ZACH MOORE: Welcome to On Health with Houston Methodist. I'm Zach Moore. I'm a photographer and editor here, and I'm also a longtime podcaster.

TODD ACKERMAN: I’m Todd Ackerman, I’m an editor here at Houston Methodist.

ZACH: Great. And Todd, how concerned are you with your testosterone levels?

TODD:  You know, I have no idea what my testosterone level is. I’m sure it’s declined since I’m not a young man anymore, but I don’t think I have any of the classic symptoms, so I don’t really worry about my testosterone. But the issue interests me when we decided we wanted to do a podcast on this, I put my hand up for it because in my newspaper medical reporting days, I covered the issue my share. A study about the surge and popularity of testosterone, about 10 years ago.

ZACH: Okay.

TODD:  Found that a lot of the users were younger people, getting testosterone without any sort of test of their blood levels. And this was accompanied at the time by a lot concern about possible health risks from testosterone. What I wrote about was more a lot of those concerns, mostly heart related being debunked.

ZACH: Now, these are people who are just going down to like a shop, and like an exercise shop or --

TODD:  Shady clinic or getting on the black market, somehow or something like that.

ZACH: Not like a – not going to your doctor or getting a prescription and this is what we’re talking about.

TODD: Right. I know I’m in the group now, where about two thirds of people my age have low testosterone, but again, it’s not something that I ever thought I was feeling the symptoms of.

ZACH: Yeah, I mean, there’s a wide variety of symptoms for that. Talk about being marketed online, and we’ve talked about that this season on podcasts. I feel like that’s something that I get marketed at. Where like, “Oh, you’re just in that beginning of that age range now, where you might, you know, need something like that. So, I feel like I’m inundated by things online about it.

TODD:  Yeah, you know, I get a lot of that with certain things in my life and for some reason, I haven’t got it with low T. But I certainly see those commercials on all the time. Which make it sound great.

[Laughing]

ZACH: If I have any of those problems, then I definitely know where to go.

TODD:  Yeah, exactly. But I kinda see this as the first of a two-parter. Next week, I know we’re doing menopause, low T has been referred as the male menopause, or “manopause,” just because testosterone is to men as estrogen is to women.

ZACH: The manly hormone.

TODD: Yes. And one of our colleagues particularly likes it when I refer to it as the manly hormone.

ZACH: And I think testosterone might be getting a bad rap, right, because I think there are certain stereotypes about it, and that’s something we’re gonna talk about today with our expert correct?

TODD: Correct. I think that’s a myth perpetuated by like, TV, media…

ZACH: So angry with their testosterone.

TODD: Yeah, I don’t think that is – a lot to do with what testosterone really is. But we’re gonna get some answers about that from Dr. Nathan Starke, who’s a urologist and the Director of the Men’s Health Center at Houston Methodist.

ZACH: Alright, let’s get into it.

[ Sound effect signaling start of interview]

TODD: How popular is testosterone therapy, I mean, how great is that demand? I can remember a study about a decade ago about use having tripled in the past decade. So, is that still going on, or has it plateaued?

DR. NATHAN STARKE: What’s interesting about that is the tripling was from the early 2000s into, I want to say, 2011, 2012, after which FDA put out a black box warning, a warning about cardiovascular side effects, heart attack, stroke, things like that, that then caused the number of new prescriptions to decline. And so, it hasn’t kept up on its rise and trajectory from back then, but at least from my view point, in my office, it certainly seems like it’s intensely popular, although some places don’t quite follow the rules in the same way as others.

TODD: So, talk with us a little bit about what testosterone is, I think a lot of people associate it with kinda machismo or roid rage. What role does it really play in the body?

DR. STARKE: Testosterone is the male sex steroid hormone that governs what most people would call “masculine traits.” Things like muscle development and sex drive and energy levels, and in men, erection function. It has a reputation, certainly, when comes to the whole roid rage concept of being related to the worst of the masculine stereotypes of excessive rage, or aggression, or violence, but realistically, when overseen by a proper provider, physician, side effects like that are extremely uncommon, what it really does is it enables men to behave like properly functioning men.

