Episode 27: Metabolic Syndrome, Diabetes and Other Common Endocrine Health Issues

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Episode Summary:

Early diagnosis—for pre-diabetes, diabetes, thyroid issues, osteoporosis, and low testosterone—is critical for a quality long life managing or even reversing these challenges.  Screening and treatment are effective and available. These health issues are under-diagnosed in guys because the symptoms are in that category of ‘my arm is not falling off, I don’t need a doc.” Except for one condition: erectile issues can get guys to the doc. Early diagnosis—for pre-diabetes, diabetes, thyroid issues, osteoporosis, and low testosterone—is critical for a quality long life managing or even reversing these challenges.  Screening and treatment are effective and available. These health issues are under-diagnosed in guys because the symptoms are in that category of ‘my arm is not falling off, I don’t need a doc.” Except for one condition: erectile issues can get guys to the doc.

Episode Guest:

Arthi Thirumalai, M.D..  Assistant Professor, Endocrinology Division, University of Washington

During This Episode We Discuss:

  • What is necessary to know about common endocrine disorders?
  •  What are the associated risk factors with these diseases?
  • Understanding the symptoms and signs of these conditions.
  • Understanding management requirements and the importance of treating these conditions.
  • What is Low Testosterone (LT)?
  • Male contraception.

Quotes (Tweetables):

“For prediabetes what will be offered is intense lifestyle modification, that essentially includes exercise activity (150 minutes of moderate exercise activity or 75 minutes of vigorous activity per week), in addition to eating a healthy diet. We recommend less than 10% of your daily caloric intake coming from refined sugars and less than 10% of the daily caloric intake being from saturated fats. So leading a healthy lifestyle in terms of diet and exercise is the first step that most people try. That said you don’t need to stop there, you can add medication, the most common being Metformin.”

“Most men are not aware of the existence of low testosterone associated when you’re on certain medications. The two that come to mind are chronic steroids like Prednisone, and chronic narcotic therapy opiates.”

Arthi Thirumalai, M.D.

Recommended Resources:

Episode Transcript: 

Dr Richard Pelman (00:07):

Baseball game, day in a park with friends and family, fishing in a remote stream, work, travels, providing for loved ones, or heading out for adventures, whatever you do, whatever you enjoy, you need your health. The Original Guide to Men’s Health, as presented by the Washington State Urology Society, to help take you through the steps necessary to get the most out of life. If you have invested in a retirement plan for your future, why not invest in your body, after all it makes better sense to retire healthy and enjoy your future. These podcasts are a guide for how to take care of yourself. If you take care of your car and maintain it, why not do the same for your personal machine, your body, if you know you should, but haven’t yet, the information in these podcasts contains some easy recommendations for where, when, and how to get started. Follow the podcast, as we explore men’s health with renowned experts and embark on a journey towards better health!

Dr Richard Pelman (01:26):

On this episode of The Original Guide to Men’s Health, we are going to be exploring common diabetic and endocrine disorders, with Dr. Arthi Thirumalai. Thirumalai is an assistant professor of medicine Division of Endocrinology here at the University of Washington School of Medicine. She did a residency and fellowship in endocrinology at the University of Washington and has research interests in andrology and male contraception clinically. She sees a variety of endocrine disorders and diabetes. Welcome. 

Dr Arthi Thirumalai

Thank you very much. 

Dr Pelman

So let’s start with the common endocrine issue diabetes, and maybe even go before that, into what’s called pre-diabetes metabolic syndrome.

Dr Arthi Thirumalai (02:16):

So given that everybody is aware of the obesity epidemic, what we’re seeing is rapidly increasing numbers of individuals with this entity called metabolic syndrome. This condition is defined mainly by the presence of three or more of the following problems. The first feature being increased in abdominal circumference. So waist circumference that is more than certain set parameters there’s a rise in blood pressure. Typically we think of numbers that are over about 130/85, rise in fasting blood glucose, over 100 milligrams per deciliter, and then cholesterol abnormalities that could either be triglycerides that are getting elevated over 150 milligrams per deciliter, or an HDL that’s falling under certain parameters, men and women, those numbers being different. So when somebody has more than three of these, we consider them as having metabolic syndrome and just by looking at those individual components. We know that all of those are risk factors for heart disease. And so we pay more attention to these individuals and try to modify these risk factors earlier so that it doesn’t evolve into diabetes. And it doesn’t evolve into heart disease.

Dr Pelman (03:23):

Say we have a patient who has not entered into the healthcare system, they’re listening to this and they go, “well, I guess I could go get my blood pressure taken.” I would have to go to a lab and have somebody order the blood work. Anything else that might give them an idea that they’re heading in that direction? 

