Testosterone supplementation: what can we learn from men’s healthcare?

This week on the podcast, Dr Louise is once again joined by her friend, retired consultant urologist Steve Payne.

Together they look at the similarities and differences in women and men’s experiences of menopause and andropause, and the effect of low testosterone levels, including loss of libido and lust for life, lethargy, mood changes, depression and muscular weakness.

They address the issues surrounding testosterone replacement and Steve questions if medical professionals can learn from the treatment of men with prostrate cancer with testosterone supplementations when treating women with breast cancer with hormones.

Steve has written a factsheet about making informed decisions during cancer care. You can also read more about his and his wife Jan’s experience, plus practical advice, here, and listen to the podcast  Making decisions about cancer treatment and the importance of quality of life with Steve Payne.

Click here for more about Newson Health.

Transcript

Dr Louise: Hello, I’m Doctor 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 today on my podcast, I’m really delighted to introduce to you someone I’ve known for many years, who has been a real inspiration, not just to me, but especially to my husband. He still manages to be a great mentor, friend and colleague often when Paul goes abroad to Africa to do charity operating. So I’ve got with me Steve Payne, who’s a urologist, who was working at Manchester Royal Infirmary when I did my medical training. So I’ve known you, Steve, for many years.

Steve: [00:01:32] Indeed.

Dr Louise: So welcome to the podcast. It’s great having you here. So I speak a lot about Paul and I’ve even had him on my podcast actually. But urologist, sometimes people don’t know what it means. So do you mind just talking about what a urologist is and why you decided to be a urologist? [00:01:50][16.9]

Steve: Let’s start with that first. I mean, I decided to be a urologist because I liked the people who were in urology. And I think that that’s a really common reason for people wanting to go into the speciality. But a urologist is somebody who deals with the urinary tract, and that is from the top of the kidneys down to the very tip of your water pipe and all of the points in between. But there are a group of urologists who are also work as andrologists and they’re people who deal with predominantly male reproductive and sexual issues. Some of those are medical, some of those are surgical. And I was a urologist and an andrologist. So I did a lot of stuff related to male sexual dysfunction and infertility.

Dr Louise: Really interesting, and really important. And actually, you’re absolutely right about working with people who you respect and enjoy working with, because many of us see more of our work colleagues than we do of our partners or families when we work long hours. And it’s certainly one of the reasons that Paul went into urology as well. And you still, I was lecturing recently at part of the British Association of Urological Surgeons, and I said to Paul, I cannot believe how chatty people are on the coffee breaks. They’re just really cohesive and just really supportive of the lecturers as well. Whereas I’ve been to many conferences where people don’t talk, they’re not supportive. They wouldn’t go up to a lecturer and say, well done. And it’s really interesting how people in medicine, you think all doctors are the same, but they really vary, don’t they?

Dr Louise: [00:03:25] They do, they do. And interestingly, I’ve been talking this week at a conference which has involved an awful lot of trainees. So there are 150 urological trainees at this meeting. And they wanted to hear what somebody at the end of their career had to say about the various bits and pieces that they were going to face along the way. So, yes, I think it’s really interesting. I think it’s a great speciality. And I would wouldn’t I?

Dr Louise: Course you would. So I was a junior doctor in the 90s and obviously Viagra had come out, Cialis, which is a sort of a purer, well, not purer form. It’s just slightly better, isn’t it, it just acts…

Steve: Different.

Dr Louise: in a different way. Came out and but when I was a GP, we could only prescribe it as an NHS script for people who had comorbidities. So if they had diabetes and they really had to prove that they were really struggling with their impotence and sexual desire, and it was quite a big thing. We could do it privately. We were allowed to. The computers were set up so we could prescribe Viagra privately. And it was really interesting because it was the first time, actually, that I’d seen so many men coming to see me, because men often don’t come to the surgery quite as often as women. But I also felt quite sad that they had to sort of, especially to me as a woman, prove how difficult something that is so important but they’d never spoken to a medical person about. But they really wanted this treatment. And now now obviously Viagra is over the counter. You know, I haven’t seen people for many years actually, who who need Viagra. But when we talk about sexual desire or libido, often it’s not just about… Libido isn’t just sexual desire. When we think about Freud’s definition of libido, it’s more pleasure of life as well. We’re having this conversation increasingly in our clinics and academically as well, because we’re talking about the role of testosterone. But also with men, it’s not just Viagra as well, is it? I mean, you’re, well you said you’re an andrologist as well, so interested in the role of male hormones, which obviously include testosterone to a large extent, don’t they?

