Dr. Diane: Welcome back to another episode of the Libido Lounge. I’m your host, Dr. Diane, and I’m so excited to dispel some myths and get to some of the truths behind testosterone today. There are so many misunderstandings about this hormone and so many people are using this hormone in isolation without understanding the whole totality of what we need to think about with men’s health and libido. So I am just absolutely thrilled to introduce to you guys all to Dr. Bernett and have this amazing conversation today. So, welcome to the show, Bud.

Dr. Bernett: It’s so great to be with you today. Thank you so much for having me, Dr. Diane. My pleasure to be with you.

Dr. Diane: It is a joy and let’s jump right in. So let’s talk about, in your experience with what you’ve seen with working with thousands of patients, how do you feel testosterone affects libido? What have you seen with using it when people are low? Is it fixing it all the time? Just walk us through what you’ve seen with that.

Dr. Bernett: Sure. Testosterone is linked with libido—libido being sexual interest, sexual drive, sexual desire, that sort of thing. And much as hormones govern many functions in the body, on the male side androgens, on the female side estrogens, testosterone is an androgen. It has some impact on various aspects of the body. I typically have three pillars: cognitive function, physical functioning, and sexual functioning. And in the area of sexual function, libido is really where testosterone has the greatest impact.

Dr. Diane: Is low libido always low testosterone?

Dr. Bernett: Now the reason why it’s so important is because there is the association that testosterone is kind of the be-all and end-all factor element of sexual functioning in all respects and it’s a much more complex story than that. It may have more to do with sexual libido and it may modify some other aspects of the male sexual response cycle, but really it has more to do with sexual libido much more directly.

Low Testosterone Symptoms and Signs in Men

Dr. Diane: How much have you seen as you’ve prescribed testosterone replacement therapy over the years that it fully fixes libido or that it’s just one part of the bigger picture and other things need to be addressed as well?

Dr. Bernett: There’s so many factors that can influence sexual libido. Other factors include general health and wellness, interpersonal relationships, how you’re functioning in other areas of your sexual ability that may influence your sexual interest or your sexual drive. So just trying to fix everything just with a testosterone treatment may be under-addressing some other contributing factors.

Dr. Diane: What do you find as far as signs and symptoms? When do I need to actually do something about it? Are you recommending that any man with low libido is getting his testosterone checked or when are you recommending that men actually look into this?

Dr. Bernett: In terms of getting tested and really considering that this is something that’s clinically relevant, it may come to a point where you feel like you’re not functioning to whatever your standard may be—seek some professional help. Start with your primary care doctor, who may then refer to a urologist or sexual medicine specialist. If it’s truly sexual libido issues, sexual desire issues, we may go ahead and get a testosterone level.

When to Get Testosterone Tested

Dr. Diane: What about ED? How much have you seen that testosterone is actually fixing an erectile dysfunction issue?

Dr. Bernett: It’s not that simple. Testosterone may be linked more with sexual desire. Erectile dysfunction may have a host of factors involved—not just interpersonal relationships, but also mental and physical health. Mental health meaning depression, anxiety; physical health may include other disease states from diabetes to cardiovascular disease. Understanding the realm of other factors that may influence a man’s ability to achieve an erection is a much more complex matter.

Dr. Diane: From a standpoint of self-advocacy, if somebody wants to talk to their doctor about this and make sure they are getting all the right lab tests done, what are you recommending? Total and free, sex hormone binding globulin, DHEA, things beyond that?

Dr. Bernett: For screening, start with total and free testosterone. See where that stands. Then depending on whether something’s abnormal there, we would dissect that further with sex hormone binding globulin, luteinizing hormone, FSH, DHEA, and so forth. Testosterone therapies should be dictated by two main considerations: a real description of compromised sexual drive, sexual desire, and at least within the realm of sexual medicine, confirming the level isn’t in the normal range.

What Causes Low Testosterone

Dr. Diane: Do you ever recommend DHEA as a precursor? Or have you seen it works better to just go straight with hormone replacement therapy?

Dr. Bernett: While there are so many supplements out there, I tend to just go with testosterone. I feel a little more confident that it’s a supplement that we can more safely prescribe and there are a variety of therapeutic delivery systems out there.

Dr. Diane: Have you seen any delivery method work better than others? Injections versus creams versus gels?

Dr. Bernett: We have such a range of options. It includes patient preference, accessibility, what is covered through insurance. Injections behave in certain ways and topical therapies in different ways. Injections may cause a surge and you have to be careful about hematocrit and blood counts going higher. Topicals offer more even administration but you have to worry about transference.

Low Testosterone vs Low Libido

Dr. Diane: Have you seen patients notice dramatic differences in how they feel day to day with injections because of the surge and fall?

Dr. Bernett: Patients have described that it’s not uniform. Some feel really great right after injection but then notice a decline. We try to tailor it. It’s not necessarily clinically detrimental, but we monitor for safety.

Dr. Diane: What other types of things have you seen to be helpful when people are using testosterone replacement therapy? Lifestyle decisions?

Dr. Bernett: At best it’s probably indirect. Understanding why men are testosterone deficient and addressing those issues—metabolic syndrome, diabetes, cardiovascular disease—certainly helps with the therapeutic benefit. For adult onset hypogonadism, it may just be chronic aging changes, but addressing underlying chronic disease states enhances results.

Dr. Diane: Are there any other root causes worth mentioning for why testosterone would go low?

Dr. Bernett: Testicular loss from trauma, cancer, or surgery. Conditions that lead to tissue damage. Head injuries, brain injuries, tumors of the pituitary. We may look further with testing like prolactin levels if levels are profoundly low.

Dr. Diane: Thank you so much for this. Everybody, we are going to invite Dr. Bernett here back for Part 2. In Part 2, we’re going to go more into things you need to know about testosterone. Can you become dependent on it? What to do if you’re in your child childbearing years where there are risks, and so much more. We’re going to talk a little bit about prostate health, erectile dysfunction, and more. So definitely stay tuned for that. And so you don’t miss that, make sure you subscribe if you have not already subscribed to the channel.

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