Dr Arthi Thirumalai (03:43):

Well, you know, everybody has a sense of how much they weigh. And if you feel like you are an unhealthy weight or borderline overweight, then those are definitely the people that I would target more specifically to go meet with a primary care doctor to get your weight checked, figure out what your body mass index is, and are you at risk for any of these problems? As you mentioned, screening blood pressure is actually recommended for all adults over the age of 18, which is really the definition of adulthood. And then even screening for diabetes is recommended in anybody over the age of 40, especially if they’re overweight or obese, and screening for diabetes has become a lot simpler than it used to be. Originally, people might’ve thought you need to do this thing where you take a glucose load and then do a measurement at one hour or two hours. But it’s not as complicated as that anymore. A simple test called the hemoglobin A1C* on your blood on a random day. you don’t need to fast, could be a starting point to see if you might have pre-diabetes or diabetes. 

*All About Your A1C (cdc.gov) –When sugar enters your bloodstream, it attaches to hemoglobin, a protein in your red blood cells. Everybody has some sugar attached to their hemoglobin, but people with higher blood sugar levels have more. The A1C test measures the percentage of your red blood cells that have sugar-coated hemoglobin.

Dr Pelman (04:40):

Somebody who gets their blood drawn and has a normal fasting glucose or blood sugar, but has an abnormal hemoglobin A1C, is that possible?

Dr Arthi Thirumalai (04:50):

It is possible because prediabetes is essentially defined as somewhere between normal and diabetes. And there are two components to that. One is called impaired fasting glucose, and the other is called impaired glucose tolerance. And the problem of the two is a little different. In impaired fasting glucose the main problem is that the liver is responsible for making extra glucose in the body and it’s doing too much of that. And so they may be time when they eat and their glucose may be normal, but when they wake up in the morning, their blood sugar is high. Whereas in impaired glucose tolerance, what ends up happening is that they’re not able to dispose of the glucose that is absorbed from any food that they eat in the proper way. And so the word prediabetes really encompasses both of these problems. They could either have one of the two abnormal or both of them abnormal, just not abnormal enough to call it diabetes. So you could have a normal fasting glucose, but still be pre-diabetic because your glucose tolerance is impaired.

Dr Pelman (05:47):

So again, we’re talking about prediabetes or metabolic syndrome, if left unchecked, what happens?

Dr Arthi Thirumalai (05:55):

Well, about a third of them will progress to diabetes. And actually the numbers have been skyrocketing as the times have gone by. And if you look at the CDC data, comparing 20 years ago to now, the rates of pre-diabetes have gone up and the rates of diabetes have also gone up. What’s actually even more interesting is that men are more likely to have undiagnosed diabetes or undiagnosed pre-diabetes compared to women. I think women tend to encounter or interact with the medical system more often just by reproductive needs. And so they get diagnosed earlier. Women tend to have other symptoms that they might seek help for earlier than men do. So I think this is definitely something important for men in the early adulthood, 18 to 30, 30 to 49 to consider. Whereas older men tend to seek medical help more often, so are less likely. 

Dr Pelman (06:41):

Then somebody, again, maybe pre-diabetic not getting treated, not turning into full blown diabetes, or they’re in the other you said two thirds. They have high blood pressure. That’s going to cause issues for them. What other manifestations form the pre-diabetes can be problematic for them if it’s not treated well?

Dr Arthi Thirumalai (07:02):

So I think the thing that to focus more on is what are the associated risk factors? So somebody might have a genetic cholesterol problem that they’re not aware of and having pre-diabetes on top of a second risk factor puts them at higher risk for heart disease. And they may have an early heart attack or a stroke in their forties or fifties that they might have otherwise prevented by seeking medical attention early. And the same goes if there’s another risk factor like smoking or they’re overweight, then multiple risk factors add up and put them at risk for more serious problems. 

Dr Pelman (07:35):

Now, if they’re not yet diabetic, we’re still talking about pre-diabetes, they do seek care. What are some of the treatment options for these people? 

Dr Arthi Thirumalai (07:45):

Right, so in general, for most people with pre-diabetes, what will be offered is intense lifestyle modification. And that essentially includes, what we consider appropriate exercise activity, which should be at least one 50 minutes of moderate intensity activity or 75 minutes of vigorous activity per week. In addition to which they need to eat a healthy diet. The definition of that is a little tenuous, but in general we recommend less than 10% of your daily caloric intake coming from refined sugars, less than 10% of the daily caloric intake being from saturated fats. And so leading a healthy lifestyle in terms of diet and exercise would be the first step that most people will try. Having said that, you don’t need to stop there. You can also add medications. And the one that’s usually offered is Metformin therapy. It’s a drug, that’s an oral medication, a tablet that’s been around for decades. And so there’s no concern about safety at all. And it has been shown to very effectively prevent the progression from prediabetes to diabetes. And it can sometimes be a little difficult to tolerate side effects, but if you titrate the dose up slowly, most people do completely fine.

