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Coming up on this episode of the Doctor's Pharmacy.

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People's sex lives are not over at age, you know, 50, 60 or 70. There are men that come to me wanting to have prescriptions for Viagra at age 70, and I always tell them, I'm not giving it to you unless I get a get a written note from your wife.

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If you've been thinking about giving up coffee, now's the perfect time to try Nduka. Peak is offering up to 20% off plus a complimentary beaker and rechargeable frother. Just visit peaklife.com hymen20 that's P-I Q U E L I F E.com hymen20 Let me ask you a question. What do you reach for after you finish a workout? If you're like most people, you probably reach for a sports drink to replenish the water and electrolytes you lost. And that's great, except that most of these drinks are also filled with sugar, food coloring and other junk. When I want to get the benefits of a sports drink without all the nasty stuff, I reach for Element. Their tasty drink mix has everything I need to give myself a science backed electrolyte boost whenever I need it. And there's no sugar, coloring, artificial ingredients, gluten or fillers, which means it aligns perfectly with my dietary choices. Element is one of the most important tools in my health and fitness toolkit and I know it can be for you too. Right now, Element is offering my listeners a free sample pack with any purchase. That's eight single serving packets free with any element order. This is a great way to try all eight flavors or share element with a friend. Get yours@drink element.com hymen today that's lmnt.com feel your max with Brooks Running and the all new Ghost Max 2. They're the shoes you deserve. Designed to streamline your stride and help protect your body. Treat yourself to feel good landings on an ultra high stack of super comfy nitrogen infused cushion that takes the edge off every step every day. The Brooks Ghost Max 2. You know technically they're a form of self care Brooks. Let's run there. Head to BrooksRunning.com to learn more. Before we jump into today's episode, I'd like to note that while I wish I could help everyone via my personal practice, there's simply not enough time for me to do this at this scale. And that's why I've been busy building several passion projects to help you better understand. Well you if you're looking for data about your biology, check out Function Health for Real Time Lab Insights. If you're in need of deepening your knowledge around your health journey, check out my membership Community Hymen Hive. And if you're looking for curated and trusted supplements and health products for your routine, visit my website Supplement Store for a summary of my favorite and tested products. Hi, I'm Dr. Mark Hyman, a practicing physician and proponent of systems medicine. A framework to help you understand the why or the root cause of your symptoms. Welcome to the Doctor's Pharmacy. Every week I bring on interesting guests to discuss the latest topics in the field of functional medicine and do a deep dive on how these topics pertain to your health. In today's episode, I have some interesting discussions with other experts in the field, so let's just jump right in. An estimated 30 million American men are affected by ED. Now, people don't like to talk about this and it's uncomfortable to talk about sex. It's kind of a taboo. But you have to talk about it because it's a significant issue that impacts so many aspects of people's lives. Now, your physical health and sexual health are totally connected. Obesity, for example, is independently linked to erectile dysfunction. People have what we call a dad bod. You know, it's becoming normalized among young men where you kind of kind of become a little pudgy around the middle. It's not normal. People with a high body mass index or who are overweight tend to have lower testosterone. I'm going to explain why that is and how you can reverse that. Also, your emotional health and wellbeing are tied to your sexual function. People are stressed, you know, have more trouble with sex. Quality, relationships and intimacy also plays a big role. And it's so common. We're going to talk about how common this problem is. In the Massachusetts male Aging Study, ED was the most common sexual health problem in 1995. It affected about 150 million men worldwide, and that's projected to reach 300 million next year. The prevalence, in other words, the number of people in the population, men particularly, obviously, who have this, is about 52% of men between ages of 40 to 70. That's a lot of guys. And what does it mean? Well, erectile dysfunction, or ed, means the inability to have or maintain an erection. Now, as you get older, it's more common. 40% of men are affected at age 40. 