Better Sex: Is Testosterone Replacement Right for You?

Better Sex: Is Testosterone Replacement Right for You? Listen To This Episode on Apple Podcasts

In this episode we discuss testosterone replacement therapy. The internet is full of ads for testosterone treatments. These ads claim that supplemental testosterone can make men look better, feel better, and even perform better in bed. But are all these claims true? Which men can actually benefit from testosterone replacement therapy? What are the risks? And how much benefit can men realistically expect from the medication? In order to answer these questions, we turned to an expert on testosterone replacement therapy in men.

This Episode's Guest:
Amy Pearlman, MD

Dr Amy Pearlman is an assistant clinical professor of Urology at the University of Iowa. Dr Pearlman earned her medical degree from the Baylor College of Medicine and then completed her residence training in Urology at the University of Pennsylvania. She subsequently completed a fellowship in urologic reconstruction, prosthetic urology and infertility at Wake Forest University.

Better Sex: Is Testosterone Replacement Right for You? Transcript:

Better Man Clinics  

What is testosterone and what does it actually do?

Dr Pearlman  

Testosterone is a hormone, and it has roles as a sex hormone but also as an anabolic steroid in men. Now we do need to clarify that women also have testosterone and that testosterone actually plays a very important role in women as well, although women do have lower levels of testosterone in their bodies. Same thing with estrogen. Men have estrogen. It’s just that the main sex hormone in women is estrogen and the main sex hormone in men is testosterone. A sex hormone plays a critical role in the development of secondary sex characteristics. Those characteristics include the development of the penis and testicles, deepening of the voice during puberty and growth of facial hair and pubic hair. Testosterone is also an anabolic steroid, meaning it leads to muscle growth and an increase in bone density. That is where part of that taboo topic of testosterone comes from. When a lot of people think of testosterone, they think of bodybuilders and of stories of how testosterone is used inappropriately. That’s not what we’re talking about here. I prescribe very similar medications that bodybuilders use. However, we’re not talking about the same patient here, we are not talking about the same indications, and we’re certainly not talking about the same doses.

Better Man Clinics 

How does testosterone contribute to sexual function? Can it be used to treat erectile dysfunction in men?

Dr Pearlman  

Testosterone wouldn’t necessarily be used to treat erectile dysfunction. That’s a whole other separate algorithm for which we’re talking about oral medications and vacuum pumps and injections and penile implants. However, it is really difficult to get a good erection if one’s testosterone level is low. What research suggests is that, for those men who were initially responding well to oral medications (Viagra, Cialis etc) but are no longer responding and their testosterone level is low, they will likely respond better to the erectile dysfunction treatments after you optimize their testosterone level. Now, with that, I will say that, regardless of what the research suggests, I see plenty of guys in my office who are coming in for a separate reason such as problems with libido or fatigue.  After starting these men on testosterone therapy, I often notice that they say that their erections are improved even though they were not primarily started on the medication for their erectile dysfunction.  In those cases, the men may not even need Viagra or Cialis to manage their erectile dysfunction. So it’s really used in combination. And the thought process behind that is just that hormones are really important in everybody. If you optimize the hormones, you can oftentimes optimize the treatment for sexual dysfunction.

Better Man Clinics  

Would you say that the testosterone mainly impacts libido or sex drive or does it have some physiological effect on erections as well, aside from libido?

Dr Pearlman  

There are some physiologic effects as well because testosterone may improve erections in those guys that do not report an improvement in their libido or in whom that may not even be an issue. Libido is a very tricky topic as well. If a guy has erectile dysfunction, it can affect his libido as well. So, you start thinking which is the chicken and which is the egg. Oftentimes, it’s hard to tease those two out, so it doesn’t necessarily matter as we really do treat both. 

Better Man Clinics  

What are the common issues associated with “low T” that can be improved with testosterone therapy?

Dr Pearlman 

Oftentimes, low testosterone is the picture of the middle aged male who is struggling.  He feels tired- he comes home from work and plays with the kids or cooks dinner, but he feels tired. He feels decreased motivation and maybe some brain fog. His sex drive isn’t what it used to be and his erections aren’t what they used to be.  He is working out at the gym, but he’s not seeing the same gains in his muscle mass that he used to when he was working out just five years ago. The research suggests that putting someone on testosterone who’s coming in with low T can improve mood, but it’s not a treatment for a mood disorder like other medications such as SSRIs. Testosterone can improve bone density but we don’t often see those guys in the office for that reason.   I remember seeing a gentleman who literally broke his back and was found to have a very low testosterone. However, he wasn’t really coming in with any of the other symptoms of low testosterone. Testosterone can also improve anemia (low blood counts), but it’s rare that we’re going to see guys in our office for that particular reason. It can improve erections and libido. More and more research is coming out now that shows that when you treat someone who has low testosterone with testosterone therapy, you can improve blood sugar control, blood pressure, and waist circumference. While some of that work is not yet published in manuscripts, more and more research is demonstrating that testosterone can really help with what we think of as the metabolic syndrome which includes some of the issues I just mentioned. 