Dr Pelman (08:54):

What sort of side effects would be concerning? 

Dr Arthi Thirumalai (08:57):

Most people experience a little bit of stomach discomfort, so they can get a little bloating, a little gassiness, some abdominal cramping or even diarrhea. But usually we start at a very low dose and very gradually increase the dose. There’re also extended-release formulations of this drug that helps circumvent those side effects. Those would be effective ways of preventing progression from prediabetes to diabetes. 

Dr Pelman (09:18):

And I remember reading something about Metformin, a longevity study, that it might be the longevity drug.

Dr Arthi Thirumalai (09:24):

Yes. And actually lots of studies are ongoing for anticancer effects of Metformin as well. So I don’t think we’ve exhausted all of the utilities of this drug yet, but definitely a very safe drug and very effective. 

Dr Pelman (09:35):

I’ve had some patients who are concerned though, “I have to go on this medicine.” I said, “well it may not be bad for you, it actually might do better than the person next to you who’s not taking it.”

Dr Arthi Thirumalai (09:45):

Some people will raise concerns that, oh, my kidney is going to be damaged by this drug. And I think that stems from some misinformation, there is a dose reduction that is recommended in people with kidney disease, but it does not cause kidney problems. So I just want to make sure that we always talk when I’m talking to my patients, that they understand the difference between a dose adjustments for a medical problem versus it causing that problem.

Dr Pelman (10:07):

So the lifestyle modification would include smoking sensation, with somebody helping them do that, exercise, diet, and we might see blood pressure get better.

 

Dr Arthi Thirumalai (10:24):

Absolutely, lowering cholesterol drops the risk for diabetes, and you can decrease all that through just exercise. And the other piece is alcohol consumption too. Especially for people with diabetes, high triglycerides, a lot of the time the problem is alcohol intake. So we recommend safe limits, which is usually one drink per day at the most for women and not more than two drinks per day for men. 

Dr Pelman (10:44):

And of course watching those refined sugars that they sneak in there.

Dr Arthi Thirumalai (10:51):

It’s so important to pay attention to packaging. And most packages will now have how much added sugar is there, and how much total sugars are there. So it’s just important to pay attention to those.

Dr Pelman (11:03):

So we want to control the issues with high blood pressure to prevent stroke and heart attack, improve cardiac function, longevity. So if you think you’re at risk and you’re listening to this, go get checked. Well, let’s move on to diabetes, a very common condition. And people get an idea that, aren’t there two forms of diabetes?

Dr Arthi Thirumalai (11:26):

Actually, a very good question. So there are more than two forms of diabetes, but there are two large buckets of diabetes. One is auto-immune diabetes. And the other is the form that’s caused by insulin resistance, there is a small third category that is not related to either of these two, but they’re very rare. So most likely a physician will think about that if the, if it applies in that situation, the first one which is type one, or the autoimmune diabetes, is due to auto antibodies. Your immune system makes them and then they go and attack beta cells, which are small cells inside the pancreas that are normally supposed to make insulin. And this used to be thought of as the “juvenile version” of diabetes where children were diagnosed. But what we’re seeing more and more is that people can get diagnosed at any age with this condition.

What Is Type 1 Diabetes? | CDC

Dr Arthi Thirumalai (12:12):

I have a patient who was diagnosed at the age of 52 with type one diabetes. But the point is that the mechanism is the destruction of the ability to make insulin. So these people don’t make enough insulin of their own. And the primary treatment for this is with insulin. Type two diabetes the problem is a little different. So the problem here is that they’re making insulin, but the tissues that respond to insulin are not responding the right way. For example, the liver, the muscle, and the fat cells are the main tissues we think of as responding to insulin. And in terms of response, what they’re really doing is taking up the glucose that you make from absorption of food, and then disposing it in the right way. And if you’re not able to dispose of that glucose properly, your blood sugar goes up. And so this is considered a problem of insulin resistance. It is definitely linked, to a great amount, with obesity and being overweight. Having said that there were several people who are obese, but do not have diabetes. And there are several people who have severe insulin resistance but are not overweight. So it isn’t an absolute connection, but there is definitely a correlation between.

Dr Pelman (13:12):

Now recognizing diabetes is important because of its effect on heart disease and general health.

