The truth about low testosterone and why so many men need TRT - with Dr Jeff Foster

22:26Dr Jeff Foster:that work out yeah i always find this a really strange question because could you imagine going up to a menopausal woman and saying well you know if you just went to the gym a bit more you like increase your sex a bit, then maybe actually your menopause would disappear. No one would ever make such an asinine suggestion. So there is some evidence, I mean, it would be a little bit tried, but there is some evidence that actually men who are significantly overweight might be able to improve their own testosterone levels by reducing body weight, and that makes sense. But I should also caveat that some pretty decent studies that show that even when these men do lose weight, their testosterone don't necessarily improve.

23:03Dr Jeff Foster:And the other thing is, supposing you have a guy who has true low testosterone and he is overweight as well. And this is one of the problems we've seen in the NHS quite a lot. They'll go to endocrinology and the endocrinologist will say to them, well, you just need to move more and eat less. If the guy could have done that, he would have ended up having not to go to endocrinology. He just would have done it, but it's not an easy thing to do anyway. And then when you say to someone who's got low testosterone, who's already going to have probably depression or low motivation and low energy and say to them, well, you just need to work twice as hard as the guy with normal testosterone, and you'll be fine.

23:36Dr Jeff Foster:There's no reason. I mean, it's so understandable where these guys come out and go, well, that was a waste of my time. So in terms of boosting testosterone, improving testosterone, there are things you can do to optimize it, but none of it's like earth-shattering revelations. So it's all the sensible things you should be doing in your life anyway. So things like ensuring you get enough protein in your diet, making sure you exercise three to four times a week. And the type of exercise does make a difference. So it needs to be relatively short exercise burst for maybe sort of 40-45 minutes. It needs to be quite intense exercise to cause a metabolic stimulus.

24:11Dr Jeff Foster:You need to make sure you get seven to nine hours of sleep a night, and good quality sleep, not just broken sleep because that doesn't count. And you can't catch up with it in the day because it's about your sleep cycles, et cetera, et cetera. Having more sex makes no difference to your testosterone, despite what people might say. And abstinence from sex makes no difference to your testosterone either. There's this whole weird thing in the states that came up called no nuts november or i think no fap or some of the weird phrase they've got which was based on the idea that if you are abstinent from any sexual function should clarify with or without another person didn't really matter here but just no no action for at least four weeks it says that your testosterone levels were supposed to go up but the study was completely flawed and there's absolutely no evidence this makes any difference whatsoever so the key is if you want to maximize what your body can do, you just lead a healthy lifestyle.

25:02Dr Jeff Foster:Because that's what evolution has designed our testosterone to do anyway.

25:05Dr Sophie Shotter:What about if a younger guy comes to you looking for testosterone? Because of course, if you give a 25-year-old guy testosterone, you'll be shutting off their natural sperm production because the hypothalamus and pituitary will think, hey, we have plenty of testosterone and closed-down production of LH, which, to explain to listeners, is what stimulates testosterone production. and FSH, which is what tells the testicles to make sperm. So I'm guessing this is a tricky balance if a younger guy has testosterone issues but may want children in the future.

25:38Dr Jeff Foster:Yeah, you're right. In fact, we really don't give testosterone to 25-year-olds. It's not impossible, but you have to have the right patient. So I have a 23-year-old patient who is on testosterone, but he had a pituitary tumour in the past, so he has no way of stimulating LH, so he has to have testosterone, otherwise his body simply won't know to make testosterone. And we tried him with LH analogs and things to try and improve it naturally, but it didn't work. So he is on testosterone and he will have to deal with those risks. But that's because he had a clearly defined medical cause for his low testosterone.

26:12Dr Jeff Foster:So my oldest patient is 91 and my youngest patient is 23, but you can get anyone on testosterone provided you know why they need it. The big concern I have is not the 91-year-old because we know now that testosterone is safe, it's the young guys. And there's a real uncomfortable trend on social media for young men. And I say young being like under 30, although that's really unfair because obviously in my mid 40s now, I'd say that I'm still young. Anyway, these young guys on social media saying that actually they're on TRT. They're not, they're on steroids. And that's not the same thing. And if you see somebody who's in their mid 20s, who's absolutely jacked, then, I think young people say hench now.

