The truth about testosterone therapy
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This is On Point. I'm Debra Becker, in for Magna Chakra Bardi. In a YouTube video made in November, 24-year-old Alex Eubank opens a package that he just got in the mail. He takes out a handful of plastic baggies holding tiny vials and syringes. It's definitely testosterone in there. Oh, man. Testosterone, cipionate, 180 milligrams slash 20 milligrams. I don't know what any of this stuff means, but I'm sure a lot of you do stuff, guys.

Eubank claims testosterone will help him build muscle faster. He's a weightlifter and social media influencer.

Testosterone replacement therapy, also known as TRT, has exploded. The American Urological Association says testing and prescriptions for the hormone have nearly tripled over the past decade. And social media is full of claims about testosterone's purported health benefits. Take this TikToker who goes by Kmartfit.

It was right around the three-month mark where I felt a massive difference. My energy levels started to skyrocket. I no longer woke up exhausted in the morning, and my mental clarity was definitely better. And here's Australian James Mantate, a self-described male online coach.

I've gained around seven kilos of lean tissue in the past eight to nine months. No fluff weight. I'm talking quality muscle. My strength has obviously shot up a ton, even in a calorie deficit. My mood is generally solid. I have a lot more focus when I'm doing just about anything. But who really benefits from testosterone therapy and what are the risks?

Joining us to talk about this is Dr. Justin Dubin. He's a urologist and men's health specialist at Memorial Healthcare System in South Florida. He's also co-host of the podcast Man Up, A Doctor's Guide to Men's Health. Dr. Dubin, welcome to On Point. Thank you so much for having me. I appreciate you having me come on today and talk about this important topic. Right, right. So before we begin, though, we should say, are there any financial arrangements or potential conflicts that our listeners should know about before we chat?

I have no conflicts financially, no. Okay, great. So let's talk about this increase in testosterone therapy that we're hearing about on social media in particular, but also there have been studies and other research suggesting that there is a lot of testosterone testing and prescriptions being given and done out there. What are you seeing in your practice?

Well, you're absolutely right. I think one thing that we know, there's a lot of data, and you've already stated it, that initiation in testosterone levels have, or testosterone treatment has tripled over the last decade for sure. And there was a study a while back showing that as many as 12.4% of all testosterone prescriptions were occurring in men under the age of 39. That study was done a while ago, and

To be honest with you, I do feel like there has been a significant increase in the last five years, especially. And I have seen it in my office. I see a lot more younger men coming in with concerns of low testosterone or men who have already been started on testosterone by other providers or other clinics.

and coming to seek additional advice. And this is something that we were interested enough in that we recently published an abstract. We're working on the manuscript where we surveyed men under the age of 40 to see their interest in testosterone replacement therapy and whether they had used it before. And

In our study, we found that about 13.5% of men under the age of 40 reported usage of testosterone supplementation of any kind, and nearly 40% of our participants considered testosterone supplementation. But why? It seems like that's very young. I was thinking this was for post-50 or talking people in their 30s. Why are they taking testosterone?

Well, a lot of it, there was concerns in our study. They were interested in energy, libido, muscle development. I do think that there has been this increase in uptick in social media usage. And I think that in many ways, social media has promoted this idea of self-improvement. And there's been, as you've already highlighted, a lot of health influencers have taken up the space in the last decade.

five or six years. Really, it feels like since COVID, where people were at home, starting to be able to focus either on their health or read more about their health, and this increase in social media had spiked. We saw this enough that I was interested in my group when I was at Northwestern. We did a project where we evaluated men's health topics on TikTok and Instagram.

And what we did is we searched various topics in men's health, including testosterone, infertility, vasectomy, something called Peyronie's disease, and erectile dysfunction. And we looked at these topics. We looked at the top posts, and we categorized them. We quantified whether they were accurate. Who were they provided by? Physicians, non-physicians, healthcare providers, non-healthcare providers. And the concerning thing was that these were not exactly accurate.

I think we lost you. Dr. Dubin, are you with us?

I think we seem to have lost Dr. Dubin's line there. I'm not sure if he is back with us or not, but he has been talking about the use of testosterone therapy and studies that he's done showing that it is increasingly common, and it is common particularly among younger men who are seeking it out for bodybuilding and other fitness reasons as well as for improved health.

