Low testosterone is a big topic online and on social media, especially among younger men. What’s most important for that population to know about the subject?
Low testosterone is a huge topic, and unfortunately, there's so much misinformation about testosterone out there. There are freestanding men's health clinics that paint a really unrealistic picture of what a man can expect from testosterone therapy — that it can reverse aging or revitalize sexuality. It leads to really poor expectations of what testosterone therapy can do. Patients come in who've seen this type of advertising, or they've talked to a friend, or they've seen some kind of messaging on social media, that, “If you have these symptoms, you need to be on testosterone, or your testosterone level needs to be higher.” And it's far from the truth, for the most part.
I see a fair number of men in their 20s and 30s who are using testosterone-type medications they get from friends at the gym, but they don’t have a full understanding of what those medications really can do to you. So many young men use these medications in that way, and they have no idea whatsoever that they are shutting off their own fertility, potentially permanently.
What causes that damage to fertility?
There is a regulation system in men called the hypothalamic-pituitary-gonadal axis. That's what regulates testosterone production and sperm production. When we introduce testosterone from the outside, we're disrupting that system. It's a supremely delicate balance, and if we don't have a very good reason for administering testosterone, we have the potential to do some great harm. Not only are we shutting off their testosterone production, we're also shutting off their sperm production. And it’s not as easy as, “Stop using the testosterone and you'll go back to normal.” It could take six, 12, 24 months before we see sperm production resume, but it could also result in a permanent suppression of sperm production. It’s impossible to predict if someone is going to be one of those lucky men whose production actually resumes, versus one of the more unfortunate men who have caused permanent harm as far as their ability to father children.
Are there things outside of testosterone therapy that can help with some of these symptoms?
I always use the example with my patients and my students of a 50-year-old man who hasn't seen the inside of a gym since he was in his 20s. He spends a lot of time sitting at a desk; he may not eat a very healthy diet; he could stand to lose a substantial amount of weight — and he also happens to have a low testosterone level. It's my job as his provider to really educate him that, “Yes, your testosterone level is low, and this therapy might help with your sexual performance, energy levels, fatigue, loss of bone density, loss of strength, loss of muscle mass,” but I always want to make sure my patients know that if I put them on testosterone, I am just fixing a lab result.
We also must focus on lifestyle modification for them to fully realize the benefits of this type of therapy. Managing those expectations for people ahead of time really paints a better picture about what they can achieve from that type of therapy. In a majority of my patients, I will actually counsel them on those lifestyle modifications for three to six months before we even start testosterone therapy. In some patients, we can see a 30% to 40% increase in their testosterone levels if we take those measures to optimize their health and their body composition. Some of those men will never need to be on testosterone therapy if we do the other stuff first.
How does mental health fit into the picture?
Mental health has a huge impact on a man's overall well-being. You could take a man who has an entirely normal testosterone level and is physiologically a fairly healthy guy, but if he has an enormous amount of stress or anxiety, he could have all of the symptoms of a low testosterone level. He could have erectile dysfunction. There's so much mental illness in our society, and so many of the sexual symptoms we see — erectile dysfunction, fatigue, low libido — can all of these things be directly related to a mental health condition? Absolutely, they can.
But also, if we flip that equation on its head, and say if a man has natural erectile dysfunction or a measurably low testosterone level, might that cause some mental distress for him? You almost have to look at which came first, the chicken or the egg? Is this man depressed because he has erectile dysfunction? Or does this man have erectile dysfunction because he's depressed? If we're going to advertise ourselves as men's health experts, we have to make sure we're helping these guys differentiate between those two things.
What’s your best advice for men to maintain long-term mental and physical health?
A lot of it comes down to positive lifestyle interventions — making sure you're moving your body on a daily basis. Strength training is important, cardiovascular training is important, following appropriate nutrition is important, getting plenty of sleep and stress reduction are important as well. If we're not taking care of our physical bodies, none of the stuff I can prescribe for folks is really going to work that well for a very long period of time.
I counsel men to get out, lift some weights, take a walk every day. A dietary regimen is also very important, because if we're not feeding ourselves right, none of our body systems are going to work properly.
Sleep deprivation is another one — so many of us will sit and stare at our phone screens until the moment our head hits the pillow. Appropriate sleep hygiene means reducing stimulating content, whether that’s being on your phone or watching television or having heated conversations before bedtime. None of those things are going to influence great sleep patterns. And we definitely see that if people are chronically sleep-deprived, their mental health declines, their physical health declines, and their sexual health declines.