The Dr Louise Newson Podcast - 106 - Seeing the bigger picture with Men’s Health specialist Dr Jeff Foster

Episode Date: July 6, 2021

If you have a male partner, this episode is definitely one for them too. Dr Jeff Foster is a GP and Men's Health specialist who shares an interest with Dr Newson in hormones and the effects of them - or lack of them - on our lives and future health.   Together they discuss what makes up the specialities of Men's Health and Women's Health, and explain why seeing the bigger picture - one that looks at the whole person - is crucial to understanding and treating hormone deficiencies. Dr Foster discusses testosterone in men and how symptoms of low testosterone can mirror some menopausal symptoms. They discuss the benefits of testosterone on wider aspects of health, and caution is shared about the worrying popularity in some young men to use steroids and newer unregulated drugs such as SARMs.   Dr Foster's advice to women is to look at the men in your life and see if they're struggling with similar symptoms such as fatigue, brain fog, or low libido, and give them a nudge to speak to their doctor.   Dr Foster's 3 tips for men are: If you think you may have low testosterone, fill in the Adam Score which is 10 simple questions that indicate whether this might be a problem. Fill in the Adam Score here. Go and speak to your doctor if you are showing symptoms of low testosterone, don't be tempted to book a testosterone test yourself online. If your test results come back normal but you continue to have symptoms, try and see a Men's Health specialist doctor for further investigation and discussion. Dr Foster's website is www.drjefffoster.co.uk and you can follow him on social media: Instagram @drjefffoster Twitter @doctor_jef   The British Society of Sexual Medicine has some useful guidance for healthcare professionals on managing testosterone deficiency, read this here.

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsom, a GP and menopause specialist, and I'm also the founder of the Menopause charity. In addition, I run the Newsome Health Menopause and Well-Being Clinic here in Stratford-upon-Avon. So today on this podcast, I'm really pleased to invite another man. We've had a lot more women than men on the podcast, so it's really great to welcome Dr. to Jeff Foster, who I've known for a few years now. He's a local GP and he's also a specialist in men's health. So thanks for coming today, Jeff. Thank you. So you've been a GP for quite a few

years and now you're sort of branched out a bit more into men's health, which we'll talk about in a bit. So how long have you been a GP for? Nearly 11 years now, but time does go quickly. And then men's health really for about six years now, nearly coming on seven. And again, it goes very, very fast. So as a GP, obviously, and I've been a GP for many years, we're trained in all sorts of things. But this whole women's health, men's health, I think for a lot of people, sounds a bit weird, doesn't it?

Because we see women, we see men. So what's so specific about men's health? You would have thought that's something that just gets done all the time really well, actually, because we see a lot of men as GP. So can you just define what you mean by men's health? Yeah, sure. the problem is there really isn't a clear definition. And you would imagine, even within women's health, that you go and see a cardiologist or an endocrinologist and they treat your person-specific

issues. And if it's a male problem, they treat it. And if it's a feeling problem, they treat it. But the problem is that specialists are very good at being specialists, but don't tend to look at the person as a whole. And that's why coming from a GP background, and you'll know more than me, you tend to look at patients slightly differently and you want to treat them as a whole person and slightly more specific in male issues or female issues depending. The problem is that no specialties and not any offence to all hospital consultants who are very good at this, but they don't tend to look at guys as a whole. They tend to treat their prostate or they tend to treat their erectile dysfunction, but then they don't tend to look at the other bits that go with it and how that might

affect it. And the biggest problem is that we used to get a lot of patients coming back to primary care saying, you know, I've seen the specialists, but I don't really understand what's happened and I don't understand where I'm on. They're kind of lost. So it was nice to find this specialty where we put all these little bits of other specialties together to say, I'm the guy that's going to look after blokes. And it's very interesting, is it? So I trained in hospital medicine for many years and I did different jobs. So I did a job special. specialising in cancer. I did a job specialising in heart medicine. I did a job specialising in lung medicine. And when I did my elective, actually, which is something you do as a student, you go to

another country and I went to Canada. And they were even more specialists there, actually. And if someone had a chest infection on the ward, they would get the chest team to come and prescribe antibiotics. And I would say, well, anyone can prescribe antibiotics. Why do you need a say, oh, no, because that's there. And then if someone had chest pain, they would get the cardiologist to come. And I'm thinking, Really? Well, we could just do that. But I think over the last 30 years or so, we've caught up with the Canadians and we're very much, you know, you do have these specialties. And that's really, really important. If I had a very unusual heart condition, I would want to see the top cardiologist. I wouldn't want a GP to sort me out. But if I had some palpitations or a bit of raised blood pressure, I wouldn't expect to go and see a cardiologist. I would want my general physician actually to sort me out because like you say, I think a lot of times in medicine, We've all done it, but healthcare professionals tend to forget the basics. So, for example, if I had palpitations, I might have something wrong with my heart, but I also might be anemic, or I might have an infection that's causing my heart to base.

