Dr Louise Newson: [01:00:00] So this is one of my most favourite podcasts. We're talking about testosterone, such an important hormone. And I'm talking with one of the probably world's leading experts of testosterone in men and women, Professor Mo Khera, who's come over from the US to be here with me in the studio in real life. We talk about how low testosterone is a marker of poor health in men and women and the role testosterone has in our bodies. So listen carefully and enjoy it. So Mo, you're in real life.  [01:00:32]

Professor Mo Khera: [01:00:33] Love it.  [01:00:34]

Dr Louise Newson: [01:00:34] So you are a urologist and you've been on my podcast before. Some people will have listened to it. Some people won't because I've got lots of new followers, which is great. My husband's a urologist. He's sat in this seat with his ridiculous long hair, talking about urology, but you're, you'll similar but different to him. So just explain a bit about what you do.  [01:00:55]

Professor Mo Khera: [01:00:56] So first, your husband is a good friend of mine. He's Paul Anderson and we've travelled throughout the world giving lectures. But my specialty is really sexual dysfunction. So it started in 2007, I finished my fellowship and I was really good at getting men great erections and great libido. And the problem was these men would go home and these wives would get very upset They'd say look everything was great until he met you But now he wants to have sex every day and I don't want to have six with him, right? It's a problem. And so I quickly realised it's true. So I went out and did a fellowship and started learning more about female sexual dysfunction. So I started treating women in 2008 because I really believe that sexual dysfunction is a couple's disease. You can't just treat one without the other. You really need to focus on the couple. And part of sexual dysfunction is hormones, right? You want to treat a woman, you want to improve her sexual function. It's the triangle, or what you call PET, right? Progesterone, estrogen, testosterone, and other things that we can do to improve her sexual functioning. But the PET not only improves her sexual function, it significantly improves her quality of life. So that's where it all started in 2008.  [01:02:01]

Dr Louise Newson: [01:02:03] It's interesting, because it is quite binary with a lot of you. I mean, I love urologists. Of course, I'm a bit biased because of being married to one. But urologists are quite open-minded, more than, a lot of specialties, a lot of doctors seem to have lost their professional curiosity, their sort of inquisitive nature, they sort of, they do what they've always done. Whereas urologists generally are kind people, they like each other, they're lifting each other up, they're not doing this pushing each other down, which happens a lot in medicine. But they often treat men or they treat women. Is that fair to say?  [01:02:37]

Professor Mo Khera: [01:02:37] I'd say most urologists treat men, right? So the reality is men, and most of the urologists treat men for sexual dysfunction. But the problem is when you treat a man for sexual disfunction and you increase his libido and you leave his partner's libido low, you've now created a problem. A big problem. It's okay to leave both libidos low, it's fine, right? Or raise both of them, but don't raise one without the other. And I'll tell you though, when you have both the couple and raise both libidoes, improve both sexual dysfunction, sexual function, you improve the quality of the relationship. That's been shown over and over again. Couples that engage in regular sexual activity significantly enhance the quality of their relationship.  [01:03:16]

Dr Louise Newson: [01:03:18] I mean, that is fact, isn't it? And you know, I've, you know I'm sure Professor Mike Kirby and Geoffrey Hackett.  [01:03:24][6.3]
Professor Mo Khera: [01:03:25] I know them very well, yes.  [01:03:26]

Dr Louise Newson: [01:03:26] I've known them for many years. And it's been great. Whenever I've lectured at the British Society of Sexual Medicine, they are so forward thinking and they talk a lot about sex, how important it is actually. It's a physiological process. It can help reduce anxiety. It can help improve mood. It can helped with cardiovascular disease. It can how with all sorts. And when he's, when they've lectured, the whole audience has been transfixed. Like when you lecture, everyone's listening, wants to know more. And then a few years ago, probably about eight years ago I went to my first one of the Menopause Society meetings I've been to many over the years and they started to talk about testosterone. Now I didn't know, I feel really embarrassed to say this. I didn't know women produce testosterone till about 12 years ago because no-one taught me. So I went a lecture and I had just started using testosterone myself then. So I'd understood about testosterone, I understood about how it works on every cell in the body. I understood for me personally, it stopped me thinking about giving up my job because my brain had come back. More than my libido, but my brain, my ability to think and to just sleep and to enjoy life was back. So I was feeling really, really brilliant about testosterone. And somebody was lecturing and talking about sex and saying, well, there is some evidence about sex and testosterone in women. It can improve the quality of sex, it might increase the frequency of sex and the whole audience laughed. Like it was almost like talking to teenagers about sex. And I sat there really, really like cross, but also embarrassed that my colleagues thought talking about sex was something that was funny. I just.  [01:05:05]