70% of men are affected at age 70. A recent study published in the Journal of Sexual medicine found that one out of every four men under the age of 40 is affected by ED. Now, that's shocking. You're talking about guys under 40, and that's about 25% of men under 40. There's also a strong relationship between testosterone and particularly testosterone deficiency and erectile dysfunction. And what's shocking, and I see this in my practice, and it kind of blows me away, honestly. Young guys have very low testosterone. I mean, what you'd see sometimes I see in a 90 year old, I see in a 20 or 30 year old. And about 30% of men age 40 to 79, according to the American Journal of Medicine article, experience low testosterone. Now, researchers show an increased prevalence is associated with aging. That's common, but it's also associated with other diseases that are causing the erectile dysfunction. It's not just the penis that's the problem. It's the rest of your biology and your body that's not operating properly. So obesity, diabetes, high blood pressure are all clues that something's awry with your hormones, your metabolic health, and likely soon with your sexual health. In fact, there's a phenomenon that's called andropause, or male menopause, which is sort of a gradual decline in testosterone after the age of 30. About one to one and a half percent drop in testosterone a year. Now, that doesn't mean it's a norm or it has to be. I mean, I have a guy who's like 62 who's got a testosterone of like 900, which is what you'd see in a, you know, healthy young 20 year old or 18 year old rearing to go all the time. And promise you, he's rearing to go all the time. It doesn't mean it's normal, right? It means it's common. It doesn't mean it's normal normal. It just means the average in a population. So it's quote, normal, but it's not optimal. And so you have to understand how you want to get to optimal ranges by addressing the root causes of the problem. And there are a lot of ways you can naturally increase testosterone. Now, there's a strong relationship between low testosterone and erectile dysfunction. And the reason is that low testosterone is a clue for other problems. It's a clue that you have poor metabolic health. And it's so common. And I've talked about this so many times on podcasts, but 93% of Americans have poor metabolic health, and that is what leads to erectile dysfunction. I'm explaining exactly how we'll get into the science. And by the way, all the references, everything I'm saying is in the show notes. You can go dive deep, you can click through, read the articles yourself. But it's, it's a sort of scary picture in America now with increasing obesity, diabetes and, and poor metabolic health. But this leads to what we call endothelial dysfunction. Now, what the heck is that? Your endothelium is aligning of your blood vessels, and the health of your blood vessels determines your sexual health and your cardiovascular health and your cognitive health and pretty much everything. In fact, that's one of the problems with COVID and with long Covid, which we've talked about, is this massive damage to the lining of our blood vessels. And that is what happens with COVID that drives so many of the pathologies. Now, men who have low testosterone are 38% more likely to die of a cardiovascular tent. That's like a heart attack or stroke. Now the question is why? Why do we see low testosterone? Well, it has to do with what we call insulin resistance. Now, I've talked about this for almost got scary now to say 30 years. It is something I paid a lot of attention to. I've written many books on this. Insulin resistance is the scourge of the modern world. Like TB was everywhere before, and it wasn't even as prevalent as insulin resistance. We're talking about 93% of Americans having some poor metabolic function. And that's some degree of insulin resistance somewhere on the spectrum from optimal metabolic health, blood sugar regulation, insulin sensitivity, to a slow decline in insulin sensitivity, more insulin resistance, Pre diabetes, type 2 diabetes. It's all, all a spectrum. And this leads to low libido or low sexual desire, low desire for sex, for masturbation. It's influenced by low testosterone. And basically, I'll give you the punchline here, but as your belly grows bigger, your testosterone gets lower. Big belly, low testosterone. Why do you have a big belly? Because you deposit fat or vat, visceral adipose tissue. And this visceral adipose tissue is, excuse me, my French here, a storm of hormonal and inflammatory chaos. Essentially it causes an increase in what we call adipocytokines. And we'll talk about why. Inflammation plays a big role in messing up hormones, particularly testosterone. And it also causes an increase in estrogen for men, lower testosterone, and that leads to sexual dysfunction. So it's a big issue. And so this low sexual desire, low sexual function is influenced by less low testosterone, but can be influenced by other things like stress, anxiety and many other chronic diseases. Now, a 2019 study of more than 12,045 year old men found that about 1 in 20 reported low sexual desire, which is a lot when you think about 45 year old guys. They should be still raring to go. Now, some desire for sex drops naturally with age, but it doesn't go away even in your 60s, 70s or 80s. I mean, Mick Jagger had a kid at 75, Picasso had a kid. This