Mel Robbins Podcast: w/ Dr. Michael Eisenberg on Men’s Health (Transcript) 

So when you were saying 10%, 20%, 30%, and then you were going 40, 50, 60, were you basically saying that your testosterone kicks in for puberty and is it relatively stable until you hit your 40s or 50s and then you start to slowly decline? Is that what’s happening and that’s normal?

DR. MICHAEL EISENBERG: (00:05:44 – 00:05:50): It is normal. I think it peaks somewhere between 20 to 30, and then it goes down a little bit. So it’s not usually kind of a steep drop-off.

MEL ROBBINS: (00:05:50 – 00:05:50): Okay.

DR. MICHAEL EISENBERG: (00:05:50 – 00:06:01): But it does slowly go down, and there’s different factors. Age is one, but also our metabolic health, adiposity, like how much weight we have. I mean, all these things will impact it.

Signs and Symptoms of Low Testosterone

MEL ROBBINS: (00:06:01 – 00:06:05): What are the signs or symptoms that you may have low testosterone?

DR. MICHAEL EISENBERG: (00:06:05 – 00:06:50): So I would say they’re sort of quality of life things. So low energy level, low sex drive. Poor mood, poor sleep, poor concentration. I will certainly admit that these are somewhat nonspecific, but if you’re having these, you notice these a little bit more, they’re bothering you, your partner notices them, I think certainly get screened for low testosterone.

And then again, some more health metrics. So low blood counts, so-called anemia. I think that’s something that can be a sign. If you’re found to have low bone mineral density with no other explanation, get screened. And then again, if you have a history of chemotherapy, radiation to the testicles specifically.

But the symptoms that we’ll see are, again, these sort of low energy level. Those are typically the things— sexual dysfunction, erectile dysfunction— those are things that we want to think, “Does this guy have low testosterone? Let’s check it.”

MEL ROBBINS: (00:06:50 – 00:07:30): Well, I’m thinking about it from the partner standpoint, because as you’re listing those things off, I was kind of going like, okay, check, check, check. At least not right now, but certainly about 5 years ago. Chris is very open about the fact that he was struggling with depression. And just was not himself, very low energy, very shut down, very low sex drive. He wasn’t irritable but just seemed down.

And so it’s helpful to hear, even though those are sort of general things that you may see as a change in your partner, but it’s helpful to understand that they can point to something deeper.

DR. MICHAEL EISENBERG: (00:07:31 – 00:07:32): Right, exactly.

MEL ROBBINS: (00:07:32 – 00:07:37): Do you often see patients alone or do they— do the spouses drag them in?

DR. MICHAEL EISENBERG: (00:07:38 – 00:08:05): I’m always so excited to see the spouses. I’ll say the majority of men come alone, but anytime I see the spouse, whether it be for testosterone-related discussions, whether it be for sexual dysfunction, fertility, I always shake the hand of the spouse and say, “I’m so glad you’re here. This is a team sport.”

And so then I think that level of engagement, I think, is very helpful. And I think I know that the wife is going to be, or the partner is going to be a huge advocate that’s going to help us get through this. And be more likely it will get treatment success.

Benefits of Testosterone Therapy

MEL ROBBINS: (00:08:06 – 00:08:09): Well, Dr. Eisenberg, what are the benefits of going on testosterone?

DR. MICHAEL EISENBERG: (00:08:10 – 00:08:53): So it can help with energy level, vitality. I think it can help with some things and not others, but we do see that consistently. We see improvement in sexual function. So again, such a powerful aspect of quality of life. But it can help with libido, it can help with erectile function. So those are all things good, penile health, keeping that.

It can help with bone mineral density. Men that have low blood counts, it can help with that. It can improve lean body mass. It can improve metabolic health. There have been some studies that followed men that were kind of pre-diabetic, and those men that were on testosterone had a lower risk of developing diabetes. So it can kind of maintain, again, longevity in that regard as well. So I think also sometimes men talk about increasing their motivation, making them more active.

MEL ROBBINS: (00:08:54 – 00:09:10): And what about some of the things related to mood? Or related to energy and the things that we see in the negative in our partners, and we’re like, wow, you don’t seem like yourself. Do you see a boost in mood and muscle development and just all the other things?

DR. MICHAEL EISENBERG: (00:09:10 – 00:09:52): Yeah, so certainly it can help with mood. I think certainly patients that get a good response definitely do, they do talk about that. People talk about having sort of better cognitive load as well.

There’s different ways that we give testosterone, and so some men come to the clinic every few months for basically a shot or some new instillation of whatever treatment we’re doing. And they say that, “I know that I needed it because I can’t sleep as well, I can’t focus at work.” And then as soon as they get on it, they see that improvement again. These are men with low testosterone, so this is the reason they’re having these symptoms. And so we see that.

And also just lean body mass can help with strength, all those things. We do have measurable improvements in patients that I see, but also we’ve done very good trials that do support this improvement.

When and How to Get Your Testosterone Checked

MEL ROBBINS: (00:09:53 – 00:10:29): I don’t know if this is something that happens in your 50s, and I don’t know how old you are, Doc, but I notice that when you hit your 50s, I’m going to be 58 in a couple of weeks. Suddenly people start talking about testosterone. It starts on walks that women have together as they’re talking about their partners. But I’ve noticed more and more people talking about it. And one of the first things that I was really wondering about is how often should men get their testosterone checked and at what age?

DR. MICHAEL EISENBERG: (00:10:30 – 00:11:26): Yeah, there’s many different reasons that we give it. Some men— they don’t produce normal testosterone because of some medical condition. So, for example, some men with testicular cancer lose one or both testicles. The levels can go down. If there’s a history of chemotherapy, that can affect it. Some men with anemia, the very low blood counts, we worry about that. Men with low bone mineral density, that’s another warning sign.

So if you’re having symptoms of low testosterone, so again, energy level, low energy level, low sex drive, mood, sleep, erectile dysfunction, these are also reasons that sort of clue you in. Could this be testosterone? Could this be hormonal? And then you can have it checked.

So just like you go to your doctor and getting checked for blood pressure, cholesterol, blood sugar, I think it’s a simple test to add on because our levels do change a lot. So getting checked, I think, sooner rather than later is a reasonable thing to do. Probably starting maybe 40, 50. But again, if you have some of these other things, you want to check much, much earlier.

MEL ROBBINS: (00:11:26 – 00:11:29): And is it just a blood draw or how do they check testosterone?

DR. MICHAEL EISENBERG: (00:11:29 – 00:11:32): That’s exactly right. It’s just a blood draw. So our levels do change based on time of day.

MEL ROBBINS: (00:11:33 – 00:11:33): Okay.

DR. MICHAEL EISENBERG: (00:11:33 – 00:11:52): So usually we check it in the morning, ideally in the fasted state. Although, honestly, in my clinic, I’m not so particular about that, but I say before 9 or 10 in the morning. And then we usually also want to repeat it. So if we get one low level, we’ll do another one. And if those are both confirmatory and also symptoms, then we talk about supplementation.

Why Men Are Embarrassed to Talk About Testosterone

MEL ROBBINS: (00:11:52 – 00:12:14): The second you said the thing about testicular cancer, I’m like, wait a minute, my husband had a hernia surgery related to— I don’t know the technical name— the balls. So he only has one ball. And I’m like, whoa, that might actually be the reason why he has low testosterone. Dr. Eisenberg, why are we so embarrassed to talk about this?

DR. MICHAEL EISENBERG: (00:12:14 – 00:12:58): I don’t know. I think that it’s gotten a lot better. And I think, to your point, I think people are more and more comfortable talking about testosterone, just like 20 years ago when Viagra came on the market for erectile dysfunction. I think that made people a lot more comfortable. And I think there are spokesmen now. People are very open about being on testosterone, all the benefits.

But I think there’s also just this feeling of shame a little bit and guilt, something, sort of concerns about their own masculinity, that if their body can’t produce enough, there’s something wrong. And that’s absolutely not the case. There’s a lot we can do. It’s very common to have these lower numbers, and treatment is certainly underway.

But I was saying, with— if you lose a testicle, oftentimes the other one is able to compensate. It’s able to grow again, depending on what happened and when it happened.

MEL ROBBINS: (00:12:58 – 00:12:59): It’s like a super testicle.

DR. MICHAEL EISENBERG: (00:12:59 – 00:13:06): Yeah. So some men with one testicle do just fine, but other men— obviously it’s a paired organ, so ideally there’s both. And if there’s only one, sometimes it’s not—

MEL ROBBINS: (00:13:06 – 00:13:08): What does that mean, it’s a paired organ?