Professor Mo Khera: [01:05:06] Yeah, but you know, now it's not. I mean, it's become the mainstream. Think about this. Sexual health is the best barometer of a man and a woman's overall health because it takes into account their physical health and their mental health. But you bring up a point about how people didn't realise that testosterone helps with libido. And I have to tell you a story. 1935, testosterone was first synthesised, 1935. And something interesting happened in 1937, a few years later, a very famous physician, he was a gynaecologist, Alfred Loeser, who was a gynaecologist in London, was the first to start prescribing testosterone to women. And he gave it to these women who started having mastitis during breastfeeding. And he realised that women have high levels of testosterone in their urine when they're breastfeeding and when they are menstruating. So he said, maybe I'll start using testosterone in these women. In 1940, Loeser published his first paper. In that paper, he talks about how women had significant improvements in their libido, sexual function. He also talks about how they had significant improvement in their mood, right? And then several years later, Greenblatt, Another gynaecologist, starts talking about improvements in libido. So this concept that testosterone improves libido is not a new phenomenon. It is not, it was 90 years ago, almost, people were talking about this. And it's just interesting that even today, some people still don't believe that it may not improve libido  [01:06:33]

Dr Louise Newson: [01:06:33] It's madness, isn't it?  [01:06:34]

Professor Mo Khera: [01:06:35] It doesn't make sense.  [01:06:35]

Dr Louise Newson: [01:06:35] It doesn't, it doesn't make sense. It really doesn't and you know reading those studies like the one from 1940 looking at men and women together. I mean that was quite ahead of its time for a start because women have been excluded for so many years. But it's there but also in medicine if I ever get confused I go back to basic physiology. It's like it's my comfort blanket, really, you go back and work out what's going wrong. So, like I know I admitted that I didn't know about testosterone in women until a decade or so ago, but testosterone as a hormone is biologically active. It affects every single cell in the body. There's been a lot more research in men than women, but most of the drugs certainly, I mean, I qualified in '94 and it was only the year before that women were included really in studies. So most of these medicines that I've ever prescribed as a doctor, we've looked at male studies and that's fine but somehow if I try and look at and extrapolate data from men for testosterone people say no you can't we haven't got enough data.  [01:07:41]

Professor Mo Khera: [01:07:42] So it's very sad, and I'll tell you that we spend only a fraction of the money that we spend on men for women to study testosterone. So I was involved in the TRAVERSE trial. This was the largest trial ever to look at testosterone, if it increases cardiovascular risk in men. It took us six years to do this paper. We published it two years ago, but that study was over $500 million. I can't imagine spending over $500 million on one study to look at testosterone for women. It's not going to happen, right? So the reality is that sometimes we use the studies in men for women, but does it really translate? Maybe some, maybe it doesn't, but it's hard to say. So I think that, you know, it's unfortunate, but we have to make a push to study testosterone in women. Look, women make estrogen, they make progesterone, they make thyroid, they make cortisol. Whenever she's deficient in any of these hormones, nobody has any problem giving it back to her. These are hormones that she makes, right? But for some reason, if she's deficient in testosterone, we're nervous in giving that one back to her. And no one can tell me why, right?  [01:08:44]

Dr Louise Newson: [01:08:44] You see I can't understand either, because testosterone is aromatased into all the different estrogens, including estradiol. So you could argue, I don't want to argue, but you could say that testosterone is more important than estradiol. Do you know what I mean? Because we've got the aromatase enzyme throughout our body and our brains and everything else. So we've go testosterone in our brain, some of it will be aromatized to estradiol. So it's almost a precursor to the hormone that everyone's talking about. So, why do you think we're so scared, or not we, I'm not scared of it, but why are so many people scared of us? I'm not scared of it, but why is so many people scared of it?  [01:09:17]

