Testosterone and the hormone triangle, with Dr Mohit Khera

On this week’s podcast, Dr Louise is joined by Dr Mohit Khera, a US-based leading urology specialist treating urinary tract disorders, male infertility, and male and female sexual dysfunction.

They discuss the role of testosterone, the most biologically active hormone in the female body, why he believes testosterone is the best barometer of health of all hormones, and testosterone replacement.

For more information about Dr Mohit, click here, and you can follow him on Instagram @ drmohitkhera.

For more information on Newson Health, click here.

Dr Louise Newson’s first-ever live theatre tour, Hormones and Menopause – The Great Debate, takes place 27 September to 12 November. For more information and tickets, click here.

Transcript

Dr Louise Newson: [00:00:00] Hello. I’m Dr Louise Newson. I’m a GP and menopause specialist, and I’m also the founder of the Newson Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. I’m also the founder of the free balance app. Each week on my podcast, join me and my special guests where we discuss all things perimenopause and menopause. We talk about the latest research, bust myths on menopause symptoms and treatments, and often share moving and always inspirational personal stories. This podcast is brought to you by the Newson Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women. So I’m very excited on the podcast today because I have someone here with me remotely because he’s in America, mo Khera. He’s a professor of urology. And I have been reading his work, I’ve been watching his work. I’ve had him in high regard. But also many of you know, my husband’s urologist. And so he’s feeling quite left out that he is not here in this podcast because him and Mo have even danced together at conferences. They enjoy each other’s company. So it’s another connection. And I love connections. So welcome, Mo. So today we’re going to be talking about testosterone. So thank you so much for agreeing to come to the podcast. [00:01:28][87.7]

Dr Mohit Khera: [00:01:28] Thank you so much for having me on the show, Louise. [00:01:30][1.3]

Dr Louise Newson: [00:01:31] So we’ve been talking a lot before we started, and I could talk to you all day and all night because your knowledge is incredible. But I wanted to just talk really basically about testosterone. But before I start, could I just ask you why you urology, why did you get into doing urology? [00:01:47][16.5]

Dr Mohit Khera: [00:01:48] It’s probably the most amazing field in medicine. You know, urologists have the ability to be surgeons. So we get to operate and we also get to make the diagnosis. So we get to do both sides. And if you think about it, the population’s ageing, so more and more people will need a urologist. By the year 2050, 20% of the population globally will be over the age of 80. So think about that. So and I think the best field in urology really is sexual medicine and infertility. It’s what I specialise in, and it’s really been a passion for mine. [00:02:16][27.3]

Dr Louise Newson: [00:02:17] And Paul would also add that urologists are the nicest people, would you agree with that? [00:02:21][3.6]

Dr Mohit Khera: [00:02:21] I would agree, 100%. [00:02:21][0.0]

Dr Louise Newson: [00:02:24] And I actually agree. So I had the pleasure last year of lecturing for the British Association of Urological Surgeons (BAUS). Paul was in the audience, my husband, but actually in the coffee breaks, in the lunch break, everyone’s really friendly. They’re chatting, they’re laughing, they’re shaking hands, they’re sharing anecdotes. There’s none, no competitiveness. Whereas I’ve lectured a lots of other healthcare professionals’ meetings and conferences where people are a bit guarded. They’re always trying to protect, whether it’s their own clinical practice or just their own way that they, I don’t know. But something about urologists is that they’re very different. I don’t know if that’s the same in America? [00:03:08][44.7]

Dr Mohit Khera: [00:03:09] I may be biased, but I completely agree with you. [00:03:11][1.8]

Dr Louise Newson: [00:03:13] Which is great because we all learn from each other every single day. I keep saying to my children, every day is a learning day. There’s so much and medicine doesn’t stop. I wish I could sleep less because there’s so much to read and understand, and I feel really embarrassed doing a podcast about testosterone. Because if I had met you 12 years ago, I didn’t even know women had testosterone in their bodies. So I feel quite cheated as a doctor Mo, that I’ve had so long without knowledge. And now I’m going to say something which not everyone might agree with. But I think testosterone is one of the most important hormones for men and women. [00:03:55][42.4]

