Low Testosterone Explained: What to Fix Before Starting Testosterone Therapy

In this episode of Hormones & Hope, Dr. Chhaya Makhija sits down with Dr. Justin Dubin, a urologist and men's health specialist based in South Florida, to unpack one of the most widely misunderstood topics in men’s health: low testosterone (hypogonadism). 

From symptoms like low libido and fatigue to the role of metabolic health and fertility preservation, this conversation explores how testosterone affects overall quality of life, not just hormone levels. Dr. Dubin explains how physicians evaluate low testosterone, why a single lab test isn’t enough for diagnosis, and how lifestyle factors like obesity, sleep apnea, and diabetes play a major role in hormone health.

The episode also dives into treatment options, including clomiphene, a medication that can raise testosterone levels while preserving fertility.

Together, Dr. Makhija and Dr. Dubin discuss the importance of looking beyond a single hormone level and instead approaching men’s health through a whole-person perspective that includes metabolic health, lifestyle, and long-term wellbeing. This is Part 1 of a two-part series, where the focus is on diagnosis, symptoms, and evaluation of low testosterone.

Dr. Justin Dubin is a Urologist who specializes in Men's Health including sexual medicine and male infertility in South Florida. Justin grew up in Wayne, NJ and graduated from Johns Hopkins University with a degree in Biology. He attended Rutgers Robert Wood Johnson for medical school then completed his training in Urology at the University of Miami followed by his Andrology fellowship at Northwestern University.  

Dr. Dubin is passionate about men’s health and education with the goal of improving both the lives of men and their partners. He has published multiple papers on both male infertility and sexual health, has been quoted in the NY Times, Insider, GQ, The Cut, USA Today, and Men’s Health and is the current co-host of the men’s health podcast Man Up: A Doctor’s Guide to Men’s Health through which he hopes to destigmatize men's health topics and motivate men to improve their overall lives.

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Transcript

00:00
Number one, true or false, a single low testosterone lab is enough to diagnose hypogonadism. Technically false.  Number two, yes or no, should testosterone levels should always be checked in the morning? True.  Number three, true or false, low libido alone automatically means low testosterone. False.  Obesity and sleep apnea can cause  secondary hypogonadism.

00:28
Absolutely associated, yes.  Yes or no, can chlomethine or chlometh increase testosterone without suppressing their fertility?  Welcome to Hormones and Hope,  a podcast where we bridge science and wellness  to help transform your health.  I'm your host, Dr. Chhaya Makhija,  or you can call me Dr. Chhaya,  a triple board certified endocrinologist and lifestyle medicine physician and founder of Unified Endocrine and Diabetes Care.

00:56
Each week we dive into the powerful intersection of clinical medicine  and real life lifestyle strategies  to help you feel stronger,  live longer,  and show up as your most vibrant self inside and out.  So let's get empowered. Hello and welcome everyone. Another delightful episode on hormones and hope. This is your host, Dr. Mekija. And today I have a guest all the way from East Coast or from South Florida.

01:23
An exciting one also, I know it's always an exciting one for me every time I interview or every time I have a guest on the podcast. But Dr. Justin Dubin, who is a urologist and a mental health specialist has been the guest that I was wanting to be on our podcast for a very long time, almost since we started the podcast in June, 2025. So I really appreciate Dr. Dubin joining us today from Florida. So welcome Dr. Dubin.

01:50
Thank you, Dr. Mukheja. It's a pleasure. And I'm sorry it took this long to get on, but I'm very honored to be here and I'm excited to talk to you all about hormones today. Yes, me too. And especially men's, you know, this month, especially Jan and February, we've been focusing on men's health. We've covered erectile dysfunction and you're covering bone health,  but your expertise, especially you being one of the leading experts  in men's health. Can you tell us more about your

02:18
Passion why urology why men's health before we dive into the you know, actual topic and the testosterone issues Absolutely. So a little bit about me. My name is Justin Dubin I'm a urologist who specializes in men's health that includes male infertility sexual medicine testosterone other sexual health issues erectile dysfunction

02:42
And originally I'm from New Jersey. We were talking before  I did my undergraduate at Johns Hopkins in Baltimore. did my medical school at Rutgers, Robert Wood Johnson. And then I did my residency at the university of Miami in urology. And then I made the decision that I really wanted to focus on men's health. So I did my fellowship in Chicago at Northwestern. Now,  currently I am the director of men's health  at Baptist in South Florida.