DR. MICHAEL EISENBERG: (00:13:08 – 00:13:26): Well, there’s 2 of them, just like we have 2 eyes. Yep. 2 lungs, kidneys, so we have 2 testicles. It’s obviously super fundamental for our species, right? It’s involved in reproduction. But testosterone production is also such a fundamental role for the testicle in making us men. So that’s some redundancy in the system for that reason.

MEL ROBBINS: (00:13:26 – 00:13:27): I’m going to sound like a real idiot.

DR. MICHAEL EISENBERG: (00:13:27 – 00:13:27): Mhm.

MEL ROBBINS: (00:13:28 – 00:13:36): I am almost embarrassed to ask you this question. Is testosterone produced in the testicles?

DR. MICHAEL EISENBERG: (00:13:36 – 00:13:37): Oh, primarily, yes.

MEL ROBBINS: (00:13:37 – 00:13:38): Okay.

DR. MICHAEL EISENBERG: (00:13:38 – 00:13:47): So the testicles produce most of the testosterone. Our adrenal glands, which are these little endocrine glands that produce different hormones, sit just on top of the kidneys. They produce a tiny fraction.

MEL ROBBINS: (00:13:47 – 00:13:48): Okay.

DR. MICHAEL EISENBERG: (00:13:48 – 00:13:51): But most of it, 90% or more, is produced in the testicles.

How Poor Sleep Affects Testosterone

MEL ROBBINS: (00:13:51 – 00:14:12): Wow. I’d love to ask a few questions about how specific things can impact your levels of testosterone. How does poor sleep impact your testosterone levels? Here we go. Okay, he’s got a— you’ve got a sign. Oh cool, poor sleep.

DR. MICHAEL EISENBERG: (00:14:12 – 00:15:06): Poor sleep. So poor sleep affects testosterone through a few mechanisms, but primarily it really just blunts our normal kind of feedback. So the way that we produce testosterone is the brain sends signals to the testicle, and it kind of senses when there’s enough testosterone. So there’s this elaborate feedback loop, and poor sleep really blunts hormonal function just broadly, but certainly involving testosterone production.

And so without this sort of normal rhythm that we see, higher levels in the morning and kind of gradually calming down as we go to sleep, without that, basically there’s just a general suppression of testosterone. So that’s one of the main mechanisms.

Certainly men that are very sleep deprived, we see that. But even if you’re just not getting enough sleep on a regular basis, ideally 7 to 9 hours, but these men that say they only need a little or they’re 4 to 5 hours a night, we do see that suppression. Shift work, all these things that disturb just normal circadian rhythm can affect it.

MEL ROBBINS: (00:15:07 – 00:15:13): Do you see any kind of connection with somebody who may struggle with sleep apnea and the low testosterone levels?

DR. MICHAEL EISENBERG: (00:15:13 – 00:15:26): Absolutely. Absolutely. And in some ways it can kind of— it sort of feeds back on itself because low testosterone is thought to be associated with sleep apnea and sleep apnea leads to low testosterone. So in some ways it’s sort of circular. Yeah, but we definitely see that association.

How Excess Body Fat Affects Testosterone

MEL ROBBINS: (00:15:27 – 00:15:36): It’s interesting and very helpful. How does excess body fat impact your testosterone levels, Dr. Eisenberg? All right.

DR. MICHAEL EISENBERG: (00:15:38 – 00:16:36): So testosterone is made in the testicle, and then in the peripheral tissue, some of it is converted to estradiol. And that’s one of the main ways that our body regulates testosterone production, because estradiol is— think of it as a female hormone, but certainly men have a lot. It’s very important for our function as well, for bone health. For sexual health, but it also impacts primarily this feedback mechanism that our body uses to regulate testosterone.

And a lot of that conversion of testosterone to estradiol happens in fatty tissue. So the more fatty tissue there is, the more conversion to estradiol. So you kind of see this as sort of a leech or pulling out of testosterone from circulation. So if we’re too big, it can affect that.

And also excess body weight can be insulation. Testicles are outside the body because they need to be a little cooler. Mostly it’s for sperm production, but it can also affect hormonal health as well. So having excess body weight, this poor metabolic state impacts just normal hormonal regulation. So it can kind of blunt the normal response that we see for normal production.

MEL ROBBINS: (00:16:36 – 00:16:48): If you see a patient go on one of these life-changing GLP-1 medications and they start to lose a lot of weight, do you typically see somebody’s testosterone levels rise when that happens?

DR. MICHAEL EISENBERG: (00:16:48 – 00:17:13): Anecdotally, I have seen that. I think losing body weight from caloric restriction, I think, not if you starve yourself, but if you— good diet, exercise, if we see that and they lose weight, we can also see improvements. Certainly GLP-1s have seen that. Bariatric surgery reliably increases testosterone. So I think any way you can lose weight, kind of getting an ideal body weight, I think that’s really going to be crucial. Anything that’s good for your heart, it’s good for testosterone.

How Chronic Stress Affects Testosterone

MEL ROBBINS: (00:17:13 – 00:17:29): That makes a lot of sense. How does chronic stress— a lot of people— the number one word that we’re seeing right now, Dr. Eisenberg, from our audience globally is exhausted. And I’d love to know, how does chronic stress impact testosterone levels?

DR. MICHAEL EISENBERG: (00:17:30 – 00:17:38): Yeah, we get stressed from so many things in our life, right? Work, home, everything. And spouses. Yes.

MEL ROBBINS: (00:17:38 – 00:17:43): Well, I’m speaking for myself. I feel like I really need to lift Chris up now.

DR. MICHAEL EISENBERG: (00:17:43 – 00:18:05): Yeah, I don’t want to get in trouble, but yeah. If there’s too much stress, we get this cortisol release in our body, and that basically just blunts the normal testosterone response. So again, it’s obviously easier to say more sleep, less stress, for example. But if you take that to heart, if there— there’s ways that you can do that to try and lower the stress in your life, you can see improvements in testosterone levels.

MEL ROBBINS: (00:18:05 – 00:18:33): I think it’s really interesting that you use the word “blunt,” that you can be doing all the right things, getting good sleep, moving your body. You have a healthy body weight. But if you’re under chronic stress from a job or caregiving or you’re going through something very stressful in your life, that the rise in cortisol and that fight or flight blunts the testosterone that’s there. Can you explain a little bit more about that?

DR. MICHAEL EISENBERG: (00:18:34 – 00:18:57): Your body is just prioritizing survival, right? And so if there’s something else going on and wants you to survive, like if a tiger comes around, nothing else matters. You need to get out of there. And so I think we see the same thing with testosterone, hormonal health, reproductive health. It’s just sort of deprioritized. So you become in survival mode more than longevity mode. And so that’s exactly the response that we would expect.

MEL ROBBINS: (00:18:57 – 00:19:41): Well, it’s helpful to hear from a doctor. And the reason why is that I think a lot of men really feel a lot of pressure to be providing, to be taking care of their partner, their family, to be earning money, to be out in the world and be successful. And whether that’s societal or self-imposed or both, that men are under a lot more pressure and stress than I think a lot of us realize because a lot of them bear it more quietly.

I feel like since guys tend not to be that great at talking about the things that are really weighing on them, you’re the one that’s seeing how that can cause health conditions in somebody.

DR. MICHAEL EISENBERG: (00:19:41 – 00:20:23): Yeah, I mean, I think for these conditions we’re talking about, it’s often the first time they’ve ever gone to the doctor, the first time they’ve ever had really anything’s kind of caught up with them to some extent. Everything’s just sort of worked, right?

I mean, the patients that I see in Silicon Valley, Type A, they’ve been very, very successful, top jobs, everything is going really well. And here, all the sacrifices they’ve made in their health, getting little sleep, bearing this unbelievable stress for a new startup or what have you. Now they start to see some of these things fall apart— hormonal health, sexual health— and they feel guilty. They try and kind of rationalize it a little bit. But I can— taking a step back and just giving them sort of these actionable things that can be done to try and reset things, I think can be very powerful.

The Connection Between Depression and Testosterone

MEL ROBBINS: (00:20:23 – 00:20:54): It’s super helpful. I’m even thinking about some of my male relatives who are all in the cattle business, or farmers, or machinists, or long-haul drivers, or police officers, and just the stress of those jobs too that you bear. It’s interesting to really stop and consider how that’s having an impact on your hormone health and on all your sexual health. So I appreciate you explaining it in detail. Dr. Eisenberg, can you talk about the connection between depression and testosterone?

DR. MICHAEL EISENBERG: (00:21:00 – 00:21:52): So depression and low testosterone, I think, are very closely linked. And this is one where we think low testosterone itself can impair mood, but also depression itself can also impair testosterone production.