TODD: Women need testosterone as well?

DR. STARKE: Yes. Women need some testosterone in the same way that men also need a little bit of estrogen. And in fact, more and more these days, women are getting supplemental testosterone in much lower doses than men do. There have been significant benefits noted, even though it’s officially off label, in terms of things like sex drive, fitness, muscle development, loss of body fat, almost like fostering some of the masculine characteristics to a woman typically who’s in her 40’s or 50’s or older.

TODD: And also part of gender affirming care in trans?

DR. STARKE: Yes, I have few patients, me personally, who are female to male transgender who we use testosterone to foster and maintain masculine characteristics. I don’t do that as a large part of my practice, but it is absolutely a fundamental part of the treatment especially during and after the transition.

TODD: Is low T pretty inevitable as we age? What are the – what percent of men have deficiencies at different milestone ages? Or, sort of, what rate do we decline at?

DR. STARKE: Well, it’s a good question Todd, and sorta depends on how you define low T. You can think of it as a number, which would just be the result typically, of the total testosterone test, which is an interesting number because it’s a huge, quote, “normal range.” Anywhere from three hundred to a thousand. And you’ll often hear people refer to “normal testosterone for my age,” when in fact, it’s not particularly well defined for any given decade of your life, what your testosterone should be. So, is the decline of your number as you get older pretty much inevitable? In most cases, yes. However, officially the type of low testosterone that we treat, the doctorly word for it would be hypogonadism, which is typically a low or borderline low number combined with any number of classic low testosterone traits. In terms of the percentages, if you read up on it, they’re a little bit all over the place, but a decent benchmark is roughly whatever decade of life you’re in, 30s, 40s, 50s, somewhere around that percentage of men have both a low to – low end of normal total testosterone test and some evidence of symptoms that would qualify them for treatment.

TODD: I’m sorry, so translating that to like if you’re 50, what would it be?

DR. STARKE: If you’re 50, roughly 50%. It holds more true the higher up you go.

TODD: And you lose like 1 to 2% every year, I’ve read.

DR. STARKE: Yes, 1 to 2% every year. What’s interesting though is that lots of guys will have this decline, even brothers or neighbors and have identically lower than they used to be testosterone levels, and one will have problematic, bothersome symptoms and the other one won’t. In which case, the one with the symptoms may want treatment and may feel a lot better after getting his testosterone replaced. But the guy who feels great and has no concerns officially is not hypogonadal and really doesn’t need any treatment.

TODD: But there’s a threshold, plus the symptoms that you would need for you to prescribe therapy?

DR. STARKE: Yes, it – when I tell patients all the time, it’s not like your blood sugar, or your blood pressure, or cholesterol, where we check a blood test and we treat the number regardless of how you feel. The current guidelines are based on both lab tests, which are often ordered and investigated because of symptoms beforehand. But if, say in a standard panel a testosterone is checked, found to be 250, so below that 300 benchmark, and the guy says he feels great and sexual function’s good, energy’s good, no complains then there’s almost assuredly no benefit to giving him therapy ‘cause he already feels good.

TODD: So, is low T itself associated with chronic disease, heart health or anything?

DR. STARKE: There are lots of chronic conditions that can precipitate low testosterone. Even just say, a brief illness and it was particularly popular three years ago or so for people to know that COVID, just like many other temporary, but fairly significant illnesses like the flu cause your testosterone to go down. Other more chronic diseases, heart disease, diabetes, can also have a negative impact on your testosterone. But at the same time, a low testosterone level, maybe we’ll say for unknown reasons, makes it harder to have a body composition that’s thought of as healthy, harder to find motivation to get up and exercise, harder to build muscle and lose fat and so, it can also be the precipitator of other health conditions just by itself.

TODD: So, what are the symptoms that most drive men to seek out therapy in your experience?

