosterone levels and diet? Is there any affectation?

Dr. Halpern:  We do have a lot of evidence that lifestyle matters a lot when it comes to testosterone. So diet and exercise can have a big impact on a man’s testosterone. Certainly we mentioned before that obesity is a risk factor for having low T and there's a lot of evidence that if you lose weight and exercise regularly, particularly doing strength building exercise, that that can lead to higher testosterone levels. Now our group actually published a study just a few months ago looking at the impact of certain popular diets, specifically kind of low fat diets which have been a fad in the last few years on testosterone. So we looked at a large nationally representative population. We found that when we controlled for some of these other risk factors like body mass index, diabetes, and other comorbid conditions that men who are on low fat diets actually had a slightly lower testosterone level than regular fat intake diets.

The problem is that these differences were really, really quite small and probably not enough that we would recommend that men don’t go on a low fat diet or don’t go on a particular fad diet just for reasons of keeping their testosterone a little bit higher. So I think the take home message is that any diet and exercise regimen that’s going to help a man keep their weight stable and is going to be good for their cardiovascular health is probably going to be the best diet for your testosterone and your overall health.

Host:   That is so interesting. As we wrap up, what else would you like providers to know really about the goals of treatment. Whether it’s to restore sexual function and libido wellbeing, to talk about bone density or osteoporosis. Or really as we stated about risk of cardiovascular disease and other chronic medical conditions, what do you feel is most important that they know and when they should refer to specialists at Northwestern Medicine?

Dr. Halpern:  The most important consideration is that we treat each patient as an individual. Every man that we see is going to have different symptoms. They're going to have different testosterone levels and they're doing to have different medical histories that are going to contribute to how we treat them. Perhaps most importantly they're going to have different goals. Some men may have decreased sex drive and that’s not important to them to get that up. Other men might have erectile dysfunction and it’s very important to them to treat that. So it’s critical that we consider all these aspects—fertility, sexual function—and everyone’s individual goals when we think about treating them. Of course, in the department of urology we’re always available to anyone who wants to send us patients, who wants to ask us questions. We’re here as a resource for anyone who’s struggling with these issues. We’re hopeful that we can provide good care to all of our men on an individual patient basis.

Host:   Fantastic. What an interesting topic. Thank you so much, Dr. Halpern, for joining us today. That wraps up this episode of Better Edge, a Northwestern Medicine podcast for physicians. To refer your patient or for more information on the latest advances in medicine, head on over to our website at to get connected with one of our providers. If you found this podcast as educational and informative as I did, please share with other providers. Share with your patients, share with friends and family, and be sure not to miss all the other fascinating podcasts in our library. Until next time I'm Melanie Cole.