And so when we think about how that would happen, I think there’s a few mechanisms, but really primarily, again, it leads to the same sort of lack of ability of the body to respond to normal stresses and normal circadian rhythms. And it just sort of blunts that hypothalamic, which is a region in the brain that stimulates this other region called the pituitary, which then stimulates the testicle. So all that signaling is basically lost a little when these men have depression.

And the other thing I think to think about depression is a lot of times there are very effective treatments for it, but those themselves, some of these medications that we talk about, are also very impactful on testosterone, meaning they make it rise. They make it go down, unfortunately.

MEL ROBBINS: (00:21:52 – 00:21:57): Oh, no. So you may be treating the depression with a medication that sort of lifts the fog.

DR. MICHAEL EISENBERG: (00:21:57 – 00:21:58): Yeah.

MEL ROBBINS: (00:21:58 – 00:22:07): But at the same time, it’s lowering testosterone, which can continue to make you feel like you’re moving through sludge as you go through your day.

DR. MICHAEL EISENBERG: (00:22:08 – 00:22:10): Yeah. It can affect hormonal health and then sexual health as well.

MEL ROBBINS: (00:22:11 – 00:22:25): So it is— wow. So it’s important to understand that these things can coexist and that it’s important to realize that the treatments for one don’t necessarily take care of the other and vice versa.

DR. MICHAEL EISENBERG: (00:22:25 – 00:22:36): Right, exactly. So you should think about them in some ways independently. And so I have patients that do have depression, are on treatment for it, and then we’re also treating their low testosterone. And together, hopefully we can get them to a good place.

Alcohol and Testosterone

MEL ROBBINS: (00:22:37 – 00:22:44): Excellent. Super, super helpful. Let’s talk about the connection between alcohol and testosterone, Dr. Eisenberg.

DR. MICHAEL EISENBERG: (00:22:51 – 00:23:18): So alcohol also is associated with low testosterone. And what alcohol does really at every level is blunts the body’s response to the feedback of regulating normal levels. And then the signal going down to the testicle, the testicle’s ability to make testosterone, all those things are blunted by too much alcohol. So think moderation. If patients are telling you they drink a lot, it’s good to try and regulate. Some men say they have 5 drinks a night, 7 drinks a night, which is a lot. So, which is a lot. Yeah.

MEL ROBBINS: (00:23:19 – 00:23:28): Okay. That makes sense. So if— and you’ve seen that when people curb the drinking, the testosterone can rise, it can go back up.

DR. MICHAEL EISENBERG: (00:23:28 – 00:23:49): That’s exactly right. It’s never quite as easy as saying stop and they stop immediately. But gradually cutting down, getting in a program, I think we do see improvements for sure. And it’s— but I think also, beyond just testosterone, really, it’s going to improve their overall health. That level of substance abuse and alcohol dependence is going to have many, many impacts. And so they do feel better when they get through the other side.

Common Concerns About Starting Testosterone

DR. MICHAEL EISENBERG: (00:25:00 – 00:25:13): I think people are more and more comfortable talking about testosterone. 20 years ago, when Viagra came on the market for erectile dysfunction, I think that made people a lot more comfortable. There are spokesmen now. People are very open about being on testosterone, all the benefits.

MEL ROBBINS: (00:25:13 – 00:25:57): So guys that end up doing testosterone or going on testosterone, it’s literally like they’re in a multilevel marketing organization. They’re so passionate about it and wanting everybody to get on it. And I’ve been very surprised because my husband has been very resistant to even considering testosterone. He’s just started talking to doctors about it.

And so I would love to dig in a little bit to some of the things that at least he’s concerned about, because I’m sure a lot of people are concerned about it. I asked him, “What’s your concern about starting it based on what you know?” And he said that with injections, I don’t even understand what this means, Doctor.

DR. MICHAEL EISENBERG: (00:25:57 – 00:25:57): Okay.

MEL ROBBINS: (00:25:58 – 00:26:21): That with injections, “It’s a lot of oil intake for the next 30 years of my life.” Oil intake. And that the long-term effects of taking it for that long of a time have not been researched. Those were his 2 concerns: the long-term effect and that it’s a lot of— I don’t know what oil intake. Maybe that was a mistake. Is it oil?

DR. MICHAEL EISENBERG: (00:26:21 – 00:26:59): It is oil. So the injectable testosterone— no, he’s exactly right— is an oil-based medicine. So you basically inject kind of this oil in the muscle and you can do it in different ways. And I usually teach men to do it in their thigh. If they have a partner, can do it in the buttocks. But it is an injection that’s done on a regular basis.

For injections, the standard is probably doing every 2 weeks. So you do kind of get this peaks and valleys. Some men feel that. So sometimes we shorten the duration. They do it once or twice a week. But testosterone therapy has been done for decades and decades. It’s very, very safe. Now, there’s different ways to give testosterone. So some men certainly don’t like the idea of injections.

MEL ROBBINS: (00:26:59 – 00:27:00): Mm-hmm.

DR. MICHAEL EISENBERG: (00:27:00 – 00:27:18): So there are longer acting injections that can be done over a few months. So that may be more appealing for him. There’s gels that you could put on every day. So again, there’s no needle at all. There’s different testosterone pellets that can be put underneath, usually under the skin in the hip area, classically where it’s done. So again, there’s not any needles with that.

MEL ROBBINS: (00:27:18 – 00:27:40): Has the pellets been tested by the FDA? Because I know that we’ve had medical experts come on and talk, at least with when it comes to women’s hormones, there’s been several medical experts that have come on to say they don’t like the pellets because they haven’t been approved by the FDA. But that was a couple years ago, so maybe things have changed.

DR. MICHAEL EISENBERG: (00:27:40 – 00:27:44): Yeah, for the men it certainly has. Yeah, there’s no FDA-approved testosterone for women.

MEL ROBBINS: (00:27:45 – 00:27:46): Oh, so gotcha.

DR. MICHAEL EISENBERG: (00:27:46 – 00:28:01): So that, I think hopefully that’s evolving. I know there’s a lot of advocates for female health that have seen that there is some good data that it can help. Mm-hmm. But for men it is approved. And there’s also testosterone oral tablets as well. So there’s many ways that it can be given. I think most commonly it is injections.

Negative Side Effects of Testosterone

MEL ROBBINS: (00:28:01 – 00:28:05): What are the negative side effects, Dr. Eisenberg, of testosterone?

DR. MICHAEL EISENBERG: (00:28:06 – 00:28:15): Testosterone has been tested by the World Health Organization as a contraceptive, so it can actually lower sperm production. Does that pretty reliably. Probably 90% of the time.

MEL ROBBINS: (00:28:16 – 00:28:21): Wait, I’m confused. Hold on a second. You said testosterone is a contraceptive?

DR. MICHAEL EISENBERG: (00:28:21 – 00:28:22): In men it is, yeah.

MEL ROBBINS: (00:28:23 – 00:28:26): It lowers your sperm count? Wouldn’t it increase it?

DR. MICHAEL EISENBERG: (00:28:27 – 00:28:46): Well, you’d think that, but there’s many reasons that it doesn’t. So if we think about how the body makes testosterone, again, we talked about the brain signaling the testicle to make testosterone, and then there’s a feedback loop. So your body knows when it needs testosterone, it’s kind of sending the signal down. So when you take testosterone exogenously, whether it be injection, gel, any of the different methods—

MEL ROBBINS: (00:28:46 – 00:28:48): What is exo— what is that?

DR. MICHAEL EISENBERG: (00:28:48 – 00:28:49): Oh, exogenous. So outside testosterone.

MEL ROBBINS: (00:28:49 – 00:28:50): Okay, got it. Okay.

DR. MICHAEL EISENBERG: (00:28:50 – 00:29:32): When you do that, your body says, “Oh, there’s enough testosterone, I don’t need to make anymore.” And so if the brain doesn’t signal the testicle to make testosterone, it stops doing that, but it also stops making sperm. So those signals are very, very closely related.

In addition, in the testicle, the testosterone levels are probably about 100-fold higher. So if your normal testosterone is kind of swimming around in the blood at 500, let’s say it needs to be 5,000 or much higher than that even. And so when your testicle doesn’t see this super 5,000, 50,000 level of testosterone, then you’re not going to make sperm efficiently either because you need those high levels of testosterone for efficient sperm production or spermatogenesis.

MEL ROBBINS: (00:29:32 – 00:29:32): Wow.

DR. MICHAEL EISENBERG: (00:29:32 – 00:29:41): So there’s sort of 2 different methods. So low testosterone in the testicle and then not that signal to make sperm. So that’s what we have. That’s what happens with testosterone.