03:11
Uh, where I'm taking on some patients and I'm very excited to be working there and helping men improve their quality of their lives. Now, this is probably why I wanted to do this. So when I originally was thinking about medicine and I think a lot of the pathways of medicine, we're telling our patients don't die, do this so you don't die. Don't, we're trying to make you not die. But when I looked at medicine, I want to do it, help people live, live their best.

03:41
quality of life.  And a lot of the patients that I see are men who are struggling with their health. They're struggling with their,  or their sexual health. They're struggling with their energy, their libido, their family planning. They want to have children.  And I really liked the idea of helping people live a better quality life. People are living longer than ever.

04:06
But we need to make sure that they're living better than ever and they're taking that life that they have and they're making the best of it. I often say to my patients, cancer sucks. Life after cancer shouldn't have to. Most men who are treated for cancer or higher risk for having things like erectile dysfunction, low testosterone, fertility issues, and some of these things really need to be met before they're even having their interventions.

04:33
And so I find this really interesting space where a lot of the things that I do  are incredibly stigmatized. Men are embarrassed to talk about them, but if we can really motivate them to  learn and open themselves up, we can really make a big difference in  their quality of life as much as their quantity.  And I've also had this idea in the last few years is that the truth is men, we like to think with our penis.

05:02
but I want to get men to think about their penis and how health  impact their sexual health, their testosterone levels and their fertility. And if we can motivate men through their sexual health and their fertility to think about their health, I think we can really motivate them to improve their overall health. Yeah, I would applaud on this.  And  it's physician specialist as yourself who are actually connecting the dots too. It's not like one organ specialty.

05:31
And the more and more, you know, I speak with surgeons, urologists  as yourself. It's like how you're connecting the, the vascular, the cardiac health, the metabolic health with the symptoms that are relevant to, know, to what you just, uh, enumerated. So thank you for sharing that. And it's very much needed now than ever when we have clitoral pharmacological options and symptoms, but the quality of life, like you mentioned. So thank you.

05:57
Dr. Dubin, you know, I just wanted to let the audience know also how I got in touch with you because of your generosity. So we had a mutual friend who introduced us, just texting. I was a stranger to you, but you know, was trying to figure out answers in terms of clinical practice regarding chlomophin and chlomophin  and the oral testosterone at that time, because I was having some challenging patients where, you know, things were not making sense. And you were so generous to talk to me, to share your expertise, to share your

06:27
Also your clinical experience  and you know, how you're approaching these patients. So out loud, I wanted to appreciate my gratitude. Honestly, the pleasure is all mine. think that, listen, we're all here to help each other. Cause at the end of the day, we're here to help our patients. And the more that we can do to educate ourselves, educate our colleagues, and hopefully educate our patients,  we're just going to all be better off in the long run. And I.

06:55
appreciate you doing things like creating these kinds of podcasts that are incredibly valuable for patients, for medical students, for residents, for fellows, for other of our colleagues who just want to learn more. I think these are incredibly valuable resources. So I give you all the credit in the world for that too. And you know what? Asking for help. If  you didn't know something, right? Like  we're in a place where people don't like to make stuff up. I'm always happy to ask if I don't know.

07:25
something to learn more. And I give you credit for saying, Hey, I need to learn more about this because this is important to me because it's important to my patients. So it's really important. And you get credit for actually asking the questions and seeking out the answers. Thank you. You know, it's always being in a loner mode and then helping our patients. Yeah. Appreciate it. So Dr. Dubin, now I'm thoroughly excited. I'm pretty sure the audience is excited about the rapid fire because that's our fun part of

07:55
the podcast before we get immersed into the details and nuances of our topic. So either one-liner or one-word answer.  And if there's something more in depth, then we can start with that particular description or discussion. Okay. You ready? Yes.  Okay. So  number one, true or false, a single low testosterone lab is enough to diagnose hypogonadism. Technically false. Okay. Thank you. Number two, yes or no. Should testosterone levels, should

08:25
always be checked in the morning. True. Okay. Thank you. Number three, true or false? Low libido alone automatically means low testosterone. False. Thank you. Out loud. Number four, yes or no? Obesity and sleep apnea can cause  secondary hypogonadism.  Absolutely associated. Yes.  Thank you. I love the absolutely. I'll put an exclamation on that.

