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168: If It's Not Low Testosterone, What Is It?

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168: If It's Not Low Testosterone, What Is It?

Feb 27, 2024

Feeling sluggish, uninterested in the gym, or more cuddly around the midsection? Before you blame it all on low testosterone and rush to the supplement aisle, join the Who Cars Guys and Dr. John Smith as they look at the other culprits that might be messing with your mojo. Spoiler: Your T levels might not be the villain here.

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    Scot: All right. You think that maybe testosterone treatment is going to help you with the symptoms you are experiencing, but then you find out your testosterone is fine. You still have symptoms, though. So then what? What's next? We're going to find out today.

    This is "Who Cares About Men's Health," with information, inspiration, and a different interpretation of men's health. My name is Scot. I bring the BS. The MD to my BS, urologist Dr. John Smith.

    Dr. Smith: Good morning. How are you?

    Scot: And also a guy who cares about men's health . . . he's become a men's health advocate, actually. It's been an amazing transformation. Mitch Sears is on the show.

    Mitch: Hey there.

    Scot: All right. So the premise of this whole show today is a guy . . . I mean, we hear through popular culture . . . The symptom list is long about all the things that testosterone can impact or could be a reason for. Why don't you list off some of those symptoms that guys come in for testosterone treatment for? Give us that list.

    Dr. Smith: Yeah. So most people come in because they have a decrease in their libido or their sex drive. They have decreased energy or difficulty with focus, or brain fog is what a lot of folks will call it as. Some people as they age, too, will say, "I'm having difficulty maintaining muscle mass at the gym. Things just feel different." And that's generally what they have.

    And oftentimes when they come in to see me, too, they've also had a friend or family member who was like, "Oh, yeah, I got on testosterone and I feel so much better."

    Scot: That was my case. I knew a couple of guys that got on testosterone and their energy came back. And to me, that's a big thing. I feel kind of tired all the time and I'm like, "This is it. This is awesome. And if I get the side effect of now all of a sudden when I go to the gym and I work out, maybe some things start happening in a better way, or maybe the muscle mass doesn't go away, that would be great." But that ended up not being my case. Does that happen to a lot of guys?

    Dr. Smith: It happens a lot. So a lot of people that come to me already have low testosterone from their primary care doctors, and then other folks that come in to see me may have had a friend that came in to see someone in the men's health space or whatever. And so we get new labs with them, and they come in and they have a normal testosterone, like in 400 or 500 or 600, which is a normal level where a majority of people on the street are hanging out at.

    At that point, it's like, "Well, this isn't the cause of all of your symptoms." And so we look for other options of "What could this be?"

    Scot: Yeah. And I want to be sure . . . because I think this is an important point. Now, we've done other episodes on low testosterone and have gone into this in depth, but I think a misconception men have is, "Well, my testosterone is in the middle of the range. Boy, if I got it to the upper end of the range, then now we're really going." But that's not the case, you've told us.

    Dr. Smith: Well, there's not a lot of evidence to suggest that that's the case, that if you live at a higher level, you're necessarily going to feel better or things are going to be better.

    Obviously, I think there probably is placebo to a lot of things that people do in their life. And I think that there is more placebo there than not. Testosterone receptors can only be stimulated to a certain point, and then beyond that, you've filled up all the receptors and what are you stimulating after that? You just have testosterone floating around.

    Scot: Right. And I was right in the middle of that range, just kind of in that sweet spot. But at the time I was going to a different provider who was of the opinion, "Well, let's get you to the upper end of that range." And I can tell you in my experience, that didn't make a difference for me.

    It actually became more of a hassle because now I'm doing testosterone therapy. I'm taking some other pill because as a result of my testosterone therapy, something else is happening. And I ended up just bailing on it because I wasn't seeing the benefits.