26:56Dr Jeff Foster:I don't know, I don't know what it is. Anyway, it's not natural and this is not TRT because you've got to remember that TRT is simply designed to replace what was missing. It's not designed to make you superhuman and it's not designed to be super physiological. So yeah, really careful with the younger blokes. Not impossible, but you have to know why. And is there anything else we can do to avoid testosterone?

27:17Dr Sophie Shotter:I have those same concerns about younger guys. This whole culture about young men and even teenagers and wanting to be hench or whatever you want to call it. And, you know, even down to 14-year-old competing in bodybuilding competitions. I think that whole culture that's developing for young men at the moment is really worrying. Can you also explain HRT transference to listeners? So this idea that people living together can be exposed to another person's synthetic hormones.

27:46Dr Jeff Foster:So I really like the idea that HRT transference is a thing because it sounds like that the hormone is so easy to spread across that it's causing men to come out with male breast tissue or become more emotional, whatever it should do. So the idea of it is that any topical treatment you use is potentially transferable to another person if it's rubbed against them within the short enough proximity of time. So maybe two hours, three hours after application. So you put your oestrogel on 8am, whatever, and then you give your husband a hug and the hug lasts maybe a little bit too long and there's a bit of rubbing and the next thing you know he comes out three months later with a massive estrogen level he's all tearful feels his sex drive has gone down and he's noticed his nipples have gone all sore but we find that actually this isn't as common so we looked at our patient population and so we've got 11 and a half thousand patients and we did a survey of all of our patients that had high estrogen levels.

28:46Dr Jeff Foster:And in fact, all of them had adjusted for the question over, do you come into contact with your partner who's on HRT? And it seems both men and women are actually pretty really well educated about this. And they seem to avoid these scenarios at all costs. I haven't yet had a case that's actually occurred. You read about it as a theoretical risk, but I've never seen men rubbing the testosterone off onto their female partners. And I haven't seen the converse either. I suppose for men going to women, a small amount of testosterone rubbing probably wouldn't cause that much harm. But I guess you certainly wouldn't want HRT rubbing off on their male partners for too long because that wouldn't be an ideal.

29:26Dr Jeff Foster:But we just don't see it very much. But it is still a theoretical risk, you're right.

29:30Dr Sophie Shotter:It's actually really interesting because I haven't come across it as being a problem. But I have interestingly heard about it being a problem with animals, with pets. Apparently, I'm trying to think what condition it is. There's a bone marrow condition in animals that can be caused by HRT being rubbed off onto their cats. So I think quite interesting. I heard about that from some vets. More generally, Geoff, do you deal with issues such as erectile dysfunction? And can you explain from your perspective some of the key reasons why ED might happen?

30:02Dr Jeff Foster:the crossover between ed and testosterone is massive although i'd always say that very few guys will come to clinic with a direct complaint over having problems with their erection because it's still seen as such an embarrassing topic that most guys would rather use the testosterone or the energy or some other way of broaching the topic because it's still really stigmatized so one of my old bosses referred to male erections as a kind of barometer of health in men and it's probably pretty correct because to get an erection is actually a really complex physiological process so you need to have an adequate blood flow which makes sense you need to have an adequate hormone to tell you to think about wanting to do that you need to have a functioning nervous system you need to make sure that your psychological state is in the right place so lots and lots of different systems all come into play the most common cause of ed in men is actually cardiovascular disease so things like narrowing of your arteries due to cholesterol or high blood pressure or diabetes so we actually say to men that if you've got erectile dysfunction and it's not testosterone then you have an average of a three-year window before something that happens down below will happen to your heart.

