The Truth About Low Testosterone (Part 1): The Symptoms You Missed and the History You Won’t Believe
November 18, 2025 • 28 mins
In the second episode of The Male Room, Dr. Jesse Mills and Jordan dive into one of the most misunderstood corners of men’s health: low testosterone. Dr. Mills explains what low T actually is — who gets it, why it’s wildly under-diagnosed, and how symptoms like fatigue, low libido, and mood changes often go overlooked. He also breaks down the science behind the diagnosis, the lifestyle factors that can drag levels down, and why testosterone has become a cultural lightning rod in the manosphere. It’s part medical lesson, part trivia night, and part myth-busting mission, setting the stage for next week’s deep dive into treatment options.
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Speaker 1 (00:00):
Let's talk about it. Let's talk about the man.
Speaker 2 (00:05):
Hero. Let's talk about it.
Speaker 1 (00:11):
Let's talk about the Man Hero. Welcome to the Man,
What up.
Speaker 2 (00:21):
To jessimn Hey? Welcome back to the mail room. Doctor
Jesse mill is your host, Professor of Urology, University of California,
Los Angeles, David Gefft School of Medicine. I am joined
by my illustrious and somewhat burdened host, Jordan Runta's burden
because he has to put up with me. But I'm
so delighted, Jordan that you decided to come back and
(00:41):
do another show. The next couple of episodes are going
to look at low testosterone. Some of it will be
the history of how we got here, some of it
will be really kind of just trivial pursuit knowledge of
estalstro and some of the wacky characters and the wacky
things we've done, including goat nuts and guinea pig testicles
(01:02):
and transplanted sheep testicles and you name it, we've tried it.
So we're going to get into that, and then not
that that isn't serious, because it is, But then we're
going to get into how do we treat this condition? Testosterone?
Deficiency is still one of the most underdiagnosed endocrine problems
in this country and in the world, and there's a
(01:23):
wealth of treatments, and I want to empower our audience
with what those therapies look like so they can decide
not only what modality is best for them, but who
should be prescribing it as well. So it's great to
have you back to and I'm ready to let this
thing rip again. Me too.
Speaker 3 (01:38):
It's going to be great.
Speaker 4 (01:39):
So, way back when we first started talking about doing
this show, you mentioned wanting to kick things off with
an episode on low tea.
Speaker 3 (01:45):
Yeah, why was that? Why did you want to start there?
Speaker 2 (01:48):
I think the world of testosterone and what and we
call low testosterone our hypogonadism. It's a perfect metaphor really
for health and information and misinformation because hypogonadism the medical
diagnosis which is when a man's testosterone falls below three
hundred naanograms per desa leader and he has symptoms of
(02:09):
low testosterum, so fatigue, loss of libido, loss of energy, deppression,
and also maybe science like low bone density, loss of
muscle mass. Those are identifiable factors that may correlate with
with low testosterone. It's a truly medical diagnosis, and it's
(02:30):
one that is surprisingly even with all the noise out
there and all the people in the manosphere, it's still
actually underdiagnosed. I mean, it's shocking how many people are
walking around that maybe aren't listening to this show, or
aren't listening to any of the other medical podcasts out
there that talk about low t It's probably underdiagnosed by
(02:50):
about ninety percent of people. In other words, that a
lot of guys are walking around low testosterone that are
not coming in and getting screened for it. And yet
on the other extreme, you know, it's a tale of
two hormones. On the other extreme, there are guys that
are certainly not experiencing pathologic low testosterone, that are juicing
(03:13):
themselves into the next century, you know, that are using
testosterone for the massive gains that we see in the gym,
or for improved or enhanced sexual function. And I'm actually
not lining up with that that's necessarily a bad thing
because we don't know, we don't actually have the data
to know if that's dangerous. And I definitely want to
(03:33):
disavow people of the thought that somehow testosterone is a
it's a substance that is as concerning as opioids. And
yet if you look at the way that the FDA
classes testosterone, it's the same schedule or the DEA, I
should say, it's the same schedule of drug as an narcotic.
(03:54):
And so that's sort of more of an act of
congress that dates back thirty odd years than it is
an act of medical discussion. And I would say that
a testosterone therapy is of all the hormone therapies, probably
the safest there is. And why is that, Well, it's
also for the same reason that low testostroone doesn't really
(04:14):
kill anybody right away. So if you look at all
of the hormones that we think about on a daily basis,
when we think of hormone deficiencies, diabetes comes to mind
pretty front and center. I think everybody knows what diabetes
is where it comes in two flavors essentially. But your
blood sugars get too high either because you're pancreas isn't
making insulin anymore, which is a hormone that regulates how
(04:36):
we metabolize sugar, or it's not sensitive to insulin anymore,
so that the sugar that you eat is not being
processed appropriately because you have what we call insulin insensitivity,
and a lot of that comes from obesity and overwhelming
the system to the point where it becomes confused, and
so diabetes actually will kill you. So if your blood
(04:58):
sugar is too high, you go into a coma. If
your blood sugar is too low, you go into a coma.
And therefore, if I'm a treating physician and I give
somebody too much insulin, I can kill them. And if
I give them too little insulin or they take too
little insulin, they can die. Thyroid is another thing that
I think everybody is comfortable or understanding. You can have
(05:19):
a high thyroid or you can have low thyroid, and
both of those can be dangerous and potentially lethal. Well,
if a guy walks around zero testosterone, his life will
be shortened for sure. And there's data going back thirty
odd years that show that men that have chronically low
testosterone have a dramatically shortened life up to about twenty years.
So the converse of a guy's walking around with healthy testosterone,
(05:41):
they have about a twenty year longevity span improvement over
guy's with low So we know that from that perspective,
low testosterone is not going to kill you like a
diabetic coma will, but it will kill you eventually. It'll
catch up with you.
Speaker 3 (05:55):
Now, can I ask you a question about that?
Speaker 2 (05:56):
Yeah? Bring it?
Speaker 4 (05:57):
Is that actually because they chemical reaction within the body
or is that more lifestyle You have low testosterone so
you're more fatigued, you aren't as active as you should be,
and you're not sleeping as well in all the accompanying things.
