Oct 25, 2022

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Scot: You guys want to hear an epic tale?

Mitch: How epic?

Troy: I'm ready.

Scot: Should I tell it in my epic tale voice?

Troy: Please.

Scot: There are other people around though and I think they can hear me, so I'm feeling a little shy about it right now.

Dr. Smith: Let it go.

Scot: The office I . . . Listen and you shall hear the tale of two guys and testosterone therapy. One guy got amazing life-changing results, the other none, nothing, nada, zip, zero, bupkis. In the telling of this tale of T, we hope we can help all men learn why T works for some guys and not others. Was that epic?

Troy: That's epic. Who uses the word bupkis anymore, though? Bupkis?

Scot: This is "Who Cares About Men's Health," providing information, inspiration, and a different interpretation of men's health. And today, to tell the tale of T are the "Who Cares About Men's Health" players. I am Scot and, obviously, I bring the BS. Balancing my BS with his MD is Dr. Troy Madsen.

Troy: I'm not part of the tale of T, but I'm excited to learn more about it.

Scot: But your name begins with T.

Troy: Oh, that's right.

Scot: Producer Mitch is also in the mix.

Mitch: Hey, there. I didn't know we were players. I kind of like that.

Scot: And Dr. John Smith is from the Division of Urology at University Utah Health. And he's going to talk us through testosterone therapy in our tale of two different guys with two very different experiences with testosterone. Dr. Smith, as always, it's great having you on the show.

Dr. Smith: Gentlemen, thank you for having me.

Scot: By the way, your shows that you do with us are quite often the most listened to shows. And I don't know if it's because the topics you talk about are just really that interesting to people, or if it's because you have lots of family members. But I don't care. It doesn't matter to me.

Dr. Smith: We Smiths are a large clan.

Scot: There's kind of this implied thing and . . . I don't know. Maybe it's just me, but I think it's a lot of guys, that testosterone is kind of a cure-all for men who are suffering from fatigue, or struggling to lose weight, or struggling to put on muscle mass, or their sex drive is reduced. So it's kind of like, "All guys should be on it," right?

But we've talked about testosterone on the show before and testosterone therapy, and it's not a magic bullet. It works for some guys, and some guys, it doesn't necessarily work for. The only time it's a magic bullet apparently is if you're Mitch. We're going to hear about his pretty amazing story with testosterone.

And then, on the other hand, we're going to hear about my experience that I had with it that I haven't really talked about on the show, because I had a hard time putting it into words and figuring out what that story was. But after hearing Mitch's story, I figured out what my story is.

And I think in this process, we could kind of learn a little something about testosterone therapy, that it's not this universal cure-all. And Dr. Smith would back that up, right? It's not a universal cure-all like the ads would have you believe.

Dr. Smith: Well, I think a lot of it depends too on your patient selection. A lot of guys come in because they hear about a guy like Mitch where it changes things for them, their life is great, they have a lot of benefit from it. And they go get their testosterone checked, and they may not even have low testosterone. It may be something else. And so you do see a relative benefit for some and not others based on lab results and other things.

Scot: So, back in Episode 102, Dr. Smith talked about how maybe some guys with low testosterone might slip through the cracks because their doctors aren't necessarily familiar with hormone therapies or they're not comfortable with them as opposed to Dr. Smith, who's studied this and has put in more time as an expert. Not saying anything bad about anybody else. It's just that he's had a lot more experience with it.

So that conversation made Mitch seek a second opinion that's made a huge difference in all aspects of his health. And I think this is a great chance to hear Mitch's story, what he was struggling with, and then the process that he went through to finally get on testosterone therapy and find out how that's impacted his life.

And I think it's a great story of how testosterone therapy can help some men, and how you also kind of need to be an advocate for your own health sometimes. You have to kind of work through the system. So, Mitch, tell us your story.

Mitch: It was very interesting. The recording of that particular episode was like smack dab in the middle of a yearlong struggle with some really, really severe fatigue, right? And we're talking physical, mental. Every day I was just tired. I was dragging myself, and I felt it in my joints. I felt it in my brain. And it just kind of kept getting worse and worse.

