The Dr Louise Newson Podcast - 018 - Low Testosterone in Men - Professor Geoffrey Hackett & Dr Louise Newson

Episode Date: October 8, 2019

Professor Geoffrey Hackett works as a consultant in Urology and Sexual Medicine. He is a prolific writer and educator about men's health and has a particular interest in low testosterone in men. In this episode, Dr Newson and Professor Hackett talk about how having a low testosterone level can affect men, how common it is and how men can receive help and treatment. Around 20% of men in the UK have low testosterone at some time in their life but few of these men are being diagnosed and treated. This is due to lack of awareness by patients and doctors, especially as symptoms are vague and often subject to incorrect diagnosis. Erectile problems can be a sign of cardiovascular disease so it is really important that men have the appropriate tests and receive the best treatment to improve their future health.  Professor Geoffrey Hackett's Three take Home Tips: Having erections and sexual activity is great for men's health. Regular sex can reduce the risk of heart failure and can prolong life. The quality of sex can matter more than the quantity. Erectile dysfunction is down to heart problems until proven otherwise. Don't just put it down to stress, age etc.

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsom, a GP and menopause specialist, and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. So today I'm very honoured to be sitting with Professor Geoffrey Hackett, who's a Professor of Sexual Medicine at Aston University. He also used to be the President of the British Society of Sexual Medicine, and we are very flattered that he is working here in the clinic sometimes as well in my menopause clinic, seeing men rather than women.

I hasten to add, so welcome to. Thank you very much, Lee. So I really wanted to spend a bit of time talking about men rather than women's. It's a bit out my comfort zone because, as you know, all I do is see women in my clinic here, but I have seen a lot of men in the past. So can we just start by maybe talking about your journey to where you came from being a GP, to being interested in men's health? Yes.

Well, I was a primary care physician for 30 years, and I always had an academic interest because I'd trained to medical registrar level in hospitals. And I started to do research into sexual problems because I noticed I was seeing a lot of men with hypertension, heart disease, who complained about erectile dysfunction. This was really before. leaders like Graham Jackson

identified the link. So I actually did a research project involving three practices where we screened the population with rather primitive inventories at that time and we found strong links between physical diseases

and sexual dysfunction. And soon after I published that, trials were being developed for Viagra and they came to me to do some of the trials and the rest, as they say, is history. History. It's very interesting.

But even in hospital medicine, were these men volunteering the fact that they had problems with sex, or were you actually directly asking them? I had to directly ask them. They just wouldn't speak at all. Because it's interesting, isn't it? So as a physician, we like to think that we're very open and that people can talk to us about anything,

and we don't get embarrassed, doing about asking all sorts of intimate questions. But when you read the data, actually, a lot of people aren't, about sex or men if they have erectile problems? Well the interesting thing is that in university at medical school we all do compulsory training in obstetrics and gynecology. So we're all trained to take a menstrual history and to even ask about how much blood loss

a woman has with each period and even ways of assessing that sort of thing. So we're quite comfortable as male doctors talking to women about those subjects. and yet we're taught absolutely nothing about asking a man about his erections at all. I learned absolutely nothing in medical school. No, I didn't either, which is staggering, isn't it? I think it was only really driven by the arrival of potential treatments that made us begin to ask the question.

Tell us just a little bit about Viagra, because Viagra, what it is useful now is not what it was initially designed for, is it? No, it was originally designed to treat men with heart disease and hypertension. And of course the patients, therefore, were taking it every day. Yes. And what happened in the trials was when they came back for follow-up visits,

they were refusing to bring back their packs of tablets, which was the first time this had ever happened. You're not getting these back because they realise at the end of the study they wouldn't get any more. Yes. And it was only when they asked the questions as to why the men weren't giving them back, that they then totally change the direction of the drug.

But what we've forgotten is, of course, that they got that far in showing that they were really excellent cardiovascular drugs, which is what we're beginning to realise 20 years later. Yeah, indeed. Because I remember listening to you lecture, I don't know, 15 years, a long time ago at a conference, and it was all about men who have erectile problems is a mark of cardiovascular disease.

So future heart attacks, even high blood pressure, even types of diabetes. And, you know, when people talk about libido and sex, people look at it in isolation almost, don't they? And this was, when I first heard this, I thought, how interesting. And so can you just explain a bit more why that is and what the data is about that? Because I think that's really interesting. Well, what we know now is that 80% of... of cases of ED. So that's a rectal dysfunction.