08:53
Number five, true or false, every man with low testosterone symptoms needs testosterone therapy. Well, do they have low testosterone?  The answer depends, right? If they have low testosterone, then yes. But if they don't, then the answer is no. Yep. Thank you. Number six, yes or no, can chlomethine or chlometh increase testosterone without suppressing their fertility? That is true. That's correct.

09:22
Protect your fertility.  Number seven,  one condition or a symptom men often ignore that affects their health. They ignore that affects their health. There's a lot.  mean, I mean the most sensitive one is going back to libido and we're talking about testosterone. It's always low libido is the most sensitive  symptom  of low testosterone, but that doesn't mean that you have it. Of course it's two ways. True. Yes. Thank you so much.

09:50
Okay, some are very clear and a few you mentioned about it depends or,  you know, the nuanced answer. So our part one episode, which is going to be right now with the questions is just learning about low testosterone or what this terminology as hypogonadism means and how you  recommend either clinicians or even how you approach your patient care in terms of evaluation. So let's start with, if you want to break it down for us, Dr. Dubin, why would you

10:20
check testosterone levels in a male. So what are the most common symptoms that Ben should be aware of or that should have a physician or it should be on a clinicians review of systems that let's get testosterone checked. And can you walk us through what would you recommend to get evaluated and you know, the timing aspect of it and any specific details about the biochemical evaluation? is really important. So I think I want to start with

10:50
the AUA, the American Urology Association guidelines for the definition  of low, having low testosterone or the medical term is hypogonadism. So the first thing you have to have is signs and symptoms of low testosterone. That can be, like I said, the most sensitive one is low libido. So that's the closest indication. You can have low energy,  like down mood, focus issues.

11:17
You can have weight gain, muscle loss, osteoporosis, osteopenia, breast development, body hair, not head hair, body hair loss. These are some very in general generalized issues. Erectile dysfunction is another, can be a sign of low testosterone, but we have to remember they can be a sign of other things as well. So not everyone with these symptoms has low testosterone, but if you're feeling those things, that's definitely something that you should be talking to a doctor to get screened for low testosterone.

11:46
The second part of the guidelines say that you actually have to have a low testosterone times two. Now, what is a low testosterone? Per the guidelines, which are currently actually being revised right now, they just started a new committee. It's probably going to come updated. It is going to come out in the next year or so  is a total testosterone level less than 300. Now, and you have to have it times two. Now I think

12:13
both you and I agree that 300 is while is a cutoff. I don't really live and die by 300. think that, you know, guidelines are guidelines. They're not law. And as you also know, the endocrine society guidelines are a little bit different. They say, you know, they give less hard cutoffs and they also include free testosterone. Now free testosterone, my cutoff is typically around 46 picograms per nanometer. I don't know what your cutoff may be. That's

12:42
typically where I'm around. but traditionally we look at total testosterone. There are situations where I will also include free testosterone, but you have to have those two qualifications in order to be diagnosed with low testosterone. Now, having said that, there are also people who should be screened no matter what for low testosterone. These people are typically people who are at higher risk. Those are people who have a history of cancer.

13:11
A history of HIV, usually autoimmune diseases. These are people with like chronic diseases that put them at higher risk for low testosterone. Obese patients are at higher risk. And you know, the truth is sometimes patients, because they've been low testosterone for so long, don't necessarily have symptoms until they're treated. And I, and it sounds kind of crazy, but there's a kind of gestalt you have for it when you see a patient.