was in the pre viagra era at 80 years old. So it's not impossible to keep going for a long time. Now what's the problem with our conventional approach to dealing with erectile dysfunction? It's not just as simple as giving people Viagra or Cialis. It's really about taking a deep dive into the why, what's the cause? Now, often your hormones are not tested. It's amazing how many people go to the doctor and never get their hormones tested, don't get testosterone free testosterone, estrogen, fsh, lh, all the important biomarkers that are critical to understand what's going on with your hormonal health. Also, doctors don't test for insulin resistance. I was recently on a conference call with some of the top scientists and doctors at Quest Laboratories Diagnostics, which is, you know, one of the biggest testing laboratories in the country, probably the biggest. And I said, how many, how many doctors are testing for insulin, fasting insulin? And they're like, well, that's pretty low. Maybe 1% of our lab tests are for fasting insulin that are ordered by doctors. Now this should be a standard test that everybody gets as part of their annual checkup. It is the most important test to determine your longevity Your risk of heart attacks, cancer, stroke, dementia, it's so critical. The other test that they almost never look at is what we call lipoprotein fractionation. I've talked about this on other podcasts. We'll link to those in terms of how to look at your lipids. But the cholesterol test that doctors do now is really so outdated. It's like, you know, looking at things, you know, with a, with a, you know, like, I mean, listen to your heart with a stethoscope instead of looking at it with an echocardiogram or an mri. You know, it's just, it's kind of old fashioned and it doesn't, it gives you some indication of what's happening, but it's really not the gold standard. And I asked again, I asked these experts in cardiovascular diagnostics at Quest. I said, well, what percent of tests out there are for the lipoprotein fractionation, which means the quality of the cholesterol, the particle number, the particle size, which gives you a much better, better indication of your insulin resistance and your risk factors. And I said, what percent of your tests are for this 21st century cholesterol panel? And they're like 1% or less than 1%. And so that means 99% of people are not getting the right cholesterol test, which prevents them from really understand what's going on with their metabolic health. Now, these tests, hormone tests, insulin, lipoprotein fractionation, A1C, many, many other things. We do test at Function Health. Now, I'm a co founder of Function Health, I'm the chief medical officer, and I believe that people should have access to their data and it's very empowering to know what's going on. We found all sorts of things. We've, we've had over 25,000 members to date. At the recording of this podcast, we've had over 3 million biomarkers tested and you can get over 110 biomarkers for less than $500. And you get testing twice a year and you can track what's going on. You can see changes based on your interventions, lifestyle, diet, supplements, and then actually be empowered with the right information and knowledge and education about what to do about these numbers. Anyway, back to the topic at hand. The other thing is most doctors don't really deal with lifestyle, you know, weight diet, exercise, sleep, it's considered soft medicine. But the truth is it is the most important thing in determining your risk factor in your health. Now what do they do if you come in complaining of erectile Dysfunction. Well, they give you the little blue pill, you know, that was a blockbuster. And that was an accident, that that pill was actually designed to high blood pressure. But it had a side effect that a lot of the people in the study noticed and they liked the side effect. And so the drug company got very smart and they were like, well, this is a lousy blood pressure pill, but it's a great pill for erectile dysfunction. And before that, it was tough for guys. They were vacuum pumps. You can have a penile implant. There was sometimes revascularization. You can do a transurethral kind of thing called Muse we used to recommend. It's like pretty scary. You put a little pellet in the end of your penis, it's painful. There's injections which you can use that work, but they're painful. But when Viagra hit the scene in 1998, within six months of approval, there were over 5.3 million prescriptions written. And then the prescriptions have just tripled in the last decade. So there are a lot of other drugs. Cialis, Levitra, Stendra. They work for different reasons and different people, different ways. But they're not bad to use. In fact, they can be helpful. They may be protective against Alzheimer's, I read recently. So they increase blood flow, they increase circulation, they increase nitric oxide. We're going to talk about all that. And those are not bad things. But, you know, more and more people are actually using this. Even younger people are getting it for off label use. They secretly take it, they're embarrassed, they