DR. STARKE: I would say the two classic sexual symptoms would be erectile dysfunction and low sex drive, libido. It is very important to note that if the only symptom is erectile dysfunction, testosterone therapy really doesn’t work very well for that. In fact, Viagra or Cialis, the good old-fashioned pills everyone’s heard of, typically work better than boosting your testosterone, especially a man with erectile dysfunction, who also has a bothersome low sex drive. And then the other big one aside from sexual symptoms, low energy, or fatigue or getting tired before the end of the day, or can’t finish a workout, various forms of more tired than he used to be, those would be the two big categories.

TODD: Muscle loss, fat gain, do people seek it out for that reason?

DR. STARKE: I would say that is absolutely third, yes. All three, very common, and commonly seen together in the same man, and yes, lower strength, decreased muscle mass, and difficulty losing body fat are -- sort of go part and parcel with the third most common.

TODD: Are those things consistent with symptoms that should cause someone to seek out help?

DR. STARKE: Yes, I would say those are definitely the big three in terms – well, I guess, we’ll say four separating erections, sex drive, energy level and then muscle mass, slash difficulty losing fat, would be the four most cited symptoms of low testosterone.

TODD: How about like mood?

DR. STARKE: Mood, sleep, irritability. There are certainly other ones that honestly can be a bit vague and multi-factorial, could be caused by a number of things, but especially in a guy with low sex drive and difficulty losing weight despite exercise and good diet. If he’s also noted by his wife to have been a little more irritable the last year or so, very much goes in line with something that may be fixed with testosterone.

TODD: So, besides aging, what causes low testosterone? What are the risk factors?

DR. STARKE: There are a number of them. I’d say there’s genetic, sorts of predispositions we don’t really understand very well, there are substances or medicines or chemicals of various sorts, for example marijuana is a classic one that chronic use of marijuana can lower your – we’ll say free testosterone level, prior steroid use of some sort, including testosterone or other anabolic steroids in the past can often lead to decreased testosterone production by the man’s testicles when he stops it, as he gets older.

TODD: And so, at what age do – in your experience, at what age do men start seeking out therapy?

DR. STARKE: I have had patients as young as teenagers, 16 is the youngest that comes to mind and usually, the younger they are, the more likely the low testosterone level and the symptoms are caused by some other issue. Whether that be an issue with the pituitary gland in their brain, it can be some sort of congenital condition or chromosomal issue. But as men get older, typically it is more similar to menopause in women, the failure of the testicles to produce as much testosterone as they use to.

TODD: Which kind of starts in earnest, in your 40s or?

DR. STARKE: Officially starts in earnest in your either late 20s or early 30s, is when you typically start to see that 1 to 2% per year decline that you talked about.

TODD: A level at which it’s noticeable enough to the average person that they come and seek treatment. Is the average that you’d start seeing people in their 40s?

DR. STARKE: I’d say, average age would be above 40, 50s or 60s. but plenty of men in their 30s and 40s and who have cross over with the patients that I see for fertility issues who may have some broader, unknown issue with their testicular function are often some of the younger men I see with symptoms and blood test levels, consistent with low testosterone.

TODD: And it is possible to test with low testosterone when you’re in your teens or 20s?

DR. STARKE: Absolutely. Do it all the time.

TODD: So, much of the increase I mentioned at the beginning came without the user testing low for testosterone. How is easy it is to get testosterone therapy without testing, are there a lot of those clinics out there that sort of advertise that and that are easy to give it?

DR. STARKE: I’d say, officially there would be two ways to go about getting testosterone the wrong way. Probably more common than a shady clinic, if we’ll call it that would be quite literally your friends or people you know from the gym or sports, or basically someone who’s willing to sell you, on the side, testosterone or other steroid products. You can also definitely find the less than scrupulous, low T center types of places. But in my fairly good experience, I have never heard of any place advertising the fact that they won’t even test you, they’ll just give you a prescription. I think that’s based on the fact that testosterone is a controlled substance similar to lower grade pain killers or Xanax, and so, to just advertise they’ll hand it to anybody is probably not a good model if they wanna stay open, but I’m certain that some places have a reputation for being easier on the rules and giving it more liberally than maybe they should.

