Testosterone Decline Driven by Comorbidities, Not Age; ED Signals Broader Health - Episode Hero Image

Testosterone Decline Driven by Comorbidities, Not Age; ED Signals Broader Health

The Dr. Gabrielle Lyon Show · · Listen to Original Episode →
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TL;DR

  • Aging alone does not cause testosterone decline; instead, acquiring comorbid conditions like obesity is the primary driver, impacting male health and function.
  • Free testosterone is a more reliable indicator of a man's hormonal status than total testosterone, as it reflects biologically available hormone levels.
  • Erectile dysfunction serves as a sensitive marker for overall cardiovascular health, indicating potential underlying risks for heart disease and other serious conditions.
  • PDE5 inhibitors like Cialis offer potential cardiac protection and urinary symptom relief beyond their primary use for erectile dysfunction, acting as a "triple-threat" drug.
  • Maintaining muscle mass is crucial for longevity and sexual function, as sarcopenia is linked to a significantly higher risk of erectile dysfunction and low libido.
  • Testosterone replacement therapy is distinct from performance-enhancing steroids; it aims to restore physiological levels, mitigating risks associated with deficiency rather than seeking supra-physiological gains.
  • The penis can be used as a "fulcrum" for behavior change, motivating men to adopt healthier lifestyles through improvements in sexual function.

Deep Dive

Testosterone is a brain hormone that also impacts muscle and fat, and its levels in men do not naturally decline with age alone. Instead, the acquisition of comorbid conditions, such as obesity, is the primary culprit for decreased testosterone. The concept of "male menopause" or andropause is a myth.

Influencers promoting testosterone use without medical supervision pose a risk, particularly concerning fertility. If an individual with normal testosterone levels takes it, they can permanently shut down their fertility, requiring invasive procedures for sperm extraction if they later wish to conceive. Approximately 90% of testosterone in men is produced by the testicles, regulated by a signal from the brain.

Defining testosterone deficiency is complex, with differing guidelines across medical specialties and geographies. In the United States, endocrinologists suggest a cutoff below 264 nanograms per deciliter, while urologists use 300 ng/dL, aligning with the FDA's threshold. However, in Europe, the cutoff is often 350 ng/dL, and some European experts may treat patients with levels up to 400 ng/dL if they exhibit symptoms. These discrepancies highlight the arbitrary nature of single numerical cutoffs for low testosterone, as individual set points vary.

Free testosterone is considered a more reliable indicator of a man's testosterone status than total testosterone. Total testosterone is measured in the blood, but a significant portion is bound to sex hormone-binding globulin (SHBG) and is biologically unavailable to cells. A smaller amount is weakly bound to albumin, and only 1-2% is free and unbound, readily entering cells. As men age, SHBG levels tend to rise, binding more testosterone and potentially leading to low free testosterone even if total testosterone appears normal. Online calculators can estimate free testosterone using total testosterone and SHBG levels. Treatment for low testosterone aims to improve symptoms, and increasing the dose can raise free testosterone levels.

Testosterone replacement therapy (TRT) is distinct from anabolic steroids, which are synthetic agents used at super-physiological doses for performance enhancement. TRT is intended to replace low testosterone within physiological norms. Individuals with low testosterone are at risk for heart disease, bone fractures, depression, and obesity.

Risks associated with TRT include potential infertility, although this is not always permanent. If fertility is desired, banking sperm or using medications like hCG can help maintain or restore natural production. For individuals who have completed childbearing, TRT is generally considered safe, provided hematocrit levels are monitored and sleep apnea is addressed. Replacing low testosterone is not inherently dangerous, and the benefits often outweigh the risks.

The notion that TRT causes prostate cancer has been challenged. Historically, testosterone levels were lowered in men with advanced prostate cancer by removing the testicles, which often relieved pain. This led to the assumption that raising testosterone would be dangerous. However, current research suggests a more nuanced relationship, and prostate cancer is not an inherent risk of TRT.

Erectile dysfunction (ED) is a sensitive marker of overall health and cardiac risk. Lifestyle modifications, including diet, exercise, sleep, and stress reduction, are the preferred first-line treatment for ED. These changes can lead to significant improvements in erectile function over six to twelve months. For instance, a study involving obese men demonstrated significant increases in erectile function with lifestyle modification and weight loss.