31:21Dr Jeff Foster:And that's because the artery, the main artery that supplies the penis is the same caliber, the same lining of type of cells as your coronary arteries that supply your heart. So if bad stuff is happening down there, it's happening up there as well, which is why it's so important not to ignore ED. The difficulty is patients don't like talking about it. Doctors don't like talking about it. So you go to see your doctor, you go, oh, I've got, I don't know, a bad toe you stall eight minutes of your consultation talking about how your fungal nail's been ruining your life and then just before you leave you go oh and by the way i've got erectile dysfunction and the doctor goes oh christ i don't want to talk about this so they go have some viagra great off you go and they're given a quick pill to try and improve their sexual function which of course doesn't actually fix any of the issue and there's nothing wrong with sildenafil and viagra and tablets like that they've been game changers for ed and men but the problem is you're not fixing the cause.

32:16Dr Jeff Foster:So unless you know why it's happening, actually you're just delaying time that a real issue could be occurring. Hence why the risk of true low testosterone and all the complications with it, or the risk of heart disease, stroke and all the other symptoms associated with high cardiovascular risk.

32:31Dr Sophie Shotter:Gosh, this is such useful information. Thank you so much. So many more questions to ask you. We're also keen to ask you about the wider role of stress and whether you feel stress is linked to men. For example, getting up in the night to take a pee, My husband does that a lot. So do you think this is to do with a cortisol spike?

32:49Dr Jeff Foster:If you're over 40, then it's pretty common to wake up once in the night to pee. And that's often a combination of various urological things like a slight increase in your prostate size, perhaps a slight decrease sensitivity to your bladder. It might even be just the case that your antidiuretic hormone that tells you to hold in your water isn't quite as good as it used to being in your 20s. But the counter to that, and going back to the original point, is that stress is massive and it's a really big problem in men. And I think we have repeatedly and recurrently failed as a medical group to tackle this in men.

33:26Dr Jeff Foster:We know that suicide rates in men are still highest in their mid-40s, and we haven't really tackled this particularly well. I remember watching a documentary on BBC a year, a couple of years ago now, that featured a very famous rock star's son who's a well-known radio DJ and he was in his early 20s talking about how his friend had committed suicide and this was all to promote mental health awareness in men which is great you know it's really good to discuss this but if you're a 45 year old I don't know delivery driver who's stressed that he can't afford to pay his bills and support his kids than watching a rich 20-year-old DJ coming from a rock star background, how he's found life stressful.

34:10Dr Jeff Foster:How do you relate to that? The guy's just going to go, and? How's this helped me? I think we still have a really difficult situation for men where we don't live in the sort of 1980s, 1970s, stereotypical, sexist, chauvinistic world that we had back then. And that's a good thing we don't. but we also don't know where men fit in society now so guys are being told they should talk about their feelings but they don't know who to and they don't know in what way and there's no support particularly that's designed for men it's all just you know one size fits all and we also know that men don't really like talking about their problems so if you have somebody who's depressed who comes into clinic and says i think i'm struggling pretty low we go yeah we'll just refer you to a talking therapy they're gonna go oh god i'm no better off so i don't think we've really adapted or addressed this issue particularly well, but I would certainly agree it's a massive problem.

35:02Dr Sophie Shotter:We want to ask you a few more generic questions, but can you possibly talk about the key signs and symptoms of prostate cancer? And can we talk about PSA screening versus, say, 4K screening?

35:15Dr Jeff Foster:So, symptoms of prostate cancer vary, and in the early stages, the difficulty with prostate cancer is that it doesn't really present any different to a benign large prostate, and by benign large prostate, I just mean that your prostate is getting bigger. So every guy, if you live long enough, your prostate is going to get bigger and you will develop prostate cancer. So we estimate that around 99 % of men who are 90 have some prostate cancer cells in their prostate. The issue is which are going to be the ones that get switched on early and kill you and which are going to be the ones that just float around in the background and then you get hit by a bus at 96 because you're on loads of testosterone.