Speaker 3 (06:09):
Or is it a combination.
Speaker 2 (06:10):
Yeah, So here's here's a quick medical school lecture on testosterone.
Is that on low test oster comes in two forms.
It's what comes what we call primary low test osteron,
which is basically what you were just saying, where the
chemical reaction is your testicles don't work and they don't
make testosterone because there's something wrong with the testicle itself.
There's genetic conditions that lead to it. There's trauma if
(06:33):
a guy has major testicular damage from some kind of
horrific trauma, and then obviously the cells that make testosterone die.
There's certain cancers that can cause low test austeron and catcer.
Treatments that can cause low testosterone, like radiation therapy for example,
and so that's what we call primary hypogonatism, where the
factory is not making testosterone, and those are less common
(06:56):
than what you said next, which is essentially a lifestyle
based low testosterone secondary hypogonatism. There's a lot of different
chemical reasons for that too. Secondary means that the governing
system for the testosteron is not working, and usually that
governing system is in your pituitary gland, a little gland
that sits right between your eyeballs in the back of
(07:17):
your nose. That is what signals the testosterone molecules in
the testicle to make testosterone, or it's even up higher
at the level of the hypothalamus, which it's a little
bit higher up in the brain. So there's three different
regulatory levels at which we make testosterone. So secondary means
that the testicles are fine, they're just not getting the
signal to make the testosterol molecule, and that if you
(07:41):
look at the common causes of secondary hypogdonism, they are
they're associated with obesity, high blood pressure, diabetes can cause
secondary hypogonadism, lack of exercise, stress levels, pituitary dysfunction in general,
which again in this day and age, a lot of
it comes from poor sleep and stress. If your body
doesn't it enough deep sleep, it does not make the
(08:04):
hormone which is called lutinizing hormone or LH that signals
a testable to make testosterone. So simply changing your sleep
patterns or changing your weight, those can help reverse secondary hypagonism.
That is the big bucket of what I see in
my daily practice is guys that have a reversible form
of testosterone deficiency that a lot of times I love
(08:26):
to treat without putting them right onto testosterone, but by
reversing lifestyle factors helping stimulate the petuitary land a little
bit more. So. Yeah, for sure, it comes in two factors.
But why does low testosterone, whether it's secondary, primary, eventually
kill us? And the answer it becomes much more of
a secondary endpoint, and that is if your testosterone is
(08:47):
chronically low, it can cause a dramatic deficit to your
bone density, that the strength of your bones. So if
you're a sixty year old guy and your testosterone is low,
your bone density, they may be perfect at that point.
You still exercise, you still work out, and you're active,
you're busy, but your testosterone is low, You're not signaling
(09:09):
good bone density deposition, the calcium that you eat and
the vitamin D that you synthesize to make bone, it's
not getting laid down as healthy bones. So by the
time you're eighty or even sixty five or seventy, if
you stub your toe or you fall on a curb
and you break a hip. We know that when an
elderly person breaks a big bone like their femur, their hip,
(09:30):
their mortality rate goes up dramatically, and so it's a
secondary endpoint for that low test austeron. So had they
treated their low testosterone, had they improved their bone density,
then by the time that they tripped on that curb,
they may have been able to catch themselves and not
break that hip, and then kind of go to the
cascade of all the bad things that hip fractures can cause,
like blood clots which can kill us. So it becomes
(09:53):
secondary or your low test auscern can lead to metabolic
syndrome or obesity, which then can lead to heart disease,
which then can lead to early death. But these are
all not light switches. You know, where if I cut
off your insulin right now in your blood sugar spocks
and you go into a coma. That's a light switch.
And so I think that's why testosterone is such a
(10:14):
fun thing to debate or talk about, because it's a
nuance and it becomes a little bit of a dial
where we have to individualize where a guy should feel
well and individualize his goals. You know, what do you
want out of treating this low testosterone? Now?
Speaker 4 (10:56):
Sometimes when we've spoken earlier, you have mentioned the incredibly
colorful i'll say history of how we treat testosterone, dating
back far earlier than I would have ever imagined, in
the eighteen eighties.
Speaker 3 (11:08):
I mean, could you tell her a little bit about that?
Speaker 2 (11:09):
Oh my gosh. Yeah. So there's a legendary guy in medicine.
His name was Brown Sikard, French, anatomist and physiologists who
figured out, for some reason that what makes men men
this essence probably comes from the testicle. Kind of makes
sense because the testicles hang out of the body. They're there,
(11:32):
and we know that that women don't have testicles and
guys do, and guys behave a certain way. And so
he got the idea of taking extract of guinea pigs
and dogs, grinding it up into a serum. Essentially and
then injecting it in himself. And so back in the
old days, physicians their best experiment was themselves. There's all
(11:54):
kinds of Nobel Prize winning physicians that have that they
were the first ones to treat. And that's a episode
in itself about the pioneers of medicine. Whether it's treating
malaria or yellow fever or even the h Pylori story
of stomach holsers, all came from doctors experimenting on themselves.
So Brown's Card said, yeah, I'm going to shoot myself
(12:15):
up with guinea pig nuts and see what happens. And
he swore he felt better, and he published a little
paper about guinea pig extract and how he retained his
vitality and he was hornier, and maybe he didn't quite
use the word horny in nineteenth century France, but that
was the that was the flavor of what he was
trying to say. And so that led to a little
rumble of where people are interested. Okay, I mean Brown's
(12:38):
Card is a smart guy. He came up with all
kinds of amazing medical discoveries, a lot in the spine,
anatomy and the neurology world. But he delved into dystostrum,
and so it actually goes into even in the early
twentieth century, where he was doing this with a lot
of patients and finding without any kind of good randomized control,
that maybe we were onto something. So there was a
(13:01):
guy in this country who capitalized on brownc of cards
early research, I guess we can call it research experimentation,
and said, well, you know, why do you go through
the trouble of putting guinea pig and dog nuts in
a blender and injecting it. Why don't we just why
don't we just transplant whole animal nuts into a guy?