    Dr. Smith: And you're not alone. I see that happen quite a bit. Now, I think there are people who say they do feel better at an upper limit of those ranges. But again, a majority of the patients that I see who are in the normal range, supplementing testosterone is not necessarily the answer and you may be actually missing other things that may be more beneficial for you.

    Scot: Now, Mitch actually did have low testosterone. Did it help you?

    Mitch: A lot, yeah. It was kind of interesting. I was constantly tired. I was having severe fatigue that just lasted forever. And finally went to a specialist and said, "Hey, can we test this?" And sure enough, I was quite low. Got me on a medication, and I got some energy back. I lost some weight. Things were going pretty well.

    But that being said, we're now, say, a year or two afterwards and my testosterone is fine, but other things are . . . I still sometimes feel tired and it's probably because of my sleeping habits or my lack of whatever. I no longer can blame testosterone for any of that.

    Scot: Right. But it did help to some extent.

    Dr. Smith, Mitch is the frustrating case for a guy like me who's like, "It worked for him, but I'm still experiencing the symptoms and it's not T." So let's go beyond that. Somebody has come in and you find out their testosterone is great. It's in that healthy range. What next? How do we address their symptoms?

    Dr. Smith: So I generally start with just asking some general questions. I mean, some of the easy ones to ask are, "What does your diet and exercise routine look like?" "Do you snore?" is a big one. "What do you do for work? What things are you involved in where you may or may not be out in the sun getting increases in your vitamin D, different vitamin deficiencies, things like that?" Those are some of the big ones that are easy, low-hanging fruit for me.

    If someone snores really bad or they're like, "Yeah, my partner says I snore like a trucker," I'm like, "You should probably get checked out for sleep apnea." And so people who have sleep apnea, they're not sleeping at night, they're not getting restful sleep, they're never getting into deep sleep, which is the restorative and restful sleep. And so those folks need to get in and see somebody.

    A lot of times, they don't want that to be the answer. "Well, I'd rather just do testosterone. I'll feel better, right?" And it's like, "No, you're not going to feel any better unless you treat the sleep apnea."

    Scot: So sleep apnea could be one of the things that you run into. In your practice, what do you tend to run into when it's not testosterone?

    Dr. Smith: So I usually run some lab work. I ask those questions and then I also get some lab work. I check people's thyroid, because thyroid is another driver of metabolism and energy kind of maintenance in the body. I'll check vitamins like vitamin D, vitamin B12, things like that, that are also known to be energy-helping vitamins.

    And I find that most people who live where we live are low on vitamin D unless they're supplementing, because we just don't get out enough in the sun. Our bodies can create vitamin D. However, we supplement our food. Some of our foods are fortified with that as well.

    And then on the flip side of that, if you're not out producing vitamin D, you've got to supplement it somehow. And that can really be a good vitamin to have. I think anybody that lives in our area, in our parallel, should be supplementing vitamin D because you're likely low.

    B12 is another one that can really be beneficial. I mean, you've probably seen ads for different places where you can come in and get an IV with vitamins in it or, "You can get your B12 shot here." Those do help quite a bit.

    And then also just looking at other things in that regard, and looking at sleep apnea, looking at those things as well, checking diabetic markers.

    And then talking to people about just overall diet and exercise. If you're eating McDonald's every single day, one meal a day, and you're not exercising, I'm going to tell you right now, your body is not going to be getting the nutrition it needs and it's going to be running in a really sluggish pace. And so some of those things of talking about diet and exercise can really be beneficial for these folks.

    Scot: Got it. So you ask some questions, you run some tests, and then after you do those things . . . back to kind of the original question there, but I'm glad you expanded on that for us . . . what generally do you see in your practice then? Is there anything that kind of tends to stand out to be the cause more than anything else?

    Dr. Smith: Yeah, most people that I check their vitamin D, it's low. I think it's a rarity that I find somebody who's not low. That would be number one.

