Interviewer: You've been looking into or perhaps your physician has recommended testosterone therapy, but you're a little hesitant. That's because of the possibility of testicular shrinkage.
Urologist Dr. John Smith from University of Utah Health is here to help us better understand this particular side effect of testosterone therapy. Dr. Smith, first of all, how much of a concern is this to men?
Dr. Smith: I think it's a big enough concern for most guys they'll ask about it. I know it's not a concern for very many other people around these men, but it seems to be something that some men, I won't say all, but quite a few, it's something that is concerning for them.
Interviewer: Sure. So I suppose you get kind of a range. Some guys are like, "No way. I don't want to do therapy if shrinkage is going to be something that happens. That's not acceptable at all." And then there are probably some guys that think it's no big deal. Or is that not even the case?
Dr. Smith: No, it's true. I mean, a lot of people don't care. Older men who want to feel better, a lot of them, they're probably past childbearing age, or they're no longer on the train of it matters, and so they just say, "It's part of the game."
I mean, there are ways to mitigate it, which we can discuss, but yeah, overall, there are quite a few people who are concerned, and then there's a subset of people who are not.
Factors Influencing Testicular Shrinkage Concerns
Interviewer: Okay. So for those guys that are concerned, what's the general reason that you get? Is it just totally self-image, or are there other reasons?
Dr. Smith: I think there are probably quite a few. I mean, some of it is going to be self-image. Other ones are going to be it is your genitalia, which a lot of people have that makes them feel masculine. And so for some, it is an emasculating type of a thing where they look at it and they say, "My testicles are shrinking, which makes me less of a man," or whatnot.
And there are plenty of reasons I've had people give. But yeah, all the reasons are valid. I mean, these folks come in, and they're concerned, and so we try to discuss and alleviate their concerns.
Interviewer: Right. So are you any less of a man? I mean, you're only less of a man by the definition of men who have big testicles, right?
Dr. Smith: Sure. And based on the law of averages, if we based it on foot size, there'd be a lot of people who would probably fall under the average there, and people who would fall over the over.
To me, a lot of it is just personal choice and how people feel about themselves with it. And so that's really where it comes down to.
Interviewer: From a physiological standpoint, though, you're not any less of a man?
Dr. Smith: No. I mean, if you look at it and you're hypogonadal and you have lower testosterone, you could consider it from a hormonal perspective of you're making less than your body needs.
How Common is Testicular Shrinkage for Individuals Who Are Using Testosterone Therapy?
Dr. Smith: It's very, very common. I would say it happens to almost everybody, and the reason is, is physiologically, your body is very smart. It's in tune. It knows what it's doing, and so there are hormones that your body produces that stimulate the testicles to produce testosterone and sperm because that's the testicle's job.
And so that production of testosterone and sperm, when you're giving exogenous testosterone via injection or topical or whatever the method is that you're replacing testosterone, you notice that there is no more feedback in that feedback loop to tell the body to stimulate for more testosterone because the body never gets low on testosterone.
So the body stops stimulating the testicles, and if you stop stimulating a factory to make the goods and services that it makes, you're going to have to lay workers off, and therefore you get the testicular shrinkage.
Usually, they shrink down to about half or a little bit less than half the size. Not less than half, but they shrink less than half of the size they are when you start.
Varying Levels of Testicular Shrinkage
Interviewer: Okay. Yeah, that was my next question. How much shrinkage can be expected? Is it pretty consistent that most guys are going to lose about half the size? Did I understand that correctly?
Dr. Smith: Yeah, a lot of the literature says around half. I mean, it's variable again. Some people lose less than that. I would say on average it's about half.
Interviewer: So if I'm understanding correctly, the shrinkage is going to occur just about in all individuals who undergo therapy?
Dr. Smith: Exactly.
Interviewer: Are there some factors that will make it more likely that somebody will have more shrinkage than somebody else?
Dr. Smith: Not that we've identified. And again, there are a few treatments that we use for testosterone therapy that don't affect testicular size.
Health Impacts of Testicular Shrinkage
Interviewer: And what about health impacts? Other than just physical shrinkage, are there health impacts? Any sort of long-term effects of testicular shrinkage?
Dr. Smith: It can affect and does affect sperm production as well. So in our younger patients who are desiring fertility later on, it's definitely a factor of something that we keep in mind. Otherwise, there's not any physical impact.
Interviewer: Okay. And then what about changes to sexual function or libido? Is that associated directly with testicular shrinkage?
Dr. Smith: Not at all. If you have low testosterone, you're likely to have a lower libido, and then when you replace the testosterone, you're likely to have an increase in your libido. So it would be the opposite.
Interviewer: Yeah, so the size really doesn't matter.
Dr. Smith: No.
Interviewer: As far as that's concerned.
Dr. Smith: Exactly.
Minimizing Testicular Shrinkage
Interviewer: So you mentioned that there are some ways to minimize shrinkage impacts. The first question a lot of guys might have is, "Is that shrinkage going to be reversed if men discontinue testosterone therapy? Will the size come back?"