The rectal dysfunction. Have an organic component. If we go back to the 70s and 80s, it was thought the other way around that 80% was psychogenic. Yes. But then we realised it was strange that these psychogenic patients seemed to have diabetes. So then everything has completely turned round. And so we should consider that a man presenting with an erection problem has cardiovascular

vascular disease or diabetes until proven otherwise. Yes. And there were just so many studies that show that your pickup rate for a man coming in with an erection problem is far, far greater than if a man came in with thrush or something. But taught that if you find thrush, check for diabetes. Yes. But with men, you rarely find it. But if you ask about erections, you pick up lots of diabetes and pre-diabetes.

And the mechanism is really that you're looking at arterial disease occurring in smaller arteries because the arteries to the penis are about 60% the diameter of the coronary arteries. So those arteries round the heart, aren't they? Yeah. So if you have the same amount of cholesterol being deposited over time, you will get symptoms of erection problems much earlier than you'll get symptoms of chest pain or heart face. and it happens about three to five years before the arteries in the heart fur up. So that's quite a long time, isn't it, for people to really wake up and think about their lifestyle,

there, anything they can do to reduce their risk of future heart. It's only a long time if two or three years of it aren't wasted by the patient suffering in silence. So I think it's, yeah, I mean, it's so important, isn't it? So if men do have erectile problems, it's not just papo, because they're strong. or they're busy or worrying about it or something else. Because a lot of the time, men don't come forward to the GPs, do they complain of erectile problems? No, and it's become much more difficult now when there's a sign in the waiting room saying

that you can only bring one problem with each consultation. So in my experience, the erectile dysfunction was always the subject that they mentioned just as they were leaving the room. Putting on their coat, they have the door handle saying goodbye. Oh, doctor, there's just one more thing and then it would happen. And it's very hard getting men to go to the doctors anyway, isn't it? And also you might only get one chance. Yes.

And if that consultation goes badly, you won't see that man again. I think so. And I think as a woman, I've had a lot of men who have been squirming in their seat wanting to say, and as soon as I've just spoken to them, of course, you're not embarrassed. I said, well, no, not at all. It's really important to talk about. But it's almost sometimes they're looking for a male GP or what someone, that they think is sympathetic and like you say if they don't get anywhere or then they're not going

to go back are they and so they say they won't think well i believe i found the only speciality in medicine where it's worthwhile still being a man yes we're being made uh rather redundant in most other fields yeah but it is key and so the earlier a man presents to a doctor or healthcare professional because they've got problems with erections the better for long-term health really, isn't it? Absolutely, because if you've got the person who is three years or so away from having their my accountal infarction, their heart attack, you've actually got a chance to modify the risk factors and prevent that happening.

So what can we do? So say, for example, someone comes to see you and they're maybe in their mid-40s, stressful job, put on a bit of weight, eating not so well, come and see you because the last few months so they found it really difficult to have erections. Well, as soon as a younger man in his 40s, and I say that's a younger man, which we do see them in their 30s and even 20s now, as soon as a younger man comes in with an erection problem,

that is really the patient where you should sit up and think something really is going on here. This isn't, particularly if he says it's happening all the time and it's persistent and it's getting worse. If it was fine when he was on holiday, No trouble at all and then it's... Yes. But in my experience, it usually is each and every time and it's getting worse.

Then that man needs as full an assessment as if he'd come in saying that he'd got pains in his chest. Yes. So you need to get him under precise blood pressure control. You need to look very close at whether he's got diabetes or pre-diabetes. You need to treat his lipids almost from the same way you treat primary, prevention. So there's none of this, oh, just go away and change to flora and I'll see you in two years time. Yeah, so we're quite aggressive. We're trying to improve all those mis-writers. Because his risk is 50% greater. So if you look at all the risk calculators now, they include

erectile dysfunction and they increase the risk by up to 50% in their heart attack. So this is increased risk of a heart attack? Yes. So if someone's got erectile dysfunction, so can't get an erection consistently, they've got a 50% increased risk of a heart attack. Correct. That's a lot, isn't it? That's right. We wouldn't ignore any other 50% risk. Absolutely not. But even then, even though it's in JBS3 calculator and Q risk,

there's still evidence that when particularly the nurses are doing the assessments, they press the return button on the computer twice when it comes to the erectile dysfunction question. I suppose to move on quicker. because they think the consultation will be longer. Yeah. I mean, I know in general practice a while ago for diabetes, it did come in as a routine question that we had to ask,

and then we often did testosterone blood tests in men, and we often found them low in men with diabetes, but then no one knew what to do about it. So then they took it off as a question, because it was saying, well, we're doing too many tests, and then we've potentially got expensive treatment, and we shouldn't be doing it, and it doesn't seem to make sense for it.