So it's looking back almost, isn't it, and taking a step back before we rush and make a diagnosis and sort of almost shoehorn each patient into a different specialty. And I think that's the beauty of doing something that's more general, isn't it, that you can really be very holistic in your approach. Yeah. So with men's health, a lot of people will think, well, that's just about erection problems and hormone problems and maybe libido,

because I don't know why. And it's a bit like that. With women's health, it's always been seen as, oh, you go see a gynaecologist if you have a woman's problem. But actually, it's far bigger than that, isn't it? The biggest problem we find is that it is an holistic way of treating male health that is the only way to really get a good result. And you're right, so many blocs will have libido issues,

but that's because what a lot of guys focus on, but supposing you're thinking along the lines of mental health or cardiovascular disease or testosterone deficiency, all of them result in libido problems, but if you go to hospital, you'll see a urologist for the urological one for the heart bit or a psychiatrist, but of course you don't need to do all that. You look at the patient overall.

Yes, they've got this symptom of libido, but there's so much more behind it. And the whole key behind men's health is, yes, we treat that symptom. That's the underlying bit that's brought them to see you. But then you have to look at the other bit behind, the bit that's really influencing them. And you're only going to get a good outcome if you address the underlying thing. I think the really good example is when you look at Viagra over the counter,

which I've got a massive thing about, I cannot stand this stuff. So you can buy Viagra over the counter if you've got a rectile dysfunction. You buy it, great, problem solved. Of course, nobody has actually asked you why you've got erectile dysfunction. And we know that, for example, you've got about a three to five year window from the onset of erectile dysfunction if it's cardiovascular base before you're going to have some sort of cardiac event, like a heart attack. If you then go to boots and buy some Viagra straight away,

you've then got another delayed amount of time before you actually see that doctor. But of course, if we did it properly, we could have fixed that issue at the start. Which is so important, isn't it? Because, I mean, I have an issue with Viagra being available over the counter because it's so easy just to go and buy it. Whereas women really struggled to get HART and estrogen actually is a lot safer than Viagra. I'm sure you'd agree. And certainly, local estrogen, vaginal estrogen, is loads safer than Viagra.

Yet we need a prescription for it as women. But you're absolutely right. And I think I went to a lecture probably 15 years ago. I think it was by Professor Mike Kirby, who has used. know is part of the British Society of Sexual Medicine. And he was talking about low libido and erectile problems. And he said, well, actually, this is a gateway to the heart. And I was thinking, what penis, heart? What was he talking about? But then you actually think about it, again, breaking it down to the basics and thinking, well, the blood vessels in the penis are very small.

If they become damaged and narrowed, then men are less likely to have erections. And therefore, there might be narrowing elsewhere. And the slightly bigger blood vessels that affect the heart. And that's exactly what you're saying, isn't it? them. And so it's really important that people are assessed really properly by someone who can understand the heart system. Some of these men might have diabetes, which isn't going to be picked up by just by and by Agro over the counter, is it, or blood pressure problems. I'm sure that's one of the things that's very interesting for you that it's not just people with Lola Vida that come and see you. It's actually these are people who have potentially reversible

conditions as well, but without the right treatment could be even fatal or very detrimental to their future health. Yeah. One of the biggest problems we've got is that guys don't really come to see doctors until it's often too late. In general, despite a lot of media effort to try and improve the attitudes of men towards their health and mental health in particular, we aren't still very good as a group at seeking medical advice when we need it. We're going to make a moment. We're going to of conflicting information. We're told on one hand you should see a doctor if you have a symptom. If you're struggling with mental health, you should speak up about it and tell us what about it and you shouldn't suffer in silence. And yet we still have societal pressures as guys to say,

