← The Dr. Gabrielle Lyon Show
The Dr. Gabrielle Lyon Show
TRT Risks & Rewards: Your Testosterone Replacement Therapy Questions Answered
00:44:53
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- [00:00]
A
If you have low testosterone, it makes you at a greater risk for cardiovascular disease.
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B
Wait, wait, wait, wait.
- [00:05]
A
Stop that. I would be concerned if you were walking around with low testosterone. I would be concerned that you were going to have a bone fracture. I would be concerned that you're going to have heart disease. I would be concerned that you are at a greater risk for obesity and diabetes.
- [00:17]
B
Wow.
- [00:19]
A
40% of men in their 40s have erectile dysfunction. If you have erectile dysfunction, you are at a greater risk for heart attack or stroke. Erectile dysfunction can predict a heart attack within three to five years.
- [00:32]
B
Scary.
- [00:32]
A
Obesity will lower testosterone levels and lower sperm health. If you have poor sperm health, you have a 2.6 time greater likelihood of having cancer. 92% of men that were depressed also had low T. When individuals age, men think that their testosterone has to go down. It's actually not true. Testosterone in, say a 75 year old could be potentially just as good as your Testosterone in your 20s, which is shocking.
- [01:04]
B
That's very exciting.
- [01:12]
A
After the statement came out from Tobias Kohler about your penis can shrink up to 1cm if you don't use it. Had you ever heard that before?
- [01:23]
B
That was scary. I can tell you. That struck fear into my heart, everybody's.
- [01:28]
A
Heart, and immediately it just went viral. Because part of the problem is there's always this echo chamber of testosterone, steroids. But when you tell a guy his penis is going to shrink 1cm if he doesn't have sex, the world is listening.
- [01:44]
B
You're going to take action immediately. Immediately.
- [01:48]
A
And those actions can include penis pumps, lots of sex. And therefore that leads us to the conversation around testosterone and erectile dysfunction. Use it or lose it.
- [02:01]
B
Yes. Yes. And as a soon to be 46 year old male, I'm coming to you as the expert. Is, is, is the doctor that you are, because I'm looking at my testosterone and I'm wondering is someone that suspects that maybe my test, testosterone isn't what it used to be? What's the first steps I take when I go to my physician?
- [02:21]
A
First of all, you're looking great for 46.
- [02:22]
B
Thank you.
- [02:23]
A
Well done. Almost 46. Testosterone is interesting. Testosterone is the primary androgen for men and also women. When individuals age, men think that their testosterone has to go down. It's actually not true. It's totally unfair and not true. Testosterone in say a 75 year old could be potentially just as good as your Testosterone in your 20s, which is shocking.
- [02:46]
B
That is shocking.
- [02:47]
A
It is shocking. There is hope for all men, something called shbg. Goes up, which may make free testosterone a little less available. But the reality is, how do you know if your testosterone is low? There are a handful of signs and symptoms. Number one, the thing that would get a man to the doctor almost immediately is if his penis doesn't work. Erectile dysfunction. 40% of men in their 40s have erectile dysfunction.
- [03:16]
B
That's scary.
- [03:16]
A
That is scary. In addition, obesity, diabetes, all of which contribute to low testosterone, which means you have to get your lifestyle right. But also, everybody should have their testosterone checked by the time they're 40. A man should know, and I would argue even earlier if someone is under 40, listening to this, the sooner you get your testosterone checked for a baseline, the better.
- [03:41]
B
Now, when I go in and get it checked, like, what do I ask for? Because there's, as you alluded to, there's different forms. So is there a particular form I'm looking at?
- [03:50]
A
And we should review your blood work, but if you are going to the doctor, what you want to look for is total testosterone. Free testosterone. Fsh. Lh. Unusual for a guy to have his estrogen checked, but we always check an estradiol. And believe it or not, everything is not testosterone related. You have to check your thyroid and even a prolactin level. Sometimes there are things in the brain, say an adenoma or some kind of benign tumor that would affect testosterone production.
- [04:22]
B
Wow. Estradiol.
- [04:24]
A
Estradiol, yes.
- [04:25]
B
Why am I. I'm a dude. Yes, you are. I don't worry about my estrogen. Why do I need my estrogen?
- [04:30]
A
For us, the target level that we like to see in our clinic is between 30 and 50. Those are the numbers that a guy would wanna look for. And I would say that when a guy goes on testosterone, one of the things that the typical TRT clinic does or has in the past is they immediately put people on an aromatase inhibitor that would be Arumidex, to suppress estrogen. What we found was that when that happened, and very early on, I mean, again, I've been in practice for, I don't know, over 10 years, the guys that had estrogen suppressed, they really, they seem to lose their libido. There may be a role for estrogen.