Dr Mohit Khera: [00:03:56] I would completely agree. And I would tell you that if you’re going to pick one hormone that’s the best barometer of overall health, it’s testosterone. And we’ll talk about that. There’s so many different body parts that are affected by testosterone in a negative and positive way. And for me it’s the best barometer of overall health. [00:04:15][18.1]

Dr Louise Newson: [00:04:16] And that’s really interesting because for many years, testosterone, certainly for women, has been spoken about just in respect to libido. And we can talk about that a bit later. And for men, it’s about whether they can have an erection or not. So when I started reading about just basic physiology, what does testosterone do in our bodies as human beings, whichever gender or sex we are? I’ve quite quickly realised that we have cells all over our body that respond to testosterone. And testosterone has really important biological process effects in our cells, including getting right down to our mitochondria. So it’s not just there for a laugh, it’s there for a reason, isn’t it? And all these cells and tissues and organs. [00:04:59][42.8]

Dr Mohit Khera: [00:05:01] Completely agree. And if you think about it, you know, we talk about testosterone for women. If you think about testosterone, actually the most commonly biologically active hormone in women, it’s not oestrogen. She has more testosterone than any other hormone in the body, but yet we don’t feel comfortable giving it back to her, which I never understood. [00:05:18][16.9]

Dr Louise Newson: [00:05:20] No. And I think more and more about this, actually, because it’s not really a menopause related decline unless someone is young and they have their ovaries removed because it’s more of an age-related decline. But it’s also not just ovaries that produce it. Of course our brain produces it. We’ve got cells that produce testosterone in our brains, but also our adrenal glands. Our muscles can produce testosterone. You know, it’s not just a gynaecological hormone, is it? [00:05:52][32.2]

Dr Mohit Khera: [00:05:53] And you bring up a good point. You know, so men and women are a little bit different. So men predominantly make their testosterone from the testicles, 90%, 10% from the adrenals. And women, it’s typically, you know, half of the testosterone is from the ovaries and half from the adrenal glands. So it’s slightly different. And, you know, with this concept of testosterone declining with age, I used to think that there was this real concept called male menopause. I used to give lectures on this and say, you know, when men get older, they go through male menopause. As they get older, the testosterone declines. But today we know that’s not true. Actually, it’s that ageing only has a slight decline in testosterone. It’s the acquisition of co-morbid conditions that drops a man’s testosterone over time. So diabetes, obesity, metabolic syndrome, slightly different than women because, as you know, women, they will have a little bit more of a decline in their late 20s and then it’ll kind of steady off over time and then maybe a slight decline during menopause as well. So, you know, I do think that age does contribute, but it’s also acquisition of co-morbid conditions that really bring us down, you know. [00:06:57][64.4]

Dr Louise Newson: [00:06:58] But I think it’s also the more I see, obviously I have a huge clinical experience. I’m very privileged with the number of women that we see through the clinic. But increasingly I see younger women. Like I saw someone today who’s only 32. She’s had awful PMDD premenstrual dysphoric disorder and she spends three or four days a month in bed because she has so exhausted. She’s been diagnosed with depression, fibromyalgia and chronic fatigue. And she had tried some synthetic combination oral contraceptive, but her testosterone level is very low. And she also has something called lichen sclerosus, which I’m sure you are aware of. And increasingly, women with lichen sclerosus respond a lot better with testosterone than oestrogen. And there are a lot more, I think, younger women who are more testosterone deficient than oestrogen deficient. But medicine often is very simplistic and guideline driven. And a lot of people say we have to give oestrogen and progesterone first and then consider testosterone only if people have got reduced libido. And I saw someone else today in my clinic who’s in her late 40s, had periods have nearly stopped. She’s been on oestrogen and progesterone. She has an okay libido. She doesn’t have a partner, but she has muscle and joint pain. She has awful brain fog. She has reduced stamina. She can’t work at the moment. She’s been told she can’t have testosterone because her libido isn’t too bad and her testosterone level is undetectable. [00:08:35][97.4]