35:53Dr Jeff Foster:We don't know. And that's really tricky because then how do we know who to screen and who needs treatment. In the early stages, as I say, the main symptoms to look for in terms of any prostate enlargement would be things like difficulty starting or stopping when you go to the toilet. You might find you get hesitancy specifically, so you're just having to wait longer at the loo. You might find that your flow has decreased in qualities. It's more of a dribble rather than a hosepipe. You might find that you get post-matrician dribbling, where you just get a bit dribbling afterwards and you notice it's a bit wet behind.

36:22Dr Jeff Foster:you might find that you're getting up at night more often to pee but i should point out still once doesn't really count it's going to be a few times to start noticing that and really the difference between all those things where it's just well this is happening because i'm getting older and the difference with prostate cancer can be really hard to tell the difference really all you can do is notice the time so maybe if it came on really quickly that could be worrying as opposed to if it came on over several years probably not cancer if you notice blood if you've bone pain, obviously those are going to be red flags that point towards cancer, but most of the time it can be incredibly hard.

36:56Dr Jeff Foster:And that's why screening would be brilliant, but we don't really have any, which is also pretty sucky. And that's because it's suggested that the PSA, which is the prostate specific antigen protein, is not a brilliant test to screen for men. But actually it's not that bad. And the point is that even, and the worry with prostate cancer screening is firstly, it can give you some false positives. So it might come back high, but it was never cancer. But actually, if you have a false positive, you're going to get sent for an MRI scan and they're going to look at your prostate anyway. So we should be able to at least adjust for that.

37:29Dr Jeff Foster:So it's not terrible. The only real worry with PSA screening is that if you have really low PSA levels, really low, that could actually mean you've got such an aggressive prostate cancer that it's just completely wiped out your prostate, in which case, you've missed the vote anyway. So my argument would be is, yes, PSA is not brilliant. It's the best we have. And we have cervical screening, we have breast screening, we have bowel screening, but we don't have prostate. And yet it's the most common cancer in guys. So why aren't we? Maybe that's more of a political question. I don't have the answer to that one.

38:05Dr Sophie Shotter:Another quickfire, but do vasectomies impact testosterone production?

38:09Dr Jeff Foster:God, no. Maybe from a psychological perspective, you might feel something. But If you imagine vasectomies are now considered to be one of the most effective form of contraception available. It's way more effective than taking the pill, and it doesn't impact on your hormone production in the way that taking a contraceptive might mess around with women's. So the way we now do vasectomies is classed as minimally invasive. So you make a very small cut, less than half a centimeter into the side of the scrotum. You then find a thing called the vas deferens, which is the tube that takes the sperm out of the testicle, and you just ligate it.

38:46Dr Jeff Foster:So you cut it and you either sort of laser it or you tie it up so the tubes are not connected. The artery and the vein that supplies your testicle is completely untouched. So your blood flow in, which carries the LH and tells your testosterone to be made, isn't disturbed. And your vein that leaves the testicle that carries the testosterone with it is also undisturbed. So there is no way that the two of them are linked in any way. And some patients will say, well, what about all that sperm that used to come out is now sitting in the testicle and must cause interactions and maybe it could decrease my testosterone that way?

39:18Dr Jeff Foster:The evidence, it doesn't. And the sperm is so, so microscopic, all it does is self-reabsorb back into the body and it doesn't cause any harm. So absolutely fine. I think the biggest issue we find with vasectomies is more the psychological impact that men have because you're kind of like bred as a guy to think, I've only got so many jobs in life I have to do, and one of them is to make sure that I'm fertile and I can carry on my race. And I know it sounds really sort of primitive, but it's kind of something in a bloat to say, you know, I should be able to father a child, and it's still bred into them.

39:51Dr Jeff Foster:And suddenly we're saying, right, you've done that for 30 years, for example, and now we're going to do something to make sure that can never happen again. A lot of guys feel that as a real big psychological impact, And that can affect their sex drive, but not their testosterone.

40:06Dr Sophie Shotter:Thank you so much. And I guess linked to Sophie's question, what are some of the biggest, back on testosterone, what are some of the biggest testosterone myths that you would like to see debunked?

