The Truth About Low Testosterone (Part 1): The Symptoms You Missed and the History You Won’t Believe

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3:39Let's talk about it in the mailroom. Let's talk about it. Let's talk about it in the mailroom. Welcome to the mailroom with Dr. Jesse Mills. Hey, welcome back to the mailroom. Dr. Jesse Mills, your host, professor of urology, University of California, Los Angeles, David Geffen, School of Medicine. I am joined by my illustrious and somewhat burdened host, Jordan Runtai. He's burdened because he has to put up with me. But I'm so delighted, Jordan, that you decided to come back and do another show. The next couple of episodes are going to look at low testosterone. Some of it will be the history of how we got here.

4:26Some of it will be really kind of just trivial pursuit knowledge of testosterone and some of the wacky characters and the wacky things we've done, including goat nuts and kitty pig testicles and transplanted sheep testicles and you name it, we've tried it. So we're going to get into that and then not that that isn't serious, because it is, but then we're going to get into how do we treat this condition? Testosterone deficiency is still one of the most underdiagnosed endocrine problems in this country and in the world. And there's a wealth of treatments and I want to empower our audience with what those therapies look like so they can decide not only what modality is best for them, but who should be prescribing it as well.

5:10So it's great to have you back, Jordan. I'm ready to let this thing rip again. Me too. It's going to be great. So way back when we first started talking about doing this show, you mentioned wanting to kick things off with an episode on low T. Yeah. Why was that? Why did you want to start there? I think the world of testosterone and what we call low testosterone or hypogonadism, it's a perfect metaphor really for health and information and misinformation. Because hypogonadism, the medical diagnosis, which is when a man's testosterone falls below 300 nanograms per deciliter and he has symptoms of low testosterone.

5:46So fatigue, loss of libido, loss of energy, depression, and also maybe signs like low bone density, loss of muscle mass. Those are identifiable factors that may correlate with low testosterone. It's a truly medical diagnosis. And it's one that is surprisingly, even with all the noise out there and all the people in the manosphere, it's still actually underdiagnosed. I mean, it's shocking how many people are walking around that maybe aren't listening to this show or aren't listening to any of the other medical podcasts out there that talk about low T. it's probably underdiagnosed by about 90 % of people.

6:29In other words, a lot of guys are walking around low testosterone that are not coming in and getting screened for it. And yet on the other extreme, it's a tale of two hormones. On the other extreme, there are guys that are certainly not experiencing pathologic low testosterone that are juicing themselves into the next century, that are using testosterone for the massive gains that we see in the gym or for improved or enhanced sexual function. And I'm actually not lining up with that that's necessarily a bad thing because we don't know. We don't actually have the data to know if that's dangerous.

7:08And I definitely want to disavow people of the thought that somehow testosterone is a substance that is as concerning as opioids. And yet, if you look at the way that the FDA classes testosterone, it's the same schedule, or the DEA, I should say, it's the same schedule of drug as a narcotic. And so that's sort of more of an act of Congress that dates back 30-odd years than it is an act of medical discussion. And I would say that testosterone therapy is, of all the hormone therapies, probably the safest there is. And why is that? Well, it's also for the same reason that low testosterone doesn't really kill anybody right away.

7:51So if you look at all of the hormones that we think about on a daily basis, when we think of hormone deficiencies, you know, diabetes comes to mind pretty front and center. I think everybody knows what diabetes is, where it comes in two flavors essentially, but your blood sugars get too high either because your pancreas isn't making insulin anymore, which is a hormone that regulates how we metabolize sugar, or it's not sensitive to insulin anymore so that the sugar that you eat is not being processed appropriately because you have what we call insulin insensitivity. And a lot of that comes from obesity and overwhelming the system to the point where it becomes confused.

8:31And so diabetes actually will kill you. So if your blood sugar is too high, you go into a coma. If your blood sugar is too low, you go into a coma. and therefore, if I'm a treating physician and I give somebody too much insulin, I can kill them, and if I give them too little insulin or they take too little insulin, they can die. Thyroid is another thing that I think everybody is comfortable or understanding. You can have a high thyroid or you can have low thyroid, and both of those can be dangerous and potentially lethal. Well, if a guy walks around with zero testosterone, his life will be shortened for sure, and there's data going back 30 odd years that show that men that have chronically low testosterone have a dramatically shortened life of up to about 20 years.

9:14So the converse of a guy's walking around with healthy testosterone, they have about a 20 year longevity span improvement over guys with low. So we know that from that perspective, low testosterone is not going to kill you like a diabetic coma will, but it will kill you. Eventually it'll catch up with Now, can I ask you a question about that? Yeah, bring it. Is that actually because of a chemical reaction within the body, or is that more lifestyle? You have low testosterone, so you're more fatigued. You aren't as active as you should be, and you're not sleeping as well and all the accompanying things.