(13:23):
And so so he developed a clinic in Kansas where
he would cast eight goats in the barn in the
back and in the front of the barn, make an
incision into guys, scrowed them, and stuff a couple of
goat testicles into a guy, scrowed them, put a couple
of stitches in him, and say, hey, let's see what happens.
This is real, Jordan, You're I mean, you're gonna look
it up. I'm sure it's on Wikipedia, which therefore makes
(13:44):
it real.
Speaker 4 (13:44):
But it I imagine this was in an era long
before medical ethics.
Speaker 2 (13:49):
For us than Yeah, well, a lot of the history
of experimentation is thankfully behind us, where we really have
such great levels of scrutiny to get good medical data.
And this is kind of a shout out to the
FDA as well. I mean, the FDA gets punched in
the nose a lot, but in fact they are there
to protect ourselves from Charlatan's and snake oil salesmen. But yeah,
(14:14):
back then they didn't have that. There were no protections,
and so the classic caveat emptor let the buyer beware
that was all they had to go on. And so
people do ethically, very unscrupulous things all the time, even
in this day and age. But back then there were
no regulatory boards to which you would go from. You
would just try it out and see what flew. So, no,
(14:36):
that's a great point. Yeah, medical ethics, that's something that,
thank goodness, we're getting much better about. So many more
guardrails in place so that we're doing the right thing
by patients. And so yeah, you're not going to see
any crazy, crazy medical experiments like we saw in the
nineteen tens and twenties for sure. Even back in the
eighteen eighties when this whole field started. So no, it's
a great point well taken that yes, based is evidence
(15:00):
based for reason, we have protections in place, and thank
god for that.
Speaker 3 (15:05):
Protections of humans, but also protections for animals. Shocking.
Speaker 2 (15:09):
Yeah the hell these poor guys exactly right, protection for
animals as well, and thank goodness. I mean, we have
really good strict regulations in medical science about what we
can do in animal experimentation. But clearly that crossed the
line that shouldn't have even been discussed or even brought up.
I wouldn't even call him a mad scientist. I would
just call him a mad man, leave it at that.
(15:33):
But a guy that's just a huckster trying to make
a buck, trying to get through the Great Depression. But wow,
what a terrible, terrible thing he did to humanity for
a little while there, but the guy became incredibly wealthy.
And yeah, a few people died of overwhelming infections because
again this was in the early nineteen hundreds, so we
didn't have antibiotics until in the nineteen forties. But every
(15:54):
once in a while he got a guy to give
him a testimonial. And this is at the time when
radio was just getting big and so, boy, you could
have a radio ad where I went to this clinic
in Kansas and had a couple of goat nuts put
into me, and I feel amazing. My wife didn't leave me,
and I even was able to father a child that
did not look like, you know, half goat half man,
(16:15):
and that's you know, led to an incredible career for
this guy. He was actually one of the two men
in this country at the time that had private that
had a private airplane. The other was Howard Hughes. So
this guy was in rare company. And anyway, eventually he
got found out that this actually was killing a lot
more people than it was saving. You got run out
of town, ran out of the country, and died in
(16:36):
poverty on the streets of Los Angeles in nineteen forties
or something like that. But it was a good run.
But anyway, that was onto something. And so along that
time there was also in Austria a guy named Steinack
who decided that if you cut one vast deference, that
you could trap the essential energy of what it means
(16:59):
to be a man and do basically what we would
call in medical terms today a unilateral vasectomy. And the
idea is that the other side would be open to release,
you know, all of the good humors that ejaculation releases,
but that if you just clipped one vaz, that you
would build up all the stuff that you would otherwise use.
And that was called a Steinack visectomy. And he was
(17:21):
multiple times nominated for a Nobel Prize for this amazing work.
Among his clients was a guy named Freud, who may
be known to some of our audience as a one
of the fathers of psychotherapy. And Sigmund Freud at the
time was dealing with a head and neck cancer that
would eventually kill him. But he had a Steinig vasectomy
(17:41):
and he you know, whether through placebo or through some
physiologic thing that we haven't been able to explain. One
hundred and about one hundred years later, he felt better
published that now I actually got some benefit out of
a Steinack visectomy. And W. B. Yates, the great Irish poet,
also decided to fount of youth and longevity was a
stinic vasectomy, and so he was a big proponent, and
(18:04):
he traveled to the United States and did some stinicks here,
and then some American physicians went over to Vienna and
learned how to do a stinic vasectomy, and eventually the
Massachusetts Medical Society put us scathing this guy as a fraud.
He needs to be unlicensed and should never set for
in the United States again, and finally, thankfully, the traditional
medical society say, wait a minute, there are no data.
(18:26):
We're just making this up. And in fact today we
know because I do hundreds of bilateral vasectomies every year
and it's a great form of birth control, probably the
best form of birth control we have on either side
of the gender spectrum. But it does really nothing to
their testosterone levels or any essential male humors. And so
(18:47):
that was another early stab at trying to figure out
how to capture testosterone, whether it's what you make or
whether you get out of a goat testicle. But you
fast forward to around the nineteen thirties, then finally we
actually synthesized testosterone as a molecule, which was a shared
Nobel prize between two a German and an Austrian physician,
(19:08):
and that was really where now we have the actual molecule,
can synthesize that, we can produce it, and so testosterone
as a commercially available product as a therapy has been
around since about the nineteen fifties, So this ain't that new.
And in fact, the testostraane prescriptions we write today are
still in some way based on that early synthetic work,
(19:29):
dating back to the Nobel Prize in the nineteen thirties.
So yeah, you know, I've been doing this for one
hundred years. It ain't that new. But you know, I
think what happens is every year. You know, I talked
about radio, and so that was the voice to get
out and advertise that you have this therapy. And now
we have you know, the Internet, and so now you
(19:49):
have amazing, amazing level one healthcare data available at our fingertips,
which you know, it's crazy, but I think when I
went to medical school, it was barely you know, was
in the late nineties. The Internet was barely a thing.
