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The Dr. Gabrielle Lyon Show
The Science of Optimizing Your Testosterone | Abraham Morgentaler, MD
01:54:29
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- [00:00]
Dr. Gabrielle Lyon
Does testosterone really cause prostate cancer? What's the relationship between testosterone and libido? And how does the modern stress of life impact your hormones and sexual health? Hi, I'm Dr. Gabrielle Lyon. These are just some of the questions we're tackling today with Dr. Abe Morgenthaler, a world renowned urologist and pioneer in men's health. Together, we'll explore the biggest myths, misconceptions about testosterone, the surprising truths about sexual health, and what every person needs to know to protect their health and their relationship. From how to spot early hormone imbalances to cutting edge advances in hormone therapy, this episode is packed with insights that could help you live longer. So are we looking at testosterone and hormones all wrong? Let's jump in because these answers could completely change how you think about your health. I just wanted to jump on here with an exciting announcement. I am hosting the second ever Forever Strong Summit April 26th, 27th, in Houston, Texas. 2025. There's going to be two days, the VIP day. On April 26th, you will learn from former Navy Seals, from former Secret Service, from individuals that you do not want to miss. Myself, my inner tribe will be there to support you to learn everything from muscle health to science to nutrition. You don't have to be an expert. You don't even have to have a background. All you have to have is a will to win and stay strong. I will put a link in the show notes below. Please go to my website, drgabriellelline.com we sold out last year and I would hate for you to miss this opportunity. So if you're waiting for a sign, if you're thinking you need to change something up and you need community friends, we've got you covered. Dr. Abe Morgenteller, welcome to the show.
- [02:13]
Dr. Abe Morgentaler
Oh, it's great to be here with you. Thank you.
- [02:15]
Dr. Gabrielle Lyon
You are really, I don't even want to say the godfather of testosterone replacement therapy, but you are responsible for bringing testosterone replacement therapy to the modern world.
- [02:30]
Dr. Abe Morgentaler
Thank you. You know, it's hard for me to accept something like that, but practically speaking, I think that that's right. And, you know, I started doing this at a time when everybody thought testosterone was going to absolutely give people prostate cancer. Like, pow. Right away. Just a little whiff for a week or two. Prostate cancer, that's the fear that we had. And I got interested in it. And I'd love to tell you how I got started, but my work has really been about using testosterone and showing that it didn't really cause prostate cancer. I didn't Know that before I started, but that's what happened. And as the barrier to testosterone dropped because people weren't so worried about prostate cancer, then all sorts of things opened up. And here we are 35 years later.
- [03:23]
Dr. Gabrielle Lyon
You know, it's really tremendous. And number one, you went to Harvard, graduated from Harvard College, then went to Harvard Medical School, and then you completed your residency at the Harvard program in urology. Just. Just tremendous. You are recognized as an international authority on men's health and a pioneer in testosterone replacement therapy, which, you know, we were all having dinner. You, your colleague, our colleague, Dr. Mokera, my husband, Shane Kronstadt, who is also a urologist. Go figure. And there aren't that many giants left. There is not a ton of innovation happening from the individual level. Right, but you were brave enough to do that at a time when testosterone therapy, and I want to talk about the history. Was really deemed dangerous.
- [04:20]
Dr. Abe Morgentaler
Right.
- [04:20]
Dr. Gabrielle Lyon
And that people were a hundred percent sure that testosterone replacement therapy was going to give people prostate cancer, and you challenged that notion. I would love to hear that backstory. And how many tomatoes were thrown at your face and how that you probably had three friends, and one of those included a sibling and maybe a parent.
- [04:41]
Dr. Abe Morgentaler
Oh, my God. So, well, listen, thank you for that. And it's kind of amazing. Sometimes I sit here and think back, like, on all the changes that have happened and how we went through things. And truthfully, it did require a certain amount of courage because I was doing something that was considered dangerous. But I always felt like what I was doing was in my patient's best interest and with open communication and discussion of what the potential risks were. So the story originally begins, if I may, when I was 19 years old and I was an undergraduate at Harvard, and I was supposed to be a hockey player. Like, in my head, I was going to be, like, a professional hockey player. And it turned out I could play at a decent level. I played freshman at Harvard, which is a good school to play freshman level. There's no way I was going to play varsity. And in my second year, I didn't know what I was doing. And I ran into a biology professor from whom I'd taken a class in Harvard Square, and I was completely lost. I was just a lost sophomore, not sure what I was doing. And he said, how you doing? I told him, actually, I'm not doing that well. I don't know if I should, you know, just stop college, you know, just drop out. And he said, why don't you come work in my lab? You might like it. His name was David Cruz and he changed my life and put me on a track from age 19 to here I am 50 years later. It's unbelievable. And so he had a reptile lab and he was interested in sex hormones and the brain. And so the first project I worked on, these little American chameleons, they're all over Florida. If you've been there, you see them everywhere. On the walls, on the sidewalks, inside your hotel room. Sometimes terrifying and terrifying. And you put a male in the cage with the female, and they have this bright colored flap of skin that comes out. It's called a dewlap. And the male sees the female, the dewlap comes up and their head bobs really quickly. It's almost like the male is going, yeah, yeah, yeah, yeah, yeah, like he's interested. The female does a little stately push up that says, okay, buddy, what you got? And then the male comes closer and repeats the behavior, and then they mate. So if you castrate the male, which means removing the testicles, which was the first procedure I ever did in a lizard, in anything, not knowing I was going to go to medical school, let alone become a urologist. But if you castrate the male, you put them in a cage with a female, they don't do anything. They have no interest. The female will sometimes do her push up and say, hey, buddy, I'm over here. But their testosterone is gone. And then my project was we'd mapped out where in the brain, the itty bitty brain of these itty bitty lizards where testosterone was taken up and what was likely to be the sexual centers. And my project that took three years to do was to put tiny implants of testosterone powder into those little sections of the brain. And when I was successful in doing it and putting it in the right place, these males that had no detectable testosterone, just testosterone in their brain, would see the female. The dewlap would come out, head would bob up and down. Yeah, yeah, yeah. And they would mate. It was the most amazing thing. And so my first publication on Testosterone is in 1978, and that was the start. And then when I became. I went to medical school, I learned almost nothing about testosterone. It was important for puberty. That was about it. It was important for men to sort of be functional. But we didn't learn about Testostero deficiency or anything like that. And then I go into practice and I start dealing with men with sexual problems. And some of these guys were desperate.
- [08:37]
Dr. Gabrielle Lyon
How did you choose urology?
- [08:40]
Dr. Abe Morgentaler
Well, it wasn't obvious. I didn't know anything about urology, really. I was in general surgery, and I loved operating. And I thought surgeons had, if you'll forgive the expression, the biggest balls in the hospital. And I said, I want to do that, but I didn't like being up at night. And a lot of the emergency operations were at night. Appendectomies, gallbladders were dealt with, perforated ulcers. And so I looked for a field where they did good surgery, and they were nice, and they had very few nighttime emergencies. And the urologists that I encountered had told the best jokes in the or, and they were, some of them, superb surgeons. I said, I'll do that, but I really didn't know much about it. And then it turned out to be perfect, because especially with my lizard experience and then human sexuality, that was a fit made in heaven. So these guys come to see me and they say, doc, I'm desperate. This was 10 years before Viagra. This is 1988. And I said, don't you have something? My wife, my girlfriend, she's going to leave me. Like, I'm desperate. I'll try anything. And I thought to myself, could testosterone work in men? Could men be like lizards?
- [09:51]
Dr. Gabrielle Lyon
How far into practice were you?
- [09:52]
Dr. Abe Morgentaler
Just starting.
- [09:53]
Dr. Gabrielle Lyon
Just starting.
- [09:55]
Dr. Abe Morgentaler
Just starting. I'd come out of residency in six years of residency, two years general surgery, four years of urology. Never once did we ever give testosterone. All we heard every week, like on weekly rounds, grand rounds. Testosterone causes prostate cancer. You give testosterone, you have prostate cancer. And of course, we were treating, get this, we were treating men with advanced prostate cancer by removing men's testicles. Not lizard testicles, men's testicles. And this is part of why there's a misunderstanding, so much misunderstanding about testosterone and prostate cancer, which is. And I'll just tell you, like, some of this was obvious and impressive. There's a relationship, clearly. So back then, PSA was just beginning to be introduced. We didn't have a blood test to screen for prostate cancer. And so almost everyone diagnosed with prostate cancer back then was diagnosed when it was already metastatic. And they'd come into the emergency room with terrible pain, pain in their bones. Prostate cancer goes to the bones preferentially, and sometimes we would operate on them to remove their testicles. And the same night after surgery, their pain was gone. And so the story made sense that lowering testosterone helped these guys. And if lowering testosterone is effective for guys with advanced prostate cancer, then raising it has to be dangerous. Like, that story kind of made sense until. Until it didn't until it didn't. Until it didn't.
- [11:39]
Dr. Gabrielle Lyon
Did anyone think to challenge that? Because one doesn't necessarily equal the other. You remove the testicles, you drop their testosterone to what? Zero.
- [11:49]
Dr. Abe Morgentaler
Gabriela, it's an amazing story. I mean, it's really. And it tells us not only about testosterone, prostate cancer, but how medicine works and how medicine can often fail us. Also how you get these crazy bad ideas. I remember when I was like 10 or 12 or something at the beach with my parents, and I had lunch, and then my dad says to me, my dad was a physician. He says, so you can't go swimming.
- [12:14]
Dr. Gabrielle Lyon
For two hours because you ate lunch?
- [12:16]
Dr. Abe Morgentaler
Yeah, because I ate lunch. I say, why? He says, well, your digestive system needs the blood supply now that you've eaten. And it made no sense to me. But that was taught to doctors at the time, who then told everybody else, it's just nonsense, like don't eat eggs, Right?
- [12:32]
Dr. Gabrielle Lyon
Yeah, yeah.
- [12:34]
Dr. Abe Morgentaler
The cholesterol thing turned out to be wrong. But for a generation, often these things are wrong. The testosterone story is wrong for 80 years. For 80 years. Now, it starts with 1941. A guy named Charles Huggins, together with his co author Clarence Hodges, took, based on experiments in dogs. They thought there was no treatment for metastatic prostate cancer. So guys would come into the hospital regularly through the emergency room in pain, like I mentioned.
- [13:03]
Dr. Gabrielle Lyon
And is that how they would find prostate cancer?
- [13:05]
Dr. Abe Morgentaler
That's how they found it, yeah. And so it shows up on X rays, plain X rays as denser than bone, which is unusual for cancer. So you could make the diagnosis almost exclusively on that. And they used a blood test. They started to use a blood test called acid phosphatase, which we don't use anymore. But that was big for Huggins. And what he did is he castrated these men. And he showed that this blood test, acid phosphatase, came down when he castrated him. He also claimed that raising testosterone made the cancers grow more quickly. And because of that work, 1941, people stopped using testosterone. It was first synthesized in 1935, became available soon afterwards. And there was this golden period of about four years where people wrote these amazing, amazing articles about the benefits of testosterone. Amazing articles. They were using it for men and women who had angina, chest pain from exertion. Right. Where you don't have enough blood flow to the heart. With remarkable, detailed case histories. I think the largest series was 99 individuals. That's pretty big series for the late 1930s. Right. And very convincing and compelling. In 1941 comes the story about testosterone more or less causes prostate cancer and makes it very dangerous and everything stops like cold. So that by the 1980s, when I was a resident, we never, ever, ever gave testosterone.