9:45Or is it a combination? Yeah, so here's a quick medical school lecture on testosterone. On low testosterone, it comes in two forms. It comes in what we call primary low testosterone, which is basically what you were just saying, where the chemical reaction is your testicles don't work and they don't make testosterone because there's something wrong with the testicle itself. There's genetic conditions that lead to it. There's trauma. If a guy has major testicular damage from some kind of horrific trauma, then obviously the cells that make testosterone die. There's certain cancers that can cause low testosterone and cancer treatments that can cause low testosterone, like radiation therapy, for example.

10:23And so that's what we call primary hypogonadism, where the factory is not making testosterone. And those are less common than what you said next, which is essentially a lifestyle-based low testosterone. Secondary hypogonadism, there's a lot of different chemical reasons for that too. Secondary means that the governing system for the testosterone is not working. And usually that governing system is in your pituitary gland, a little gland that sits right between your eyeballs and in back of your nose. That is what signals the testosterone molecules in the testicle to make testosterone. Or it's even up higher at the level of the hypothalamus, which it's a little bit higher up in the brain.

11:03So there's three different regulatory levels at which we make testosterone. So secondary means that the testicles are fine. They're just not getting the signal to make the testosterone molecule. And that, if you look at the common causes of secondary hypogonautism, they are. They're associated with obesity, high blood pressure, diabetes can cause secondary hypogonautism. lack of exercise, stress levels, pituitary dysfunction in general, which again, in this day and age, a lot of it comes from poor sleep and stress. If your body doesn't get enough deep sleep, it does not make the hormone, which is called luteinizing hormone or LH that signals the testicle to make testosterone.

11:44So simply changing your sleep patterns or changing your weight, those can help reverse secondary hypogonism. But that is the big bucket of what I see in my daily practice is guys that have a reversible form of testosterone deficiency that a lot of times I love to treat without putting them right onto testosterone, but by reversing lifestyle factors, helping stimulate the pituitary gland a little bit more. So yeah, for sure, it comes in two factors, but why does low testosterone, whether it's secondary, primary, eventually kill us? And the answer, it becomes much more of a secondary endpoint. And And that is, if your testosterone is chronically low, it can cause a dramatic deficit to your bone density, the strength of your bones.

12:30So if you're a 60-year-old guy and your testosterone is low, your bone density may be perfect at that point. You still exercise, you still work out, and you're active, you're busy. But your testosterone is low. You're not signaling good bone density deposition, the calcium that you eat and the vitamin D that you synthesize to make bone, it's not getting laid down as healthy bones. So by the time you're 80 or even 65 or 70, if you stub your toe or you fall on a curb and you break a hip, we know that when an elderly person breaks a big bone, like their femur, their hip, their mortality rate goes up dramatically.

13:08And so it's a secondary endpoint for that low testosterone. So had they treated their low testosterone, had they improved their bone density, then by the time that they tripped on that curb, they may have been able to catch themselves and not break that hip and then kind of go to the cascade of all the bad things that hip fractures can cause, like blood clots, which can kill us. So it becomes secondary. Or your low testosterone can lead to metabolic syndrome or obesity, which then can lead to heart disease, which then can lead to early death. But these are all not light switches, where if I cut off your insulin right now and your blood sugar spikes and you go into a coma, that's a light switch.

13:47And so I think that's why testosterone is such a fun thing to debate or talk about because it's a nuance and it becomes a little bit of a dial where we have to individualize where a guy should feel well and individualize his goals. You know, what do you one out of treating this low testosterone.

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18:12now some of the times when we've spoken earlier you have mentioned the incredibly colorful i'll say history of how we treat testosterone dating back far earlier than I would have ever imagined the 1880s. I mean, could you go over a little bit about that? Oh my gosh. Yeah. So, so there's a legendary guy in medicine. His name was Brown Saccard, French anatomist and physiologist who figured out for some reason that what makes men, men, this essence probably comes from the testicle kind of makes sense because the testicles hang out of the body. They're there. And we know that women don't have testicles and guys do and guys behave a certain way.

18:54And so he got the idea of taking extract of guinea pigs and dogs, grinding it up into a serum essentially, and then injecting it in himself. So back in the old days, physicians, their best experiment was themselves. There's all kinds of Nobel Prize winning physicians that they were the first ones to treat. And that's an episode in itself about the pioneers of medicine, whether it's treating malaria or yellow fever, or even the H. pylori story of stomach ulcers all came from doctors experimenting on themselves. So Brown's card said, yeah, I'm going to shoot myself up with guinea pig nuts and see what happens.

19:34And he swore he felt better. And he published a little paper about guinea pig extract and how he retained his vitality and he was hornier and maybe didn't quite use the word horny in 19th century France, but that was the flavor of what he was trying to say. And so that led to a little rumble of where people are interested. Okay, I mean, Brown's card's a smart guy. He came up with all kinds of amazing medical discoveries, a lot in the spine anatomy and the neurology world, but he delved into testosterone. And so it actually goes into, even in the early 20th century, where he was doing this with a lot of, you know, patients and finding without any kind of good randomized control that maybe we were onto something.