13:41
And you treat them who like, you know, you'll see a patient who's severely overweight, their testosterone is low, but they, they're not really sure if they feel low energy and you give them the medication and they feel like a completely different person. just, when your baseline is bad, you may not know what  the new baseline is. Now that's not typical, but that's something that I also consider having experience in it. So I think that, you know, when a patient comes in,

14:08
It's really important to understand a lot of these things. It's important to understand also, you mentioned sleep apnea. I have every patient fill out a stop bang form to assess. It's a screener, a validated tool for sleep apnea. Because what I have found over the years is that I've found guys who you treat for testosterone. Their main complaint was they were tired. They did have low testosterone. And then I've told them.

14:35
Every time I see them, have sleep apnea, you have sleep apnea, they don't want to get tested. But now I give them the validated survey. say, look, this data really suggests you have sleep apnea. You really need to go see it. And they often get tested and they have sleep apnea and their energy is better. So these things are generalizable. But  as the provider, you also have to understand the additional factors that can play a role in how people feel. And while testosterone can be the solution a lot of times,

15:04
It's maybe sometimes just part of the problem that's going on. Yeah. Well said. In endocrinology,  most of the times what I encounter is, you know, they are having gynecomastia or nipple discharge, which is called gallic doria. And that's why they're referred to me, men,  and either they'll have hyperprolactinemia or prolactin producing tumor in the pituitary. So that's, one of the common causes,  which is not related to the metabolic health.

15:33
The second one is like you mentioned, either sleep apnea, very poorly controlled, type two diabetes, obesity. So in your world, right. I feel surrounded with more of these patients and these type of diagnoses. How does the role of  utilizing pituitary hormones or the sex hormone binding glovulim, how do you use that in your clinical evaluation? That's a really important question. Now, if you.

15:59
come to any of our conferences, the typical like sexual medicine society, some of our AUA conferences, when we go deep into these conversations, I think a lot of people  use those labs a different way. I'll tell you my typical workup for anyone who comes in with concerns of low testosterone, whether it's erectile dysfunction or other signs, I get a total testosterone. I get a CBC.

16:26
to check their hematocrit and, uh, and their hemoglobin. get an estradiol. I do get a prolactin. I get an LH. If they're interested in fertility, I also get an FSH. If they're above the age of 40, I then get  a, a PSA. Now where does SHBG and free testosterone come in? These are often for me, kind of like a

16:52
I'm unsure where this patient lies. If sometimes, you know, a total testosterone, and I think we should explain this to our listeners. So what's the difference, total testosterone and free testosterone. So total testosterone, as the name states, is all the testosterone in your body. However, most of it is not actually available for your receptors to bind to. It's about, you know, 97, 98 % of it is bound to two things. SHBG, which is sex hormone binding globulin, as well as

17:21
Albumin and so free tea is that one to two percent that is actually available for usage and many people I think Pretty much rightfully so will argue that free tea is the more important one now in endocrine society has your guidelines stated in our  old Testosterone guidelines, it's not brought up and I think that that's one of the things that endocrine society has done better So most urologists at a standard practice

17:49
Probably don't use it. think that's going to change in the updated guidelines from what I've,  I'd imagine, but typically I use free testosterone really when I have patients after that testosterone, if they're borderline or they're a little bit normal, I will order another total testosterone, SHBG  and a free testosterone to see if I'm missing something because

18:14
For me, it's very hard. We don't have in our guidelines and there's no  in the endocrine society guidelines, a goal free testosterone. I can give you a goal total testosterone, which is a guide for me on where to,  to dose your medications and to set an appropriate goal that you're not too high in your testosterone, which can theoretically come with risks. But I don't have a goal free testosterone. And when I don't have a goal, it's hard for me to use it as a marker.

18:43
I can use it as a marker for low, but then I still end up going to the total testosterone, which for the norm to get to my goal level. And it's hard for me to rationalize that, right? If something was borderline normal to normal, but your free T is low. So there's a lot of nuances there, but that's kind of how I look at all these labs. have to look at them as an individual person. If someone's testosterone, total testosterone is 150 times two.

19:10
I'm not worried about looking at their free testosterone, but if someone's testosterone is 400, 450, and their free testosterone is 25 and their SH which is low and their SHBG is like 58, which is quite high. Then it's like something else is going on here that we need to investigate. And there's different options that maybe we could discuss in terms of medications and how we want to treat it. But there is this disconnect currently.