MEL ROBBINS: (00:29:42 – 00:29:52): That makes a lot of sense. So low sperm count is one negative side effect. What are some other potential negative side effects from taking testosterone?

DR. MICHAEL EISENBERG: (00:29:52 – 00:30:56): There can be skin changes, can lead to oily skin, acne, can lead to hair loss, breast growth as well, because testosterone is converted to estrogen, which we do need for normal function. But if estrogen levels get too high, there can be some breast growth. So sometimes we see that as well.

Now, there used to also some concerns about prostate health and even heart health with testosterone. But there was a very landmark study of about 5,000 men called the TRAVERSE trial, where men were given testosterone, men were given placebo. So kind of a dummy gel and then just followed to see if there are higher risks of any of these adverse outcomes. And it turns out there weren’t.

So we used to worry that if you add testosterone to men, they’re going to see more levels of prostate cancer. That was debunked. And then there was also some earlier signals that men on testosterone are at higher risk of heart attacks and strokes. Also with the study, we didn’t see that. So that’s also been debunked.

So the FDA is actually going to update guidance on the prescribing and some of the warning labels to remove those, because I think that was also a barrier similar to female hormone replacement. So I think hopefully that’ll help a lot of men as well.

Why a Doctor Should Oversee Testosterone Therapy

MEL ROBBINS: (00:30:56 – 00:31:05): Dr. Eisenberg, is it important that you go see a urologist or your general practitioner and that a doctor’s overseeing this?

DR. MICHAEL EISENBERG: (00:31:05 – 00:31:26): It’s so crucial that a doctor oversees this because you can certainly be abused or misused or misprescribed. You can give anybody testosterone, but you really want to make sure you’re giving it to people that need it. Otherwise, you’re just exposing them to all the risks and none of the benefits. We’ve seen from our best evidence that if your testosterone is normal and you’re given testosterone, it’s very unlikely to help any problem you have.

MEL ROBBINS: (00:31:26 – 00:31:27): Wait, say that again.

DR. MICHAEL EISENBERG: (00:31:28 – 00:32:27): It’s such a crucial point that if you have a normal testosterone, and you’re given testosterone, it’s unlikely to help with some of these other symptoms that people would come in for, for sexual dysfunction, for example, for performance. People think that if I take testosterone, I’m going to be a better version of me. And that’s not the case.

There have been studies in the military thinking about testosterone as a performance enhancer. And while it did help with lean body mass for kind of military sort of hero exercises these men were doing, whether they got testosterone or whether they got placebo, their performance was similar, their recovery was similar. So if you have normal levels, you probably shouldn’t be on testosterone.

And so I do worry that some of these clinics that’ll just prescribe it, right, that’s how they make money, right, is just giving these prescriptions, upselling. If you don’t need it, you shouldn’t be on it because you’re going to get exposed to all these risks that we talked about, right, hair loss, breast growth, higher levels of red blood cell count, which can lead to clotting risk.

MEL ROBBINS: (00:32:28 – 00:32:52): I am so glad you’re saying this because I just assumed that if you’re a guy in your 20s, 30s, or 40s and you want to look more ripped and you want to perform better in the bedroom and you want to be more energized, just start testosterone now. It never even occurred to me that it might not do anything except for lower your sperm count. Yeah. Raise your blood count. Make you lose hair. Wow. Yeah.

DR. MICHAEL EISENBERG: (00:32:52 – 00:33:09): Yeah. I think that’s something that men need to be aware of, that it’s not all upside. And I think it’s not for everybody. And so I think seeing somebody that understands all of our guidelines from the American Urological Association, the Endocrine Society, very thoughtful, data-driven approaches to this. And so I think that’s really crucial.

Do You Have to Take Testosterone for the Rest of Your Life?

MEL ROBBINS: (00:33:10 – 00:33:23): One of my husband’s big concerns is that “once I start this, I have to take this for the rest of my life.” And so, Dr. Eisenberg, once you start testosterone, do you have to take it for the rest of your life?

DR. MICHAEL EISENBERG: (00:33:24 – 00:34:25): So I think it depends. For men that don’t make their own testosterone— so for men that have lost both their testicles or some congenital conditions where the testicles don’t function properly— those men do need to be on testosterone forever.

But for these other conditions where men have some symptoms— low energy level, sexual dysfunction— found to have some lower levels, usually we start it as a trial period. I think all the different societies recommend this. We start testosterone, we’ll check the levels to make sure you’re in a therapeutic range. Sometimes we’ll switch between formulations so we can get there so it’s convenient. And if they see the benefit again, which a lot of men do, they want to be on it because they do see sort of a better version of themselves.

But if they really don’t notice any changes, then we’ll just stop it. So after 6 months, after a year, if they’re not seeing those improvements, then we can stop it. Or if there’s other reasons, we talked about some of the causes of low testosterone, like obesity, for example. So if they can start testosterone, sort of reclaim their health, lose some of that weight, then the body’s own production can kind of boost up and then we can wean them off. Their body takes over and hopefully they’re at a normal level after that.

How to Bring Up Testosterone With Your Partner

MEL ROBBINS: (00:34:26 – 00:34:48): So let you bring this up with your partner because I can already hear the send. I can hear somebody copying the link to this episode as they’re listening to it right now and texting it to their partner. But how do you bring this up? All my girlfriends and I are talking about this and the fact that we have all diagnosed our husbands with low testosterone.

DR. MICHAEL EISENBERG: (00:34:48 – 00:34:49): Yeah.

MEL ROBBINS: (00:34:49 – 00:34:54): What’s the most empowering and compassionate way to bring this up?

DR. MICHAEL EISENBERG: (00:34:54 – 00:35:38): It’s a good question. It’s going to be kind of individualized. But I think there’s many ways to sort of approach the subject. “I think we’ve talked about these symptoms before. Could be testosterone. Have you thought about bringing it up to Dr. Smith next time you go in to see her?” Or “Heard this super interesting podcast about testosterone. It sounds like it’s really just linked to some function, but it’s also linked to longevity. And I love you. I want you to be there forever. If you haven’t had it checked, it sounds like it’s easy enough to do. Maybe we can do that.”

So I think kind of with health, with strength, in your 30s, everything’s super easy to do. But as you kind of getting older, normal household chores, bringing in a bag of groceries, everything gets a little bit harder. So I think an easy way to get checked and maybe there’s something that can be done to help with some of those things too.

What Is Erectile Dysfunction?

MEL ROBBINS: (00:35:39 – 00:35:54): Amazing. Dr. Eisenberg, thank you for explaining everything that you just did about hormone health, testosterone. I want to switch gears and talk about a topic that can be really difficult to talk about, which is erectile dysfunction.

DR. MICHAEL EISENBERG: (00:35:54 – 00:35:55): Yeah.

MEL ROBBINS: (00:35:55 – 00:35:57): What is erectile dysfunction?

DR. MICHAEL EISENBERG: (00:35:58 – 00:36:07): Erectile dysfunction is the consistent or recurrent inability of a man to attain or maintain an erection sufficient for sexual activity.

MEL ROBBINS: (00:36:07 – 00:36:08): How common is it?

DR. MICHAEL EISENBERG: (00:36:09 – 00:36:24): It’s so common. I think that when men come in, they think they’re the only one affected. But if you look at studies, there’s a famous study called the Massachusetts Male Aging Study done here about 20 years ago or so that shows that if you look at men over the age of 40, over half have some trouble with erectile dysfunction.

MEL ROBBINS: (00:36:24 – 00:36:25): Over half.

DR. MICHAEL EISENBERG: (00:36:25 – 00:36:43): Over half. And it increases every decade of life. So men in their 40s, about 40%. 50s, 50%. 60s, 60%. 70s, 70% have some trouble with erections. And even men, it kind of goes all the way down the other range, too. So men that I see in their 20s, 30s, probably 15 to 20%. So it’s a very common issue.

What Causes Erectile Dysfunction

MEL ROBBINS: (00:36:43 – 00:36:45): What causes erectile dysfunction?

DR. MICHAEL EISENBERG: (00:36:46 – 00:36:53): There’s a host of things. So ultimately, what erections are is blood going into the penis and getting trapped there. And I think it may be helpful just to—

MEL ROBBINS: (00:36:53 – 00:36:53): Sure.

DR. MICHAEL EISENBERG: (00:36:54 – 00:36:55): We can look at a model here.

MEL ROBBINS: (00:36:58 – 00:36:58): Okay.

DR. MICHAEL EISENBERG: (00:36:59 – 00:37:08): So if you can kind of see this, so this is the erectile body. There’s a urethra on the bottom here. So this is where blood actually goes. So blood—

MEL ROBBINS: (00:37:08 – 00:37:08): On the top of it?