Better Man Clinics  

Are there certain groups of men that are more prone to testosterone deficiency? We’ve always heard about it as being problem of older guys? Is that the case or can guys of any age have testosterone deficiency?

Dr Pearlman  

Men of any age can get testosterone deficiency but, you’re right, we do talk about it in terms of late onset hypogonadism, or something that occurs as men get older. While that does happen in a lot of men, we really think that a lot of those men have reduced testosterone related to comorbid conditions like diabetes and obesity and having heart disease. All of those factors are also going to contribute. And as our society has become more overweight and have all of these other conditions, we’re going to also see hormone issues. So yeah, it can be due to age. But I will say some of my most disappointed guys that I see in the office are like the 80 year old farmers who are used to working hard, and they come in because they feel a little bit more tired. But they still have work to do. They have like 10 years left on the farm. And so they come in, and they say, “I think it’s my testosterone”, because they’re hoping their testosterone level is low so that I can put them on therapy and they can get back to working at 100%. Usually, their testosterone levels are actually well within the normal range (I’m talking like levels of 800). Those guys are not happy because I’m not going to give them testosterone. But I see young men in my office with legitimately low testosterone levels. I’m talking, you know, late 20s, early 30s. And a lot of those guys don’t think that it’s going to be a problem so early on in their life, but they tend to be the unhealthier patients – the guys who are overweight, who have Type two diabetes, who have heart disease at a very young age – and so their testosterone level is affected. But I’ve been surprised, because in my training, I didn’t think I was going to see such young men with low testosterone levels. And I would say that most of my patients that I see are in their late 30s and early 40s, with legitimately low testosterone levels.

Better Man Clinics  

Can men raise or change their testosterone levels through their diets?

Dr Pearlman  

I think this conversation is one of the most important conversations we can have because first line therapy for really anything that we treat is going to be lifestyle modification. Most of the guys who see us in the office are probably going to be looking for some of that conversation. But by the time they wait to see us in the office, a lot of them are looking for medication or something further down that line. But we can’t forget first line therapies like behavioral modification. Anything that is good for overall health is going to be good for testosterone. We just have to keep that in mind even though it’s not really a sexy thing to talk about. But I think there’s a way to make it a little bit sexy, especially with fancy infographics, which is a lot of what we see on social media. The research is a little bit mixed. I was recently working with some colleagues of mine on writing a review paper on what macronutrients might be helpful when it comes to improving testosterone levels. And as I was reviewing that work, I found that it’s a bit confusing. You finish reading the paragraphs and you’re like, “Okay, so what do I make of this information?” Because this study showed that and that study showed this. They use this amount of carbohydrates and this amount of fat, and so you’re never going to put someone on a strict dietary plan as was done in those studies. 

There was a recent study that was published in the Journal of Urology and was recently quoted in the Urology Times that talks about pro inflammatory foods and how those foods can lower testosterone levels. More and more research is coming out related to pro and anti-inflammatory foods. In general, foods that promote inflammation are just not going to be good for us, whether that’s related to testosterone or heart disease or diabetes. It’s really all of the same things that we’re talking about here. We’re talking about overall health and wellness. And so that recent study looked at a national database. Now, those databases, they’re not great. You don’t have that much granularity with any of those large databases. So all we can say is that work from that database suggests that those who eat more pro inflammatory foods will have a higher rate of low testosterone levels.

Better Man Clinics 

Can you give us some examples for the guys out there of pro inflammatory foods?

Dr Pearlman 

Pro inflammatory diets are those that are high in saturated fats and refined carbohydrates. So, everything like processed foods; you know, the stuff that has to have like five different things on the front to try to convince us that it’s healthy for us. My sister is a gastroenterologist and specializes in nutrition. She says, “Amy, when you walk down the health food aisle, and you look at the protein bar, think about all the things that are on that protein bar that is trying to convince me (as a physician), that that chocolate candy bar is good for me.” We’re talking about things like “gluten free”, “high protein”, “low fat”, and “low carb”. And then she asked me, “What is the marketing on the broccoli? What is the packaging, say?” And I’m like, “Michelle, I don’t think there is any packaging on the broccoli”. And she’s like, “Yeah, broccoli doesn’t have to tell anyone that it’s healthy”. The foods that we know, the good produce, the fresh fruits and vegetables- we know those things are healthy, and they’re also going to be good for our bodies and our hormones.

Better Man Clinics 

To what extent can weight loss and exercise improve testosterone levels?

Dr Pearlman  

Maintaining a good weight within the recommended ranges and losing weight can help. But research suggests that you have to lose a certain amount of weight to actually see those changes. And so there’s no perfect amount of weight that anyone has to lose. But again, if you’re overweight, there’s more inflammation and it’s going to contribute to testosterone issues.

Better Man Clinics  

There is a huge industry out there for testosterone supplements, right? There are pills or tablets or other ways to orally increase your testosterone. What are your thoughts on that?