And this has become unbelievably popular on social media, as Dr. Dubin mentioned. Popular podcast host Joe Rogan is among those who has repeatedly said that testosterone therapy has helped him. Rogan is in his 50s, and here he is discussing testosterone therapy on his podcast, The Joe Rogan Experience, back in 2022. I take testosterone replacement. So I'm not demonizing it. I don't think it's bad. I think it's wise.

If you want your body to perform well, I think you should get regular blood work. You should do it from a very good doctor that understands hormone replacement therapy. You should be very smart about it. You shouldn't take too much of it. But if you want your body to perform well, it wards off diseases better. It keeps your immune system healthier. The more muscle you have and the stronger your body is, the healthier your body is. I mean to a point and to get to this bodybuilding range where you just look –

obscene. And that's popular podcast host Joe Rogan talking about his use of testosterone. That's what we're talking about this hour on Point. And back with us is Dr. Justin Dubin. And Dr. Dubin, before we were cut off there, you were talking about social media and the influence of social media on taking testosterone and some of your research into that. We just heard from Joe Rogan, who talked about why he uses testosterone. What did your research suggest?

Thank you so much. Sorry about that disconnection there. So what we found on our study was that men's health topics on TikTok and Instagram were incredibly popular. We're talking about billions and billions of views. But what was concerning was the majority of the men's health topics were

were information that was not provided by a healthcare provider of any kind. And in fact, overall, the content was incredibly poor and incredibly inaccurate. What was encouraging, though, when we compared physician to non-physician posts, the physician posts were overwhelmingly accurate, but obviously not even close to as popular as the non-physician posts.

physician posts were not prevalent, only about 10% of TikTok posts and 12.9% of Instagram posts, respectively. And only about 16.8% of the educational posts on TikTok were created by physicians. So when you have this

distinct discrepancy in who is providing health information, whether it's a person who is trying to gain financial means, it's a company, or someone who's just trying to socially be an influencer. There is this

of getting appropriate, correct information into the men's health space. Right, but there's also, of course, resistance on the part of traditional medicine, right, to using testosterone for some of the health issues. So,

I, how do you balance that out, right? People do look to social media because they're not getting relief from traditional medicine and there you have it. Social media is full of disinformation and folks who may not be medical professionals. So how do they ferret that out? Well, I do want to highlight that because that is an incredibly important aspect here. So men's health

However, you know, the idea of men's health is men have issues, erectile dysfunction, low testosterone. These are all signs and symptoms of other health issues potentially going on or warning signs of other health issues coming down the pipeline.

The problem, though, when we have men's health, erectile dysfunction, low testosterone, are the things that men associate with it. These are very stigmatized things, right? Having low energy, low libido, that is not what men want to picture themselves as. When they go to these social media posts, they see these ideas of what men are and what they want to be.

And the reason why they're not going to doctors in the standard setting is because of these stigmas. Men don't feel comfortable going to a place, sitting in an office and really identifying or pointing out almost to everyone else there that they have an issue.

And this is where social media, direct-to-consumer, it provides you with the opportunity to have privacy and learn or improve your health. And I like to call this actually the IKEA problem, or I used to call it the directions problem, but I think a lot of listeners aren't familiar with not using Google Maps anymore. But the idea used to be,

And you can, I mean, I don't know how old you are, but it would be guys, you know, we had this thing. We would never ask for directions. We would drive around for hours and hours, right? And that was the old joke. We were going to figure it out on our own. If it took us three hours longer, we were going to figure it out. And now I translate that to the Ikea problem, right? Where as a guy, I'm going to go to Ikea. I'm going to buy a piece of furniture. I have the instructions in front of me.

I'm not reading the instructions. I'm going to figure this thing out by myself. It's going to come out maybe three hours later. It could have taken me 45 minutes. The chair is going to be a little bit wonky when I sit and it's going to bother me after about a week. Then I'm finally going to go back, read the instructions and fix it. And this is what guys are starting to do with their health.

They are going online in the privacies of their home. They want to fix the problem themselves. They want to do it in the privacy of their homes because they don't want to announce to the other people around them, their friends, their families, that they have this issue. Okay. We're going to just pause for a moment to take a break. We're talking about testosterone therapy. We're going to be talking more about that and about some of the risks when we come back. I'm Debra Becker. This is On Point.