Dr Mohit Khera: [00:08:37] Yeah, I think that’s very unfortunate. You know, when patients, women come into my clinic and I speak to them about hormones, I tell them there’s something called the triangle and the triangle is oestrogen, progesterone and testosterone. And unfortunately, most people just focus on the oestrogen, progesterone, but they’re missing the third component of the triangle. And hormone replacement is not rocket science. Essentially what we’re doing is taking someone who’s low and putting them back into the normal range. Nothing fancy. We’re just taking someone’s who low and putting them back into the normal range. Now, there are other hormones we also think about you should think about thyroid, cortisol. We call that outside the triangle, very important but the triangle really is the testosterone, oestrogen and progesterone. Unfortunately, most women are deprived of the testosterone, maybe because of fear prescribing. And right now, most societies will say that testosterone should only be prescribed for HSD, right, so for a low libido. But I do believe that there are other benefits with testosterone besides just HSDD. And even if the literature doesn’t support that yet, I think it’s because we don’t have enough studies. Because clinically, I do see women see improvements in muscle mass. I can see improvements in depression. I can see improvements in brain fog. I mean, I can see a lot of other improvements besides just libido when I treat women with testosterone. [00:09:58][81.6]

Dr Louise Newson: [00:09:59] And it makes sense because we have testosterone receptors all over our brain. And also testosterone works as a neurotransmitter and affects other neurotransmitters in our brain as well. But one of the reasons I take HRT is because I’m very worried about osteoporosis. I have doctored so many women, especially with osteoporosis of their spine, it’s so painful, it’s so uncomfortable, so hard to treat when it’s more advanced. So I know that oestrogen and progesterone help strengthen my bones and my muscles. But we have testosterone receptors in our bones as well. And we know for men, helps strengthen our bones. And it’s very likely common sense will dictate won’t it Mo that it will help strengthen our bones and improve our muscle strength? [00:10:43][44.0]

Dr Mohit Khera: [00:10:45] Yes, absolutely. I mean, you know, some of the, a lot of the data, unfortunately, it comes from the men, from the study of men. But when you give men testosterone, if you look at a graph, you can see increased bone mineral density as early as three months. And a lot of the trials will be statistically significant. Every three months that you give the testosterone, you increase the bone mineral density on the men. In other words, reversing osteopenia and reversing osteoporosis. And really so so men and women are not that different in certain categories. I’d say, for example, bone mineral density. And I’m sure Louise you’re familiar with the studies when you give women oestrogen or testosterone and look at bone mineral density, the group that does the best is the combination when you give them oestrogen and testosterone. But we don’t talk about testosterone for bone mineral density in women. We talk about vitamin C and vitamin D and oestrogen, but we don’t talk about testosterone, which we should. So, again, I think this is a big unmet need. I think there are a lot of women that could benefit from testosterone in terms of bone mineral density. We just need the trials. We need the studies. And unfortunately most of the money is spent on the men, not the women. [00:11:50][65.7]

Dr Louise Newson: [00:11:52] Absolutely. And also, a lot of studies now are funded by pharmaceutical companies who make the bisphosphonates, they make the other drugs that are used. And the new drug came out for osteoporosis treatment and it’s 300 pounds a month as opposed to HRT, which is a few pounds a month. So there is a bit of vested interest for these drugs. But often in medicine it’s using some common sense and some basic knowledge. And people keep talking about we need randomised controlled studies that actually we also need other observational data. But the most important thing for me is patient choice, people being allowed to choose. And often that isn’t happening. And we increasingly see women who’ve just been told they can’t have testosterone because their libido isn’t severe enough or they don’t fulfill the criteria for HSDD which says you have to have at least six months of severe psychological distress. Now, I don’t know about you, but I went into medicine to help people, not watch them for six months have severe psychological distress. Is it is it like that in America that you have to wait six months to be severely psychologically distressed? [00:13:00][68.2]

Dr Mohit Khera: [00:13:01] Yeah. So, I mean, I guess for us, it’s a clinical judgment. And so like in the UK, I assume in the United States, it’s off label, we call it off label. I think all that off license, the same thing. You know, essentially I can’t walk into Walgreen’s and buy a testosterone for women. It doesn’t exist. Right. Which is unfortunate because testosterone has been around since 1935. It’s been a long time. It was used in women in the early 40s. And today we still don’t have an FDA approved testosterone for women both in the US and the UK. If we go to Australia, we could get licensed or FDA approved, but we don’t have in the US. But basically it’s a clinical judgment that if a woman comes in and she complains of low libido and I check her levels and it’s low testosterone, I don’t necessarily wait six months to treat her with testosterone supplementation. I do think that she could benefit now. And what’s the harm of giving her a three month trial to see if it improves her sexual function and libido? I don’t think there’s any. And so typically, I will treat her with supplementation. Now, we because we’re off label, we do it slightly different. I mean, I tell the patients, you can use a gel or a cream from a compounder. I do use a lot of pellets and injections and I know that there have been many guidelines stating to stay away from the injections and the pellets. The main reason why they say to stay away from the injections and the pellets is because of the worry of the super physiologic levels. And you would see that maybe with a pellet, but with injections, you don’t necessarily see that because we get it compounded. We use a much smaller dose and the women will inject once a week and it’s extremely effective. [00:14:37][96.0]