TODD: So, those TV ads make the therapy seem like a fountain of youth. In those who have low T, how beneficial is it?

DR. STARKE: I don’t wanna make it sound like a panacea, but in properly selected men, with the right symptoms and sufficiently low blood test numbers, it really can, and men will tell me this, several times a week, feel like it turns the clock back 20, 30, 40 years, makes it much easier to have the energy to do what you want, to sexually engage with your partner whenever you want to, to build muscle, strength, endurance, exercise. I have a triathlete patient who’s 77 and he’s on the testosterone of some sort, I can’t remember the details, who regularly beats 40-year-olds in triathlons, both because he’s naturally gifted and the testosterone helps him turn the clock back to be about the same age as those guys.

TODD: And is it not uncommon for men to still be getting testosterone therapy late in life like that? When do men tend to stop seeking it, do you find?

DR. STARKE: Typically, testosterone is thought of as a long-term treatment. I tell patients all the time, who are apprehensive about starting, it is not something you’re locked into, but the vast majority of men, again, with the right symptoms and blood test numbers feel so much better when they take testosterone that they don’t wanna stop taking it, and if they do, they often will say something like, “Doc, I feel normal. It doesn’t feel so different like it used to.” I will always give them the opportunity to stop for a few months, come back, recheck blood tests, see how they feel, and with rare exception, they remember what the testosterone was doing for them after they were off of it for a few months and start it right back up. There’s not really an age at which men stop therapy altogether. And by the same token, there’s not really an age at which above 80, for example, there’s really no point in boosting your testosterone. I’ve given it to some form and there’s lots of caveats there because it can impact fertility in younger men. Have given it in some form to teenagers, all the way up to guys in their 80s and 90s.

[Music plays to signal a pause in the episode]

ZACH: Dr. Starke noted that male testosterone begins an annual decline of 1 to 2%, starting in their late 20s or early 30s, but there’s another time when there’s a more precipitous decline, impending fatherhood. Men about to become fathers for the first time, experience significant testosterone drops before their babies are born, according to the most recent of a number of studies on the subject conducted over the past decade. It had been unclear in the initial research whether fatherhood lowered testosterone levels, or whether males with established, low testosterone levels made for better fathers. In the studies, researchers collected saliva samples from men and women, during and after pregnancies. The women showed large increases in a number of hormones, while the men showed a large decrease in their level of testosterone. In one study, testosterone plunged about 40% in the first month after men became dads. The studies also found that men who had the larger declines were more engaged with their infants, researchers concluded that the drop in testosterone is part of the process preparing the man for fatherhood. Testosterone gives a male behaviors and other characteristics needed when competing for a mate, but as soon as that’s been achieved hormone levels go down because such mating related behaviors in many ways aren’t compatible with the responsibilities of nurturing offspring. The good news for men who take pride in their testosterone, the sharp drop in levels is temporary.

[Music plays to signal resumption of episode]

TODD: So, what’s the latest on the risk of testosterone, I know there’s been a lot study on that.

DR. STARKE: The two biggest risks that used to be touted were enhanced risk of cardiovascular disease, or progression of previously existing cardiovascular disease and increased risk or worsening of prostate cancer. The cardiovascular disease business, which was part of that black box warning I mentioned at the very beginning, really has been largely disproven, was based on some studies with issues we might say, and very recently the conclusions from a traverse trial which involve topical testosterone in about 5,000 men, about half of them on topical testosterone therapy, applied on the skin, and about half of them of placebo topical therapy. And all of the major cardiac events we used to worry about like heart attack and stroke were pretty much equivalent between the two groups whether it was placebo or testosterone. However, they found small, but definitely detectable increases in three different things that weren’t necessarily expected. One was acute kidney injury or acute renal failure as it used to be called, another was atrial fibrillation, which was a bit of a surprise, or the spasm of one of the parts of the heart. And the final one was pulmonary embolism which can be very dangerous or even lethal in extremely small numbers of men, but definitely statistically, significantly higher in men who got testosterone versus the placebo.