Dr Arthi Thirumalai (13:17):

Actually heart diseases, and the thing is that we worry the most about it because diabetes is actually considered as equivalent to kidney disease, or Alzheimer’s in terms of overall risk of death. But it is the single biggest risk factor for heart disease, which is the leading cause of death. And so it’s important to think about diabetes control from a heart disease perspective. But again, there’s also other complications like kidney disease, chronic kidney disease, diabetes cause complications in terms of nerve damage. So people get neuropathies and pain in their hands and feet. People can also get erectile dysfunction from neuropathy. And so diabetic neuropathy is one of the leading causes of erectile dysfunction in men. And then there’s also retinal damage. So eye changes that can happen from diabetes. And so it’s very important to control diabetes,

Speaker 2 (14:03):

And the endothelial dysfunction, the small vessel dysfunction from diabetes, it’s not been checked and treated in run-on causes and contributes to the erectile dysfunction, besides the neuropathy. So good motivator for the guys if we want to maintain erections.

Dr Arthi Thirumalai(14:21):

Yep. Absolutely get checked. And we’re also realizing more and more that diabetes contributes also to poor bone health. And this is again true for older men because as you age bone loss is a real thing and men are not always going to get checked for bone loss or osteoporosis like women are. And so if they have uncontrolled diabetes or have lived with diabetes for several decades, it puts them at risk for it as well.

Dr Pelman (14:42):

So we’ve spoken about the auto-immune and then insulin resistance. Now, somebody, before we go to treatment, who hasn’t been good about going and getting checked, what symptoms might they have?

Dr Arthi Thirumalai (14:56):

So type one diabetes very rarely presents sort of insidiously, it’s usually associated with symptoms. The symptoms that they can experience are increased thirst, increased urination, increased appetite and weight loss. So those are the ones we typically experience. People can also present with an acute infection and then get diagnosed with type one diabetes or just a severe crisis called diabetic ketoacidosis, where they end up in the hospital with a lot of nausea and vomiting and abdominal pain. Type two diabetes, on the other hand, can be very sneaky. It can be lingering for months and months or years, even where people have no symptoms at all. Sometimes people will ignore subtle symptoms like, “oh, my vision got blurry after I ate that big meal and then it went away,” but those can be some subtle symptoms that people can experience. And also the nerve pain, neuropathy can be something that can happen acutely, and people will feel tingling or numbness in their feet or hands that can get better. And again, it get worse over time. And so they might ignore it, but those would be symptoms to watch for and get screened for diabetes. 

Dr Pelman (16:01):

So the thirsts and excessive urination that comes on. “Gee, why am I so thirsty all the time?” Now, if somebody says, why? I go to my doctor once a year for a physical, we would assume that most people would have a hemoglobin A1C as a screening test. 

Dr Arthi Thirumalai (16:15):

I think having said that, I have seen that not all primary care doctors will utilize a hemoglobin A1C. A lot of them will do the fasting glucose. I think if your fasting glucose is completely normal, it’s reasonable. If you don’t have a strong family history of diabetes, just use that test. But if you have a strong family history of type two diabetes or the fasting glucose is creeping up over time, and it was very close to that 100 mark that you should really get screened with a hemoglobin A1C. The other group of people that I would recommend to hemoglobin A1C are people who have other medical problems like thyroid disease or kidney disease and where you might be missing the picture with just that one glucose measurement. So you just want to make sure that you’re checking everything. 

Dr Pelman (16:58):

And so then someone is diagnosed, what are the treatment options for them?

Dr Arthi Thirumalai (17:02):

So the world of type one diabetes or auto-immune debt diabetes is still largely insulin dependent. So most people will only be treated with insulin over their entire lifetime. There is a role of some of the other newer agents, but it’s really not FDA approved yet, and so it’s more exploratory in terms of treatment. In type two diabetes, on the other hand, we’ve gone from Metformin and a couple of drugs like glipizide, glimepiride, and insulin to 15 new drugs getting headed in the last 15 years or so. So there’s a lot of newer medications, the focus being either weight reduction or reduction of cardiovascular disease or prevention of progression of chronic kidney disease. So there are a lot of new medications. And typically what a doctor will do is start you. I said, on lifestyle modification and Metformin therapy, and if you’re unable to achieve your target glucose control with that, then they will add on a second agent, which can be anyone of a category of drugs called SGLT2 inhibitors, which are drugs like Jardiance, Farxiga, or Invokana, or the injectable drugs like GLP1 receptor agonists, which are go by the names of Victoza, Trulicity or Zambak.

