TRT: Who Actually Needs It? Risks, Benefits, and Fertility Considerations | Dr. Suks Minhas | Be Well Moments

0:00Welcome to Live Well Be Well, a show to help high performers improve their health and well-being.

0:10So let's talk about TRT because I think this is something that's been spoken about a lot online. When should people look at this as a treatment and when should they not look at this as a treatment? What's the risk versus the benefits of TRT therapy? Sure. I think one of the problems about TRT is the concept that it is used more and more recreationally. Now, historically, and I think probably one of the negative factors about science is that we now know that testosterone has less harmful effects than what it used to in terms of exogenous or testosterone that's given either in injections or in the form of gels.

0:51I mean, we used to talk about the risk of prostate cancer, for example, where we now believe that it doesn't cause prostate cancer per se. Okay, so given it doesn't cause prostate cancer if you don't have prostate cancer. The other thing about it is that there used to be this issue of cardiovascular disease, a higher risk of cardiovascular disease, oddly, with testosterone, taking exogenous testosterone. We now believe from studies done that it doesn't. So it's become more and more acceptable that it's a safe treatment, especially now with more data emerging. We talked about metabolic syndrome and low testosterone association with longevity as well.

1:29So if we look at testosterone replacement therapy itself, there are various forms, but which patients are indicated? Well, I think that's if patients are symptomatic that we talked about earlier and have truly biochemical evidence of low testosterone. the group of patients we talk about if your total testosterone is normal above 12 you don't need testosterone placement therapy because there's also this concept isn't it that people sell and say my testosterone could have been 20 odd when i was when i was in my 20s it's now um 12 that's halved so therefore i need it that's not correct i mean ultimately it's about these thresholds and these values have been studies that have done that show what these thresholds mean in terms of symptoms.

2:16So testosterone, there are two different types. You've got to go back to basics, two different types of hypogandalism or low testosterone. One is secondary, which can include late onset, which is the commonest one, the so-called male menopause, if we talk about that. So once you fall below the age of 50, certainly testosterone levels fall and can fall significantly. The other group is the primary hypogranalism. So men who have an intrinsic problem with their testicles, but might have had chemotherapy, radiotherapy, surgery, twists of the testicle, cancers of the testicle, where there's primarily a problem with the function of the testicle.

2:54So there's two different types. You've got to differentiate that. So it's important to see a clinician and differentiate that rather than just starting testosterone placement therapy. You want to know why is my testosterone low and also screen you for other types of problems. Like we talked about dyslipidemias, we talked about prediabetes or type 2 diabetes that can occur as well. So it's also important to look at all of that as well as lifestyle. So the type of patient that you would treat are patients genuinely biochemically with low testosterone who, after you've gone through a comprehensive testing and trying to differentiate the two different types, so those patients who have generally low testosterone with symptoms and those are usually in clinical practice the late onset group of patients.

3:41In other words, the so-called male andropause or menopause as well. TRT generally is safe. There are some contraindications, for example, active prostate cancer, for example, patients who have breast cancer, which is very rare, patients who may have too much thickened blood, so-called polycythemia as well, and patients who may have heart failure as well. But generally speaking, it's a safe drug, which therefore means that one of the problems, of course, is it's often used as a recreational type of drug, that kind of image, social perception and concept of men, you know, who are muscular and strong.

4:19And that's the image that people want. That's more of a societal perception and more the problem in terms of the media in portraying what is a male, an ideal male. And I think that's kind of one of the problems that we face because we've got to remember, as you just said, that testosterone itself can have a negative impact on your sperm, exogenous. Although we need testosterone, paradoxically, intratesticular testosterone for your sperm production, testosterone itself exogenous inhibits the brain hormones called FSH, which drives sperm production, so it suppresses it. So therefore it acts like a male contraceptive.

4:54So this concept of taking it now, and that's kind of emerged over many years, but we still don't fully understand the full cycle of that. And there are also various other types of treatment people have tried, of course, which we can talk about. So I think anyone who hasn't had a child yet or is looking for fertility, it's really not a good idea to be doing TRT. No, and although it's reversible in the vast majority, but in some patients it's not reversible, androgen abuse as we call it. And a certain number of patients don't recover their axis. There are other drugs that people can use. Generally, patients who have hypergonalism or low testosterone can give things such off-label treatments, which should be prescribed by a specialist I had as well, but often aren't actually.

5:39This is kind of the gym environment. Drugs such as Clomid or HCG, which act differently, they boost your endogenous or your own body's testosterone rather than relying on exogenous form. But exactly what you just said is that if you're thinking of having children, you shouldn't really be starting TRT or considering TRT. Something I found really interesting when I was looking at testosterone levels in men is that testosterone levels seem to drop after men have children. And I saw a study that said men with the highest levels of testosterone were more likely to become committed partners and fathers, at which point they showed steeper drops in their testosterone than did their single childless counterparts.

6:23I found that quite interesting. I haven't seen that study, but my comment would be that if you're in a relationship and it's a good relationship, invariably it's probably going to be a long-term relationship. And where I'm coming to is that if you've had kids, invariably you've been in that relationship for a while. So therefore you're going to be older. So therefore is it just an age-dependent factor that testosterone drops, as we know, as you get older. yeah so if you think you're going to have kids if you if we're having kids in our 30s you might have a 10 year old an 8 year old you mean your 40s and chestnut might be dropping that's the way i would look at it that's really interesting because i was thinking is it the body saying no more children it could be biologically you know it could be we don't know enough do we about it why do women you know in terms of their ovarian reserve by 40 become it's very difficult isn't it?

7:13Why is that? Why should it switch off? I mean, that's really kind of an evolutionary discussion, isn't it? Yeah, I mean, that's one question that I think about a lot. But it's an interesting concept because you don't look at it in men, do we? We don't look at it in men. I think everything around children and fertility is always anchored towards women. And men just seem to, I think, it's just not conceptually spoken about at all. But I do think it is becoming now, I think men are becoming so much more aware of their health, They're becoming much more conscious of their health. And as you said, I think, you know, looking back at the 1970s, people weren't having children later.

7:48And so now we are, we're wanting to try and become more acutely aware of things that we can actively do. That are, as you said, also living in an environment that is, has so many more endocrine disruptors around us. Thanks so much for listening. To hear the full episode, there's a link in the description.

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