TRT: Your Complete Guide to Safe Dosing, Risks, and Boosting Longevity

What is the role of testosterone and erectile function? If testosterone is very low, then PAs ain't gonna work. Testosterone is a brain hormone. Yes, it also works on muscle and fad and all these other organs, but it's a brain hormone. As we were taught in the medical school, this concept called male menopause. Hand-draupause doesn't exist. It doesn't exist. I know. As men get older, aging alone doesn't drop their testosterone level. It's the acquisition of comorbid conditions that drops their level. I remember I was listening to someone speak and they were talking about how everyone should be on testosterone. What if an individual has normal testosterone levels? That individual is listening to an influencer. They go on testosterone and they shut down their fertility forever. In order to conceive, they're gonna have to go get sperm extracted from their testicles with a needle or something. Not fun. 90% of testosterone men is made from the testicles. There's a signal from the brain which goes to the testicles and says, come on, let's make testosterone. If someone has low testosterone, there's only two areas the problem can be, from the brain or from the testicles. People were 100% sure that testosterone replacement therapy was going to give people prostate cancer. And you challenged that notion. I would love to hear that backstory. Oh my god, so... Let's define testosterone deficiency in terms of numbers and when one could consider treatment. Yeah, good. So 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. 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, the 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. The challenge is what's a low level of testosterone. And critics of testosterone therapy say the experts can't even agree on what a low level is and that's true. And part of it is that some of the decisions about what a low level is has been arbitrary. The FDA uses a number of 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 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 what a low level is. There, I mean, that's totally fair. 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. And free testosterone was not discussed. Nobody's talked about, we have to talk about free testosterone, but nobody's, that hasn't been part of the conversation forever. And so this guy said, apparently, to the FDA, I think 300 is a fair number. Not to find out age. So my producer could have 300 and my dad, Nate, could have 300 and let's say it's 310 for both of them. Right. Could we treat them? Well, of course you can if they have symptoms, in my opinion. The idea that there's a, first of all, the idea that there's a single number that separates everybody is just, it's anti-scientific. We don't work like that. Our bodies are not clones of each other. 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 low number is, is defined by specialty and by geography. So the endocrine... And geography. Geography. You have to say that because you've got to pause. 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 an 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. But that's not the guideline. 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. Because 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 endocrinologist that write that have also performed many of the most important studies we have where they use values under 300, or in some case, 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. So what is, and also age doesn't matter, right? It doesn't. Well, according to guidelines. According to the guidelines. And as physicians, we are taught to treat according to guidelines. What does that mean for the well-being of the patient? Yeah. So 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, 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 that be mornings? Happy 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, often outweighs what the guidelines say. In terms of free testosterone, that's what is that, I won't put words on you about, is that what you care about more? Yeah, I'm so glad you asked. So 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. 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 the short bullet is that free testosterone is the most reliable indicator of a man's testosterone status. So I hope I don't get too nerdy with this, but your viewers can handle it, I'm sure. Yeah. 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. And 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 SHBG is just floating past the 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 one or two percent is free, which means that 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. The cell, 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 one or two percent 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. The total can look normal, but actually the free may be low. 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 for my daily life and written takeaways to keep at your fingertips. But 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.SuperCasque.com or through the link in the show notes. How would, you know, this makes me think about women who go on birth control and increase SHBG irreversibly. How would, and perhaps it's different for men and women, how would they increase free testosterone? 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, you just put in the SHBG value, the testosterone value, and it'll spit out a number for you for the free testosterone. And when I 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 150 milligrams 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. 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. 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 levels of 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. Because oftentimes providers and the patient will become concerned that their total testosterone is outside of normal range, but their free testosterone is barely there, barely over the minimum. 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. And most people say, oh, that's robust. But he had all the symptoms. He had low free testosterone. So we treated him and all the symptoms got better. It's interesting. This is a man who was on taught, who should, 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. He was really struggling. Yeah. And you know, life is hard like it just is. We have challenges every day whether you have small children, elderly parents, difficult relationships work. Life is hard. And what would 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. Testosterone does not. Does not. 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 song. I think it's really important. But 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 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. It was good. I was working hard just to be okay at what I was supposed to be okay. And 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 it because nobody, none of my colleagues were treating with testosterone. It's not just that they weren't treating, they thought I was doing dangerous medicine. And they, I'm sure they shunned you, yeah? I caught a lot of, a lot of flak. I had some tough, some tough situations. But, but what kept me going was I was seeing something that wasn't being described in the literature or that I had been taught. I was seeing something that was like, these guys saw all the best known urologists or endocrinologists like in Boston where I was, and they'd come, and 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 said, oh my God, like my life is better. I travel often and spend long days on my feet and circulation and recovery really matter. Most compression socks I've tried, they feel gross, restrictive, synthetic and impossible to wear for more than an hour. Hollow socks changed that completely on my last trip. And by the way, they're ultra soft. They're made from baby alpaca fiber, which is naturally breathable, moisture wicking. So whether you are sweating on your feet or under your armpits, you are dry and comfortable all day long. The graduated compression supports blood flow from ankle gently tapering up the leg. It helps reduce swelling and fatigue. And I am so grateful that they have agreed to sponsor this show. And for a limited time only, you buy three and you get three free head to hollow socks.com to check it out. That's hollow socks.com. And after you purchase, let them know that you heard it from us hollow socks.com for up to 50% off your order. 