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This is On Point. I'm Debra Becker. Today we're talking about the growing popularity of testosterone therapy. Dr. Justin Dubin is with us. He's a urologist and men's health specialist at Memorial Healthcare System in South Florida.

Also with us is Dr. Abraham Morgenthaler. He's a Blavatnik Faculty Fellow in Health and Longevity at Harvard Medical School's Beth Israel Deaconess Medical Center. He's also a urologist and helps treat testosterone deficiency in men. Dr. Morgenthaler, welcome to On Point. Hi, Deborah. Great to be with you. So before we start, as we asked Dr. Dubin, I'd like to ask you as well, any financial arrangements or potential conflicts that our listeners should know about before we chat?

Yes, I've received consulting and speaking fees from Marius Pharmaceuticals and Besson's Healthcare. And they help make testosterone medications. Is that right? Correct. Okay. So, but that does not pose a conflict, at least in terms of what you'll be telling us today during this conversation.

It does not. I don't have stock or anything like that. It doesn't matter to me whether those companies do well or poorly. Okay, great. So on to the conversation. We were talking with Dr. Dubin about this unbelievable rise in the popularity of testosterone therapy. And he says a lot of folks are looking to social media to get advice about their health.

And some of that advice may not be great. Would you agree with that statement? And why do you think we're seeing so many more people taking testosterone or engaging in testosterone therapy?

You know, Debra, I've been studying testosterone for, it's amazing to say, 50 years, my entire adult life. And for most of that time, especially once I became a physician and started treating patients, I was busy advocating for physicians to pay more attention to what I call testosterone deficiency, which is the preferred term now.

And we were finally making some headway. And now we have the situation where testosterone is having a moment, if you will, where it's being advertised everywhere and often for the wrong reasons.

And whereas I've been kind of pushing in one direction, I listened to the ads that you played at the top of the show and I just cringe and recoil in horror because the problem is, is that we're confusing and these ads confuse two separate issues.

One is the true medical condition where men suffer from having too little testosterone. It can affect them sexually, it can affect their mood, it can affect their vitality, their quality of life, and it's bad for them in terms of general health. And then we have these ads that are saying, let's add muscle. One of the ads that you played, I think from Australia, the guy mentions that he gained seven kilograms of muscle. That's about 15 pounds of muscle.

And I just have to tell you that the men that I treat, and I'm sure Dr. Dubin treats too, where we're trying to just normalize healthy, youthful levels of testosterone will never cause 15 pounds of muscle mass.

The only way you do that is by overusing, using incredibly high levels, not just of testosterone, but usually the guys who are doing that, looking for this muscle growth and muscle development, are stacking medicines. They're using multiple agents at a time, and some of those anabolic steroids are more potent.

than testosterone. So we've confused the younger guys who have this idea in their head with bodybuilding and looking fantastic and muscular and ripped with a condition that is really very important associated with a host of important medical conditions like diabetes, obesity, osteoporosis,

And they're not the same. And we need to be able to make that distinction. Well, I wonder, though, aren't there regulations about some of these promises? I just, you know, can anyone go on social media and claim that you can gain 15 pounds of muscle mass if you take this? And I mean, what are the rules about how that should be done?

Well, I'm not an expert on what people can post on their podcasts and stuff. But physicians are limited. Testosterone as a therapy is a controlled substance, just like narcotics. So doctors have to jump through a bunch of hoops in order to prescribe testosterone.

And on the whole, you know, what we want is for the doctors to be doing a good job identifying men who have the symptoms consistent with the deficiency, doing the appropriate blood tests, treating to appropriate levels, but not excessive levels, and then monitoring carefully the men so that they don't get into any of the health issues that are associated with that.

If there's a blogger out there who says, hey, I did this, I don't really know what governs his ability to say that. But, you know, we have like part of this moment, I think, does come because of these social media influencers. And there's been a state I got interviewed by recently, just in the last few weeks, by a number of national media outlets. And I said, what's going on? Did I miss like some big study or something? And the thing that precipitated it all was

was that RFK Jr. said on a podcast that he takes testosterone. We actually have a clip of him saying that. So let's play that right now. This is Robert F. Kennedy Jr., newly confirmed Health and Human Services Secretary. He was interviewed on the Lex Friedman podcast in 2023 where he talked about his diet and exercise routine and mentioned testosterone. I'm on an anti-aging protocol from my doctor,

That includes testosterone replacement, but I don't take any steroids. I don't take any anabolic steroids or anything like that. And the DRT I use is bio-identical to what my body produced.