Phosphodiesterase-5 (PDE5) inhibitors like Cialis (tadalafil) and Viagra (sildenafil) can be effective for ED and may also offer cardiac protection. A large review of 1.26 million people indicated that regular Cialis use reduced major cardiac events by 22% and lowered all-cause mortality by 30%. Tadalafil, in particular, has a 24-hour duration and also helps with urinary symptoms, making it a "triple-threat" drug for cardiac, urinary, and sexual health, often available affordably.

The story of Viagra's development highlights its initial testing as a heart drug for angina before its efficacy for ED was discovered. Similarly, Cialis has shown benefits beyond erections. While PDE5 inhibitors are primarily prescribed for men, studies are needed to confirm their efficacy and cardioprotective effects in women, particularly for overactive bladder symptoms. Off-label use of these drugs is permissible with informed consent regarding risks and benefits.

Shockwave therapy for ED involves using a pulsed electrical pulse to induce a trauma state in the penis, stimulating the body's healing response and promoting neoangiogenesis (formation of new blood vessels). While early devices were less effective, regulated Class III machines have demonstrated efficacy. However, these treatments are often expensive and not covered by insurance. Penile tissue can atrophy with disuse, and maintaining its health is important for future sexual function.

Testosterone boosters and natural supplements like Tongkat Ali and Ashwagandha are not considered first or second-line therapies for low testosterone compared to evidence-based protocols. Ashwagandha may offer benefits for stress and cortisol response.

Influencers on social media, who are not physicians, can spread misinformation about testosterone. The Dunning-Kruger effect suggests that confidence does not equate to competence. It is crucial to seek medical advice from trained professionals rather than relying on influencers who may lack the necessary expertise and rigor. The velocity of information spread on platforms like TikTok can lead to rapid popularity without accuracy.

Regarding muscle gain and body composition, studies show that combining exercise with testosterone replacement can significantly increase lean mass. For example, a study involving 600 milligrams of testosterone weekly with exercise resulted in a 13-pound gain in lean muscle over 10 weeks. However, the optimal dosing for TRT varies, with typical starting doses for men ranging from 125 to 200 milligrams weekly. Individual sensitivity to androgens can influence how well a person responds to testosterone.

When testosterone levels are within the normal range, increasing them further typically does not enhance libido. However, muscle mass is an area that may continue to respond to higher testosterone levels, which explains the significant muscle development seen in bodybuilders using anabolic steroids, which are often testosterone-based compounds. Muscle has an additional receptor for testosterone, potentially allowing for super-physiological responses.

Common complaints encountered in men include erectile dysfunction (ED), premature ejaculation (PE), and Peyronie's disease. ED is defined as the inability to obtain or maintain an erection, affecting approximately 50% of men over 60. PE affects about 30% of men, with some ejaculating within one minute. Peyronie's disease, characterized by penile curvature due to scar tissue, affects 7-9% of men and can be devastating psychologically.

For women, common complaints include low libido, pain with intercourse (dyspareunia), poor arousal, decreased blood flow to the genitalia, and orgasmic dysfunction. While testosterone can play a role in female libido, it is multifactorial and influenced by stress, relationships, and hormonal conditions.

Sexual dysfunction is often a "couple's disease," requiring treatment for both partners. Improving testosterone levels, using local vaginal estrogen therapy, and addressing pain can help women. For men, reducing stress is crucial for improving sexual function, while for women, reducing stress is a prerequisite for sexual activity.

Hypogonadism, or low testosterone, can

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Related Episodes

Key Quotes

"Testosterone is a brain hormone. Yes, it also works on muscle and fat and all these other organs, but it's a brain hormone. We were taught in medical school that this concept called male menopause (andropause) doesn't exist. It doesn't exist."

Dr. Morgentaler argues that the concept of "male menopause" or andropause is a myth. He explains that aging alone does not cause testosterone levels to drop; rather, it is the development of other health conditions that leads to this decline.

"The challenge is what's a low level of testosterone. So, and critics of testosterone therapy say the experts can't even agree on what a low level is, and that's true. And that's true. And it's part of the part of it is that some of the decisions about what a low level is has been arbitrary."