have performance anxiety, maybe they have erectile dysfunction when they're younger. But let's talk about how these drugs work and how. What is the physiology of actually having an erection when you have sexual arousal, it causes the release of nitric oxide, which is a good thing, in those cells that we call that line, your blood vessels, called the endothelial cells, and they're in your penis. And so basically you get increased blood flow because it helps to activate something called guanylate cyclase, an enzyme. You don't remember it, promise no test on this. And that leads to an increase in something called cgmp. Now, that particular thing causes the relaxation of smooth muscle cells, or it causes your muscles to relax and that leads to the dilation of the blood vessels in your penis and that increases blood flow and that leads to an erection. And then it gets trapped inside the penis in the corpus cavernosum, which then maintain the erection and have fun. Now, after you ejaculate, there's an enzyme called PDE5 or phosphodiesterized type 5 and that degrades the CGMP. So a thing that keeps your erection going. Now that causes the smooth muscles to contract again and that reduces blood flow to the penis and that ends the erection. Now how Viagra works, Sildenafil and Cialis to Dafinil, how they work is they inhibit this PDE5, they inhibit 5 phosphodiesterase, which is this enzyme that degrades CGMP. Now in that prolongs the effect of this particular compound, CGMP keeps the blood vessels constricted in your penis and it helps maintain the erection for longer, which is fun and great and that's no problem. But, you know, side effects are common. About over one in 100 people, you get mild headaches, dizziness, flushing, congestion and sinus. Basically sex. You're congested, runny nose and have a headache. Well, it's not so much fun always. It can cause backaches, muscle pain, sometimes can cause low blood pressure. Because it was designed for a blood pressure pill, it can rarely cause a painful erection to last a long time, like over four hours. And that's called preapism. And that can damage your penis and it can cause all the heart issues. Rarely. It can cause vision or hearing loss, but that's very rare. Now, if you're taking drugs like nitrate drugs, if you have angina, you have heart disease, if you have liver issues, you don't want to take them. So they're not bad. But let's talk about maybe getting to the root cause, which is exactly what functional medicine is about. It's not about treating the symptoms, it's about the cause. So how do we get to the root cause? We have to really understand the full picture. And so we have to look at diagnostics. And I think it's really important to do a proper testing so you understand what's happening with your biology. And that's really why we've created Function Health, why I'm the co founder and chief medical officer. Because all the tests that I'm going to mention right now are all available@functionhealth.com and you can sign up, you can just get in there and get your test done. And right there's a waitlist, but we can get you off the waitlist if you use the code Dr. Hyman. Now, the first thing you want to know is something called sex hormone binding globulin or shbg. Now this is important because it regulates the amount of free hormone, free testosterone It's a protein made by the liver. It binds to testosterone and estrogen and it basically makes them inactive. So it's sort of like a reservoir of extra hormones when you need them. Uhm, also albumin combined to estrogen and testosterone, but not as well. And that's something eats normally in your blood. Now when you have insulin resistance, high insulin, the liver suppresses the sex hormone binding globulin and that leads to potentially more free testosterone and that can kind of screw up normal hormone balance. And we often see an increase in prostate cancer and enlarged prostates in guys who have insulin resistance and big bellies, and that's a concern. Inflammation on the other hand, can also increase sex hormone binding globulin. So why does that matter? If there's inflammation, you get higher binding globulin, it means you get less free testosterone. And that's what matters, that's what does the job. And so when you have less free testosterone from any source of inflammation, you can end up in trouble. So sometimes guys, even with insulin resistance tend to have the high sex hormone binding globulin because of the belly fat, which is basically a factory of inflammatory molecules. Now what does testosterone do? Well, it increases your sex drive or libido. It is involved in the production of red blood cells, which can sometimes be an issue. If you actually taking testosterone, it is involved in sperm production mood, so makes you happy. Or if you take too much, you can make angry motivation. So it's very important for motivation in men and women. And by the way, women have a lot of testosterone too. It's really critical to build lean muscle mass, which we'll talk about why that's important for sexual function. It helps energy or cognition recovery from exercise or injury, and