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, but then synthetic agents that are given at super physiological 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. What am I looking at? 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 would you go off? Follow on question of that. What if you are done having kids, let's say, and you're just wanting to feel good and kind of regain some of that 23-year old vigor? What risks are to that individual? I would say 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 one of the things that you had said to me, said, okay, Gabrielle, we're going to sit down, we're going to 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 20% 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 treating. Let's talk about drugs. And I have, and when I say drugs, I'm talking about PDE5 inhibitors, Viagra, Cialis. There was a massive review of 1.26 million people found that regular Cialis use reduced major cardiac events by 22% and lowered all cause mortality by 30%. Do you think there is a place for people that are healthy to be on these types of medications like Cialis? Yeah, if you ask me if there's data to support that for all patients, not yet. From a personal standpoint, I believe so. Like my read on the data is these are preventative drugs that can prevent significant disease. Do you know the story of Viagra? It's an interesting one. So Viagra was initially a drug developed and they were tested in England. And so it was initially a drug designed to treat angina, chest pain. So you get all these men who have a history of chest pain, you give them Viagra, say, okay, when you get the chest pain, take the drug, see what happens. Turns out lousy drug for chest pain, like that doesn't work. And so that's what nitroglycerin does, right? It reduces pain with lack of blood flow to the heart. And then the people who do the study are like, back to the drawing board and they're like, send us the drugs back. And like, they weren't getting them back. Like what is happening? Patients never keep these drugs. And so of course, the patients noted that their penis was working better on these drugs. That's how Viagra was born. It was initially a heart drug for angina, but then we developed into a penis drug. And see, Alice had a similar history. And so it's not that surprising as we look back at the data, which has been in front of us now for 20, 25 years, the men who take these drugs consistently seem to have a much lower risk of heart disease. The mechanism is unclear. It probably has to do with endothelial health, the inner lining of the blood vessels being healthy has to do with maybe decreasing clotting in the major blood vessels. You get drugs like Viagra and Cialis, Sildenaphyl, Tidalaphyl, the names. And if you take them, not only do they help erection, we also discover that Tidalaphyl, which is a drug that stays in your bloodstream for 24 hours, used to be called the Weekend, actually helps with urinary symptoms as well. And then now- It helps how? It helps with these urgency, frequency getting up in the middle of the night type symptoms. So Tidalaphyl has an FDA indication for urinary symptoms or lots lower urinary tract symptoms. And so I write for these drugs a lot because I find every excuse I can to give them to men, whether they have problems with erections, whether they have problems with urination, or- and then they get this likely benefit of cardiac protection. So it's like this triple threat drug, which by the way is like 25 cents a pill. You can get a prescription, you know, through Mark Cuban's pharmacy, yourgoodrx.com, literally three months for 30 bucks. So even if insurance doesn't pay for it, it's worth it. And so we routinely use these drugs and they're massively effective, restore confidence, probably good for your overall help with urination. I mean, it's great. There are downsides any pill, but you know, they're relatively low with this class of drugs. One in 33 men will stop because of side effects. One in 33. That can include headache, facial flushing, maybe worsened reflux disease, but 32 out of 33 men are like, I'm good. I'll take the reflux, give me extra flushing. And this is Cialis. Five million. Is it, do you prescribe five milligrams of Cialis daily? We do too in clinic. It's going to be the most effective because it's in your bloodstream constantly. So if you, if you believe the data that it's cardio protective, it makes sense. You need to have it in your bloodstream the whole day, as opposed to like a window, which Viagra is identical, it gives you a four hour window of efficacy whereas Cialis 24 hours. You only see men to be fair, right? For the most part, yeah, especially where I am now in my job and primarily men's health used to see a lot of women for stones when I was in Springfield, Illinois. Stones are very, very common for urologists. Yes. Did you, at that time, use Cialis in women? This is a study that clearly needs to be done for a variety of reasons. Number one, you know, overactive bladder. This is symptoms where people have to pee so often that it negatively affects their life. And like 40% of all humans above age 50 have overactive bladder. And this really 40% it's super, super common. You know, my dad's always saying, I have BPH. I'm peeing 100 times an hour. It just lets me meditate. I'd love to dive into that because there's a lot of misconceptions about the prostate being at fault for everything. But when we get older, we get physiologic changes in the bladder. So like the bladder capacity goes down and our sense of urgency and the sense of stretch is increased. So we end up peeing more often at lower volumes. There's like many things as we get older, things tend to get worse. As you're, when you're a baby, when you're born, the bladder just squeezes when it wants to. And then age four or five, the bladder takes commands from the brain says, no, no, no, you can't squeeze now. I'm in public. I can't pee my pants. And so you learn this continents. But as we age, like many things, the bladder kind of goes rogue and just ignores the brain's advice and just squeezes when it wants to. So patients, they'll put keys in the door, they'll hear running water, and obviously they'll get this crazy urge to go to the bathroom. And if you're lucky, you make it in time. If you're unlucky, you don't have a bathroom there, you're more likely to have accidents. And so women, like one of the main reasons women physiologists is for urinary incontinence, not only stress incontinence from when you cough or sneeze, you lose your urine, but this urgent comment, you know, this is very, very common. But men also have urgent comments. And so this can be treated by addressing bladder health. And so that's why I think a