well, don't be a girl. You don't cry. You know, man up. That's still a big one we use. And these are still in rain from a young age. So why on earth would you want to go to a doctor to tell them you've got problems down below in the bedroom? You just buy the thing off the internet. makes it really hard to get past that initial problem. It's very difficult, isn't it? And certainly I used to ask all patients, male patients with diabetes if they had erectile problems. And a lot of them were really quite shocked that I'm a woman and I've asked that. But a lot of them actually were really relieved that I'd ask this as well. And it's a bit like us in the clinic here we ask a lot of, well, I ask all the women that's relevant to about their libido. And so many times, they're so

relieved actually because they haven't had sex for a long time and sometimes they have symptoms such as vaginal dryness that's stopping them but no one's ever spoken to them and then they don't know that there are ways to improve and I'm sure that's the same men sex is even more important you could argue so to not be able to function if you like is it takes a lot of guts doesn't it to talk about yeah which is why we're often seeing them too late I think in looking at women very few doctors, certainly very few male doctors will ask women about their sexual dysfunction, especially going through menopause, and exactly the same parallels with men. We may ask that simple question, how has your sex, have yes, good, no, and then we move on quickly as possible.

Because doctors find it awkward to talk about, and if the doctor finds it awkward, then the patient's certainly not going to open up about it, and then suddenly you've missed your window, and that's another year or another six months before that happens when you could have treated the problem. It's very hard, isn't it? And I used to find in general practice a lot of men, especially younger men, would come for a different reason. So they might come with a headache or they might come for a low mood or sometimes even just because they had a viral infection. I'm thinking, why have they come with a bit of a cold?

And then I'd say, is there anything else that's bothering you? And then they'd look a bit sheepish. And I'd say, look, I can talk about anything. It's fine. I'm a doctor. And then they would suddenly say, but their sort of shoulders would go down about 20 inches and they'd feel so much more comfortable once somebody had asked. and it's very, very hard, isn't it? Ours get labelled as personal issue.

And then you kind of know ahead of time it's going to be something that they may want to discuss. I think, thank goodness now, I've started to get at least enough of reputation that people know if they're coming to see me. It's something that we've dealt with before. And perhaps if you feel that the doctor you're speaking to is comfortable in that environment,

then you're more likely to feel comfortable opening it up in that sort of discussion. The other way sometimes is I will just blatantly ask them rather early on, especially when we think of things like guys and sex drive and testosterone. And it's a question, like you said, they almost want to be asked. So rather than giving them the opportunity, I'll say to them, you know, how is your erectile function? A big one we ask is when was the last time you had a morning erection? Because I often get thinking about where they might be in that cycle of life and testosterone and erectile dysfunction, because then they can start feeling more comfortable that talking about it again. Yeah, there's very few people that wouldn't talk about

it if their questions are asked. So testosterone, let's talk about testosterone. Some of you have listened to the podcast before I talk a lot about testosterone in women, because as many of you know, women produce more testosterone than estrogen, yet we don't have a licensed product in the UK, which is incredibly frustrating. But we're not here to talk about women. We're talking about men. So testosterone is obviously a very important hormone in men, isn't it, Jeff? Tell us what it does. So similarly to women, and my big drive behind all these sorts of things is that I don't believe men and women are that different. Certainly when it comes to hormonal health and sex hormonal health. So yes, you need testosterone to get you through puberty.

It's going to be the defining factors that make you appear male. And the sheer points of the volume of testosterone that we're going to use or need compared with a woman. So you're going to get your second big sexual characteristics. But the whole point of testosterone, which I think is, mimic in the menopause side of things so well with estrogens as well as it does so much more than just giving you a beard and your muscles bigger. So testosterone is required for metabolic health. It reduces your risk of diabetes. It improves your blood pressure and cholesterol ratios. It reduce depression. It improves mental clarity. And there's so much that you start ticking this box

and think, Christ, everyone should be on this stuff. And it's so similar to HRT in the sense that you think, every woman's going to go through this process of menopause, but dyes don't quite have that same pattern. And although everyone will drop their testosterone at some stage, the difficulty is working at who needs it when and why, which makes it a much trickier pattern to try and get to. Yeah, it's very interesting, is it? Because there are so many similarities.