So, Dr. Morgenthaler, that is RFK Jr., newly confirmed Health and Human Services Secretary, talking about his use of testosterone. And you said you got a lot of national media calls recently when he had brought it up again. I'm wondering, what advice do you give to folks when there is so much talk about the use of testosterone and how it might be beneficial? And how can they figure out if it might be something that might help them?

I'm just shaking my head as you played that clip because testosterone is a steroid. A steroid is just a chemical structure. Estrogen is a steroid. Cholesterol is a steroid. But testosterone is also a steroid.

And it is anabolic, even though he says it's not. Anabolic just means that we build up muscle and bone. That's what anabolism is. And so technically, testosterone is an anabolic steroid, but it's not the usual ones that people talk about for bodybuilding or doping in athletes. So there's just that. But listen, so on the one hand,

There is something really marvelous that's happening where there is now a conversation that's happening where regular folk are saying, geez, I wonder if I have something that would be part of the reason I'm just feeling so poorly, not getting up off the couch. I used to be active. I used to enjoy lovemaking with my partner.

Maybe could that possibly be related to testosterone? So for that reason, I'm delighted because there's been way too little awareness of that. And there's a lot of physicians, you know, sort of the mainstream medical community has been reluctant to embrace the incredible evidence we have now about the benefits and safety of testosterone.

So that part's great. It's the other ones where people say, oh, you can be amazing. It cheapens the whole testosterone story with some of these ads and makes it sound like they're being promised something.

something that is impossible. Dr. Dubin, I want to just make sure that we clarify this as soon as we can. Testosterone can be used for some of the things that we've heard both of you mention sort of in passing, low energy, erectile dysfunction, cognitive or brain fog, if you will, folks just not feeling like they have enough energy. It's also said to improve

bone density, to help people who are dealing with or prevent obesity. Are those sort of the big things that testosterone is expected to help? Well, yeah. So testosterone is the male hormone. So it does play an impact on a lot of these things. And as Dr. Morgenthaler, who has done

more research than anyone on testosterone can agree with. We continue to see unknown benefits or newer benefits that we didn't really highlight in the past. We know that low testosterone is associated with cardiovascular risk. Now, it used to be the opposite way where we used to think it caused heart attack or stroke. We know that's no longer the case.

We know that having low testosterone puts certain people at risk for other comorbidities. We know that if you have things like diabetes, obesity, cancer history,

You're at higher risk for having low testosterone. In fact, there's been other data suggesting, especially in the orthopedic surgery space, the recovery process after surgery, there's higher risks of complications or a slower recovery in patients who have lower testosterone levels. So a lot of the things that you have mentioned absolutely can improve recovery.

with testosterone replacement. But it is, when you highlighted before, muscle health, bone health, heart health. There are so many things that all play along. It is a pretty well-rounded hormone in impacting your health. It seems very similar to what we're hearing about in terms of estrogen therapy for women. Would you say that it is quite similar? Yeah.

I do think, you know, that's why they have termed this, there's this term of menopause and, you know, we're talking about a menopause and we do know that estrogen is very important in women, obviously. And we've also started to understand the importance of estrogen in women even after menopause and the benefits that can continue to have, even though there was controversy for a long time on

that. And, and the same goes with, with testosterone, right? Uh, testosterone can decline as you get older. We know that the rates of testosterone, uh, declined the Baltimore longitudinal aging study showed that high, low testosterone levels increases with age about 20% in their sixties, 30% in their seventies, 50% of men in their eighties. There's been several papers showing that men under the age of 40, about 20% of guys have low T. So, and, and

And to be honest, I wouldn't be surprised if some of these, these are older studies and as a society, we've never been really more sedentary. We've never eaten worse. And these are things that can compromise our overall health.