- [05:08]
B
And libido, but what about. So you're suppressing the estrogen because of the concerns with gynecomastia. Yeah, but having that 30 to 50, I don't have to worry about that.
- [05:17]
A
Hopefully not. And obviously everyone is individual. And for someone listening, we're not giving medical advice, but how we dose it is very Low people do not get put on an estrogen blocker just because if their estrogen is above 50, we would start an estrogen blocker, and that would be at a very low dose. And Arimidex of 0.25 twice a week, or, or maybe even just 0.5 once a week. Here is the catch. When a guy is obese, he might make more estrogen. Oh, yeah, but that doesn't mean that you wouldn't treat him for testosterone. You don't use an aromatase inhibitor as monotherapy. Meaning, let's say you have an estrogen that's 100. And I've had guys in my clinic that have an estrogen of 100. We don't immediately go, you know what? I'm gonna block your estrogen before starting testosterone.
- [06:02]
B
Ah, so you just go to the testosterone now, I'm not obese. I exercise. I try to get enough sleep regardless of what my kids do. What, what is the cutoff? Because, you know, I look at 300 nanograms per deciliter and I'm. I'm still above that. But, but then how do you determine, is that a hard number for you, or are there other things you look at?
- [06:22]
A
There are the guidelines, which. The medical guidelines would make 300 the hard number. So the AUA guidelines. But, but these numbers, it is kind of arbitrary. That 300 number was just picked. Here's the rub with that. It's not just about testosterone. It's also about your androgen receptor sensitivity. It's something called a CAG repeat. And some individuals have very sensitive androgen receptors, meaning they require less testosterone. And some individuals have very low sensitivity receptors, meaning they would require higher levels of testosterone. 300 would be the cutoff. But it depends on where you go in and what country. The cutoff in other countries is lower. It's an arbitrary number. You also have to look at how people feel. And it's funny. One of the things, aside from just looking at the testosterone level, the diagnostic criteria for low t would be two levels in the morning with 300 or less, 290 nanograms per deciliter. But what if this person also is starting to have erectile dysfunction, is starting to have fat deposition, fatigue, depression? I was looking at one study, 92% of men that were depressed also had low T. It's not surprising. That's. No, yeah, it is. And, and actually, it's not surprising. Makes that. It's a good point. Because if someone has low testosterone, how are they going to want to exercise and eat? Well, it's tough.
- [07:56]
B
In your great interview you had with Dr. Morgan Taylor, he talks about that last, what, like 5%, that motivation that people have and testosterone gives them. The other piece of it, though, that I thought was interesting, I wanted to ask you about is what about the health concerns? Because, again, got young kids. I want to be around for them. Is taking exogenous testosterone going to put me at greater risk for prostate cancer or things like that?
- [08:20]
A
There are very few areas in medicine where the myths surrounding the concepts and the way that we practice medicine have been devastating. The hormone area is probably the biggest area where we have failed people. For years, we castrated men because there was this belief, as Abe spoke about, that testosterone caused prostate cancer.
- [08:46]
B
Yeah.
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A
For 30 years or more, they castrated men. Can you imagine?
- [08:50]
B
No, I don't want to.
- [08:53]
A
And testosterone has been around for a long time. The first testosterone has been used since the 1930s because of this myth and this thought process that testosterone caused prostate cancer. It really created a snowball effect. Meaning testosterone therapy has not been routinely used. You do not go to your doctor when you have depression, and they don't typically measure a testosterone level.
- [09:21]
B
Yeah, right.
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A
Testosterone replacement therapy is really critical for a number of reasons. If you have low testosterone, it makes you at a greater risk for cardiovascular disease. If you have.
- [09:33]
B
Wait, wait, wait, wait.
- [09:34]
A
Stop that.
- [09:35]
B
Wait, wait, wait. I've always heard that it puts me at greater risk. Like, what about my cholesterol? And I like that. So you're telling me it's protective?
- [09:41]
A
It is. It is protective. And that's where the Traverse trial came. They did a. A trial called the Traverse trial, and it did not increase the risk of cardiac events.
- [09:51]
B
Wow.
- [09:51]
A
Again, total myth. And if you have erectile dysfunction, you are at a greater risk for heart attack or stroke.
- [09:58]
B
So I'm hearing I shouldn't be concerned about testosterone replacement therapy. It could actually be protective. It could actually not put me at greater risk for some of these diseases. Cardiovascular health, prostate cancer, et cetera. It could actually be protective against some of.
- [10:15]
A
I would be concerned if you were walking around with low testosterone. I would be concerned that you were going to have a bone fracture. I would be concerned that you're going to have heart disease. I would be concerned that you are at a greater risk for obesity and diabetes.