Dr Pearlman  

We just don’t know what’s in a lot of those over the counter supplements. And they look great- I mean, we all see the commercials: Dude with five hot women surrounding him and we’re like, “I want whatever he’s taking”. Unfortunately, taking those pills will not get you five hot women necessarily. They’re not FDA approved. We don’t know what’s in those compounds. And they can be harmful for some folks. Those things that you buy over the counter, they can be quite expensive. There’s very little research, if any behind them, and you just don’t know what’s in them. So sometimes those ads look very sexy, but they’re a little bit of the unknown, unchartered territory.

Better Man Clinics  

Can you actually get prescribed testosterone pills by your doctor or by anybody else to increase your testosterone? Is there such a thing as a testosterone pill?

Dr Pearlman  

There is one that actually came out recently. I want to say it came out about a year ago. The indications for the oral medication, though is very narrow. For most of the guys that we see in the office, it wouldn’t be covered for them to have that oral medication. In the past, the therapies that they looked at could cause liver damage. And so that’s why there are a lot of different other formulations for getting testosterone.

Better Man Clinics  

So, generally speaking, if someone is concerned about low testosterone and want testosterone supplementation, do they need to see a physician for that?

Dr Pearlman  

Not necessarily a physician, but a health care provider. A lot of my work is done to train nurse practitioners and physician assistants, who I firmly believe are some of the best people to treat the hormonal deficiencies, because those guys will never require a trip to the operating room. So you don’t necessarily need a surgeon to see those patients. But it’s really anyone who has expertise in male hormonal deficiencies, which could be a nurse practitioner, a physician assistant, Family Medicine provider, a urologist, an endocrinologist, a variety of different people. I will say, though, that in general, the reason why a lot of these clinics in the community (what we call “shot clinics”) have been able to be so successful is because, as healthcare providers, we’ve done a very poor job of telling men in the community that “Your health is important and we want to help you and we want to listen to your concerns”. And so, in many ways, when I think about men’s health, we’re very behind women’s health. Women have milestones that necessitate a trip to see a health care provider. When I was maybe 16, my mother said, “Amy, it’s time to see a gynecologist”. I was dreading that visit for several weeks leading up to the appointment. But out of necessity, my mother made me go and so I was plugged in to the health care system before I had any signs and symptoms of any health care issue. And then, if we have children, then we see a health care provider again or when we go through menopause, you might see a health care provider again. There is no real equivalent milestone in a man’s life that says, “Okay, now it’s time to see a health care provider”. And, so, we’ve kind of forgotten about men. Now it’s time for all of us, whether we’re in family practice, or urology or endocrinology, to kind of open our doors and say, “hey, you know, your hormones are important too. And your quality of life and your fatigue is important too”. And really treating the whole man like we’ve done for a lot of women, but there’s still obviously room to grow. 

Better Man Clinics  

Is there anything that men should ask to see if these shot clinics are right for them?  Any screening questions they should ask?

Dr Pearlman  

First of all, I agree that these shot clinics look awesome – kind of like the over the counter supplements. I was able to sort of like weasel my way into one of those clinics. It was convenient. It was in a shopping center. You could park right out front.  You walked right in and, as soon as we open the door, it was like this wall of motivation. You see all these words come together and it’s like, “okay, I want to be a better person. I want to get treated. I want to feel better and live my life.” So, like even me as a woman walking in, I was like, “alright, let’s do this.” It was a very nice clinic.  They specialize in a subset of Men’s Health -they’re not doing too much. And I think that is part of the issue.  I can say this just being a part of a big academic center – we do a lot, we treat a lot of complex disease, we’re part of these huge buildings. But sometimes men just want to walk right into a building, get their care, and leave. There something to be said for convenience and not sitting in a big waiting room and waiting. I know my patients have to wait one or two hours to see me. I hate it but it’s a reality because I like to talk. There is something to be said for the convenience. I like that about those clinics that are accessible to men in the community. The first person that people oftentimes meet with is someone from billing to talk through the different packages. But you know, I like that.  I think that is cost transparency at its finest to walk into a clinic and know how much you’re going to have to pay, and you know exactly what you are going to get in return. It’s really hard in a health care system to have cost transparency, I’ve had a few patients over the years reach out regarding care that I just would have assumed would have been covered by their insurance plan. And they got unexpected bills in the mail, even for a minor procedure- like, let’s say $1,200, which, for someone who’s not expecting that, that changes the way that person spends their money the rest of the year.  So even though I don’t know how I feel about that (billing person) being the first person you see, I think cost transparency is what a lot of men and people in general want out of their healthcare system. 