What we do to ourselves, how we live our lives, our lifestyles, our diets, our exercises, all impact our health. And that can impact what we like to say as urologists, what's good for your heart is good for your parts and vice versa. So these are all important things that, you know, when people say, why are we having lower testosterone levels? Why are people complaining of testosterone? Why are we having these fertility issues? Well, we have to look at the big picture and we have to say, hey, listen,

how good are we taking care of ourselves and how can we do better? Let's talk about some of the risks of testosterone use first before we get into sort of some of the why there might be such a huge surge right now. And Dr. Morgenthaler, I'd like to ask you this. I know that, you know, we've sort of mentioned or Dr. Dubin said there's no longer the belief that there's a significant cardiovascular risk from taking testosterone. But

I wonder what are some of the risks? Is infertility, prostate cancer, all the things that we had heard about before from taking testosterone, are those still somewhat of a risk for folks who might be using this for some of the health issues we mentioned?

So the big bugaboo for 80 years has been the fear that testosterone increases the risk of prostate cancer. It's an amazing story that really started in 1941 with a fellow named Charles Huggins, who later was awarded the Nobel Prize. And he discovered that in men who had metastatic prostate cancer, that if he removed the testicles, which is the source of the testosterone,

that this blood test that they used back then called acid phosphatase would go down. And he wrote that in every case where he gave testosterone, that blood test would go up.

And because he wrote that and he became the preeminent authority in prostate cancer, for 50 years there was a global prohibition against the use of testosterone. Everybody was certain that it would cause cancer almost as soon as a man got a whiff of testosterone. They get prostate cancer. I was a resident in my training in the 1980s and this was like a certainty. We never gave testosterone.

And a lot of my work has been in the prostate cancer area. And I started with this because I had worked with lizards as an undergraduate for three years, putting testosterone in their brain to see if we could regulate the male sexual behavior in the lizard. And it worked even in the males who didn't have testicles anymore. And I won. And this was 10 years. I came out 10 years before Viagra showed up.

And there were men who were desperate around sexual issues. Doc, you got to have something you can give me. And I wondered whether men might be like lizards. And it turned out that they were. I gave them some testosterone. And what was fascinating was that their sexual symptoms improved, which now is extremely well established. But I heard the men saying things that I had never expected. Things like, my wife likes me again.

I wake up in the morning, I swing my legs over the side of the bed and I feel optimistic about my day. I haven't felt that way in 15 years. A guy with four small kids says, I come home at the end of the day and I've never, you know, I used to be, I play with my kids, but man, I was just beat and I've never had so much patience to play with them.

So that was a real thing. And as I started treating men with testosterone because of these rather remarkable benefits, but only if they had low testosterone to start with, that's important. My patients didn't get prostate cancer. And I published with my colleagues a number of papers on that. And that whole story has been challenged. And then in 2023, I think comes really the definitive study. It's called Traverse, largest randomized control trial ever with testosterone.

And it showed number one, what Dr. Dubin was mentioning that cardiovascular risk was no greater in men who got testosterone than in men who got placebo. And also that the prostate cancer risk was identical

in men who got testosterone and men who didn't. Testosterone didn't increase it. So prostate cancer, I think, should be done. That's not a risk anymore. But so then the risk, and we only have about a minute here, the big risk then is not prostate cancer, not cardiovascular disease, but perhaps blood clotting, correct? Because your red blood cells increase, perhaps infertility. Tell me what the main risks are for folks who are taking testosterone.

So here's what they are. So if you take testosterone, it shuts down basically the male reproductive system. So you stop making sperm or very much sperm. Testicles get smaller because much of the size of the testicles devoted to making those sperm. Young guys can get pimples or acne that they may not have seen in years.

Some men can get some fluid retention, especially older men where they see like their ankles can swell a little bit. It's not associated with heart failure. It's just a thing that rarely men can get some swelling of one or both breasts. We call that gynecomastia. It's reversible. It goes away if you stop it. And then the one concern is that you can get an increase in your red blood cell count, whether that's really associated with

Blood clots or not is yet to be determined. All right. Well, we'll talk more after a break. We're talking about testosterone therapy. I'm Debra Becker. This is On Point. Have you ever spotted McDonald's hot, crispy fries right as they're being scooped into the carton? And time just stands still. Ba-da-ba-ba-ba.

This is On Point. I'm Debra Becker. A quick word now about a show we're working on for next week. It's about the surging popularity of weight loss drugs such as Ozempic and Wegovy. As many as one in eight Americans have been prescribed these drugs, according to a recent study. And it's been reported that the drugs can treat other disorders, including alcoholism or other addictions. So if you're among those one in eight, we'd like your help.