Steve: They do. They do. I mean, obviously testosterone is much more important than anything else. And the biggest issue, of course, if men are suffering from low testosterone, then the biggest issue that comes to the fore is libido. Because, you know, that is the thing which decreases most in men who have a low testosterone over 90%. But they also suffer from lethargy, which is almost as prevalent as reduction in libido, reduction in their erectile function, loss of strangely pubic rather than facial hair. They also get mood changes and over half of them get significant depression. And then something which they also notice, which obviously becomes more of an issue to men as they get older anyway is muscular weakness. So testosterone clearly is very important in maintaining an awful lot of those functions.

Dr Louise: Yeah. And it’s interesting. I only knew, I started to read more about testosterone in women about eight, nine years ago, because before that time, Steve, I can admit I didn’t know women had testosterone in their bodies because no one taught me. But it’s actually the most biologically active hormone in women. So I presume it’s up there as being one of the most biologically active hormones in men as well, because we have cells that respond to testosterone all over our body to help with various biological processes. And men do, too, don’t they?

Steve: [00:07:05] They do. They do. I mean, the really interesting thing about testosterone is that it’s only the free testosterone which is majorly active in men. That’s only 1 to 3% of the testosterone that a man produces, because the vast majority of it is bound to a couple of proteins, one’s albumin, and the other one’s something called sex hormone binding globulin, which is produced in the liver. So it’s only that very, very small percentage of circulating testosterone which is biologically active and creates all of the positive effects that a man sees.

Dr Louise: Yes. Which is the same in women, isn’t it? We have bound testosterone. We have sex hormone binding globulin, which can be increased or reduced with various factors. So it’s only the freely available testosterone that’s going to have these biological active processes working in our bodies.

Steve: Yeah. No I think it’s really important that people understand that a relatively small amount of the hormone can have such dramatic effects on various different bodily systems.

Dr Louise: Yeah. So I mean, testosterone in men and women actually was sort of first spoken about really in 1940 and they were doing experiments on both sexes, which obviously they then stopped looking at it in women and carried on with men. But actually, we know it’s produced via sexual organs. It’s produced by our ovaries and the testes, but it’s also produced in the brain as well as, you know, oestrogen and progesterone are produced in our brains as well. So testosterone does work as a neurotransmitter. And it also can be produced in our muscles as well, and probably… and our adrenal glands and probably other places that we we don’t even know. But the effects that it can have, like you say on our energy, on our mood and our concentration is really important. But I’m also interested in diseases as well, because I’m quite keen to prevent diseases, not just treat them as a doctor. And when I read about the effects of testosterone on our nervous system and also can help obviously reduce inflammation, but it helps improve mitochondrial function as well, which is like the powerhouse of all our cells, but also on the nerves. It can help rebuild the myelin sheath, and the myelin sheath is the, well you can explain, even as a urologist, you know what a myelin sheath is, don’t you, Steve? Putting you on the spot here.

Steve: Well, it just, helps increase the efficiency of the neural transmission, in other words…

Dr Louise: Yes. It’s like the conductor bit isn’t it?

Steve: …Stimuli go quicker.