But some of the issues occur when I see some patients who have been seen in some of these clinics and I look at their labs.  They get so many labs, so much blood work is done on these patients, full sets of panels- like, way, way more often than needs to be drawn – at the beginning of the month, and at the end of the month, and like every month people are getting blood draws. I just don’t see the reason, when we talk about cost conscious care, to get so much blood work. And then it just very expensive.  I always asked my patients, “like how much are you paying a month for these therapies”. Oftentimes, it’s like $200 a month, whether or not they’re being seen in person. You can actually get these medications for a reasonable price especially if you use something like a medication assistance program like Good Rx, let’s say, if your insurance doesn’t cover it. Also, some of the clinics may offer only a few types or one type of testosterone replacement. I’ve had some patients put on pellets because that was really the only option. And the pellets are one of many options. A really cost effective approach would be to use testosterone injections instead. Also, a lot of these clinics will make patients come in.  I’ve heard patients say they feel like they’re cattle because they’re just kind of going through the line and having to come in every week for their medication. As a result, you have these patients that become reliant on these clinics to actually get their therapy. But in terms of the regimens that they put patients on, I mean, I use a lot of the same medications. They actually have very decent regimens. But I just think with the they tend to check blood work very frequently, and make patients feel like they’re reliant because they make them come into the clinic for their therapy on many occasions.

Better Man Clinics  

Guys are pretty reluctant to go through the process of seeking medical care.   Part of the reason why they don’t want to go to a doctor is that they don’t know what to expect. If a guy is coming to your clinic (maybe they’re seeing you or a nurse practitioner or a PA), what should they expect? What questions will be asked of them? What type of exam will be done? What should they expect with that first visit?

Dr Pearlman 

I oftentimes start the conversation with “what are you hoping to get out of today’s visit? What would make today’s visit successful for you?” And oftentimes, guys will take, you know, even a few moments to think about what that means. And some people might say, “I want to have my testosterone level checked, I feel like it’s low.” Or they might say, “well, you see my buddy, Dan, and Dan comes to you for testosterone and he feels great and he’s doing great. And I’m wondering if I might be a candidate for what Dan’s on”. Then we’ll get into some questions like “why do you think your testosterone level is low? What are you hoping to get from testosterone therapy? Your current weight? Are you up, down, or about the same as you’ve been in the past? How is your sleep? Do you feel like you could take a nap in the afternoon? How are your erections? Are you taking anything for the erections?”  We get into the sexual function aspect of what’s typically associated with low testosterone. But we’re also looking at these other factors like weight, sleep, exercise and nutrition. It’s hard to have that comprehensive discussion in a visit when you’re running a busy clinic, but that first visit is going to take a little bit longer just to set the scene, get a lay of the land, figure out if this person coming in is already optimizing their health and doing everything that they can do. Or do they need a little bit of help and more education on lifestyle modification?

Better Man Clinics  

What about physical exam and tests?  Are we going to do a lot of invasive procedures or tests to check testosterone?

Dr Pearlman 

I’m going read the room first. I have a I have a lot of social media content.  I think it makes for a better visit when they’ve seen some of my social media content, or at least have done a Google search to know that I’m a woman. My first name is Amy. It is a pretty common female name. Also, I’m not saying that I’m young, but I’m on the younger side. If someone has not done that search beforehand and they’re expecting to see a 75 year old woman, it takes like five or 10 minutes to get that person to be like, “Okay, I’m going to talk about these sensitive subjects with a youngish woman today.” It’s always nice when people come in with a little bit of a knowledge of who you are, what your personality is like, what types of questions you ask, and the common things that you treat in your practice so they’re more comfortable. As for the physical exam, it is an important part of this whole evaluation. But if someone seems like they’re uncomfortable, I’m not going to force anyone to do a physical exam.  But if I feel like the need is there, and they’re comfortable with it, I’ll do it. Otherwise, I don’t have to do a physical exam  at this stage of the game. But it is never the wrong thing to do. During the exam, I am going to have that person drop their bottoms and just do a genital exam- look at the penis, make sure I’m not missing anything else. I’m also a reconstructive surgeon and treat penile curvature so I’m also thinking whether there is a structural problem going on with the penis (like some scar tissue in that area) and am making sure we’re not missing any lesions that could be concerning. I then complete the genital exam by feeling the testicles, making sure they’re both down in the scrotum, that there are no masses, that they have a normal consistency and that they feel normal in size.

Better Man Clinics  

I’m assuming that the labs play a big deal here in terms of identifying testosterone deficiency. Is it just testosterone you are checking? There are a lot of different labs that are out there: free testosterone and hormone sex hormone binding globulin, FSH and LH?  What labs do you check?

Dr Pearlman  

It’s like the alphabet soup when it comes to testosterone. The beauty of testosterone, though, is that we can check for it- we don’t have to guess. When our patients come into any of our clinics, as healthcare providers, if they’re worried about low testosterone, it takes less effort for us to say, “well, that’s a reasonable concern. Let’s check it” than for us to try to convince the patient that it’s not important, and we don’t need to check it.  We just should check the testosterone level. And it’s a blood test, right? So it’s easy enough. We check for tests in the blood all the time. So all of these tests that we’re talking about here are all from a venipuncture, a blood test.