And we talk about on the show, "Oh, yeah, get more physical activity. Change your diet." If you're so tired all the time, the idea of getting up and running for 30 minutes, I'd be completely worn out for the rest of the day. I would just be that physically exhausted.

And it was even my therapist, my mental health person, who was saying, "Hey, you're obviously not doing the work that we're doing every week because you're so tired. You're so out of it. We can't help pull you out of whatever's going on if you're this out of it."

So after kind of talking through it and just struggling with all of this, I decided to go to my PCP. And I told him, "Hey, I'm dealing with some severe fatigue. It's been going for a very long time," blah, blah, blah. But I was like, "Hey, what could be wrong?" And so he did a whole bunch of panels. We ruled out things like diabetes and all these other conditions. He took tons of vials of blood out of me, and they all came back normal.

And he kind of said, "Well, why don't we try some lifestyle changes?" So I tried. For months, I was doing healthy meals every day. I was going to bed at a certain time. I was trying to drag myself out of bed every morning just to go on a little jog or working out. I was doing everything I possibly could, but I still was tired and I was putting on weight.

And even when I went back and I said, "Hey, I've tried the things and I don't mean to backseat doctor, I'm just a podcaster, but I have a feeling that something else is going on. I'm not lying to you. I really am doing all the things I think I'm supposed to." And the response was to prescribe me antidepressants. There was such a confidence in my doctor that it must be something mental that's causing my exhaustion.

And I took him at face value, so I went and I took the antidepressants. I tried it out and had kind of weird motional swings for a week or two. And I don't know, it still wasn't going away.

And about that time is when we recorded the episode. If there's any love letter to the show and the idea that talking about health can be a huge change for people, we had a conversation about this very thing where it's like, "Hey, sometimes your PCP might not feel super comfortable giving you hormone therapy because they're not super trained in it."

And after hearing that, I decided to reach out to Dr. John Smith because what better men's health person to talk to you than someone I've already interviewed? We got the test done, and sure enough, my levels were pretty low. They were under 300. We took both of them in the morning to make sure we were minimizing any other potential things that were going on. But I had really low testosterone.

Dr. Smith: Mitch, I love your story because your PCP is awesome. The fact that he took the time to go through all of those things with you and make sure that it's not something else. I have a lot of people's PCPs who won't take that time. Not that they don't have the time, but sometimes PCPs are overwhelmed.

But bless his heart, or her, for going through the time to get the blood work and make sure all those things are normal. Because I've found plenty of folks who come in who have thyroid issues or other issues that are causing their fatigue. So I just wanted to put a plug in for your PCP and some kudos and a pat on the back for taking the time to really make sure that they covered all their bases.

Troy: I'm curious too, John, hearing this, what do you think happened with that blood test with the testosterone level with his PCP? Because it sounds like it was above 300 and then when you tested it was well under 300. Do you think that was testosterone levels dropping over time, or maybe just the way the PCP did the test? What's your take there?

Dr. Smith: So I've had patients who've had three or four testosterone levels done. They'll have one that's in the low 300s, and then the next one will be like 240. And then they'll have one that's like 380. And so it does vary based on diet, exercise, and some of those things that are going on. We don't fully know 100% why, but it is variable. But most of the time, those people who are lower tend to be lower on average.

And so insurance requires two morning draw testosterones. And the AUA, or the American Urologic Association, has also kind of backed that up of two morning draw testosterones that show a low level.

Scot: And what if a patient is at, like, 320? Three hundred is the lower limit. Is it up to a doctor's discretion at that point based on symptoms, or how does that work?

Dr. Smith: Patients who are symptomatic in the low 300s, sometimes they do benefit from testosterone where their body does need to be a little bit higher in that normal range. And so taking the opportunity to try it. Like you said, some people it's great and it works, and some people don't notice a huge benefit when they are supplemented in that range.

But sometimes it's worth a try, especially if you've tried other things, you've got other lab work, and everything looks normal. Well, let's try it and see if we can benefit you and help your fatigue and those other things.

So it is kind of doctor discretion and having that conversation with your patient of, "Hey, this is may be very helpful and it may not. Let's find out and just see."

Troy: You mentioned also insurance coverage. Does insurance require levels less than 300 to pay for the treatment?