20:17So there was a guy in this country who capitalized on Browns and Cards early research, I guess we can call it research, experimentation, and said, well, you know, why go through the trouble of putting guinea pig and dog nuts in a blender and injecting it? Why don't we just, why don't we just transplant whole animal nuts into a guy and so so he developed a clinic in kansas where he would castrate goats in the barn in the back and in the front of the barn make an incision into a guy's scrotum and stuff a couple of goat testicles into a guy's scrotum put a couple stitches in him and say hey let's see what happens this is real jordan you're i mean you're gonna look it up i'm sure it's on wikipedia which therefore makes it real but but it uh i imagine this was in an era long before medical ethics were established.

21:07Yeah, well, a lot of the history of experimentation is thankfully behind us, where we really have such great levels of scrutiny to get good medical data. And this is kind of a shout out to the FDA as well. I mean, the FDA gets punched in the nose a lot. But in fact, they are there to protect ourselves from charlatans and snake oil salesmen. But yeah, back then, they didn't have that. There were no protections. And And so the classic caveat emptor, let the buyer beware, that was all they had to go on. And so people do ethically very unscrupulous things all the time, even in this day and age. But back then, there were no regulatory boards to which you would go front.

21:50You would just try it out and see what flew. So no, that's a great point. Yeah, medical ethics, that's something that, thank goodness, we're getting much better about. So many more guardrails in place so that we're doing the right thing by patients. And so, yeah, you're not going to see any crazy, crazy medical experiments like we saw in the 1910s and 20s, for sure, even back in the 1880s when this whole field started. So, no, that's a great point. Well taken that, yes, evidence-based is evidence-based for a reason. We have protections in place. And thank God for that. Protections of humans, but also protections for animals, too.

22:25Yeah, those poor goats. Shocking, yeah. What the hell? These poor guys? Exactly right. Protection for animals as well. And thank goodness, I mean, we have really good, strict regulations in medical science about what we can do in animal experimentation. But clearly that crossed a line that shouldn't even have been discussed or even brought up. I wouldn't even call him a mad scientist. I would just call him a mad man. Leave it at that. But a guy that's just a huckster trying to make a buck, trying to get through the Great Depression. But wow, what a terrible, terrible thing he did to humanity for a little while there.

22:58but the guy became incredibly wealthy and yeah a few people died of overwhelming infections because again this was in the early 1900s so we didn't have antibiotics until in the 1940s but every once in a while he got a guy to give him a testimonial and this was at the time when radio was just getting big and so boy you could have a radio ad where I went to this clinic in Kansas and and had a couple of goat nuts put into me and I feel amazing my wife didn't leave me and I even was able to father a child that did not look like, you know, half goat, half man. And that's, you know, led to an incredible career for this guy.

23:37He was actually one of the two men in this country at the time that had a private airplane. The other was Howard Hughes. So this guy was in rare company. And anyway, eventually he got found out that this actually was killing a lot more people than it was saving. He got run out of town, ran out of the country and died in poverty on the streets of Los Angeles in 1940s or something like that. But it was a good run. But anyway, that was onto something. And so along that time, there was also in Austria, a guy named Steinach, who decided that if you cut one vas deferens, that you could trap the essential energy of what it means to be a man and do basically what we would call in medical terms today, a unilateral vasectomy.

24:22And the idea is that the other side would be open to release all of the good humors that ejaculation releases, but that if you just clipped one vas, that you would build up all the stuff that you'd otherwise waste. And that was called a Steinach vasectomy. And he was multiple times nominated for a Nobel Prize for this amazing work. Among his clients was a guy named Freud, who may be known to some of our audience as one of the fathers of psychotherapy. And Sigmund Freud at the time was dealing with a head and neck cancer that would eventually kill him, but he had a steinic vasectomy. And he, you know, whether through placebo or through some physiologic thing that we haven't been able to explain about 100 years later, he felt better, published that, no, I actually got some benefit out of a steinic vasectomy.

25:12And W.B. Yeats, the great Irish poet, also decided the fountain of youth and longevity was a steinic vasectomy. And so he was a big proponent. And he traveled to the United States and did some steinics here. And then some American physicians went over to Vienna and learned how to do a steinic vasectomy. And eventually the Massachusetts Medical Society put a scathing, this guy is a fraud. He needs to be unlicensed and should never set foot in the United States again. And finally, thankfully, the traditional medical society say, wait a minute, there are no data. We're just making this up. And in fact, today we know because I do hundreds of bilateral vasectomies every year, and it's a great form of birth control, probably the best form of birth control we have on either side of the gender spectrum.