- [14:43]
Dr. Gabrielle Lyon
For 40 years, men were castrated, not given testosterone, because of a few innovators. I have a question for you.
- [14:54]
Dr. Abe Morgentaler
Yeah.
- [14:55]
Dr. Gabrielle Lyon
That seems extreme. So my question is, you know, just fast forwarding, thinking about, you know, I've been in practice since. I've been a physician since 2006. Yeah, that would be very extreme for an individual, no matter what their specialty is, to make a significant change, like castrate an individual, where there has to be some kind of reasoning, where we know without a shadow of a doubt perhaps, that what you're going to do is absolutely going to benefit the patient, because there's no reversing that.
- [15:33]
Dr. Abe Morgentaler
Right. So that's true. But what made it compelling, the castration part. And they also used estrogen treatment also, which they didn't know it lowered testosterone. They thought it just antagonized how testosterone worked.
- [15:48]
Dr. Gabrielle Lyon
Meaning they gave estrogen or fucked it.
- [15:50]
Dr. Abe Morgentaler
No, they gave testosterone. They gave. I'm sorry, estrogen as a form of blocking the testosterone effect. They both worked. But what was compelling about it was just like I told you, that I saw in my own. With my own eyes, just talking to the patients who came in when I was a resident, and we would remove their testicles and their pain would get better. This was the first treatment for these guys. Otherwise, they just got pain meds. There was nothing else. And Huggins rightly won the Nobel Prize awarded to him 25 years later. He didn't just work on. He was really the first or one of the first to ever show that any cancer could be sensitive to hormonal manipulation. And so other doctors would. Did what he did, and they saw with their own eyes that this worked. So that became the thing. And it wasn't just. And where the things went awry is the idea not just that lowering testosterone to severely low levels was beneficial, but it got thrown in with this idea that testosterone must be dangerous, and that's where things are off.
- [17:00]
Dr. Gabrielle Lyon
How did you figure that out? Yeah, I mean, because you were the only one, I'm assuming, that was willing to challenge that or to think outside the box in a way that perhaps this wasn't right.
- [17:12]
Dr. Abe Morgentaler
Yeah. So here's how that happened. And just to lay the background a little bit, the reason nobody challenged it is because there was. Testosterone had just started. There was no. We didn't think about it the way we think about it. Now, right? So there's a lot of physicians now who are very pro testosterone. Let's find these guys who are doing poorly in one way or another. Let's make them feel better and their health better. Right? But that wasn't true back then. It was this new chemical that was available and there was no doctor who had a huge number of patients in his practice that could say, now hold on a second, I've treated 200 guys. This doesn't happen. They don't get prostate cancer. Those things didn't happen because it was a self perpetuating concept, like if you really believe it, you're not going to use testosterone. Why would you put your patient at risk?
- [18:06]
Dr. Gabrielle Lyon
Totally.
- [18:07]
Dr. Abe Morgentaler
So nobody did it. And the only reason I did it was because of my experience with lizards and the desperation of some of these men. So I lined up when I started, I wasn't trying to change the world and I had no idea if testosterone would be good for them. No idea. But they were willing to try. And I told them, this could cause prostate cancer for you. They said, doc, I'll sign anything, I don't care. I'm in trouble right now and I'll do whatever it takes. And so we tried a few things and right away what these guys said to me is, yeah, not only was sex better, sex drive erections were firmer, but they said things to me I had never expected to hear and I didn't really know what to do with it. They said, my wife likes me again. They said, I have four small children. I've never had so much patience with them before. One guy says, I wake up in the morning, I swing my legs over the side of the bed and I'm optimistic about my day. I haven't felt that way in 15, 20 years. And I wondered, maybe this is, you know, in medical school you learn a lot about placebo effect. These guys were getting the male hormone.
- [19:23]
Dr. Gabrielle Lyon
30% should improve. Yes.
- [19:25]
Dr. Abe Morgentaler
And maybe there's a placebo effect, the non sexual part. But what convinced me that it wasn't was that when I had to find out, how do you treat men with testosterone? So I say, nobody gave testosterone. There were exceptions, but they were rare and they were treated by endocrinologists. For these young men generally who didn't get through puberty, even though they were in their 20s because of genetic issues like Kalman syndrome, Klinefelter syndrome, or they had pituitary tumors, or maybe they had lost their testicles, both of their testicles to trauma or cancer. So there were in every city There would be a handful of men with these rare conditions. And the endocrinologists learned how to treat those guys. But the idea that you could treat a regular guy without a pituitary tumor with two testicles wasn't known. So. But I went to the endocrinologist, the senior person, I said, how do you treat with testosterone?
- [20:22]
Dr. Gabrielle Lyon
At Harvard or somewhere else?
- [20:24]
Dr. Abe Morgentaler
Yeah, at my hospital, Beth Israel Deaconess Medical Center. And she said, oh, it's easy. You give 200 milligrams of testosterone Cypionate every four weeks. So that's what I did. And the patients came back and what I told you, all the good stories they had to say were true. But every one of these first guys I lined up said, but, doctor, I gotta tell you, for a week or two before my next injection, all my symptoms comes back. What's up with that? And I joke that it's like a bad version of a double blind experiment, because the patient didn't know and I didn't know. I didn't know what was going on. So they feel so much better, and then they don't. Until I started checking blood tests on these men. And it turned out by two weeks, everybody's blood level of testosterone had returned to their baseline low value. And so what I learned from that, from the first three patients was that because there's no way the guys knew what their blood levels were. I didn't know. Right. I said, guys can tell when their levels are good and they can tell when their levels are low. It changes almost on a daily, on a daily basis. They can tell the moment that they drop. So I said, this is real. This is no placebo effect. And so that gave me. And they didn't get prostate cancer. Were you worried?
- [21:48]
Dr. Gabrielle Lyon
You must have been. Oh, I was terrified.
- [21:50]
Dr. Abe Morgentaler
Terrified. I spent most of my career terrified.
- [21:53]
Dr. Gabrielle Lyon
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- [23:17]
Dr. Abe Morgentaler
Say that is not with every patient.
- [23:20]
Dr. Gabrielle Lyon
But until it was proven otherwise.
- [23:24]
Dr. Abe Morgentaler
So I, well, I'll tell you. So I pushed the envelope in a lot of different ways. So the first hurdle was just can you give testosterone without making it so these guys get prostate cancer? Where it went next was that there were men who had like pre cancers. We called them technical term is prostatic intraepithelial neoplasia. Pin, which we used to think meant if somebody had a biopsy and they had pin, we said, oh there's gotta be a cancer hiding in there somewhere. And we would rebiopsy them like within weeks. And I gave testosterone to these guys with these pre cancers. Nothing happened. Published that data and then gave it to men after they'd been probably cured of their, of their cancer by surgery. There's about a 15% recurrence rate after surgery. So you never know. And then eventually at near the end of my career even gave it to men who had metastatic cancer or their cancers had come back. And at every point I was still worried that maybe something's kind of bad's going to happen to her. And it never happened, never once. So this metastatic cancer thing is amazing. So today the controversy is so I think everybody is clear out in the medical community pretty much that giving testosterone does not increase the rate of cancer compared to a placebo. The biggest study that we've had is called Traverse, came out about a year and a half ago. In 2023, numbers of cancers in the testosterone group were 12. Number in placebo was 11. This over 5,000 men. Three years of follow up. Roughly it's the same. It's the same. And so that part is kind of clear. Giving testosterone to men who have prostate cancer, that's still controversial. But I've treated many hundreds and hundreds of men like that. Never seen anything bad happen.
- [25:33]
Dr. Gabrielle Lyon
Do you think that, and this is a global statement and partially I'm setting it up because I think I know your answer. Do you think that there is any, in any chronic disease state or for any reason that someone who has low testosterone from A safety perspective should not be given testosterone.
- [25:59]
Dr. Abe Morgentaler
I don't know. I can't think of any condition where that's a problem. You know, where it comes up is there's still some debate about venothrombotic events, dvts, pulmonary emboli, things like that. I think the data are clear. I've been involved in a couple of studies around this and the Traverse trial too showed nothing with that. But I'll tell you where, how people think and how. What they do. There was a guy, there's a doctor who has published on testosterone and this venous thrombosis risk has published a lot on it and he believes testosterone increases that risk. So there's a epidemiology type guy who invited me to participate in research that he was doing looking at this problem and he invited that other doctor who thinks that it's a problem to be an author on the paper. The study comes out or the data comes out and we're all just discussing it, it's written up and it doesn't show any increased risk, none. And this guy's a very, his name, Jacques Bayard, he's a very accomplished sort of public health researcher. And the fellow who thinks that it's a problem looks at the data and says, well, you didn't look at this and that. I think if you do, we're going to find more of these events. So Jacques goes back and he re looks at the data the way this guy wanted him to and nothing. At which point there's an interesting conversation with the other author and says, listen, you know, if you don't want to be an author on this, I'll understand it. But these are the data we have. And to that fellow's credit, he said, well, listen, you did the analysis and if that's what it is, I'm happy to be a part of it. Which is really the way medicine and science should work. So a credit to him. But where his original work came from is he took people who already were at risk for having DVTs and PEs. Like you can have clotting problems, right?
- [28:04]
Dr. Gabrielle Lyon
Meaning did they have genetic disorders that make them hypercoagulable or cancer or something else?
- [28:12]
Dr. Abe Morgentaler
Exactly. So some have this Leiden phi factor that predisposes to it. And so some people say, well, maybe you shouldn't give testosterone to those people. But this is not, this is not clear thinking. So people who are at risk for something are at risk for something. If you then add in something like testosterone, which has not been shown to anything yes. They can get clots again, but it's not because of testosterone. It's because they're at risk for it. Right. You might as well say you just stick a margarine.
- [28:42]
Dr. Gabrielle Lyon
Let's see if that's what happens.
- [28:44]
Dr. Abe Morgentaler
Exactly. Exactly. Right, yeah. So, no. So the answer is, listen, the big ticket items that we've worried about, prostate cancer, cardiovascular risk, those are now clean as far as I'm concerned. Like, there's just no data to show that there's a problem.
- [29:00]
Dr. Gabrielle Lyon
I think this is a really important conversation because I have, you know, I have one dear friend that I can think of right now that he would really benefit from testosterone replacement. Very active individual. He's on the lower end. And we should talk about what low is and the numbers. And if you're 310 in the US versus 310 somewhere else, is it still low? But he is concerned about two things. He's, number one, concerned about safety, and number two, he's concerned what other people would think that he is using it because they're worried about safety.
- [29:38]
Dr. Abe Morgentaler
Oh, yeah.