Dr. Morgentaler highlights the inconsistency in defining what constitutes a "low" testosterone level. He points out that experts disagree, and the established cutoffs, such as the FDA's 300 ng/dL, appear to be arbitrary with no clear scientific citation.

"So, when you measure total testosterone, what they do is they take a certain amount of your blood and they measure how much testosterone in total is there per a little unit of blood... but testosterone circulates in three forms: more than half is bound to this carrier molecule called SHBG... and one or two percent is free, which means that the... unbound and what gets through that cell membrane is the free testosterone only."

Dr. Morgentaler explains the different forms of testosterone in the blood. He clarifies that while total testosterone is measured, a significant portion is bound and unavailable to the body's cells. He emphasizes that only the small percentage of "free" testosterone is biologically active and can enter cells.

"The goal of treatment is not to get the total testosterone into the normal range. The goal is to improve the symptoms that the man is having and hopefully resolve them, and they will resolve if it's hormone related."

Dr. Morgentaler states that the primary objective of testosterone replacement therapy is symptom relief, not necessarily achieving a specific total testosterone level. He explains that if a man's symptoms are indeed hormone-related, they should improve with treatment.

"The conversation is totally wrong and misleading. We make testosterone. The idea of steroids and testosterone replacement therapy being one and the same is just not true. Steroids, if we were to define steroids, let's think about testosterone, but then synthetic agents that are given at super physiological doses for specific performance outcome. That is not the same as a testosterone replacement therapy replacing something that is low within physiological norms."

Dr. Morgentaler distinguishes between testosterone replacement therapy (TRT) and anabolic steroids. He asserts that TRT aims to restore testosterone to normal physiological levels when deficient, whereas steroids are synthetic substances used at supra-physiological doses for performance enhancement, and conflating the two is misleading.

"The penis is the first to go when overall health declines. So, don't get unwell. Stay strong. So when men train, when men lose weight, when men gain muscle, erections get better. Aerobic activity is as powerful as PDE5 inhibitors."

Dr. Morgentaler emphasizes the penis's sensitivity to overall health, stating it is often the first indicator of declining health. He links improved erectile function to weight loss, muscle gain, and aerobic exercise, suggesting these lifestyle changes can be as effective as medications like PDE5 inhibitors.

Resources

External Resources

Books

  • "Forever Strong PLAYBOOK" - Mentioned as a pre-orderable item with exclusive bonuses.
  • "The Forever Strong Insider" - Mentioned as a premium community for ad-free episodes, exclusive content, and community Q&As.

Articles & Papers

  • "Study by Zhang et al. (2024)" (NHANES data) - Discussed for findings on exercise duration and decreased erectile dysfunction rates.
  • "Study by Esposito et al." (JAMA) - Referenced for demonstrating significant increases in erectile function with lifestyle modification and weight loss in obese men.

People

  • Dr. Abraham Morgentaler - Guest, Associate Clinical Professor of Urology at Harvard Medical School, founder of Men's Health Boston, expert in testosterone therapy, credited with challenging the notion that TRT causes prostate cancer.
  • Dr. Tobias Kohler - Guest, co-founder of the Erectile Restoration Outcomes Study (EROS) penile implant registry, active in education and mentorship.
  • David Cruz - Biology professor at Harvard, changed the life path of Dr. Morgentaler by offering him lab work.
  • Peter Attia - Concept creator of "geriatric decathlon" for health preparation.

Organizations & Institutions

  • Harvard Medical School - Affiliation of Dr. Abraham Morgentaler.
  • Men's Health Boston - Founded by Dr. Abraham Morgentaler.
  • Erectile Restoration Outcomes Study (EROS) - Penile implant registry co-founded by Dr. Tobias Kohler.
  • Mayo Clinic - Affiliation of Dr. Tobias Kohler.
  • T4L Education - Mentioned in relation to Dr. Abraham Morgentaler.
  • FDA (Food and Drug Administration) - Mentioned regarding guidelines for testosterone levels.
  • Kinsey Institute - Mentioned in relation to the popularity of the Atkins diet.