I still went to the medical library when I was
doing my master's research. I remember spending hours in the
library going through paper medical journals from the eighteen thirties,
(20:11):
eighteen fifties, thinking just wow, this is so cool, so fascinating. Well,
now I can just get on my laptop and look
at those same journals. So we have this explosion of
not information because the information is really hard to write
a paper. I mean, if I submit a paper to
a journal, that represents hours and hours and days of
work of my research team and me editing and getting
(20:33):
it ready for submission, and then it takes multiple reviewers
before it gets into the literature, so from start to finish.
And I do a lot of reviews for some of
the big medical journals in urology and men's health, and
the process of reviewing is hours, and the process of
getting publishes hours and so that hasn't really accelerated. But
the ability to consume all of those papers that takes
(20:57):
one individual team hours of actual labor to produce, you
can do in five minutes. That's where it becomes really awesome,
is that that we can synthesize high level medical data
and put it into you know, an AI engine and say, hey,
you know, should I be on testosterone and tell me
why or why not? And here are my symptoms And
(21:18):
so that's where it gets really cool. But the other
problem is that a lot of times you can go
off the rails, you know, very quickly, and start doing
a lot of things that don't work.
Speaker 3 (21:27):
AI and the health sphere.
Speaker 4 (21:29):
I think it's definitely an episode we should tackle at
some point because that's all so fascinating.
Speaker 2 (21:33):
Dude, It is crazy because I learned from it. Again,
I if I had a rash on my knee, that
would be the first place I go is to say,
is this really rash on my knee? And it ain't
bad and it's just going to get better and better.
The hard part is garbage in garbage out right. So
if there's a lot of garbage that that the chat
(21:54):
engines bring in, then it ends up with some horrific,
horrific recommendations. And I think that's where you have to
have common sense, you know, or or have a healthcare
professional that can help you do this. It's sort of
in the world of legal advice, you know. I don't
know that I want to go in front of the
Supreme Court with an engine, an AI engine, and not
(22:14):
a good attorney. But I don't know. Maybe we're getting there, Jordan.
That might be be on the sphere of what that
I know about, but it'll be fun to delve into
for sure. So let's let's wrap this up, Jordan. So
(22:53):
you know, testosterone, it's the molecule of the hour for
men men's health. It's it's definitely some that takes up
so much bandwidth for me. It's probably one of the
more common diagnoses I see today in my clinic in
the afternoon, I'll have ten new patients and probably four
of them will be for low testosterone, and some of
them will already have labs. Will come in and say,
(23:14):
you know, my doctor said, my testoster is two hundred
and they said go see mails. And some of them
will just have all the symptoms. And I think the
goal is to is for the person listening to this show,
you know, whether you're a man or somebody that loves
a man, and say, gush, you know what, yeah he
does you know his his libido sucks, or he's just
not you know, anywhere near. He's grumpy, he's moody, he's
(23:38):
sitting on the couch way too much. He's he's just
not being the guy I used to know him. He's
the guy that should come in to at least get screened.
And screening is as simple as a nice interview where
we get into all the questions and the nuances of
what got him off the couch and into my office
that day, and then is let's talk about what that
(23:58):
looks like, let's talk about what treatment looks like, because
it is just a feast of ways that we can
treat testosterone. And the teaser moving forward is there pills,
there's injections, there's long acting injections, there's gels. There's even
a little pouch of testostera can put between your cheek
and gums and make it like atchew in to back it.
And so you got all kinds of different ways to
(24:21):
get testosterone in. And I think we're gonna have a
lot of fun with this next episode just going into
what is the best treatment. And again, the theme that
I want you to leave this with is that you
have to pick the testosterone therapy that's right for you,
not with somebody selling you. And so one of the
buyer bewares that I want our audience to walk away
(24:44):
from almost every episode is going to be if I
go someplace and the guy opens up a briefcase and says,
here's what I'm going to sell you, then you should
probably walk away because there are a lot of different
ways to do testosterone therapy and if you're going to
a place that just does one thing, whether it's a
pellet or whether it's an injection, or whether it's a
(25:06):
pill or whether it's a compounded gel, and they want
to sell it to you. That's not really the way
that top level medical practices work, right, That we should
not be profiting off of the prescription directly, but really
profiting off of my intellectual property. And that's what we're
going to get into, is that I want people to
(25:26):
know that your provider should be agnostic to the vehicle,
meaning that if a guy comes in and says, doctor Mills,
I can't I can't take a gel. I can't put
a gel on because you know, I've got a toddler
or a newborn and I don't want to transfer testosteron.
That's a legitimate reportable medical event. A bad thing that
would happen is if you transferred testosterone. But if all
(25:48):
I had is if doctor Mills is just selling doctor
Mills's testosterone, Jael, then I'm going to convince you that
the gel is the right thing for you. You shouldn't
be convinced into what you're going to buy. So you
have to have your patient hat and your consumer hat
at the same time. And that's what we're gonna We're
gonna really hit this next this next half hour. So
I really appreciate the dialogue, the conversation. It has been
(26:09):
really fun. Let me just ramble on about something that
that I dedicated the last twenty odd years of my
life too. And we're gonna we're gonna go deeper, deeper,
farther better.
Speaker 3 (26:19):
We can rebuild him. We have the technology, yeah.
Speaker 2 (26:22):
The technology, Yes, I love it. All right, Well, it's
great talking to you today, Jordan. Let's let's do this
again sometime real soon.
Speaker 3 (26:30):
Let's keep it going. Talk, Let's talk about it.
Speaker 1 (26:43):
Let's talk about the marrow.
Speaker 2 (26:48):
Let's talk about it.
Speaker 1 (26:51):
Let's talk about him, the man hero, Let's talk about it.
Let's talk about the May.
Speaker 4 (27:04):
The mail Room with Doctor Jesse Mills was a production
of iHeartRadio. It was executive produced by Jordan Runtagg. It
was edited, mixed, and mastered by Beheid Fraser, and the
theme was provided by long Transit. If you liked what
you heard, please subscribe and leave a review. For more
podcasts from iHeart Radio, check out the iHeartRadio app, Apple Podcasts,
(27:25):
or wherever you listen to your favorite shows. This program
is intended for educational and informational purposes only. It is
not a substitute for professional medical advice, diagnosis, or treatment.