study is a long, long overdue for women to see if Cialis will help with these overactive bladder symptoms like they do in men, because they do. And then is a current protective in women? These are questions that need to be answered with a randomized control trial. If a woman was taking Cialis, the indication would not be, I suppose it would be off-label for overactive bladders. It could be off-label. Until we get an indication to be off-label. But off-label doesn't mean wrong. Oh, totally. Right. And a lot of patients will think, you know, this is off-label, this is wrong. Now, off-label means as a physician, I have to tell you the risk is benefits of this therapy. And then you decide if it's right for you, just like many other things in life. So yeah, it's a study that needs to be done. And there have been studies to look at sexual function and these classes of drugs, and it does increase blood flow to the genitalia. You know, sexual function and orgasm in women is a lot more complicated, sophisticated. A lot of other things have to happen for orgasm to occur. There isn't this obvious yes, no, penis hard, penis soft kind of thing in women. And so these drugs have been disappointing for sexual function in women. However, it doesn't mean they might not help. Thank you to Cozy Earth for sponsoring this episode of the show. Now, if you've been following me for a while, you know how much I struggle with recovery. However, I recognize that that includes quality rest. And for me, the holidays are about slowing down, being with my family, and actually enjoying the quiet moments, even if I find popcorn in my bed. And that's why I love Cozy Earth. Their bamboo pajama set has become a staple in our house. We always gift it. It's a lightweight, incredibly soft, and sleeps degrees cooler than cotton, which means I stay cozy without overheating. I honestly look forward to putting them on at the end of a long day, and maybe even in the middle of the day. And gifting them, yes, that's the best part. You know how there's always that one person who's impossible to shop for. Well, these are the gifts for people that they will actually use. Cozy Earth's mission is to make your five to nine the time that matters the most and is the most comfortable. And right now, Black Friday has come early at Cozy Earth. You can stack my code, DrLion, on top of their site-wide sale and save up to 40% off. Just head to CozyEarth.com DrLion. That's CozyEarth.com DrLion for 40% off. There is a connection between muscle mass, sarcopenia, and sexual function. Absolutely. Muscle mass is imperative for longevity. If you want to live a long time, you have to move iron. You've got to be strong. You've got to keep it that way. We have this age-related sarcopenia where you will lose muscle as you get older, relate to hormone production. But if you fight to be elite in our age now, I'm going to put us as young, we'll be fine when we're 90. So that's my paradigm. Like right now, we're in preparation for a geriatric to cathalon. This is Peter Tia's concept. It's amazing. So you've got to be really healthy now. So Muscles does so many things in your book, Forever Strong, talks about the metabolic capacity as one of the biggest organs humans have to control insulin sensitivity to control inflammation. And it's not surprising at all that when you look at well-done studies, men with more muscle mass have better erections. Men with less muscle mass have horrible erections, have low libido, have lower testosterone. It's all about overall health. Again, think to the paradigm about how the body is willing to give away its erectile function if it has to sacrifice something, but it's going to keep brain function. And as we get sicker and unwell, the penis is the first to go. So don't get unwell. Stay strong. So when men train, when men lose weight, when men gain muscle, erections get better. Aerobic activity is as powerful as P5 inhibitors, the drugs like Cialis that we talked about earlier, in helping with erections, a modest 10% decrease in body weight is as powerful as pills in helping with erections. Not only all the other benefits of keeping it on the right side of the grass. So again, if you take good care of your body, your body will take good care of you. Anything you do for penis health is good for cardiac health. So it is not surprising at all that there's a direct correlation between muscle mass, strength, grip strength, and erectile quality. You just got the attention of every male listener on the planet. Yeah. Well, good. Or at least we're listening to the show because who doesn't want a better erectile function and better penis health. And you know, just to jump in, we use the penis as a fulcrum for behavior change. It is very difficult for the average man to change your behavior if you tell them, listen, your blood pressure is eight points too high. But if you tell them, listen, if you lose a little bit of weight, if you start exercising, just minimal gains, 150 minutes a week of exercise, 30 minutes, five times a day, you will see tremendous improvement. And so we can use this as a fulcrum to get guys to be healthier. In Canada, the cigarette packages have like this flaccid cigarette on the side. And it basically says smoking is bad for your erections. So we should lean into this fact and get people to be healthier because, yes, sexual function is very sensitive to oral health. And we should use it as a way to get people to be healthier. Is there a dose you said 150 minutes of moderate to vigorous activity? Is there a known specific dose that is good for penis health or vascular health primarily? I mean, I know that we're talking about vascular health in general. But again, as a urologist, I thought that we would focus on your organ of longevity, the urologist organ of longevity versus my definition. Do we know is there a dose? Study by Zhang et al. I think from last year, 2024, they looked at the NHANES data, which is like a community cohort database from like the early 2000s. And basically, I found that 150 minutes of exercise per week decreased the rate of rectal dysfunction by 20%, 300 minutes by essentially 40%. Something very close to that. So, you know, intensity and duration as it gets higher, you get improvements. There is a eventually you plateau is like if you do 1000 minutes, you're not going to get perfect erections. But even a modest amount of exercise really moves the needle. And then if you really are exercising 300 minutes a week, that's an hour, five days a week, which is a great goal. You'll see a 40% improvement in erections. I'm going to just lay out a handful of other statistics and numbers because I think they're so powerful. Studies showing men who maintain muscle mass strength are 66% less likely to report multiple sexual issues. Older men, this was fascinating, but not surprising. Sarcopenia was linked to 2.7 times greater risk of moderate to severe ED. Both of the studies are, you know, excellent in that, you know, a lot of them are self reported studies and where the people are quantifying their own strength. The one study about the muscle mass that's from like a bunch of Scandinavian patients and the people who reported that they still were strong, had awesome erections, the people who said, yeah, I feel a little bit weaker than when I was 10 years ago, they had lousy erections and lousy libido too. What is the role of testosterone and erectile function? Testosterone is essential to a certain point, right? So if you have normal testosterone and you give more testosterone, testosterone there typically isn't added benefit, right? So a mistake you'll make is like assuming if somebody comes in with