Websites & Online Resources

  • drgabriellelyon.com/playbook/ - URL for pre-ordering "The Forever Strong PLAYBOOK".
  • foreverstrong.supercast.com - URL for subscribing to "Forever Strong Insider".
  • researchgate.net/profile/Tobias-Koehler-4 - ResearchGate profile for Dr. Tobias Kohler.
  • linkedin.com/in/abraham-morgentaler-md-81628b6/ - LinkedIn profile for Dr. Abraham Morgentaler.
  • linkedin.com/in/tobias-k%C3%B6hler-58637667 - LinkedIn profile for Dr. Tobias Kohler.
  • x.com/DrMorgentaler - X/Twitter handle for Dr. Abraham Morgentaler.
  • x.com/sexhealthmd - X/Twitter handle mentioned in relation to Dr. Tobias Kohler.
  • mayoclinic.org/biographies/kohler-tobias-s-m-d-m-p-h/bio-20382084 - Mayo Clinic biography for Dr. Tobias Kohler.
  • goodrx.com - Mentioned as a resource for prescription pricing.
  • fromourplace.com - Website for Our Place cookware, mentioned with a sale offer.
  • hollowsocks.com - Website for Hilo Socks, mentioned with a sponsorship offer.
  • timeline nutrition.com/dr-lion - URL for Timeline Nutrition, mentioned with a discount code.
  • cozyearth.com/dr-lion - URL for Cozy Earth, mentioned with a discount code.

Podcasts & Audio

  • The Dr. Gabrielle Lyon Show - Podcast hosting the episode.
  • The Sex Doctors - Podcast hosted by Dr. Abraham Morgentaler and his wife.