Consult your healthcare provider for any medical or other related
questions or concerns. The views and discussions aired on this
podcast or those of doctor Mills and do not represent
(27:48):
the official positions of UCLA or UCLA help
Speaker 2 (28:00):
W
Let's talk about it. Let's talk about the man.
Speaker 2 (00:05):
Hero. Let's talk about it.
Speaker 1 (00:11):
Let's talk about the Man Hero. Welcome to the Man,
What up.
Speaker 2 (00:21):
To jessimn Hey? Welcome back to the mail room. Doctor
Jesse mill is your host, Professor of Urology, University of California,
Los Angeles, David Gefft School of Medicine. I am joined
by my illustrious and somewhat burdened host, Jordan Runta's burden
because he has to put up with me. But I'm
so delighted, Jordan that you decided to come back and
(00:41):
do another show. The next couple of episodes are going
to look at low testosterone. Some of it will be
the history of how we got here, some of it
will be really kind of just trivial pursuit knowledge of
estalstro and some of the wacky characters and the wacky
things we've done, including goat nuts and guinea pig testicles
(01:02):
and transplanted sheep testicles and you name it, we've tried it.
So we're going to get into that, and then not
that that isn't serious, because it is, But then we're
going to get into how do we treat this condition? Testosterone?
Deficiency is still one of the most underdiagnosed endocrine problems
in this country and in the world, and there's a
(01:23):
wealth of treatments, and I want to empower our audience
with what those therapies look like so they can decide
not only what modality is best for them, but who
should be prescribing it as well. So it's great to
have you back to and I'm ready to let this
thing rip again. Me too.
Speaker 3 (01:38):
It's going to be great.
Speaker 4 (01:39):
So, way back when we first started talking about doing
this show, you mentioned wanting to kick things off with
an episode on low tea.
Speaker 3 (01:45):
Yeah, why was that? Why did you want to start there?
Speaker 2 (01:48):
I think the world of testosterone and what and we
call low testosterone our hypogonadism. It's a perfect metaphor really
for health and information and misinformation because hypogonadism the medical
diagnosis which is when a man's testosterone falls below three
hundred naanograms per desa leader and he has symptoms of
(02:09):
low testosterum, so fatigue, loss of libido, loss of energy, deppression,
and also maybe science like low bone density, loss of
muscle mass. Those are identifiable factors that may correlate with
with low testosterone. It's a truly medical diagnosis, and it's
(02:30):
one that is surprisingly even with all the noise out
there and all the people in the manosphere, it's still
actually underdiagnosed. I mean, it's shocking how many people are
walking around that maybe aren't listening to this show, or
aren't listening to any of the other medical podcasts out
there that talk about low t It's probably underdiagnosed by
(02:50):
about ninety percent of people. In other words, that a
lot of guys are walking around low testosterone that are
not coming in and getting screened for it. And yet
on the other extreme, you know, it's a tale of
two hormones. On the other extreme, there are guys that
are certainly not experiencing pathologic low testosterone, that are juicing
(03:13):
themselves into the next century, you know, that are using
testosterone for the massive gains that we see in the gym,
or for improved or enhanced sexual function. And I'm actually
not lining up with that that's necessarily a bad thing
because we don't know, we don't actually have the data
to know if that's dangerous. And I definitely want to
(03:33):
disavow people of the thought that somehow testosterone is a
it's a substance that is as concerning as opioids. And
yet if you look at the way that the FDA
classes testosterone, it's the same schedule or the DEA, I
should say, it's the same schedule of drug as an narcotic.
(03:54):
And so that's sort of more of an act of
congress that dates back thirty odd years than it is
an act of medical discussion. And I would say that
a testosterone therapy is of all the hormone therapies, probably
the safest there is. And why is that, Well, it's
also for the same reason that low testostroone doesn't really
(04:14):
kill anybody right away. So if you look at all
of the hormones that we think about on a daily basis,
when we think of hormone deficiencies, diabetes comes to mind
pretty front and center. I think everybody knows what diabetes
is where it comes in two flavors essentially. But your
blood sugars get too high either because you're pancreas isn't
making insulin anymore, which is a hormone that regulates how
(04:36):
we metabolize sugar, or it's not sensitive to insulin anymore,
so that the sugar that you eat is not being
processed appropriately because you have what we call insulin insensitivity,
and a lot of that comes from obesity and overwhelming
the system to the point where it becomes confused, and
so diabetes actually will kill you. So if your blood
(04:58):
sugar is too high, you go into a coma. If
your blood sugar is too low, you go into a coma.
And therefore, if I'm a treating physician and I give
somebody too much insulin, I can kill them. And if
I give them too little insulin or they take too
little insulin, they can die. Thyroid is another thing that
I think everybody is comfortable or understanding. You can have
(05:19):
a high thyroid or you can have low thyroid, and
both of those can be dangerous and potentially lethal. Well,
if a guy walks around zero testosterone, his life will
be shortened for sure. And there's data going back thirty
odd years that show that men that have chronically low
testosterone have a dramatically shortened life up to about twenty years.
So the converse of a guy's walking around with healthy testosterone,
(05:41):
they have about a twenty year longevity span improvement over
guy's with low So we know that from that perspective,
low testosterone is not going to kill you like a
diabetic coma will, but it will kill you eventually. It'll
catch up with you.
Speaker 3 (05:55):
Now, can I ask you a question about that?
Speaker 2 (05:56):
Yeah? Bring it?
Speaker 4 (05:57):
Is that actually because they chemical reaction within the body
or is that more lifestyle You have low testosterone so
you're more fatigued, you aren't as active as you should be,
and you're not sleeping as well in all the accompanying things.
Speaker 3 (06:09):
Or is it a combination.
Speaker 2 (06:10):
Yeah, So here's here's a quick medical school lecture on testosterone.
Is that on low test oster comes in two forms.
It's what comes what we call primary low test osteron,
which is basically what you were just saying, where the
chemical reaction is your testicles don't work and they don't
make testosterone because there's something wrong with the testicle itself.