TODD: That study was men that were at risk of heart issues, right?

DR. STARKE: Yes.

TODD: So, if you are without risk, these new risks wouldn’t – probably would be a factor.

DR. STARKE: That is exactly what we think, yes.

TODD: And then, prostate cancer?

DR. STARKE: The prostate cancer fears have been present ever since the 1940s or so, when a couple of gentlemen won a Nobel prize for discovering that castrating, removing of testicles of dog and then men led to essentially cessation of progression of pro – of advanced prostate cancer. Which sort of proved that testosterone had a hand in aggressive and worsening prostate cancer. Because it was effective in stopping or halting the progression of prostate cancer, when the testosterone was brought to zero, the entire scientific community for about 70 years, incorrectly extrapolated that if no testosterone would stop the cancer, then any testosterone or even worse, giving supplemental testosterone must make the cancer worse. And over the last, really, ten years at the most, we have since discovered that there is certainly a relationship between prostate cancer and testosterone, but interestingly having a normal testosterone level, meaning somewhere in that three hundred to a thousand range is actually protective against prostate cancer development and recurrence as compared to having a low testosterone level. And so, giving testosterone, again, not to be a body builder, but to keep it in the normal range and keep the man feeling good is likely protective, at absolute worst neutral, as compared to what we thought 15 years ago that we were dooming him to prostate cancer by giving it.

TODD: Therapy is neutral, not just naturally occurring testosterone therapy as well?

DR. STARKE: Exactly, both.

TODD: And so then, there are also, non-deadly side effects like acne, breast swelling, things like that?

DR. STARKE: Yes. So, acne is one of the unfortunate ones that if a guy in his teenage years, for example, was just kinda prone to getting more pimples than his buddies, often times, if he were to start on testosterone therapy, sure enough he’ll get acne again. The risk of that is mitigated by either decreasing the dose or increasing it very slowly, if that’s what we plan to do. Or based on their other symptoms and symptomatic improvement in those low T symptoms, visiting with a dermatologist and getting a good skin care routine like they did back in high school will often take care of that problem. When it comes to sensitive nipples or swollen breast tissue, that is related to a specific aspect of testosterone metabolism that occurs in people’s fat cells, by an enzyme called aromatase. It converts testosterone into estrogen. And as we mentioned as the beginning, it’s normal and good for men to have a low level of estrogen, but as you supplement the testosterone made in the testicles with for example, injections of testosterone, they also have a similar, but much smaller rise in their estrogen which causes feminizing symptoms like sensitive nipples, breast growth, hot flashes, occasionally even intense emotionality that they didn’t used to have.

TODD: In regards to some of those health risks, I guess the ones shown in the traverse study, how you balance those risks with patients that need low T therapy or could benefit from it, and do have some inherent heart risk?

DR. STARKE: Luckily, here at Methodist, one of my first orders of business, when I arrived seven years ago was to establish very close contacts with very specific preventative cardiologists and other specialties within cardiology to see all of the patients about whom there was a concern for possible cardiac risk or increasing cardiac risk. So, we have sort of a seamless referral network set up so that anybody with pre-existing or certainly possible, but undiagnosed cardiovascular issues, who we put on testosterone will immediately be given an appointment to see a cardiologist at some point in the next month or so, so that they can be assessed, look at the risks and if changes on that side of things need to be made, then they will.

TODD: And so, what are the forms of low T therapy? There’s injections, gels, patches, not pills?