- [10:28]
B
Wow. You touched a little bit about the. The sexual health component. Why take testosterone? Like, why not just, like, Cialis or Viagra?
- [10:38]
A
Well, erectile dysfunction, just going back to erectile dysfunction can predict a heart attack within three to five years.
- [10:44]
B
Wow.
- [10:45]
A
I don't care about if your penis is shrinking. I care about if you are going to die from a heart attack and a stroke within one to two years. An individual who presents with erectile dysfunction. Obviously there's psychogenic components, typically when guys are younger, but if a 40 year old male is having problems with an erection, we have to think about cardiovascular disease. If you listen every week and feel like we are in this together, which I believe that we are learning, growing and building strength, then I created a way for us to get connected even more closely. It's called Forever Strong Insider, a premium community for listeners who want to go deeper. You'll get ad free episodes, which I know you'll love. Bonus Q&As, where your questions shape the conversation behind the scene moments because let's face it, I'm hilarious from my daily life and written takeaways to keep at your fingertips. But more, more than that, you'll be supporting the show so that we can keep creating content that matters. If you've ever wanted to feel part of the inner circle, this is your invitation. Join us at foreverstrong.supercast.com or through the link in the show notes. And I don't want to marginalize this or make fun of it, but it reminds me of the gauge on a car. Yeah, right. And the overall health of a man. If I were to give you one marker, it would be testosterone. The 1 marker for overall health and wellness for a man and his morbidity, mortality, his risk of heart disease would be testosterone.
- [12:19]
B
Why is there this stigma with it? I mean, I hear this from you, but I've had a lot of other physicians throughout my career, the military moving around and having it, and not one of them has ever talked to me about testosterone. Were like, have it checked. They're like, you're young, you're healthy, you're exercising, you're fine.
- [12:37]
A
It's a great question. And individuals are really misinformed. There's always been a stigma with sexual health. I believe that that's part of it. And because of the perceived risks of testosterone replacement therapy that have been out there. And then of course, you bring in this idea of steroids that people are afraid.
- [12:58]
B
Well, you mentioned steroids. Yes, I want to ask about that because, you know, I hear testosterone replacement therapy and then I look at like a bodybuilder online and it's like talking about they're on steroids. Where does that line. It seems that line's blurry. Like, where is that?
- [13:12]
A
Is that, is that the whole Matt and I were Talking about this, is that the whole natty or not, that's.
- [13:16]
B
The natty or not, like the Kenny Ko thing.
- [13:17]
A
They do the natty or not. The conversation is totally wrong and misleading. We make testosterone. The idea of steroids and testosterone replacement therapy being one and the same is just not true. Steroids. If we were to define steroids, let's think about testosterone. Synthetic agents that are given at supraphysiological doses for a specific performance outcome that is not the same as a testosterone replacement therapy. Replacing something that is low within physiological norms. An individual who has low testosterone is at risk for heart disease, is at risk for bone fractures, is at risk for depression, is at risk for obesity. There are a whole host of comorbidities that make testosterone really critical rather than thinking about synthetic steroids and then turning an entire generation off. But I will say it's not without risk. Testosterone replacement therapy, there is some risk. There is risk.
- [14:24]
B
What am I looking at?
- [14:26]
A
Infertility doesn't mean it always happens. If someone is listening to this and says, you know What, I am 30 years old, I want to go on testosterone because my levels are low, I feel terrible, but I want to have children. One of two things. Number one, you bank sperm. And number two, an individual can go on TRT with the understanding that they will take HCG and that it might take three to seven months to get the body back to functioning normally without testosterone replacement therapy. But once you start, it doesn't mean that you have to always be on it. But then on the flip side, why.
- [15:06]
B
Would you go off following question of that? What if you are done having kids, let's say, and you're just wanting to feel good and, you know, kind of regain some of that 23 year old vigor. What risks are to that individual?
- [15:19]
A
I would say the. There is no inherent risk that I could think of. An individual would want to make sure that their hematocrit, hemoglobin, hematocrit is not too high. Maybe they have sleep apnea. So you'd want to check that prior or if someone had active prostate cancer, then you'd obviously want to see someone just to again find out the details. But from my perspective in the literature, there is no risk for replacing low testosterone. Which is crazy because, you know, one of the things that you had said to me said, okay, Gabrielle, we're gonna sit down, we're gonna do this episode. I want you to convince me to go on trt. And I thought to myself, okay, well, how can I convince you if your levels are Good. Do you need more testosterone? And the answer? I would say no. If your free testosterone is where let's say it's in an ideal range and you're feeling great, more isn't better. Would you feel great? Probably. If you went on testosterone? Probably. But would there be a medical indication? No. Would there be dangers for an individual with low testosterone going on testosterone? No. And that has been one of the biggest misconceptions because we have millions of men. I was looking at the data. Let's say 40%, 25 to 40% of men in their 40s have low testosterone. Roughly a very small percentage would ever look to get treated. The most recent data that I've seen in the general male population, maybe 3% of men are treated, which means we're failing guys from a primary care level. If a guy comes in who's overweight and obese and he has low testosterone, we should be treating him. Yes. Diet and exercise, you have to do all those things. But we should be training.