- [29:39]
Dr. Gabrielle Lyon
And that just makes me think about the beginning of the conversation when you went back to examine the data from. Is it Hutchinson, Huggins. Huggins. Well, Hutchinson's now Charles Huggins. Huggins. You went back and you looked at the original data that everyone had spent 40 years building upon.
- [30:03]
Dr. Abe Morgentaler
Yeah.
- [30:04]
Dr. Gabrielle Lyon
Can you share what that is? Because I know at the time we were talking last night at dinner, at the time, we didn't have the Internet, so you actually had to go to the basement of Harvard to get this study. And I am just curious, as is the listener, what. What did it show?
- [30:18]
Dr. Abe Morgentaler
Yeah, it's an amazing story. So. So I started publishing data showing that this old relationship we thought existed between testosterone, prostate cancer wasn't true and even published in the New England Journal of Medicine.
- [30:35]
Dr. Gabrielle Lyon
Not without recourse, though. It wasn't easy to get that published.
- [30:38]
Dr. Abe Morgentaler
No, no, no. But we published New England Journal of Medicine together with my former fellow Ernani Roden, this in 2004, that we just could not find a single piece of evidence that supported this idea that testosterone was dangerous for prostate cancer. We couldn't find it. We didn't say it didn't exist. We say we can't find it. And the editors at New England Journal, they didn't want to publish that. That was a crazy idea. Everybody was taught this around the world in medical school. It was a foundational concept in oncology that testosterone makes prostate cancer grow. It's bad. You can't Use it. And they sent it out over the course of a year to three sets of reviewers. First, urologists, they couldn't find anything wrong with it. Then three endocrinologists, they couldn't find anything. Finally, to three oncologists. And listen, when we did it, I was relatively young. I thought maybe we missed it. I mean, I believed it until that. Until actually, I pulled all those papers. I believed that high testosterone must still be a problem in some way, even though I couldn't define it. But that's what I've been taught. And then nobody could find any fault in what we'd written. So it was published 2004, took a year. And so I'm kind of on the lecture circuit within medicine and urology, and I'm talking about how we couldn't find the evidence, blah, blah, blah. And there's a great prostate cancer specialist named Paul Lang, and he was on the same faculty at this thing, I think it was at Vail. And we're talking afterwards, and he says, listen, Abe, this is really interesting stuff you got, but you better be careful because it could be different in metastatic cancer. Huggins said so. So I'd heard, of course, of Huggins. Huggins is probably the most important, biggest character in all of urology. Prostate cancer is our biggest topic. He's the prostate cancer guy, Nobel Prize winner. The only urologist to ever win the Nobel Prize. So everybody knows Huggins, but we didn't have access at that time to articles online the way we do today. You can pull up Huggins article now in 20 seconds. I'll give you a couple of keywords. Boom, you'll have it. But not then. Where articles, especially old literature existed was in bound volumes of published journals. And in a department of urology or any department, surgery, gastroenterology, whatever, people would have their bound volumes behind their desk. But it's stuff that they had collected, and maybe it went back there in practice 15 years. They had 15 years worth of bound journals. I was very proud when I started getting my own journals, bound. But nobody had articles that went back 40 years. To do that, you had to go to this crazy building that housed old stuff. It's called the library.
- [33:47]
Dr. Gabrielle Lyon
People don't even people.
- [33:50]
Dr. Abe Morgentaler
And down in the basement of the Harvard. And so I went, because this guy, Paul Lang, said to me, Huggins said so, excuse me.
- [33:58]
Dr. Gabrielle Lyon
And everybody believed it, and everybody practiced based on it for 40 years.
- [34:02]
Dr. Abe Morgentaler
Well, we knew about it, but I'd never read his article. I knew what people said about his article. I knew what My former teachers taught me about his article. So at some point I said, I gotta see what he wrote. I was nervous about it.
- [34:19]
Dr. Gabrielle Lyon
Armpits were sweating is the whole thing.
- [34:21]
Dr. Abe Morgentaler
Well, to be honest, I had a good thing going around this testosterone product. My patients were happy, and I didn't want to mess it up. And in the end, I said, I gotta do it. So I go down to the basement of the library. There are all these old dusty volumes. You take it out, you have to blow the dust off the top. And there it is. 1941, cancer research. And there's the article by Huggins and Hodges. And I read through it, and I had two small children at the time. And I'm thinking, I read through it in the last sentence. The last sentence of the article says, testosterone injections activate prostate cancer. And I was sick to my stomach. I was awful. My hands were sweaty. And I had visions of the Harvard police coming and arresting me then and there. And it being a big Boston Globe front page store that my kids would see, you know, the Harvard doctor, like, arrested for, you know, ethical malpractice by giving testosterone. And so I forced myself to reread the article and just wrote down a few basic questions. How many men did he treat for how long? And it turned out that the number of men he had treated, most of this was about the guys he'd castrated. The number of men he treated was only three. And of only three of the three he had treated, he only actually gave any information about two of them. One of those men had already been castrated, which today we know is a special case. So this whole idea that testosterone causes, as general concept, makes prostate cancer grow, or as Huggins said, activated, was based on one guy who received Testosterone for only 18 days. And his curve is uninterpretable. Goes up and down, up and down, before and after testosterone. It was amazing.
- [36:20]
Dr. Gabrielle Lyon
We have to pause there. Why we have to pause is the gravity of what you're saying. People have to understand.
- [36:30]
Dr. Abe Morgentaler
Yeah.
- [36:31]
Dr. Gabrielle Lyon
They were castrating men based on a belief from this individual, who, again, is probably a phenomenal scientist. There were two viable patients in the study. Maybe one viable because one was castrated.
- [36:48]
Dr. Abe Morgentaler
Only one.
- [36:49]
Dr. Gabrielle Lyon
One viable patient. Based on a way you guys were looking at this acid.
- [36:55]
Dr. Abe Morgentaler
Acid phosphatase.
- [36:56]
Dr. Gabrielle Lyon
Acid phosphatase, which now isn't even used, treated for 18 days with testosterone and changed the lives of millions. Yeah, millions.
- [37:09]
Dr. Abe Morgentaler
Yeah.
- [37:10]
Dr. Gabrielle Lyon
Of brothers, of fathers, of husbands.
- [37:14]
Dr. Abe Morgentaler
Yeah.
- [37:16]
Dr. Gabrielle Lyon
What can we learn from that?
- [37:18]
Dr. Abe Morgentaler
Yeah. I'm so glad that you're underscoring. This point because, you know, I've done research since. For 50 years, since I was not just yesterday. And all different kinds, right? Like randomized trials, pharmacokinetic studies, animal studies, basic science studies. My greatest discovery was actually figuring out, finding out that Huggins based this whole thing on one patient. And he was wrong about. There was a misinterpretation of that information. And that's the basis why people around the world have learned for 80 years have been told that testosterone activates prostate cancer. And later it switched. Huggins never said this, but people started to believe that testosterone actually caused. Caused prostate cancer, which it doesn't do either. There's no evidence for that. None, Zero. Nor does it make the cancer any worse. Unless. Here's the thing, unless you're already castrated, which only happens if you've already been treated for advanced prostate cancer. And that's where people have messed up.
- [38:34]
Dr. Gabrielle Lyon
Do you think that this is a bigger conversation about blind spots and critical thinking?
- [38:39]
Dr. Abe Morgentaler
Yeah, it absolutely is. You know, so the field has moved. I'm proud to have been involved in some of that. But, man, it's hard. I've been railing at this point for so long. You know, I've been debating on stage at the national urology meetings, prostate cancer stuff for so long, and that's probably.
- [39:05]
Dr. Gabrielle Lyon
Not a comfortable place to be.
- [39:07]
Dr. Abe Morgentaler
Well, I have to tell you, there's a part of me that enjoys that. I do, especially because all the arguments are on my side. It's an amazing thing and to try and get people to open their minds. But these ideas die hard. I would say that the myth about testosterone and prostate cancer is the most persistent myth in medicine. It's been pervasive. And just the other day I had somebody that I know who's in his mid-70s, he's got an uncertain spot by MRI of his prostate. So he went to see this prostate cancer specialist, says, listen, we're going to biopsy it. I don't know that we're going to treat it necessarily, you know, given your age. And it may just be, you know, a low risk thing, but if we find anything at all, you're going to have to stop your testosterone. Which he's been taking for about 10 years with great success. Now, this is an academic center in a major city. There's no reason, it makes no sense that academic people are still saying this garbage to people. It's based on nothing.
- [40:14]
Dr. Gabrielle Lyon
Why? Why is that still happening? It's the same thing where someone says, don't eat eggs because they are raise Your cholesterol raise your cholesterol.
- [40:23]
Dr. Abe Morgentaler
Yeah. Which they don't. But that's a whole other topic. So, you know who said it best is so old ideas die hard. And there's this guy, Max Planck, who won the Nobel Prize for physics somewhere in the 40s or 50s, and he wrote about new ideas. And I'll try and do the quote credit because I think it's great. He says new scientific concepts do not triumph because the opponents to it have been convinced and now they see, all of a sudden, see the light. It's because they die. Because they die. And the new generation that's familiar with it grows up with it. And the short version of that is that science precedes one funeral at a time.
- [41:13]
Dr. Gabrielle Lyon
And you're not the first scientific expert that has said that.
- [41:17]
Dr. Abe Morgentaler
Right. So it's just amazing. People hold on. And what happens is people don't like new information. They don't like new concepts that differ from what they've been taught. I've had people, you know, early days, I had people walk out of my lectures. I gave grand rounds at important places like UCLA and elsewhere. And there was an older chief, and the chief always has the last word after the guest speaks. And I remember at ucla, Gene De Kernian, who was a famous and very important brilliant man. So some of the stuff I'm talking to you about today is. Was not nearly as. It didn't have as many supporters as it did then. And he said, well, this is all very well and good, but, you know, I remember back in the day we had experiences that were completely different with that. So I'm not going to take it too seriously right now.
- [42:12]
Dr. Gabrielle Lyon
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- [43:09]
Dr. Abe Morgentaler
And that was it. He had the final word. The students are there, the residents are there, the other faculty are there. And it's just hard. Some of the old ideas have to just. The people who hold them don't want to change their minds. There's a lot of evidence that people confronted with evidence that contradicts what their beliefs are actually double down and they hold their beliefs even more strongly.
- [43:37]
Dr. Gabrielle Lyon
It's just so fascinating. And I think especially, you know, we all have bias. Right, Right. I believe that there's a certain way to stimulate muscle, and I believe that muscle is so important and how we're going to feed it and nutritional aspects of it. And it is a struggle to remain open minded about other input. But I'm well aware that there's multiple ways to get something done. If you show me, well done, randomized control trials, great evidence, then I have to be willing to change my mind.
- [44:12]
Dr. Abe Morgentaler
Right.
- [44:13]
Dr. Gabrielle Lyon
You know, it brings me to testosterone, testosterone replacement, and there's a few things. There's incredible stigma now still. Would you agree with that?