DR. STARKE: All of the above and interestingly, pills are now an option. Maybe 30 or more years ago there was a pill version called Methyltestosterone, it was toxic to your liver. So that, I don’t believe was ever allowed in the United States, but within the last five years or so, maybe ten, there have been three different oral testosterone options that have become available, which do not cause any liver toxicity. They are a great option for men with a little money to spend out of pocket, ‘cause they’re brand new and typically not well covered by the insurance companies, often taken once or twice a day, as opposed to injections which are often every week, every two weeks. The pills tend to keep guys at a very stable level, day in, day out and some forms of the pills can actually minimize the risk of increasing your blood count, which is another side effect we didn’t mention, where a man’s blood can get thick because of the action of testosterone causing you to make more red blood cells. Doesn’t do that quite so much, doesn’t increase your estrogen so much, doesn’t cause your testicles to shrink as much because you’re basically giving testosterone in the same way your testicles used to give it when you were younger. Becoming much more popular these days, we’ve only been prescribing it about six months, but have had great results. Injections are by far the most common version of testosterone therapy, whether they are the traditional intramuscular version or sort of a subcutaneous auto injector that’s become popular ‘cause it’s easy and painless and then you mentioned the gels, patches, topical things you put on your skin, are also pretty widely used. And then there’s some others like a nasal gel and pellets that go under your skin, there’s a variety of things that –even things that you put inside of your cheek, but by far the most common would be the first three, pills, shots, or topical.

TODD: But when it becomes more widely covered by insurance, pills would be what you would recommend?

DR. STARKE: Very likely, and they’re doing some interesting studies on those pills because they noticed that unlike injections, the pills don’t seem to suppress a man’s testicles in their own natural productivity nearly as much as the injections do. And there’s a thought that they may not even cause fertility issues, meaning a declining sperm count, in the same way that the injections definitely can harm your fertility.

TODD: Is the therapy expensive?

DR. STARKE: There’s a range, but even at the – with the Cadillac of TRT, as we call it, Testosterone Replacement Therapy, which would be either these brand-new pills that you take twice a day, or the subcutaneous injectors with no insurance coverage whatsoever, it’s about $150 a month. The traditional intramuscular injections or generic topical, say gel, if covered by insurance can be as cheap as $0 per month, more often something like $10, $20, $30.

TODD: So, what’s the difference between, low T therapy and say, performance enhancing steroids?

DR. STARKE: Well testosterone, I’d say, is the original performance enhancing steroid, and anybody who is taking steroids, much of the time is taking a super physiologic, or much higher than they should, dose of testosterone, almost as the base of their steroids. The other chemicals that a lot of people have heard of like,  Dianabol, or Deca Durabolin, or Anavar are various, what they call AAS sorts of chemicals, androgenic anabolic steroids, which are sort of like testosterone, only more so. They have a higher affinity for and bind more strongly the testosterone receptors and it sort of, so to speak, like super testosterone.

TODD: You mentioned older people going back on testosterone, is that typical because the body has a hard time starting to make it again once you’ve been on the therapy for a while?

DR. STARKE: Whenever a man takes – and just using the example that’s by far the most common. When a man takes injections of testosterone for several years, his testicles are almost from the get go, suppressed, in that the body sees that there’s enough testosterone circulating and so, the brain, which controls the testicles, more or less turns off the activation signals and your testicles go to sleep and they don’t do anything. And the higher the dose the man takes, and the longer they’ve been asleep, the harder it can be for them to wake back up. And that’s not only true for older men, that’s true for young men, teens, 20s, 30s, and I’ve seen some unfortunate guys, very young in life who took, either testosterone, some sort of steroids or similar when they younger, playing sports and have almost permanently ruined their own testicular function because took high doses for five or ten years and now are pretty much reliant on some sort of supplementation, ‘cause their testicles just won’t rev back up.

TODD: So, it’s pretty hard to come off of, is that reason that people should take caution in starting it in the first place?

DR. STARKE: I suppose my argument, to play devil’s advocate, would be, our goal is never to get a guy’s testosterone to a super high unsafe, abnormal level. It’s just to get their testosterone back within that normal range and to get their symptoms, whatever they’ve presented with, under control. And so, if the goal is to be on something for a short period of time, to for example, rev the testicles back up and so, they start working better, we have medicines that we can use to stimulate your brain to tell your testicles to work harder instead of giving actual testosterone. It doesn’t work quite as well in older men, ‘cause the machinery doesn’t work as well anymore, if you will, but I would say, we are clear for most guys, as I told you before that once they start it, they will likely feel such an improvement that they won’t want to stop it, and then also that taking testosterone does not then cure the problem of low testosterone such that if you stop it you feel great for forever. You sorta have to continue to supplement what your testicles aren’t making.

