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Announcer Introduction:
Welcome to Clinician’s Roundtable on ReachMD. Here’s your host, Dr. Brian McDonough.

Dr. McDonough:
This is Clinician’s Roundtable on ReachMD. I'm Dr. Brian McDonough, and joining me to discuss the signs and symptoms of patients with low testosterone is Dr. Mo Khara. He's a Professor of Urology and the F Brantley Scott Chair of Urology at Baylor College of Medicine in Houston, Texas. Dr. Khara, thanks for joining us today.

Dr. Khara:
Thank you for the invitation.

Dr. McDonough:
To start out, Dr. Khara, what are the common symptoms of low testosterone, and how do they vary across different patient populations?

Dr. Khera:
There's numerous signs and symptoms of low T, most commonly low energy, low libido, erectile dysfunction, decreased muscle mass, increased fat deposition, depression, and poor sleep. These are some of the very common symptoms that we see. Now low testosterone can be associated with other conditions, more concerning conditions, such as osteoporosis and osteopenia. It's been shown to be associated with increased cardiovascular risk, and it can also be associated with increased risk of developing diabetes.

Dr. McDonough:
And are those signs and symptoms the only indicators of low testosterone?

Dr. Khera:
Those are the main signs and symptoms of low testosterone, but there are some physical signs that can also be identified as well. For example, if you notice that patients have decreased facial hair, decreased development, these can also be signs of low testosterone.

Dr. McDonough:
So when you think a patient has low testosterone, what screening and diagnostic methods do you use?

Dr. Khera:
This is based on clinical exam. There are questionnaires out there, such as the Adam questionnaire, to screen for low testosterone. The problem is that these questionnaires have very low sensitivity and specificity. The best way to make the diagnosis is to identify the symptoms the patient may be suffering from, low energy, low libido, erectile dysfunction, decreased muscle mass, increased fat deposition, poor sleep, and depression. If the patient has those symptoms and they have the low testosterone value, then they are a candidate for therapy. But it's important to realize that they must have both. They can't just have signs and symptoms, they can't just have a low testosterone level, they must have both.

Dr. McDonough:
Let's zero in even a little further. How do you differentiate between primary and secondary hypogonadism?

 Dr. Khera:
Well, in order to answer that question, we have to think about the physiology. So remember that from the pituitary we secrete LH and FSH. LH goes to the testicles and produces testosterone. So if you have a problem with the pituitary and you're not secreting LH, that is called secondary hypogonadism.

If you're having a problem with the testicles and they are not producing testosterone, that is called primary hypogonadism. So what we try to do when we diagnose patients is to decide is this primary or secondary hypogonadism? Remember that 85 percent of patients who suffer from hypogonadism have secondary hypogonadism.

Dr. McDonough:
That's a really interesting point. But I want to say for those joining in, this is Clinician’s Roundtable. It's on ReachMD, and I'm Dr. Brian McDonough. I'm speaking with Dr. Mo Khera. We're talking about the signs, symptoms, and diagnostic tools for low testosterone.

So let's go on with the discussion. With those screening and diagnostic methods that you discussed earlier in mind, Dr. Khera, what potential challenges could occur with them?

Dr. Khera:
Well, the first is that many of the signs and symptoms of hypogonadism are nonspecific. So maybe this patient suffering from depression, maybe they have anxiety, maybe there's some other conditions, like low thyroid can mimic this condition as well, so you really want to make sure that the low testosterone is really the true etiology for their symptoms. That's number one. Number two is that there are numerous treatment options that can be available out there for these patients. In fact, there's seven different options. You can have injections, you can have pellets, you can have patches, you have oral pills, you can have long-acting injections, short-acting injection. So we have quite a bit of options.

So how do you decide? A lot of times I call it the 4 C's. We want to make sure that they have a good cost, they can be compliant with the medication, it's convenient, and they can get a good concentration. So those are the 4 C's I talk about when I talk to my patients about what's best for them. But those will typically be the challenges is that you want to find the right testosterone formulation for the right patient.

Dr. McDonough:
And I would think, adding on to that, knowing your patient, having conversations with them, that has to be really important.

Dr. Khera:
It's very important because you have to understand, what are their goals? For example, let's say you have a patient who's wanting to achieve a pregnancy in the near future. You would never give them testosterone supplementation because testosterone serves as a natural contraceptive, so that would cause them to be infertile.

So you really have to understand what their goals are and what they're trying to achieve. Some patients have young children at home, they have a pregnant wife. You would not want to give them a gel because the risk of transference, so that would be an issue. Other examples, if you use an injection, it has a high rate of something called erythrocytosis. The red blood cell count goes up. So if the patient already suffers from this condition, you'd probably want to stay away from injection. So really, it's tailored to the patient's need.

Dr. McDonough:
So you answered part of my next question, but I'll ask anyway because I want to know what solutions you would recommend to our audience today to overcome those challenges. Certainly, part of it is understanding who the patient is, their situation, where they are in life, but what other solutions do you have?

Dr. Khera:
Well, first, it depends on what are your goals. If someone is trying to achieve a pregnancy or maintain fertility, they would stay away from testosterone and use medications that would raise their own natural testosterone, so that's very important. It's also important to understand that testosterone is not the magic panacea for everything. You must take into account lifestyle modification, diet, exercise, sleep, stress reduction. If you combine lifestyle modification with testosterone supplementation, the efficacy goes up significantly. Many times, patients come to my office, and they say, 'Just give me the testosterone. I want it to fix everything.’ That's not how it works. It helps, and if you combine it with lifestyle modification, it makes it much more effective.

Dr. McDonough:
Well, with those solutions in mind, I want to thank Dr. Mo Khera for joining me for an excellent conversation and review on how to recognize the signs and symptoms of low testosterone.

Dr. Khera, it was great having you on the program.

Dr. Khera:
Thank you very much.

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