Dr. Smith: Usually they do want to see low levels of testosterone before they'll pay for treatment. A lot of them aren't sticklers. If you're like 330, 320 and you have a second level that's like 289 or 301, they're usually pretty good about making sure that things are taken care of.

However, that being said, certain forms of testosterone replacement are fairly inexpensive with discount programs like GoodRx, and SingleCare, some of these websites online that have kind of created relationships with pharmacies to give people discounts. So it's not this cost burden if insurance did ever balk it and your doctor was like, "Hey, I think you'd really benefit."

Troy: So I have to ask you this just because you kind of went that direction too. If someone's paying out of pocket, what does it cost?

Dr. Smith: So injectable testosterone is by far the least expensive. And depending on what your dose is, you can get two or three months for $20, $25.

Mitch: Oh, wow.

Troy: Oh, wow. That's super cheap.

Dr. Smith: So it's not this killer expense. And then other forms of it, if you want to be fertility friendly and things like that, there are some other off-label uses for medications like clomiphene, which we've talked about, or Clomid. And that again is something that you're going to pay $20, $30 for a few months' worth of medication. So the cost burden is there but $20, $30, if it changed your energy level and a lot of those things, is completely worth it.

Troy: That's surprisingly inexpensive. As someone who's purchased over-the-counter omeprazole, I will say that's a whole lot less expensive than treating yourself for heartburn.

Scot: Wow.

Troy: I'm surprised at how inexpensive that is.

Scot: So what was Mitch diagnosed with? Was it just low testosterone or is there a specific name for it or?

Dr. Smith: So the $500 word is hypogonadism. Everyone else just says low T. But it's the exact same thing.

Scot: I'm going to choose low T.

Troy: I know. Hypogonadism just doesn't sound good. Let's go low T.

Dr. Smith: Low T works very well.

Scot: Yeah. So I was surprised when Mitch told me what his particular treatment option was because . . . and I'll get to my story in a bit. I used a rub-on cream, which I think is actually testosterone, right? But it wasn't testosterone that Mitch got. It was something else.

Dr. Smith: So Mitch was put on a drug called Clomid. And this drug stimulates the brain, the pituitary to produce hormones. One is called luteinizing hormone. The other one is called follicle-stimulating hormone. And these two hormones stimulate the testicles to make testosterone and sperm. And in that way, we were able to alter the body's production of sperm and up-regulate it. And so that's what the drug that Mitch had, or has, does.

Now, the creams and the injections are giving exogenous testosterone into the body and actually causes the body to kind of shut down its own production because we're giving the body this exogenous testosterone. And so that's kind of the difference between those two, even though both of them are very beneficial for patients.

Mitch: So with the medication I'm on, my body and my testicles are capable of producing testosterone, but for one reason or another, it wasn't making enough. And so we're now putting a drug into jack those numbers up. Is that how it kind of works?

Dr. Smith: Exactly.

Troy: Talking about the Clomid . . . I don't know that we ever really talked about why Mitch is on Clomid versus exogenous testosterone. Mitch, was that a decision you made kind of hearing side effects and what's involved in each one? Or, John, is that typically first-line treatment? What was that decision process?

Mitch: So Dr. Smith was really, really good. We had a conversation, right? He talked through the different options and he said, "Hey, some patients prefer this over this. Here's why." Here's blah, blah, blah. And so, for me at least, it was a joint decision.

And it sounded like, for me, that Clomid was the easiest entry point, right? See if my body can make this stuff anyway, and if it can, great. If not, we can try something else. And taking half a pill every other day is a whole lot easier for me than getting injections or a magic cream or whatever. So I thought I would start with that first.

Scot: Dr. Smith, does Clomid work for some men and not quite so well for others? Are there kind of some criteria that you would use to have that be the first thing, or is that generally the first thing you try?

Dr. Smith: No. I usually have a conversation, like Mitch said. I like to lay out the options because I feel like the more information the patient has, the better off they are.

And some people prefer to take a pill versus giving themselves an injection versus having a cream. Each one of them has a plus and a minus to them. And so having that conversation, giving them the options, letting them know what is available, and then what fits best for their lifestyle. That's how I like to do it personally.