Well, I think it's fair. fairly obvious that if you do seek out a problem by asking questions, you're bound to diagnose more. And if you don't, why are you asking the questions? So it was fairly obvious that that would happen. But it was also very interesting that in that one year in 2013 where it did appear on the cough, the diagnosis and prescribing rate more than doubled. But in the following year, when it was removed from the cloth for simplification, as they put it. It went back to actually below the levels of diagnosis of the year before. So talk about that testosterone.

Lots of people say to me, is there a male menopause or an andropause or whatever? What's your sort of terminology and what's your take on? No, there isn't a male menopause or an andropause. It's a term that's used by the media. to draw similarities to the female menopause because all women go through a menopause and 80% of men maintain normal or adequate levels of testosterone throughout their life.

So only about 20% of men have significantly low testosterone levels and it's generally associated with other diseases such as type 2 diabetes, such as obesity, such as taking medications, such as opiate pain killers, and more and more nowadays anabolic steroid use in younger men, which is a real problem. It's a real concern. We might do maybe a podcast on that alone

because there's certainly a big increase in using these drugs for young bodybuilders, aren't there, which has long-term problems. Absolutely. So you say, so 20% 1 in 5 men have low testosterone. That's a lot. men roughly have testosterone as a replacement treatment, do you think, in the UK? Of that, where still in the UK, it all depends where you draw your level. Because the problem is what you have is action limits, which are guideline driven,

where you will show evidence of benefit. And then you have reference ranges by the laboratory, which are purely statistical results based on screening a population of 100 people. And so the majority of those 20% don't get treated because they're in the just low range where the symptoms are mainly sexual symptoms, erectile dysfunction, loss of libido, loss of morning erections. This occurs between testosterone levels of about 12 and 8 nanomoles per litre. But if you get below 8, then that's when there's proven significant risk of mortality.

and of developing more diabetes. So those should definitely be treated. And there's general acknowledgement of that. But when it comes to men in the slightly low range when they're just getting sexual symptoms, I don't think a lot of NHS doctors are necessarily seeing restoring a middle-aged man's libido as a top priority for them on only working day.

Which is a shame, isn't it? It is a shame. Because low testosterone, in men is similar to low estrogen and even low testosterone, women in that it's not just about symptoms, is it? It's about future diseases as well. So men who have low testosterone, certainly blow out like you're saying, do have an increased risk of heart disease, osteoporosis. Type 2 diabetes, which is a major problem for the developed world. And in fact, we're hoping an intervention study in Australia, which is the T4D study, which will be published early next year,

will actually show that intervening in younger men with pre-diabetes will actually prevent progression to type 2 diabetes. It's one thing to have an observational study that shows that this happens. It's another thing to do an RCT. So this is giving testosterone to those who have a higher risk of developing type 2 diabetes. Or placebo in a randomised trial over a period of four years. So giving testosterone back, we know that it would lower the risk of heart disease and osteoporosis for these men who've got low testosterone, wouldn't it?

Yeah, and there were several studies that show that. But the problem is that you've got to give the, because the low testosterone puts them at increased risk in the first place, if you don't do the job properly, they'll be at the increased risk because of the low testosterone that hasn't been treated. So therefore the reliable studies are the ones that actually show, A, that the men took the treatment and B, that they normalised their levels for a sustained period of time. And that's why a few bad studies have confused the literature.

Yeah. Because it's quite different. Because as you know, in women, certainly if they're over 45, we don't do blood tests to diagnose the menopause. it's just a history taking if their periods have changed in nature or frequency. They've got symptoms. Then we often try them on HRT and see how they are after three months. Whereas for men, they need to have at least two blood tests taken, don't they?

Yes. And it should be what time of the day? It should be before 11 o'clock in the morning. Just explain why that is? Because there's a diurnal variation. Levels of testosterone are higher in the morning than they are in the evening. And conventionally, all the trials, done on morning samples because that's the way they were done. And so that's where the reference

ranges for all the tests come in. So if it's low and it's in the afternoon, it's not so, it might not be significant. So it's in the morning. And then they should have two blood tests done. So one normal blood test and man's still got symptoms, they could still have low testosterone. Yes. If you get a borderline one, you should repeat it. I believe that even if you get the first one being normal. If the symptoms are bad enough, you should repeat it. Right. Yeah. Because otherwise, what's the logic if you'd repeated if the first one was low? And then take the normal one when you repeated as being a good one. Yes. So, you know, if the symptoms are clear, then you should do two even if the first one was, if the first one is right at the top of the

range, you'd probably be all right. But if it certainly was in the middle range, you'd repeat it. And then, so the commonest symptoms, obviously people know about, erectile dysfunction, but then you're also saying tiredness? Well, a study called the European male aging study showed that the best predictive symptoms were erectile dysfunction, loss of libido, and most importantly, nighttime or early morning erections, these erections, spontaneous erections that men get in the morning are very testosterone dependent. Right.

