Male hormone health: testosterone, ED and fertility

Male hormonal, sexual and reproductive health are fundamental to quality of life and longevity, yet many men avoid the conversation out of shame or worry about masculinity. Stanford urologist Dr. Michael Eisenberg, who leads a male reproductive medicine and surgery program, explained the essentials on the Mel Robbins podcast.

What normal testosterone looks like

Testosterone is the main male hormone. The normal range is wide, about 300 to 900 nanograms per deciliter, so some men sit near the low end and others near the top. It peaks between 20 and 30 and then falls roughly 1% a year. Roughly 10 to 20% of men in their 40s and 50s have low levels, 20% in their 60s, 30% in their 70s and about half in their 80s. That is why it is often said that about half of men over 50 have low testosterone.

Around 90% of testosterone is made in the testicles, with the rest from the adrenal glands.

Signs of low testosterone

• Low energy and low sex drive
• Poor mood, sleep or concentration
• Erectile dysfunction
• Anemia or low bone density with no other explanation
• A history of chemotherapy or radiation to the testicles

These signs are nonspecific, but if they bother you or your partner notices them, get screened. Testing is a simple blood draw, ideally before 9 or 10 in the morning, repeated if the first level is low.

What lowers testosterone

• Poor sleep: It blunts the brain to testicle signaling. Aim for 7 to 9 hours. Sleep apnea and low testosterone feed each other.
• Excess body fat: Fat tissue converts testosterone to estradiol, and excess weight disrupts the feedback system. Weight loss, including with GLP-1 drugs and bariatric surgery, tends to raise levels. Anything that is good for your heart is good for testosterone.
• Chronic stress: Cortisol deprioritizes reproductive hormones, putting your body in survival mode.
• Depression and some antidepressants: Depression and low testosterone are closely linked, and some medications lower levels.
• Heavy alcohol use: It blunts every step of testosterone production, and cutting back can raise levels.

Testosterone therapy: benefits, risks and myths

Treatment can improve energy, libido, erections, bone density, lean body mass, mood and metabolic health. It comes as injections, gels, pellets, oral tablets and long acting shots. Injectable testosterone is oil based and usually given every two weeks, sometimes weekly to smooth peaks and valleys.

The main side effects are:

• Reduced sperm production, in about 90% of men, because outside testosterone shuts down the brain's signal to make it and sperm
• Acne, oily skin and hair loss
• Breast growth, from conversion to estrogen
• Higher red blood cell counts and clot risk

Older fears about prostate cancer and heart attacks have not held up. The TRAVERSE trial, which followed about 5,000 men on testosterone or placebo, found no higher risk of either, and the FDA plans to update its warning labels.

Two caveats matter. First, a doctor should oversee treatment. If your testosterone is normal, testosterone is very unlikely to help, as military studies showed no performance gain over placebo. Second, you do not always take it for life. Doctors usually start with a trial, check levels and stop after six months to a year if there is no benefit. Men who lose weight may even wean off. Only men without functioning testicles need it permanently.

Erectile dysfunction

ED is the consistent inability to get or keep an erection sufficient for sex. It is very common: over half of men over 40 have some trouble, according to the Massachusetts Male Aging Study, with about 15 to 20% of men in their 20s and 30s. An erection depends on nitric oxide and cyclic GMP relaxing blood vessels, so anything that harms blood flow, such as smoking, diabetes, high cholesterol, high blood pressure or heart disease, can cause ED. Prostate surgery, trauma and some bike saddles can injure nerves. The doctor's mantra: what is good for your heart is good for the penis.

Treatment steps

1. Review medications, especially blood pressure drugs, antipsychotics and antidepressants, and address exercise, diet and weight.
2. Use PDE5 inhibitor pills: sildenafil, tadalafil and vardenafil. They keep blood vessels open, are taken on demand and do not cause constant erections. Tadalafil lasts longer, 16 to 18 hours, and allows a daily low dose. Observational data suggest possible heart benefits, but this is not proven.
3. Try a medicated gel or pellet placed in the urethra, which works 60 to 80% of the time.
4. Consider penile injections, which work about 90% of the time.

Prostate, urination and relationships

Men who ejaculate 20 or more times a month had about 20% lower prostate cancer risk in a study of roughly 30,000 men. Regular sexual activity has also been linked with longer life, and a Swedish registry found that lacking a partner raised mortality about 60%. See a doctor if you wake two to four times a night to urinate or have urinary symptoms, because the prostate enlarges with age, and ask about PSA screening in your 50s.

Male fertility

Sperm counts are falling globally. Half of fertility problems involve a male factor, 30% only men and 20% both partners, yet a third of men are never evaluated. Test both partners early, because sperm take two to three months to make.

Conclusion

The core message is agency. Get your blood pressure, cholesterol and testosterone checked, sleep, move and manage stress, and do not suffer in silence, because nearly every problem here has a treatment.