Other Resources

  • Testosterone (T levels) - Discussed extensively regarding deficiency, measurement, effects, and treatment.
  • Free Testosterone - Highlighted as a more reliable indicator of male health than total testosterone.
  • SHBG (Sex Hormone Binding Globulin) - Explained as a carrier molecule for testosterone.
  • TRT (Testosterone Replacement Therapy) - Discussed as a treatment for testosterone deficiency.
  • Steroids - Differentiated from TRT, referring to synthetic agents used at super-physiological doses.
  • PDE5 Inhibitors (e.g., Cialis/Viagra) - Discussed for erectile dysfunction, cardiac protection, and urinary symptoms.
  • Sildenafil (Viagra) - Mentioned for its history as a heart drug and its use for ED.
  • Tadalafil (Cialis) - Discussed for ED, cardiac protection, and urinary symptoms, noted as a "triple-threat drug."
  • Shockwave Therapy - Discussed as a treatment for ED, with different classes of devices noted.
  • PRP (Platelet-Rich Plasma) - Mentioned as a potential treatment for ED.
  • Stem Cells - Mentioned in relation to a trial for ED.
  • HCG (Human Chorionic Gonadotropin) - Discussed as a medication to stimulate natural testosterone production.
  • Clomiphene Citrate (Clomid) - Discussed as an off-label medication to increase LH and FSH, stimulating natural testosterone production.
  • LH (Luteinizing Hormone) - Mentioned as a signal from the brain to the testicles to make testosterone.
  • FSH (Follicle-Stimulating Hormone) - Mentioned in relation to clomiphene citrate's effect on the testicles.
  • PSA (Prostate-Specific Antigen) - Mentioned as a screening test for prostate cancer that was beginning to be introduced.
  • Hematocrit/Red Blood Cell Count - Discussed in relation to testosterone levels and potential risks.
  • Erectile Dysfunction (ED) - A primary topic of discussion, defined and discussed in relation to various factors.
  • Peyronie's Disease - Discussed as a condition causing penile curvature due to scar tissue.
  • Sarcopenia - Age-related loss of muscle mass, linked to sexual function.
  • Overactive Bladder (OAB) - Discussed in relation to urinary symptoms and potential treatment with tadalafil.
  • BPH (Benign Prostatic Hyperplasia) - Mentioned in relation to urinary frequency in older men.
  • Androgen Insensitivity - A potential reason for not feeling better on testosterone therapy despite normal levels.
  • G Protein Coupled Receptor - A second receptor for testosterone found in muscle.
  • Anabolic Agents - Mentioned in the context of bodybuilders and athletes.
  • Hypogonadism - Discussed in relation to low testosterone and its treatment.
  • Vaginal Atrophy - Mentioned as a postmenopausal symptom affecting sexual function.
  • Ashwagandha - Mentioned as a supplement, potentially for stress or cortisol response.
  • Tongkat Ali - Mentioned as a natural testosterone booster alternative.
  • Saw Palmetto - Mentioned as a natural testosterone booster alternative.
  • Dunning-Kruger Effect - Referenced in the context of influencer competence.
  • Atkins Diet - Mentioned as an example of a diet that achieved widespread popularity.
  • Erythrocytosis - Elevated red blood cell count, a potential side effect of testosterone therapy.
  • Endothelium - The inner lining of blood vessels, discussed in relation to testosterone's actions.
  • Vasectomy - Mentioned in the context of male fertility and potential reversal.
  • IVF (In Vitro Fertilization) - Mentioned in relation to working with fertility centers.
  • Aromatization - The conversion of testosterone to estrogen by fat cells.
  • Male Menopause (Andropause) - Debunked as a concept.
  • Comorbid Conditions - Factors that can lead to a drop in testosterone levels with age.
  • Obesity - Mentioned as a condition that can lead to lower testosterone levels.
  • Hypertension - Mentioned as a condition that can lead to lower testosterone levels.
  • HIV/AIDS - Mentioned as a condition that can lead to lower testosterone levels.
  • Ovaries - Mentioned as a source of testosterone production in women.
  • Adrenal Glands - Mentioned as a source of testosterone production in both men and women.
  • Clomiphene - Mentioned as a medication to increase testosterone.
  • HCG - Mentioned as a medication to increase testosterone.
  • Testosterone Boosters - Discussed as natural alternatives.
  • Diet and Lifestyle Modification - Emphasized as crucial for overall health and sexual function.
  • Aerobic Activity - Discussed for its benefits on erections and overall health.
  • Muscle Mass - Linked to erectile function, libido, and overall health.
  • Grip Strength - Mentioned as an indicator of overall health and erectile quality.
  • Vascular Integrity - Essential for erectile function.
  • Mental Health - Crucial for erectile function.
  • Psychiatric Perspective (Depression, Anxiety) - Mentioned as factors affecting erectile function.
  • Penile Tissue Atrophy - Occurs with non-use of penile tissue.
  • Venous Leak - A condition where blood exits the penis faster than it enters, affecting erections.
  • Fibrosis and Scarring - Can develop in penile tissue with non-use, making reversal difficult.
  • Hormonal Conditions - Can contribute to low libido in women.
  • Pain with Intercourse (Dyspareunia) - A common complaint in women.
  • Poor Arousal - A complaint in women.
  • Orgasmic Dysfunction - Inability to obtain an orgasm in women.
  • Couples Disease - Sexual dysfunction is described as a couple's issue.
  • Female Sexual Dysfunction - Discussed in relation to improving libido and sexual function in women.
  • Local Vaginal Estrogen Therapy - Mentioned as a treatment for postmenopausal women.
  • Fertility - Discussed in relation to testosterone use and natural production.
  • Sperm Production - Affected by testosterone levels and age.
  • Testicular Biopsy - A procedure to find sperm if not produced in ejaculate.
  • Alcohol Consumption - Can damage testicles and affect fertility.
  • Marijuana Consumption - Mentioned in relation to male fertility.
  • Processed Foods - Mentioned as something to reduce for better fertility.
  • Sleep - Crucial for endogenous testosterone production.
  • Endogenous Testosterone - Testosterone produced naturally by the body.
  • Exogenous Testosterone - Testosterone taken from external sources.
  • Testosterone Equivalency - Used to compare the muscle potency of different agents.
  • Androgen Receptor - A receptor for testosterone in the body.
  • Erectile Function - Considered the best overall marker for male health.
  • Libido - Primarily driven by testosterone in women.
  • Menopause - The physiological drop in hormone production in women.
  • Peyronie's Disease - Mentioned as a condition affecting men.
  • Premature Ejaculation - A common condition affecting men.
  • Sexual Dysfunction - A frequent complaint in both men and women.
  • Testosterone Boosters - Natural supplements aimed at increasing testosterone

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