40:15Dr Jeff Foster:So one is that testosterone does not cause heart disease. It does not cause prostate cancer. Two, it's surprisingly safe for the vast majority of patients. And the evidence is it results in really good long term health outcomes. I would say that things like cold baths, cold showers, cold plunges, that kind of stuff, no evidence it improved your testosterone whatsoever. Most of the supplements you can buy from supplement stores or online do nothing for your testosterone either. There is a suggestion that taking the mineral boron might be able to improve your free testosterone. But again, the evidence around this is terrible.

40:54Dr Jeff Foster:and it was something like a one or two weeks study that showed there was a slight decrease in free testosterone so your total testosterone was better, etc, etc. But actually these are not long-term studies. These are not evidence-based. So again, there are virtually, I mean there are one or two, but virtually no supplements out there that you can take that will improve your testosterone naturally. I guess other myths around testosterone would be that every guy needs it and as much as I keep saying testosterone is really important, that we need to think about it. Most guys don't need to have testosterone.

41:27Dr Jeff Foster:It's not like HRT and menopause. Not every bloke is going to have a problem with their testosterone. The key is just trying to find out which are the right ones that need it because then it's a life-changing drug.

41:37Dr Sophie Shotter:So useful. Thank you. And as Sophie mentioned, you are clearly hugely busy. We wondered, what's your usual routine in terms of, I guess, the non-negotiables for your health? So for example, any habits that have stuck, any supplements you religiously take? you mentioned supplements just now any biohacks like what is your kind of protocol if you like

41:57Dr Jeff Foster:yeah I mean I'm kind of weird but I'm also type 1 diabetic and have been since I was 17 so a lot of my diet has always been what can I do to try and maintain my metabolic health forever interestingly the fact that I was cutting out sugar in my 20s because I had to for medical reasons kind of fed into what is now a healthier life in my 40s. So I shouldn't be stacking a load of Oreos and fruit pastels on a daily basis anyway, diabetes or not. But the diabetes just kind of helped me make sure that I was leading a healthier lifestyle anyway. So point being is that I don't have really any simple sugars unless I'm doing something very metabolically driven.

42:43So I might have a bit of

42:45Dr Jeff Foster:sugar for leg day for example but so i suppose my last time so breakfast every day is kind of unusual in that i'll have a protein shake with some eggs in and some flaxseed and some creatine and some inulin and i'll take that every day and i do that every morning and i'll do a similar-ish sort of thing every night and that's always worked really well for me the evidence based around creatine for both sexes just seems to be getting better and better every year it's just such a good supplements. I make sure I have at least one or two cups of coffee in the morning. And I know there's lots of debates around the evidence for coffee or not, but generally early caffeine in the day seems to be pretty good for you from a evidence-based.

43:26Dr Jeff Foster:I just try to make sure I don't have it at least eight hours before bed. And then that seems pretty much fine. I think daily Tadalafil from a prescription perspective is extremely good for you. And so Tadalafil is a prescribed drug only, but comes from the same family of drugs as Viagra, but it works very differently. And Tadalafil is still a vasodilating drug, but it has various other effects that Viagra doesn't. So you will get better erections off it, and that's not the main use of it. But if you ever said to a guy, here's a supplement or a drug we're going to give you, oh, and by the way, it'll make your erections better.

43:59Dr Jeff Foster:No guy's ever going to go, well, I don't want that. I mean, that's the last thing I need. But Tadalafil has been shown in various studies to improve urinary flow and prostate function in men. So over 40, you'll find that you just pee better. and it's also been shown to have good cardiovascular health. So it does appear that taking daily Tadalafil can improve your cardiovascular risk in men because it acts like a vasodilator, a bit like a nitrate, so it opens the arteries to your heart, which has got great evidence for that. And we also know that testosterone can improve your testosterone to estrogen ratio only by a very small amount, but in a very safe way.