DR. MICHAEL EISENBERG: (00:37:09 – 00:37:09): On the top.

MEL ROBBINS: (00:37:09 – 00:37:10): Okay.

DR. MICHAEL EISENBERG: (00:37:10 – 00:37:13): So these are the erectile bodies. These are what engorge with blood.

MEL ROBBINS: (00:37:13 – 00:37:13): Yep.

DR. MICHAEL EISENBERG: (00:37:13 – 00:37:38): And essentially what happens is when you get stimulation, whether it be visual, auditory, touch. Yes, there’s many ways it can be done. Absolutely. You get different neurotransmitter release, nitric oxide release, which releases this other chemical called cyclic GMP, which then causes the blood vessels in the penis to dilate, to open up, to let more blood in.

MEL ROBBINS: (00:37:38 – 00:37:38): Okay.

DR. MICHAEL EISENBERG: (00:37:38 – 00:38:11): And then that’s what leads to erection. So anything that can affect blood flow anywhere in the body can affect in the penis. So for example, smoking, diabetes, high cholesterol, high blood pressure, all the things that we think about can affect, heart problems can also affect blood flow in the penis and causing that.

Trauma is also notorious for doing that. So, for example, prostate cancer surgery can affect a lot of the main nerve supply to the penis. Some bike saddle seats, for example, can also put pressure on some of the main nerves that conduct into the penis.

MEL ROBBINS: (00:38:11 – 00:38:13): Really? Bike saddle seats?

DR. MICHAEL EISENBERG: (00:38:14 – 00:38:14): Yeah.

MEL ROBBINS: (00:38:14 – 00:38:16): All the cyclists are now going to be mad at you.

DR. MICHAEL EISENBERG: (00:38:17 – 00:38:45): Well, I think for some men, I think in general, anything that’s good for your heart is going to be good for the penis. It’s sort of one of my mantras. So usually maintaining good cardiovascular health is important. But for some saddle designs and some men, it can actually put a lot of pressure on some of those nerves and some of the arteries to the penis. And over a long period of time, not everybody, but maybe 20, 25% of men do notice numbness, pain, and erectile problems. Especially after long rides. So something to be aware of as well.

How Erectile Dysfunction Makes Men Feel

MEL ROBBINS: (00:40:03): How do men feel when they’re experiencing erectile dysfunction?

DR. MICHAEL EISENBERG: (00:40:03 – 00:40:46): I mean, erectile dysfunction is such a profound effect on a man. I mean, they feel inadequate, lack of masculinity. They feel a sense of guilt, like they’ve done something wrong. If they’re in a relationship, they feel like they’re contributing to marital problems. They sometimes withdraw a little bit. So we see that can lead to depression. Again, these just feelings of inadequacy.

So ultimately, it’s a quality of life kind of function. And reproductive at young age. But towards the end, it’s sort of this way of intimacy and connection with somebody. And then when you lose that, when you see that you’re the issue and you feel like you’re the issue, you kind of feel hopeless. A lot of men are not comfortable talking about this. They don’t realize all the things that can be done. We see all these problems.

MEL ROBBINS: (00:40:47 – 00:41:42): Well, it’s an important thing to stop and really think about, because when I went through perimenopause and menopause, I absolutely did not feel like myself. I did not feel attractive. My body started changing in ways that I did not like. And it certainly impacted how I felt about myself. But listening to you, I’m sitting here thinking, but my vagina still worked. I mean, I might not have liked what my body felt like, but I could still be intimate with Chris.

And when you really stop and think, not just that your body no longer feels like it’s your own and you can’t count on something that you have for a lot of your life. So I can understand that piece of losing control, but also feeling like you can’t perform something that’s one of the most awesome things about life with your partner.

DR. MICHAEL EISENBERG: (00:41:42 – 00:41:51): Yeah, I think that’s exactly right. I think— and it also something that it just separates yourself from your partner as you’re going through this huge problem. One of the ways you used to connect is now lost.

MEL ROBBINS: (00:41:52 – 00:41:52): Yeah.

DR. MICHAEL EISENBERG: (00:41:52 – 00:41:58): And some of these men feel that it’s their problem and there’s nothing that can be done. I think this hopelessness is something that I definitely hear about a lot.

MEL ROBBINS: (00:41:58 – 00:42:05): What do you want women in particular to know if you are with somebody who is experiencing erectile dysfunction?

DR. MICHAEL EISENBERG: (00:42:06 – 00:42:21): I think there’s 2 things. I think that one is it’s very common. So just know that your man is not alone. And then I think the other thing is that there’s a lot that can be done. I always like to tell men, “As long as you have a penis, we can always make it hard.” So just let them know that there’s therapies that are available.

MEL ROBBINS: (00:42:23 – 00:42:26): “As long as you have a penis, we can always make it hard.”

DR. MICHAEL EISENBERG: (00:42:26 – 00:42:26): Yeah.

MEL ROBBINS: (00:42:26 – 00:42:27): Really?

DR. MICHAEL EISENBERG: (00:42:27 – 00:42:28): That’s right. Yeah.

MEL ROBBINS: (00:42:28 – 00:42:29): You can fix any— anything.

DR. MICHAEL EISENBERG: (00:42:30 – 00:42:36): Anything. Yeah. It’s— there’s things that we do. So you have to be willing to be very aggressive, but there’s always a therapy.

Treatments for Erectile Dysfunction: Viagra, Cialis, and Levitra

MEL ROBBINS: (00:42:36 – 00:42:42): Wow. Well, let’s talk about what can be done if you’re experiencing erectile dysfunction.

DR. MICHAEL EISENBERG: (00:42:42 – 00:43:27): All right. So the first thing we want to do is look holistically at their health to sort of understand what medications they’re on, because there are some medications that can affect it. Sometimes we see blood pressure medications are notorious for causing problems. Sometimes antipsychotics, antidepressants, those are all things to think about. Maybe talk to some of their other doctors. That’s one of the reasons I do get on the phone with referring providers sometimes.

And then look at their health too. What are they doing? Are they exercising? What is their diet like? What’s their BMI, their body mass index? Because these are things that we could potentially correct.

Once we’ve done that and everything’s optimized as much as possible, we talked about some treatments. So the first line is going to be pills. And I actually brought some here just so everybody knows. So these are called phosphodiesterase inhibitors.

MEL ROBBINS: (00:43:28 – 00:43:28): Who?

DR. MICHAEL EISENBERG: (00:43:29 – 00:43:40): So the things that we hear about like Viagra, sildenafil, vardenafil or Levitra, tadalafil, Cialis, these are the ones that are on TV. So these are the pills that help with erections.

MEL ROBBINS: (00:43:40 – 00:43:44): And basically, are they all the same by a different name or do they work differently?

DR. MICHAEL EISENBERG: (00:43:44 – 00:44:07): They’re sort of cousins, so they have the same mechanism of action. The molecule is a little bit different. Some of their chemical properties are a little different, so some last longer in the body, some act a little quicker. So depending on what the goals are, we prescribe some in different conditions, and some men do respond better to one than the other. Sometimes men have different side effects with all of them, but again, they’re very, very similar, but men kind of react a little bit differently.

MEL ROBBINS: (00:44:07 – 00:44:12): Do all of these medications impact blood flow? Is that basically what they’re doing?

DR. MICHAEL EISENBERG: (00:44:12 – 00:44:37): That’s basically what they do. The way that erections work, again, is we get the stimulation which leads to this vasodilation or opening up of the blood vessels. So one of the main signals for that is this medic— is this chemical called cyclic GMP, and it’s broken down. So what these medications do is prevent the breaking down of this chemical. So the more the chemical’s there, the more the blood vessels stay open, the longer the erection can last, easier it is to get erection, all those sorts of things.

MEL ROBBINS: (00:44:37 – 00:45:01): Wow. Can you walk us what the drug does and what are the— what’s the downside to it and why you would prescribe that one versus a different one? Well, or I don’t know if that’s a fair question. I certainly won’t turn this into an ad for anything. I’m just going to come right out and say it. If you’re a woman and you see these ads, a couple of things happen for me. One is, where is the female version of this?

DR. MICHAEL EISENBERG: (00:45:01 – 00:45:02): Yeah.

MEL ROBBINS: (00:45:02 – 00:45:23): And the second one is, okay, if my partner starts taking this, is he going to pop a boner immediately, and then I’m going to be running away from him, and now I’m going to have a different problem than him being depressed? He’s going to want sex all the time. And so as a woman, I’m just now sharing the stuff we say on a walk when we talk about this stuff.