19:38
And as we're learning more about testosterone and it's how it  interacts in our body and how medications work,  like an impact SHBG and free tea, I think we're going to have a better grasp of that. I'm hoping the guidelines, the newer guidelines will give us light, but I do think that there's still a lot of work to be done.  I'm curious, is this, is it a set year with the guidelines for the American? No, I know that they just gather, they're gathering for their first meeting, I think in the next two months.

20:08
I forgot to finish the application, but that's another story.  I forgot to finish the application to be honest, but that's okay.  Yeah. No, we rely on the clinical expertise for sure, because that's really speaking about, you know, what are the patients actually feeling, what's their outcome as. Yeah. So we're going to simplify this further. So thank you for breaking down what total three and six hormone binding global means and how you're assessing them.

20:36
Since we are focusing the part one  on just hypogonadism and then we work on the next piece  in regards to like a lot of deep dive into testosterone  replacement. If you can tell  us or even me  in regards to the use of clomiphon citrate. So the reason I bring this as my second question is if we are focusing on secondary cause for hypogonadism, which is

21:04
not related to a direct testicular damage or a direct pathology in the testicles, but something which is other than the testicular pathology.  When would you consider  use of plomyfin and what is it and why would you consider it as a pharmacological option for someone  who has a picture of secondary hypogonadism? So I do want to clarify, you're right. So between primary and secondary. So primary, I think

21:34
The primary source of your testosterone, would be your testicle secondary is the signaling system to your primary source is not functioning. Right. So to give a little bit of background, which is important on  HPG axis. So your hypothalamus sends a signal to your pituitary, which then creates two hormones,  FSH, which is follicle stimulating hormone. It's in men and women.

22:03
For men, it is the hormone that is sent to your testicles and tells your testicles to make sperm.  LH, which is luteinizing hormone, is the hormone made in your pituitary as well. It's sent to your testicles and that tells your testicles to make testosterone. So together  as a primary source, that's why your testicles are the main source of fertility, sperm being made and testosterone. When you have a primary issue,

22:29
That means that FSH and LH are being signaled normally to your testicle, but your testicle for whatever reason is just not able to produce or respond to the signal and not make testosterone  or FSH. An important aspect of this relationship also is there's a negative feedback loop. Now in the periphery of your body, testosterone is also  converted to estrogen or estradiol. And that

22:59
is actually signaled back. The production level is signaled by the receptors in your brain and saying, Hey, we're making adequate testosterone because we have these levels of estrogen. So we don't need to keep telling our, our pituitary to make more  LH or FSH. So it comes to an equilibrium based off of how these things work.  FSH also, a sperm usually gives off inhibin B as well to give a similar feedback loop to your brain. Now, when you have

23:28
Uh, secondary, you're not getting the signal. your FSH and LH is low, which means that your testosterone is low. And so if we can find a way to tell your body to make more FSH and LH, your testicle is technically normal and functional, and it should respond appropriately to a normal level of FSH and LH. And that's where a medication like Clomid comes in. Clomid.

23:58
is a selective estrogen receptor modifier. Now you're like, well,  you just said estrogen, but we're talking about testosterone. I gave you the feedback loop and how it basically works is it, it tricks the receptors in your brain.  think it's competitively blocking the estrogen receptors so that they are not seeing that negative feedback loop of estrogen, which naturally then your brain and your hypothalamus and your pituitary

24:27
Then says, Oh, we're not making enough testosterone.  it tells your body to make more FSH and LH naturally. So you can increase your FSH and LH, which naturally then has your testicles producing more testosterone and actually more sperm. So that's why when we're talking about options to increase your, your testosterone while preserving your fertility, Clomid is an excellent  option.

24:54
Beautiful. I think like if there were first year medical students or an eighth grader or a fifth grader, beautifully explained. Thank you. So now with that understanding, right, of what's the signaling defect and how you're  using the medication to correct that signaling defect, based on your clinical expertise and your clinical experience for these many years,  what type of a patient scenario?

25:22
would be an ideal one that you would consider that, okay, let's just consider a clomiphon because it's, you know, it's not still FDA approved or it's an off-label treatment. And how do you counsel your patients that, you know, this is worth considering, this is what the response is going to be, or if they have questions on how long do I need to use it? How are you assessing that? So I think the biggest thing is I offer this to almost anyone who wants to preserve their fertility.