- [17:14]
B
So even. Because that's my next question, you have somebody who's overweight or obese. We know that, that obesity is probably contributing to them having low testosterone. So you wouldn't just have them lose weight, you would do it concurrently or would you try to have them lose weight?
- [17:29]
A
Great question. Honestly, personally, I would have them do it concurrently. Here's why. When an individual has low testosterone, it's setting them up for issues later on. And as a physician, my perspective is, does lifestyle matter? Yes. But come in and treat it. If 92% of men in this one veteran study had depression and low T, Now I'm asking a depressed person, potentially depressed and obese, to give them another three months with how they're feeling. I would say I wouldn't feel comfortable doing that. Of course, diet and exercise, we have to do those pillars. But it's not like women. Women go through menopause, Tax day, New Year's, Christmas, it's coming. Menopause is coming for women. But for men, it's not true. Men can maintain the same level of testosterone. Again, certain things change. But to have a man suffer in silence for absolutely no reason and know that it's something that is treatable, I think is a huge mistake. We have to go in there and we have to treat. It's not to say that again. Diet and exercise, we know. And sleep are key. I was looking at one of some Data, looking at five nights of poor sleep decreases testosterone by 15%.
- [18:52]
B
Oh, yeah.
- [18:53]
A
And then also you and I were talking that an individual can increase. If they lose roughly 15% of their body weight, they can increase their testosterone by 250 nanograms per deciliter. That's a lot. Oh yeah, that would take someone from 300 to 550. But the same goes for if someone gains weight, they would go from 550 down to.
- [19:17]
B
Well, and I love that because you talk about the, the reality of the motivation and the mental component that if you can start treating them, they might actually have that motivation to start losing that weight they never lost. Whereas if we're assuming they're going to do something that they have not done before to get their testosterone back up. Now what about these testosterone boosters, like natural, like supplementation tongot, Ashwagandha, how effective are they?
- [19:42]
A
It's not my first line therapy and it's also not my second line therapy. And we have evidence based protocols that work. We have spent, we, I mean I haven't spent but there's billions of dollars that go in to make sure of the evidence, efficacy and safety. We know testosterone works. If someone wants to use Ashwagandha. You know, when I was treating the military operators, I always put them on 500mg of ashwagandha. But it wasn't for their testosterone per se. Maybe it was for their stress stress, maybe it was for their cortisol response. We have to be very clear as to what we are treating and if we are not clear as to what we are treating then the outcomes that we are measuring become blurry. This episode is brought to you by something sweet. And it's not me, it's Manicura. Let's talk carbs, specifically honey. And no, it's not another nickname for my husband. I usually call him something else. People have this idea that carbs are bad and that is simply not true. I use Manicura honey daily. Well positioned carbs like Manicura honey. They have been amazing for my personal training. I think of Manuka honey, which is what it is as a functional carbohydrate. Not just the sugar. It's serving a purpose. It's not just adding empty carbs. Honestly, we use it anytime we need a natural sweeteners. The bees collect the nectar from the Manuka tea tree in New Zealand. It's very complicated. The nectar is then packed with bioactive ingredients and the honey that is produced has three times more antioxidants than your average honey. If you are looking for good honey and you're looking for something sweet, you can check out their website to Learn more. Head to manicura.com doctorlion for $25 off your starter kit.
- [21:23]
B
So along those same lines, we talk about some of the alternatives. I also see a lot of influencers on Instagram who are not physicians, talk about testosterone. Everybody should be taking a testosterone. What are your thoughts on that?
- [21:36]
A
It goes something like this, and this is being generous. If you had abdominal pain, would you go to the dentist? No. You mean to tell me that if you had abdominal pain, you wouldn't go and call your dentist for abdominal pain?
- [21:55]
B
I would not.
- [21:56]
A
Okay, well, if you were looking to get your testosterone treated, would you have a criteria for people that you are listening to?
- [22:07]
B
Speaking of the dietary supplements and kind of those testosterone alternatives, what do you think about these influencers on Instagram who are talking about testosterone but aren't physicians?
- [22:17]
A
Social media landscape is fascinating in the era of the velocity of information that spreads. It's unbelievable. Do you know that Atkins. You've heard of the Atkins diet?
- [22:31]
B
Yes, of course.