- [44:28]
Dr. Abe Morgentaler
Which, which stigma?
- [44:30]
Dr. Gabrielle Lyon
Just take out testosterone and prostate cancer, take out testosterone and cardiovascular disease. If one were to just look at testosterone replacement in a man or a woman, people still feel like it's edgy, it's controversial, it's an anabolic, which it is. Why do you think that that is? And then of course, I want to get into, if someone has low testosterone, how do these numbers make sense?
- [45:00]
Dr. Abe Morgentaler
Yeah.
- [45:01]
Dr. Gabrielle Lyon
And how are they different here versus other places?
- [45:03]
Dr. Abe Morgentaler
Yeah. So part of the challenge is that testosterone is still considered by many to be fringe medicine. Right. And the reason for that, in my opinion, is that it's not taught in the medical schools still. So people, you know, we have remarkable amounts of information, wonderful scientific data about testosterone. What's amazing about it is that it's a natural chemical in the body. And it's also true in all these different animals. All the vertebrates have testosterone, have testosterone, or something very close to it, including fish. And so we have natural models to even look at testosterone. The wealth of research into testosterone is phenomenal. Right. And yet people. And we have studies in the top medical journals in the world. Right. New England Journal has really liked all the RCTs about testosterone. Jama has published it, we have stuff in Lancet, all the top journals have data on this. And sort of the regular physician who wants to keep up with the literature, you know, they trust those journals, but it hasn't impacted what they do. And part of the reason. And so what we have is we have a medical Condition testosterone deficiency used to be called hypogonadism, where people have too little of it. Men or women? Men get most of the publicity around this and it's better studied in men, but it's true for both. And do you know that testosterone deficiency either predicts the development of or is associated with many of the most important medical conditions we deal with in healthcare. So obesity, diabetes, the metabolic syndrome, cardiovascular disease, mortality, dementia, osteoporosis, these things are all associated with the deficient amount of testosterone in the body. And beyond that, these men. Let's focus on men for a moment. These men have symptoms that often make them. I say that testosterone deficiency is a reduced state of the human condition. There are data. I told you. There was a golden period of testosterone research from the late 1930s to about 1940. 1940. This guy, Dr. Joseph Aub. Aub writes an article in New England Journal of Medicine that says this is one of the most potent medications that we have in our armamentarium. And they describe men who were basically, they called them broken men back then. Broken men, that was the term. They were these men who just, they lacked confidence. They were quiet, they were introverted, and they got testosterone and they became better. Now, I suspect that we didn't have blood tests back then, not till the 1970s. I suspect that many of these men who underwent these trials had extremely low levels. And the lower your level, the more of a benefit you're going to see, right? And the more the low level is going to impact who you are and how you carry yourself. But, man, this makes a huge difference in how people live their lives. And so the fact that it's not yet accepted by what, you know, I'm a mainstream doctor, but I'm going to call this not accepted by mainstream medicine is our number one problem. And what gets compounded then is that because there's a tremendous need, people now know that testosterone deficiency exists. They know somebody, they heard of somebody who got treated. They say, maybe I can get some too. If the regular primary care doctors aren't treating it, they go elsewhere. And so some of the docs that are doing this are docs that the sort of. I'm an academic guy, you know, it's like science based. But the academic docs see that, those groups of physicians, and they say, I don't want to get involved with that. I don't think that. Well, of those practices.
- [49:23]
Dr. Gabrielle Lyon
Do you think it came from sport? Do you think it. Because maybe potentially it got demonized from sport and anabolic use, part of testosterone's problems.
- [49:33]
Dr. Abe Morgentaler
Has a bad rap. Has a bad rap.
- [49:36]
Dr. Gabrielle Lyon
Because what drug. We'll call it a drug or synth or naturally occurring hormone that one could give, could affect bone, brain, heart, blood vessels.
- [49:49]
Dr. Abe Morgentaler
Blood vessels, everything.
- [49:51]
Dr. Gabrielle Lyon
Nearly every organ system. Yet it is not routine. You don't go into the hospital. And it's not as if 50% of the hypogonadal or testosterone deficiency in men, it's being treated, right?
- [50:06]
Dr. Abe Morgentaler
No, we're treating a. We're treating a tiny fraction of the men who have it. And it's funny because in some ways, testosterone is. The men who really need it don't get treated. Not enough of them. And a lot of the men who don't need testosterone are getting it right through whatever gyms or. Now there's a trend to give it to people who aren't even deficient. You know, I've simply.
- [50:29]
Dr. Gabrielle Lyon
Can we talk about that?
- [50:30]
Dr. Abe Morgentaler
Yeah. Feelings about that.
- [50:31]
Dr. Gabrielle Lyon
I would love to chat with you about that. Let's define testosterone deficiency.
- [50:36]
Dr. Abe Morgentaler
Good.
- [50:37]
Dr. Gabrielle Lyon
In terms of numbers and when one could consider treatment.
- [50:43]
Dr. Abe Morgentaler
Yeah, good. So I think there's broad agreement, and I certainly agree with it, that people should be treated if they have low levels of testosterone. They have either symptoms or what we call signs. Symptoms are things that people experience, like my sex drive is down. Signs are something you can measure, like they're hematocrit, their red blood cell count is reduced, or their bone density is down, something you can measure. So traditionally, all the guidelines say you should have both. Um, the, the challenge is, what's a low level of testosterone? So, and critics of testosterone therapy say the experts can't even agree on what a low level is. And that's true. And that's true. And it's part of the. Part of it is that some of the decisions about what a low level is has been arbitrary. So, you know, the, the. If you. The FDA uses a number below 300 nanograms per deciliter, and if you look at any of their writing, they have no citations for that. There's no reference that says where they got that number from. So the, the, the urban myth that I think is true is based on talking to people, is that when there was a first new testosterone product brought to the FDA in the late 1998, I think it was a patch. The FDA said, well, you have a drug that's supposed to normalize testosterone. Please tell us where the low level is. Fair.
- [52:08]
Dr. Gabrielle Lyon
I mean, that's totally fair.
- [52:09]
Dr. Abe Morgentaler
And so they had a very senior expert, and he said, well, people disagree on the number, but Some people think it should be 400, some say 350, some say 250.
- [52:18]
Dr. Gabrielle Lyon
And free testosterone was not discussed.
- [52:20]
Dr. Abe Morgentaler
Nobody's talked about we have to talk about free testosterone. But nobody's. That hasn't been part of the conversation forever. But. And so this guy said, apparently to the FDA, I think 300 is a fair number.
- [52:34]
Dr. Gabrielle Lyon
Not defined on age. So Matt, my producer, could have 300 and my dad Nate could have 300. And let's say it's 310 for both of them.
- [52:44]
Dr. Abe Morgentaler
Right.
- [52:45]
Dr. Gabrielle Lyon
Could we treat them?
- [52:46]
Dr. Abe Morgentaler
Well, of course you can if they have symptoms. In my opinion, the idea that there's a single. First of all, the idea that there's a single number that separates everybody is just, it's anti scientific. Right. Like we're not, like we don't work like that. Our bodies are not, we're not clones of each other. Right. You do research in animals like rats. They're all the same genetic strain. They're all basically identical twins. That's not true for humans. And we all have different set points for a lot of different things. People can tolerate cold, heat, pain. Like we're all different with all these things. And true also for when people become symptomatic in terms of having low levels of testosterone. But it's worse than that. It's worse than that because what a lone number is, is defined by specialty and by geography. So the endocrine and geography.
- [53:41]
Dr. Gabrielle Lyon
Geography, you have to say that because you got to pause on that.
- [53:43]
Dr. Abe Morgentaler
Yeah. So get this. So in the United States, the endocrinologists, their guidelines say you have to be below 264. Urologists say 300. FDA says 300. Guess what happens in Europe. In Europe, they use 350. I ran a expert panel on testosterone some years ago, which we published and we had a couple of European guys and there's one guy from Europe who says if they have symptoms and they're under 400, I'll treat them.
- [54:13]
Dr. Gabrielle Lyon
But that's not the guideline.
- [54:15]
Dr. Abe Morgentaler
No, it's not. Guidelines. So geography. So if you have a guy like 310 in the United States, you go to a primary care doctor, he says it's normal. I'm not going to treat you. If you go to Europe, they say, oh yeah, you're low, we'll treat you. Well, that doesn't make any sense. If you go see an endocrinologist, they say you could have a testosterone at 275. The endocrinologist said, according to the guidelines, you're normal. I shouldn't treat you. But the same endocrinologists that write that have also performed many of the most important studies we have where they use values under 300 or in some cases they had one, they said we wanted unequivocally low levels, 275. But that's not even what their numbers are now. Now it's even lower.
- [55:01]
Dr. Gabrielle Lyon
So what is. And also age doesn't matter, right? It doesn't.
- [55:05]
Dr. Abe Morgentaler
Right. Well, according to guidelines.
- [55:08]
Dr. Gabrielle Lyon
According to the guidelines. And as physicians we are taught to treat according to guidelines.
- [55:14]
Dr. Abe Morgentaler
Yeah.
- [55:16]
Dr. Gabrielle Lyon
What does that mean for the well being of the patient?
- [55:19]
Dr. Abe Morgentaler
Yeah. So, you know, listen, I'll give you my take on guidelines. Guidelines is an important, has been an important step forward in the last. It's really only in the century, you know, the last 20 years or so. And it's really, they provide guidance, but they're not the rule of law. Right. And in the end it's a group of individuals. You could have 10 people sitting in a guideline panel and they all might practice differently 10 different ways. But they have to come up with basically a consensus document. So they might say, okay, let's say 300 is the number. So they put that out and maybe they have other requirements too. How many times do you check? Does it have to be morning, does it have to be afternoon? And at the end, after putting that out, they all go home to their practices and they can still practice differently than the guidelines 10 different ways. But people think, oh, it's guidelines. There's a clear way, right way to do things and wrong thing. And you can't deviate. No, not at all. I think guidelines are helpful for the novice. In my opinion, that gives you a general sense of what's probably safe to do and in almost all circumstances, conservative. But I think once a physician or a healthcare provider gains a certain amount of clinical experience. Clinical experience can in my opinion offer often outweighs what the guidelines say.
- [56:40]
Dr. Gabrielle Lyon
Is there a saturation point? So what I mean by that is, would there be any benefit from going if someone was taking 200 milligrams of testosterone up to 400. And we're not saying that we recommend that, but would it affect all tissues equally? And how do we think about is more better if we know testosterone is great, is just in terms of a safety profile, if at all.
