Testosterone, "Low T" and Exercise

From radio and TV ads to social media posts, there's a lot of buzz about testosterone and something called "Low T."  What are the facts behind all the hype?  We clear up the confusion with guest expert  Michael Swartzon, M.D., a primary care sports medicine physician at Miami Orthopedics and Sports Medicine Institute, a part of Baptist Health South Florida.

Host, Jonathan Fialkow, M.D., leads a lively conversation about how testosterone levels affect both men and women, how exercise plays a role, and how to separate science from marketing pitches in ads promoting testosterone therapies.

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Announcer:

At Baptist Health, South Florida, it's our mission to care for you when you're injured or sick and help you stay healthy and fit. Welcome to the Baptist HealthTalk podcast, where our respected experts bring you timely practical health and wellness information to improve your family's quality of life.

Dr. Fialkow:

Welcome Baptist HealthTalk podcast listeners. I'm Dr. Jonathan Fialkow. I'm a preventative cardiologist and lipidologist at Baptist Health's Miami Cardiac and Vascular Institute, where I'm also the Chief of Cardiology at Baptist Hospital and Chief Population Health Officer at Baptist Health. There's a lot of buzz in the popular press on social media and in hundreds of advertisements about testosterone, but what are the medical facts you need to know? In a future episode, we'll explore the subject of testosterone and male aging with an endocrinologist, but for today's episode, we're going to attempt to clear up some confusion about what testosterone does, how it's produced and how exercise can affect it. And to do that, we have our guests, Dr. Michael Swartzon. Welcome to the podcast, Michael.

Dr. Swartzon:

Hi, Dr Fialkow. Thanks for bringing me on.

Dr. Fialkow:

Thanks again for joining us. I'm looking forward to having you share your wealth of experience and knowledge in this space. Michael, before we get started, tell us a little bit about yourself, your specialization, the kind of patients that you generally see in your practice. So we can put that into the context of the discussion.

Dr. Swartzon:

Sure. So I am a sports medicine physician with the Miami Orthopedics and Sports Medicine Institute. My background is training in family medicine, and I did a subspecialty or fellowship training for sports medicine and orthopedics, which basically means in English is that I work with kids and adults who are active and have trouble with either acute or chronic injuries. And I also work directly with a lot of athletes and their coaching staffs on getting them to perform at their highest potential.

Dr. Fialkow:

And I appreciate that. And I think that's what intrigued me regarding your experience, because you see people in the real world, you're seeing a broad based population, and you've probably seen everything and heard everything that's out there. So let's see if we can dive into that a little bit.

Dr. Swartzon:

Sure, absolutely.

Dr. Fialkow:

Let's start with some basics. What is testosterone? What's its purpose in our body?

Dr. Swartzon:

So testosterone is a hormone. It's the major sex hormone, and it plays a lot of roles in our bodies. It's made in males, it's made mainly in the testes or testicles. Women do have some production in the ovaries, but it's the typical responses that you would think of in a male when they hit puberty. They get hair, they get a deeper voice, they get larger muscles, facial hair, strength, the bones grow. And a lot of times when you think of puberty, you think of kids discovering sex and going sex crazy. And again, that's partly responsible. Testosterone is partly responsible for that aspect.

Dr. Fialkow:

Do testosterone levels, generally, as you said, they start going up in puberty, I guess it triggers puberty.

Dr. Swartzon:

Right.

Dr. Fialkow:

Do they continue to go up throughout your life or do they change at all as a part of natural progression?

Dr. Swartzon:

They peak and then starting in your late twenties, early thirties, you start to see a very, very small decline. It's less than a percent per year, but there is an overall decline with aging. Correct.

Dr. Fialkow:

And it's fair to say that also varies from person to person. There's no hard and fast rule.

Dr. Swartzon:

Correct.

Dr. Fialkow:

Okay.

Dr. Swartzon:

Yeah.

Dr. Fialkow:

I'm sorry. Go ahead.

Dr. Swartzon:

No, there are definitely ways that speed up the loss of testosterone and there are ways to slow it down. And some of those are intrinsic, like genetic factors and sometimes they're things that are entirely within your control.

Dr. Fialkow:

We'll get to that a little bit because I do think those are the real important take home points, but going back to the kinds of questions that you probably get asked or you're exposed to more than I, though I certainly had my fair share, certainly listened to sports radio, low T.

Dr. Swartzon:

Low T.

Dr. Fialkow:

So you got to start with what is low T? And what causes it? Is it a real thing? What should we be concerned about? Here's your chance to get on your soapbox.

Dr. Swartzon:

Okay. So low T, when they say low T, the T stands for testosterone and they're lumping together a myriad of symptoms or a combination of a lot of symptoms that most commonly people get as they get older. And the suggestion is that possibly low testosterone is responsible for your plight or your issues, and that replacing it at this clinic will result in improvement in your life.