Dr Louise Newson: [00:14:38] And again, it’s about choice. We see some people who don’t absorb the cream very well, but then they absorb the gel better or vice versa, having it through the skin or even as the injection or the pellet is far better, like you wouldn’t give oral testosterone because it gets metabolised through the liver. So that’s something that we wouldn’t do. But it’s very difficult in countries where you haven’t got anything licensed. But the thing is about it, is it is just a natural hormone. So when you’re talking about injecting, you’re injecting pure testosterone. This is quite different Mo, isn’t it, to injections that you might, I don’t know, I’ve not tried and I hope you haven’t either, that you might buy over the internet because you’re going to the gym and you’re wanting to build. They’re not anabolic steroids in the way that these synthetic testosterones are, are they? [00:15:29][50.5]

Dr Mohit Khera: [00:15:30] That’s exactly right. And you mentioned something very important about the gels and the creams. So remember, I tell them my patients a very simple formula. It’s the milligrams times the percent penetrance gives you the level. So let’s say give you 1000 milligrams of testosterone, but you have 0% penetrance. You get nothing. Absolutely nothing. So sometimes if someone has a low percent penetrance, you have to increase the milligram dose to get the level that you want. And so that variability on skin can be an issue. Injections typically don’t have that. You can get it into the body without having to worry about the skin penetration. You bypass the skin pentration. Louise, sometimes patients come to me and say, which one is the best one to take? I say, Look, testosterone is a molecule. It’s a compound. It’s not more magical if it’s in a pellet or a gel or an injection. It’s the same drug. All we’re doing, these are different ways to get the drug into your body. And let’s find the one that works the best. But the testosterone is the same. That’s a very important point. [00:16:32][62.2]

Dr Louise Newson: [00:16:33] Absolutely. And it’s the same with the oestradiol, which is the most anti-inflammatory type of oestrogen, and progesterone. And, you know, I often have conversations with Paul, my husband, as you know, he’s a reconstructive surgeon. And…but he could definitely, well he does prescribe hormones for me, he could definitely do my clinic. It’s very simplistic medicine. It’s three, like you say, basic hormones. It’s not synthetic hormones. I don’t prescribe the contraceptive implant. I don’t prescribe synthetic progestogens or synthetic oestrogen. We we’ve sort of moving away and we’re making it very safe, actually. So safe that it seems a shame, like you say about it, having to be by prescription and see a specialist, because a lot of my patients are buying all sorts of things over the counter to try and help their symptoms that we have zero evidence for. And not everything we buy over the counter is safe. But there’s a reason that we have these hormones, and like you say at the beginning, quite rightly, we are living so much longer. We weren’t designed really to live this long, were we, without our hormones. So it’s not just the symptoms, it’s the effects of not having the testosterone and hormones. That can be a real problem, can’t it? [00:17:51][78.2]

Dr Mohit Khera: [00:17:52] Louise, these hormones improve the quality of life. That’s very important. They improve one’s quality of life. Most of the time, we are spending all our time trying to increase our life span. Our life span now in the United States is 77 years old. Women are 79, men are 75. But the concept of health span, how long live healthy is 67 years old. There is a a ten year gap from when you will die to when you’re healthy that you will live in poor health. And really, what we should be doing is not trying to prolong our lifespan. We should be trying to prolong our health span. And I really believe that these hormones can make a big difference in improving someone’s health span. Not only do they improve someone’s health span, they also improve someone’s sex span. Right. So sex span is the time of life you are able to engage in sexual activity. And most people want their sex span to last as long as their lifespan, using the hormones definitely improves someone’s sex span as well. [00:18:50][57.9]