But the other thing that I think that's quite different is that for women, we can't do a blood test to diagnose our menopause or perimenopause. I'm sure if blood tests are low, it might be an indication, but blood tests can be normal and people can still have hormonal changes. So we go very much on symptoms. So the menopals questionnaire that can be downloaded from my website, menopause doctor, or the balance app. But for men, there is, you can do a blood test, can't you? Yeah. It makes it easier almost to determine. I think the difficulty with male low testosterone is the fact that it is so variable and can be mimicked by other conditions.

we know that a low testosterone will give all the symptoms we sort of just that are very, very similar to menopause. So, for example, a low testosterone will classically cause low mood, low energy, loss of sex drive, in more extreme cases, night sweats, irritability. I can just read off the menopause list. Even the weirdest stuff, like osteoporosis, will occur if testosterone drops because a guy loses as estrogen as a result. So much of it mimics that. But the difficulty with this, as I said, is that not every guy gets it at the same point in life. The best testosterone deficiency, however, is that we can do a blood test,

and provided the blood test is done in the right environment, so it's not a finger-prick test, it's done in the morning and the early hours. And we have enough symptoms to go with it, and we look for the right test, because the other thing is there's a difference between how much total testosterone you release and how much of it is really available, which is the free testosterone. but that's more about how I've had a discussion with the doctor, you can diagnose it pretty easily. So it shouldn't be hard to pick up cases.

So do you think it should be more of a screening program that men should have their testosterone done? You know, like we do blood pressure checks regularly or, you know, the sort of screening sometimes we do for diabetes. Should we be doing more testosterone tests? It's a bit of a double-edged sword with low testosterone because, for example, from the age of 30, we know your testosterone is going to drop by approximately 1% a year. But you're doing lots of very healthy lifestyle stuff and you're really fit and active or you had naturally high levels to start with.

You may not notice that until you're 70. And on the other hand, you might be somebody who's 30 and levels were very low and it doesn't take long to reach that symptomatic point. The reason is that it's difficult is because not everyone gets symptoms at the same point. in their life and not everyone is symptomatic based on the same number. And that's the key. So you can have a 60 year old whose level is, say, 12, where normal would say 15 to 30, but he's absolutely fine and he feels great, in which case you say to him, well, do we still give you testosterone? And you could argue there are some biomedical benefits, but it's not licensed for that. But as well, so you might find another guy whose level is, say, 1819, again,

so at the lower end of a normal range. And even within the guidance, you can't really give this guy testosterone because it's unlikely to benefit and we may be causing risk by pushing it too far the other way. So I would like to see more screening, but really, I think the best way to do it

would be to screen it and speak to someone because just it's going to give you a lot of false positives and we're going to be giving stuff to people that didn't really need it and we might also miss stuff. So, yeah, it's a tricky one. It is tricky, isn't it? I mean, probably about 10, 15 years ago,

there was a move for people with type 2 diabetes to be asked about libido, and then we did testosterone levels. And I remember doing lows in general practice. And then there was a big resistance to actually give these people testosterone because everyone was scared about it, a bit like people are scared of HRT.

But as you say, if a level is low and someone's having symptoms, yes, it can improve their symptoms, but it also can have health benefits as well, can't it? Yeah, so 50% of type G diabetics have low testosterone And we've got a lot of type two diabetics now That's a standard 50% So that's half of men who have type 2 diabetes

And how many of those will have treatment? That's a very different Sadly, it will be minimal Because again the argument is That well if you simply get them to lose weight And you improve their insulin sensitivity Then they may not need testosterone So my argument to that, Jeff, would be that if men are on testosterone, they might lose weight

and exercise and feel better. So it would help them to do that because we all know as healthcare professionals, if you run a clinic for people with diabetes, it's incredibly hard for them to lose weight. And often because of the metabolic changes that occur, it's a bit like menopause or women, you can try your best to lose weight, but it's so much easy when you've got the right hormones on board. And surely that must be the same in men as well. But also the thing that really concerns me, I suppose, about menopoles and women not getting HRT is their future health risks. So I was doing some calculations recently looking at how women taking HRT reduce their risk

of a heart attack once they take HRT. And I was comparing it with women who take a blood pressure lowering treatment or a statin that reduces cholesterol. And I was looking at the reduction risk for all these on people who are fit and healthy trying to avoid a heart attack. So we call that primary prevention. And you can guess which one came out top. It was having HRT.