25:51
Right. Young men have low testosterone, more young men than ever are having low testosterone. We've never been more sedentary as a society, eating worse, obese, having higher diabetes, as you know. So I'm seeing a lot of young men who want to preserve their fertility, but want to feel better because their testosterone is low. And I offer them this. Now there are caveats, right? It is a medication that will improve your FSH and LH and oftentimes.

26:18
We see patients who have very high FSHs or LHs to start with, and it signals more as a primary, primary hypogonadism. Because remember if the testicles not working, they're not getting the negative feedback. So your body's saying, make more testosterone, make more testosterone. So it increases naturally your LH and FSH. Now in those situations, I still offer it. Does it always work? It's probably less likely to work right in the higher FSH and LH because

26:46
If you think from a logical standpoint, your body's pretty much maxing out that  LH and FSH and your testicles just can't do the work. But I always want to give people a shot. I think that the harm is quite low. When we, when I counsel patients about Clomid, there's a lot of benefits that  you don't see in regular testosterone replacement therapy. Obviously the biggest one is fertility preservation. The second one is that people like the idea of naturally improving their testosterone through their own body.

27:15
instead of taking what we call exogenous testosterone. So that's something that's appealing to a lot of people. The third thing  is actually this idea that you can come off of it at any time, right? You know, there's no, like, you don't have to be winged off. You don't have to, you can kind of just stop it as you, as you please. So, you know, some people like the idea of, doc, I'm trying to get healthy. I want to lose some weight. I'm a young guy.  I lose 30 pounds. I really want to see if I can stop the Clomid.

27:44
Okay, we can stop it. And if it doesn't work, then we can go right back on. But sometimes, you know, you did what you needed to do, uh, very rarely, but sometimes you can do that, right? If you lose significant weight, your testosterone levels do go up and your body does accommodate. But these kinds of things that make this medication reversible or not potentially harmful in the long run to your body, I think is, is really great. Now it is off label.

28:10
It will always be off label for men. That doesn't mean it's bad. That doesn't mean it should be frowned upon, right? Um, it's just something that I don't think the FDA will ever approve for that reason, just whatever reason. But I do tell people, typically people are on these things for life, right? Any kind of medication like this, but this one, if you want to stop, we can stop. And it's a lot easier than if we stopped with real testosterone replacement therapy.

28:36
If this doesn't work, there's also alternative options that we can always try as well. But, you know, I think it's an individualized conversation. Even guys who I think are better candidates for TRT, true testosterone, like testosterone, cypionate. A lot of them choose this as the bridge. A lot of people want to try these medications first just because they do like this idea of naturally stimulating testosterone in their body. And I've recommended real testosterone to a lot of guys who start here.

29:05
And then they, they either love it or they'll go on to TRT at a later time. But the one thing I have noticed, and I don't have any, and you'll ask any practitioner who gives Clomid versus testosterone. The response is quite variable  and everyone's different, right? Some people's testosterone  goes much higher. Some people's testosterone doesn't budge.  Even for people though, whose testosterone goes higher, we still see people who are, don't have symptomatic relief.

29:35
Especially when it's compared to the real deal testosterone exogenous. You know, we can all speculate. think my own personal opinion is that although you're taking testosterone, think hypogonadal people inherently where we're human, our DNA is not perfect. I think that our proteins or our hormones may have less, I guess it's affinity for  receptors than if we.

30:02
We go in a lab and we make real testosterone. Now I can't prove that. will never be able to prove that, but you know, although theoretically  it's all bioidentical, I think that there's inherently some  difference there. Now, are we taking people who have low testosterone and there's a defect in their testosterone affinity or receptors, and then we're just making more of it naturally. Now it's either getting there, but they're not feeling the impact. Maybe that's why, but in general,

30:31
It's hard to really predict the people that are going to feel amazing on Clomid versus not. And some people respond and feel, don't feel a difference. And some people feel better and don't respond as much. So I find overall, there is a lot more variability on the response to Clomid than there is on typical testosterone replacement therapy. But that as a provider, you have to, you know, I always counsel like, Hey, sometimes it works. Sometimes it doesn't.