Clomid may not work for some people because if the testicles of a certain individual are not able to produce sufficient testosterone, then the Clomid isn't going to help. No matter how much we stimulate the testicles, if they're unable to produce what we need them to produce, it's not going to make a difference. And so in certain individuals, that isn't an option that works.

We'll try it and then they'll come back and their labs haven't changed and they're like, "Well, what happened?" And I say, "Well, your testicles just can't produce anymore, so you need to be on exogenous testosterone. We need to give you testosterone because you can't make your own." So those would be the people who Clomid would not work for.

Scot: So is there anything else we need to cover about what Mitch is on? Should we just get to Mitch's results? Is there anything else to that part of the story, Mitch? You went through this.

Mitch: No, not really. I got on a cheap pill and things turned around. It was awesome.

Scot: Yeah, but drastically, the kind of drastic that we make fun of. Like, it's the silver bullet. We spent a lot of time . . . at least I felt like I did. Maybe Dr. Smith didn't. But upon reflection, I wanted to communicate this is not a silver bullet, right? You still have to do these other things, and you should try these other things. But for you, it was kind of a silver bullet.

Mitch: Yeah. It was night and day. It took me about a week to notice anything. So I show up to the pharmacy, I pay my $30, I get this big pile of meds, and I just start taking one. And after about a week, that weekend I woke up feeling like I had had the first full night's rest that I've had in years, right? I just woke up and felt amazing.

And it kept going. I could keep having energy. When I got done with work I actually felt like I could do something in my evening, like I could work out, or go for a walk, or do a hobby, or something, rather than just crash in front of Netflix and order GrubHub.

And it wasn't just that. I was suddenly able to work out without feeling completely wrecked, right? It used to be I'd do a hard set at a gym or something like that and I would just . . . it would drain the last bit of energy I had left in me, and so I just would crash.

And it just felt good mentally. Mentally, I was able to be sharper. I was able to focus on things. This brain fog and overall physical fatigue that was going on completely disappeared. And then on top of that, I lost 25 pounds in a month.

Troy: That was the crazy part.

Mitch: After years of struggling with weight and doing everything I was supposed to and never seeing anything, suddenly a month after getting on this medication, I lost all of . . . It's slowed down now. I'm not continuing to lose all this weight. But it's like something suddenly fell into place and my body worked.

Troy: You lost weight, and you also put on muscle mass too, didn't you?

Mitch: Yeah, I did. But we don't know the exact number.

Scot: He's got to be honest about that.

Troy: You're just downplaying that part. "Yeah, I'm pretty ripped now."

Mitch: I am not ripped, but . . .

Troy: You probably are.

Mitch: No.

Troy: I haven't seen you in a couple months. But this was how long ago? When did you first start the treatment?

Mitch: This summer actually, so a couple months ago.

Troy: So it's been a couple of months. That's what I wondered too with treatment. Is it like there's sort of this honeymoon phase where everything is great and you feel good, and you lose weight, and then after a month, everything kind of levels off or maybe there's a little bit of a rebound? But it sounds like, in your case, everything is still good. Things are going well.

Mitch: I mean, I'm not still losing two or three pounds a week, but I still have my energy. I still feel mentally sharp and good. And they're talking about maybe even minimizing and taking me off of some of my mental health medication I've been on because of how much better I'm doing.

Troy: Wow.

Mitch: Yeah, big change.

Troy: That's great. No, that's huge. John, is that typical? Is Mitch's experience typical?

Dr. Smith: I think Mitch is at the higher end of what people experience. I will say most people within the first year, the testosterone literature will tell you that you'll have a body mass change where you'll lose about 2.5 kilograms of body fat and you'll increase lean muscle mass. So that's something that you see across the board.

Mitch is probably someone who is in better shape than most of my patients. So folks who are a little bit more out of shape may not notice that muscle mass change as much as Mitch did. Because Mitch has done a very nice job of staying in shape and taking care of his body and being in a good body mass to start, and that makes a huge difference for patients.

But I would say Mitch is on the higher end of people who have done very, very well and are very pleased with their treatment.

I would say, overall, most people who get a benefit, they do maintain that energy improvement and things like that.

On a caveat, if you have the desire to go to the gym and you're just too tired, the testosterone isn't going to make you want to go to the gym. But if you had that inherently before and the fatigue was impacting you, once you get that energy back, you're going to want to go back to those things that you enjoyed, if that makes sense.