a normal, you check their tea, it's normal, but they have problems with erections. But given the testosterone, that typically doesn't fix the problem. Remember the main etiology of erectile dysfunction is probably vascular blood flow problems. So you got to fix the blood flow. If testosterone is very low though, then penis ain't going to work. How would you define very low? Well, you know, if you want to use the scientific definition, a repeated measurement of testosterone less than 300 or free testosterone less than five. So if it's low, if you give testosterone back to those men, they typically will see better erections, especially when they're trying to use pills. Cialis, Viagra, they rely on testosterone for nitric oxide, synthetase, or the chemicals that are required for erections. If your tea is low and you give tea back, the pills will work better. Again, I just can't stress enough though, if you take your carrier cell, your tea will stay normal. There's data where, you know, people who are look healthy in their 70s and 80s, their testosterone is way higher than people who look unwell. My dad is really low. Yeah. Let's just throw Nate Dogger under the bus again. We ran his labs and I'm looking at this testosterone of over 700. No, that's amazing. And I would argue that the best single blood test for overall health in men is testosterone in women, maybe, but maybe there's a ratio we need to look at. And then along those same same lines, the best overall marker for overall health in men is erectile function. Why? Because you have to have excellent vascular integrity, excellent overall health, and the penis requires normal mental health. If you're anxious, if you're depressed, the penis ain't going to work. So you can be in great physical shape, but if you're unwell from a psychiatric perspective, whether it's depression or whatever it is, anxiety because you're having stress at work, again, the penis ain't going to function well. So all systems have to be on full go for the erections to be awesome. So that's a really reassuring thing. If you're a 70 year old and you're getting greater erections, you're probably pretty healthy. Oh, sorry, it's time to record an ad for the show. Thank you to one of the sponsors of the show, Timeline, and listen, my kids still sleep with me. And after 470 nighttime snack requests, bathroom breaks, my husband snoring, my cell is there like, yo, gee, we're tapped out, enter my dopier. Timeline nutrition is one of the most thoroughly researched products I have come across in over a decade. Look, it's carried in my purse. They have peer reviewed published science. And this is where it gets really interesting. 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People were 100% sure that testosterone replacement therapy was going to give people prostate cancer. And you challenge that notion. I would love to hear that backstory. And how many tomatoes were thrown in your face and how that you probably had three friends and one of those included a sibling and maybe a parent. Oh my God. So, 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 knew I was doing something that was considered dangerous. But I always felt like what I was doing was in the patient's best 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 for playing 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? And 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 you put a male in the cage with the female and they had this bright colored flap of skin that comes out. It's called a doulap. And the male sees the female, the doulap comes out in 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 make. 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 for the 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, what, 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 doulap 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 testosterone deficiency or anything like that. And then I go on to practice and I start dealing with men with sexual problems. And some of these guys were desperate. How did you choose urology? It wasn't obvious. I didn't know anything about urology. 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'd 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. I'm desperate. I'll try anything. And I thought to myself, could testosterone work in men? Could men be like lizards? How far into practice were you? Just starting. Just starting. 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 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, 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. Thank you to our place for sponsoring this episode of the show. And as a community that values strength, longevity, and real health, we know nutrition starts long before that first bite. It actually starts with what you cook it in. And most traditional non-stick pans still contain chemicals like Teflon and PFAS that can leach into your food and environment. In fact, one study found that even a single scratch on a non-stick pan can release over 9,000 plastic particles. That's not something that I want anywhere near my kitchen or my family. And that is why I've switched to our place. Their cookware is completely toxin free and designed for both performance and safety. They're beautiful. Their four piece cookware set is honestly all you need. It replaces that entire pile of mismatched pans. I can sear, saute, steam, bake with it with four pieces. If you get that four piece, you can save $150 compared to buying them individually. Cooking is such an important part of our health. Let's do it right. And our place is having the biggest sale of the year. You can save up to 35% site-wide through December 2nd at fromourplace.com. With their 100 day risk-free trial, free shipping, free returns, there's no reason to not upgrade your kitchen. Better for you, better for your home, better for your family. My favorite way to treat ED is lifestyle modifications. Let's be clear. I say, look, don't go for the pill. Go for the diet, exercise, sleep, and stress reduction. How fast will you see a change, you think, from a rectangle? It depends on how quickly someone is willing to put in the lifestyle modification changes, right? But we can see them over, of course, six to 12 months if patients want to commit. There was a wonderful by Esposito. She did a wonderful study, randomized control trial, two years, lifestyle modification, or no lifestyle modification in 110 obese men, 55 in each arm. She followed them for two years. This was in JAMA. And with lifestyle modification and weight loss, they saw a significant increase in rectile function without pills. I mean, this is just without pills. So I say, look, the best way to do this is to lifestyle modification, because it's not just directions. Your overall health is going to improve. Unfortunately, most men say, just give me the pill. I say, fine. But lifestyle modification makes a big difference. The key is here that if you can do the lifestyle modification, most patients, if they stick with it, I see numerous other benefits as well. And then the shockwave therapy. Does that work? Shockwave therapy is brilliant. So essentially, when I first saw this, this came out in 2010 by a gentleman named Dr. Vardy in Europe. And what he was doing was he was taking a device. It's a shockwave device, essentially, and shocking the penis. It's basically like a pulse, electrical pulse. What he showed was in those patients that got shockwave, they were seeing improvements in rectile function. Now, I'll be honest with you, when I first saw this, I thought it was ridiculous. It made no sense to me. But it's actually brilliant. Because what you're