- [22:31]
A
At its peak, one out of 11 people were on the Atkins diet.
- [22:34]
B
Oh, I can't believe it.
- [22:35]
A
That's crazy.
- [22:36]
B
I believe it.
- [22:36]
A
Do you know how many books he had to sell before that happened?
- [22:39]
B
Had no idea.
- [22:39]
A
10 million.
- [22:40]
B
Okay.
- [22:41]
A
An individual can go on TikTok and they become a viral success in two days. Doesn't mean that they are correct, but it does mean that they are popular. My perspective on influencers. Influencers by definition are there to influence. They are not experts. They should be if they are smart. The best influencers are educated by the experts and then go and quote influence. The problem that I'm seeing is that it's like taking medical advice from a mechanic. Maybe you want that mechanic to read your mri.
- [23:19]
B
Don't want that to happen.
- [23:19]
A
Don't want that. They might be confident. The question is, are they competent?
- [23:25]
B
The Dunning Kruger effect, right?
- [23:26]
A
I believe, yeah. Therefore, when I am thinking about who I'm going to go to and listen to, they have to be trained professionals. The reason that people go to influencers are no offense to the physicians and scientists. They're not usually entertaining and it can be very boring and it can be heavy. But they're typically well trained and correct the influencer space. They believe that they are experts and that can become damaging, I think because.
- [23:56]
B
Of when you talk about sound clips, right. Even asking you about testosterone, there's pauses and there's considerations because you're going through this breadth of knowledge that's in your head of all these different situations and things that we know of and research Whereas that influencer, they're, they're so absolute and they can give that sound bite, basically because of their ignorance.
- [24:15]
A
That's right. They also have nothing to lose. A trained professional spends years cultivating knowledge and excellence. They're very thoughtful as to how they think about things. An influencer, they don't have the same rigor. They come across confident. Doesn't mean that it's competent. And it becomes very damaging for people. Because I remember I was listening to someone speak and they were talking about how everyone should be on testosterone. I mean, is that true? No. What if an individual has normal testosterone levels and that individual is listening to an influencer, they go on testosterone and they shut down their fertility forever. Then this child, then this person isn't able to conceive, or in order to conceive, they're going to have to go get sperm, you know, extracted from their testicles with a needle or something.
- [25:05]
B
Not fun.
- [25:05]
A
I mean, I don't know. I don't have a set, but I can imagine that that's not fun. Yeah. They have to be very, very careful. Influencing can be a good thing, but it comes with responsibility. And again, the people that are reckless have nothing to lose because they never worked for anything in the first place.
- [25:23]
B
It's a good, good point. And why people should listen to your show to get qualified information.
- [25:28]
A
Also, it's not me. Right. I am not. If I have an opinion, I will tell you. This is my opinion. I will also tell you this is where the evidence is. This is where it's limiting. These are the things that we have to be cautious of. But I would say that the smartest people, the most impactful individuals, have a scope of knowledge and they will tell you where that knowledge ends because there is intellectual integrity.
- [25:54]
B
Love it.
- [25:55]
A
The influencer hotline. I mean, what could possibly go wrong with the influencer hotline?
- [26:00]
B
What could possibly go wrong? Well, back to testosterone.
- [26:03]
A
Yes.
- [26:03]
B
And now we, we've agreed that it's, it's pretty good stuff. What about the different forms of administration? So I'm, I'm looking to, to go on it. What's the best way to do that?
- [26:14]
A
Great question. The first thing that you have to figure out is what is someone willing to do? There are a number of different modalities as to how to get testosterone. And there is testosterone intermuscular injections. That would be in the shoulder or the butt there or the thigh. But I don't recommend that. There is.
- [26:33]
B
Why don't you recommend this?
- [26:34]
A
Because it, I mean, it hurts.
- [26:36]
B
Okay. All Right.
- [26:39]
A
It seems like it hurts. Yeah. There is testosterone, sub Q. And that's my favorite way of delivery. Sub Q testosterone a few times a week allows for a steady state as opposed to a weekly injection. Gives you a high peak and a high trough.
- [26:56]
B
That's what you and Dr. Morgan Taylor were talking about. He. He naturally discovered his patients started feeling bad, what at the end of two weeks. And he checked their testosterone. It's because of that trough. So you're not getting that with the sub Q.
- [27:08]
A
You are not. And also one of the reasons that we monitor blood work so much is the elevated hematocrit, which is the blood viscosity can go up because of in part that big peak. If you are administering it through the week, sub Q, you don't get that huge peak. And for someone who is a responder and seems to get elevated hematocrit, which is why people go donate blood, this could be an alternative which I think is fascinating. There's also other ways of administering testosterone which people don't often think about. Internasal.