Scot: Mitch also talked about how mentally he was feeling better. Is that common that the testosterone can help there? What do you think is going on with that, Dr. Smith?

Dr. Smith: So there is some debate on that, but overall, when you have more energy, you feel better, you're able to go and do the things that you like to do, you have the energy to go do the things you like to do, your mental health status changes, and you feel better. And I think that just stands to reason.

People who get a good result from hormone therapy of one reason or another, they tend to be happier. They tend to feel better. Because when you feel better and you're able to go and be active and do things and have energy to do things, overall you do feel better. Overall, things are just better.

Scot: All right, Mitch. Now the dark side. Are there any side effects?

Mitch: But they're all testosterone related. It's not like the medication . . . It's like Dr. Smith was talking about earlier. I used to have to shave maybe once every week and a half. Now I'm shaving twice a week. So we'll see if I can . . .

Scot: Like a regular teen wolf.

Troy: Wait a second. You used to only shave once every week and a half? Was this because you wanted to grow out a beard and then you'd shave it off, or . . .

Mitch: No, I couldn't grow any facial hair. I've always been a little baby face. So yeah, I'm having to learn how to shave all over again and more frequently.

Troy: But to say more frequently, just twice a week, though.

Mitch: Yeah. That's a significant change.

Troy: From every week and a half, yeah.

Mitch: I'm doing that. I got a little bit of acne on the body. I've been like zit-free since I was 18, 19, and now I'm getting little bumps on my body every now and then. But nothing, a little bit of whatever little special acne stuff or whatever won't help.

And after we chitchatted last time, I'm growing my hair out. I've got this awesome mane going these days, and I started to see it coming out in my comb. So went to Dr. Smith and was like, "Hey, I think I might be losing some of my hair." And he's got me on Propecia. Haven't had any side effects with that. And I guess that'll help control any hair loss that might be involved.

But any of those changes, I would not trade for the world. Being a little hairier, a little zittier, and maybe a little thinner in the hair, I am fine. I would much prefer that than just being tired and miserable all the time.

Troy: So you're going to have this killer beard going on and shave your head, but you're going to feel good.

Mitch: Yeah, 100%.

Troy: Take it.

Dr. Smith: Mr. March of the "Who Cares About Men's Health Podcast," Mountain Man Mitch.

Mitch: We'll see.

Scot: I've been looking for a name for you. I think we might have it there. Thanks, Dr. Smith. I like it.

Troy: Triple M.

Scot: Yeah, that's good. Are there other side effects that some guys would experience in addition to what Mitch is talking about?

Dr. Smith: So those are very typical. Increased testosterone can increase male-pattern baldness. You can get some acne, increased body hair, facial hair, those types of things. Kind of like when you're going through puberty, some of those similar things when the testosterone levels kind of raise like that.

We always watch the red blood cell count because it will stimulate that. Testicular size changes in the case of people who are on exogenous testosterone. It doesn't happen with the Clomid like Mitch is on.

Those are the big ones that most people see. The medication that Mitch is on, the Clomid, some people will have a little bit more of a moodiness or mood swings. They feel like they would cry during a Hallmark movie kind of a thing. Their emotions are a little bit closer to the surface.

I had a guy literally tell me that one time. He's like, "I feel great. I feel like I'm going to cry at a Hallmark movie." And I said, "Okay, so your emotions are a little bit closer to the surface." And he's like, "Yeah, that's kind of what's going on." And so that's the biggest thing with Clomid that people tend to see. But that's pretty typical.

Scot: So after hearing Mitch's story, I got curious about testosterone again myself because I feel like I kind of have the same things. I feel like I've been exercising and doing the right things, but losing body fat is difficult. I feel like I kind of have low energy and some of those things.

I had tried testosterone before back around 2010, so 13 years ago. I had just turned 40 and it really didn't work for me. So I thought, "Well, I'll get my levels tested again and see how they look." And my levels came back right in the middle, like at 650.

That's about as average as you can get, right, Dr. Smith? Because I am the most average man on the face of the earth. You ask me my skills and ability in anything, it's going to be average.