What is your weight loss drug story? What made you decide to take Ozempic or Wegovy or another form of the drug? How did you get your prescription and what was it like being on these medications? Did it work? How quickly? And what about if you are no longer taking them? Share your experience by recording a message in the On Point VoxPop app. If it's not on your phone already, just search for On Point VoxPop wherever you get your apps.

You can also leave us a voicemail at 617-353-0683. That's 617-353-0683. That's for next week. Today we're talking about testosterone therapy's increasing popularity and health claims about it.

Testosterone Therapy. We're joined by Dr. Abraham Morgan-Taller. He is a Blavatnik Faculty Fellow in Health and Longevity at Harvard Medical School's Beth Israel Deaconess Medical Center. And before the break, we heard from Dr. Dubin about some of the risks of testosterone therapy. And we heard actually from you about some of the risks of

from testosterone therapy. And I'm wondering if there are others that you would add to. You mentioned red blood cell counts and fluid retention and acne. Are there other risks that folks should be aware of if they are considering testosterone therapy?

You know, I think that Dr. Morgenthaler really did a great job of highlighting the risks involved. The one thing that I always ask a lot of patients and one thing that we hear a lot is like, why can't we just keep going higher? And a lot of these risks don't come at therapeutic levels. And I think that that's the important thing to highlight that Dr. Morgenthaler said in the beginning, right? We are trying to treat patients who are deficient. And

And the analogy that I like to use when patients ask me this is, believe it or not, I say heroin. And while I say probably heroin feels good, but does more heroin feel good?

feel better? Yeah, probably. Is it good for you? Probably not. So I'm not saying obviously that testosterone is something that is bad, but more does not always equal better. And when we really go to supra therapeutic levels of testosterone, that's where we start to see people complaining of these things.

And a lot of the people that we see on socials, like Dr. Morgenthaler said, are people who are probably not just on testosterone. They may be promoting a company or some product.

that is testosterone, but it's very possible that they're on other things. Now, the one thing that I always, I also treat a lot of male infertility, is I really want to highlight this idea of infertility in men. Because as we've already established, a lot more younger people are seeking out testosterone replacement therapy. So,

The data shows that about 65% of men with normal sperm become sterile just within about four months of using testosterone therapy. So, you know, the good news though is if you are taking it, you know, you can recover. But this recovery time really depends on how long you're taking the medication. The longer you're on it, typically the more dependent you become on the medication and the longer it takes for your testicles to reboot.

The data shows in general about 90% of people have return of sperm to their ejaculate, which is not the same as having normal levels at about 90%, about 12 months after, about 100% at 24 months. But the thing here is that a lot of the data shows that

Compared to your pre-treatment semen parameters, you can get at best about 85%. Now, a lot of these younger guys don't know what their semen parameters are prior. They don't know their fertility status. And they're also not aware of this risk factor.

So I can't tell you how many guys I've seen who have been trying for fertility for two years with a partner who came in after two years and I'm asking them what they're taking and they say testosterone therapy. And they were never informed of that. We do a semen analysis. It's either very low or zero. And then we have to do a recovery protocol. Now, education in these situations is key, right? You know, would these people have gone on true testosterone replacement therapy?

if they knew that their goal later on in life was to have children. There are alternatives, things like Clomid and HCG, and Clomiphene has become more popular, especially on the socials. But these are ways to increase your testosterone and preserve your fertility. So it's not taking testosterone. It's ways to make your body increase the amount of testosterone or increase your testosterone levels.

Correct. You are preserving your fertility by stimulating your testicles to create more testosterone and potentially even improve fertility in people who have low testosterone, who come see me, young men who want to preserve their fertility, who have...

you know, testosterone deficiency. These are the things I offer them. I never offer them true testosterone replacement therapy because of the information that we have discussed. Now, the one thing I do want to highlight is we were seeing enough of this where a few years ago at Northwestern, I did a secret shopper study where I pretended to be a patient at these direct to consumer companies. I went through seven different companies,

all that were presenting, you know, providing care to 50 states. And I pretended to be myself. I was a 34-year-old man at the time. And I had a script. I had the signs and symptoms of low testosterone. However, I did say that I wanted to preserve my fertility. And at the time, I went through the blood work. And we had not established yet, I think, on this podcast that

testosterone levels per our guidelines AUI are 300 is considered low my testosterone levels at the time were 675 clearly not a good candidate when you combine my testosterone levels with my desire for fertility now having said that

About six of the seven companies offered me testosterone replacement therapy, and only half of the companies discussed fertility risks with me. So obviously, one thing that I really do want to highlight is this fertility concern, because we need to educate our patients. We need to educate people interested in testosterone replacement therapy that they know these kinds of risks before taking these kinds of medications.

