Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And today, we're highlighting testosterone deficiency in the national spotlight, an opportunity to get it right. Joining me is Dr. Nelson Bennett. He's a professor of urology at Northwestern Medicine. Dr. Bennett, thank you so much for joining us.

This is such an interesting topic. So, the Department of Defense screening initiative has put testosterone deficiency in the national spotlight. Do you feel this is a major opportunity for men's health, or are there risks that come with widespread screening?

Nelson Bennett, MD: Thanks for having me, and I'm really happy to dig into this. The DOD did announce routine testosterone screening for service members 30 years and older. And initially, my first reaction was very optimistic. It's the first time that we've seen this at an institution of this size commit to population-level testosterone deficiency.

But my second reaction was that when we wrote this piece, this editorial, our concern was the execution. Measuring testosterone is very, very easy, but managing what you find responsibly is the hard part, and that's where the decades of clinical evidence really begin to matter

Cole: Well, sure. That's what makes this so interesting. So you write that testosterone deficiency is more than a laboratory diagnosis. What do you see are the most common mistakes clinicians make when evaluating low testosterone in their patients?

Dr. Bennett: Well, they first get a number. They get a lab test, and if that lab test is low, then they, you know, reflexively prescribe medication or prescribe treatment. But you actually need to have two low levels biochemically, and that's because testosterone fluctuates day to day, week to week, month to month, and you need to have an average of that.

Also, you need to have symptoms, and that's what I see in the office. Men come in, they complain of lower libido, erectile dysfunction, brain fog, gaining weight in the middle section of the body maybe just not when they go to the gym, they don't see the results of the effort that they're putting in. So, you need to have both of those.

You need to have symptoms plus two low levels biochemically to have that diagnosis of low testosterone

Cole: So if they have those symptoms along those lines, then what would you say is the next step?

Dr. Bennett: after the diagnosis, I always give patients the opportunity to perform lifestyle modifications. So that's, you know, losing weight on their own, getting better sleep, eating right, exercising. That alone will increase testosterone levels biochemically. But sometimes men need a jumpstart. So, we can either talk to them about testosterone supplementation, meaning giving them extra testosterone, or testosterone-boosting medication, which are encouraging or helping their body make their own testosterone.

It all really depends on their age. If they're on the reproductive age, then we go for the testosterone-boosting medications. If they're beyond their reproductive age, we tend to stick with the testosterone supplementation

Cole: Well, I'd like to expand on the testosterone supplementation for a minute. So, if low testosterone can reflect an underlying health issue, and you just stated that you like to look at behavior modifications and lifestyle. When we think about identifying reversible causes before moving on to those treatments, whether it's obesity or alcohol use, smoking, there are a bunch of these that have been identified.

So, elaborate on that replacement therapy within that context of the larger care plan and any other elements that should be considered. Are we working with patients on those reversible behavior and lifestyle modifications? Is there a multidisciplinary care team that's involved in that case?

Dr. Bennett: Sure. Of course, you know, a lot of men with low testosterone, the the low testosterone isn't the real primary problem. It's a symptom of something else, whether that's obesity or sleep apnea, diabetes, some other chronic illnesses, even certain medications or even poor sleep. All of these we call this secondary hypogonadism, so low testosterone caused by something else.

The number's low, but there's something upstream suppressing it. So in those cases, I can send patients back to their primary care doctor, to an endocrinologist, to a weight specialist, so on and so forth to clear up those things. And those typically will raise testosterone if not a lot, but even into the normal level

Cole: Dr. Bennett, one of the strongest points in your editorial centers on fertility. So why is fertility counseling such a critical part of the conversation before initiating testosterone therapy?

Dr. Bennett: The administration of exogenous testosterone or testosterone from outside the body will suppress spermatogenesis or the body's ability to make sperm. And if you're on testosterone supplementation for a long period of time, that suppression may become permanent. Yes, there is a possibility that if you stop that supplementation, that you will regain your spermatogenesis, but that's not always true and not 100% possible.

The problem with screening on a population level and administering medication on a population level is that a lot of those men are not gonna have that discussion about fertility, meaning that the doctors are not talking to those patients about the side effects or the consequences of testosterone replacement therapy.

And if you've not completed your family yet, it's a really unfortunate thing if fertility or paternity is taken away from you because you have not asked those questions

Cole: The title of your editorial is: an opportunity to get it right. What would getting it right look like for other urologists that are caring for men with testosterone deficiency? What would you like them to consider and think about?

Dr. Bennett: I would like for them to consider testing testosterone on two separate occasions, both in the morning. I would love for them to discuss the risk benefits of testosterone supplementation to those patients in detail before starting medication. And that's the fertility discussion and the other side effects that come along with testosterone supplementation like oily skin increased acne, muscle mass, maybe steroid rage, maybe also increase in the blood cell count, the red blood cell count of the body

Cole: Dr. Bennett, this is really such an important discussion to have. And how is the team at Northwestern Medicine working to address testosterone deficiency and other issues related to men's health and fertility? I'd like you to offer your best advice here as your final thoughts. Tell other urologists what you want them to know about the work that you are doing at Northwestern Medicine and how you want them to look at this broad picture

Dr. Bennett: Well, I would counsel other doctors in my field to listen to the patients. If they have real symptoms, they come in talking about low libido, fatigue, erectile dysfunction, and mood changes, take the patient at their word they're having those issues, and then perform confirmed low early morning testing for the testosterone, and not just one test, a couple of tests before initiating treatment.

That's what we're doing downtown, and we're following the patients not only after we start medication, but we're following them for months and years afterwards. We're also testing their testosterone levels every six months while they're on treatment, as well as PSA and a blood count to make sure that their red blood cell count doesn't increase and become dangerously high

I like the main message to be counsel on fertility before treatment every single time for men in reproductive age. That's the piece that's most likely to be overlooked and the one with the most consequences and that's the hardest to reverse

Cole: Thank you so much, Dr. Bennett, for joining us today. What an interesting and important discussion that was. Thank you again. And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/urology to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians.

I'm Melanie Cole.