In this landmark episode of Pearls & Perspectives, host Amy Pearlman, MD, sits down with one of the world’s foremost experts in sexual medicine, John P. Mulhall, MD, of Memorial Sloan Kettering Cancer Center in New York, New York. Known for shaping the way clinicians understand and manage testosterone deficiency and male sexual dysfunction, Mulhall offers an unfiltered, evidence-based deep dive into testosterone evaluation, treatment nuances, and evolving prostate cancer management strategies. The episode covers: • When and how to accurately measure total vs free testosterone—and why lab assays matter more than most think. • Why symptoms alone are unreliable and why objective signs like bone density, A1c, and hematocrit are vital. • The clinical implications of functional hypogonadism and the flaws in "wait-and-see" lifestyle approaches for obese men. • The controversial relationship between testosterone and prostate cancer recurrence—and how the saturation model is changing practice. • Emerging strategies in androgen deprivation therapy survivorship, including testosterone reintroduction post-treatment. • Rational prescribing of testosterone therapies and clomiphene, with emphasis on LH targeting, fertility preservation, and cost-conscious decisions. • The overlooked connection between unexplained high hematocrit and untreated sleep apnea in men with low T. From redefining how we interpret prostate-specific antigen to confronting outdated fears around testosterone therapy, Mulhall brings clarity, passion, and bold insights to every minute of this discussion. Chapters 1:20 Checking total vs free testosterone 16:00 Preventing frailty in patients on ADT 26:25 A hypothetical patient 3 months away from radical prostatectomy 33:48 Collaborating with oncologists 28:15 Testosterone formulations 42:59 Topical testosterone 55:54 Obstructive sleep apnea and low testosterone REFERENCE 1. Flores JM, Mulhall JP. The pre-testosterone therapy checklist. J Sex Med. 2022 Aug;19(8):1214-1217. doi:10.1016/j.jsxm.2022.03.619

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