There's genetic conditions that lead to it. There's trauma if
(06:33):
a guy has major testicular damage from some kind of
horrific trauma, and then obviously the cells that make testosterone die.
There's certain cancers that can cause low test austeron and catcer.
Treatments that can cause low testosterone, like radiation therapy for example,
and so that's what we call primary hypogonatism, where the
factory is not making testosterone, and those are less common
(06:56):
than what you said next, which is essentially a lifestyle
based low testosterone secondary hypogonatism. There's a lot of different
chemical reasons for that too. Secondary means that the governing
system for the testosteron is not working, and usually that
governing system is in your pituitary gland, a little gland
that sits right between your eyeballs in the back of
(07:17):
your nose. That is what signals the testosterone molecules in
the testicle to make testosterone, or it's even up higher
at the level of the hypothalamus, which it's a little
bit higher up in the brain. So there's three different
regulatory levels at which we make testosterone. So secondary means
that the testicles are fine, they're just not getting the
signal to make the testosterol molecule, and that if you
(07:41):
look at the common causes of secondary hypogdonism, they are
they're associated with obesity, high blood pressure, diabetes can cause
secondary hypogonadism, lack of exercise, stress levels, pituitary dysfunction in general,
which again in this day and age, a lot of
it comes from poor sleep and stress. If your body
doesn't it enough deep sleep, it does not make the
(08:04):
hormone which is called lutinizing hormone or LH that signals
a testable to make testosterone. So simply changing your sleep
patterns or changing your weight, those can help reverse secondary hypagonism.
That is the big bucket of what I see in
my daily practice is guys that have a reversible form
of testosterone deficiency that a lot of times I love
(08:26):
to treat without putting them right onto testosterone, but by
reversing lifestyle factors helping stimulate the petuitary land a little
bit more. So. Yeah, for sure, it comes in two factors.
But why does low testosterone, whether it's secondary, primary, eventually
kill us? And the answer it becomes much more of
a secondary endpoint, and that is if your testosterone is
(08:47):
chronically low, it can cause a dramatic deficit to your
bone density, that the strength of your bones. So if
you're a sixty year old guy and your testosterone is low,
your bone density, they may be perfect at that point.
You still exercise, you still work out, and you're active,
you're busy, but your testosterone is low, You're not signaling
(09:09):
good bone density deposition, the calcium that you eat and
the vitamin D that you synthesize to make bone, it's
not getting laid down as healthy bones. So by the
time you're eighty or even sixty five or seventy, if
you stub your toe or you fall on a curb
and you break a hip. We know that when an
elderly person breaks a big bone like their femur, their hip,
(09:30):
their mortality rate goes up dramatically, and so it's a
secondary endpoint for that low test austeron. So had they
treated their low testosterone, had they improved their bone density,
then by the time that they tripped on that curb,
they may have been able to catch themselves and not
break that hip, and then kind of go to the
cascade of all the bad things that hip fractures can cause,
like blood clots which can kill us. So it becomes
(09:53):
secondary or your low test auscern can lead to metabolic
syndrome or obesity, which then can lead to heart disease,
which then can lead to early death. But these are
all not light switches. You know, where if I cut
off your insulin right now in your blood sugar spocks
and you go into a coma. That's a light switch.
And so I think that's why testosterone is such a
(10:14):
fun thing to debate or talk about, because it's a
nuance and it becomes a little bit of a dial
where we have to individualize where a guy should feel
well and individualize his goals. You know, what do you
want out of treating this low testosterone? Now?
Speaker 4 (10:56):
Sometimes when we've spoken earlier, you have mentioned the incredibly
colorful i'll say history of how we treat testosterone, dating
back far earlier than I would have ever imagined, in
the eighteen eighties.
Speaker 3 (11:08):
I mean, could you tell her a little bit about that?
Speaker 2 (11:09):
Oh my gosh. Yeah. So there's a legendary guy in medicine.
His name was Brown Sikard, French, anatomist and physiologists who
figured out, for some reason that what makes men men
this essence probably comes from the testicle. Kind of makes
sense because the testicles hang out of the body. They're there,
(11:32):
and we know that that women don't have testicles and
guys do, and guys behave a certain way. And so
he got the idea of taking extract of guinea pigs
and dogs, grinding it up into a serum. Essentially and
then injecting it in himself. And so back in the
old days, physicians their best experiment was themselves. There's all
(11:54):
kinds of Nobel Prize winning physicians that have that they
were the first ones to treat. And that's a episode
in itself about the pioneers of medicine. Whether it's treating
malaria or yellow fever or even the h Pylori story
of stomach holsers, all came from doctors experimenting on themselves.
So Brown's Card said, yeah, I'm going to shoot myself
(12:15):
up with guinea pig nuts and see what happens. And
he swore he felt better, and he published a little
paper about guinea pig extract and how he retained his
vitality and he was hornier, and maybe he didn't quite
use the word horny in nineteenth century France, but that
was the that was the flavor of what he was
trying to say. And so that led to a little
rumble of where people are interested. Okay, I mean Brown's
(12:38):
Card is a smart guy. He came up with all
kinds of amazing medical discoveries, a lot in the spine,
anatomy and the neurology world. But he delved into dystostrum,
and so it actually goes into even in the early
twentieth century, where he was doing this with a lot
of patients and finding without any kind of good randomized control,
that maybe we were onto something. So there was a
(13:01):
guy in this country who capitalized on brownc of cards
early research, I guess we can call it research experimentation,
and said, well, you know, why do you go through
the trouble of putting guinea pig and dog nuts in
a blender and injecting it. Why don't we just why
don't we just transplant whole animal nuts into a guy?
(13:23):
And so so he developed a clinic in Kansas where
he would cast eight goats in the barn in the
back and in the front of the barn, make an
incision into guys, scrowed them, and stuff a couple of
goat testicles into a guy, scrowed them, put a couple
of stitches in him, and say, hey, let's see what happens.