Dr. Fialkow:

So they take a lot of common things that happen as one gets older, not necessarily related to testosterone, but someone thinks people feel, they say, "I don't want to feel this anymore. Here's a solution." And it's invariably what?

Dr. Swartzon:

They always check statements. You ever hear fact checkers? Is it completely right? Completely wrong? So I would say their advertisements are kind of a mix, right? Yes, it's true that there are some people who have low T. It's about 15 to 20% of the population.

Dr. Fialkow:

So now we're talking about true low testosterone.

Dr. Swartzon:

Correct.

Dr. Fialkow:

Meaning a clinically low testosterone level.

Dr. Swartzon:

Right, so there is a clinically low testosterone that is in the general population, like I said, around 15 to 20%. And there are some things that can do to help them with their symptoms. And again, the major thing that we're looking for is some kind of sexual dysfunction.

Dr. Fialkow:

Is it decreased libido, decreased desire for sex? Is it erectile dysfunction, inability to perform the sexual act? Is it both? What would we define?

Dr. Swartzon:

It's all of the above, everything excluding, I don't want to get into the sperm production aspect of it. I'm definitely not an expert in fertility because it can be complicated when it comes to testosterone, but specifically with what the two you mentioned. So erectile dysfunction and sexual appetite, libido, are both affected by testosterone. And so not enough of it, and you will notice it.

Dr. Fialkow:

Now, those things can occur, not related to low T.

Dr. Swartzon:

Correct.

Dr. Fialkow:

So, if you're seeing a man, whatever age, 35, 50, and they bring to your attention, or you elicit those types of complaints, do you order a testosterone level? Was that part of your workup? Would that be something that's appropriate?

Dr. Swartzon:

No, no, it is not. That would be a further down the line. Much more commonly the issues with sexual libido or erectile dysfunction are related to some kind of metabolic syndrome. And that's a big group of things that have to do with how your heart and blood cells, your blood vessels, your plumbing, and your heart pump and how that works. Because without having the blood pumping to your penis, you're not going to be able to get an erection. There's another aspect of it that's psychological. And then there's a third, which can be the other category, which the testosterone would certainly fall into.

Dr. Fialkow:

So if a man feels, or is aware of a diminution in their sexual function and desire, the marketing will bring them to low T and potentially a testosterone replacement, which may have concerns which we'll get to. But as you just articulated, there are more common, other reasons why they may feel those things.

Dr. Swartzon:

Yeah, much more common that your primary care doctor is the best place to start. Do not be afraid to mention these kinds of symptoms. This is routine stuff that we get regularly, very regularly. There's concern, your doctor is a safe place, much safer than the internet.

Dr. Fialkow:

Let's talk a little bit back, let's going back to the testosterone specifically. So you mentioned some of the more common things that could occur in one's life that will lower their testosterone, not necessarily in a pathological way, like a decreased production, but more related to this other lifestyle. Well, articulate those a little bit. You brought up a few.

Dr. Swartzon:

So certainly diabetes is probably the most common. If you're a diabetic, there are issues with blood vessels and nerves that can affect your testosterone slash libido slash erectile function. There are other hormones like hypothyroidism that can get involved. Obesity, lack of exercise, certainly are among the biggest ones that we see.

Dr. Fialkow:

If someone gains weight and it's more common in the belly, the central obesity, doesn't exercise because they're tired or don't have time, or lazy, although let's assume mostly it's tired or not having time, that can lower their testosterone level.

Dr. Swartzon:

Correct.

Dr. Fialkow:

Would then that also make it harder for them to lose weight and exercise? Does that cycle get set up?

Dr. Swartzon:

It does. And then, there's also the stress aspect of it. As you increase your stress, your cortisol level goes up and generally speaking, your testosterone level goes down as you're stressed, and then you don't sleep. And of course you need your sleep cycle to be full for your body to function properly.

Dr. Fialkow:

Do you see in your practice, more concerns of testosterone levels by the individual in the man who's athletic, is concerned about athletic performance or more of the overweight diabetic who has other reasons for it?

Dr. Swartzon:

Mostly it's the athletes. I traditionally don't see patients that are diabetic looking for care. I'll see the 45 year old coach or retired player, who's starting to notice that their body isn't the same and they have questions, whether it's physical performance or sexual performance, it can be a mix, but that's the typical patient that I see.

Dr. Fialkow:

So, let's take for the purposes again of this testosterone related podcast, let's take that population. What do you speak to them about? What's part of your assessment? What are your treatment recommendations?