- [27:43]
B
I can snort it.
- [27:44]
A
Well, I wouldn't necessarily say snorting it, but you can get it. Yeah. Put it in your nose.
- [27:50]
B
Okay.
- [27:50]
A
Twice a day, one to three times a day. Here's why someone would use that short acting. You could use it before sex. You could use it before a workout. It does not seem to have the same long blood lasting effects as an injection.
- [28:06]
B
Wow.
- [28:07]
A
Internasal. And also may affect fertility differently. A less impact, less impact on fertility. All testosterone you have to disclose must can affect fertility. But this seems to be a bit less.
- [28:21]
B
I wonder like cognitive function and brain. I mean it's just from the proximity piece. Is there any. Do you know if there's any?
- [28:27]
A
That's a fascinating question. Know, but that is a fascinating question. There's also oral testosterone that's lymphatically absorbed and that's Kaiser. Typically you take it with a fatty meal.
- [28:38]
B
What about my. My liver?
- [28:39]
A
It doesn't go through first pass metabolism.
- [28:41]
B
All right.
- [28:42]
A
There's also Androgel. If you have kids, don't recommend that. Also I would say once someone goes to injections, they have a really hard time going back. So we have gel, potentially patch. But no one really uses that. You have IM injection, sub Q injection, internasal and oral.
- [29:03]
B
The sub Q. I just got to pinch my skin, throw it in.
- [29:07]
A
And we could probably show people how to use that. It works really well for people. What they have to look out for is depending on sensitivity, they can get a reaction which is very Itchy, but seems to be the best way. Both men and women seem to really like that the best.
- [29:23]
B
And so do I have to mix that or can I just. Can you just pull it straight out?
- [29:28]
A
Yeah. Right.
- [29:28]
B
Okay. Easy, easy. Super easy. Are there any, like, needless options besides, like, the oral job, but, like, because there's some injectors.
- [29:36]
A
There is an auto injector now, too.
- [29:38]
B
Oh, okay.
- [29:39]
A
Yeah. Again, the needleless option would be the intranasal, which I don't think has the same impact on the blood levels. We don't see that. But also has potentially less effect on fertility. Great to use for sex and for working out. The other thing is Kaisertrex, which you take more than once a day. A lot of people like that as well, which is the oral, which is absorbed in the lymphatic system and the gel. But don't recommend the gel if you have kids, because you don't want your kids growing a beard.
- [30:10]
B
I don't. I mean, now that you put that in my head, I'm just. I'm thinking about it and they would be pretty cute with the beard, but. Okay.
- [30:17]
A
Would you, as someone who wants to or someone who is considering testosterone, do you think you would have a proclivity to one or the other?
- [30:25]
B
I think I'm okay with injection. Never injected myself with anything, but I don't have a problem with needles. I can watch somebody draw my blood, so I don't think I would.
- [30:36]
A
One of the other things is managing someone's expectation. How fast is it going to take them to feel better?
- [30:43]
B
Yes.
- [30:44]
A
And you don't start testosterone and feel better immediately. Do not put that in your head, because guys will say, okay, well, I started. I just don't feel anything. You should really give it three months. Will it take three months? It won't take three months, but give it three months. After that first month, you should start to feel better, typically faster. But the reality is, let's say you start testosterone, your levels are low, you go on it, what can you expect to feel? Yes, Typically, people feel less joint pain, they feel less fatigue, their sex drive increases, their mood gets better. From a physical standpoint, they find that their recovery seems to be more robust. Three months in, when you are on a good dose of testosterone, the world looks different. Like Abe was saying that 5% people feel better.
- [31:42]
B
I love that. That's very exciting.
- [31:45]
A
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- [33:00]
B
So Gabrielle, I'm vain. What can I expect if I go on testosterone in the next three to six months in terms of my body composition and muscle gain?
- [33:08]
A
Your vanity will not improve. But aside from that, you and I were talking about Bachan, his study and there was a study design where it was 600 milligrams of testosterone enantate weekly for 10 weeks. There was 25, I think it was 25, 50, 125 and 600 milligrams which is a lot of testosterone. Anthea Weekly no exercise plus testosterone. No exercise. People gained 7 pounds of lean mass. Yes, exercise plus testosterone was 13 pounds of lean mass.
- [33:43]
B
13 pounds. So you're telling me some exercise, some testosterone replacement. I could gain 13 pounds of lean.
- [33:51]
A
Muscle mass and I'm sorry, it was 25, 50, 125, 300 milligrams and 600 milligrams.
- [33:58]
B
Do you ever go as high as 600?