DR. MICHAEL EISENBERG: (00:45:23 – 00:45:43): Yeah, that’s a good question. No, in general, no, this is not going to give you a permanent erection. Okay, this is basically just going to augment the partner’s ability to get an erection when they want it. So it’s an— it kind of helps with on-demand erections, essentially. And it can help with performance, for performance anxiety, but also again when you’re just not getting erections when you need them, when you want them.

MEL ROBBINS: (00:45:43 – 00:45:44): Gotcha.

DR. MICHAEL EISENBERG: (00:45:44 – 00:46:49): The first one was Viagra. The way you take it is about an hour before sex. For most of these, better to take it on empty stomach, so hour before, hour after you eat makes it easier to get, to keep erections. Also things to know about is some of the side effects. So most men do fine, but the rare side effects would be headache, facial flushing, backaches, leg cramps, indigestion, or nasal congestion.

So the way they work again is they open up blood vessels mostly in the penis, but they can do it in other parts of the body as well. So you can get some of those side effects. But again, most men do fine. So I think Viagra is certainly a good one to start with, or sildenafil.

Cialis or tadalafil is the other one. So this one lasts a little longer in the system. It’s kind of marketed as “the weekend pill.” So for example, Viagra, the half-life, how long it takes to clear from our body, so half of it is out of our body in about 6 to 8 hours. For Cialis, it’s probably 16 to 18 hours. So it just, wow, it stays around a lot longer. So if you take a pill on Friday, there’s still some on Saturday as well. This also allows daily dosing, so you can give them kind of a low-dose medication every day, so it’s sort of always there to help.

MEL ROBBINS: (00:46:49 – 00:46:50): Mm-hmm.

DR. MICHAEL EISENBERG: (00:46:50 – 00:47:04): There’s also been some studies that show that it may be cardioprotective in some ways. It’s not FDA approved for that. But there’s emerging data that if men that are taking the kind of low-dose Cialis every day, a lower risk of cardiovascular events.

MEL ROBBINS: (00:47:04 – 00:47:17): And is that— and I realize we’re just kind of imagining what the connection might be, but do you think that’s because if you’re increasing blood flow to the penis, you’re increasing blood flow everywhere and that helps your heart?

DR. MICHAEL EISENBERG: (00:47:17 – 00:47:29): That’s thought to be the mechanism. Originally these medications were designed as a treatment for blood pressure, a treatment for angina or chest pain. Oh, it didn’t work that well at that. But they— this was kind of an unexpected but very profitable side effect.

MEL ROBBINS: (00:47:29 – 00:47:32): It’s that that’s growing, but this isn’t.

DR. MICHAEL EISENBERG: (00:47:32 – 00:48:02): Okay, exactly. So that’s kind of the thought about it, that it’s, again, cardioprotective by increased blood flow. But I should also say these are observational studies. So they basically look back at who was on Cialis, for example, who was not, and just compared them. And those are different groups. So just to say, this has not been studied in the most rigorous medical trial that we could do.

But I think it’s at least sort of reassuring. Some men do ask, “Is this going to be safe? Am I going to have a heart attack when I’m on this?” The data says that that will not happen. It may even be the other way.

MEL ROBBINS: (00:48:02 – 00:48:05): And are there side effects to taking the longer acting one?

DR. MICHAEL EISENBERG: (00:48:06 – 00:48:11): The same ones. I think the same ones that we’ll see. Oh, and again, the low dose, maybe it’s even better tolerated.

Second- and Third-Line Treatments for Erectile Dysfunction

MEL ROBBINS: (00:48:13 – 00:48:18): So as a Stanford urologist, when somebody comes in with erectile dysfunction, what do you recommend?

DR. MICHAEL EISENBERG: (00:48:19 – 00:48:24): Well, if they’ve never been on any of these and we can’t correct anything further than they already have, then I think I usually start with one of these medications.

MEL ROBBINS: (00:48:25 – 00:48:25): Gotcha.

DR. MICHAEL EISENBERG: (00:48:26 – 00:48:31): A lot of times when men have seen me, they’ve already failed these. And so they’re ready for second-line and third-line options as well.

MEL ROBBINS: (00:48:31 – 00:48:34): And what’s the second line that you would do?

DR. MICHAEL EISENBERG: (00:48:34 – 00:48:43): So there’s also medications that you can put in the tip of the penis that are absorbed by the penis. So if we go back to our model here, that sounds painful.

MEL ROBBINS: (00:48:44 – 00:48:47): I’m just going to say the tip of the penis sounds very painful to put something in.

DR. MICHAEL EISENBERG: (00:48:49 – 00:48:57): So just in the urethra, you can put this medication that’s absorbed then, and it works in the same way as Viagra does. It’s like a gel.

MEL ROBBINS: (00:48:58 – 00:48:58): Okay.

DR. MICHAEL EISENBERG: (00:48:58 – 00:49:19): There’s a little pellet, but there’s also a gel, and it’s basically just absorbed throughout the whole penis. It’s a vasodilator, so it works in a similar mechanism to the pills that it opens up blood vessels. Men do describe kind of a tingling or a low-grade burn. Usually they get used to it. Safe for their partner, any orifice. And that works probably 60 to 80% of the time. So that can also be pretty effective.

MEL ROBBINS: (00:49:19 – 00:49:23): Got it. And is that something you do before you’re having sex, or you have to do it every day, or—

DR. MICHAEL EISENBERG: (00:49:24 – 00:49:28): It’s on demand. So yeah, so about 5 to 10 minutes before you’re going to have sex, it’s something you want to do.

MEL ROBBINS: (00:49:28 – 00:49:29): Okay.

DR. MICHAEL EISENBERG: (00:49:29 – 00:49:50): So if those don’t work, so the next option is injections. So penile injections are another thing that can be done. So essentially you take a small needle, and I think in with the GLP-1s, people are more used to giving themselves injections, maybe not on the penis, but I think there’s a lot more comfort in that. And it’s a vasodilator you’re putting directly into the erectile bodies, leads to this vasodilation that works probably 90% of the time.

MEL ROBBINS: (00:49:50 – 00:49:51): 90?

DR. MICHAEL EISENBERG: (00:49:51 – 00:49:59): 90. Now, what I’ll say is that there is a huge psychological barrier to putting a needle in your penis. But if men are willing to do it, it’s very, very effective.

MEL ROBBINS: (00:50:00 – 00:50:02): Wow. And you do it. It’s an on-demand thing.

DR. MICHAEL EISENBERG: (00:50:02 – 00:50:20): It’s an on-demand thing. It’s such an interesting story because the first time it was ever discovered and brought to sort of the medical world was by a pharmacologist at a national urology convention in 1980. And what he did is he injected himself in his hotel room. He went down, delivered the lecture, and then lowered his pants.

MEL ROBBINS: (00:50:20 – 00:50:20): Oh my God.

DR. MICHAEL EISENBERG: (00:50:21 – 00:50:29): And showed the audience. And beyond that, he actually walked up and down the aisles inviting people to inspect it. And you can imagine sort of the level of his penis. His penis.

MEL ROBBINS: (00:50:30 – 00:50:36): Well, it is an audience full of penis doctors, so you guys know what they look like.

DR. MICHAEL EISENBERG: (00:50:36 – 00:50:53): Yeah. But the amount of shame and fear, right, that you would normally have doing something like that. But the medication is so powerful, it’s able to sort of suppress that response that would normally cause erections to go away. So it is a very effective medication. I certainly don’t advocate men injecting themselves and walking around naked, but just to say that it does work.

MEL ROBBINS: (00:50:53 – 00:50:59): Wow, that’s— I mean, he’s doing one for all the urologists and men out there.

DR. MICHAEL EISENBERG: (00:50:59 – 00:51:00): It’s a very famous—

MEL ROBBINS: (00:51:00 – 00:51:08): But most conventions are in Vegas, so when you said there was a urologist in a hotel room in Vegas injecting himself, I thought, where the hell is this?

DR. MICHAEL EISENBERG: (00:51:08 – 00:51:09): You knew where this was going?

MEL ROBBINS: (00:51:09 – 00:51:34): No, I didn’t know where this was going. I thought it ended sort of like that Hangover movie, but no, I’m glad to hear that it was something that he was willing to not only try, but it had such a profound breakthrough that he was willing to remove the shame and show all of his colleagues that were at this conference.

DR. MICHAEL EISENBERG: (00:51:34 – 00:51:37): Yeah, it’s a very important medication and a very important option that we give men.

Why Dr. Eisenberg Went Into Urology

MEL ROBBINS: (00:51:38 – 00:51:40): Wow. What made you want to go into urology?