Professor Mo Khera: [01:09:17] I think the reality is that most of us are not trained in it, right? We haven't got the education. In most countries don't have an FDA approved product. So if you don't an FDA-approved product, you're gonna be writing it off label. Right, there's some concern. And I think it's been dogma for decades saying that it's dangerous to give it to a woman. But the reality it just makes sense to me that if she makes a hormone and she's deficient, I would be able to give back to her in the normal physiologic range. Right, that makes sense, right? And patients do better when you put their levels back into the normal range. So it doesn't make any sense meanwhile we would withhold that medication. Now let's say you say, I question the beneficial effects of testosterone. There are numerous studies showing that combination estrogen plus testosterone is better than estrogen alone in many symptoms. Osteopenia, osteoporosis, bone mineral density, has been shown for one, right. So you look at that. You just had a wonderful abstract that was presented. We did it together. It was presented in the US showing that you look at women who are on HRT and you look at adding T and the women that HRT plus T do much better than HRT alone for many areas like cognition, it was energy, right? So adding testosterone does make an added benefit to your HRT programme. So if you're getting, and I think the take home message is this... If you're just getting HRT and not the T itself, you're missing one third of the boat, right? I mean, that's important. I used to call it the triangle, right? It's very important.  [01:10:49]

Dr Louise Newson: [01:10:50] It is, I mean, I still use your triangle analogy, or sometimes I'll say to patients, it's like a three-legged stool. You can have normal levels of two of the hormones, but it's still not going to be right if you haven't got that third leg. But also, when I was reading, I'm very interested in the history of hormones, and one of the things is there's always been concern because there's not an absolute level, like a blood test, and there's big debate all the time. How do you measure the level? Is it free testosterone? Is it bound? Do you do free-androgen index? Do you use mass spectrometry? How do you do it? And actually, like, when I take a step back from all of this discussion and noise, really, I think, well, not everything in medicine you have to have a blood test for. You know, I could diagnose clinical depression or migraine in a patient. I don't have to do a blood test. I don't have to a scan. I take really good history and I work it out. So a blood testing is a guide rather than a panacea. And... [01:11:46]

Professor Mo Khera: [01:11:46] Yes, so Louise, think about this. Let's talk about estrogen for a second, okay? A woman comes into my office, this is standard of care, and she says, look doctor, I'm now post-menopausal, I am having vasomotor symptoms, I'm having horrible hot flashes, could you please help me? I start her on some estrogen therapy, and she comes back six weeks later, and says I'm doing much better. Now remember, I didn't check her estrogen before I started, that's not standard of care. The standard of care is to start her on the estrogen without checking the levels and go ahead and start it. She comes back six weeks later and she says, I'm doing better, but I still have some hot flashes. What's the standard of care? It's not to check another estrogen level. It's to give her higher doses of estrogen until the symptoms go away. That's standard of care, right? And so I look at other hormones like testosterone, yes, you should at somewhat, I do think, consider the levels, but symptoms are also very important.  [01:12:42]

Dr Louise Newson: [01:12:43] A lot of people DM me on Instagram or patients who come to the clinic and they say I've been told my testosterone level is normal, so I'll say give me the figure and it's something like 0.7. I mean, anything with a zero in front really is low, isn't it? But the lab has been tested, it's set up that it's only flags as abnormal if it's raised, which it seems madness. But also some laboratories, the NHS laboratories or the ones that the NHS use, the level is actually quite low of the upper limit of normal. So it will flag as high, even if it's like 1.6, which in our money is still quite low. But they've reduced it recently. I was talking to the person who works in the laboratory that we use, and he was looking at the data to work out the normal so-called levels for women. And it's done on a very small number of women, like 20 women. Like, it's appalling, I said, is there any other data? Have you got any other data that, you know, the companies use who make the machines? He said, no, Louise, this is it. And it's a joke, isn't it? Because levels change all the time, even if you're not on testosterone, your body's making testosterone at different rates, different amounts. And I don't know whether I showed you the graph, but I did my own testosterone level like eight times in a day. And it's completely different. At one time in the day, it was 3.2, which you could say is slightly high. Another time it was 1.2 which you would say is slightly low. And I use the same dose, I've used the same dose for like nearly 10 years in the morning. Like, but that's, so any blood test is, it has to be interpreted properly, doesn't it?  [01:14:24]