Dr Louise: Yeah. And that’s very interesting, so I was doing a talk recently for, it was a debate actually, for a society about multiple sclerosis and whether menopause care should be better for women with multiple sclerosis. And actually the person that was saying against it, didn’t win and she still agreed with me. But actually, if we’ve got a hormonal deficiency, especially testosterone, and we’ve got a condition affecting our nerves, it’s a double whammy. But also, I’m very interested in diseases that are more common in women than men. So there are a lot more autoimmune diseases that become more prevalent in women in their late 40s. Multiple sclerosis, for example, is far more common in women than men. And for many years I’ve been thinking, well is it something about oestrogen? Because although men have oestrogen, we have a lot more oestrogen when we’re having our periods. But more recently I’ve been thinking, is it because of testosterone deficiency? And those men that have some of these, you know, men can have multiple sclerosis, is some of that going to be related to testosterone deficiency in men as well? And we don’t really know the answer do we?

Steve: No, certainly not. I mean, if one just concentrates on multiple sclerosis, it’s always been said that the further north you go and the further west you go, the higher the incidence of multiple sclerosis. Maybe we ought to be looking at the hormonal levels in people in those locations.

Dr Louise: Yeah. And the more I see and speak to women and treat them and also speak to other experts, not just in the UK but worldwide, there’s a lot of us who are picking up a lot more women who are testosterone deficient before they come oestrogen deficient, and they often have various symptoms affecting their mood, their energy, their concentration. But like you say, their muscle strength, their stamina, sometimes they do have flushes that are related to their testosterone. And men can have flushes and sweats, can’t they when their testosterone levels low?

Steve: They can. I mean, interestingly, although testosterone levels may be significantly reduced in men, it’s only about 40% of them who actually get what we would call an andropause.

Dr Louise: Yes.

Steve: So not by any manner of means to all men who have a low circulating testosterone actually get significant symptoms as a consequence of it. So they’re obviously, it’s obviously an important co-factor in a generation with a lot of other symptoms, but it’s probably not the whole answer. But it’s an important co-factor.

Dr Louise: Yeah. And it’s interesting because we often don’t know, like, you know, when I see people in the clinic, as you know there’s no diagnostic test for the menopause and if someone has low testosterone, I’ll say to them, your testosterone is low. You may benefit from having testosterone, but I don’t know how many of your symptoms are related to the low testosterone, because there’s often lots of reasons why people are tired or they don’t sleep well or whatever. But sometimes, as you know, in medicine things are multifactorial. So it’s sometimes the missing piece of the jigsaw. And many years ago, it must’ve been about 20 odd years ago, we were… In general practice you have these sort of QOF where people have to ask certain things, and it actually goes to the way many GP practices are paid. I’ve always been salaried, so nothing affected my pay. But the QOF was added for asking people with type 2 diabetes, men with type 2 diabetes, if they had erectile dysfunction, and then we were doing testosterone levels on those people. But what we found was that nearly everyone had erectile dysfunction, but they didn’t talk about it. But then when we did testosterone levels, they were always low. And then that was a whole can of worms because they didn’t want us to treat with testosterone. So they withdrew that. So then we didn’t have to ask. And then it’s almost like, if you don’t test for it, you won’t know.

Steve: All of these things are so multifactorial aren’t they. I mean, it’s definitely been found that men who suffer from an andropause often have an increase of visceral fat. So there seems to be a significant association between obesity and what we would call hypogonadism, in other words, not producing enough testosterone. And if you take a man with a BMI so there’s a body mass index above 30, which is moderately obese, then they will have a testosterone which is approximately 30% lower than and with a normal BMI of less than 25. So you know, as with oestrogen and various other hormones, obesity can have a significant effect on their circulating levels and therefore their bioavailability.

Dr Louise: Absolutely. So and it’s so important that people are, well all our patients we look at holistically and we often find actually when people have their hormones replaced they find it easier to exercise, they have more stamina. They’re sleeping better, which obviously can help with weight as well, but also the metabolic changes that occur. And low oestrogen in the menopause and low testosterone can drive a metabolic state. So we know people with low testosterone, men and women, can increase their risk of type 2 diabetes and obesity. So it’s a sort of chicken and egg thing, really. So addressing both of them can make quite a difference. And some people who have testosterone or some men who have testosterone and are overweight or obese, when their weight reduces, their exercise improves. If they’ve started on testosterone, they might find that they don’t have to continue on testosterone as well, didn’t they?