44:34Dr Jeff Foster:And the long-term evidence around Tadalafil is a really good and safe drug to take. So if you're going to take somebody who's got lots of little benefits around it, I say Tadalafil is really good. The only other thing I always try and do is make sure I exercise enough in the week. So I try and make sure I do four to five times a week of something, usually weights and one or two days of painful cardio a week, because actually, like if you could do one thing for a patient and said, here's the one thing that will decrease your risk of every disease, it's still going to be exercise. And I do say to patients, I don't really care what exercise you pick, which sounds a bit flippant, but just find something that works for you.

45:11Dr Jeff Foster:And as long as you can find that one thing and you keep doing it, that's the key to longevity and that will massively reduce your risk of other diseases.

45:19Dr Sophie Shotter:And finally, how do you feel about this idea that when it comes to healthcare, women are typically great at advocating for themselves, but men have to be dragged along to the doctor by a concerned wife or partner? And possibly linked to that, what are your thoughts on the male mental health crisis and the fact that collectively we're not raising boys to feel comfortable expressing their needs.

45:39Dr Jeff Foster:I think that's very accurate. When we first started doing the testosterone clinic, let's say like 10, 12 years ago, we used to find that about 40 % of our patients were brought in by female partners or loved ones saying, look, I think my husband, partner, whatever, has low testosterone. And they'd be sort of dragged along. So the way you phrase the question is exactly what we found in practice and especially jumping on the back of menopause there's a real cultural shift in how we approach menopause compared to 20 years ago when i was in med school a little bit before that but anyway around that time because now menopause and i appreciate it's not where it should be but it's better and there doesn't always have to be that same shame around menopause and hrt and in our nhs practice we had menopause cafes and we have menopause support groups we have menopause doctors who are specifically focusing just on that and you don't get anything like that in men i mean could you imagine having i don't know a low testosterone erectile dysfunction support group i mean nobody's going to go to this if i said to my mates yeah we're going to go to the pub at the weekend we've got four or five guys i went right who wants to talk about their erectile dysfunction i mean i'm not getting invited back again and clearly well he's gone all weird so we don't have that same cultural acceptance around talking about sexual dysfunction or hormones in men because testosterone is still considered to be this kind of manly, stigmatized, you've got to have it to be a bloke sort of issue.

47:13Dr Jeff Foster:And it makes it really hard for men to come in, which does focus in very nicely into the concept of mental health in men and where the young guys fit into that. So we are constantly telling men, and younger men in particular, that they need to open up about their mental health, that they need to be able to talk about their feelings, they should be comfortable crying, they should be comfortable going to their doctor if they don't feel happy about things. On the other hand, we're also still perpetuating the idea that men should be tough and they should be massive, as shown on social media and influencers, saying, look how stacked they are.

47:49Dr Jeff Foster:Look at the way that Hollywood actors, leading male actors, have changed in their physiques in the last 20 years. A really good example of this was highlighted in a newspaper article, actually looking at Hugh Jackman, who played Wolverine, and he is now bigger, more muscular in his early 50s than he was when he first filmed the first time he played this role 20 years ago. Because the cultural expectation of what a leading male, alpha male kind of guy should look like has changed so radically. So on one hand, we're saying, yeah, you need to open up about your feelings. On the other hand, you know, you're getting coaches in sports teams telling their kids not to cry like a girl still.

48:28Dr Jeff Foster:so young guys don't know where they fit in society because there is no defined role where young men should be and they don't know how they should be opening up they just know they should be doing it but what that means god knows thank you so much jeff this has been such

48:44Dr Sophie Shotter:a useful chat for all of you listening you can find out more at dr jeff spout j-e-f-f foster dot co dot uk and you can also follow jeff at dr jeff foster and jeff what's the best way of booking in with you for anyone who's interested so you can either go to either of our sites if

49:04Dr Jeff Foster:you go to h3 health or manual either site and you can get your testosterone or your men's health

49:10Dr Sophie Shotter:check done there thank you very much amazing thank you so much for joining us jeff thank you and that ends this week's podcast if you want to find out more about me and my work or maybe book a consultation head to dr sophie shotter.com and you can find me on socials at dr sophie shotter and again thank you so much for listening