Dr Arthi Thirumalai (18:15):

And sometimes in some select individuals, they might add glipizide or glimepiride, or pioglitazone, those three drugs are less used in patients who can afford the other medications because they do unfortunately come with the side effect of weight gain, but they’re definitely very cost efficient. And so for people in whom that is a factor, those would be the second line agent. When adding all of these does not effectively control somebody’s glucose, that’s when we resort to insulin and insulin comes in two forms. One is a long-acting injection where you only inject once a day, and then there’s short acting versions, which you have to inject every time you’re eating. And that would sort of be the last step in the management of type two diabetes.

Dr Pelman (18:53):

Has data shown that if you treat the diabetes, you can reverse the condition, or you just stop them from progressing?

Dr Arthi Thirumalai (19:00):

That’s a terrific question. So I think it depends to some extent on the duration of the problems, for example, if somebody comes in with a month’s worth of nerve pain, like they’re feeling very numb in their toes, it’s tingly all the time, but it’s only been going on for a month. A lot of the times, if I can bring their blood glucose down, those symptoms will reverse. This is true for early retinal changes as well. Like if they have just a few changes in the retinal exam, those will reverse with better glucose control and even early changes in the kidneys, like small amounts of protein in the urine can be reversed effectively with intense glucose control. It’s the people that have been living with these symptoms for a long period of time that are less likely to see full reversal of those problems. It will still be improved to some extent with intense glucose control.

Dr Pelman (19:48):

So you’re going to still be controlling and at least halting progression, improving somebody’s lifespan.

Dr Arthi Thirumalai (19:57):

Absolutely, as well as morbidity. Like if somebody has really bad neuropathy, they put themselves at risk for infections of their toes or fingers and amputations. If somebody has really bad retinal problems, they put themselves at risk for blindness due to complications of that. And again, with kidney damage, of course, putting yourself at risk for chronic kidney disease and failure, and the complications that come from them. 

Dr Pelman (20:19):

Now, many people would be concerned about, “oh, I have to go to insulin right away.” First of all, there is a lot of support in most areas, have a diabetic clinic and support staff.

Dr Arthi Thirumalai (20:32):

Yep. Absolutely. So most even primary care clinics will usually have the ability to meet with a nutritionist and go over the basics of how you should structure your diet, what components to include in every meal, how to break down at the different meals the day and how much calorie restriction to implement. So that support definitely exists. And then when you go to specific diabetes clinics, there’s a lot of ancillary staff. You see a physician, you see pharmacists that help you gauge the different systems of drug coverage and what are your best options in terms of obtaining different drugs and are there programs that they can use to get discounted rates for medications, most diabetes clinics will also have certified diabetes educators that can help patients understand better how to manage their blood sugars. And you control that. 

Dr Pelman (21:19):

And most insurers are going to cover diabetic treatment, right?

Dr Arthi Thirumalai (21:22):

I think the cost of drug treatment is reducing, but it is still a problem. The population that tends to face a problem is obviously the Medicare group of people, as well as people whose private insurance is not offering very good prescription drug coverage, but that is improving rapidly over time. I hope it would improve faster, insulin coverage is still an issue in terms of cost. And the bigger concern is checking your blood sugar. The test drips tend to be expensive, but it is definitely something you can work with your physician on and see how to optimize it. 

Dr Pelman (21:56):

And if somebody says, “well, I’m listening and I don’t have a job at the moment, and I don’t have health insurance,” they shouldn’t not get taken care of.

Dr Arthi Thirumalai (22:03):

In fact, if you actually don’t have a job and your income is lower than a certain limit, most clinics will be able to get you on some sort of financial aid system that will help you get the supplies you need.

Dr Pelman

Because it’s not going to go away.

Dr Arthi Thirumalai

Nope

Dr Pelman (22:14):

You are just going to get sicker and have more issues. So we’ve explored diabetes. Pre-diabetes what else could we look at as a common endocrine issue?

Dr Arthi Thirumalai (22:29):

So thyroid disease, I think tends to get missed in men because the symptoms of thyroid disease can be very similar to that of low testosterone. And when men experience these symptoms, the first place their mind goes to is low testosterone because it’s advertised so much. And then they might go and specifically ask their primary care doctor to check their testosterone level but checking the thyroid might get missed. So the symptoms of thyroid disease can be one of two directions, too little thyroid hormone can present with symptoms of fatigue, feeling very sleepy, feeling tired all the time. It can have cold intolerance, which is, they feel cold all the time. They can also experience constipation and weight gain and a lot of dry skin. So if anybody experiences those symptoms, they should definitely ask their primary care doctor to check their thyroid level. On the other extreme is also hyperthyroidism, which is too much thyroid hormone, which can present with a sort of this burst of energy, unable to fall asleep at night. They can feel warm all the time and flushed. They can feel palpitations. They could feel shaky or jittery or can feel extremely anxious and also lose weight. So if people experience those symptoms again, important to ask your primary care doctor to check your thyroid level.