DR. MICHAEL EISENBERG: (00:51:41 – 00:52:03): Well, I like the problems that we deal with. When I looked at andrology specifically, so hormonal, sexual, reproductive health, I thought there was really a lack of treatments that were available. There were lots of research opportunities to try and do better by these men. So I just found that really fascinating, just the powerful impact we can have on their quality of life, their overall health, sense of self. All that really got me excited about the field.

Ejaculation, Prostate Cancer, and Longevity

MEL ROBBINS: (00:52:03 – 00:52:20): That’s really cool because it’s an important and unique specialty. I would love to have you— I’ve heard you talk about the connection between having sex and prostate cancer. Can you unpack that for us?

DR. MICHAEL EISENBERG: (00:52:21 – 00:52:38): Yeah. So there was a famous study that sort of looked at this 30 years ago now, and it said that the more you— a man ejaculates, the lower the risk of prostate cancer. So really fascinating. So what they found is that men that ejaculated 20 times a month or more compared to those less had about a 20% lower risk of developing prostate cancer.

MEL ROBBINS: (00:52:38 – 00:52:39): 20% lower.

DR. MICHAEL EISENBERG: (00:52:40 – 00:54:30): So this is a study of about 30,000 men followed for about 20 years, and they saw this pretty consistently all the different ways they looked at it, all the different age groups. This has been looked at in other studies as well, hundreds of thousands of men. It’s been supported.

So why this is is not certain. It doesn’t seem to be tied to how a man ejaculates. So whether it be sex, masturbation, for example, all those seem to give the same trend. It’s thought maybe you’re kind of clearing toxins from seminal fluid, preventing crystal formation. I think mechanisms are not clear. We do see that association.

Now, 20 ejaculations is a lot a month. Maybe for teenagers it’s a little easier, but certainly as you get older, it can get more challenging. So I don’t want to prescribe that for everybody as something to do. But it’s an interesting observation. And when men ask, “Can I masturbate too much?” for example, this is sort of the study that I always relay that it’s probably not harmful. Again, there are some studies say maybe it’s even beneficial.

The other thing I was going to say is that there’s also been studies linking sexual activity and a number of ejaculations and orgasms to longevity as well. We’ve talked a lot about how sexual function is related to overall health. So it may be kind of a marker for that. But there have been studies that show that men that have sex maybe once or twice a week compared to men that have sex sort of rarely, less than once a month, live longer, live twice as long, in fact.

And this is, again, looking at men in their— when they started observation kind of in their 50s, 60s. If you follow these men, they reported regular sexual activity, they’d live longer. And that may be having a partner, all that things are very beneficial to longevity. But I think it’s also something to be aware of.

So another reason maybe they get checked out is that, in addition to sort of the joys of sex, which obviously are numerous, it’s— I think when you think about longevity, which is a huge push now in our culture, which is great, you can also see some benefits for that as well.

Relationships, Intimacy, and Living Longer

MEL ROBBINS: (00:54:31 – 00:54:47): Well, I’m glad you said the thing about relationships. Because it is true. And so many renowned medical experts have come on to talk about the connection between your relationships long term and the quality of your life.

DR. MICHAEL EISENBERG: (00:54:47 – 00:54:47): Yeah.

MEL ROBBINS: (00:54:48 – 00:55:23): And that when you don’t have great relationships as you get older and loneliness kicks in, that that is devastating to your physical health. And so I’m really glad that you’re also highlighting that having a healthy sex life, being able to connect intimately with another person— you’re right, it’s not only one of the great joys in life, but it is a sign that you have relationships that are meaningful to you on a consistent basis. Yeah. And that intimacy isn’t just about the orgasm, it’s about the quality of your life.

DR. MICHAEL EISENBERG: (00:55:24 – 00:55:55): Yeah. And that’s so, so crucial. I think this sort of— the studies that I always like to quote are from Scandinavia, where they have these great population birth and death. So the famous one I quote from Sweden, where they looked at what effect having a partner has on a man’s longevity and mortality and having kids.

And it turns out if our ideal is a man that has a partner, is living with her and kids that are living with them, if you get rid of having a partner, the chance of that man dying goes up 60%. And if you get rid of kids, we see the same thing. If a man doesn’t have any kids compared to someone that does, 60% higher risk of death.

MEL ROBBINS: (00:55:56 – 00:55:56): Wow.

DR. MICHAEL EISENBERG: (00:55:56 – 00:56:06): And if a man doesn’t have a partner or have children, about a threefold higher risk of death. So I think to your point, relationships are so, so crucial. They take care of you, but also it just gives you purpose, right?

MEL ROBBINS: (00:56:07 – 00:56:26): And if you’re silently struggling with either issues related to low testosterone or you’re struggling with issues related to erectile dysfunction, which is making you pull back from those relationships, that has a profound impact on the overall quality of your life is what you’re saying.

DR. MICHAEL EISENBERG: (00:56:26 – 00:56:27): Absolutely. Absolutely.

MEL ROBBINS: (00:56:27 – 00:56:36): Well, I can see why this is critical. And it’s not just about sex. It’s not just about your mood or your energy. It’s about your overall health.

DR. MICHAEL EISENBERG: (00:56:36 – 00:57:00): Yeah, exactly right. You want to be there as long as you can for your partner, for everybody, for yourself. So I think that’s one of the reasons you should pay attention to this. And this can be a “check engine light,” right? That if erections are not as good, it’s not just a convenience issue. This also may be sort of a sense of how you’re doing. And so you should— yeah, talk to your partner, talk to your doctor, go to a doctor and get evaluated because I think powerful insights you can get and there’s a lot that can be done.

Why Male Fertility Matters

MEL ROBBINS: (00:57:01 – 00:57:22): You do a lot of work in male fertility and I’d love to have you speak to what we might find surprising about the issues that you’re seeing with male fertility and if you’re not even thinking about having children right now. Why is male fertility an important thing to pay attention to?

DR. MICHAEL EISENBERG: (00:57:23 – 01:00:18): I’m super passionate about male fertility as well. There’s been lots of studies that show that sperm counts are going down globally. So there’s a famous study in the ’90s that suggested this. It’s very criticized. They updated it 20 years later, still somewhat criticized. And then just a couple of years ago, they did one of the biggest updates they’ve ever done and showed this all over the world. So in Western countries, Eastern countries, really every continent, we see this decline in sperm counts. And obviously the question is, why.

So I think if you’re a male, you should definitely care that our sperm counts are going down. And it’s still somewhat controversial how fast that decline is, although the data suggests that it’s accelerating in the last probably 20 years. We also see declines in testosterone levels. We see changes in pubertal timing in boys, higher risk of testis cancer. So I think male reproductive health is declining.

So even if you’re not sort of immediately planning for a pregnancy, there’s so much that we can do to help optimize fertility that I think that you should be aware and kind of get a sense of where you are to get checked out because it gives us an opportunity to sort of improve things.

I think one of the problems, just from an education standpoint, when you look at couples that are having problems with infertility, about half the time there’s a male factor. At a societal level, usually everybody thinks that all fertility is related to female partners’ issues. And so a lot of times the male’s never evaluated in this country. Probably a third of the time a male’s never seen by a specialist, never checked, bypassed to go through IVF, for example, which is very powerful, very effective, but it kind of removes the opportunity to try and optimize the male, to try and figure out what’s going on.

Some things can be corrected. Sperm counts also are very tied to overall health. And so it may also be kind of a “check engine light.” Your sperm count’s low. What else is going on? What do we need to check out? Is there something really dangerous going on? There’s different anatomic factors we can look at. We can measure hormonal health and optimize that, look at their overall lifestyle factors, look at different medications they’re on, looking at different health conditions.

So I think the earlier you can do that, the better, because what we found is that when men come in to see us, they’ve already been struggling with their partners for a year or more, and they don’t want us to do anything because they don’t want to wait any longer. It takes 2 to 3 months to make a sperm, but they wanted to get pregnant a year ago, so they don’t want to wait 2 months for a surgery or a pill or anything. They’re ready to just go. And so I think that’s really a disservice to men, to male reproduction, because we can’t really fix things. Puts all the burden on women.

We’ve seen sort of an abundance of awareness of male fertility. There’s a lot of home testing now to make it easier for men to see where they are. So you don’t have to go to a doctor anymore. They used to send patients to bathrooms to collect things that are super uncomfortable. There’s no question. So now you can just do it at home. You get the results immediately. It’s very personal, very private. And I think that’s really done a great job for awareness of this and also just making it more accessible for everybody.

MEL ROBBINS: (01:00:18 – 01:00:22): Dr. Eisenberg, I want to make sure I followed the statistics you said and I got them right.

DR. MICHAEL EISENBERG: (01:00:22 – 01:00:22): Okay.