Anyway, with that number, I made the assumption that testosterone therapy is really not going to help me. Would that be a good assumption to make, that that's probably not the issue?

Dr. Smith: Yes. If you're asking me the question, I would say yes. Because if you're in the normal range, there's not a lot of benefit to be had. Now, some people may disagree, but I look at you have a certain number of receptors for testosterone. And if you think about it like a parking lot, if you have 600 parking spaces and 1,400 cars, it really doesn't matter how many parking spaces you have, you're not going to be able to fit all the cars.

And so with a normal testosterone in a normal range, you're going to be saturating those parking spaces, aka those receptors, that the testosterone interacts with. And so the benefit ratio of taking someone with low testosterone where there are too many open parking spaces, so to speak, to someone who's got almost all the parking spaces full all the time, you can see how the benefit would be there or wouldn't be there. And so normal testosterone, adding more doesn't necessarily improve things.

Scot: So I'm going to say, first of all, you have the best analogies of any of our guests ever. Every single episode, you just nail it with an analogy. That was awesome.

Troy: Parking spaces. That makes perfect sense.

Scot: That was fantastic. So I'm going to try to keep my story short when I tried testosterone for the first time. I tried it for a couple of years and really didn't notice any benefits, and it was a lot more hassle than it was worth.

So I had just turned 40 and I was working at a place and there was this guy that was really super muscular. He was younger, and he was like, "Oh, man, as soon as I turn 30, I'm going to go to the doctor and get testosterone therapy." Because he is under this impression that you start losing testosterone as you get older, which is true.

And then you see the ads in the media, and there, again, this seems to be recurring in my life, low energy. I've always wanted to put on muscle and I've always found it difficult even when I weight train. Losing the fat is difficult even when I feel as though I'm doing things right.

So I had another friend who started testosterone, had some results like Mitch. It gave him this energy and drive again. So he referred me to this particular doctor. I got the test. They got the levels. They put me on the cream. I did that for a couple years. After a few months, they ended up putting me on some pills to balance the hormones that the testosterone cream was causing.

And I also didn't like the fact that since I was using the cream, I had to be really careful my spouse didn't get near it. And I really wasn't noticing any difference. So I just ultimately kind of ended up quitting that.

Fast forward to the last episode we did, I thought, "Wow, I wonder if I could go back and pull those old labs and see what my testosterone levels were." And even back then, they were around 600 and 650.

So what this physician and I were trying to do is we were trying to optimize, get at that upper level thinking that that's going to make me feel even better.

And after learning from you, Dr. Smith, and your awesome parking space analogy, it makes total sense why that didn't help me. So in that case, testosterone really wasn't the solution for my problems or my perceived problems of energy and whatnot.

So in a way, I'm kind of jealous of Mitch, but also in a way, I'm glad to know that everything is okay. And maybe now I can kind of be a little bit more honest with myself. Am I going to bed at a decent time? Am I eating the way I need to be eating? Am I getting enough calories? Could there be some other reasons why I feel like I'm tired, or is it just my perception?

So that was my story, which is very drastically different from Mitch's, but I think it really illustrates that if you don't need it, getting more is not going to necessarily help.

Mitch: So did you have any response to the treatment? Did you feel anything other than just kind of the same?

Scot: No, not really. I think at first I kind of thought maybe I did, but that could have been the placebo effect. I don't know. Ultimately, I didn't notice a whole lot of difference over the long term. And that, in combination with the downsides, is kind of why I just decided to stop.

Dr. Smith: Scot, that's been a little while ago. Have you had your levels rechecked recently?

Scot: Yeah, I just had them rechecked after Mitch had such success with his treatment and found that they're just dead in the middle.

Troy: They're still . . .

Scot: That's that 650 level.

Troy: Okay. So still 650. Yeah, maybe I missed that. Because you were 650 years ago, and just everything has stayed exactly the same. Clearly no benefit for you to go on testosterone at this point.

Scot: Yeah. So what was the difference there between my experience and Mitch's experience, Dr. Smith? Do you have any more insight to that?

Dr. Smith: So we kind of talked about this a little earlier. Mitch had low testosterone, so adding more cars to the parking lot made sense. For you, you could make the argument that you may have even changed the cars in the parking lot initially because when you start testosterone, your body is going to shut down your production. And so you're really just keeping yourself at that same level.