doing is you're tricking the body and you're inducing a trauma state. And when the body sees trauma, the body is an unbelievable healer, unbelievable healer. So you're telling the body, I have trauma in the penis. And what he showed in that study was that those patients who did the shockwave saw significant improvement in rectile function. Since then, there's been a boom in the United States. Absolutely. Everywhere you look, there's shockwave devices. And for women too. There have been also for women, for sexual dysfunction, for many causes. But for sexual dysfunction, and it makes sense, this actually came out in the cardiac literature before it came out in the urologic literature. And still doing. Where they use shockwave on the heart, induce trauma, and you get neo-angiogenesis and blood vessels within the coronaries. So we use it now for ED. But you have to be careful. There's different classes of drugs. There's class one, some class three, class one, do nothing. They're pneumatic. They don't do anything. But they make a click. And so patients hear it. And it's a big business. It's anywhere from $500 to $1,000 of treatment. And if you buy a class one drug, anyone can buy a machine, anyone can buy it. And so you have to be careful because they don't really do anything at all. And if you treat someone for six treatments and they pay $6,000, that's very expensive. It's very expensive. There's a placebo effect. Is it 30%? 30 to 40%. Is it really? How'd you know that? What do you mean? It's 30, 40% with this thing. So 30 to 40% of patients who get the class one machine will say, I got the best directions I've ever had in my life. It's a placebo effect, right? But the class three ones are regulated. And those machines have been shown to have efficacy in improving sexual function. So using the right type of machine, these are called electromagnetic, electrolyte, they're very good machines. And remember that not everyone sees improvement. So remember that a lot of patients will, I think mild to moderate, see the most improvement. But not everyone will because ED is multifactorial. There could be a psychogenic cause. There could be a lot of other factors going on as well. But right now, those are not covered by insurance. So it's a cash business. Do you think they're effective? I do think they're effective if you're using the right machine and the right patient. Right? The right machine and the right patient. If you're losing a class, the electrolyte, electromagnetic, if you have patients with mild or moderate ED, they don't have significant fibrosis and scarring, then you have a better shot. But would it be it's not necessarily correcting the underlying cause? I mean, again, there's, it's multifactorial. It's multifactorial, but it's improving the quality of the tissue. And that's really important because you're bringing in new blood vessels into that phenyl tissue. You're improving the cause. So basically the body is one of the best healers. If I cause any trauma to your body, your body can heal it. It's pretty clever, except when it's gone to the state of fibrosis. If the phenyl tissue is completely fibrotic, I can't get you from scar back to normal tissue. Right. But if they're not fibrotic, you can actually reverse the ED process by using these. Now there's stem cells that have out there. We had the first stem cell trial in the United States for ED using a, this trial was though using a FDA approved machine. And we did find that there was some benefit in ED, but it wasn't sustained. It was only about six months. So unfortunately, there's not a randomized placebo control study with stem cells for ED yet. And that's sad because that's an easy study, right? But there's not a randomized placebo. There's a lot of randomized placebo control trials for shockwave showing benefit. And the last one is PRP. So platelets is a third realm. There have been a few studies suggesting that maybe beneficial. You, a recent one out of the university of Miami showing no benefit at all. So again, be careful because a lot of these treatments are cash and you just have to be very careful because this is a very vulnerable population and they're willing to pay the money. So I just got to be careful. And I just thought about this as you were talking, does the penile tissue atrophy? It does with non use for sure, like any muscle. And so where do you see the most atrophy in men, typically around 52 years of age, why 52? That's an odd number. It's because that's when women go through menopause, right? So as she goes through menopause and they stop engaging in sexual activity, he will see more and more atrophy of the penile tissue. He'll develop something called venous leak. So now the blood will come out faster than it goes in. And so once you get venous leak, then it's harder to get an erection. So really important to keep the penile tissue healthy as we get older. Do you think educating on this, if you were to wave a magic wand, do you feel like your contribution would be to educate on this much earlier? Absolutely. Because as you stop using the penile tissue, you can start developing fibrosis and scarring, which I cannot reverse, right? So you want to keep the tissue as healthy as long as possible. Maybe you're not having sex today, maybe you're not. But maybe you will want to have sex in five years. And if you don't keep the penile tissue healthy today, you won't be able to have sex in five years. So it's really important to keep the tissue healthy. What about these testosterone boosters like natural, like supplementation, tongot, ashwagandha, how effective are they? 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 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 500 milligrams 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. So along those same lines, when 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? 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? I would not. Okay, mom. If you were looking to get your testosterone treated, would you have a criteria for people that you are listening to? 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? 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? Yes, of course. At its peak, one out of 11 people were on the Atkins diet. That's crazy. I believe it. I believe it. Do you know how many books he had to sell before that happened? I had no idea. 10 million. Okay. 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 two 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. Don't want that to happen. Don't want that. They might be confident. The question is, are they competent? The Denning Krueger effect, right? I believe you said that. 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 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 so absolute and they can give that sound bite basically because of their ignorance. 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. Yeah. Extremely. 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? That individual is listening to an influencer. They go on testosterone and they shut down their fertility forever. Then this person isn't able to conceive or in order to conceive, they're going to have to go get sperm extracted from their testicles with a needle or something. Not fun. 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. Again, the people that are reckless have nothing to lose because they never work for anything in the first place. It's a good point and why people should listen to your show to get qualified information. Also, it's not me. 