Real Benefits of Male Hormone Replacement

anabolic steroid bodybuilder
Testosterone: good for your health or good for a healthy look? (Courtesy: Unsplash)

Is testosterone therapy really all it’s cracked up to be? Does it really help your sex life? Does it actually help you live longer? Is testosterone the medicinal Holy Grail for men? And how, pray tell, have we come to believe that anabolic-suffused competitive bodybuilders, those (spray) tanned Adonis’ with ripped, ballooned muscles everywhere, are truly “healthy” when in fact they are not: their mortality rate as young men is unspeakably high. Yet there are those, including my patients, who swear by testosterone as the secret sauce to their quality of life. They just wouldn’t be the same without it. So, maybe the 1st Century BC Roman poet Lucretius was right when he said that one man’s cure is another man’s poison.

“Vitamin T” Benefits

What does testosterone actually do? During development, it helps male fetuses develop male genital organs. At puberty, it turns boys into men by helping them grow tall, build muscle, and become fertile. In adult men, it maintains fertility and sexual function, and preserves muscle and bone mass. The best data on the benefits of testosterone come from The Testosterone Trials, a group of 7 double-blind trials in 788 men. These men averaged 72 years old and had very low testosterone levels, which were boosted to levels considered the mid-normal range for young men and followed for a year. Here what testosterone did for them:

  • Sexual desire, erections and sexual activity increased.
  • Improved mood, lessened depressive symptoms, but did not increase energy.
  • Increased 6-minute walk distances.
  • Improved blood counts.
  • Improved bone density and bone strength.

This all fits in with my analogy that, like oil in an engine, testosterone keeps things running smoothly as we age. Likewise, when the “oil” of testosterone is low, you could say that the engine wears out faster and doesn’t work as well or as long as it should. Note too, that when testosterone levels are truly low in much younger men, we would expect more benefit than that obtained in the older men in the T-Trials.

Testosterone: Myths

Clearly normal testosterone levels are good for the body. But what testosterone doesn’t do is also worth noting:

  • It’s not a common cause of either erectile dysfunction or low sex drive.
  • By itself it will not help you build muscle or lose fat.
  • It does not increase energy levels substantially.
  • It will not help you live forever.
  • It will not get you more dates or make you a sex machine.
  • It will not make you taller as an adult.

The Small Print

There are a lot of ways to take testosterone these days: applied gels or creams, injections, implants, patches, buccal adhesives and most recently, pills. However, if you’re considering taking testosterone, also consider its potential side effects and complications:

  • Fertility will be impaired as testosterone supplements are effective contraceptives.
  • Testicles will become smaller and softer.
  • Blood counts can increase, leading to thick blood, leg clots and strokes.
  • Male pattern baldness will be accelerated.
  • Breast enlargement and tenderness.
  • Acne can return. Skin may become oily.
  • Sleep apnea and prostate enlargement may worsen.
  • Monitoring for prostate and breast cancer is more important.
  • Possible increased risk of heart attacks.

Doctor’s Orders

In my practice, this plethora of pluses and minuses are applied to each patient considering testosterone replacement. I also perform a root cause analysis to decide whether the symptoms might be due to a dozen or so underlying (and treatable) medical conditions that can mimic or result in low T. It’s also impressive how often simple lifestyle choices that encourage exercise, healthy eating and adequate sleep may “cure” symptoms that were attributed to low T. The bottom line is taking testosterone is a serious commitment to a serious medication and needs some serious thought and so I urge you to consult with an expert before beginning this medical odyssey.

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The Best Medicine for Humans is Humanness

Fishing boats, Soumbedioune beach
(Photo courtesy Jeff Attaway; Wikipedia)

I have to say that I have led a truly privileged life in medicine. Throughout my long and storied education as a physician and caregiver, I have stood on the shoulders of many great mentors. In high school I had teachers who imbued biology and physics with wonder, awe, and hard-to-see logic. And then there were those Yale college professors who demanded critical and astute thinking in all things spoken and written. Finally, my mentors at Stanford Medical School taught me the sheer beauty and magnificence of human anatomy and physiology. Yes, they all shaped how I now think about medicine and disease. But it was my time in Europe and Africa that really taught me the way to actually heal patients. It was there that I learned that the patient is the “book,” and they need to be “read” accurately to best heal what ails them.