And I don't know what your labs looked like, if they rechecked your labs and things. But I've had people who've come in to me from other outside places who've said, "I've been on testosterone for about a year and a half." And they bring me their original labs and they're kind of like yours or kind of in the middle of the range, 550, 600. And I look at their numbers on testosterone and they're, like, 720. And so really, they didn't do a whole lot other than shut down their body's native production.

Now, I've had some people come in who were just being dosed up very, very high, who their testosterone levels were off the charts. And some of them said, "Oh, I feel great." And some of that, I'm guessing, is placebo.

But I've had some patients who, at a higher range, they do say they feel better. And I don't know that it's all placebo. And so there could be some benefit to that.

But being in the normal range, you're not going to get a ton of benefit. And so I think that's really where we look at it and we say there's not a whole lot more that you need to do.

And I would say that some of the patients I have that come in, they'll get sent by their primary doctor after they've had a couple of testosterone tests that are in the normal range. And they'll come in and I'll look at them and they may be . . . Their body habitus may be larger.

I'll ask them questions like, "Do you snore?" Because I've diagnosed plenty of folks with sleep apnea where they get that treated and they feel like a million dollars. And it wasn't their testosterone. It's that they were waking up 30 times a night because they were having sleep apnea events during the night. Things like that I've seen.

You have to ask the questions around to get to the answer for some of those folks. Some people may be on extreme diets trying to lose weight and they're like, "I'm just tired." And I'm like, "Yeah, you're eating 500 calories a day. I don't know why you would be tired."

Things like that are going on where you've got to ask the questions because you'll get to the answer. "Hey, well, if you start eating 1,200 calories or 1,500 calories, you'll probably have more energy because your body is not going to try to store everything thinking that it's never going to eat again."

And so some of those things I see in folks where they have symptoms but their testosterone is in that middle of the road, kind of like yours was, Scot.

Troy: Speaking of levels, I know we're talking about you, Scot, but I've got to bring it back to Mitch. Mitch, do you know what your level is now?

Mitch: It's in the 700s.

Dr. Smith: So he's not through the roof, but he's pushing towards the upper end of the normal range.

Troy: Yeah. Nice.

Scot: I mean, I feel completely great with my decision now in retrospect, because I think being on it could cause more problems for me when I didn't have a problem to begin with, right? Because there are downsides. Doesn't your body kind of stop making it if you're putting cream on long enough?

Dr. Smith: Yeah.

Scot: Any take-home messages? What are the take-home messages here, Troy? What do you think? What did you get out of this episode?

Troy: My take-home message from all this is if you're experiencing something like Mitch experienced, it makes sense to get your testosterone level checked. And it also makes sense to pursue treatment when treatment will work. And if the parking spaces are full, there's no point in putting more cars in the parking lot. That's my takeaway.

Mitch: Sure. That's a good one.

Scot: How about you, Mitch?

Mitch: I think the big one for me is to talk to each other about health. I would not have been on this kind of journey, I would not have advocated for myself, I would not have sought out a second opinion had I not talked to other men on this podcast and in my life about testosterone, about their experience with it, etc. I would not be where I am today or thinking about my health the way it was if I did not talk to other men about my health.

Scot: Dr. Smith, do you have something that you'd like to throw out as a take-home message?

Dr. Smith: I love it. I'm super happy for Mitch. And I'm also happy that you were able to kind of find your way. You mentioned it earlier about being an advocate. I tell patients all the time, "I get to see you for 15 minutes and you know your body a heck of a lot better than I do. And so if you think something is wrong . . ." Like Mitch, he was like, "There's just something missing here. What is it?"

Being an advocate for yourself and finding someone to have that conversation with about these things, because it can make the difference. Or it may not make the difference, but at least you'll understand the reason why and you can then make the informed decision of which way to go.

So I think that, for me, was the take-home. You guys both did that in your own way even though you ended up in two different places.

Scot: And those gentlemen are the two tales of T today on "Who Cares About Men's Health." Great conversation. Guys, as always, it's a pleasure to get together and talk about men's health. Dr. Smith, it was great having you on the show. Thank you for listening, and thank you for caring about men's health.

Dr. Smith: Take care.


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