- [57:12]
Dr. Abe Morgentaler
Right, so let me use that question to get back to solving the mystery of testosterone and prostate cancer. Like how is it that lowering it is helpful but raising it doesn't seem to be dangerous? Right. And the answer is the term that you used, which is saturation, that I came up with in about 2007. And then together with my dear colleague, Dual Trache, we really put the finishing touches on it. And what saturation means is that if you started out either prostate cancer cells or prostate cells or animals or humans with essentially zero testosterone, and you give them more testosterone, prostate tissue does need androgens, testosterone, like substances, in order to grow. True, it's a requirement for them, but it turns out that the maximum ability to grow maxes out at a relatively low concentration of testosterone, which looks like it's around 250 nanograms per deciliter. So there's studies, and I'm part of one Mokira that you mentioned published another one where if you have men who have levels below 250 and they get testosterone, the PSA, which is a marker of prostate activity, goes up. If they start with a testosterone above 250 and you give more testosterone, nothing happens. So that saturation, imagine a sponge with water, you can put it on a scale, has a certain weight. You add a little water, it absorbs it, the weight goes up, you add more and more water. At some point it's saturated. It can only hold so much water. Adding any more water doesn't do anything. Right. So it's maxed out and different prostate. It looks like the saturation point is around 250 different tissues are different. So you know men, men who are castrated or undergo treatment, so medical equivalent of castration, get hot flashes, just like women in menopause, it turns out. And we call that vasomotor instability, like the blood vessels and whatever is sensing it centrally in the brain goes crazy. Right. But it turns out that if you let a guy's testosterone get back to about 100, which is an extremely low number, it's gone. No more vasomotor instability. So whatever that is, that saturation point is probably around 100. Prostate's around 250. But a lot of guys at 250 still have symptoms from testosterone deficiency, like low libido. And some of that probably gets satisfied at numbers around 500, maybe 600, depending on who the guy is. That saturation for that symptom in the brain. So that's what's interesting.
- [59:55]
Dr. Gabrielle Lyon
It's a brain. Some of this is brain symptoms.
- [59:58]
Dr. Abe Morgentaler
Yeah, listen, my lizard stuff. Testosterone is a brain hormone. Yes. It also works on muscle and fat and all these other organs, but it's a brain hormone. Absolutely. So one thing that's interesting is that it's so the question comes up, if somebody who doesn't have low testosterone takes testosterone, what's going to happen to them?
- [60:25]
Dr. Gabrielle Lyon
Great question.
- [60:26]
Dr. Abe Morgentaler
Yeah. So this. Sorry, I didn't mean to take you.
- [60:28]
Dr. Gabrielle Lyon
Wonderful. No, no, you're doing great.
- [60:31]
Dr. Abe Morgentaler
Forgive me, forgive me, please. But, but this is part of.
- [60:36]
Dr. Gabrielle Lyon
Because we have all kinds of people that listen to the show and let's say a woman is listening for her husband and she's concerned that her husband is on testosterone or that he doesn't need it.
- [60:46]
Dr. Abe Morgentaler
Right.
- [60:47]
Dr. Gabrielle Lyon
We have to be able to rethink about these conversations and because the ultimate outcome that we want is health and longevity.
- [60:54]
Dr. Abe Morgentaler
Right.
- [60:55]
Dr. Gabrielle Lyon
And muscle.
- [60:55]
Dr. Abe Morgentaler
Yep. Which is all part of the same. Right?
- [60:58]
Dr. Gabrielle Lyon
Exactly, exactly. So what if someone isn't low? And if we were to define. But let's say they are on the lower end, 350.
- [61:08]
Dr. Abe Morgentaler
Sure.
- [61:09]
Dr. Gabrielle Lyon
If you increase someone's testosterone, I mean, you had mentioned that there might be brain effect at 4 or 500. Is there a number? Well, what happens if someone is not low and, or how would you define not low and if you give them testosterone, what would happen?
- [61:26]
Dr. Abe Morgentaler
So what I mean by not loathe. In some ways the easiest way to define is it's certainly well within the normal range and that individual has no symptoms. Right. They just say, I think I might be better in some way with testosterone. So if you have a guy with, let's look at sex drive, for example, a guy whose upper end of normal we often define as around a thousand. Okay. So if you have a guy who's 900 compared to another guy who's 700, which they're both well within the normal range, they're going to have on average the same amount of libido. As a matter of fact, you could take the same guy, let's say you could manipulate his hormones at 700 to 900, nothing changes for him. Non erection and nothing because his testosterone is normal. The one area that does not seem to max out is muscle, is muscle. And that's why the bodybuilders, the athletes who are taking anabolic steroids that are all versions of testosterone, like compounds, versions of testosterone. Why they can have muscles on top of muscles on top of muscles. Right. So anybody that's on normal amounts of testosterone therapy, just trying to get them maybe to the upper, into the normal range or the upper end, or even if they might slip a little bit above it here and there, it's not a problem. I've, I've treated thousands and thousands of men. There's nobody who walked into my Office looking like just regular muscular who walked out like super built.
- [63:00]
Dr. Gabrielle Lyon
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- [64:36]
Dr. Abe Morgentaler
You need to get levels that are 10 to 50 times higher in terms of testosterone equivalents to start doing this.
- [64:44]
Dr. Gabrielle Lyon
So what would that look like? Would that be a total testosterone of 5,000?
- [64:49]
Dr. Abe Morgentaler
So here's the thing, most of these people don't actually use testosterone or maybe part of their regimen. So they stack, they use multiple agents that do this. And some of these agents have never been really tested in humans. They've been used in cattle and horses, for example, like Windstraw. And they seem to be more potent for the muscle effects rather than sort of the libido effects and things like that. But in terms of testosterone equivalency, in terms of muscle potency, some of them are more potent. And the reason that testosterone works differently in muscle is muscle has an extra receptor for testosterone. So for almost everything testosterone does in the body, there's one receptor which is a chemical that binds it. It's called the androgen receptor. In muscle, there is a second receptor that's bound to the cell membrane. It's called a G protein coupled receptor. And it's hard to see. It's. I'm not sure that there's an upper limit to how much you could get with testosterone, with testosterone, through that second mechanism.
- [65:57]
Dr. Gabrielle Lyon
That's fascinating. And then I'm sure that there is a muscular potential for an individual, and maybe one could only get so big or maybe if they use anabolics, then it would overcome that muscular potential. It would be really fascinating.
- [66:11]
Dr. Abe Morgentaler
Yeah.
- [66:12]
Dr. Gabrielle Lyon
In terms of free testosterone, that's. What is that? I won't put words in your mouth. Is that what you care about more?
- [66:19]
Dr. Abe Morgentaler
Yeah. I'm so glad you asked. So, you know, the everyday scenario that I hear about is that somebody goes to the doctor and they have symptoms of low testosterone and their testosterone comes back in what is called low normal range. Right. So let's say it's 310 or 320 or 350, and the doctor says, well, you're normal. Almost all of those men will have low levels of free testosterone. And. And the short bullet is that free testosterone is the most reliable indicator of a man's testosterone status. So I don't get. I hope I don't get too sort of nerdy with this, but your viewers can handle it, I'm sure.
- [67:07]
Dr. Gabrielle Lyon
Yeah.
- [67:08]
Dr. Abe Morgentaler
So listen, so when you measure total testosterone, what they do is they take a certain amount of your blood and they measure how much testosterone in total is there per little unit of blood. So it's measured in nanograms per deciliter, a tenth of a liter. But testosterone circulates in three forms. More than half is bound to this carrier molecule called shbg, Sex hormone binding globulin. And what's important about that binding is it's so tight that testosterone can't come off it. So if the testosterone attached to SHPG is just floating past a cell that's saying, hey, give me some testosterone. I'm hungry for testosterone. Testosterone can't get in there. That portion is not biologically available. Most of the rest is attached to these other proteins in the blood, like albumin, but it's weakly bound. So it goes on and comes off. Goes on and comes off. And so when that cell is saying, hey, I need some, there's enough of it coming off of that that it can get in there. And 1 or 2% is free, which means that the. Not that the test doesn't cost you anything, but that it's unbound. Unbound. And what gets through that cell membrane is the free Testosterone only. So testosterone is lipophilic. It likes lipids. All cell membranes are lipid bilayers. It's like, like, likes, like. And it can just go right through it. It doesn't need any carrier proteins, it doesn't need sodium channels, calcium channels. It just gets into the cell that needs it. And so the free only makes up 1 or 2% of the total. So as we get older, our SHBG rises and it tends to bind more of our testosterone. And so most of that isn't available to the cells. So the total can look normal, but actually the free may be low.
- [69:13]
Dr. Gabrielle Lyon
How would you know? This makes me think about women who go on birth control and increase SHBG irreversibly. Ye. How would. And perhaps it's different for men and women. How would they increase free testosterone?
- [69:28]
Dr. Abe Morgentaler
Right. So SHBG is. The beauty of free testosterone is it's unrelated to whatever SHBG is doing. So SHBG is binding up a lot of the testosterone that gets measured in that blood test, but the free testosterone is just hanging out, doing its thing. So it is, whatever it is, it's either low or it's normal, or potentially it could be high if you're on treatment. So it's unrelated. But what it means is that women who have been on birth control pills and women in general tend to have higher SHBGs than men do. It means that their total testosterone is even less reliable in women than it is in men. And so in order to properly interpret what a man's status is, you either need to get a free testosterone test or we always measure shbg. And you can actually, they're these online calculators. Just put in the SHBG value, the testosterone value, and it'll spit out a number for you for the free testosterone.
- [70:26]
Dr. Gabrielle Lyon
And when I had asked about how to increase the free testosterone, would that be. One would have to increase the dose. So if for some reason someone is on 150mg a week of testosterone and the free testosterone is still in the lower range, you would have to increase to 200 or even potentially beyond.
- [70:48]
Dr. Abe Morgentaler
Yeah, I mean, so what happens is that the total testosterone number, when SHBG is generous or high, is unreliable, it's going to look like it's fine when the person is really deficient. Right. But if you give testosterone, the free will go up and the total also goes up. And so when I have somebody where there's a discrepancy. So most of the time when there is a man who has a Lot of symptoms. We say, oh, man. His blood tests are for sure going to show low levels of testosterone and his total comes back within the normal range. It's almost always explained by having low levels of free testosterone, which usually goes along with generous levels of shbg. The treatment is the same. The treatment is the same. And the goal of treatment is not to get the total testosterone into the normal range. The goal is to improve the symptoms that the man is having and hopefully resolve them. And they will resolve if it's hormone related. But because these guys with elevated or generous SHBG levels already may have good total levels, I always tell the patient, and I put it in the record because other doctors will see these notes, that the total testosterone is likely to be very high with treatment because we're treating a free testosterone.
- [72:10]
Dr. Gabrielle Lyon
Because oftentimes providers and the patients will become concerned.
- [72:14]
Dr. Abe Morgentaler
Yeah.
- [72:14]
Dr. Gabrielle Lyon
That their free testosterone is outside or their total testosterone is outside of normal range. But their free testosterone is barely there. We're, you know, barely over the minimum.
- [72:27]
Dr. Abe Morgentaler
Yeah. I have a very prominent patient who has a lot of doctors and he's just like that. His total testosterone is fine. His doctors didn't think he needed anything. His free testosterone was low and his total testosterone was mid range normal. I don't remember the exact number. It's many years ago since we've started treating him. Let's say it was 500. Yeah. And most people say, oh, that's robust. Right. But he had all the symptoms. He had low free testosterone. So we treated him and all his symptoms got better. It's interesting. This is a man who was on taught who you and I would think that everything he's done, he should be on top of the world. But he wasn't. He's a guy like everybody. And when testosterone is low, he wasn't who I thought he should. He would be.