- [33:59]
A
I would not. And here's why. Okay, it's a great question and I have very much struggled with dosing because the average starting dose is anywhere from 125-200mg weekly for a man. What if a man goes on testosterone and doesn't feel better, but he clearly has low testosterone and when I say low, let's define less than 300. He might be an individual who has androgen insensitivity. Typically people do not measure CAG repeats. You cannot go to the lab and get a CAG repeat. The average person will never know if they have an androgen sensitivity or not, receptor sensitivity or not. What if and I, you know, looking back on My practice, I had a guy who many, many years ago came to me and he was taking probably 500 milligrams of testosterone a week. And I said brother, listen, I'm sorry, I'm not going to be prescribing that. And he said, doc, I swear this is the only amount that makes me feel good. Even though his total and his free were high because there is individual variation, but I personally would never go that high.
- [35:11]
B
I guess that makes sense. And this is more probably in that steroids line because I have heard bodybuilders say they don't take that much like compared to other guys, but they still grow. So that individual could just be very androgen sensitive. And so yeah, it's true. Like a lower dose might be more.
- [35:26]
A
Question could, is there a certain amount of muscle that someone is going to be able to put on? Probably there is probably a cap. But when an individual starts with testosterone, let's not say steroids, it changes how much they can probably put on. Again, I'm not saying this in absolute because this is my opinion. Think about it. An individual goes on testosterone, is there a level as to how much muscle they could put on? I mean there's probably a genetic cap, right? But if someone then adds additional anabolic agents like we're seeing in the enhanced games, is there a cap for the amount of muscle that they would be able to put on? There might be a cap, but it's still super physiologic.
- [36:09]
B
Right? This is very interesting stuff.
- [36:11]
A
Well, it's interesting because there should be a level of again, we are talking about health and wellness and should you go on testosterone or not? If someone is low, they're hypogonadal, I believe that they should be able to be replaced. I am not concerned about the risks. I think the benefits outweigh the risks. Now if we're talking about someone who is using agents to enhance performance and enhance physique, you are going to arguably trade risk for performance for vanity.
- [36:47]
B
Yeah, but if you are not in the optimal range for free testosterone and you go on it, there is very little risk. You're going to get the health benefits and you're going to get some vanity. You're probably going to improve your body composition all so it sounds like a win, win, win across the board.
- [37:02]
A
I believe that to be true. And of course, if you are going on testosterone, how do you do it responsibly? Number one, you educate yourself. Number two, you are taking frequent blood work. You start with how frequent exactly. You start with a baseline Fasted in the morning when your testosterone is supposed to be the highest. If you go and have breakfast before your blood draw, you potentially could lower your Testosterone reading maybe 20%, maybe even higher. Not saying anyone should do that.
- [37:35]
B
Of course not.
- [37:35]
A
It's possible. Two readings of less than 300 would then put you in the hypogonadal category. Once you initiate treatment, we typically check it four to six weeks later because you want to make sure that the hemoglobin, hematocrit. Again, there's some controversy as to do you need to donate if you're hematocrit, which is that viscosity, that blood goes up. And I would say we should follow guidelines. Yes, you should probably donate. Is the evidence great? Not necessarily. Right. And someone who lives in altitude will always have an elevated hemoglobin and hematocrit.
- [38:11]
B
Right. But say that there's a performance benefit there too. Right. My, my runs might get a little better.
- [38:16]
A
They might, might get slower. Who knows? But yeah, and then you want to check, you know, we typically check every three to three to four months.
- [38:24]
B
And then what range are you trying to keep people at?
- [38:26]
A
If we were just talking about total testosterone, it should be anywhere. From what I have found is that men feel better, you know, anywhere from 500 to a thousand. But if you have very sensitive receptors, you might feel great at 3:50.
- [38:42]
B
So it's, it's just looking at the blood work and then following up with that individual, seeing how they feel and.
- [38:48]
A
Then making sure they are doing all of the other things like diet and exercise and training. You know, we were talking about erectile dysfunction and, and how are you going to solve for erectile dysfunction? Well, believe it or not, exercise can improve erections.
- [39:02]
B
That's awesome.
- [39:03]
A
A penis pump can also improve erections. And that would be somewhere I was reading 80 to 90% effective. Not very romantic, but still. And then exercise 150 minutes with just the guidelines, because you need blood flow, right? The vasodilation, you need blood flow.
- [39:19]
B
What diets? I guess fat intake. I mean, how does that affect testosterone?
- [39:24]
A
Now you definitely know that answer. As a PhD in nutritional sciences, we.
- [39:29]
B
Gotta have a certain amount. You gotta have a certain amount of fat. So you would never go, you never want to go too low or that could negatively affect your testosterone. So, you know, under 20% total fat in your macronutrients.
- [39:40]
A
I would absolutely agree with that. And also don't gain weight if you can stay lean. Obesity will lower testosterone levels and lower sperm health. I was looking at some data earlier that if you have poor sperm health, you have a 2.6 time greater likelihood of having cancer.