This is real, Jordan, You're I mean, you're gonna look
it up. I'm sure it's on Wikipedia, which therefore makes
(13:44):
it real.
Speaker 4 (13:44):
But it I imagine this was in an era long
before medical ethics.
Speaker 2 (13:49):
For us than Yeah, well, a lot of the history
of experimentation is thankfully behind us, where we really have
such great levels of scrutiny to get good medical data.
And this is kind of a shout out to the
FDA as well. I mean, the FDA gets punched in
the nose a lot, but in fact they are there
to protect ourselves from Charlatan's and snake oil salesmen. But yeah,
(14:14):
back then they didn't have that. There were no protections,
and so the classic caveat emptor let the buyer beware
that was all they had to go on. And so
people do ethically, very unscrupulous things all the time, even
in this day and age. But back then there were
no regulatory boards to which you would go from. You
would just try it out and see what flew. So, no,
(14:36):
that's a great point. Yeah, medical ethics, that's something that,
thank goodness, we're getting much better about. So many more
guardrails in place so that we're doing the right thing
by patients. And so yeah, you're not going to see
any crazy, crazy medical experiments like we saw in the
nineteen tens and twenties for sure. Even back in the
eighteen eighties when this whole field started. So no, it's
a great point well taken that yes, based is evidence
(15:00):
based for reason, we have protections in place, and thank
god for that.
Speaker 3 (15:05):
Protections of humans, but also protections for animals. Shocking.
Speaker 2 (15:09):
Yeah the hell these poor guys exactly right, protection for
animals as well, and thank goodness. I mean, we have
really good strict regulations in medical science about what we
can do in animal experimentation. But clearly that crossed the
line that shouldn't have even been discussed or even brought up.
I wouldn't even call him a mad scientist. I would
just call him a mad man, leave it at that.
(15:33):
But a guy that's just a huckster trying to make
a buck, trying to get through the Great Depression. But wow,
what a terrible, terrible thing he did to humanity for
a little while there, but the guy became incredibly wealthy.
And yeah, a few people died of overwhelming infections because
again this was in the early nineteen hundreds, so we
didn't have antibiotics until in the nineteen forties. But every
(15:54):
once in a while he got a guy to give
him a testimonial. And this is at the time when
radio was just getting big and so, boy, you could
have a radio ad where I went to this clinic
in Kansas and had a couple of goat nuts put
into me, and I feel amazing. My wife didn't leave me,
and I even was able to father a child that
did not look like, you know, half goat half man,
(16:15):
and that's you know, led to an incredible career for
this guy. He was actually one of the two men
in this country at the time that had private that
had a private airplane. The other was Howard Hughes. So
this guy was in rare company. And anyway, eventually he
got found out that this actually was killing a lot
more people than it was saving. You got run out
of town, ran out of the country, and died in
(16:36):
poverty on the streets of Los Angeles in nineteen forties
or something like that. But it was a good run.
But anyway, that was onto something. And so along that
time there was also in Austria a guy named Steinack
who decided that if you cut one vast deference, that
you could trap the essential energy of what it means
(16:59):
to be a man and do basically what we would
call in medical terms today a unilateral vasectomy. And the
idea is that the other side would be open to release,
you know, all of the good humors that ejaculation releases,
but that if you just clipped one vaz, that you
would build up all the stuff that you would otherwise use.
And that was called a Steinack visectomy. And he was
(17:21):
multiple times nominated for a Nobel Prize for this amazing work.
Among his clients was a guy named Freud, who may
be known to some of our audience as a one
of the fathers of psychotherapy. And Sigmund Freud at the
time was dealing with a head and neck cancer that
would eventually kill him. But he had a Steinig vasectomy
(17:41):
and he you know, whether through placebo or through some
physiologic thing that we haven't been able to explain. One
hundred and about one hundred years later, he felt better
published that now I actually got some benefit out of
a Steinack visectomy. And W. B. Yates, the great Irish poet,
also decided to fount of youth and longevity was a
stinic vasectomy, and so he was a big proponent, and
(18:04):
he traveled to the United States and did some stinicks here,
and then some American physicians went over to Vienna and
learned how to do a stinic vasectomy, and eventually the
Massachusetts Medical Society put us scathing this guy as a fraud.
He needs to be unlicensed and should never set for
in the United States again, and finally, thankfully, the traditional
medical society say, wait a minute, there are no data.
(18:26):
We're just making this up. And in fact today we
know because I do hundreds of bilateral vasectomies every year
and it's a great form of birth control, probably the
best form of birth control we have on either side
of the gender spectrum. But it does really nothing to
their testosterone levels or any essential male humors. And so
(18:47):
that was another early stab at trying to figure out
how to capture testosterone, whether it's what you make or
whether you get out of a goat testicle. But you
fast forward to around the nineteen thirties, then finally we
actually synthesized testosterone as a molecule, which was a shared
Nobel prize between two a German and an Austrian physician,
(19:08):
and that was really where now we have the actual molecule,
can synthesize that, we can produce it, and so testosterone
as a commercially available product as a therapy has been
around since about the nineteen fifties, So this ain't that new.
And in fact, the testostraane prescriptions we write today are
still in some way based on that early synthetic work,
(19:29):
dating back to the Nobel Prize in the nineteen thirties.
So yeah, you know, I've been doing this for one
hundred years. It ain't that new. But you know, I
think what happens is every year. You know, I talked
about radio, and so that was the voice to get
out and advertise that you have this therapy. And now
we have you know, the Internet, and so now you
(19:49):
have amazing, amazing level one healthcare data available at our fingertips,
which you know, it's crazy, but I think when I
went to medical school, it was barely you know, was
in the late nineties. The Internet was barely a thing.
I still went to the medical library when I was
doing my master's research. I remember spending hours in the
library going through paper medical journals from the eighteen thirties,
(20:11):
eighteen fifties, thinking just wow, this is so cool, so fascinating. Well,
now I can just get on my laptop and look
at those same journals. So we have this explosion of
not information because the information is really hard to write
a paper. I mean, if I submit a paper to
a journal, that represents hours and hours and days of
work of my research team and me editing and getting
(20:33):
it ready for submission, and then it takes multiple reviewers
before it gets into the literature, so from start to finish.