- [73:25]
Dr. Gabrielle Lyon
He was really struggling.
- [73:26]
Dr. Abe Morgentaler
Yeah. And, you know, life is hard, like it just is. Right. We have challenges every day, whether you have small children, elderly parents, difficult relationships, work like life is hard. And what I see testosterone doing for a lot of people, even if they're not like out and out miserable, is they lose what I call the critical 5%. There's a certain way that you, for example, are successful because you've got drive and passion and skill. But if you lost a little 5% of you, you could get through your day. You could do podcasts, you could write, but it would be a chore for you and you would lose some of what it is that makes you you. And that's what I would see with a lot of these men. They lose their sense of humor. Right? They lose their sense of play, they lose their reserves. People think testosterone makes people irritable and aggressive. It does not.
- [74:29]
Dr. Gabrielle Lyon
Testosterone does not.
- [74:30]
Dr. Abe Morgentaler
Does he not does. But irritability happens when people don't have emotional reserves and they lose those reserves when their gas tank is approaching empty. So, yeah, so I'm sorry for that little sauce.
- [74:47]
Dr. Gabrielle Lyon
I think it's really important.
- [74:49]
Dr. Abe Morgentaler
But yeah, in the end, what I'm really saying is, you know, here we're talking about numbers and they're important and they're going to help people out there who are listening and hopefully healthcare providers too. But in the end, what we're talking about are people. We're talking about people. And I've had discussions with prominent endocrinologists and other academics, but why don't you take this testosterone business more seriously? We've got great research and they say things like, I remember this one conversation, this very, you know, academically important person said, well, I think we'll take it more seriously once we have studies that show, you know, important differences in outcomes. And what she's talking, talking about are, you know, mortality rates or complication rates of this, that or the other. But what gets lost in all of that is the individual person. The individual person. And one of the most gratifying things for me, and part of why I fought on with the testosterone story, especially early days, is that I was, I was making a huge difference in the lives of these individual people. I didn't have an agenda to show testosterone was good. I was working hard just to be okay at what I was supposed to be okay at. I was learning surgical skills, trying to become an expert in all these things. But I had these patients and it turned out that these guys who had low levels of testosterone, some of them just low free testosterone, if I treated them, they'd come back and they had the most marvelous stories about how their lives were improved. And when I was especially early days, what was amazing I felt like I was seeing because none of my colleagues were treating with testosterone. It's not just that they weren't treating. They thought I was doing dangerous medicine.
- [76:40]
Dr. Gabrielle Lyon
And I'm sure they shunned you.
- [76:42]
Dr. Abe Morgentaler
Yeah, I caught a lot of flak. I had some tough situations. But what kept me going was I was seeing something that wasn't being described in the literature or that I'd been taught I was seeing something. It was like these guys saw all the best known urologists or endocrinologists like in Boston, where I was, and they'd come without success, and they'd see me. I said, well, your testosterone's low. Let's see what happens. I mean, I didn't have any guarantees. And they'd come back and they'd say, oh, my gosh, like, my life is better. I tell you one story. This guy came to see me. It was a surgeon he didn't care about. I don't know whether sex wasn't an issue for him in his life or he just didn't care about it. He says the problem is that he's up all night operating, and the next day he has full clinic, see a full day of seeing patients. And he says, you know, for the first 15 years of my career, that's not a problem. He says, now I find that I'm falling asleep the next day after being up all night, and I'm just wondering if it could be testosterone. His testosterone was low, and I treated him. And he came back in follow up. I said, how's it going? And he said, well, I don't fall asleep anymore the next day. So he was, like, happy. I said, well, that sounds great. He says, but it's more than that. He says, since I started with you, he says, I've reorganized my entire division. I've written three papers, I've made two educational videotapes. Like, this guy had gone to town. That's who he was before he had stopped doing that. What got him is he couldn't stay awake, right? Like, that's what brought him to the office. But in fact, this guy was a superstar. He was a dynamo, and he'd lost part of his dynamism. And that's what testosterone can do for people who are deficient.
- [78:36]
Dr. Gabrielle Lyon
Do you think that that is the same? And I know you don't treat women, but do you think that that's also the same for women?
- [78:42]
Dr. Abe Morgentaler
Absolutely.
- [78:44]
Dr. Gabrielle Lyon
Have you seen. Obviously, I know the answer to this question, but I'm asking you, have you seen the transition of various types of testosterone delivery systems?
- [78:54]
Dr. Abe Morgentaler
Oh, yeah.
- [78:55]
Dr. Gabrielle Lyon
From oral to gel to sub Q injection. Do you think that there is one that is better? But before you answer that, I am curious your thoughts.
- [79:05]
Dr. Abe Morgentaler
We have so much to talk about.
- [79:07]
Dr. Gabrielle Lyon
I know, I know, but testosterone in women.
- [79:10]
Dr. Abe Morgentaler
Women, yeah.
- [79:12]
Dr. Gabrielle Lyon
Do you think that it will have the same impact?
- [79:15]
Dr. Abe Morgentaler
You know, I'm chuckling. So listen, testosterone is the most interesting chemical.
- [79:19]
Dr. Gabrielle Lyon
It reminds me of. What is that Don Perrion? Or this the most interesting madame?
- [79:24]
Dr. Abe Morgentaler
Or.
- [79:25]
Dr. Gabrielle Lyon
You know what I'm talking.
- [79:26]
Dr. Abe Morgentaler
I do I know the curses.
- [79:27]
Dr. Gabrielle Lyon
Yeah, but yet.
- [79:28]
Dr. Abe Morgentaler
And it's not that guy or I think it's Dosaki.
- [79:32]
Dr. Gabrielle Lyon
So if dose equi was a molecule.
- [79:35]
Dr. Abe Morgentaler
It would be testosterone.
- [79:37]
Dr. Gabrielle Lyon
Testosterone, yes.
- [79:39]
Dr. Abe Morgentaler
No, it's true. It's fat. The amount of stuff that's involved, it's everywhere. We had a talk, we have a annual meeting. It's called the, excuse me, the Androgen Society. We had an ophthalmologist come and talk about effects of testosterone on the eye. Turns out that the number one cause of office visits to eye doctors is dry eyes. Guess what testosterone does? It makes lubrication for the eye or helps to enhance it. So people who have dry eyes often have deficient tear production.
- [80:08]
Dr. Gabrielle Lyon
Wow.
- [80:09]
Dr. Abe Morgentaler
Testosterone's involved with that, would they?
- [80:11]
Dr. Gabrielle Lyon
This is just a side note. Do you think that there's ever a place for intra eye drops that are hormones?
- [80:18]
Dr. Abe Morgentaler
They have. So according to this guy, they use some ointment that has testosterone in it. They use that for the eye.
- [80:23]
Dr. Gabrielle Lyon
Sign me up.
- [80:24]
Dr. Abe Morgentaler
Right.
- [80:24]
Dr. Gabrielle Lyon
My eyes are going to be super sharp, right?
- [80:26]
Dr. Abe Morgentaler
Yeah. And it happens more in women who have less testosterone than men. I'm not saying that testosterone is the entirety of that story, but it's a contributing factor. Yeah. So testosterone in women. So I don't, you know, I started years ago a men's health center and so I saw exclusively men.
- [80:41]
Dr. Gabrielle Lyon
Actually the first. You started the first men's health clinic.
- [80:46]
Dr. Abe Morgentaler
Yeah. Thank you for, thank you for saying that. The, the, you know, it's funny. So I was so proud when it, we opened it up, 1999. And Men's Health was hardly a concept back, back then. And I was full time faculty at the hospital Beth Israel Deaconess Medical center, one of the Harvard teaching hospitals. And I go to the president and I say, and we have all these hospitals in Boston. They're all these high powered places, they all compete with each other. And I went to the president, I said, listen, every hospital in Boston has a women's health center. Nobody has a men's health center. I say, I think I practice what could be termed men's health. I do male infertility, male sexual stuff, testosterone, some prostate. I think the hospital should open up a men's health center. I'd like to run it. And we had a couple of conversations and at the end of the. He says, oh my God, this is great, let's do this. And I said, super. And I said, how long will it take? And he said, four years. And I said, what? He said, listen, we're a big institution, we're A bureaucracy. We can get this done, but it'll take a lot of years. And so, so I left my sort of lab research stuff and I went out on my own and I thought it was a great idea and it worked out well for me.
- [82:00]
Dr. Gabrielle Lyon
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- [84:09]
Dr. Abe Morgentaler
And what that was 1999, it was called Men's Health Boston. It still exists, but I'm not part of it anymore. But what's funny is that Men's Health, these men's health centers have now gotten a little bit of a wonky reputation. And so I used to be so proud of it. Now I don't always mention it, but the idea was to have a place that really focused on various aspects of men's health health and to do it in a respectful and way with expertise. And I still think it's a great idea.
- [84:41]
Dr. Gabrielle Lyon
Do you think that they have somewhat of a stigma because individuals experience it as kind of a turn and burn. It's just everyone's getting the same treatment. Do you think that that's where that comes from?
- [84:53]
Dr. Abe Morgentaler
Yeah. So these syntax are often. They advertise on radio, on sports radio, things like that. They've gotten a reputation for not necessarily practicing the best medicine. And yeah, there's a lot of churning is sort of what you hear. Now there's a funny part to that, I have to tell you. So I don't share those criticisms completely. And the reason is that within what I would call sort of more institutional medicine, right, mainstream, you're here in Houston with all these tremendous academic centers. If you go see an average doctor, Houston may be different because there's some key individuals here who have popularized use of testosterone. But in most American cities, you go to a hospital based doctor or hospital affiliated with symptoms around testosterone, male or female, and you will not get treated. You just won't. You'll be shut down. So even at my own institution, the endocrinology folks, I'll never forget this. Can I tell a story?
- [86:01]
Dr. Gabrielle Lyon
Yeah, please.
- [86:02]
Dr. Abe Morgentaler
All of them. So I would see a lot of second and third opinions, right? Like people have. Were shut out somewhere else. And this one guy comes in, he's in his mid-40s, 45 or so, and he's married. And his problem is he has no sex drive and his wife is complaining and. And he feels like it's wrong. He's not holding up his end of the bargain, if you will. And so his primary care got testosterone levels on him and they were low. Really quite low. And so he got referred to the. I need to be careful about how specific I get. He goes to see an endocrinologist at one of the teaching hospitals in Boston and the guy says to him, looks at his labs and says, you absolutely have low testosterone, but I'm not going to treat you. He says, why not? He says, well, in ancient Egypt, there used to be eunuchs, guys who were castrated and they were regarded with great respect. They often had important positions in the queen's coterie. And your testosterone is a lot better than any eunuch. And they did okay, you don't need it. And when the guy comes to see me, he tells me this story and he says to me, very funny, I thought. He says, I don't give a rat's patootie about some ancient queen in Egypt. I care about the princess sleeping next to me in bed. Every night. Right. So we treated him, and of course he did very well. It's actually not rocket science. And I know some rocket scientists.