Dr Pelman (23:42):

And when we assume that for a general yearly physical, at least some thyroid is getting screened. 

Dr Arthi Thirumalai (23:47):

That’s a very good question. So the USPSTF, which is the United States Preventive Services Task Force does not recommend screening routinely for thyroid dysfunction. And the vast majority of primary care doctors are probably going to follow those guidelines and not be routinely screening for thyroid disease. However, if you look at the Endocrine Bodies, the American Thyroid Association actually recommends screening. Thyroid levels are a TSH in everybody over the age of 35 and the American Association of Clinical Endocrinologists or AACE recommend screening older people, without an emphasis on what age to start at. I think in general, my practice has been that anybody who is over the age of 65, I will screen them for thyroid disease, but anybody else who has other risk factors, like if they have autoimmune conditions like type one diabetes or vitiligo or Crohn’s disease or celiac disease, those were people I would start screening even earlier around age 35. And I would screen them every five years.

Dr Pelman (24:44):

So thyroid disease is somewhat age-related. 

Dr Arthi Thirumalai (24:47):

Is age-related as well as it is auto immune. So if it runs in your family, you are more likely to get it. If you have another auto-immune disease, you’re more likely to get it. And the older you get, the more likely you are to get it.

Dr Pelman (24:58):

And then treatment is if you’re hypo, you get thyroid replacement?

Dr Arthi Thirumalai (25:03):

Yeah, it’s sort of like taking a vitamin, it’s a pill that you take every day. The dose could be very variable depending on the cause of low thyroid function and the degree of it. And if you have too much thyroid hormone that can be treated in one of two ways, one is either pills or there’s also something called radioactive iodine therapy, where they give you sort of a radio labeled iodine that you swallow as a pill. And it just kills off the cells in the thyroid gland that are making too much thyroid hormone.

Dr Pelman (25:29):

And then you just go and replace it.

Dr Arthi Thirumalai (25:32):

It depends on the cause. And the vast majority will end up on some replacement of thyroid hormone and some people get away without any, it’s well tolerated. It’s very well tolerated. And the doses that are used for treatment of hyperthyroidism, there’s really no concern that it would result in cancer or anything, very treatable.

Dr Pelman (25:49):

 Good to find out about. And if left untreated?

Dr Arthi Thirumalai (25:54):

That’s an important point, especially as you get older. So untreated hyperthyroidism, even if that is too much thyroid hormone, which is not even to the level that the blood tests are, frankly abnormal, they might just be subtly abnormal. That has actually been shown to increase your risk of both osteoporosis and atrial fibrillation in people over the age of 50. So the recommendation is that if you’re over 50 years of age and you have a low TSH, even with a normal free T4, which is the thyroid hormone level, the recommendation is to consider treatment in anybody over the age of 50.

Dr Pelman (26:28):

Nice. Now we’ve talked about pre-diabetes diabetes, thyroid, what else? 

Dr Arthi Thirumalai (26:35):

So osteoporosis Is the other thing that I think we should discuss, because I think men tend to, again, not think about their bones as much. They don’t worry that they’re going to have a fracture, whereas it’s so drilled into women that, you know, once you go through menopause, you’re at risk for bone loss and you need to check on this. But the reality is while the risk of osteoporosis is lower in men than in women, it isn’t zero. And so, especially as you get older, once you’re over the age of 80, the risk goes up considerably. And as people are living longer and longer, over 80 is a significant chunk of the population. And having osteoporosis puts you at risk for having a fracture. And the fracture could be from something as simple as slipping on something and falling down and breaking your hip.

Dr Arthi Thirumalai (27:20):

And the problem with all of this is that when you have a fracture late in life, it puts you at higher risk of death from that fracture and recovering from it. And so I think it’s important to think about the people that I screened for osteoporosis, the men that I screen for it would include anybody who’s on steroids like prednisone for long periods of time. Anybody who’s on it for more than three months really should be screened for osteoporosis and treated for it. So I’m talking people with rheumatoid arthritis or Sjogren’s disease or lupus, anybody with diabetes, I would screen for osteoporosis in their later life, because it does increase your risk of low bone density. And then men who have no testosterone, I would screen for osteoporosis. There are some people who are on normal doses of steroids, like hydrocortisone or things like Cushing’s disease, or have had pituitary surgery or traumatic brain injury and are on replacement.