    And then the other things, I do diagnose quite a bit of sleep apnea because a lot of people are like, "Oh, I thought it was testosterone." And then when you're like, "No, it's not testosterone. You should get that checked out," then they're finally like, "Well, I don't have an excuse not to get this checked out now." And so they go and get that done, and that does a world of difference for people.

    I do catch people's thyroid disease when they haven't seen their primary doctor, because as we've talked about before, men don't like to go to the doctor. And so once they get into my office, I can check some of those labs and really kind of drill down on that.

    I think overall, a lot of the diet exercise. But another one that Mitch hit on is sleeping patterns. And that's something that I'll drill down on with people too, called sleep hygiene. When are you going to bed? What are you doing around the times you're going to bed? Are you getting restful sleep? Are you allowing yourself to get restful sleep?

    A lot of people will stay up later than they need to, and then they've got to get up early for work. So they're going to bed at 12:30, 1:00, and waking up at 5:30 to get to work. And so you're really not giving your body adequate rest. Of course you're tired, but they don't think about it because they've been doing it for so many years and their body just gets run down.

    And then maybe your diet gets a little bit less clean, and those things just really . . . I drill down on that with people because it makes a huge difference.

    Scot: Yeah. We talk about the Core Four, and sleep is one of them, right? What you're putting in your body for food/your diet, your exercise, your mental health, and sleep is right up there. Mitch, go ahead.

    Mitch: Recently I've felt kind of tired and fatigued, and there was just a moment where I'm like, "Am I low on testosterone again?" But then I checked my sleep tracker and I've been having some insomnia episodes, etc. It's like, "Oh, okay. Yep. That's what's going on. Not this magic hormone that's causing all of my ills."

    Dr. Smith: Yeah, I think we tend to understate those things because it's like, "Oh, man, I used to pull all-nighters when I was in college to get through classes and it didn't bother me. I could go out and party on Friday night with my friends or whatever." And so a lot of times we like to discount those things to make them not the thing, but it's always those simple things. It's like you say, your Core Four.

    And the mental health side of things is another thing. People who have high levels of anxiety and depression tend to have fatigue and have those things as well. And so getting those things treated and putting yourself in a good headspace can make a huge difference as well.

    Scot: I remember when I went to a doctor at one point who I said, "Could it be low testosterone?" And he started talking about the things you started talking about and I didn't want to hear it. I'm like, "No." In my head I'm like, "Fine. Whatever," and I went and found a different doctor who, like I said, had a different philosophy on it.

    But in retrospect, those were the things that I should have been focusing on, obviously, because testosterone was not the issue. And it was very challenging for me to be honest with myself about, "I get to bed pretty early. I'm getting enough sleep." But as soon as I start really paying attention, I'm like, "No, you're actually not. You're not getting the seven to nine hours that they say you should have."

    You're not getting to bed as early as you think. Maybe you're not eating as well as you think. You have this story you've been telling yourself that you're a person who gets out and gets activity, but actually in the past couple years that's changed quite a bit because of your job and your lifestyle. So you really have to kind of be honest.

    Is it difficult for men to be honest with themselves about that, or was that just me?

    Dr. Smith: No, I think you're right on. We juxtapose your tale of having normal testosterone and it not being the problem, and now Mitch had low testosterone, he felt great, but then when those other things tend to slide, you tend to have symptom return that you think is low testosterone, because that's what you heard on the TV. That's what you heard from your friends, right?

    And in reality, it is hard to be honest with ourselves. It's like when we talked about men who don't like to go to the doctor. None of us like to think that we're in any way not healthy. But when we really take stock on our lifestyle, it's like, "Well, what have you been eating? What have you been doing? How is your sleep?" A lot of those things do play a huge role.

    And again, I tend to level with people and I'm very blunt, for better or for worse. Some of my patients appreciate it, some of them not as much. But I tend to tell people, "Hey, I'm not here to be your best friend and tell you that everything is going to be okay. I'm here to help you feel better. That's why you came here and paid your copay, was so that I could help you understand what's going on that can better your life. And if testosterone is the answer, then great. But if it's not the answer, then we need to look at things that are really going to be of benefit to you."

