Dr. Tobias Kohler on men’s health, heart risk, and testosterone
What if the earliest warning sign of cardiovascular disease wasn’t chest pain, but a change in the bedroom?
That question stays with me, and it’s why I was so glad to welcome Dr. Tobias Kohler, Chair of Men’s Health at Mayo Clinic, back to the podcast. We covered male longevity, cardiovascular screening, and what actually happens when men push testosterone far past where it belongs. If you’re a man, or you love one, this conversation is about taking ownership of your health before a crisis forces the issue.
Men are falling behind
The longevity numbers are sobering. The average American man lives to about 76, while the average woman lives to roughly 82. That six-year gap is the widest we’ve seen in decades. Of the top ten leading causes of death in the U.S., men lead in nine. Women lead only in Alzheimer’s, which is largely a function of living longer.
Part of the problem is structural, and it’s something I think about constantly. After pediatrics, young women move to an OB/GYN for regular preventive care. Young men often move to no one. That leaves a 10- to 20-year gap in care during exactly the decades when screening and lifestyle intervention could change the trajectory of a man’s life.
Dr. Kohler pointed to a bipartisan bill to establish a federal Office of Men’s Health, modeled on the Office of Women’s Health created 30 years ago. When Ireland and Brazil launched dedicated men’s health initiatives, they saw dramatic drops in male cardiac and cancer mortality. We can bring that same intentionality to medicine here, and it’s long overdue.
Erectile dysfunction is a vascular warning system
Dr. Kohler repeated the line that made his first episode so memorable: the penis is the ultimate check engine light.
An erection requires healthy blood flow, functional nerves, balanced hormones, and psychological well-being all working together. There’s also a simple mechanical reason it’s often the first thing to fail, known as the artery size hypothesis. The arteries supplying the penis are much smaller than the coronary arteries supplying the heart. When endothelial dysfunction and vascular disease begin, the smaller vessels show it first. Symptoms often appear in the bedroom years before a blockage ever causes chest pain. On average, erectile dysfunction shows up two to five years before a major cardiovascular event like a heart attack or stroke.
Erectile dysfunction often appears two to five years before a major cardiovascular event.
That window is an opportunity. The updated Princeton IV guidelines formalize the connection: when a young or middle-aged man presents with vascular ED, his physician shouldn’t just write a prescription and move on. He should get an ACC/AHA cardiovascular risk calculation. For men at borderline or intermediate risk, a coronary artery calcium (CAC) score can find early arterial plaque long before it becomes fatal.
There’s also encouraging news about treatment. Observational data suggest that daily low-dose PDE5 inhibitors like tadalafil (Cialis) may improve endothelial function and support vascular health, on top of their urinary benefits. Randomized trials are still needed to prove a direct cardioprotective effect, but the mechanistic signals are compelling.
The ceramide score: a biomarker that responds to how you live
Standard lipid panels like LDL and ApoB give us critical baselines. Mayo Clinic also helped validate a more specialized marker: ceramides.
Ceramides are membrane lipids that reflect active injury to the vessel wall and endothelial inflammation. The test is reported on a 0 to 12 scale across four risk tiers, and high ceramide ratios signal a significantly elevated risk of cardiovascular events.
What I love about this test is that it responds to behavior. Unlike static genetic risk factors, ceramide levels change relatively quickly with lifestyle. Better nutrition, intelligent training, and weight management can bring a high score back into a safer range. As someone who has spent her career arguing that muscle is the organ of longevity, I find it powerful to have a marker that shows the work is paying off.
We also talked about where lipid targets should sit, drawing on guidance from Mayo preventive cardiologist Dr. Stephen Kopecky. For someone with established plaque or a prior cardiac event, the target LDL is under 55 mg/dL. For primary prevention in a high-risk person, it’s under 70 mg/dL. For someone at moderate risk, it’s under 100 mg/dL.
The truth about testosterone: physiologic range versus redlining
Testosterone follows the rules of basic physiology. Too little creates systemic dysfunction. A healthy physiological range supports tissue and metabolic health. Redlining the engine causes long-term organ strain.
Healthy young men in their prime typically sit around a median of 500 to 530 ng/dL, with a normal reference range of roughly 264 to 916 ng/dL.
Testosterone ranges, from below range to redlining (not to scale).
One of the most practical ideas from this conversation is to establish a young baseline. Checking your testosterone around age 25, when you feel great, gives you a personal reference point. That’s far more useful than comparing yourself to population averages once symptoms show up at 45.
At the other extreme, running levels in the thousands, which is common with anabolic steroid abuse, is linked to left ventricular hypertrophy, impaired cardiac strain, and disrupted electrical signaling. That last one raises the risk of fatal arrhythmias. The side effects are not trivial either. High-dose androgen abuse frequently causes severe cystic acne, accelerated hair loss, and tendon injuries, because muscle growth outpaces connective tissue adaptation. In women, it can cause irreversible changes such as a deepened voice.
This is where I want everyone to pay attention, because it’s the heart of what I teach. In the landmark 1996 Bhasin study on testosterone and strength, supraphysiologic testosterone increased muscle mass, but the most profound strength gains came from combining testosterone with structured resistance training. Hormones amplify a signal. The signal itself, the mechanical tension of lifting heavy, is still the primary stimulus your body needs. There is no shortcut around the work.
Peyronie’s, the treatment ladder, and rehab after prostate cancer
We also got into topics many men never feel comfortable raising with their doctor.
Peyronie’s disease is localized scarring in the tunica albuginea, the connective tissue of the penis, which causes an abnormal curve or pain during erections. It’s often triggered by buckling microtraumas during sex when an erection isn’t fully firm. Men with fibrotic conditions like Dupuytren’s contracture share a genetic tendency toward this kind of scarring.
When it comes to managing erectile dysfunction, treatment follows a progression.
The erectile dysfunction treatment ladder.
Penile implants are reserved for end-stage dysfunction, when every other therapy has failed, and patient satisfaction is high at 85 to 90 percent or more. Removing an implant does leave the organ nonfunctional, but only because baseline erectile capacity was already permanently lost before the surgery.
For men treated for aggressive prostate cancer, surgery or radiation often affects the surrounding nerves and blood flow. Structured penile rehabilitation supports vascular recovery and helps preserve tissue length. That can include regular PDE5 inhibitor dosing, vacuum devices, and injections. The strongest predictors of success are a man’s health before surgery and whether the nerves were spared. Between 25 and 50 percent of men recover functional erections on oral medication alone.
Final takeaway
You are the CEO of your own body. Health isn’t something that happens to you; it’s something you manage.
Get your baseline data early: hormones, lipid panels, and a CAC score when it’s indicated. Treat training and movement as non-negotiable, because heavy lifting, daily activity, and recovery are the foundation everything else is built on. And be your own advocate. Bring a written list of questions to your appointments, insist on clear answers, and take early warning signs seriously before they turn into major health events.