it improves insulin sensitivity. So it's good. Now free testosterone is the active kind. It's not bound to the sex hormone binding globulin. It's the active form of testosterone and it's about less than 2% of the total amount. Now the optimal range, and these are all going to be in the show notes. You have to memorize them now, but you can check it out in the show notes. The optimal range is over 30 picograms per deciliter. Now you want to look also at the total and the free, so you want to get both. Now if you look at the total testosterone, the ranges are kind of screwy because you know, how we develop reference ranges in America is based on the average or quote, normal in a population. So if you're a Martian, you land In America, it's, quote, normal to be overweight. Because 75% are overweight, it doesn't mean it's optimal. So the ranges that we see are not the really optimal levels, but you see ranges of 200 or 300 nanograms per deciliter, but the range should really be over 500. And you have to look at the combination of free and total, but it can be up to a thousand or more. And I think it's important to sort of look at what the symptoms are, what the person's overall health is, and look at the free in total, and you get a sense of how much is going on there. Now, even if your test total can be normal, you can still have issues of low testosterone because your sex hormone binding globulin is high. In other words, there's not enough free testosterone. So I see that very often in my patients. Also, the other hormone that guys have, which you probably may not know, is estrogen or particularly estradiol. Now, men and women have estrogen, and it has a lot of important functions. It does affect the libido, it affects erectile dysfunction, sperm production. It's also important for bone health or brain function, and also for nitric oxide production. You don't want it too high or too low. And often guys who have big bellies have basically something called aromatase in their fat, which turns testosterone into estrogen. You don't want that. You don't want testosterone turning into estrogen. It's not nice. The other hormone you want to look at is the pituitary hormones and the hypothalamic hormones. Your pituitary hormones are really important. We call LH and FSH luteinizing hormone and follicle stimulating hormone. Now, it's kind of a weird thing because follicle stimulating hormone sounds like it's for women's follicles that produce eggs, but it's also active in men. So in men, the way this works is your hypothalamus, which is kind of way in the top of your brain. It's kind of the master control center, creates a hormone called gonadotropin, releasing hormones. So gonadotropin essentially are the hormones that make gonadal hormones. So it's like stimulates the pituitary to produce the gonadal gonadotropic hormones, which are hormones that stimulate the testicles or the ovaries, which may be the case in women, to produce more hormones. So lh, our luteinizing hormone, which, again, it's kind of a weird name because basically luteal phase of the menstrual cycle. It's named after women's hormones, but it really affects men too. So LH affects cells in the, in the testicles called the Leydig cells. Now these cells produce testosterone, so higher LH will increase testosterone. FSH affects different cells in the testicles called the Sertoli cells, and they lead to sperm production. So lh, testosterone, fsh, sperm, really important. And it's important to assess fertility. What's going on with somebody, it's really important. You may not know what's going on and you might have low testosterone, but you could have a pituitary tumor for some reason. So you got to check all these things. Also we look at prolactin, another hormone we check with function, health, again, not usually checked. Prolactin is another pituitary hormone that is involved in many things, including lactation. That's what I call prolactin, prolactin. But it can be high in certain benign tumors that grow in the pituitary, which are not that uncommon. And the treatment usually is surgery. Sometimes there's drugs that can treat it. We also need to look at inflammation. And we look at something called HSCRP or high sensitivity C reaction protein. Inflammation is such an important factor in our overall health and aging and longevity. High inflammation is a root cause of sexual dysfunction. Whatever's causing it now, many things can cause it, including our diet. That's the number one cause really. Sugar, starch, processed foods, all that's driving inflammation. Our gut microbiome, environmental chemicals, heavy metals, toxins. You know, there's also endocrine disrupting hormones which are really concerning to me. And I, I see a change in the population, in the birth rates of men and women. We see changes, fertility. We're going to talk about that on another podcast. And, and I think a lot of it has to do with, with these forever chemicals that are petrochemicals, that are in the environment that don't go away. We used to have dioxin and PCBs and DDT. They're still around. And now we have other plastics and other pesticides and