- [40:02]
B
Sexual health with the male obviously is so important, but it is kind of this canary in the coal mine in terms of what goes on with that is predictive of cardiovascular health, cancer, all these other factors.
- [40:13]
A
Yeah. So semen. Okay. If I were to say, all right, Nick, what health marker should we measure so that I know that you're healthy or anyone or my husband? Testosterone. Believe it or not, a semen analysis is something that people are really beginning to look at as a marker for overall health. The more obese you are, the more unhealthy you are, the poorer semen quality is also affecting fertility.
- [40:41]
B
Makes sense. But, yeah, I imagine a lot of people aren't doing that right. Thinking about it, hey, yeah.
- [40:47]
A
No, but what about the fact that obesity is wrong, rising? If 74% of adults are either overweight or obese and the youth is becoming increasingly more obese, we are going to have increasing rates of infertility, which we're already having.
- [41:00]
B
Yes.
- [41:01]
A
Poor sperm quality and lower testosterone. And for the individual, it's a problem. But where it's also going to be a problem is if we think about the world that we're trying to create. And I know you and I believe the same thing, that we should have robust humans build a stronger, better world. We are not setting ourselves up for success. We are absolutely setting ourselves up for failure. And you have to attack diet and lifestyle early. It's much easier to raise kids.
- [41:33]
B
I'll stop you there. Yeah, there's nothing easy about raising kids. All right, but yes, I hear you. Terrible.
- [41:40]
A
So let's say someone doesn't want to go on testosterone. What could they do if someone wants to try to raise it naturally? They could try hcg.
- [41:48]
B
Okay.
- [41:48]
A
They could try Clomid. Some clinics use enclomiphene. Those are two ways that I would consider trying to increase testosterone naturally. Would I say saw palmetto or all this other stuff? I wouldn't. I would say sleep, train hard, eat better, have sex.
- [42:08]
B
I think that's very helpful because people are being sold. There's a lot of test boosters out there, marketing, we're seeing. And so from an expert like you to say, hey, I'm not using any of that. This is what I'm using. Any. Anything orally is pharmaceutical grade is from what I'm hearing.
- [42:24]
A
Well, there is one thing that we touched on, which was Cialis and Viagra daily. Cialis is really good for blood flow overall.
- [42:33]
B
The nitric oxide, it is.
- [42:34]
A
And it's really good. I think we're going to start seeing more and more use of Cialis, especially with the prevention or augmentation for cardiovascular health as well.
- [42:46]
B
I've seen some performance benefits and exercise, but, but, so then let me make sure I'm hearing you right. So again, 46 year old healthy male looking to optimize performance. Might be on testosterone, but otherwise fine sexual health. But you would say Cialis for cardiovascular health, potentially Lotos.
- [43:05]
A
Think about it. If erectile dysfunction is going to be a predictor of a heart disease or heart disease, heart attack, stroke within three to five years or stroke within one to two, Cialis is good for the penis. It's also good for the heart.
- [43:21]
B
So, so kind of a preemptive strategy. What, what dose? Is there a dose?
- [43:25]
A
5Mg, 2.5 to 5mg, 2.5 to five.
- [43:29]
B
Milligrams of Cialis a day. Just normal.
- [43:33]
A
I think that most people should be taking it. Nick's going, oh, God. I'm not on that. Damn.
- [43:38]
B
Actually, I'm taking notes here. Let me put that down.
- [43:41]
A
We're seeing that again. It's really important for blood flow. If erectile health is an indicator of overall health and erectile function. Calis is used for that.
- [43:53]
B
Makes perfect sense. And even like cerebral blood flow. I'm thinking about like before a talk or before now. That's. That's exciting. Thank you for all of that.
- [44:00]
A
Nick, you and I have been talking about if you're going to be starting TRT for a long time and you came to me and you had all of these concerns.
- [44:07]
B
I did. I'm ready to go.
- [44:09]
A
You were afraid that it was going to cause prostate cancer. You were also afraid that it was going to cause heart disease.
- [44:13]
B
Yes.
- [44:14]
A
You were afraid that. What else?
- [44:18]
B
Irreversible. I didn't know about the administration, how hard that would be. You know, did I have to inject into my vein, et cetera. You answered all that.
- [44:26]
A
Do you think that people will have additional questions if you were to say, okay, what did we miss? Or what is next?
- [44:34]
B
No, I think you should charge everybody for this episode because you gave them a free consultation.
- [44:39]
A
I'm going to hold you to that. And with that, Nick, thank you so much for making the conversation so accessible to everyone. Thank you.
- [44:45]
B
Thank you.