Watch The Dance

I remember the time a Sheikh was evaluated at Stanford while I was a student there because his leg went weak while dancing. After several blood tests and fancy scans, he was told that he had a 1 cm brain lesion in his cerebellum which is likely due to multiple sclerosis. Then, 6 months later, while I was taking an away rotation in neurology at Queen’s Square in London, England, that same Sheikh was seen for a second opinion. This time, after simply receiving a series of physical exams by master clinicians, he was told that he had a 1 cm lesion in his cerebellum and that he had multiple sclerosis. The diagnostic power of a well-performed physical examination was now forever etched into my nascent medical mind.

Better to See Than Look

And then I took it a step further. What was medicine like in Africa, where fancy scans and blood tests might not be available? After months of research and dozens of letters sent (sorry no internet), I secured a clerkship rotation in general surgery at Hôpital Aristide Le Dantec in Dakar, Senegal, a large public hospital in West Africa. And it was there that I learned the true power of observing and “reading” patients. Like the time an extremely ill child was diagnosed with typhoid fever and small bowel perforation based solely on a fever curve and abdominal exams. Or when I watched a surgeon diagnose acute appendicitis rather than kidney stones by simply observing the patient from his bedside for several minutes as he lie still like a board, instead of exhibiting the constant, writhing, restless pain characteristic of stone disease. Yes, I learned that patients, like books, can be “read,” like a mystery novel with clues, to help solve the riddle of disease.

Look. Listen. Feel.

What stuck with me through these experiences around the world was the enormous value that the power of observation holds in medicine. It’s really the essence of holistic medicine. Use all your senses to make sense of disease. Look. Listen. Feel. Perceive and learn from basic human observation and interaction. No doubt, we “look” all the time—Tik-Tok videos, TV, traffic, phones, clocks and the like—but how often do we actually “see” and “observe?” In the words of Publilius Syrus: “Observation, not old age, brings wisdom.” And so it seems that the best way to take care of our fellow humans is simply to be human.

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When Should a Man Check His Fertility?

Men’s Fertility Clinic, Turek Clinic
The Holy Grail of health care is prevention. (Photo by Dawn McDonald on Unsplash)

Having practiced medicine for almost three decades now, I’ve learned quite a few things.  As one who always seeks to improve, the one thing that I would most like to change in our healthcare system is its “defensive” orientation. Medicine spends too much time reacting to health problems after they occur, like treating kidney stones and cancer. Medicine desperately needs to become more “preventative” in nature. In my view, identifying risk well before it becomes disease allows for disease prevention, and that my friends is the Holy Grail of medicine.

In the Box

People know this. That’s why they take $360 billion of nutritional supplements annually in the US alone. And maybe that’s why over 100 million individuals have mailed off their spit or blood for personal DNA testing since the technology was introduced 15 years ago. Many of us really want to know what might happen to us as we age. Along these lines, I’d like to propose another preventative measure: consider checking the fertility of young men before they consider family building.

Out of the Box

Why check young men’s fertility potential? Well, it can tell us a lot about their fertility potential and that may change how and when they approach family building. Equally importantly, a man’s fertility potential is now known to be a biomarker of his health. And not only his current health, but his future health.

What Does Being Infertile Mean for a Man?

The same lifestyle choices that make you healthy also keep you fertile. Here is a summary of the risk that being infertile brings to bear on a man’s health:

  • 30% increased risk of cardiovascular disease
  • 150-300% increased risk of cancer
  • 120-1000% increased risk of chronic disease
  • twofold increased risk of early mortality

How do I see this fertility check happening? Well, the lowest hanging fruit to grab would be to check a semen sample. Traditionally requiring a doctor’s order, my belief is that laboratory-certified semen analyses give better and more information than simpler over-the-counter sperm check kits. Luckily, high quality semen analyses can now be done from the comfort of your own abode through on-line, mail-in companies like Legacy. The best checkup would also involve a visit with a reproductive urologist for a good old-fashioned medical history and physical exam (it doesn’t hurt!) and an interpretation of the semen analysis, because the sperm count alone does not make or break the man. Bowing to the COVID pandemic, even a virtual visit or telehealth visit with a urologist would be better than no visit. And that’s it. Really.

I see the pre-fertility check for men as a neat way of instilling a little preventative care into the half of our species that for the better part of their lives, feels nothing if not immortal. As the old proverb goes, an ounce of prevention is worth a pound of cure.

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