TODD: What are alternatives to testosterone therapy? Can you kinda will your body to overcome the issues through exercise or diet?

DR. STARKE: Definitely, and I playfully say all the time to patients who ask that exact question, or ask about more natural alternatives, the four things that all of us know to be healthy, which sound extremely easy, but in fact, are often very, very difficult: eating better, exercising more, getting good sleep, and minimizing stress, are sort of the four big things that can be done to enhance your own body’s production of testosterone. But in certain cases, a man’s testosterone is so low or for example, if he suffers from obesity has a really hard time losing weight, and just kinda can’t get the jumpstart that he needs, it can, in certain cases be unrealistic to expect him to start exercising. And so, he’s sort of stuck. And so, guys with various issues like that – our cases where sometimes we start testosterone to give ‘em a boost to get them moving around, get the muscle to fat ratio a little better and as they’re feeling better, losing weight, feeling great basically, we can slowly taper off the testosterone and try to let their body take back over, which definitely has had success in many cases.

TODD: Same question for prevention or at least slowing the onset. Diet, exercise, sleep, stress, can that cause you not to ever encounter the issue?

DR. STARKE: That’s a wonderful question, and I could never say definitively, “Yes. If you get good sleep and never have stress, and eat right and exercise, you’ll never have low testosterone issues.” But men who are able to do those things, again, which are easy on paper and a lot more difficult in the real world, certainly are minimizing the risk that they have low testosterone, period. And also minimizing the risk that they have low testosterone as early as some of their peers, who maybe don’t live in the same healthy ways.

TODD: And how about over-the-counter supplements, DHEA.

DR. STARKE: Over-the-counter supplements like those, Dehydroepiandrosterone, and its relatives and then there’s also things like NuGenix and various, we’ll say, herbal sorts of medicines you might get at – supplements you might get at GNC, the DHEA business, I think there’s some decent evidence that it may sort of help things. In my view, it’s a bit of a half measure, if that’s really what you’re looking for, of course depending on a lot of different circumstances there usually there are better ways to go about it.

TODD: But that’s a steroid of sorts too, right?

DR. STARKE: Officially yes, it’s one primarily made in the adrenal glands. But more common, at least, in my line of work that we see are testosterone boosting supplements, herbs, powders, whatever they might get from the health food store, which very interestingly often contain illicit testosterone. And so, while those can certainly be effective, because they actually have testosterone in them, by the same token, they’re not regulated, you have no idea what you’re taking and the likelihood of harm, side effects, and unwanted consequences from those sort of black box jars of powder are certainly much, much higher than they would be with sort of a prescription grade, very precisely measured version of testosterone that we would give you.

TODD: All right, is there any you wanna add, or in summary what message would you want to send to men who think they might signs of low T.

DR. STARKE: I think the take home message from all of this is that there a whole lot of press and my Lord, a whole lot of websites, YouTube videos, all sorts of things on the internet that my patients often refer to as, quote, “research.” And you can read a million different things that will give you lots of contradictory, confusing information. But the real short version from a doctor who deals with testosterone all the time is that, while there are plenty of guys who don’t need it or don’t go about acquiring medicines like that in the right way, there are millions of men in the United States who unquestionably have a pathologically low testosterone level, and very bothersome to sometimes life altering side effects that really can stand to benefit from getting their testosterone level properly boosted. And really, the only way to differentiate that is to go see a trusted physician, of course, for example at our Men’s Health Center as opposed to the low T center on the freeway. And it’s not that those are necessarily bad, but I’d say, can be highly variable, whereas, here at Methodist, I know that we do it properly.

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ZACH: So, Dr. Starke had a lot to say about testosterone, Todd. What were some of your biggest takeaways.