30:58
but we're going to work through this together and there's other options. And it's a game of trial. And as long as you have a buffet of options, which we all do, and you're counseling the patients appropriately, they're going to be on this journey with you with no issues. Yes, absolutely. I echo the same experience, like since, you know, it's been like more than 15 years since practicing endocrinology. That's, I would vouch that for Clomiphon.

31:22
And thank you for sharing, like for breaking it down and how you're bringing about that discussion of here are the options, right? And this patient is still  feeling empowered to make that decision that let me go through this route. You know, where I've had challenges with this  aspect and also with the widely available internet supply of is end-chromephin.  And that was one of the reasons that, you know, initially I had reached out to you. So before we  end this part one discussion,

31:52
Can you just shine some light in terms of the evidence  or again, your clinical experience and why would someone not take it or not consider it versus what are the few rare scenarios that you would have a discussion with your patient about the N-Clomidin? So N-Clomophene, to bring it back to Clomid, because it all starts with Clomid for this. Clomid is an isomer of two different, you know, I guess hormones or serums.  There's Zuclomophene.

32:21
which is more  andra, it's inactive form with some estrogenetic. So one of the side effects potentially of Clomid, although very rare is nipple sensitivity. Some people also have some GI issues and some hot flashes the first month or so. It's quite rare. It's a very tolerable medication. That's those Zuclomophene and those estrogenic impacts are kind of what people believe the side effects are from. And then the other isomer is  N-Clomophene.

32:51
And over the last five, 10 years, they've been able to isolate and Clomaphene, which is more androgenic that is shown to have less side effects and use that as a medication in itself. It's an oral medication. The dosage is a little bit different. It's 12.5 milligrams and 25 milligrams versus 25 milligrams and 50 milligrams for Clomid. But the problem is getting access to it because it's actually only really made in a compound pharmacy. Now it's not approved by the FDA. It's,  it's a compounded.

33:21
product, but I will tell you, I find it a very valuable thing to offer patients. Now I usually don't start with in-chlamophene unless a patient has read about it and they ask, and I'm always happy to give it for two reasons. One, it's a little bit more expensive and two, I don't think most people need in-chlamophene because the side effects for Clomid are quite low and the access to Clomid is a little bit easier to get. But I think people who  really benefit from in-chlamophene are two people.

33:50
One, people who do have nipple sensitivity. I often, if you see a patient who you put on Clomid and they're complaining of nipple sensitivity or nipple puffiness, I changed them to an enclomophene and I've never had a patient have an issue on it. literally everyone who's had that issue, it goes away when we change to an enclomophene. So that's one benefit. And I have also put people on who, like I said, it may improve their testosterone levels, Clomid.

34:19
they're not feeling a symptomatic improvement, I'll switch them over to enchlomophen. And I think a lot of them do improve, but it's still, there is still variability there. But, but that's kind of the two times where I'm like, I definitely want to try and clomophene with you to see if we can get a different impact. Usually it's the side effects that are driving me, but I think there is an opportunity to also see if we can get the symptom relief that we're looking for that Clomid may not have been providing.

34:48
even though was getting you to your testosterone goal levels that we wanted. Yeah. So now this, have like a personal set of question, which wasn't there in my plan,  but have you witnessed, all right, witnessed any of your patients who've had a secondary cause for hypoconadism? And it could be any cause that could have been, you know, obesity or untreated sleep apnea or really poorly controlled metabolic disease or type two diabetes or an event.

35:18
Have you seen them get better in terms of their metabolic health and seen the improvement in testosterone where they are not requiring any pharmacological intervention for a low testosterone because it's normalized after treating the metabolic condition? Absolutely. 100%. And this is the thing, but I think that's an important point, but there's also a fallacy with that. I think that I've seen a lot of guys

35:47
And this is a theme I see all the time, whether it's other urologists, primary carers, endocrinologists, where they see a guy, he's overweight, he has diabetes. He says he's got signs and symptoms of low testosterone. He has low testosterone and the provider says, well, just eat healthy and exercise, lose the weight and your testosterone is going to go up. That's not a solution. You have to understand these patients are in this like catch-22 situation where