Dr Arthi Thirumalai (28:11):

Even those people that we think we’re giving normal levels of steroids to, I would still screen for osteoporosis people with celiac disease or any absorption disorders. Treatment for osteoporosis, it usually consists of drugs that are either an infusion that you take once a year or pills that you take once a week. Again, very effective drugs that have been shown to reduce your risk of fractures considerably the side effects of those, again, tend to get hyped online, but really they’re mostly very well tolerated. And the risks are not really something to worry about. 

Dr Pelman (28:46):

And I think I recall that if we maintain muscle mass and movement helps maintain our bone health.

Dr Arthi Thirumalai (28:51):

Absolutely. In fact, if you look at the recommendations for daily activity, it includes not just cardio, but also resistance training. And that’s extremely important for the bones because the bones don’t care so much about what the heart is pumping, but what the muscles around the bones are doing. And so it’s very important to include weight training as part of your workout regimen, especially the older you get. There’s actually studies that have looked at CT scans of people’s muscles as they age, and the muscle competency goes down drastically as you age. So the loss of muscle is very real and it’s definitely something to pay attention to. 

Speaker 2 (29:27):

Yeah. I remember a Stanford gerontologist who coined something, a term “frailty scale” and people who are sedentary are at a very steep slope into frailty.  And so if you keep moving and maintain some muscle mass, you’re going to be much better off. But let’s talk about testosterone. Now we did an episode on testosterone, but from an endocrinologist point of view, what would you contribute on testosterone?

Dr Arthi Thirumalai(29:57):

So I think most people, most men, are now aware of the existence of low testosterone and the need to treat it. And so they’re watchful for the symptoms of low testosterone, but I think what people may not be quite aware of is the risk of developing low testosterone when you’re on certain medications. And the two that come to mind for me are chronic steroids like prednisone and chronic narcotic therapy or opiates. With how many people we now have on chronic narcotic prescriptions, as have all sorts of pain syndromes, the prevalence of hypogonadism in these people is going up. And we don’t always look to screen for low testosterone in these people. A lot of the times their symptoms might be missed or overlooked. And so it’s important to look at these individuals and screen them for a low testosterone. The other group that I think is important is any gentleman who presents with a fracture without a clear mechanism, or a clear cause of trauma. Like, as I said, you slipped and fell down, broke her wrist or broke his ankle. I think those are people that we should consider screening for osteoporosis as well as low testosterone, because low testosterone is one of the single biggest risk factors for bone loss in men. And so they need to be screened for the presence of low testosterone as well. 

Dr Pelman (31:12):

And then we go and replace and monitor, but there really are criteria or replacements clinical and laboratory, correct?

Dr Arthi Thirumalai (31:21):

Yes. And I think that one of the problems is a lot of people come in with the idea, “but this is low for me.” And “shouldn’t this be more in the middle or the upper end of normal?” And the reality is that’s actually not true. So unless you’ve happened to check your testosterone level throughout your life, and you know, this is definitely lower than your baseline. There’s no such thing as “this is low for me.” I think it’s really correlation of low testosterone as well as the symptoms that makes the most sense to make this diagnosis. As you mentioned earlier, I do a lot of research in andrology. So we take a lot of healthy men in the age range of 18 to 30, who participate in our trials. And a lot of them have testosterone levels that are about 200 or 250 nanograms per deciliter, which would be considered low in a lot of cases, but these men are healthy and fine and virile and have no symptoms whatsoever. So I think this is something that is important for people to remember that as the assays get more and more refined, the lab value, cutoffs.

Dr Pelman (32:18):

Other endocrine issues are more rare concerning pituitary tumors and anything that you want to go over in those? 

Dr Arthi Thirumalai (32:28):

And, you know, I would say that whenever you see massive changes in your body in terms of weight distribution, or you’ve had massive weight gain, that’s something to probably at least talk to your doctor about. And if your primary care doctor feels it’s important for you to meet with an endocrinologist, because you can get certain hormone excess, like excess growth hormone, or excess cortisol production that could present with changes like that. Anybody that is presenting to the hospital with inability to, you know, resolve an infection without the need of extra lots of medications in an ICU state should be concerned about not enough cortisol. Those are very rare disorders though. I don’t think these are really something people need to have in the back of their mind on a day to day.

Dr Pelman (33:09):

If somebody, has an abrupt change, when the libido in a male who says, “I used to be really, really interested in sex and that just changed,” that there certainly can be screened. Correct?

Dr Arthi Thirumalai (33:21):

Absolutely. Yeah. Any rapid change that you’re noticing is definitely worth bringing up to your doctor.