I’ll start with a total testosterone level. Our national American Urological Association guidelines really talk about using total testosterone, and they really don’t promote much of checking free testosterone bioavailable or SHBG (sex hormone binding globulin). Their focus is on total testosterone. I would say that’s my focus as well – checking that total testosterone level.  If they’re coming with all the symptoms, but their hormones don’t quite make sense -that’s where I might check a SHBG level or that’s where I might check a free testosterone level. My sense is that more providers will check the free Testosterone if they’re trying to figure out maybe why not to treat a total testosterone level that’s low.  That is why I tend not to do so because I’m always thinking, “can I hurt this person?”  If I can’t hurt this person, then I’m more inclined to treat that person’s low testosterone level. I try to simplify it:  start with checking the total testosterone level- if that’s low or low normal.  Our national guidelines use 300, which is somewhat of an arbitrary cut off but that tends to be what I use in my clinic.  Then you want to know why it is low. Is it a signaling problem? Or is it a primary testicular problem? To tease that out, that’s where you’re going to check a pituitary hormone called LH or luteinizing hormone, because LH gets secreted from the pituitary gland, and goes down to the testicles, to say, “hey cells, we need to ramp up testosterone production.”  If you’re not producing enough of that signaling molecule (LH), the testosterone level can oftentimes be low. So that’s mostly what I see in my clinic because I don’t run a primary infertility clinic, even though I do see some of those patients. Most of the time, I’m not seeing a problem with the testicles. I’m seeing a problem with the signaling. And the signaling is often times also associated with these other comorbid conditions we discussed like diabetes and obesity – all of those conditions can affect the signaling to the testicles. Oftentimes, LH in these guys is going to be low or low, normal or even normal. Now, a normal LH is actually not a normal response to seeing low testosterone.  If the brain is seeing that low testosterone, it should ramp up its LH to say, “Hey, we got low testosterone, we need to send more signal.” And so having an LH that is technically within the normal range is actually an inappropriate response to having low testosterone. If that LH is on the low side or normal, then you’re going to check a prolactin level. Prolactin is another pituitary hormone that can sometimes be elevated and that shuts off downstream production of testosterone. And prolactin can be elevated if someone has a growth in the pituitary gland called a prolactinoma, which is not a cancer. It is a growth which sometimes can be treated with a medication or, sometimes, if it’s bigger and causing vision changes, then we send those patients to see a neurosurgeon to have that growth removed. That happens in the minority of the time, but you don’t want to miss it. And that’s why we do check the prolactin level in that workup. So those are the main things :you start off with a test of total testosterone. You have to repeat that on a second day because testosterone levels can vary day to day. They can vary depending on how much sleep you’re getting, if you’re dealing with stress, they could vary depending on the time of day that you have it drawn.  We like to check the testosterone level in the morning, usually before l10am, especially in young men.  In guys who are younger than 40, you get more of those peaks and valleys related to testosterone levels. So if you check it later in the afternoon, and it’s low, you don’t really know what to do with that information. So you do want to check a morning level on two occasions to confirm that diagnosis.

Better Man Clinics  

You said the accepted normal level for testosterone is around value of 300? Does that mean that all men with testosterone levels below 300 should get testosterone supplementation?

Dr Pearlman  

No, that’s a great question. And I would say this is also where it gets a little bit complicated, because the reference ranges at all of these different labs vary. You’ll see some reference ranges at a lab facility where normal testosterone is like 190 to 800 and at another lab it may be 240 to 1000.  I don’t necessarily look at those reference ranges because someone who has a level that’s technically within the normal reference range of 250 might still be low. To make that low testosterone or testosterone deficiency diagnosis, it does require low levels and some of the signs and symptoms that we discussed that are associated with low testosterone. Everyone has their value that they feel well at or are optimized at. There are some guys who feel best when their levels are at 400, 500 or 600 and other people with a level of 250 that really don’t have any of these signs or symptoms we’ve discussed.  So it’s really the combination of both of those factors. Now, for someone who has a very low testosterone level, like that guy who literally broke his back with a testosterone of 70- even if that guy were to say, “look, Dr. Perlman, I feel fine. I’m at a good weight, I don’t feel tired, I feel well, I don’t really want to be on testosterone,” -he broke his back because of a hormone issue or the hormonal issue contributed in some way. I would definitely treat that guy and I do treat that guy because of his osteoporosis. But some guys will feel fine with their levels being low. It just depends on what their other risk factors are. We know that low testosterone levels are a risk factor for heart disease. So that’s something that needs to come into play when we’re talking and counseling our patients. If they have a level of 200 and they feel well – then we just have to do our due diligence as say, “I understand you don’t want to add another medication. But what we know from research is that low testosterone is a risk factor for heart disease. So let’s talk about other ways that we can optimize your heart health.” Whether that’s with nutrition or exercise, those are other ways that you can at least optimize heart health in that situation.

Better Man Clinics  

What about guys who have a normal testosterone of say, 350, but who have the symptoms of low testosterone?  Should they still be offered testosterone supplementation?