- [87:40]
Dr. Gabrielle Lyon
Do you really? I know one. Yes, absolutely. I know an astronaut.
- [87:44]
Dr. Abe Morgentaler
It's not that complicated. Right. You just need to know a couple of key facts and about how to treat and we improve the lives of people. And the argument to not treat them is mystifying to me. And so getting back to these men's health centers, the reason I'm not so critical about them is, although I don't agree with necessarily everything they do, they often are giving three medicines instead of one that they need. And like inostatisal, and they throw in all this other stuff too, is at least those patients are getting treated.
- [88:18]
Dr. Gabrielle Lyon
I agree with you. I agree with you.
- [88:20]
Dr. Abe Morgentaler
At least they're getting treated. And I think most of the other stuff may not help them, but probably doesn't hurt them. So I can't give them, like, my wholehearted blessing. But geez Louise, I mean, it's better than nothing.
- [88:33]
Dr. Gabrielle Lyon
And there's a need. If primary care physicians were to be treating these testosterone deficiencies in both men.
- [88:40]
Dr. Abe Morgentaler
And women, it would stop.
- [88:42]
Dr. Gabrielle Lyon
Then we wouldn't require more, I don't know, outside the box method.
- [88:50]
Dr. Abe Morgentaler
Exactly.
- [88:50]
Dr. Gabrielle Lyon
Delivering these medications.
- [88:51]
Dr. Abe Morgentaler
Exactly. Right. What's missing is that what should be the normal response. Right?
- [88:56]
Dr. Gabrielle Lyon
It will be. I think that it will be in the next 10 years. If individuals are likely not treated with hormone replacement therapy, then it's just as.
- [89:04]
Dr. Abe Morgentaler
They say, from your lips to God's ears.
- [89:07]
Dr. Gabrielle Lyon
God, are you listening? I have a number of issues I'd like to take up with you. I'll do that later. I think it's really important. And in terms of, you know, I also selfishly wonder about women's levels. I think that men are really well studied and we have a sense of what I mean. And I don't know if there's a free testosterone that you think is optimal for a man. Is there? As all the men pull up their labs, What? And what would that be?
- [89:33]
Dr. Abe Morgentaler
So free testosterone comes. It gets complicated because there are different units that are used for measurement in different tests. But the most commonly used test is now called a calculated free testosterone. The lab reference ranges are useless. None of them will say that anybody. You have to be incredibly low to be categorized as low. Anything less than 100 picograms per mill is together with symptoms, in my opinion, bears treatment. And that's what I used for 30 years.
- [90:02]
Dr. Gabrielle Lyon
And then women. I know you don't treat women. Women are Would they be one tenth that?
- [90:09]
Dr. Abe Morgentaler
So women have about one tenth the amount of testosterone that men do. Free testosterone is more important in women as it is in men. Maybe even more important because they have so much shbg. And the data in women. There actually is many very good studies in women. Women, and some of them go back also to the 40s and the 50s.
- [90:28]
Dr. Gabrielle Lyon
Seems like there's a robust amount of data during that. There's a period where there seems to be robust data.
- [90:33]
Dr. Abe Morgentaler
You know what happened in women is.
- [90:36]
Dr. Gabrielle Lyon
That all their hair fell out.
- [90:39]
Dr. Abe Morgentaler
No.
- [90:39]
Dr. Gabrielle Lyon
Because of testosterone. Which can happen. Yeah.
- [90:42]
Dr. Abe Morgentaler
It's rare. Rare. It's one of the risks in women, of course. But what happened is there's no FDA approved testosterone product. And when women. And FDA has a funny relationship to medicine. FDA does not regulate the practice of medicine. They have nothing to do with what healthcare providers do or how they manage things, except for making pharmaceutical products available on the market. They govern the pharmaceutical industry, not the Pratt. And they will say straight out, we are not involved in the practice of medicine. Somehow along the way, some kind of institutional part of medical education got tied into the FDA in a way that I think is actually unhealthy. So, for example, I organize and speak at a lot of continuing medical education events. It is. Is part of the requirements. We call them cme, part of the requirement before that, all speakers say whether or not they're going to be speaking about anything that is considered off label. Off label means use a medicine in a way that the FDA didn't say is. Okay. So let's say a drug like, I don't know, the new GLP1s. Right.
- [92:06]
Dr. Gabrielle Lyon
Great example.
- [92:07]
Dr. Abe Morgentaler
So they start off with whatever the first indication was. I don't know, weight loss, diabetes.
- [92:12]
Dr. Gabrielle Lyon
Diabetes, yeah.
- [92:13]
Dr. Abe Morgentaler
But, you know, it could be. It turns out there's incredible data that some of these medicines are good for other things. Right. Like kidney function and heart disease. Right. But unless the drug company has applied for essentially permission from the FDA to state that as one of the benefits, then it's not. Then the FDA won't give that as an indication. So every drug, every time you pick up a. A medicine, it's got a label inside. Right. Inside the box or whatever, and with a lot of fine print and all these scary things that can happen. And part of what it says is indications. That's what the FDA says the pharmaceutical company can promote that drug for.
- [92:57]
Dr. Gabrielle Lyon
But that doesn't change the ability to use it. It would just be used off label.
- [93:01]
Dr. Abe Morgentaler
And so physicians have discovered that all sorts of medicines have benefits and uses beyond what the label says. So at these conferences and many of them are in guidelines. So for example, one of the treatments for in my field, erectile dysfunction is there's for people who don't respond to Viagra Cialis. Often the next line is medicine that the man injects in his penis that gives him an erection more powerful than Viagra.
- [93:28]
Dr. Gabrielle Lyon
And what is that medicine called?
- [93:29]
Dr. Abe Morgentaler
So there's usually it's a combination. The most potent is a combination of three and we call it Trimix. But Trimix has never been approved by the fda. So it's off label. You can't pick it up at a prescription at a pharmacy like Walgreens or Rite Aid. You have to go to a compounding room. But it's been around now for, since the 1980s. It's standard treatment. So if I was giving a lecture that involved a comment about that, I would have to say ahead of time to the organizers of the CME of event. I'm going to be talk discussing something off label. But the off label part for a lot of people say, well, that's kind of iffy. No, it's not. It's standard medicine. Often. Often.
- [94:14]
Dr. Gabrielle Lyon
And so I have to pause you there. It's because this is so important because basically what we're trying to do is break through the barrier to entry and we cannot do that as physicians to our patients or patients that are listening or individuals that are listening so that they can advocate for themselves that just because something is deemed off label doesn't necessarily mean that it is unsafe or that it's shoddy or that it shouldn't be used. Case in point, testosterone use in women. In women, exactly. Which one of the treatments for hyp? I'll ask you this. What is the treatment in women for hyposexual desire disorder?
- [95:04]
Dr. Abe Morgentaler
Right. Well, in some cases, if their testosterone is low, testosterone will be perfect.
- [95:08]
Dr. Gabrielle Lyon
Testosterone.
- [95:09]
Dr. Abe Morgentaler
But it's not indicated. There are no products for it. So.
- [95:14]
Dr. Gabrielle Lyon
Well, Addie. Yes, we just got approved.
- [95:16]
Dr. Abe Morgentaler
Yes. No, there's, there's a couple of products that are used for that, but there's no testosterone products.
- [95:21]
Dr. Gabrielle Lyon
Exactly.
- [95:21]
Dr. Abe Morgentaler
Right. So. So listen, Addi is a non hormonal treatment. The medicine is called Flibanserin. The data are actually very strong. It is FDA approved for that. Right. For a woman who is postmenopausal and has basically her gas tank for a couple of those sexual hormones is at zero, testosterone can help. Some women who are pre or perimenopausal may have low levels of testosterone, they can benefit from it too. And women's symptoms are often very similar to men. Men, they have fatigue that isn't sort of normal, explained by activities. Right. It's out of proportion fatigue. They don't feel right. Their energy, their zip is gone, libido may be down. And testosterone works for them just like it works for men. We're not, you know, there are differences between men and women, but we have a lot that's so similar.
- [96:12]
Dr. Gabrielle Lyon
Do you think that if it were FDA approved for women, just your personal opinion, would it change things?
- [96:18]
Dr. Abe Morgentaler
Yeah, it would, it would, it would make it much easier.
- [96:20]
Dr. Gabrielle Lyon
Because here's the thing, easier to get, easier to.
- [96:23]
Dr. Abe Morgentaler
So I mentioned that institutional medicine or academic medicine has this weird, I think unhealthy. They, they bow down to the fda as if the FDA is some arbiter of something. It's not. It's an. Well, it is, but only with regards to what their mission is, which is to make sure that the drugs approved in the United States are safe and effective. That's their mission. It's not to regulate how medicine works. And yet there are too many people within the medical community say, well, if the FDA doesn't list it as an indication, I shouldn't use it. Our studies are just as with or without an FDA approved indication. The studies are the studies and the studies show testosterone therapy in women can be highly efficacious and safe for women who have symptoms related to low testosterone.
- [97:10]
Dr. Gabrielle Lyon
And, and to be clear, do you think, again, I know you don't treat women. Do you think a free testosterone of 10 picograms per milliliter would be.
- [97:22]
Dr. Abe Morgentaler
Yeah, so that starts to be around the right place. So the sim. The thing again, it's the person, the data around women and actual levels are less strong, you know, and what's funny is that they're. Well, that's a whole other topic. So I hesitate to take you too far afield, but, but the world of endocrinology is based on blood tests of hormones and to treat people who are too low or too high. Right. Whether it's thyroid or whatever it is, in order to decide what's normal, you have to have a control population in men. This is really hard, but they've tried. Like who's the control population? Right. Is it 80 year old men? Is it 25 year old healthy guys? Is it the average, the average assortment of people you might see in a doctor's office? Or is it an idealized group of individuals with no medical conditions whatsoever and people struggle with this, the reference ranges for laboratory tests for testosterone, for example, I mentioned earlier, they're useless. They're useless because they all differ their reference ranges, and they're not based on clinical symptoms. So there's been an effort with testosterone to use young, healthy men with no obesity, no medical problems whatsoever. And to say, this is our reference population. And then what's funny about that is it is a central tenet of laboratory medicine that if you had, let's say, 100 individuals in your reference population, that the central 95% of them are categorized as normal. That's how labs work for any blood test you want, with a few exceptions, like where there's targets like cholesterol, psa, otherwise whatever it is, hemoglobin, hematocrit, liver tests, they have a reference population, and they say that the lowest 2.5% are low, low by definition, and the highest 2.5% are high. So if you had a condition where the prevalence is, let's say, testosterone, let's say low testosterone, let's say you had a perfect reference population, whatever that is, it would be fine if the lowest 2.5% of the population had that condition, if the prevalence was 2.5%. But what if the percentage is 5% or 10%, but only the lowest 2.5% are getting categorized as abnormally low? It means that you're missing and miscategorizing in the 10% prevalence, which I think is a conservative number for adult men. You're mischaracterizing 75% of them as normal when they're actually low. And so. So a lot of people don't understand what reference ranges are and how we use them. They're a guide, but they cannot be used as some rigid application of anything. So with women, the data on levels and symptoms have been harder to find correlations with than in men. So I know I have a lot of my colleagues in the testosterone world do treat women with testosterone, and they won't base it generally on a level. They say, well, we just base it on symptoms. And that's not necessarily wrong, but into the world of in those. I'm not an endocrinologist, but maybe I play one on tv, but I'm a frustrated one.