    Mitch: Dr. Smith, I have this question. We do know that in my case, where I did have lower testosterone outside of the normal range, one of the reasons that I started feeling better was once my hormones got to a regular level, I could go and do more exercise. I did find myself sleeping better, and one thing after another, I was doing pretty well initially.

    Is there ever a point where we recognize that it might not be testosterone, but if someone is in the kind of lower ranges, that maybe a little bit of something will help kick start some of those life changes?"

    Dr. Smith: Sure. And I think people who are on the low-normal side of things, I've erred on the side of just saying, "Hey, let's see if this helps. Let's give you a dose that puts you into the normal range." Let's say you're 350, and low is considered 300 or whatever.

    I mean, that's the nice thing about hormone replacement, is there's no hard and fast rule of you have to be below a certain range. However, there are also the people who run fast and loose of, "Hey, you're at 600, 700. Let's put you at 1,300." And I don't think that's the right answer.

    But I think sometimes, yeah, I've given people that opportunity to see how it's beneficial. The difficult part, then, is to get somebody who can honestly assess it and say, "Yes, this has really been beneficial," or in Scot's case where he was like, "I really didn't see a benefit."

    And I think that's where you've got to have that open, honest conversation of, "How is this really going to benefit you and help you?" I've done that plenty of times. I don't think that's a bad thing to do, but I also think it's getting people to actually get out and exercise.

    The thing I tell patients all the time is testosterone is not this magic shot, magic pill, magic cream, whatever, that the second you start taking it, you're going to wake up in the morning and go, "I need to be at the gym."

    Mitch: It's not. One hundred percent it's not.

    Dr. Smith: The same motivation you had to play video games is the same motivation you're going to have to play video games whether you're on testosterone or not. It's not going to change your motivation.

    Now, it may change your energy level where you could go to the gym and work out, but you still . . . And that's where all these other things come in. If you've been in kind of a funk and you're like, "Things have been difficult and whatever," you've got to just get yourself to go and do those things.

    And a lot of times, I think if people would do that, that have normal testosterone, they would notice the benefits of exercise. They would notice the benefits of a lot of those things that really would kind of turn things, and they'd go, "Oh, man, I feel pretty good."

    Scot: I have a couple things, and then I want to talk about . . . We've talked a lot about testosterone for people who are experiencing energy issues, lack of energy, but let's talk about the sexual performance part of it and what you find helps men in that aspect when testosterone is not the issue.

    But before we get there, I think part of the other frustration is when you tell somebody, or when I hear, "Oh, you just need to eat better or exercise more," that can take some time to start feeling the benefits of those things. And maybe those benefits come so slowly you don't really notice them as they're coming. It's like the putting the frog in the water before it's boiling. You don't notice that heat. You don't notice the changes.

    Do you find that to be the case? Does it take some time? Are the changes kind of so slow, or do you notice both ends of that spectrum?

    Dr. Smith: I see both. Obviously, the people who see the really wham bam impressions come back and they're like, "Man, I feel like myself again. I could play high school football again, whatever." And then you've got the people who come back and they're like, "I don't feel that much better, but I'm going to keep doing it because I think it's helping."

    And then they come back and I say, "Let's honestly retrospectively look at your activity level and your ability to recover from six months ago." And they go, "It's much, much better." They're able to kind of objectively look back and say, "Yeah, this all pans out." And so, yeah, I get to see both sides.

    But again, we live in a culture now where I can turn on my television and I can watch anything I want whenever I want. I don't have to wait for the song on the radio that I think sucks to be gone before I can move on. I can just go to my playlist and play something that I want to listen to. I can switch. And I think we look for those quick answers.

    There's nothing wrong with that. I think that's a society we live in, is this fast-paced, "get in, get out" society, when in reality some of these changes take a lot more time than maybe we're used to given our current culture.