Had you not been so aware of, you know, testosterone and testosterone therapy, I mean, could that have been dangerous if you had actually taken that level of testosterone?

So, you know, it's a good question. And I would love to hear Dr. Morgenthaler's opinion on that after I answer. But I think the answer is we still kind of don't know. We don't have many studies looking at putting people who are normal levels of testosterone on testosterone and what happens. Right.

But what is concerning when I asked in these clinical settings, what was your testosterone level goal for me? Because as a patient, I get that question all the time. And several companies would say we're going to keep going higher until you feel where you want to feel. Some were saying 1,200, 1,200.

1,500. And these are, as Dr. Morgenthaler would agree, super therapeutic. We really don't want to see above 1,000 is where our cutoff is. So obviously, I don't know, and I would love to hear Dr. Morgenthaler's thoughts on this, but we just don't know at this point. But

Okay, let's hear from Dr. Morgenthaler. What do you say about potential risks of someone who has a normal testosterone level and may in fact take testosterone, which according to Dr. Dubin's secret shopper study, that may not be all that difficult?

Yeah, that was a good little study. It really points out some of the issues. Listen, the first thing around that story is that the men who don't have a low level of testosterone do not have a medical condition. And therefore, as a physician myself, there's nothing for me to treat them for. Like they're not who we really want to be treating with this medication testosterone.

There are studies, but they're kind of more really about looking at sort of what's the effects of these very high levels in men. There are only a few, but they've looked at men who got like five times the normal upper limit of normal of testosterone for usually for short periods of time.

And, you know, they gain a lot of muscle. That part is real. And in those short studies, they really haven't found much that's troubling. But most of the stuff that goes on goes on without ever being studied. Right. So the bodybuilders and all that, there used to be anecdotal stories of them having like arrhythmias and hyaluronidase.

heart attacks in these young people. It's hard to know from those anecdotal things. The part that concerns me the most around all this as we focus on the young guys who are healthy without testosterone

And the thing where this program could play a very important beneficial role is that there are plenty of men who are listening right now or their partners who are concerned about them or daughters of their fathers who recognize that something has changed in their male relationships.

partners, father, sibling, whatever. Like something's different about them. These people who used to be active, engaged, full of personality may have become withdrawn. They're not doing the things that they used to enjoy. They've become grumpy old men before their time.

And what's important to get out there is that most doctors have a testosterone test is not part of the normal blood test routine that we get, like it's your annual event, annual physical or whatever.

And a lot of the medical community still is stuck in olden times with the fears about prostate cancer or more recently cardiovascular issues. Or they think that testosterone is just related to muscle, which is how we've been described, how these promotional stuff goes on. And they say, I don't want any part of that.

It's like this is fringe medicine. And it's kind of this anti-aging aspect in the clip with RFK Jr. sort of talked about. He said, I'm on an anti-aging regimen.

And doctors hate that. You know, one of the first things we learn in medical school is beware of anything that smacks of snake oil where you're going to get all these benefits. If it's too good to be true, it's too good to be true. It's not real. Right. And yet there is something the guys who have low testosterone and go on treatment.

will not infrequently say, I feel younger. Right. And we should say there are women taking testosterone as part of hormone replacement therapy as well. It's not just estrogen for women. Absolutely. Are there different risks there for women when they're taking testosterone? There are some. But before we get to risks, what you're saying is very important. So women also have testosterone.

And women can also become deficient in testosterone, especially in the perimenopause and in the postmenopausal years. And testosterone, the benefits are the same in women as they are in men. Has to do with sex drive and energy and fitness and strength and loss of fat. Probably has effects on appetite, not well studied, but anecdotally, that's what we hear. People sleep better.

So there's plenty of benefits in women, though. Testosterone, you know, is the hormone that's responsible for puberty in in males, adolescents. And it does that by doing what we call mesen virilizing the individual, making them more manlike, if you will.