Professor Mo Khera: [01:14:24] It's not just about the levels. So, I'll give you the example I give in men. So when I started my practice in 2007, I started a basic science lab. In the lab, to this day, we still take blood and we look at something called the sensitivity of the androgen receptor. This is called the CAG repeat. What we showed many years ago was that those men with very insensitive receptors need more testosterone. Men with very sensitive receptors need less testosterone. But we're all not the same. Right? And so there's going to be a certain number where each man is going to feel better. And it can't be one number fit all. And right now it is. 300.  [01:14:59]

Dr Louise Newson: [01:15:00] It's madness, isn't it?  [01:15:01]

Professor Mo Khera: [01:15:01] Same concept goes for women. We did the same thing. We published this on CAG repeats in women. And we also showed, it was a small series, 30 women, and we showed that in those women, those with more insensitive receptors, were more likely in this case to have vasibulitis. In other words, problems with gynaecological issues. So every woman is different genetically. And they may require different levels to feel better. That's a very important point.  [01:15:26]

Dr Louise Newson: [01:15:26] It's so important, I remember years ago, the clinic hadn't been open very long and this lady came back with a high raised testosterone level and in one of our weekly meetings, we all met together and we're like, what are we going to do? What are we gonna do? And I said, well, the first thing we need to do is phone the patient and see how she is. And so she was feeling absolutely fine. She was feeling great actually. But the recommendation we decided was just to reduce the amount a little bit. And then she came back literally just really tired coming to the clinic and she said I feel awful since you reduced my dose. Anyway one of the other doctors had seen her but it materialised that she was an Olympic swimmer and she used to swim across the channel. She'd done it like something ridiculous like 20 times across the Channel. And as she became older you know her stamina would reduce, everything had just slowed down. Giving back her testosterone had made a huge difference. But obviously, reducing the dose had made it back to how she was before. And we all came to the conclusion she probably, when she was younger, had a naturally high testosterone.  [01:16:31]

Professor Mo Khera: [01:16:31] Yeah, so remember that that more testosterone we give doesn't keep doubling and tripling the improvement symptoms. In other words if a man has a great libido at 500 giving him a thousand will not double, we call it an inflection point, same with women. [01:16:43]

Dr Louise Newson: [01:16:44] I know we've got studies about libido in women, but we know naturally that testosterone is very anti-inflammatory. It works on every organ, every cell in our body. We know that it helps, as you say, bone density. It helps with our metabolism, so it will help reduce incidence of diabetes. It will help, it's cardio-protective as well. It helps the mitochondria to function. It's really important as a biologically active hormone, isn't it?  [01:17:13]

Professor Mo Khera: [01:17:12] Yeah, to me testosterone is probably one of the most important hormones in men and women. It's probably one the best markers of a man or a woman's overall health if you think about it because, you know, we think about low testosterone, it's the single most important test to me to predict what your current health status is and what your future health status is gonna be, you now? So I can't think of another marker, a biomarker that can give me a better indicator of someone's overall health.  [01:17:39]

Dr Louise Newson: [01:17:40] So why is it so hard for men and women to access testosterone, do you think, Mo?  [01:17:44]

Professor Mo Khera: [01:17:44] Well, I think it's based on the country. I mean, in the US, it's quite easy now, and a lot of the online pharmacies, most clinicians are still nervous giving it to them, and there's still some safety concerns. With the TRAVERSE trial, the safety concerns in men have gone down. We're not worried as much about prostate cancer and cardiovascular risk, which is great. So I do think it's country by country. UK, still far behind us, way behind us in terms of utilisation in testosterone from men and women. Way behind.  [01:18:14]

Dr Louise Newson: [01:18:15] It's interesting, isn't it? I mean, last year's figures show that for the male testosterone, because in the NHS, the only way to have it is off licence, the male gel that we can prescribe for women on the NHS. We've got the cream that we give privately, but NHS. So looking at the NHS data last year, there were more women than men that were prescribed.  [01:18:36]

Professor Mo Khera: [01:18:38] Unbelievable.  [01:18:38]

Dr Louise Newson: [01:18:40] I mean it's great for me as a woman, but actually, the figures are still really low. And actually, if you look at the data and tease out by socioeconomic class, people from lower socioeconomic classes are less likely to be prescribed testosterone. And in my mind, they would benefit more because often they have a higher risk of heart disease and diabetes and mental health. And one of the things that I've really learned in my clinical experience is that testosterone can really improve mental health.  [01:19:10]