    And so, yeah, I think sometimes you've got to be patient with yourself and realize that the little bit that you're doing now, six months down the road, if you took a picture of yourself every week at the changes in your body as you started working out, you would go, "Holy cow."

    It's kind of like that thing when you haven't seen somebody for a couple years and they've lost some weight or gained some weight or whatever. And you look at him and you go, "Man, he looks way different than before." But if you'd have seen him every single day, you probably wouldn't have said that.

    Scot: Yeah. And we had an episode where we talked about reevaluating. How are you evaluating successes when you make those types of changes in your life, like nutrition and exercise? It might not be, "Now all of a sudden you've got the beach body." It might be now, "Oh, wait, when I go in and try to do just a hang," which the internet tells me is a pretty good thing to do, where you just hang on a pull-up bar and kind of stretch out, "I can do it twice as long as I could three months ago."

    Your health and your physical ability have improved. That might not seem like much, and it might not be something you're going to brag about on the internet, but it is a positive change.

    The other thing I think that's important to bring up here is that testosterone does not improve your health. I mean, in the case where Mitch was then able to exercise, he decided he wanted to and he got a plan and he stuck to it and those hormonal changes did help him stick to it. That doesn't improve your health. That's accurate. However, we know that improving your diet and improving your activity level does improve your health even if you don't see that.

    Dr. Smith: Right. And again, testosterone is going to help optimize your body to be able to do what it's going to do. But if you're not giving it the right fuel, you're not giving it anything . . .

    I mean, you think about it like a car. If you put a new exhaust on your car, it may help some of those things, but it's not going to make the engine run any smoother and it's not going to fill the tank up with gas. It's going to give you some performance, but it's not going to do what your car wasn't doing before, if that makes sense.

    Scot: Your analogies are the best, by the way.

    Dr. Smith: I'm glad you appreciate them. But in reality, you're right. A lot of times, if you put good food in your body and then you get the desire to exercise and to put yourself in a good space to be healthy, you're going to see that benefit down the line.

    Scot: Yep. And it's small changes and the consistency, stuff we've talked about in different episodes. It doesn't have to be a major change.

    And to the time thing, I've been consistent with strength training. I have not been pushing myself super hard. But I've been consistent twice a week, one-hour sessions for seven months. And finally now I'm starting to notice some of those changes. So it doesn't necessarily always happen fast.

    But the way I keep myself going is I'm like, "Doing this is better for my health than not doing it." So even if I don't notice anything, I know that something is happening for the positive.

    Let's get to this other aspect of some of the symptoms some people might come in for, and that is their sexual performance. What do you notice there if you've got a guy that's got normal testosterone, but sexual performance is the concern?

    Dr. Smith: So testosterone is actually not known to improve erectile quality. It will improve libido, or your sex drive, your desire for sex. But it's not noted to be this great change of erectile quality.

    And so a lot of men come in and they're like, "I have erectile problems and I have low testosterone." Well, I look at those as two separate problems. Might the testosterone help your erections? Sure. But it might also do nothing. And so a lot of times we have those discussions with people.

    Erectile dysfunction and sexual performance and those types of things, there's a lot that kind of goes into that. But getting a general idea of people's sexual health and those types of things is important.

    And then discussing if they have a desire to improve things, whether they want to try to do that naturally or if they want to try medications and things like that.

    There's a lot of nuance there. Sometimes people have just gone through a rough patch or a breakup in a relationship and their confidence is down. And so their erectile quality is not what it normally would've been. And all they need is a short-term use of medication to help them get their confidence back. Sometimes they have vascular issues from diabetes or heart disease.

    So there's a lot of nuance there and things you kind of have to parse out. But again, finding someone that you can ask the right questions to and get the answers that you're looking for is what I would recommend.

    Scot: And as far as desire, I mean, that could be a lot of different things too. That could be a statement of the relationship with your partner. It could be mental health issues. It could come back to diet and nutrition. Is that correct?

