Testosterone & Hypogonadism: A Clinical Perspective w/ Dr. Mohit Khera | Urology Podcast Ep. 124

In this episode of BackTable Urology, Dr. Jose Silva interviews Dr. Mohit Khera, professor of Urology at Baylor College of Medicine, about hypogonadism and testosterone replacement therapy.
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SHOW NOTES
First, Dr. Khera explains how comorbid conditions, such as diabetes, metabolic syndrome, and obesity, can decrease testosterone levels as men age. We also discuss the importance of the four pillars of health - diet, exercise, sleep, and stress reduction - and the role of weight loss in increasing natural testosterone levels. Additionally, Dr. Kera outlines the lab results he orders to confirm hypogonadism, which includes testosterone, free testosterone, LH, FSH, prolactin, estradiol, DHT, TSH, IGF-1, and vitamins D and B12.
Next, Dr. Khera discusses how to detect low free testosterone levels in patients with normal total testosterone levels and how to adjust treatment depending on the patient's sensitivity to testosterone. The doctors also discuss the role of testosterone in treating depression, the importance of managing estrogen levels, and avoiding overuse of aromatase inhibitors. Dr. Khera gives a brief history of testosterone replacement therapy (TRT), starting from the first oral testosterone formulation created in the 1930s to the new testosterone products developed in 2019. They also discuss the FDA's 2015 requirement for hypertensive testing, as well as the low risk of erythrocytosis associated with these new medications.
Finally, Dr. Khera discusses the importance of checking testosterone levels frequently and the controversy surrounding the best time to do so. He explains the difference between using injectables, gels, and pellets, and the importance of checking the trough level instead of the mid-week level. He explains the need to check the liver enzymes when patients are using oral testosterone. He ends by sharing why it is important to consider the whole couple when treating patients with testosterone and not just one partner.
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RESOURCES
Miner MM, Khera M, Bhattacharya RK, Blick G, Kushner H. Baseline data from the TRiUS registry: symptoms and comorbidities of testosterone deficiency. Postgrad Med. 2011 May;123(3):17-27. doi: 10.3810/pgm.2011.05.2280. PMID: 21566412.
pubmed.ncbi.nlm.nih.gov/21566...
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[@CamperMan727]

Excellent interview!

[@paperandmedals8316]

As a nurse practitioner that has hypogonadism diagnosed patients I’m curious as to why different testosterone levels are achieved at similar doses. I have a 40yo male who routinely takes 200mg a week of testosterone cypiantate and with 36hrs of a self administered IM they’re at 750ng/dl. Other males of similar age can achieve greater levels at 100mg a week. Since testosterone lab values consist of weight measured in a volume does a male’s weight and size influence total testosterone levels? Wouldn’t 100mg IM a week give a 300lbs male a lower total testosterone levels as opposed to a 150lbs male?

[@chiggedycheckyoself]

It depends on a variety of factors such as the frequency they inject. Once weekly or even every two weeks will result in more side effects and for example higher estradiol levels than those who inject 2x/week. It also depends on the cause of hypogonadism, SHBG, FSH and LH levels and a few other factors.
I sincerely hope that you don’t treat/prescribe anything hypogonadism related and refer your patients to a real doctor who knows what they’re doing.

[@paperandmedals8316]

@@chiggedycheckyoself I read through your answer and its the sort of answer a non-clinical person would write. I explained there were once a week shots, yet you bring up if it’s one or more shots week. Simply put you have no explanation as to why similar dosing across similar males with similar TRT use history will cause varying levels. I appreciate your attempt, but googling an answer and attempting to make it your own is obvious and doesn’t make you educated no less a provider.

[@swoops41]

Probably has at least something to do with the amount of esterase enzymes. Each person has. There was a study done showing that people broke down the propionate Esther at different rates. Ulting in different total testosterone levels. That’s probably the biggest reason, with SHEG estradiol, five AR etc. being factored in
EDIT: voice text fails lol

[@jonasleonas173]

What are the diagnostic results for thyroid function tests, and imaging such as ultrasonography, alongside Pituitary MRI findings, to assess the status of the hypothalamus-pituitary-thyroid?

[@notofthisworld5998]

Obesity is a factor. Fat will aromatize the T into estrogen

[@mikewood2201]

The brain produces testosterone as well