Dr Pelman (33:27):

Right, and then since it’s an interest of yours, talk about male contraception.

Dr Arthi Thirumalai (33:34):

So, the joke in our group is that we’ve always been 5 to 10 years away from the next birth control method for men. The world of male contraception is very interesting. My personal area focuses just hormonal male contraception, where we try to give men testosterone like agents in the form of either an injection or a pill or a patch or a gel that they can apply. And then what it does is it gets absorbed into their blood and suppresses the production of hormones from the brain that then tell the testicles to stop making testosterone and sperm. But by virtue of this drug being present in their blood, it will act in place of testosterone and make them feel completely normal. This field has been researched over the last 40 to 50 years now. And though we have a lot of regimens that work effectively in the vast majority of men.

Dr Arthi Thirumalai (34:19):

The problem we’ve run into is making a regimen that is easy for men to use and also completely safe in terms of both side effects, as well as what we would be considered safe in terms of changes in blood pressure or cholesterol changes. Currently, our group is actually working on a few different formulations that are novel androgens. So those are modifications of testosterone that have been made. One of them is called dimethandrolone undecanoate. And the other is called 11-beta-MNTDC, both of these are being investigated as pills. So we’re hoping that we could make the next male pill, but they’re very early in the stages of development. They’ve pretty much just done phase one trials at this point, but it’s promising in that they definitely suppress the hormones to the levels that we want to see. And they’ve very well tolerated by the men that took them.

Dr Arthi Thirumalai (35:06):

We obviously need to see longer studies before they go anywhere. But the agent that is actually furthest ahead right now is a combination gel. So it’s a gel that consists of testosterone, which is an FDA approved drug, but also has an investigational product called nestorone, which is a progesterone like agent. This is actually used in female birth control rings. It’s never been used in men in long studies. There have been sort of six month long studies that we have done in men that have shown that the drug works very well. It brings sperm counts down zero. So right now there is an efficacy study going on, which is recruiting couples, where they will only use this drug as their birth control method. And we’ll see how effective it is at preventing pregnancies. This is an ongoing study at the University of Washington as well as multiple other sites throughout the world. We’re hoping to complete this study within the next year or at the most two, and then show we should have results shortly. 

Dr Pelman (36:02):

And then you brought up an interesting point on testosterone is a birth control, but for young men who are listening, want to make certain, they don’t go on testosterone if they want to be fertile. Correct?

Dr Arthi Thirumalai (36:13):

It isn’t that the chances are zero, but you diminish your chance of being able to successfully father a pregnancy considerably with testosterone therapy. So that is an important discussion to have if you require testosterone therapy, because there are alternate agents that can be used in that.

Dr Pelman (36:28):

Absolutely. Well, I remind our audience of resources that are available. So let’s go back to diabetes.

Dr Arthi Thirumalai (36:36):

The American Diabetes Association website usually does have a lot of resources that you can be guided towards. The American Association of Clinical Endocrinologists also has a lot of resources that you can go to. So that’s the ADA and the AACE websites, but, Facebook has actually become a very good place. I have a lot of patients, especially with type one diabetes who tell me that they find all these different groups about how to manage type one diabetes, how to use glucose monitors and things more efficiently, how to use their insulin pump. And I think these are amazing resources for people living with these problems. Nowadays, if you have type one diabetes, there’s a lot of research studies that are ongoing about diabetes technology, clinical trials.gov is a very good source to find what trials are ongoing and definitely in Seattle, multiple locations that are doing a lot of research. There’s also a lot of type one diabetes research that is in relatives of type one diabetes. So those who do not yet have diabetes but are at risk for getting diabetes. And so the Benaroya Research Institute or the BRI is doing a lot of those trials.

Home | ADA (diabetes.org)

| American Association of Clinical Endocrinology (aace.com)

Dr Pelman (37:37):

Excellent. Well, Dr Thirumalai, appreciate your time. This was wonderful. Thank you very much.

Dr Pelman :

This completes another podcast chapter of the Washington State Urology Societies: “The Original Guide to Men’s Health.” This is Dr. Richard Pelman reminding you to take care of yourself. The Washington State Urology Society wishes to thank all contributors, who volunteered their time and knowledge. The information presented is the opinion of the speakers. The Society also wishes to thank Sean Fox for his invaluable technical assistance, music theme “San Juan Bells” written and performed by Dr. Dave Whiting, the podcast is the property of the Washington State Urology Society.  Reproduction and use without the express consent of the Society is strictly prohibited. For more information about men’s health visit wsus.org or visit your physician or care provider.

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