    Dr. Smith: Absolutely. I mean, all those things factor in. Life. If you're worried about a parent that's in the hospital and they may pass soon, you're likely not focused on intercourse as much as you may have been during a newlywed period.

    And so, yeah, a lot of those things in life. You've got huge deadlines at work. You've got pressures. A lot of those things play roles in your desire for sexual activity at different times in your life.

    Scot: And I think the testosterone industry has done such a great job of saying, "This is the panacea. This is the pill that's going to change at all." Right? And sometimes that's just not the case.

    Dr. Smith: Oh, they're brilliant. Now, do I think that testosterone can be very helpful? Absolutely. I mean, listen to Mitch and listen to all the people who have low testosterone who get replacement/supplementation and then they feel really, really good about themselves. I mean, there's a reason. You've got all these people who are out there ready to go knock on doors and tell people the beauty of testosterone because it changed their life. But it's not always what's causing the problem.

    Scot: So if you're one of the guys who was hoping that maybe testosterone . . . I guess I chose those words very specifically because I was one of those guys. I was hoping that the testosterone was going to be what was going to help me with what was ailing me.

    But then you find out you're well within the normal range, as Dr. Smith explained. For the most part, research doesn't support that going above that range helps. Although sometimes it might, right? I mean, that's the nuance of why you want to have a professional.

    Just know that there are things you can do and your doctor should start diving in a little bit more deeply as opposed to just saying, "Well, testosterone is fine. Have a good day."

    Dr. Smith: Yeah. Exactly.

    Scot: And if you don't have a doctor that's doing that, then you probably should find somebody. I think we like to, as men, make things simple too, right? And it's a lot more nuanced than that.

    All right. Let's go ahead and wrap this up. Mitch, what are your takeaways from this episode?

    Mitch: It's to tell myself and remind myself that sometimes it is the simple things like diet, exercise, sleep, and mental health, and not always testosterone. But that doesn't mean you shouldn't know your body and find a professional that you can work with to find out where your testosterone actually is.

    Scot: I think mine is the same as when I came in. It's just that if you go in and testosterone is the cause and you get on treatment, great. And if that helps you, great. But if you're just kind of right in where you need to be, just be open and honest with yourself about those other things that Dr. Smith discussed.

    Find a physician that you can talk through those things with. Sometimes just the process of having those conversations can really help you better understand and also be more honest with yourself.

    And I think know that there is hope. So if you went to a primary care physician and they said, "Nope, you're good," that conversation needs to continue with either that person or someone. I think maybe that's it. That conversation needs to continue if you find yourself in that average range.

    Dr. Smith, do you have any last things you'd like to add?

    Dr. Smith: I think you nailed it. I think being open to testosterone being the thing, great. And if it's not, be open to looking at those avenues that are going to give you what you want.

    Ultimately, you're there to improve the fatigue, to improve the brain fog, to improve whatever symptoms you're having, and allowing yourself the opportunity to find a way to improve your situation is always there and always available. And finding the right person to help work with you on that is imperative.

    So I agree with all that completely, and I think that those are wise words for patients to really take in and say, "Hey, these are things that could change my life. And if it's not testosterone, I am willing to explore other options." Sometimes that is a hard thing to hear, is that it's not the thing we thought it was.

    Scot: Right. Explore other options, and then sometimes it's also not going to be as easy as a pill.

    Dr. Smith: Right.

    Scot: You might have to change some lifestyle stuff, which can be hard and difficult.

    Dr. Smith: The Core Four aren't a pill, and they are the things that will change your life.

    Scot: And if you need help with that, ask for that as well. Don't just think that it's easy to start exercising when that's not something you've done, or easy to start eating healthier when that's something you haven't done. You can ask for help for those things as well.

    Hit our back library. We talk about all those issues on past episodes of "Who Cares About Men's Health."

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