Dr Pearlman 

This is where that art of medicine comes in and we are asking ourselves (and our patients), “can I hurt this person?”  And once we understand how and if we can hurt our patients, everything else is fair game. At least that’s the way that I think about it. It is in that range of about 300 to 400 where I’m thinking, “Okay, what do we think here in terms of optimizing this person’s testosterone levels?”  So we will talk about some of the lifestyle modifications that we already discussed such as nutrition and exercise and sleep. I send a lot of guys for sleep studies.  Getting poor sleep or having sleep apnea can certainly contribute to low testosterone levels. I might also check some of these other hormones that we discussed previously. What is their free testosterone in this case? Even if their total testosterone is well within the normal range of 340 (technically normal), I might check someone’s free testosterone level and, if that’s low, I’m going to be more inclined to treat them with testosterone therapy. I’m also thinking about some of the other medications that we have in our toolbox that can help boost endogenous production of testosterone. Those medications include aromatase inhibitors and selective estrogen receptor modulators and gonadotropins like HCG.  I use those medications very frequently. It just depends on exactly what I am trying to improve. It’s great to have the numbers look better. It’s great if you put someone on an estrogen blocker and their testosterone level gets better. The question is, does that person feel better? That’s ultimately what we’re treating at the end of the day. So it’s rare that I would put someone with a total testosterone of 340 and estrogen levels that are a little bit elevated on an estrogen blocker. Some of those guys are coming in with breast symptoms and they might have some improvements. I’ve definitely seen that if you knock their estrogen level down a little bit, their breast symptoms improve., There may also be some decrease in fluid retention or acne. But I oftentimes will go to HCG because HCG will directly stimulate the testicles to produce some testosterone. But it does depend on what these other lab values come back as. For example, lets go back to  LH, that pituitary signaling hormone we discussed. If that person’s LH is high, it doesn’t make sense for me to give that person HCG. Okay, I kind of went a little bit too far there. Let me like take a step back here.  The body sees HCG (human chorionic gonadotropin) as LH. So I can essentially give a guy the pituitary hormone to directly stimulate the testicles. But if he already has enough hormone signaling the testicles, I don’t need to give him more signal. So the guys that I’m going to consider for HCG therapy are going to be those who have a low or low normal LH level and a low testosterone level. And, through the HCG therapy, I’m trying to directly stimulate the testicles to produce testosterone. Now, all these medications that we’re talking about are going to be used off label for this indication- they’re not FDA approved to boost testosterone levels. And I tell my patients it’s used off label and it’s likely not going to be covered by insurance. So they know that going into it because, depending on which pharmacy you get something like HCG from, it can actually be cost prohibitive. 

Better Man Clinics 

So let me ask you a really stupid question. In those patients that you just decribed, why not just give them testosterone?

Dr Pearlman  

Sometimes I do. It depends on some of their other risk factors. Is this guy coming in with congestive heart failure? Am I worried that by giving him testosterone I’m going to increase his estrogen and increase his fluid retention and worsen his congestive heart failure? For men in that 300 – 400 range, I oftentimes do put people on testosterone. However, sometimes I see a guy coming in with a 300 -400 testosterone level who might want to have a child in a couple of years or is actively trying to have a child – those are the guys who you could hurt by worsening his fertility or making him infertile by putting them on testosterone. So, it depends. 

Better Man Clinics  

You said a while ago, “I want to optimize their testosterone.” What does that mean? If their testosterone level is 240, does that means that the optimized value is 301? Or, do we say, “hey, the more the better”?  Is 900 the goal. How do you define or quantify and optimized testosterone level?

Dr Pearlman  

I probably misspoke a little bit when I said that because I actually don’t know how much I optimize testosterone levels because I do it completely based on symptoms.  I mostly use injectable testosterone and have the patients inject themselves at home because, then, I don’t have to worry about absorption. It’s very cost effective and a lot of guys actually prefer that therapy. When I have guys on injectable testosterone, I rarely actually check their testosterone levels. Shh, Don’t tell anyone that!  Our national guidelines recommend that you check testosterone levels every six to 12 months while someone is on therapy. If you are going to check the level, you have to make sure that you’re checking in at the appropriate time. If you are putting them on injectables, the levels become super physiologic and then they’ll go down.  So, if you check the level the day before someone is due for their injection, it’s probably going to be pretty low.  I actually do it based on how someone feels. I may ask the patient,  “when you initially came to me, Mr. Smith, you were coming in with fatigue, and decreased muscle mass and inability to lose weight and low libido and erectile dysfunction. Now that you’ve been on therapy for three months, in what ways do you feel like your symptoms have changed or have not changed.”  Mr Smith might respond, “ I have an overall sense of wellness, my brain fog is better, which I wasn’t expecting was going to get better. I feel great on therapy.”  In that case, I’m not going to change anything  I’m going to check some lab work during follow up, I will be checking his hematocrit (blood count) because, especially with the injectable testosterone formulations, we can drive up the hematocrit because they have an increased risk for causing polycythemia.  I’m also going to check his estrogen level.  Our guidelines say that we should check estrogen at baseline and for those who are coming in with breast symptoms. I check estrogen at baseline in every guy that I’m considering testosterone therapy on and then I check estrogen every time that I’m checking follow up labs which, for those that are doing well on therapy, is usually once a year.  The men get increased estrogen levels when they convert some of their testosterone to estrogen. When I give someone testosterone therapy, I know that some of that testosterone is going to get converted to estrogen. That is where a lot of the bothersome side effects come into play  breast tenderness such as breast swelling, fluid retention, moodiness, and acne. That’s why when bodybuilders use up to 10-20 times the usual dose of testosterone, they also take these anti-estrogen medications, because the estrogenic side effects are so bothersome. So I’m definitely checking the estrogen and making sure that I’m not running their estrogen too high. But I’m also making sure I’m not running their estrogen too low if I put them on an estrogen blocker, because estrogen is really important for bone health and things like orgasmic function.  For guys that are on topical therapy, it’s a good idea to check testosterone levels in those men. If someone is on testosterone by means of a gel or a patch, and they don’t feel any better on therapy, you want to make sure that they’re actually absorbing the medication, as some men won’t absorb the medication. In that case, it may have nothing to do with the therapy at all, only that they’re not absorbing it- but not that they don’t benefit from having higher testosterone levels.