TODD: Well, I was really struck at the different ages, the extremes in ages that he prescribes it for. From teenagers to people in their 80’s and 90’s.

ZACH: Yeah, like that one patient of his that did a triathlon in his 70’s or something like that. And I feel like that’s the exception to the rule.

TODD: Yes, and I was a little puzzled by that one because anybody that can – who’s a triathlete and competes against 40-year-olds, seems like their blood level wouldn’t be testing low enough to need it.

ZACH: Right. That’s the other thing, right? The testing is a requirement in order to get these medicines kind of above board. Yeah.

TODD: But I was also interested in the – how it declines your likelihood of having low testosterone at different ages. I think I already mentioned that, you know, for me it’s about 65% of people my age have it. For you, it’s still 35% of people or thereabouts. Are you sure that maybe you’re not one of them?

ZACH: I haven’t been tested, I haven’t felt the need to, Todd. But, you’re not gonna question my manly-hood here.

TODD: No, no, I’m sorry. I didn’t mean to that.

[Laughing]

ZACH: No, but you’re absolutely right though, it’s something that you should start to keep track of at some point.

TODD: Yes, but I don’t think they want you to go in and do blood testing if you don’t feel like you’re experiencing any of these symptoms. But if you are then, you definitely should. That was one of my big takeaways, was that you needing a combination of a blood test and the symptoms. I was honestly struck at how gung-ho Dr. Starke was about testosterone. I guess, partly because I’ve – I’d written enough about the concerns about the health issues. I think they’ve – most of those aren’t big risks at this point, they’ve ascertained, but at the same time, he really did kinda make it sound like a fountain of youth there where he said, “People feels like it turns back the clock, 20, 30, 40 years. It still doesn’t seem like something I’d be interested in, although that was quite a testimonial, I thought – and the fact that also, you know, if insurance ever started covering – starts covering the pills, it seems like there is less side effects with that and it’d be easy to take. So, you know, ten years from now, maybe if I’m starting to feel a little lagging, I should try that out.

ZACH: Alright.

TODD: But it sounds like it’s a lifetime commitment, you know, once you do it – start it, most people stay with it.

ZACH: Right, and that’s something that makes me hesitant to it as well. I don’t want to have to sign up for something for life, right. Some other preventative techniques that he mentioned, right, were pretty basic stuff. Like, hey, get a lot of sleep, eat healthy, don’t be stressed. I’m like, “Well, yeah, that’s good advice for anything, right?” But it is gonna help those testosterone levels.

TODD: Yes, if you can do it, yes.

ZACH: Just make sure, don’t be stressed everybody. If you can just not be stressed, you’ll be fine.

TODD: I thought it was interesting that thought that would – could be something that was preventative. There’s not really hard data out there yet, but you improve your chances of your testosterone won’t as rapidly if you can do all those things.

ZACH: And I also liked and we mentioned briefly, before we got into the conversation, but I like that Dr. Starke, kind of addressed, “Hey, you know, these stereotypes of like, anger and high volition, right? It’s not necessarily, you know, an A to B correlation with testosterone.” Now, there are some scientific facts about like, oh, your emotions are higher and that kinda thing, but it doesn’t translate into a negative as the stereotypes seem to claim sometimes.

TODD: Right. Yeah, I thought his takeaway was good that, you might have heard some bad things about testosterone, but if you’re experiencing those symptoms, you should go see your doctor because they can do a blood test. And if you are low on testosterone, it can really alter your life to get on the right prescription.

ZACH: Yeah, and go to your primary care physician, they can refer you to a specialist and don’t go to one of these, maybe, random stores, or the back of a car in a mall parking lot, or something like that. It’s probably not where you wanna go get your testosterone.

TODD: Exactly.

[Laughing]

ZACH: Alright, well, that’s gonna do it for this episode of On Health with Houston Methodist. Be sure to share, like, and subscribe wherever you get your podcasts. We drop episodes Tuesday mornings. So, until then, stay tuned and stay healthy.

[Music ends signaling end of episode]