Professor Mo Khera: [01:19:11] Yeah, cognition, we see that in men as well. And so what are the two big mimickers of low testosterone? It's depression and hypothyroidism. So you have to screen for both, I tell that. If a woman comes in and she has low libido, low energy, some depression, screen for the TSH and screen for maybe she has depression. It's really important, right? Those are two big mimickers, but it is true. Low T has been associated with increased depressive symptoms, and giving T has been shown to improve depressive symptoms. And we had a large study published in 2011 where we had almost 900 men, and we showed that even if they were on an SSRI, an antiantidepressant, adding testosterone in our trial improved depressive symptoms, maybe some synergy between adding the two, you know, but it's really important because, you know a lot of these patients, I think also are suffering from clinical depression. And you gotta screen for them.  [01:20:06]

Dr Louise Newson: [01:20:07] Yeah and it's hard because there's an overlap but my problem or not problem but one of the things I worry about is women and men actually who are misdiagnosed with a mental health condition and once they're under psychiatrists no-one thinks about hormones and I see a lot of women who have been under psychiatry often for many years so they've been given antidepressants and antidepressants can reduce testosterone levels. They're given anti-psychotics which, as you know, can push up prolactin and then reduce testosterone levels. And then lithium, they're given ECT. So by the time I see them, all their hormones are really low. And I give them back the progesterone, the estradiol, and it helps with some of their symptoms. Give them testosterone and wait, and it can be transformational. And as you knew, some of our de-prescribing data that we've just published show that women can come off their antidepressants and antipsychotics when they're on hormones, but it's higher, it's up to 40% can come off when you add in testosterone as well. And you have to do it very slowly and carefully. And some women, as you say, and men as well need both, but they're not gonna improve their mental health if it's caused by a low hormone.  [01:21:23]

Professor Mo Khera: [01:21:24] Remember, I treat sexual dysfunction, right? So the last thing I wanna do is give someone an SSRI, right? It's gonna shut down the libido, right? It delays the ejaculatory time or the orgasmic time for women significantly, right. So that is my last pull. My first pull is to go with either checking the testosterone, treating the testosterone and we hit them hard, men and women, on lifestyle modification, diet, exercise, sleep, and stress reduction. I don't have a pill on the planet, Louise, stronger than diet, exercise, sleep, and stress reduction. And each one independently has been shown not only to improve sexual function, but also improve testosterone levels, right? We make testosterone when we sleep. Exercise helps raise testosterone. Reducing stress raises testosterone, right. A proper diet can help raise testosterone, so think about the natural ways that we can do it. And if you improve the natural ways to raise your T, you're not just improving just your quality of life, just your health. Your health span, right? That's very important.  [01:22:23]

Dr Louise Newson: [01:22:24] Because it all is so close together but it can be very hard if you've got low testosterone to do all those things and I found certainly my lifestyle was not as good when I didn't have testosterone and testosterone's enabled me to continue the lifestyle that I want and we've seen this in men and women as well and I sometimes you know treat younger women with testosterone on it on its own, they've got regular periods, their estradiol, progesterone's fine but their testosterone is starting to decline. But often when they have testosterone, and then their nutrition improves, their exercise, their sleep, like you say, they don't need as much testosterone. And it's, I mean, it's definitely the same in men as well, isn't it?  [01:23:05]

Professor Mo Khera: [01:23:05] I agree 100% and most people would say, Doc, I know what you're saying about diet, exercise, sleep, and stress, but also give me the T. I want both. I say fine, but what I don't want to do is give you the T and you don't do anything. Just meet me halfway is the concept. You meet me halfway, I'll fine-tune your hormones, I will optimise your health, but you're going to give me diet, exercise, and sleep, and stress reduction, and then you're on fire. The combination is very, very effective.  [01:23:29]

Dr Louise Newson: [01:23:30] It's very rewarding medicine, isn't it?  [01:23:31]