Steve: Yeah, absolutely. Absolutely. I mean, as I said, it’s really complicated. But no doubt, you know, lifestyle factors and lifestyle modification, reducing smoking, reducing alcohol consumption, apart from the effects on weight and things from drinking because they say, you’re drinking another bottle of fat don’t they if you drink a bottle of wine?

Dr Louise: Absolutely. So we’re sort of talking about the beneficial effects of a natural hormone that men, women produce. We all produce. But there’s a lot of people that are quite scared of giving testosterone back. And many years ago, again, when I was a GP, about 15 years ago, I saw a man in the clinic who was 62, and I remember him because I knew his wife really well, but she kept bringing him in because she was worried about him and she said, he’s really sweaty. He’s really worse at night, actually. He’s just really vacant. He’s just not himself at all. He’s really just got no interest, no joy. He’s got no energy. We used to go out walking in our retirement. He’s not doing anything of that. He’s quite distant. And because he was getting night sweats, that can be a symptom of lymphoma, as you know. So I had some blood test done. He was a little bit anaemic. He went to the haematologist. Everything was fine. Things went on and on. And I remember coming home one day and saying to Paul, I’ve got this man, this patient, I just, I’m not sure what’s going on. And Paul said, well, what’s his testosterone level? I went oh, I’ve never done that. And I did it. And it was incredibly low. His free testosterone was very, very low. And so I gave him some testosterone to try. And the effect was transformational. It really made such a difference. And then one of the partners said to me you shouldn’t be doing this. You need to refer him to the specialist. It shouldn’t be you that’s giving, you know, a natural hormone back to a patient. So I said oh OK, so I sent him to the local urologist and they stopped it straightaway. And they said, well, he’s got a history of raised blood pressure. And, giving testosterone is going to increase his risk of stroke. He needs to stop it straight away. And I was really upset because his quality of life completely deteriorated and vanished in front of my eyes. And they went from driving down to Cornwall to do nice walks, to him being housebound again. And it really struck me that I was wondering about benefits and risks, shared decision making, but also I couldn’t quite understand how giving a natural hormone could increase risk of stroke because I wasn’t giving him high doses or levels. But there’s always been this thing about people have been scared of testosterone, and I don’t quite know where it’s come from Steve, can you explain?

Steve: Well, I think there are two drivers for this aren’t there. There are a group of individuals who look at all of the adverse effects that you can have from various hormones without looking at the positive aspects. And I think the other thing is, as you say, it’s all about shared decision making. And, you know, we are still very paternalistic in medicine in this country. Not perhaps as paternalistic as they are in other countries, but we are still pretty paternalistic, and we have our beliefs and those beliefs are very largely unshaken, often not based on significant scientific evidence. And they’re perpetuated, dependent upon the speciality that you work in. I mean, I think in urology, we’ve actually been really quite fortunate in as far as urologists have been able to have reasonable conversations with GPs about somebody being started on testosterone. And I think the evidence that is out there now about the downsides of testosterone are really quite small. There was a recent paper in the Journal of the American Medical Association which showed, for example, that men who were treated with the testosterone had no higher incidence in the development of prostate cancer than a placebo group. And I think that that is something which is really, really important. You know, people were worried and are worried, continue to be worried about whether giving more testosterone causes more prostate cancer. But interestingly, the American Urological Association in its guidelines in 2018, has actually said that hypogonadal patients, in other words, ones who haven’t got a significant amount of testosterone circulating, should make an informed consent before starting testosterone replacement therapy. And that was basically designed for treating hypogonadal men who’ve already been treated for prostate cancer. So I think that there’s quite a lot of acceptance in the urological field that testosterone replacement therapy isn’t necessarily a bad thing. And interestingly, I was at a recent meeting where the use of drugs for the treatment of prostate cancer that caused hypogonadism were responsible for a much higher incidence of cardiovascular disease, and that in certain men with cardiovascular risk factors, those drugs should not be used. So there’s a strong association, as I know there is in women between testosterone and cardiovascular disease.