- [101:07]
Dr. Gabrielle Lyon
Or maybe on your show. This is Ex Doctors. Yeah, he has a podcast. It's not a visual show, guys. Yes, and maybe it's your lovely wife.
- [101:16]
Dr. Abe Morgentaler
Thank you. Yeah, My wife is a clinical site. Marianne Brandon is a clinical psychologist and sex therapist. We met at a sex therapy conference where I was lecturing and so we have a lot to talk about. And so we talk about that in our show, the Sex Doctors. It's fun.
- [101:33]
Dr. Gabrielle Lyon
The delivery mode for testosterone. So now we have Kaisertrex and we just have various testosterone forms. I would love to hear your thoughts in terms of efficacy. What you prefer, what you've seen.
- [101:47]
Dr. Abe Morgentaler
Yeah, so I've used, over the course of my career, every available form of testosterone for my patients. Patients. I always wanted to know what the story is with them because everybody wants to hear what I have to say about it, and I want the experience. And I'm a firm believer that until you actually get some clinical experience with something, it's hard to know what's real and what isn't real in terms of. All of these products work. If we can raise testosterone in men to adequate levels, they respond. And it doesn't matter whether they got it through a pill or an injection or a pellet or a crop cream. And the beauty of the orals is that most men are used to taking medicines by mouth. So the orals have been a great advance. That's just the last few years. We have three of them. Kaisertrex is one. And the one that I have the most experience with, it's got the easiest dosage. Dosages, by the way, have some weird numbers for the others, but they all work. But what's interesting about the orals is that they have the potential to have fewer side effects, too. So what's interesting is if I give somebody an injection once a week or every two weeks, levels go up. They usually go above the normal range, and then they decline over days to a week or two. With the orals, you have to take them twice a day because the levels go up and stay up only for about six hours or so, four to six hours, they come down and then you got to do it again. Again. There's a part of that day where the levels are back to normal, but the guys respond as if their levels are good all day long. So that's very clever. The fact, though, that when we. The fact that it comes back to normal for part of the day means, though, that the body isn't getting the experience of there being excessive amounts of testosterone if I give an injection. One of the side effects of testosterone therapy, we say, is it reduces fertility for while you're on it, because the body, the brain, hypothalamus and pituitary have a sensing mechanism, and normally they send chemical signals to the testicle to make testosterone and make sperm. If the sensing mechanism gets the feeling that there's too much testosterone, it stops sending those signals. And so the testicles basically go to sleep, they take a nap, they hibernate. And so sperm counts go down. And some men may notice that their testicles are getting softer, a little smaller. Most guys, if they're in married relationships or stable relationships or they're over the age of 45 or 50, they don't care. The single guy who's out there dating might care some. And so there are ways that we can deal with that. But the orals don't seem to suppress those pituitary signals as much. And I think there's a study that's undergoing now looking at sperm counts, and I think that that's probably going to be positive, in other words, that the guys will still have sperm. Whereas with injections, usually we get guys down to zero or very close to zero.
- [104:52]
Dr. Gabrielle Lyon
I read that the orals, there's maybe 20% are affected, their fertility is affected maybe 20%, as opposed to almost all the individuals taking.
- [105:06]
Dr. Abe Morgentaler
I don't think we have enough data yet to say definitively those studies, if they've come out, I haven't seen them yet, but I know that they're underway and I think that's pretty good. The other thing that we worry about is the risk of testosterone is what's called erythrocytosis. The red blood cell count goes up too high. So here's a fun fact.
- [105:25]
Dr. Gabrielle Lyon
You don't really worry about that. No, I'm just kidding.
- [105:27]
Dr. Abe Morgentaler
No. So here's the thing is that men.
- [105:29]
Dr. Gabrielle Lyon
And women, lots of controversy around that.
- [105:31]
Dr. Abe Morgentaler
Yeah. But just in terms of our regular biology, most labs will say that the normal red blood cell count hematocr is between, let's say, 38 and 50%. Different, slightly off, depending on the lab, but roughly that it turns out that there's almost a clean cut between women and men. And that clean cut happens around 44 or 45. Women tend to be 44 or less, men tend to be 45 and higher. And that difference appears to be related to testosterone. So when I see men who are testosterone deficient, their hematocrites are often in what I would consider the female range. And some of them actually, if your count is too low, we call that anemia. If somebody says you're anemic, it means your red blood cell count is too low, below 38 or whatever the number is for the lab. So there now have been two large randomized controlled trials else where often when people are anemic, nobody knows the answer. It's called unexplained anemia. Right. You're not bleeding from anywhere. You don't have a genetic abnormality. The doctors say, we don't know, but it's not dangerous. So you're okay. And it turns out that testosterone is better than placebo in these trials at making people not anemic anymore.
- [106:55]
Dr. Gabrielle Lyon
Amazing.
- [106:56]
Dr. Abe Morgentaler
Because testosterone increases the red blood cell count. I had a guy years ago, young guy, who just before he'd seen me for sexual symptoms that turned out to be related to low testosterone. He'd had a whole big GI Workup because he was anemic. They did this whole workup. They looked with a telescope from above. They looked with a telescope from below. They did these other tests. Final diagnosis. We don't know. But you're okay. We don't know. And when I treated him with testosterone, his blood count became normal. Normal. And he said to me, if I had seen you before the. Before them, would I have needed those tests? And the answer is no, you wouldn't have. Right. He would have had a normal hematocrit. So because testosterone can raise the hematocrit, some people may go up beyond what we want them to do. And so we say that's one of the risks. But the truth is, we don't know anything hard. Hard evidence that that's dangerous. The Endocrine Society has helped everybody in this way. They're normally a very conservative group, and they put a number at 54, which is. Actually gives a lot of room for people to go above the normal range of 50. And they say it shouldn't be above 54. It's an arbitrary number. But if somebody's at 53 or 52, I don't think you need to do anything.
- [108:18]
Dr. Gabrielle Lyon
I am glad to hear you say that, because I think that there's a lot of blood donations that happen, and then people actually don't feel so great or become anemic. There's just a whole. You know, it's a. It's interesting, right? Yeah. Especially when we're talking about, like, what you said, Patients.
- [108:39]
Dr. Abe Morgentaler
Yeah. And, you know, there's a. So in medicine, as I've discovered, there is a lack, often a lack of what I would call common sense. So it turns out that people who live at altitude have high hematocrites. Right. If you go and you live in the mountains of Colorado, their normal range for these things can be up to 54. So the guidelines say, well, don't treat anybody whose hematocrit is too high. But these people live with A hematocrit that's too high. And no one has ever shown that they're at any increased risk of anything because of them.
- [109:20]
Dr. Gabrielle Lyon
Yes, and it's a challenge because I'm curious as to how those at altitude, if they get treated or not.
- [109:30]
Dr. Abe Morgentaler
Right. So the Colorado docs are cool about this.
- [109:34]
Dr. Gabrielle Lyon
Amazing.
- [109:34]
Dr. Abe Morgentaler
I know a couple, they come to the meetings. One in particular says it's an everyday occurrence for me to see somebody not on testosterone with hematocrit of 54. So why can't I treat them with testosterone? They're already used to that hematocrit.
- [109:50]
Dr. Gabrielle Lyon
And then what about women? Is there a number for women for hematocrit above.
- [109:56]
Dr. Abe Morgentaler
So the labs don't really make that distinction. That's why I say the normal range is usually between 38 and 50. And it applies to both men and women. But listen, I don't think that having a somewhat higher hematocrit does anything. The concept is theoretical, it's not based on anything. The theory is if you have more red blood cells, your blood may be more viscous, more thick, and if it's more thick, maybe it's more sluggish getting through tiny vessels. I don't know that that's true. Testosterone, by the way, has actions on the endothelium, on the lining of the blood vessels that may in fact, may make them more pliable. Even if it were true that the blood is more viscous, it doesn't show up anywhere in studies. It's just not so that people with high hematocrits because of testosterone have been shown to have any problems at all.
- [110:47]
Dr. Gabrielle Lyon
I mean, there's a lot of myths. I think that we have covered a tremendous amount of myths and the biggest myths that create a barrier to entry for people because of misinformation.
- [110:57]
Dr. Abe Morgentaler
Yeah.
- [110:58]
Dr. Gabrielle Lyon
You also wrote a book and I want you to mention the book because I would love for the listener to get it. I expect to sign Copy that. You.
- [111:08]
Dr. Abe Morgentaler
How did I not bring one for you?
- [111:10]
Dr. Gabrielle Lyon
Exactly. Tell me about your book, the name, where we can find it.
- [111:15]
Dr. Abe Morgentaler
Yeah. So I've written four books. The one that's the most. The one that's the most popular is called Testosterone for Life. Life. And it's basically a primer for non medical people about how testosterone works. It doesn't. It's not dumbed down, but it's. I hope I've made it easily understandable. And I've had a lot of doctors tell me it's a paperback. You can get it off of Amazon and a lot of doctors tell me that instead of discussing everything about testosterone with their patients, they just give them a copy of my book. I've had physicians who tell me that what they've learned about testosterone they got from my book. So it's intended to be. It's full of patient stories and it talks about levels and things like that and free testosterone like we talked about. The book I'm most proud of is actually was originally called why Men Fake it and it was stories from my practice and what we Learned about what I Learned. A true education about men and sexuality and how men are very different than their stereotype. Its current title in paperback form is the Truth about Men and Sex. It's got some amazing cases and stories and you know, the bottom line that I would just share with you is that men have. I say testosterone has gotten a bad rap. I say men have gotten a bad rap too. It's a difficult period. The last, I would say 20 years for men. Somehow they've become a punching bag. And we think of men as if they're all 19 year olds on spring break, out of control. And that's not my experience of men having seen them behind closed doors in the doctor's office. By and large, with relationships, especially sexual relationships, there always are some bad apples, of course, but by and large, men are trying to be the best people they can in their relationships. And they may not always do it the right way. They may not do it, they may not express themselves or behave in a way that their partner would like them to or that suits them best, but they're trying. And that feature of men and their, their interest in service, and I use the term in the book and don't laugh at me, an effort at nobility I think is something that has been under recognized and unappreciated.
- [114:00]
Dr. Gabrielle Lyon
I think that that's tremendous. I think that's a tremendous statement and true. So, Dr. Abe Morgenteller, thank you so much for being, being generous with your time and your knowledge. I have just a world of respect for you and I'm so grateful that you are here and that you're here to share with the world. So thank you.
- [114:22]
Dr. Abe Morgentaler
You're so kind. Thank you so much for having.