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. What can I expect by going on testosterone in the next three to six months in terms of my body composition and muscle gain? Your vanity will not improve, but aside from that, you and I were talking about the Bouchin study. There was a study design where it was 600 milligrams of testosterone in antatequility for 10 weeks. There was 25, I think it was 25, 50, 125, and 600 milligrams, which is a lot of testosterone in antatequility. No exercise plus testosterone, no exercise. People gained seven pounds of lean mass. Yes. Exercise plus testosterone was 13 pounds of lean mass. 13 pounds. You're telling me some exercise, some testosterone replacement, I could gain 13 pounds of lean muscle mass. I'm sorry, it was 25, 50, 125, 300 milligrams, and 600 milligrams. Would you ever go as high as 600? I would not. Here's why. It's a great question. I have very much struggled with dosing because the average starting dose is anywhere from 125 to 200 milligrams weekly for a man. What if a man goes on testosterone and doesn't feel better, but he clearly has low testosterone? 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. 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. 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 it's true. Like a lower dose might be more effective. It's a great 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. 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. Right. This is very interesting stuff. Well, it's interesting because there should be a level of, again, we are talking about health and wellness. And should you go on to 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 out, 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. 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 the question comes up. If somebody who doesn't have low testosterone takes testosterone, what's going to happen to them? Great question. Yeah. So this, sorry, I didn't take you too long. Wonderful. No, no, you're doing great. But it's related. Forgive me, forgive me. Please. But this is part of- 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. We have to be able to rethink about these conversations because the ultimate outcome that we want is health and longevity and muscle. Which is all part of the same, right? 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. Sure. If you increase someone's testosterone, I mean, you had mentioned that there might be brain effect at 400 or 500. Is there a number? Well, what happens if someone is not low? Or how would you define not low? And if you give them testosterone, what would happen? So what I mean by not low, 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 1000. 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 can take the same guy. Let's say you could manipulate his hormones at 700 to 900. Nothing changes for him. Not erection. Nothing. Because his testosterone is normal. The one area that does not seem to max out is muscle. This muscle. And that's why the body builders, 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 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. You need to get levels that are 10 to 50 times higher in terms of testosterone equivalents to start doing that. So what would that look like? Would that be a total testosterone of 5,000? 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 wind strong. 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 the G protein coupled receptor. And it's hard to see. I'm not sure that there's an upper limit to how much you can get with testosterone through that second mechanism. In your practice, what are some of the most frequent disease, disease processes, complaints that you encounter in both men and women? I see so many men and women for sexual dysfunction. So when I see men for sexual dysfunction, I see a lot of men for erectile dysfunction, right? So that's a very common condition. And how would that be defined? So it's inability to obtain or maintain an erection, right? So inability to obtain or maintain. That's the easiest way to define it. Some men can obtain the erection, they can't maintain the erection, right? And the statistics are very similar to what I told you about low testosterone. 50% of men are over these 50, 60% over 60, same numbers. It's amazing how many men suffer from this condition, and we don't talk about it, right? So erectile dysfunction is a very common condition. Premature ejaculation, right? So 30% of men will suffer from some degree of premature ejaculation, which can be very bothersome to the relationship. The average man will ejaculate within seven minutes. Premature ejaculation, most men will ejaculate less than one minute, right? And there's a discrepancy, so it's very important to realize that men and women, premature ejaculation can have a big impact on their relationship. How about Peroni's disease? Seven to nine percent of men suffer from this. And what is the cause of that? So we, I believe that, so as men get older and as they start developing a mild erectile dysfunction, they start increasing the risk of having a buckling incident during sex. So let me give you an example. If a man has 100% rigid penis, he's fine. He's not going to injure himself. If he has a 50% rigid penis, he's not going to be able to penetrate in the first place. But he's in trouble when he has a 90%, 80%, 70% rigid penis because of what's going to happen is he's going to penetrate and he's going to buckle and injure the penile tissue. And when he injures the penile tissue, what happens is you develop a scar. Now the best way I want you to think about this is if you have a balloon. And if I put a piece of duct tape on that balloon and I blow that balloon up, what do you think is going to happen? It's going to curve in the direction of the duct tape. That's exactly what happens in terms of Peroni's disease. And seven to nine percent of men in the world suffer from this condition. And these men tend to be more devastated. I mean, they are truly depressed when you look at them psychologically to have this kind of curvature. And when the curvature is greater than 60 degrees, they can't penetrate. So it's very devastating. Yeah. And then for women, when you see women on the flip side, what are their most common complaints? The most common complaint I see is low libido, right? So many of these women have low libido, but it can be multifactorial. So you can't just say, hey, give them testosterone, the world is great. I mean, there's many things. It's her stress, it's her relationship with her partner. I mean, there's her medical condition. So you have to take into account everything for her low libido. Many women suffer from pain with intercourse, dysperunia, right? So we talked about that earlier. Many women just have poor arousal, decreased blood flow to the genitalia. And they have orgasmic dysfunction, inability to obtain an orgasm. So you really have to do a deep dive and figure out what is the actual cause. I firmly believe that lifestyle modification for men and women does help with sexual dysfunction. And I will repeat that over and over again, the four pillars are diet, exercise, sleep, and stress reduction. Diet, exercise, sleep, and stress reduction significantly help with sexual function and men and women. There's something very interesting between the difference between men and women. If you look at a man typically, a man typically has sex to reduce his stress. He has a very stressful day. He comes home. He just wants to have sex to reduce his stress. In women, it's the opposite. She has to reduce her stress. Oh, that is interesting. Right? It's a 180. So if I tell men, if you want to have a better sex life with your partner, reduce her stress. Do the dishes. Do the dishes. No, seriously. I'm