36:16
They don't have the energy, the metabolism or the motivation. Even if they want to have, they want to want because their testosterone is low because of their other diseases. And if you tell them to do the things that they can't do because they have low testosterone, they're never going to get there. So all of these things should be in conjunction with each other. If you have diabetes, you need to get your diabetes under control. If you have  high blood pressure, you need to get your blood pressure under control. If you have low testosterone, we need to get your testosterone

36:45
to a normal level. All of them work together to get you to be your healthiest. Having said that, I have had guys, I'm in Florida, right? People don't like taking medications. A lot of you guys want to go this natural route. I do have guys who I say, hey, listen, let's put you on something. They go, hey, I want to just try to exercise. I want to try to eat healthier. I haven't been doing that. This is a wake up call to me.  We see it. I say, okay, we'll see in three months. We can repeat labs.

37:15
And I have guys who've lost, you know, 25 pounds  and their testosterone levels are normal. And I say, are you feeling better? They say, yeah, I am. I've gotten my sugars under control. My blood pressure is better, but that's not everyone. Right. It can be done and it should be an important emphasis that losing weight and getting your body and your health overall better will improve your testosterone. But that's not always just the correct first step for a lot of people.

37:45
Absolutely, it's so individualized and you gave examples of both sets of patient population and I totally agree in conjunction because you want to support and I think it correlates with your mission or when you describe why you entered urology and why men's health was also the quality of life. You can't push them to go work out in the gym and lift weights where they're just exhausted and fatigued.

38:10
and can't do that part of the intervention because of the low testosterone. So beautiful. I love that in true sense, it's,  you're educating them, you're figuring out the dysfunction that is happening because of the metabolic issues or even with the signaling, but we're not waiting for years to help them, you know, either treat their sleep apnea or get to a steady weight and then decide that, okay, it's been a year, you know, we failed or we've been partially.

38:39
Better with your metabolic health. Now you need something for testosterone. Yeah. I mean, I can't tell you  first off, interesting statistic, less than 50 % of men under the age of 40, uh, see a primary care doctor on an annual basis. So oftentimes  I see patients, this is a very common story. I see they're 45 years old. come in because they have erectile dysfunction or they have low testosterone and they're overweight. Their blood pressure on the intake is very high.

39:09
And I'm asking them like, Hey, do you have any medical problems? go, Nope, very healthy. go, when was the last time you saw a doctor? He goes, 30 years ago. So, you know, and then I diagnosed them with high blood pressure, diabetes, obesity, and I'm sending them to their primary care or their endocrinologist for the first time. And this is something that we need to prevent. And it starts early and it starts with identifying these things and motivating men. Like I said before, like if we can show that you can live your best, longest life.

39:37
And that includes your sex life with your partner. Then every guy should be lining up to go see the doctor  on a, on an annual basis. And just going back, I'm not trying to get political or anything here, but this idea that diet and exercise that  I keep seeing online all the time. Doctors are just not, they're shills. They're not like promoting diet and exercise. The answer is.

40:02
I've never met a doctor on earth who's never said diet and exercise is the solution. Isn't the solution to a problem because we are all fans of having a healthy diet and exercising. And all of a sudden though, we are the bad guys. And the truth is people have been told for 150 years to diet and exercise. It hasn't worked. I don't know why all of a sudden now the burden is,  Oh, now we have to teach them more diet and exercise. Everyone should be dieting and exercising, but

40:32
We're coming in because we want to help you get to that point if you can't, and we're trying to help find the other ways to motivate you to do so. But the answer is always diet and exercise. Diet, exercise, decreasing your stress and getting better sleep. These are the pillars of your overall health. And everything that we're doing is just making sure that you can get the best of those.  Absolutely. Well said. I don't have any words now.

40:59
Thank you. I really love  this discussion, Dr. Dubin, and I'm thrilled that  you broke it down so beautifully, so scientifically, but also with simplification  and looking forward to our part two in relevance with lots of other pharmacological options that we have in men's health. Thank you so much.  Absolutely. Thank you for having me. I'm excited.  Thanks for hanging out with me on Hormones and Hope.  If you've loved this episode,

41:29
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