Dr Louise Newson: [00:18:51] Yeah, and that is crucially important. I found a paper recently from 1984, so when I was at school and it was giving oestrogen to women who’ve had their ovaries removed and a hysterectomy or it was giving oestrogen and testosterone and the results showed that wellbeing was better in people who had testosterone as well as oestrogen, which echoes what you’ve just said. But why is wellbeing not seen as so important? I don’t really understand and it’s a very hard thing I think, to measure. You know, when I started taking testosterone in the first six, eight weeks did nothing. And I thought what what’s the great… I don’t really understand. And then suddenly I realised and this sounds a bit trivial, but I could run up the stairs quicker. I could open the blind in the morning and smile because the sun was shining. I could empty the dishwasher in a second rather than thinking, I’m just too tired. I didn’t have this treacle thinking through treacle feeling in my brain. I just felt the clouds had been lifted. Things were more in colour. And that’s what patients say to me a lot. But I don’t know how you measure that, but I don’t know whether you have to measure it. Can you just ask women, do you feel better because you’re having a natural hormone? Is that a bad thing? [00:20:11][80.1]

Dr Mohit Khera: [00:20:12] At the end of the day, it’s really how she feels, right? It’s not about the number, it’s not about the testosterone value. How do you feel? If you feel better and symptomatic improvement, then we’ve accomplished our goal, right? And I think that’s very important. And one thing that you probably have done that others do as well is that I tell patients, this is a partnership. Okay, I’m going to give you back the triangle. I’m going to fine tune the hormones, but that is only half the story. Your job is to focus on the four pillars of health, diet, exercise, sleep and stress reduction. And if you focus on even one has a profound impact on your life. And if you do those four and I do my side as well. Very powerful together. In fact, giving testosterone makes these four a lot easier. So I do think that it’s a combination. And I do think if you give a patient that’s awesome and they lift weights, it increases the muscle mass. You know, so again, there’s synergy between lifestyle and hormone replacement therapy. [00:21:12][60.3]

Dr Louise Newson: [00:21:13] Yeah. And that’s crucially important. And sometimes I see people who’ve been told by other doctors that you can only have your hormones once you’ve improved your lifestyle. But actually, it can be really difficult. I know when I didn’t have hormones the last thing I wanted to do was to do any exercise at all. And also I couldn’t sleep. I like, Paul can tell you, I was awful. I was tossing and turning and I was awake and I was catastrophising at four in the morning and now Paul’s really annoyed because I can sleep a lot less than him. I go to bed. Later. I get up earlier. But I look on my ring or my device and I just sleep really efficiently because my organs are working. My brain is, and but also I’m exercising more, I’m eating better, I’m happier. I’m, you know, and those things as a doctor, we have to take into account. And like you say, it’s it’s a partnership with our patients. We work together. But the other thing I think people don’t realise is that, all our hormones are derived from cholesterol and cholesterol then obviously goes down to progesterone. But the other, the fourth bit, if you’re going to make a square, is cortisone and cortisol, which is our stress hormone. So as you’re saying, quite rightly Mo, if we improve our wellbeing, we improve our mental health our physical health, then that cortisol is going to improve as well. But often when people don’t have the hormones, they’re sort of, our body produces more cortisol, stress hormone and adrenaline and everything else because they’re trying is trying to compensate for what we don’t have. And it’s all about doing the right dose and the right choice of treatment for the right patient. And that’s what we do in everything we do in medicine. But somehow there’s sort of politics and personalities that get in the way of women being able to receive hormones and men actually, because there are a lot of men who would benefit from testosterone instead of other treatments for other conditions. But it seems always like, sex hormones, that maybe because they’re called sex hormones and I don’t think they are, I think they’re health hormones. And it seems a bit like a trivial form of medicine. And I do think it is at all. [00:23:27][133.3]