Dr. Swartzon:

Well, the advantage that I have is most of the times I know these people well, and so I can see if there's been a difference in their behavior and their attitude, in their weight, in their size, in their performance, whether it's athletic or in their job. So, I can notice if they've had less energy, less endurance, and any of those things can sometimes be obvious to a physician that knows you. But otherwise, it's a lot of talking, a lot of finding out what's going on with someone is their history, right? The subjective part. And you tell me what your symptoms are. And then I ask you more about them, and we go through it one at a time.

Dr. Fialkow:

I think that response was brilliant and it was a subtle, but well-placed plug for having a good relationship with your family physician. You can make a much better assessment when you know the person, you know what changes there are in the way they address their conversations with you, then if you just treat a diagnosis or as the internet will. So, again, I think that's well said. Specific to exercise. How does testosterone affect exercise and what would one look to do with exercise in terms of improving any testosterone related issues?

Dr. Swartzon:

I'm glad you mentioned that because I should have mentioned it earlier, exercise or using your muscles is one of the ways to cause a production in testosterone. Testosterone is necessary, it's one of the hormones necessary for not only strength, but growth of the muscle. Those are two different parts. You can get stronger without getting bigger. And testosterone is a big part of that. And so working out large muscle groups like your legs and your glutes results in an increase or jump in testosterone level in your body to allow for recovery.

Dr. Fialkow:

So, a natural and more holistic way of improving those low testosterone symptoms, if you will, with other benefits as well, towards weight management and blood pressure control and all the other benefits you get from exercising.

Dr. Swartzon:

Correct.

Dr. Fialkow:

In the interest of time, for the questions, testosterone of women, do women make testosterone? Is it a natural part of a woman's health? And do they wind up with problems from over or under production of testosterone?

Dr. Swartzon:

So, they do make testosterone. Certainly, it's part of their function as well. Some of it's made in the ovary, some of it is made in the body. It's converted, whether it's through fat or in the periphery, it's converted to testosterone. Yes, they need it for some of the same reasons that males need it. Women still have muscles. Women have bones that need structure. They have basically the same issues. Very rarely do women have low T. Most of the time you're seeing women for this testosterone issue is when they make too much. And a lot of times they have something called polycystic ovarian syndrome. And these women have trouble with fertility, they'll have acne, obesity, hair. And so they come in with certain symptoms that, and this is part of the workup, it's quite rare to see a woman for low T.

Dr. Fialkow:

Thank you. Last question. And as we mentioned, sometimes there's a stigma, a man does not want to discuss with their doctor any sexual related issues. They hear on the radio, "Oh, you could have low T. Come to our X, Y, and Z and get it." Is there a danger with getting put on any testosterone replacement?

Dr. Swartzon:

Yes. If you weren't going to ask me about this, I was going to mention it right off the bat. So everything that's done, you're coming in with a complaint and you're trying to improve on things. And one of the big tenants of medicine is do no harm. And so you come in and I'll do an evaluation, and let's say you do have low T and we start discussing treatment options or sending you to a specialist for this. Understand that mainly we're trying to help you with your life. Normally your sexual function, not so much your fatigue and energy level, but it does have risks.

Dr. Swartzon:

Some of it are quite simple, like acne, but it can increase your risk of prostate cancer, of blood clots, heart disease, balding. You might even be at increased risk for breast cancer taking this. And that's aside from the local reactions, which there's many formulations and there's many different ways to take it. And there's gels and shots and shots can cause problems and topicals can cause problems. So it can be worth exploring if you truly have low T, but understand that it's not a risk-free adventure. This is a process like anything else.

Dr. Fialkow:

As expected, well said. Great stuff, really appreciate again, your time and your experience and knowledge that you're bringing to this conversation. Any final advice, anything to reiterate or anything that we missed in the discussion that you want to bring up?

Dr. Swartzon:

Usually, there's two things that I try and tell my patients and athletes, there are no shortcuts in life. And if someone's promising you a quick fix, it's probably not true. And then the second thing is, if it sounds too good to be true, if all of a sudden an announcer on the radio is giving you all the symptoms that you have that you don't want and promising you a cure, it sounds too good to be true. It usually is. I'm not saying you can't go see these clinics, but I would definitely check your primary care doctor who will have your interests in mind.

Dr. Fialkow:

I would add to that with one of my mantras, which is there's lots of ways to separate anxious people from their money. And I think that's along those lines.

Dr. Swartzon:

The wall as biopsies.

Dr. Fialkow:

Exactly right. Well, again, thank you, Dr. Michael Swartzon from Baptist Health Miami Orthopedic and Sports Medicine Institute. Great, great, great information. Enjoyed speaking with you and learning from you. And to our listeners as always, if you have any comments, thoughts, or ideas for future topics for this podcast, please email us at baptisthealthtalk@baptisthealth.net. That's baptisthealthtalk@baptisthealth.net. Thanks for listening. And until next time, stay safe.

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