And it's a question that we should ask all men. Yes. but it often gets neglected. That's to me the most important one. But then tiredness, a lack of strength. I always find that when a man says that he can't play football with his son, and his son says, you're useless, dad. Johnny's mates much more fun than you.

Or his wife has to lift the shopping into the car because she's stronger than him. So muscle strength goes. Yeah. Another thing which has really hit us when we've been doing a lot of meetings is the number of men who say that they fall asleep at the wheel of their car. Yeah, which is a real concern. Yeah, particularly in the afternoon when the levels are likely to be lower. Right.

And particularly worrying if they're HGV drivers. Mm, absolutely. And a lot pull over and turn off their cockpit monitor and have asleep by the roadside. And do men tend to put on weight if they've got low testosterone levels? Yes, it works both ways. If you've got a low testosterone, because testosterone controls the distribution between fat and muscle. So if you have a low testosterone, you will lose muscle and have more fat. Likewise, if you are obese in the first place, the fat is particularly that fat around the abdomen, is metabolically active.

and it produces a load of chemicals that cause you to break down your own testosterone and convert it to estrogen. Yes. Which is why when you see the men on the football matches where they get their shirt off, they've got big bellies and often some man boobs showing that there's probably a bit too much estrogen. So those men who do have that body shape, who are having erectile problems, feeling more tired, a bit weaker, just a bit lower in their mood. really should consider having testosterone levels undertaken, shouldn't they?

Absolutely. I just count them up every time I go to a football match. You see them all. No, I mean, I always laugh for my children because I can spot menopoles or women are a mile away, but actually you can spot men who are likely to have low testosterone. And it's a bit like with the menopause, I often think for women, it's a bit like it is really should be thought of as a female hormone deficiency syndrome. Yeah. Because if we don't provide the hormones back, we've got this increased risk of heart disease, osteoporosis diabetes.

So it's not just about symptoms. And it's exactly the same for men, isn't it? Obviously, if you give them testosterone, their symptoms improve, but also you're really investing in their future health, aren't you? Yes, and you have to explain this to them because men, I think, are worse than women, they want a quick fix.

Absolutely. This is why they never read the instructions on any electrical appliance they open. They just push all the buttons. So they want an instant. fix and even if you tell them that not to expect anything for at least two or three months, they will still contact you two weeks later saying that they're no better. And the longer that they've had a problem, the longer it's going to take for it to be correct.

So it can take several months, can it? Yeah, because obviously things like change of body shape takes time. We'd be laughed at if we'd gone our gym membership on the 1st of January and then turned up two weeks later and wants our money back because we hadn't got a six-pack. You know, this takes an awful lot of work to convert meaningful amounts of fat into muscle. And that's the mechanism by the way of how a lot of the symptoms improve. Because obviously the physical strength and the energy levels and the improvement of insulin levels and glucose levels are related to this balance between fat and muscle. Yeah.

They take time. Yeah. So it's really important to persevere and be monitored as well, isn't it? That's right. And the interesting thing is often the libido improves before the erections. Right. So men should always be offered a tablet to help with their erections. So something like Viagra equivalent.

Yeah. Because otherwise it can be more frustrating if your libido comes back. They can't perform. And he can't perform. Yeah. So talk just briefly about Viagra. Because we can buy it over the counter now, or men can buy it over the counter, can't they? Yes.

And is that a good thing? Because from what we've talked about, even just now, surely men with low testosterone will we buying Viagra and maybe disappointed that it's not working or ignoring the fact that there might be other reasons for their erect cell response? Well, as we discussed earlier, what we were doing before wasn't working. because some GPs just weren't asking even though they were following up men who were prime candidates for erectile dysfunction so something needed to be done and I was involved in the committee that looked into this

and in general I think it's positive because there are a group of men out there who whatever you say won't go to their GP about it this is the way they leave their lives everything is done through the internet and what it does is it puts them in contact with a healthcare professional because all the pharmacists have been trained to ask some questions and to spot risk factors

so when they see a man come in who looks like they've got some of the features that we've said they will be directing that patient straight along to their general practitioner and they even have the facility to be able to check their blood pressure measure their cholesterol, even now measure their testosterone. Which is great, so they can help to screen those men. And you'll correct me, the percentages of counterfeits on the internet of Viagro is really high, isn't it? When they've looked to see those blue tablets that are bought online.