So women who are getting too much testosterone are prone, even though they're well through puberty, can be susceptible if levels are too high to getting dark hairs on their chin, right? Like almost like a beard, the voice can deepen, the clitoris can enlarge. So there are things that women have to be more careful about than men do. Mm-hmm.

And I wonder, Dr. Dubin, if you can tell us also what folks might want to know about if they are considering testosterone, and it is becoming increasingly prevalent among men and women, is, you know, some of the other potential pitfalls here. Is there any risk of addiction or dependency? And we have just a few minutes left.

No worries. So it's an important question. And I think the idea of addiction, I would say, does not exist for testosterone replacement therapy. However, dependency does exist, right? When you take what we say is exogenous testosterone or testosterone coming from an outside source, whether you're injecting it, putting on a gel or a pellet or an oral version of it, you are signaling to your brain that you are making enough testosterone.

And when your brain makes that read, it stops the signal to your testicles. There's two hormones, FSH, follicle stimulating hormone, is the hormone your testicles receive from your pituitary to make sperm. And LH is made by your brain, luteinizing hormone, the hormone that your testicles receive to make testosterone. That signal pathway gets shut off. Why? Because your brain thinks you're making enough testosterone. So...

That's where this cause of fertility and shrinkage of your testicle comes because you're not feeding your testicles anymore. Your testicles can atrophy and they're not functioning to produce testosterone and they're not functioning to produce sperm. So the longer you're on testosterone is the longer risk of becoming what we like to say is dependent on it.

Now we have a lot of different guys who can come off and I've seen guys come off who end up getting normal levels and live their lives normally. I have guys though who have been on it for a year and we sometimes call this a burnt out testicle. You know, they just cannot create testosterone anymore.

And they require it for the long term. But you have to understand the longer you're on it, that's more likely to happen. Okay. In our last minute here, I want each of you to ask each of you what advice you would give to folks who are trying to, you know, decipher all of this information. Obviously, it sounds like a miraculous cure-all for many things that folks

might like to feel better, might like to have more energy. Yet there are things that people should be aware of. One sentence to each of you. What advice do you give to people who may be looking at testosterone therapy? Dr. Morgenthaler, let's start with you.

I would say to men or to their partners listening in that if you feel like there's something that's wrong and it's not everybody's tired, it's not just the usual tired. These men feel depleted and unable to do their normal things. If your sex drive has disappeared or greatly weakened, that's not normal. And my advice is get a blood test for testosterone, total testosterone less than 350 or a calculated free testosterone less than 100 picograms per mil.

is an indication for treatment. Okay, Dr. Dubin, you've got about 10 words now. What's your advice? Okay. Always ask who you're getting your care from. Ask what their motivations are. Ask how are you getting that care and what's the benefit from you. Ask their backgrounds and understand their care. Dr. Justin Dubin, a urologist in Florida, thanks for being with us. Also, thanks to Dr. Abraham Morgenthaler,

who is with Harvard Medical School's Beth Israel Deaconess Medical Center. Thanks to both of you. I'm Deborah Becker. This is On Point. Support for this podcast comes from Is Business Broken?, a podcast from Boston University Questrom School of Business. A recent episode offers a primer on executive compensation. Listen on for a preview. Here's BU Questrom professor Charlie Tharp. The whole basis of executive compensation is really...

The idea of what's called agency theory. Shareholders don't manage the company. They can't observe what executives do every day. So they rely on a board to use compensation to try to align the interests of CEOs and other managers with the people who own the company, the shareholders. And how do you do that? By making a lot of their pay contingent upon increasing the value of the company stock over time.

And for, I would say, the vast majority of companies, they require executives to personally own a significant stake in the company, shares they actually own. For a CEO in a big company, the requirement's usually six times salary. So a CEO would have to hold, while they are CEO, personal ownership of at least $9 million, as an example, in company stock.

So you've got incentives aligned with shareholders. You have skin in the game through ownership by CEOs. And it's all meant so that they're doing things that are in the best interest of shareholders. Again, agency theory, they're the agents of the owners.

Find the full episode by searching for Is Business Broken? wherever you get your podcasts. And learn more about the Marotra Institute for Business, Markets, and Society at ibms.bu.edu.