Professor Mo Khera: [01:23:31] It is. I mean, I think it's a disservice many times just to hand the Viagra and let them go, or hand the T. You got to go deeper. You have the opportunity to go deeper and this is your chance, right? And so if you say, here's your testosterone, we'll see you later. No. Here's your testosterone. Here are the things I want you to do with your diet, exercise, sleep, and stress reduction to help raise your natural testosterone. And in fact, if you do those things, you will make my testosterone programme even more efficacious. Because the outcome will be greater than me just giving you T alone. No question.  [01:24:02][30.9]
Dr Louise Newson: [01:24:04] Absolutely. So before we finish, I want to ask you a question because I think, as you probably tell, about all sorts of things all the time, and I was trying to think recently, which drugs in your medical career, my medical career have made the biggest difference to patients or even in the history of medicine? I can think about antibiotics. [01:24:23]

Professor Mo Khera: [01:24:24] Yeah, penicillin. Penicillins is a big one, yeah, huge. You know, I think statins came out, now there's some controversy about statins, but when they came out it was a big thing in dropping or reducing the risk of cardiovascular disease. To me, testosterone's one of the biggest ones as well. I mean, it really is a transformative medication that made a big impact on numerous patients' lives. And it's not a sex drug or a quality of life drug. I mean it is a true improvement in your medical condition, right? To me I'm a very big proponent of daily Cialis. Daily Cialis is one of those magic drugs where it not only improves the quality of the erections, it actually can improve the endothelial lining of the blood vessels. A wonderful study that came out with Dr Kloner last year with a 13% reduction in cardiovascular disease, 25% reduction of mortality in those men taking test... excuse me, daily Cialis alone, and it's FDA approved for BPH. So you tell me, any man that walks into my clinic, I can protect your penis, your heart and your prostate with one pill. Uh, it is really important.  [01:25:25]

Dr Louise Newson: [01:25:24] So this is tadalafil for those who don't know, which is similar to Viagra, but it's longer acting. And I have done a podcast with Professor Mike Kirby talking about this because it's really interesting. So I agree, those drugs and other hormones as well. So thyroxine, insulin, but there aren't many other drugs that can really transform your patient sitting in front of you as in improving the quality of their life. But also improving their future health as well.  [01:25:54]

Professor Mo Khera: [01:25:55] Yeah, very important that we said that your current quality of life and your future health as well, because all of us and I think we talked about this before all we care about is our healthspan lasts as long as our lifespan. You and I don't want to live till 90, but be healthy to 70. That is not what we want. We want to be playing tennis the day we die, right, in very very good shape. And I think the same goes with our sexspan, right? Most people would say that they want their sexspan to last as long as their lifespan. Right, it makes sense. And in order to do that, you need to take care of yourself and your partner. Right, that's important as well. [01:26:32]

Dr Louise Newson: [01:26:32] Absolutely, I totally agree and I feel very lucky that I have a clinical job where I transform people's lives and their partners and their families, it all works together, it's great. But what makes me sad and frustrated is it's so difficult for so many women and men to access their own hormones.  [01:26:51][18.9]
Professor Mo Khera: [01:26:52] Yeah, but you're paving the way.  [01:26:53]

Dr Louise Newson: [01:26:53] Oh, thanks, Mo. We've got a lot to do, but it's education. So before I end, I'm going to just have to ask you three take home tips. Three reasons why testosterone or low testosterone is a marker of poor health.  [01:27:12]

Professor Mo Khera: [01:27:12] I'll give you five.  [01:27:13]

Dr Louise Newson: [01:27:14] Oh, go on then!  [01:27:14]

Professor Mo Khera: [01:27:16] We know that low testosterone, low testosterone is a marker of cardiovascular events. But man or in some cases even women with low testosterone levels increase cardiovascular events. Low testosterone is increased risk for depression. Low testosterone is increased risk for diabetes, obesity, metabolic syndrome, right? And we know that low testosterone is increased risk also for bone fracture, right. So it's not about sex. It's about your quality of life.  [01:27:41]

Dr Louise Newson: [01:27:44] That's quite a depressing way to end.  [01:27:45]

Professor Mo Khera: [01:27:46] Well, let's make it positive, let's make it positive. If you give it back, you could potentially improve these conditions, right? And that's the important point.  [01:27:55]

Dr Louise Newson: [01:27:56] Perfect. What a great way to end. Thank you so much and thank you for coming from the US.  [01:28:00]

Professor Mo Khera: [01:28:01] My pleasure. Great to be here. Yes, great to be here. Thank You, thank you so much. [01:28:01]