A lot of them are not real, are they? They're not real, and a lot of the proceeds go towards organised crime. Yeah. And even if you see an advert that says it's from a Canadian, pharmacy with a nice looking lady in a white coat, it probably comes from India. Yes. And whereas a lot of them do contain some active drug, they also tend to contain whatever happens to be lying around at the time, a bit of chalk dust, a bit of brick dust, anything

just to make up the tablet. So having it available over the counter least people know they're getting what, you know, what they want as opposed to ordering it online and getting something else. Yeah, we wouldn't treat our car this way. We wouldn't put some brake fluid in our car that we'd got from another source. We wouldn't trust our car unless it was a qualifying mechanic looking at it. So to treat our bodies in this way is absurd really. Yeah.

So it has its role as long as people are aware that Viagra isn't just for everyone and it's not just the only treatment. But there are a rather tablets, aren't there? Vagra was the first one that came out and all the studies. That's what everyone knows. But you tend to not really use Vagraph first line for a lot of men, do you? Well, if we turn back to what we discussed at the beginning, where I said that these were good drugs that were being developed

to treat cardiovascular disease, the drug companies weren't stupid because they got as far as the advanced studies and they knew these drugs were likely to have benefits. and the way in which these drugs work is by opening up blood vessels to improve the blood supply to the penis. They're also improving the blood supply to other organs like the heart, like the kidneys, like the peripheral circulation. So there'll be good treatment for cold hands, cold feet, even possibly improving the circulation to the brain. But you won't get these benefits if you're only doing it for one tablet, for four hours a week.

So they should be given, as they were in the studies, on a daily basis. And there are formulations now which are long acting, whereby you can take a tablet every day. Because Viagra doesn't last very long, does it? No, it only lasts for about four hours, probably at the most. And also, there are a lot of relationships whereby that link of having to take a tablet at an hour before sex can actually be very detrimental

to a relationship. It's quite pressurised, isn't it? It makes it very clinical. Yeah, yeah. And Viagra can be affected sometimes if you eat a meal, can't it? Absolutely, and a lot of romance happens in this country after a nice meal and a bottle of wine.

And so both food and alcohol delay the absorption. So after the romantic meal, it's slowing the absorption of the drug and both of them were asleep by the time. So the alternatives are often better for various reasons. A lot of times the longer acting tablet to Dala Filmm as previously Cialis can be even better the day after than the day that you took it. Okay.

And that makes it more spontaneous, which is... Particularly in new relationships. Yeah. Because, you know, if you were going on a first date with somebody, it wouldn't be the most romantic thing to tell them that it will always happen once a week on a Saturday night after taking a tablet an hour before. Yeah, so that's good. It's nice to know there are options,

and I think for men who maybe have tried, bag over the counter, and it's not for them, knowing that there are alternatives is really important. Absolutely. And the earlier you get treated, the better the results, because the results from treating early, milder problems

are much better than if you get a patient who hasn't had an erection for five years, the like if you have somebody who hasn't got off their couch for five years, getting them back walking or running regularly will be very difficult for longer. They've been out of there. So there's no prizes for suffering in silence? Absolutely not. Absolutely good.

Oh, that's been really interesting. Before we finish, could I just ask for you for three take home points just for men or even partners of men to think about regarding their sort of libido, sexual health, Well, I would say that the first message is that having erections and sexual activity is great for men's health. Lots of studies have shown that if you have intercourse two or more times a week, it significantly reduces your chances of a heart attack and you live longer. I like that one, great. And for women, in case they're wondering, the quality of the sex seems to matter more than the quantity.

The second message would be that if you have a problem with your erections, a man in that situation has heart disease or a medical problem causing it until proven otherwise. Don't put it down to be stress, age, work or anything like that. And the third point I would make is that the treatments that we use for erectile dysfunction are great medications that potentially might reduce the rate of heart attacks. There is no risk whatsoever.

They are extremely safe and a physician shouldn't be telling patients that there is any risk in taking these drugs because if you're fit enough for sexual activity then there's no problem whatsoever in taking the medication. Really reassuring. So thank you ever so much, Jeff. And Jeff's got a website, jefferyhackett.com.

UK and you see patients here and in other places but all the details are on the website so thank you very much thank you thanks to us for more information about the menopause please visit our website www.mennepause doctor.com.ukukukh