Well, this was from good data. This was from Cochran, which we all know is very good data analysis. So I think, well, actually, doctors will prescribe statins very easily. They'll prescribe blood pressure treatment very easily, but we know most women don't get HRT. So I don't know if you know anything about what are the figures like for testosterone for primary prevention of heart disease. it's probably fairly similar, I would have thought.

Yeah, it's very similar. In fact, that if you look at the metabolic and, if it stems from metabolic, we look to metabolic bone density benefits and psychological benefits, and you stuck all that together, and you compare that with the cost of monthly testosterone, it's a minuscule cost.

If you get a little further, and you said, well, how many 67-year-old or 8-year-old bloats are getting osteoporosis, hip fractures, various other traumatic injuries, that could have been prevented. We even had one guy at my clinic who was diagnosed with dementia, and in fact it was a very low testosterone. This was surely the fact he just didn't have any of this stuff, and he'd been on various antidepressants and even started a dementia drug, which we amazing managed to stop. So that sounds like a lot of women we see in my clinic, but I remember

in general practice actually we had one of my patients was in his early 70s and he had sweats all the time, and we were worried that he had some sort of lymphoma or cancer and he had lots of tests. And it was only actually, after talking to my husband, who's a urologist, as you know, and I said, I just don't know what's wrong with this man, but it just doesn't look right. He's just a bit sort of just not quite himself, really. And his wife, I'd known for many years. So I decided to do a testosterone level, and he hardly had any. It was really, really low.

And I repeated it because, you know, sometimes if you're not sure, you repeat. So I did it again in the morning and again, it was incredibly low. And I gave him some testosterone, actually, under the guidance of my husband, because I wanted to make sure I was doing it right. And he felt incredibly well very quickly. And his wife was just amazed that he was coming back. You know, his brain was working. He was physically fitter. But I thought, I can't really do this on my own because he'd actually had like a mini stroke, like a TIA 15 years before.

So I sent him to the local hospital and they said, no, you can't have this. This is really going to affect you. You can't. You need to come off it. and he said, well, it's a real difficulty because this is the first time I've been on holiday for 10 years because I've been really struggling, and they had a mobile taravan in Cornwall, and he'd actually driven on the motorway for the first time, and his wife didn't have to drive. And he said to the person, they said, don't worry, you can just drive on the country lanes,

but you don't need the testosterone because it's got a risk of stroke. And I was really upset, actually, and we took it to the practice, and all my senior partners decided this man couldn't have testosterone. and I was really, really saddened actually that someone wasn't allowed their own natural hormone back. And it's very different. Like you say, there are risks if you give too much testosterone, but if you're giving it to replace something that's missing, it's not really risky, is it? No. And in fact, the data from the Royal College urologists actually suggests that if you get patients into a normal or high normal testosterone level at any age, it reduces all cause mortality.

So every is likely to improve, which just sounds crazy. It's amazing, isn't it, really? I mean, I think the role osteoporosis starts to tell us that one in two women over the age of 50 will develop osteoporosis and one in five men. So if all women that needed it or wanted it were on HRT and if all men with low testosterone with symptoms on testosterone, I think those figures would be a lot different, isn't they? Yeah. But a lot of it is comfort with prescribing. And I think you see that so much with HRT.

Historically, it's been something that we're not very well informed about. It was probably bad for you. We don't really know. Don't go into that. And then I think testosterone just follows that exact same pattern, probably maybe 10 years behind menthols. And we're doing the same thing. So we see doctors going, well, I don't really know much about it.

So we'll just leave it and it'll be something else. It's not. And of course, if you fix the issue, people get better and risks are well the benefits are so much better simply getting into that high normal range yeah and so the testosterone that you prescribed that is available on the NHS from doctors is given usually as a gel isn't it that you rub on is that right so they used to give pills for testosterone but really it's just not safe and the problem is liver problems and risks to liver safety so we kind of moved away from that and we tend to use either a topical gel

topical cream or injectable therapies depending. And again, a lot of guys will go on the internet and they read. And a lot of folks will have said, I know which one I want. I want this one because I read on the internet, it's the best type of treatment. But really that isn't the case.

The best treatment is really the one that suits that patient individually risk and their symptoms. Not every guy wants to be injecting. Conversely, not every guy wants to be putting gel on their shoulders every day. everything in male health and testosterone has a risk and a benefit. And the idea is you balance that with your individual patient.