Dr. Smith: Yes, and in most cases, you'll see the size return. Not in all cases. I never guarantee that to patients because you never know what the body's going to do. Prior to starting testosterone therapy, if it's diagnosed the correct way and you have low testosterone, your body is already not making a sufficient quantity. And so it's not going to be able to go back to making a sufficient quantity if you were to stop testosterone therapy.
Interviewer: And then let's talk about specific treatments or strategies to minimize that risk of testicular shrinkage while on testosterone therapy. What are some of those?
Dr. Smith: Sure. So one of the most common, or used to be very common, was an off-label medicine called clomiphene. Clomiphene is a drug that's used to stimulate the precursor hormones, LH and FSH that I mentioned previously. And those two hormones stimulate the testicles to make testosterone and sperm. And so, by using this medication, you're not actually shutting down the signals for production. You're actually increasing them.
Now, the contrast of "Will this give you larger testicles?" doesn't necessarily apply and doesn't usually happen. But that's one way to minimize testicular size loss.
Human Chorionic Gonadotropin (HCG)
There's also a medication that you can inject called HCG, or human chorionic gonadotropin. This is a precursor... or not a precursor. It's an LH analog, meaning that it acts just like LH even though it's not LH, and it stimulates the testicles to continue the production of sperm and testosterone.
That medication also will help to maintain testicular size, and so we'll utilize that sometimes in combination with testosterone injection therapy to maintain the size of the testicles.
Alternative Treatments and Over-the-Counter Options for Testicular Shrinkage
Interviewer: Are there some instances where those aren't things that can be done for a guy and it's just inevitable if you're on testosterone therapy that you're going to have size shrinkage?
Dr. Smith: Sure. I mean, during the pandemic that we just had, there was a shortage of a lot of these medications, so they were unavailable. And so if you wanted to maintain your testosterone therapy, you didn't have a choice to get HCG in some cases. Clomid was pretty available throughout, but there was a shortage of it for a short time and you just didn't have access to it. And if you wanted to maintain your testosterone therapy, you went without some of those medicines at times.
Interviewer: And what about other alternative treatments or therapies that can provide similar benefits to testosterone therapy without that risk of shrinkage? And I'm thinking maybe something you'd see a doctor for, or maybe something you'd get over the counter. How are those?
Dr. Smith: So a lot of the over-the-counter stuff you're going to see, none of those are regulated by the Food and Drug Association. So it's really hard for me to speak to those. I've had patients anecdotally tell me in the clinic, "Oh, I tried this supplement or that supplement. I felt like it really helped me."
But there are not a ton of other options. There are some other medications like DHEA and other ones that are precursors. I don't use them often just because there's not a super robust amount of data that's been convincing for me to use them in my practice.
Interviewer: You just don't feel comfortable recommending those to patients as a result of that, huh?
Dr. Smith: Right.
Beyond Testicular Shrinkage, is Testosterone Therapy Right for You?
Interviewer: So if a guy is considering testosterone therapy, and has been properly diagnosed, and thinks it would be a benefit for them, and they just really are hung up on the size, the shrinkage thing, how do you talk with a man to help them maybe come to accept that a little bit more? Do you have any points of view that you can give them that they've found useful?
Dr. Smith: Yeah. I mean, I think a lot of the patients, if we're already past... Say I've got a patient who's in their 40s or 50s who is past the time where they want to have any further childbearing, I have those conversations with them of, "It doesn't really matter testicular-wise because the function of the testicles at this point is to make testosterone and sperm, and you don't need the sperm because you're not looking to have more kids, and it's already not making enough testosterone. So, in reality, who cares?"
And if they're there with their spouse, I usually will make a... not a joke, but I'll usually say, "And she doesn't care how big your testicles are," and they usually affirm that because nobody really cares how big they are. It's more of a personal thing.
And so the wife or the girlfriend or spouse or whoever's there usually looks around and goes, "Yeah, I don't care." In some cases it is reassuring to the individual as well because sometimes they think that their partner cares about that, and then to hear that it may not be an important factor in their relationship, it does give them at times some reassurance that, "Hey, who cares? It's not as big of a deal."
And so I try to reassure folks that way because those are just the facts of how it is. And also, "Hey, if you lose some of your testicular size, but you have a better libido, and you have better energy, isn't that worth it in the end?"
And so kind of having those conversations of, "Hey, the benefits are going to outweigh this little thing that you've got a hang-up on."
Interviewer: Right. So you just kind of have to let them work through it. Have you ever had patients that are just like, "Absolutely not. I can't do it"?
Dr. Smith: Oftentimes, if they're interested in testosterone therapy, they'll usually look for an addition of HCG to try to maintain that testicular size, and it's usually not a deal breaker for them in that regard. I've never had anybody come in and say, "Absolutely not. I would never do it because of the testicular size loss."
Interviewer: It sounds like most guys realize, "If this is a treatment that I need, the benefits are going to far outweigh the downside of some shrinkage."
Dr. Smith: Exactly. And I think that's very apparent when you see how a lot of these guys just start on therapy. They realize how good they feel. Their energy levels go up. They have an increase in their libido. For some of them, it helps erectile quality, and they look and they say, "Okay, this is much more beneficial than worrying about the testicular size."
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