Better Man Clinics  

How  do you counsel your patients in terms of the risks of getting testosterone therapy?

Dr Pearlman  

I counsel patients on the pros and cons of testosterone therapy.  The American Urological Association has excellent guidelines that provide about 10 risks that doctors should counsel patients on. So I pretty much go through each of those one by one it for my patients. First, we know that low testosterone is a risk factor for heart disease. We don’t know whether putting someone on testosterone therapy increases or decreases that risk. There is one gentleman that I remember very vividly. He was in his 40s had a history of a heart attack at a young age and had previously been on testosterone. And I said, “you know, I don’t know if putting you on testosterone is going to increase or decrease your risk.” And he said, “Dr. Pearlman, I feel so much better when I’m on testosterone, that if you were to tell me that I was going to die in a year from being on therapy, I would take that risk because of how much better I feel. I just don’t feel well off testosterone, right.” So that’s really all it takes- having that conversation -and people understand what you’re saying. You know, people were so scared of testosterone.  We think of all the other medications we put people on. A lot of the other medications we use actually have way more detrimental side effects, then testosterone does. So we talked about the cardiovascular risks. Then I’ll mention that, “because I’m putting you on testosterone, I might raise your estrogen level and so, when I see you back for follow up, we’re going to to check your estrogen level. If in the interim, between now and your follow up visit, you develop breast tenderness, breast swelling, mood changes, acne, or fluid retention, let me know and we’ll check your estrogen level to see if we need to either lower your testosterone dose or add an estrogen blocker.”   We talked previously about fertility, especially in young men.  You never want to assume that a 40 or 50 year old guy who shows up in your office doesn’t want to have a child.  We never want to make that assumption so we do need to ask all the guys who come into our office if they are interested in future fertility and/or if they are currently trying to conceive? Because that’s how we can really hurt patients -when you get testosterone from the outside and shut down that communication from the brain to the testicles – you can make someone infertile. That person might then need to do something like IVF (in vitro fertilization), or something that’s way more expensive, and go through that whole process if they were never told. So you definitely want to ask about fertility and counsel patients that testosterone therapy can worsen fertility.

Better Man Clinics  

What about men with prostate issues like enlarged prostate? You hear a lot about how testosterone therapy could make it worse. Do you feel that same way? Or what kind of counseling do your patients with regards to that?

Dr Pearlman 

So much of my practice also involves lower urinary tract symptoms.   As men get older, they will often develop an enlarged prostate.  It certainly does not make it a contraindication to treat them with testosterone. We are oftentimes treating both at the same time, you know.  They are coming in with low testosterone issues, erectile dysfunction, and lower urinary tract symptoms.  The prostate is a hormone sensitive organ. So certainly, testosterone can have an effect. But we are going to be asking about those questions as well to be able to address them. 

Better Man Clinics  

What are the contraindications to testosterone therapy, if any?