And that's why this is a holistic thing. In general, and this is, again, not a slight on secondary care, but sometimes they don't always have that great understanding of how a guy might want to approach his testosterone treatment. And commonly endocrinologists will give nabedo injections, and urologists will give gel. but of course to me a couple months later

again, I've got a slide my shoulders and I can't get it off or my bum is so sore from being injected everything to be this thing that I want to change so having that informed

discussion really makes a big difference yeah so it's having a choice which is really important but when you Google testosterone for men there are all sorts of clinics

doing all sorts of things that really scare me actually and it's I don't know what you think but it's similar there's a comprehensive founded by our identical hormones, which a lot of people go to, which are not licensed, they're not regulated, and they're frightfully expensive, and they're not recommended by any of their national or international bodies. And some of the testosterone clinics for men,

some of the products might be licensed, but they have this massive marketing that, you know, anyone can have testosterone. And I think what you've said so clearly is that not everyone should have it or can have it, and it really have to be individualized. So I think people need to be really careful, don't they, if they're male and going to a clinic? I would always say that if you come to see me and you have low testosterone and we find a way to not give you testosterone and it comes up, then we've done a better job than having to do testosterone. Giving you testosterone should be the last resort because we couldn't find any other way of getting it improved. And admittedly, you know, age is the most common reason that it's going

down, but it's not always, and not everyone needs the stuff and not everyone should be treated. I think a big thing as well is when you do pick a treatment, you don't want to be a guinea pig. Whenever I see a patient, I want to make sure that hundreds of thousands of people have already had that drug before my patient, so they're not the risk of taking this. And my goal in testosterone replacement is to say, well, yes, I'll make you feel better now, but I want you to be overall healthier in 20, 30 years and not to come back with the complication because we gave you a drug that we had a crack at

and didn't know if it was good. And I think it's really important actually probably to mention now about these testosterone analogs. So these drugs of treatments that people can buy, especially people who go to the gym, and they stimulate the testosterone receptors, but they're not actual pure testosterone. Just explain a bit about that

because we've all seen people with quite weird, body shapes now especially. But they do, don't they? And it is to try and enhance their muscles. Sometimes they're not all testosterone. Sometimes they're growth hormone as well. But these, it's quite a culture, isn't it? In lots of gyms now.

And it really scares me because they're on risks, aren't they? Can you just explain a bit about this? Because I think it's really important. Yeah, I've gone the gym for 25 years, but I'm still young. It doesn't matter. But a long time, long time. And in the last 10 years, I have seen an explosion of younger guys, late teens, early 20s, who are big. And these are guys who have just accelerated in the way that could never happen on a natural scale.

They use these drugs that we refer to as SARMs, and these are kind of drugs that allow you to sort of precursors to testosterone, ways around of negotiating the fact you might be using anabolic steroid. But the push comes to shove is that you're still messing. with your hormonal pathways. And so for my clinic, I wouldn't give anyone under the age of 30 testosterone unless we have ruled out any reversible cause, any genetic cause, anything that will effectively allow your testosterone to improve naturally. Because it's going to keep going up until you hit 30. And if you mess with it in your early 20,

and that's a psalm or an injectable or anabolic cell with growth or anything, then potentially that ruins that natural growth you get over time and the next thing you know you've got a diet who's 30 that's now having to take testosterone replacement forever only because he did something he regretted 10 years before. Which is a big problem and I know my husband, I've already said, is a urologist and he's seen people with testicular atrophy and infertility actually.

So that means that their balls basically have shrunk, but also they're infertile. So they don't realise that at the time because they think, well, if it's like testosterone, So it'd probably be good if you saw something, is that right? There's a general consensus that if you take anabolic steroids, you're doing it for the short term, so everything will be fine. And you can just stop and it will all go okay.

But of course, irrespect of the fact this isn't a medically prescribed thing, these tend to be enormously high doses to get you to this super dosing of a big size quickly, which can have irreversible damage to your testicles and your opportunity to produce the testosterone to start with. But I guess in that scenario, when you're in your early 20s and you're invincible, you don't think about the long-term analysis. And admittedly, you get quite a lot of guys coming who are in their mid-30s, who were very athletic and younger.