And I do a lot of reviews for some of
the big medical journals in urology and men's health, and
the process of reviewing is hours, and the process of
getting publishes hours and so that hasn't really accelerated. But
the ability to consume all of those papers that takes
(20:57):
one individual team hours of actual labor to produce, you
can do in five minutes. That's where it becomes really awesome,
is that that we can synthesize high level medical data
and put it into you know, an AI engine and say, hey,
you know, should I be on testosterone and tell me
why or why not? And here are my symptoms And
(21:18):
so that's where it gets really cool. But the other
problem is that a lot of times you can go
off the rails, you know, very quickly, and start doing
a lot of things that don't work.
Speaker 3 (21:27):
AI and the health sphere.
Speaker 4 (21:29):
I think it's definitely an episode we should tackle at
some point because that's all so fascinating.
Speaker 2 (21:33):
Dude, It is crazy because I learned from it. Again,
I if I had a rash on my knee, that
would be the first place I go is to say,
is this really rash on my knee? And it ain't
bad and it's just going to get better and better.
The hard part is garbage in garbage out right. So
if there's a lot of garbage that that the chat
(21:54):
engines bring in, then it ends up with some horrific,
horrific recommendations. And I think that's where you have to
have common sense, you know, or or have a healthcare
professional that can help you do this. It's sort of
in the world of legal advice, you know. I don't
know that I want to go in front of the
Supreme Court with an engine, an AI engine, and not
(22:14):
a good attorney. But I don't know. Maybe we're getting there, Jordan.
That might be be on the sphere of what that
I know about, but it'll be fun to delve into
for sure. So let's let's wrap this up, Jordan. So
(22:53):
you know, testosterone, it's the molecule of the hour for
men men's health. It's it's definitely some that takes up
so much bandwidth for me. It's probably one of the
more common diagnoses I see today in my clinic in
the afternoon, I'll have ten new patients and probably four
of them will be for low testosterone, and some of
them will already have labs. Will come in and say,
(23:14):
you know, my doctor said, my testoster is two hundred
and they said go see mails. And some of them
will just have all the symptoms. And I think the
goal is to is for the person listening to this show,
you know, whether you're a man or somebody that loves
a man, and say, gush, you know what, yeah he
does you know his his libido sucks, or he's just
not you know, anywhere near. He's grumpy, he's moody, he's
(23:38):
sitting on the couch way too much. He's he's just
not being the guy I used to know him. He's
the guy that should come in to at least get screened.
And screening is as simple as a nice interview where
we get into all the questions and the nuances of
what got him off the couch and into my office
that day, and then is let's talk about what that
(23:58):
looks like, let's talk about what treatment looks like, because
it is just a feast of ways that we can
treat testosterone. And the teaser moving forward is there pills,
there's injections, there's long acting injections, there's gels. There's even
a little pouch of testostera can put between your cheek
and gums and make it like atchew in to back it.
And so you got all kinds of different ways to
(24:21):
get testosterone in. And I think we're gonna have a
lot of fun with this next episode just going into
what is the best treatment. And again, the theme that
I want you to leave this with is that you
have to pick the testosterone therapy that's right for you,
not with somebody selling you. And so one of the
buyer bewares that I want our audience to walk away
(24:44):
from almost every episode is going to be if I
go someplace and the guy opens up a briefcase and says,
here's what I'm going to sell you, then you should
probably walk away because there are a lot of different
ways to do testosterone therapy and if you're going to
a place that just does one thing, whether it's a
pellet or whether it's an injection, or whether it's a
(25:06):
pill or whether it's a compounded gel, and they want
to sell it to you. That's not really the way
that top level medical practices work, right, That we should
not be profiting off of the prescription directly, but really
profiting off of my intellectual property. And that's what we're
going to get into, is that I want people to
(25:26):
know that your provider should be agnostic to the vehicle,
meaning that if a guy comes in and says, doctor Mills,
I can't I can't take a gel. I can't put
a gel on because you know, I've got a toddler
or a newborn and I don't want to transfer testosteron.
That's a legitimate reportable medical event. A bad thing that
would happen is if you transferred testosterone. But if all
(25:48):
I had is if doctor Mills is just selling doctor
Mills's testosterone, Jael, then I'm going to convince you that
the gel is the right thing for you. You shouldn't
be convinced into what you're going to buy. So you
have to have your patient hat and your consumer hat
at the same time. And that's what we're gonna We're
gonna really hit this next this next half hour. So
I really appreciate the dialogue, the conversation. It has been
(26:09):
really fun. Let me just ramble on about something that
that I dedicated the last twenty odd years of my
life too. And we're gonna we're gonna go deeper, deeper,
farther better.
Speaker 3 (26:19):
We can rebuild him. We have the technology, yeah.
Speaker 2 (26:22):
The technology, Yes, I love it. All right, Well, it's
great talking to you today, Jordan. Let's let's do this
again sometime real soon.
Speaker 3 (26:30):
Let's keep it going. Talk, Let's talk about it.
Speaker 1 (26:43):
Let's talk about the marrow.
Speaker 2 (26:48):
Let's talk about it.
Speaker 1 (26:51):
Let's talk about him, the man hero, Let's talk about it.
Let's talk about the May.
Speaker 4 (27:04):
The mail Room with Doctor Jesse Mills was a production
of iHeartRadio. It was executive produced by Jordan Runtagg. It
was edited, mixed, and mastered by Beheid Fraser, and the
theme was provided by long Transit. If you liked what
you heard, please subscribe and leave a review. For more
podcasts from iHeart Radio, check out the iHeartRadio app, Apple Podcasts,
(27:25):
or wherever you listen to your favorite shows. This program
is intended for educational and informational purposes only. It is
not a substitute for professional medical advice, diagnosis, or treatment.
Consult your healthcare provider for any medical or other related
questions or concerns. The views and discussions aired on this
podcast or those of doctor Mills and do not represent
(27:48):
the official positions of UCLA or UCLA help
Speaker 2 (28:00):
W
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