Dr Pearlman  

Our guidelines will say that if someone has had a heart attack within three to six months to not start Testosterone therapy nor restart therapy within that time. I also want to  touch back on what we discussed earlier in the conversation regarding prostate cancer.   Initially, we thought that starting someone on testosterone therapy with a history of prostate cancer was adding fuel to the fire and that just is not the case. Research does not suggest that anymore and a lot of research has been done in that area.  I get a lot of guys who get referred to me who have had a history of prostate cancer, have had it removed, either surgically or with radiation, their PSA is undetectable and they’re coming in because they want to be on testosterone therapy or restart therapy. There is no evidence to suggest that those guys are at higher risk of a prostate cancer recurrence. I will put a lot of guys like that on therapy, if there’s ever any question – let’s say they had high risk disease, and they had a positive margin, but their PSA level is now undetectable- I will always reach out to whoever is managing their prostate cancer to say, “Hey doctor so and so, I saw our mutual patient today.  You removed his prostate nine months ago.  This is his PSA. This was his pathology. Are you okay with me starting him on testosterone?”  I’m always having that discussion.  I would never just go and start someone on therapy without talking to the person managing their prostate cancer. I’m really lucky with the people that I collaborate with on a regular basis in that none of those providers have a problem with me starting those patients on testosterone who really be safely started on testosterone. Now where it gets into a little bit of a murky area is within what time period can you start them on testosterone after prostate cancer therapy? We don’t know the answer to that. It really just depends on the patient.  If he says, “Look, I was on testosterone therapy before and I felt great. I had my prostate removed. It’s three months later and my PSA is undetectable. I’m really struggling without my testosterone therapy. Can we start it again?”  I would reach out to the oncologist to make sure they would be okay with it. I’d be okay with that as well. We are going to still continue to check his PSA.  Alternatively, there are guys who have had radiation therapy and are on hormone therapy that specifically drops their testosterone level down. Those guys, if they have high risk disease and are on hormone therapy to specifically drop their testosterone, I can’t put on testosterone therapy. That is the purpose of the treatment they’re on to treat their prostate cancer. But those guys often struggle, and you see the negative consequences of what a really low testosterone level: hot flashes, fatigue, weight gain, difficulty building muscle, poor, difficulty controlling diabetes.  You can definitely see this when testosterone levels are really low, you definitely see it in those patients. I wish I could put them on testosterone therapy, but that actually could be a big problem. I have still other patients who are on active surveillance where they have known prostate cancer that has not been treated. They were biopsied and were found to have very low risk prostate cancer and they are being followed closely with a PSA and let’s say a prostate MRI.  We have a shared discussion that says, “we’ll keep an eye on your PSA”  and they’re like, “I understand. I want to start therap. I feel better on the therapy.  Lets do this. And I have no problem doing it on a lot of those guys either. So the tide is changing.  A recent paper came out by Dr. Morgentaler, who is very well known in the Boston area and worldwide when it comes to testosterone deficiency. He recently published a paper where they gave testosterone therapy to men with known metastatic prostate cancer for quality of life concerns. With those guys, it’s the same- shared decision making.  When you’re struggling in so many ways, if we could improve your quality of life by putting you on testosterone, maybe it’s worth it in that case.  For some people, it may be worth it. Some of my most meaningful collaborations are with people outside of Urology. They’re with surgical oncologists and oncologists who treat patients for really tough cancers, like malignant melanoma, and glioblastoma and pancreatic cancer. We are finding that a lot of these patients have low testosterone levels for any number of reasons – because they’ve had chemo and radiation and immunotherapy and big surgery. The question  in those patient populations is, if I put them on testosterone for low testosterone, can I improve any of these quality of life factors? We don’t quite know the answer yet. I think in some of them, the answer is yes. Or in some small way, the answer is yes. So really, you know, the big contraindication is for someone with a hormone sensitive cancer like prostate cancer, who has not been treated and has bad disease.  Its going to always be this shared discussion. And for those who are actively trying to conceive or interested in future fertility, sometimes you have to be a little bit more creative when it comes to putting them on testosterone -having them bank sperm beforehand, making sure they’re on HCG, and making sure that even if we take all these measures, I might still worsen your fertility. A lot of guys understand that. And they’re like, Okay, well, let me bank beforehand. So we have a safety measure and then let’s start therapy. 

Better Man Clinics  

What type of expectations do you set for men who undergo testosterone therapy? How much better should they expect to get?

Dr Pearlman  

Low expectations.   Go with low expectations because if you would meet those expectations, everyone is happy.  That is exactly what I tell my patients. Some of my patients are very hopeful that their low testosterone is the cause of so many concerns currently going on in their life. However, low testosterone doesn’t primarily or doesn’t directly fix a relationship issue. It doesn’t take care of the kids. It doesn’t fix financial issues. It doesn’t necessarily fix sleep or poor eating habits. So while it can greatly improve how a person feels, I think some guys are coming in with expectations that are too high.  They have low testosterone and are struggling in. They believe that if they start testosterone therapy, they are going to excel in every aspect of their life, which is not necessarily the case. But in some folks, it is an absolute game changer. Because if guys just feel tired and have a lack of motivation, then all those areas I just listed are going to suffer. So, sometimes, all you need to do is improve someone’s energy and then they wake up in the morning they’re ready to go. They are productive at work. They come home and they work out. I would say I see people all along that spectrum. But the guys who come in with a lot of concerns going on in their lives, who suspect that testosterone is the sole thing that’s contributing to every aspect of their life- I don’t think they’re as happy when I start them on testosterone therapy. Now, when it comes to starting someone on therapy, I always tell them from the beginning, “I don’t want to just add medications to your medication list. So, we’re going to put you on a trial. And when I see you in three months, I’m going to ask you,  ‘Do you feel better? And in what ways? Do you want to continue therapy or do you want to come off therapy?’” And I might ask them every time they come in,  “how are you doing?”  And if at any point in that time they say, “You know what, I don’t really feel like I’m benefiting from this therapy. I’d like to come off”, then I have no problem taking them off therapy. It is always this conversation of, “do you feel like it’s worth it? Are you benefiting? Do you want to stay on? Or do you want to try coming off?”