And they will, with some coercion admit that they may have taken something in the past. Quite often it has impacted on their ability to produce their testosterone naturally. And it's a real shame because, again, I don't know, maybe when I was 20, did I want to be bigger, probably. But I felt even if that was around, the ability and ease to gain drugs to improve your size is now so easy that the temptation is there. And you have to be really careful,

especially women who are listening, whose sons might be going to the gym. It's very important that are educated because of the longer-term risks. So it's been absolutely brilliant talking like this. I just wanted, we mentioned about symptoms as well as the levels that can be done. if women have got a partner who they think might be struggling with low testosterone

or if men themselves are listening, what's the best way of getting the symptoms? Would they go to your website or what would they do? They can come to my website, which is Dr. Jeff Foster.k.k.uk, unsurprisingly, our new website, which will be h3health.com.uk. The other thing I was just going to highlight very briefly is that going back to symptoms, if you're not sure if you might have symptoms of low testosterone, the best thing is if you're in your 40s or sometimes even younger, look at your partner. If your partners going to the Newsom Clinic for HRT and you suddenly think,

I have all those things, then that's when guys start to get that light bulb change. The flick of the switch that they realised that other people, in particular their partners are often the ones that have those same things. Hang on a minute, they're deficient in something. So am I. I'm not going to we pick them up. I think that's a really good point. And I think that's certainly similar to the menopause and perimenopause.

Often it's the partners, male or female partners, that pick it up, actually. Or sometimes it's their children. Say, you know, I know thinking about I used to forget so much of my children and what they told me. I'd forget their games kit for school. I'd forget their packed lunch if they were going on a school trip. And I used to think it was because I was too busy. And it wasn't. It's because I didn't have any hormones in my body.

But it's really useful sometimes. And nobody likes to be criticized. But actually, if you've got a partner that's coming home and fall in. asleep on the sofa that they'd never used to, just less interested in things, just slowing down a bit and they're only in their 40s, 50s or 60s. You know, you have to be questioning, is there another reason? And certainly men who have put on weight in their medline as well and are a bit slower. Most of those men are probably likely to have low testosterone, I think if you're on HRT, you should look at your partner and think, where is he on that scale?

If he's still running around really happy and wanting sex, then forget about it. If you fell actually, you've overtaken him and feel that you're much better in your quality of life, then really he needs a nudge. Yeah. No, it's really good advice, and I'm hoping, you know, over the next few years we'll see a lot more talk in a really good evidence face way about testosterone. I think what you're doing is really good. And just finally, Jeff has got a book coming out, which I have had the delight of reading,

which encompasses not just testosterone, everything about. men's health, which I think men might be more resistant to read, but I think partners will be more encouraged to read. And it's certainly something that I think all men should read to really look at their health. So we'll put links to that in the podcast notes. But I hope that does really well, because I know how hard it is to write a book and the level of detail. And the evidence base that you've done is amazing, Jeff. So you should be really proud of what you've done that. That's incredible. So just to finish, I would like, as in my usual way, three take-home tips. actually. So for men who have been listening or for female partners of men who think their partners

might have low testosterone, what are the three things that you would do if you thought, oh goodness, maybe I've got no testosterone and I need help with three things they should do? First thing is, there's a thing called the Adam score or Adam questionnaire. You can Google it, and it's the name Adam, but it's a testosterone deficiency questionnaire. It's 10 questions, and you have a likely chance of having low testosterone. Very easy to do. It's easily available. It's on my website.

It's on every website. It's male health. Secondly, the next thing is, speak to a doctor and ask them for a test. Do not just order a test, because, again, we don't know how to always interpret that. And getting that information is really important to make sure you do the right test in the right way.

And the only other bit, in the third bit of advice, is once you have that information, if the blood test comes back as normal, but you're highly symptomatic and you still think you have a low testosterone, speak to a male health specialist, because it may be that the information wasn't gained in the right way, or it may need to alter the way the test is done, or it might be that the reference range used in the NHS, for example, might be higher and doesn't really fit what the British Society of Sexual Medicine guidance would be, and you actually might have the condition. Fantastic. Really, really good advice. So lots of information there,

and I hope that's been really helpful for people. And hopefully they'll all go and buy your book as well when it comes out. So thanks ever so much, Jeff, today. It's been great. Thank you. For more information about the perimenopause and menopause, you can go to my website, menopausedoctor.com. Or you can download our free app called Balance, available through the App Store and Google Play.