Dr Louise: Yes. Yeah. We know that women who have low levels of testosterone have a greater risk of cardiovascular disease. And there seems to be real resistance to replacing testosterone to see if it reduces risk in women of cardiovascular disease. But I’m very interested in this because with prostate cancer, some people listening might know in certain types of prostate, not all types of prostate cancer, but certain types drugs are given to block the effects of testosterone in the body. And it’s the same with oestrogen receptor positive breast cancer. Often they give oestrogen blocking drugs. And you’ve been part of this group that I’ll do another podcast on in the future looking at the effects of these drugs. And I’m very interested in the different types of oestrogen. So we have oestradiol, which is a very good type of oestrogen, and oestrone which is an inflammatory type. And increasingly there’s evidence that it’s the oestrone that is related to the breast cancer, not oestradiol. So if we’re blocking all types of oestrogen, you’re blocking the good oestrogen as well. And there’s an increased risk of heart disease, osteoporosis, diabetes when you’re blocking but also the effect of symptoms as well. So even if we’re “just” and I say just in inverted commas. So we’re ignoring health risks, but we’re just looking at the person in front of us and how they’re suffering. The effects of blocking testosterone in men, blocking oestrogen in women are very similar. So you become menopausal basically. Or andropausal, don’t you?

Steve: You do. And I mean, in fact, my brother has recently been treated with androgen analogues. That is a strange thing. You actually give something which switches off the pituitary gland in your brain, which drives your testicle. So you produce an initial high level of testosterone, which then switches everything off. But he had all of the things that you normally ascribe to a menopause. So lots of hot flushes and this and that and the other. But I mean it’s also been recognised relatively recently that men become osteoporotic if they stay on those drugs for any length of time. And indeed they need to have Dexa scans if they’re on it for more than a couple of years. So, I mean, there’s great similarities between the two hormones.

Dr Louise: Well, there is and for those of you listening that haven’t listened to the podcast I’ve done with Steve before, it’s worth listening because you’ve got very, very close experience of your wife taking oestrogen blocking drugs following her breast cancer diagnosis. And it’s a really, really great podcast to listen to, but it is about quality of life. But the other thing is looking at the prognosis and there are different types, there are different grades, there are different stages of breast cancer as there is in prostate cancer. So this is a very general conversation. But for some people or many people, thankfully the outlook from prostate cancer is very good. And we know there’s a lot of men that die with prostate cancer, but not from it. It’s not their cause of death. Most men, like women, die from cardiovascular disease. And so actually it’s weighing up the quality of life. And if the beneficial effects of blocking those, the testosterone with a relative increased risk of diseases and reduced quality of life. And so it’s very interesting that they even did a study looking at replacing testosterone in men that had had prostate cancer. And very reassuring looking at the results, wasn’t it?

Steve: It was indeed. There is no significant evidence. And in fact, all of the evidence has been put together in guidelines by a number of different urological associations to say that there is no convincing evidence, there needs to be a sensible discussion between whoever is treating that individual and the individual themselves about the pros and the cons of treatment. And as you know, Louise, prostate cancer becomes much commoner as you get older. So that, you know, it is said that 80% of men if they get to the age of 80, will have some evidence of cancer in their prostate. And as you say, most of them die with it rather than of it. But in fact, I mean, the outlook for men who are much younger, who are treated for prostate cancer is much better, with 90% of men surviving ten years.

Dr Louise: Which is wonderful, isn’t it?

Steve: It is. And it’s a dramatic change. And of course, there is the possibility that there are a lot of new treatments out there, biological agents, which are going to change things significantly. So maybe surgery won’t be required, surgery or radiotherapy won’t be required. But then again, we do need to look at the way that those work and the effects that they may have. As you know, Jan had problems with aromatase inhibitors. And whilst they may be very good from an oncological perspective, consequences upon quality of life were really quite significant. We really do need to look at the quality of life aspects of all new treatments and all new medications.