Dr Mohit Khera: [00:23:27] It’s not trivial at all. I, as I mentioned earlier, the best barometer of, particularly a man and I think also about a man’s overall health, is his testosterone level. So did you know if a man has low testosterone, it significantly increases the risk for having a cardiovascular event. Nonnegotiable. Low testosterone increases risk for heart attack, low testosterone increases risk for breaking a bone, osteopenia, oesteoporosis. Low testosterone increases a man’s risk for diabetes and metabolic syndrome. It’s non debatable. Low testosterone can be associated with depression. And low testosterone can be associated with prostate cancer. So, so I think, you know, it’s not just about sex Louise. It’s about his overall health. And if you don’t have the same amount of studies we have in men as we do on women. But I can assume also that women with low testosterone should be at increased risk for depression, low testosterone, women should be increased risk for osteopenia, oesteoporosis, cardiovascular risk. We just don’t have the trials. But again, I do think that those trials need to be done. And men and women in many cases are not that different. [00:24:30][62.2]

Dr Louise Newson: [00:24:30] Yeah, absolutely. Of course, we’re not different as much as people expect us to. Of course we’re not. And we learning all the time. But in the meantime and we don’t have the studies, we can act on common sense. We can share decision making. We can allow women to make choices. And as I say to people every day in my clinic, everything is reversible. You can choose. We give therapeutic trials of all sorts of medication, and hormones are no different. People take it, don’t like it, that’s fine. They don’t have to continue. And I think that’s really important as well, isn’t it? [00:25:02][31.6]

Dr Mohit Khera: [00:25:03] Yep. But again, and you nailed it. So I tell my patients, male and female, that if you take this medication and you don’t see symptomatic improvement, there’s no point continuing because because I’m not here to treat your number so much. I’m here to treat you. And if you don’t see the improvement, we can consider stopping. So in men in our guidelines, typically about three months, a lot of the other guidelines like ISSWSH up to six months. So I would say for three to six months for a trial is very reasonable to see if there’s any benefit. You know, the side effect profile is not as bad as people think, particularly in women. A lot of women say, if I take it, am I going to get a beard and am I going to? Well, you know, the difference in women is we start low. We started a low dose and we go up and, you know, you can get acne. You cant get facial hair. I have not yet to see a patient who has a deepening of the voice or clitoromegaly in my practice. I think those typically happen at super physiologic level, but acne and facial hair can happen. And quite honestly, many women who do develop that will say, Look, I can deal with it on the back end. I love my testosterone. I’m not going to stop. I say, okay, then we’ll look at you. But the side effect profile, we do check for erythrocytosis. So I do think that’s important to check. We just presented one of our big papers, so I have a long history of treating women on pellets for many years, and we presented our data last year at the, in San Diego at the SMSNA meeting . And what’s interesting about women when I put them on pellets is that they have a much lower rate of erythrocytosis and hypertension than I see in men. [00:26:31][88.5]

Dr Louise Newson: [00:26:32] So just before we end, though, I’m very grateful for your time, but I always I’m just going to spring this on you because I always do three take home tips. So for people who are listening, just three things. So if they’re men or women and they’re thinking about testosterone, whatever age they are, whatever symptoms they have, what are the three things that you think they should take home and really learn about testosterone for their future health? [00:26:56][24.6]

Dr Mohit Khera: [00:26:57] First and foremost, if you have signs and symptoms of low testosterone, meaning low libido, low energy, sexual dysfunction, increased fat deposition and decreased muscle mass, maybe even some depression, check your testosterone level. It’s a simple, simple blood test which can make a significant difference in your quality of life. I would also say that one of the best barometers I think, of a person’s overall health is their testosterone level. It’s a marker. It’s a marker of other underlying conditions that could be existing. And so take the low testosterone seriously if you do have a low T level. And finally, I would say that our our knowledge about the safety of testosterone is getting better and better. And I do think that testosterone, if prescribed appropriately, is a safe medication to prescribe, but it should be monitored. But it is a safe medication. So this dogma, this conception that it’s dangerous, it’s putting fuel on the fire. It really is not true. I do think that it’s a safe medication, particularly if it’s monitored and prescribed appropriately. [00:28:00][63.1]

Dr Louise Newson: [00:28:01] I totally agree. So thank you so much for your time and hopefully I will meet you in real life at some stage. So thank you. [00:28:07][6.0]

Dr Mohit Khera: [00:28:08] I appreciate it. Thank you so much for the invitation, Louise. [00:28:09][1.3]

Dr Louise Newson: [00:28:12] You can find out more about Newson Health Group by visiting www.newsonhealth.co.uk and you can download the free balance app on the App Store or Google Play. [00:28:12][0.0]