serious. Reduce the stress. If you can reduce her stress, you're more likely to engage in sexual activity. For him, it is for sex to reduce the stress. I can see where that would create relationship issues. And probably one would have to treat both parties as opposed to treating one party. You nailed it. It is a couples disease. When I started my practice in 2007, I was so proud of myself. I was able to get these men, these amazing erections, amazing libido. Everything was great. They'd go home and they'd have no enough sex with. In fact, the women were very upset. They said, look, we haven't had sex in 10 years. And now he wants to have sex all the time. It's ruining our relationship. And I thought to myself, they're right. I mean, the reality is that you can't raise one libido without raising the other, or you're going to set up for conflict. So if you're going to raise one libido, raise the other. So very quickly, I started getting into the field of female sexual dysfunction. I said to myself, if I'm going to treat the men, I'm also going to treat the women and raise the libidos together, raise the sexual function together. Otherwise, it's a set up for conflict. You have been saving marriages for decades now, which is incredible. Let's talk a little bit about hypogonadism and the signs and the symptoms, the definitions and how one would go about treating that. And what does the evidence show? Let's go back to like the basic signs, just the basics. Remember that testosterone in men, 90% of testosterone in men is made from the testicles. 10% is made from the adrenal glands. Women are a little bit different. 50% from the ovaries, 50% from the adrenals. Now, there's a signal from the brain and that signal is called LH, which goes to the testicles and says, come on, let's make testosterone. It's like the gas, right? So if someone has low testosterone, there's only two areas the problem can be, from the brain or from the testicles, either the testicles are not producing or the brain's not producing one or the other. So my job is to figure out where is it coming from? Number one, secondly, you want to be able to treat them. And you want to understand that giving men testosterone can make them infertile. So many patients who go to these clinics that are 32 years old and they take the testosterone and they come to me and say, no one told me I could become infertile, now I want to have a child. Well, a little bit of an issue. Now we can reverse it, right? But the reality is if you're thinking about taking testosterone and you're planning on having a child, hold off. You can use medications to make you make testosterone. That's safe. I can use off-label clomaphoensitrate. I can use HCG. I can use things to make you make testosterone. But do not give a young man testosterone if he's planning to conceive and make sure he's fully aware that if he does take testosterone, it will shut down his natural production, right? So I think that's very important to have those discussions with the patients. But testosterone, again, is not only for men, it's also for women. I use a lot of testosterone in women and they also benefit equally as well as men. And I would say for libido, women benefit more from testosterone than men do. And with the men, when you start them on HCG or in clomaphoensitrate or clomid, do you expect to get a certain percentage rise in free testosterone? If you say, I'm going to give you 3,000 IUs of HCG a week. I expect your testosterone free and total, I don't know, the percentage that it increases to go up by 300 points. Is there some kind of expectation that you have? Yes. So remember this, when you're using medications to raise a man's natural testosterone, you are dependent on his ability to do it. Some men can, some men cannot. As they age, they're less likely to. So I tell the residents, it's like putting fuel in the car. You can put all you want. The car will only go as fast as it can. Right? So the younger men tend to respond better. So typically what we do is we use HCG or clomaphoensitrate, but at some point, at some point, the body says, I can't do it anymore. I can't make any more testosterone. But younger men tend to respond. I like to use clomaphoensitrate. It's off label. It's used for women for fertility, but what it will do is it goes to the brain, increases something called LH and FSH, that goes to the testicles, and the man can start producing his own testosterone. Now there's, I'm a little biased. I believe that Clomid can do something called the discrepancy effect. 40% of men, in my opinion, roughly will have an increased number in their testosterone, but they don't feel it. They say, doc, I know my number went to 800, but I don't feel it. And there's a reason for that. The way Clomid works, it blocks estrogen receptors in the brain, and men need estrogen for libido. So they have a bunch of estrogen sitting around. They can't see it. You take that same man and put him on testosterone. He'll say, okay, now my libido is back. So some men who take Clomid will not feel that improvement in libido. HCG doesn't depend on the brain. It goes straight to the testicles and starts producing testosterone. To be clear, do you think, again, I know you don't treat women, do you think a free testosterone of 10 pika grams per ml would be- Yeah, so that starts to be around the right place. So the same thing- And it's the person. The data around women and actual levels are less strong. And what's funny is that there, well, there's a whole other topic, so I hesitate to take you too far afield. But the world of endocrinology is based on blood tests of hormones. And to treat people who are too low or too high, whether it's thyroid or whatever it is. In order to decide what's normal, you have to have a control population. And so 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 assortment of people you might see in a doctor's office? Or is 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, a hundred 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 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. Yikes. And 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 in the world of, and I'm not an endocrinologist, but maybe I play one on TV, but I'm a frustrated one. Or maybe on your show, this is the next doctor's. Yeah, he has a podcast. It's not a visual show guys. Like, yes, I'm maybe a lovely wife. Thank you. My wife is a clinical site, Mary Ann Brand, and 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. The delivery mode for testosterone. So now we have Kaiser Tracks 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. Yeah. So I've used over the course of my career every available form of testosterone for my 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 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. Kaiser Tracks 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've got to do it 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 men while you're on it because the body of 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 and 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 aurels 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. I read that the aurels, there's maybe 20% are affected. Their fertility is affected, maybe 20% as opposed to almost all the individuals take you. 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. You don't really worry about that? No, I'm just kidding. So here's the thing is that men and women, lots of controversy around that. Yeah. But just in terms of our regular biology, most labs will say that the normal red blood cell count hematocrit is between, let's say 38 and 50%. It's 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 where often when people are anemic, nobody knows the answer. It's called unexplained anemia. 