herbicides. These are highly dangerous and they're toxic at very small levels. So you're like, I'm so what? I'm not getting that much this or that. But. But you are. Cumulatively you are over your lifetime. And they've done fat biopsies of people and they found pretty much every human is a toxic waste hub. And we probably wouldn't be Safe to eat if we were food. Other hormones are important as well. Leptin, again, something we check on function, health, that mostly doctors don't check. But leptin is the appetite suppressing hormone. But sometimes when you have insulin resistance, you also get leptin resistance. So you see high levels of leptin and that leads to low testosterone and suppressed lh. So that's concerning. In one study in the Journal of Clinical Endocrinology, they looked at three groups of men and they found that those with higher leptin levels, mostly due to leptin resistance, had a higher body mass index, so they were heavier and they had lower levels of testosterone. So it's an important thing to check. Adiponectin, another important hormone, it's an anti diabetic hormone, it's an anti inflammatory hormone, it prevents heart disease and it's often low in insulin resistance and inflammation, obesity. So you want to check out epinectin again and we check that as part of our panel with Function Health. Again, it's not usually checked, but it's important because if it's high, it's good and if it's low, it's bad. We also check your fasting insulin and Hemingway 1C because you know, insulin resistance is really, I would say, the majority of the causes of erectile dysfunction as we get older. And it leads to, like I said, low testosterone, higher belly fat, more estrogen, abnormal cholesterol, more inflammation, low sex drive. It's just not a good thing. And your insulin you really want between 2 and 5. Now, most reference ranges are 15 again because the average American is unhealthy and overweight. So the reference range is wrong, basically, is what I'm saying. So in functional health, we talk about what are the current reference ranges and what are the optimum ranges. Also you want to look at stress hormones like cortisol and dhea. And you also look at cardiovascular testing and not just a regular cholesterol panel, as I mentioned, but looking at what we call lipoprotein fractionation. This really looks at cardiovascular risk, insulin resistance, really important. And I think if you don't look at the right cholesterol panel, you're basically just living in the 20th century and not the 21st century in terms of cardiovascular health. Thyroid also really important. And we have to look at thyroid properly, not just the way doctors do it on their traditional panel over the tshirts. You have to look at the TSH, the free T3, free T4, even thyroid antibodies, which we all check on function, health and they're really important because thyroid function, if it's low, will cause a low libido, low sex drive, a low, low mood, and it may be as simple as taking thyroid and also will influence sex hormone binding allotment. Now none of these tests are hard to get or expensive, but unfortunately your doctor is probably not doing most of them or doing them properly. So that's why again, I co founded Function Health and encourage you to check out your own test so you can see what's going on and be empowered with your own health data and be the CEO of your own health. Now you probably figured out by now that I'm super passionate about getting regular, deep, restful sleep. It's a foundational piece for optimizing metabolism, brain function, and pretty much our health as a whole. One hack that has made such a huge difference in my own sleep quality was keeping my bed nice and cool. That's one of the reasons I love the POD from eight Sleep. For me, the most common reason for waking up in the middle of the night is getting too hot. In fact, it happened often even with the AC cranked. Sometimes my bed just gets really warm for my own body heat, making it impossible to sleep well. But ever since trying the eight Sleep pod, I haven't had that problem and I sleep soundly all night long and wake up feeling rested and energized. The POD can go on your existing mattress and it pairs dynamic heating and cooling thermoregulation with biometric tracking. So it actually adjusts to my needs throughout the night and gives me interesting data to learn from the next day, like a sleep score and heart rate variability. So whether you sleep hot or cold, the POD is so smart it will actively account for your unique needs to keep your bed just the right temperature. Eight Sleep has even found their products to help people fall asleep 32% faster and reduce waking by 40%. None of us can afford to lose out on high quality sleep. If you're ready to take your nights to the next level, check out eightsleep.com mark and you can save $300 off Pod 4 Ultra and $200 off the Pod 4. That's 8 sleep.com mark E I G H T S L E E p.com Mar K this episode is brought to you by Etsy. Oh, hear that? Okay, thank you. Etsy knows these aren't the sounds of holiday gifting. Well, not the ones you're hoping for. You want squeals of delight? Happy tears?