Dr Louise: Yeah, absolutely. And involve patients, you know, in our clinic if women have had breast cancer and they choose to take hormones for quality of life, but also disease preventative effects such as osteoporosis or cardiovascular disease, they often sign a shared decision making document that we have to say that they understand there are benefits, they understand there are potential risks and maybe risks that we don’t know because the studies haven’t been done. But on balance, they’re keen to, you know, go ahead. And they’ve we’ve had a informed decision making consultation. And that often helps when they go and see other doctors. So I’ve got a patient at the moment who’s GP’s refusing to prescribe her HRT for her. And the oncologist had written to the GP last week to say I fully support her having HRT because without it, she will not be able to sleep, she’s at a very high risk of osteoporosis because she’s very slim. And her breast cancer was a really good prognosis. It was very small without any spread. Her lymph nodes were clear, and she’s thinking about taking tamoxifen, which she can have with her HRT. And so to work in the shared sort of care where I’m involving the oncologist, sadly the GP I can’t involve, but the oncologist is helping as well. But putting the patient in the centre and you know, that’s really crucial in everything that we do, even, you know, the way you operate on people, the way you decide which operations or which treatment, it varies between people because it’s what their expectations, what their knowledge, what their beliefs are and any risks they want to take compared to any benefits they might have. And we can’t decide, I don’t think, for patients, can we? We have to just assist them.

Steve: Absolutely not. I mean we are slightly more fortunate in urology as far as we do have a moderately reliable marker of disease progression, which isn’t something that’s present for women with breast cancer. So although PSA gets very bad press, it is a very useful indicator of the efficacy of treatment. And of course, you can utilise that when you are treating men with testosterone supplementation. And indeed, the American Urological Association guidelines say that you basically should just bring their testosterone up to a physiological level. In other words, what would be normal for a man of that age. And as long as it improves their quality of life, then that’s fine. You shouldn’t give them increased levels of testosterone.

Dr Louise: No, which makes perfect sense. And the other thing just before we finish to add is that when people have testosterone, especially if they’re using it as the gel or sometimes in women we use a cream. It doesn’t build up in the body. You know, if they stop using it, it goes out of the body very quickly, which is very reassuring. So often people know they can do a trial, have a therapeutic trial, see if it helps. Like we’ve already said at the beginning, not everybody who’s tired it’s going to be related to low testosterone. So if they don’t feel any better, they don’t have to carry it on either. So it’s a choice of starting and stopping medication, which I think is also really important.

Steve: Yeah, yeah. No, I totally agree with that. I mean, there does seem to be a difference in the culture or the opinion between andrologists, urological oncologists and oncologists and menopause specialists treating women with breast cancer. And maybe there’s something to learn from what has happened in the treatment of men with prostate cancer, with testosterone supplementation for our colleagues who are treating women with breast cancer.

Dr Louise: Absolutely. And a joined-up approach in medicine, joining up patients and various specialists is really crucial. So I’m very grateful for your time, Steve. Before we finish, I always do three take-home tips. So I’m very keen to ask you three things, if people have been listening and think, whether they’re men or women, could any of my symptoms be related to low testosterone? What three things would you recommend for them to do?

Steve: Well, number one is if they’re not feeling how they feel they should be feeling at their age, say they’re over 50, then it’s probably worth seeking your GP’s advice and getting a testosterone done. The second is if you do have urinary symptoms, a very royal problem to have just at this point in time, then do go along and see your GP and get yourself checked out to make sure that those aren’t related to prostate cancer, even though the vast majority of them, greater than 90% of them, will be due to benign disease and not due to cancer. And the third thing is, if you are a man who has been treated for prostate cancer and is having sexual difficulties when none existed prior to the treatment for prostate cancer, then always ask whether you could have a testosterone level checked and if it is low, whether you could be treated with testosterone. So I think those are the three things that I would suggest.

Dr Louise: Ah thanks, Steve. Thanks for sharing some of your phenomenal knowledge and experience, and I’m very grateful for your time today. So thank you.

Steve: Okie doke Louise.

Dr Louise: 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.

ENDS