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. Because testosterone increases the red blood cell count. I had a guy years ago, a 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. And he said to me, if I had seen you 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. 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 normally a very conservative group, and they put a number at 54, which 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 is at 53 or 52, I don't think you need to do anything. 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. It's interesting, right? Especially when we're talking about what you said, patience. In medicine, as I've discovered, there is 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 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. Yes. And it's a challenge because I'm curious as to how those at altitude, if they get treated or not. Right. So the Colorado docs are cool about this. Amazing. 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. And then what about women? Is there a number for women for hematocrit above? 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 hematocrit because of testosterone have been shown to have any problems at all. You have to attack diet and lifestyle early. It's much easier to raise kids. No, well, let me stop you there. There's nothing easy about raising kids. All right. But yes, I hear you. It's terrible. 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. Okay. They could try clomid, some clinics use enclomaphen. Those are two ways that I would consider trying to increase testosterone naturally. Would I say saw a palmetto or all this other stuff? I wouldn't. I would say sleep, train hard, eat better, have sex. Most important is lifestyle modification. Healthier men are more fertile period. All right. So if you want to improve your fertility, lose weight, exercise, alcohol consumption. So remember that alcohol can actually cause damage to the testicles as well. And typically when it's about 40 grams of alcohol, 40 grams. So each drink that you take in alcohol is about 14 grams roughly. So that second drink probably okay. That third drink is where you cross. Right. So you want to watch the alcohol, marijuana consumption. So healthier people tend to be more fertile. And so I tell men you want to become fertile, exercise, lose weight, right. Less processed foods are very important as well. Right. Sleep. Remember that we men only make their testosterone when they sleep. You don't make to, you don't sleep. You don't make your testosterone. And endogenous testosterone is very important for sperm production. Let me repeat that. So endogenous testosterone is very important for sperm production. Exogenous testosterone makes you infertile. Right. But endogenous. So reversible. Yeah. But reversible. It takes some time. On average, our studies showed anywhere from three to seven months. But we could do it three to seven months. But there's no guarantee that I can get you back to baseline. Right. So I started out with 80 million sperm per milliliter. I took testosterone. I went down to zero. And now I'm back to 30 million. Okay. I have 30 million per ML. But I'm not as fertile as I used to be. But I am fertile. Right. So just be very careful on the definition. And for, for men, you know, women go through menopause and then that's it. They, they can't have a child. But for men, can they always produce sperm? Do they always produce sperm? Sperm production goes down as men age. And we see that typically 40 to 45 years of age is starting a precipitous drop. So it does go down. So it's not that you can always. Now, there's other ways to get the sperm. I can always do a biopsy of the testicle and get the sperm if I need to, if he's not producing. Male fertility is pretty easy. It's only two things I got to figure out. It's either they're blocked. Yep. Or they're not making it. There's only two options when I see these patients. They're blocked or not making it. And so if they're blocked, I can unblock them. And if they had a vasectomy, I can unblock the vasectomy. Right. If they're not making it, it's a little trickier. So you have to figure out why they're not making it, what you can do to help them. And many times you have to go in and do a biopsy of the testicle, find the sperm. I don't need very many. Just need several. Yeah, you know, one good one. Yeah, one good one. And, but again, I tell the patients, healthier people are more fertile. I need you to focus on your quality and health. Very important. And what about for women? I think you focus primarily on men in your clinic when it comes to fertility. Do you work with women at all? I work with women in the sense that I work with all the IVF centers here in Houston. And so when the couple are trying to conceive, they'll send me the male patient say, Hey, we have an issue. We can't get this find the sperm. He has no sperm on as a jackal. Can you help us retrieve it? And that sense is where I work with the women for fertility. Do I work with women for female sexual dysfunction all the time? All the time. All the time. Right. But fertility, my main focus is improving the quality of the sperm and finding the sperm in these men. You know, just circling back to women and sexual function, you'd mentioned that their SHBG goes up and both men and women, right? A male will and can always make testosterone. And he can, for example, my dad, my dad's 74. He cringes every time I say it. Maybe he's 73. We got his blood work done. His total testosterone was 800. Yeah. His free testosterone was amazing. And he again, he's an older gentleman who does all of the offensive pillars that you talk about for women and testosterone production. Does that always decline? Yeah. So you bring up two important points. The first one is that we were taught in residency in medical school of this concept called male menopause. Handropeause. Doesn't exist. It doesn't exist. I know. It does not exist. It doesn't exist because what happens is as men get older, aging alone doesn't drop their testosterone level. It's the acquisition of comorbid conditions that drops their level. So obesity, fat cells eat up testosterone, convert them to estrogen, called aromatization, right? HIV, AIDS, hypertension, all these conditions that you can acquire start dropping your T levels. But if you look at healthy, healthy 80-year-old men, they have normal testosterone levels. It's still in the normal range, right? So healthy men will maintain their testosterone. But women are a little bit different. So women will typically make 50% of their testosterone from their ovaries, 50% from their adrenals. And as she goes through menopause, it's a precipitous drop in her testosterone. And her adrenals are starting to decline every year at 20 years of age. So it absolutely makes sense that her desire for sex goes down because the number one desire, driver for sex in a woman is her testosterone level. And at 55 years old, when she's post-menopausal, there's almost no testosterone. So you can't blame her for having low desire. Secondly, she has vaginal atrophy. She has pain. So now she has no desire and she has pain within, of course, and you want to have sex all the time. She's a baphilicia. Right. So come on. But it's not fair. So if you improve the testosterone level, if you use local vaginal estrogen therapy, if you help her, then it makes sense. But to assume that a woman post-menopausal is going to want to have a great libido, doesn't make a lot of sense.