MEL ROBBINS: (01:00:23 – 01:00:32): So in 50% of the cases where there are fertility issues, it is a male issue, not a female issue.

DR. MICHAEL EISENBERG: (01:00:33 – 01:00:47): Right. Well, so what I should say is that it’s all causes, 50%. So that’s 30% only men, 20% men and women together. But there is a male factor that we can optimize in half of these cases of fertility problems. Wow.

MEL ROBBINS: (01:00:47 – 01:01:11): So in 50% of fertility problems, it’s either the dude or it’s the woman and the dude together. And what you’re saying is that what happens for a lot of couples is when you are having fertility issues, you focus on the woman, you race to IVF instead of also looking at this 50%, which is there could be a lot of issues with your partner.

DR. MICHAEL EISENBERG: (01:01:11 – 01:01:12): That’s right.

MEL ROBBINS: (01:01:13 – 01:01:13): Wow.

DR. MICHAEL EISENBERG: (01:01:13 – 01:01:38): Yeah. Yeah. And again, there’s so much that can be done. I think there’s standard evaluation. And if you look at guidelines by the American Society for Reproductive Medicine, the American Urological Association, everybody says you should check out both members of the couple simultaneously, but for different reasons. I think a lot of it is just knowledge from patients, from some of the providers. They just never think to check the man out. So it’s a huge opportunity and I think a disservice to men.

MEL ROBBINS: (01:01:38 – 01:01:39): Wow.

DR. MICHAEL EISENBERG: (01:01:39 – 01:01:39): And women.

Men’s Pelvic Floor Health

MEL ROBBINS: (01:01:40 – 01:01:57): It’s a disservice to everybody. I’m really happy that you explained it like that. So if you’re having fertility issues, both of you should get checked out immediately. Can you talk about men’s pelvic floor health? Why is it important to pay attention to and what is pelvic floor health?

DR. MICHAEL EISENBERG: (01:01:58 – 01:02:42): So there’s a lot of muscles in the pelvic floor that really control everything. So they control ejaculation, orgasm. They’re also involved in urine control, bowel control. So it’s very important to sort of be aware how important they are. And a lot of times we just take it for granted, but there are some times where it can lead to problems.

So there can be chronic pelvic pain we see. Sometimes some scrotal pain is due to spasms in some of these muscles. After pelvic surgery, like prostate removal for prostate cancer, for example, we teach men how to do some pelvic floor exercises to strengthen some of these muscles to try and regain some of the urinary control. That’s sometimes compromised after surgery. So I think that there’s a lot that can be done having some understanding awareness that it’s very important for men and for women to know that.

How Urination Changes With Age

MEL ROBBINS: (01:02:42 – 01:02:55): Let’s talk about peeing. So as you age, do you start to drip? Do you pee more at night? What do you do if your partner is getting up 3 or 4 times a night to pee?

DR. MICHAEL EISENBERG: (01:02:56 – 01:03:54): Yeah, so yeah, urination definitely changes with age. So we do see that men wake at night. There’s different reasons for that. The bladder’s under a lot more pressure ’cause as we age, prostate gets bigger. So the resistance of the outflow tract, if we go back to this model, which I think is super helpful.

So we see we make urine, collects in the bladder, then it goes through this channel, the urethra out. And so this is the prostate. So you can imagine as we age, the prostate can get bigger out, but it can also get bigger in. So this can narrow this channel, make it harder to empty. So the bladder has to work a little harder. It gets spastic. Sometimes it can reduce capacity, the ability to fill. And so sometimes we just have to wake up at night.

Sometimes at night, with obstructive sleep apnea or other things, we produce more urine at night. And so that also makes us have to wake up more. So once a night’s pretty normal, but when it starts to be a little more disruptive, 2, 3, 4 times, I think definitely you want to get evaluated because there are different medications that can help with that, different treatments that are available. So there are things that can be done.

MEL ROBBINS: (01:03:56 – 01:04:00): Standing there and it’s just taking a lot of time for anything to come out?

DR. MICHAEL EISENBERG: (01:04:00 – 01:04:05): It depends how much that bothers you. I think if you empty your bladder, it’s probably not a problem.

MEL ROBBINS: (01:04:05 – 01:04:05): Okay.

DR. MICHAEL EISENBERG: (01:04:05 – 01:04:19): But if it does bother you, bothers your partner, I mean, there’s things that can be done. I think one of the big issues is just the prostate resistance. It’s harder for everything to relax on time, to contract on time. And so there’s medications that can help optimize that a little bit too. So that’s another option.

MEL ROBBINS: (01:04:19 – 01:04:25): If you’re having trouble with frequency or emptying your bladder, could it be a sign of a deeper issue with the prostate?

DR. MICHAEL EISENBERG: (01:04:26 – 01:05:06): Anytime men have any urinary symptoms, we always want to evaluate to make sure there’s nothing we’re missing. So we usually check a urine test to make sure there’s no signs of infection, inflammation. Those can certainly be some of the symptoms that we see. A lot of times, again, depending on the age, we’ll check the prostate-specific antigen or PSA. It gives us a sense of how big the prostate is, but also it’s a screening test for prostate cancer.

Usually this is more of a quality of life issue, not a life and death issue. So I think that’s what men should be aware of. Your partners should be aware of that as well. And— but talk to your doctor about it. I think that it is something that men just kind of think is normal and they just tend to live with it. And if it’s not worth a pill, maybe that’s fine. But there’s usually treatments that are available that are very effective.

Warning Signs of Prostate Cancer

MEL ROBBINS: (01:05:07 – 01:05:15): That’s super helpful. Are there any warning signs that we should be aware of that may indicate prostate cancer?

DR. MICHAEL EISENBERG: (01:05:16 – 01:05:32): Usually, most commonly, prostate cancer is diagnosed just with a blood test. So it tends to be asymptomatic and it’s just done by screening. So if there’s a strong family history, usually we start screening a little bit earlier. But otherwise, guidelines about starting in your 50s just with an annual or semiannual test.

The Most Important Action to Take

MEL ROBBINS: (01:05:33 – 01:05:49): Terrific. That’s so helpful. You have taught us so much today, Dr. Eisenberg. If the person listening does just one thing after hearing all of this, what do you think the most important action to take is?

DR. MICHAEL EISENBERG: (01:05:50 – 01:06:20): The most important thing I would say is just to be aware of your health. Realize that you have agency, that you can improve things. Take an internal inventory because we’re not just talking about sort of quality of life. I think some of these things could have real impacts on longevity too. Try and be more active.

If you haven’t seen a doctor before, you don’t have to go every year, but getting checked is important to find out what your blood pressure is, what your cholesterol is, because all those things tie so closely to some of these issues that we talked about— testosterone, sexual function, reproductive function. So I think those are also going to be really crucial and just know that you can improve them.

Parting Words

MEL ROBBINS: (01:06:22 – 01:06:24): Dr. Eisenberg, what are your parting words?

DR. MICHAEL EISENBERG: (01:06:25 – 01:06:41): First, I want to thank you for just highlighting men’s health. I think men’s hormonal health, sexual health, reproductive health— I think it’s so important. It’s not talked about, but I just want to let everybody know that this is a very important topic and something that a lot needs to be done about and can be done about.

MEL ROBBINS: (01:06:41 – 01:07:27): Well, what I love about your work and the way that you talk about it is you make me believe that you can do something. The fact that when I asked about erectile dysfunction, you’re like, “Oh, no, no, no, we can— you got a penis, I can make it hard.” “Oh, no, no, no, no, no. Testosterone. We can work this out.”

And knowing that you don’t have to live in shame, you don’t have to live feeling low mood, low energy, that there may be and there probably are underlying conditions that medical experts like you have incredible tools and different medications that can truly help you not only feel better but live a more fulfilling life. I just think that’s so cool.

DR. MICHAEL EISENBERG: (01:07:28 – 01:07:28): It is really cool.

MEL ROBBINS: (01:07:29 – 01:07:58): Thank you for taking time out of your schedule. Thank you for doing the research that you do, and thank you for coming here and educating all of us and giving us the ultimate guide, in my opinion, to male hormone health and also helping us understand why it actually matters. I love that it’s tied to longevity. I love that it’s tied to a sense of agency over yourself. And I love that there are things that you can do for every issue that we talked about. So thank you.

DR. MICHAEL EISENBERG: (01:07:59 – 01:08:00): Thank you, Mel. This has been a pleasure.

MEL ROBBINS: (01:08:00 – 01:09:04): You’re welcome. And thank you. Thank you for making time to listen to this. Thank you for being generous with Dr. Eisenberg’s teaching and all the time and wisdom that he poured into you. And thank you for sharing this with the men in your life that you care deeply about.

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