TRT Risks & Rewards: Your Testosterone Replacement Therapy Questions Answered

0:00If you have low testosterone, it makes you at a greater risk for cardiovascular disease. Wait, wait, wait, wait. Stop that. I would be concerned if you were walking around with low testosterone. I would be concerned that you were going to have a bone fracture. I would be concerned that you're going to have heart disease. I would be concerned that you are at a greater risk for obesity and diabetes. Wow. 40 % of men in their 40s have erectile dysfunction. If you have erectile dysfunction, you are at a greater risk for heart attack or stroke. Erectile dysfunction can predict a heart attack within three to five years.

0:31That's scary. obesity will lower testosterone levels and lower sperm health. If you have poor sperm health, you have a 2.6 time greater likelihood of having cancer. 92 % of men that were depressed also had low T. When individuals age, men think that their testosterone has to go down. It's actually not true. Testosterone in, say, a 75-year-old could be potentially just as good as your testosterone in your 20s, which is shocking. That's very exciting.

1:11After the statement came out from Tobias Kohler about your penis can shrink up to one centimeter if you don't use it. Had you ever heard that before? That was scary. I can tell you that struck fear into my heart. Everybody's heart. And immediately it just went viral because part of the problem is there's always this echo chamber of testosterone, steroids. But when you tell a guy his penis is going to shrink one centimeter, if he doesn't have sex, the world is listening. You're going to take action. Immediately. Immediately. And those actions can include penis pumps, lots of sex. And therefore that leads us to the conversation around testosterone and erectile dysfunction.

1:59Use it or lose it. Yes. Yes. And as a soon to be 46 year old male, I'm coming to you as the expert, as the doctor that you are, because I'm looking at my testosterone and I'm wondering, is someone that suspects that maybe my testosterone isn't what it used to be? What's the first steps I take when I go to my physician? First of all, you're looking great for 46. Well done, almost 46. Testosterone is interesting. Testosterone is the primary androgen for men and also women. When individuals age, men think that their testosterone has to go down. It's actually not true. It's totally unfair and not true.

2:39Testosterone in say a 75 year old could be potentially just as good as your testosterone in your 20s, which is shocking. That is shocking. It is shocking. There is hope for all men. something called shbg goes up which may make free testosterone a little less available but the reality is how do you know if your testosterone is low there are a handful of signs and symptoms number one the thing that would get a man to the doctor almost immediately is if his penis doesn't work erectile dysfunction 40 of men in their 40s have erectile dysfunction that's scary that is scary. In addition, obesity, diabetes, all of which contribute to low testosterone, which means you have to get your lifestyle right.

3:28But also, everybody should have their testosterone checked. By the time they're 40, a man should know, and I would argue even earlier, if someone is under 40 listening to this, the sooner you get your testosterone checked for a baseline, the better. No, we're not going to get it checked. Like, what do I ask for? Because there's, as you alluded to, there's different forms. So is there a particular form I'm looking at? And we should review your blood work. But if you are going to the doctor, what you want to look for is total testosterone, free testosterone, FSH, LH, unusual for a guy to have his estrogen checked, but we always check an estradiol.

4:06And believe it or not, everything is not testosterone related. You have to check your thyroid and even a prolactin level. Sometimes there are things in the brain, say an adenoma or some kind of benign tumor that would affect testosterone production. Wow. Estradiol. Estradiol. Why am I, I'm a, I'm a dude. I don't worry about my estrogen. Why do I need my estrogen? For us, the target level that we like to see in our clinic is between 30 and 50. Those are the numbers that a guy would want to look for. And And I would say that when a guy goes on testosterone, one of the things that the typical TRT clinic does or has in the past is they immediately put people on an aromatase inhibitor.

4:49That would be a Remedex to suppress estrogen. What we found was that when that happened and very early on, I mean, again, I've been in practice for, I don't know, over 10 years. The guys that had estrogen suppressed, they really, they seem to lose their libido. There may be a role for estrogen and libido. But what about, so you're suppressing the estrogen because of the concerns with gynecomastia? Yeah. But having that 30 to 50, I don't have to worry about that. Hopefully not. And obviously everyone is individual. And for someone listening, we're not giving medical advice, but how we dose it is very low.

5:23People do not get put on an estrogen blocker just because. If their estrogen is above 50, we would start an estrogen blocker and that would be at a very low dose and a Remedex of 0.25 twice a week, or maybe even just 0.5 once a week. Here's the catch. When a guy is obese, he might make more estrogen. Oh, yeah. But that doesn't mean that you wouldn't treat him for testosterone. You don't use an aromatase inhibitor as monotherapy, meaning let's say you have an estrogen that's 100. And I've had guys in my clinic that have an estrogen of 100. We don't immediately go, you know what, I'm going to block your estrogen before starting testosterone.

6:01Ah, so you just go to the testosterone. Now, I'm not obese. I exercise. I try to get enough sleep regardless of what my kids do. What is the cutoff? Because, you know, I look at 300 nanograms per deciliter and I'm still above that. But then how do you determine, is that a hard number for you or are there other things you look at? There are the guidelines, which the medical guidelines would make 300 the hard number. so the AUA guidelines, but these numbers, it is kind of arbitrary. That 300 number was just picked. Here's the rub with that. It's not just about testosterone. It's also about your androgen receptor sensitivity.

6:41It's something called a CAG repeat. And some individuals have very sensitive androgen receptors, meaning they require less testosterone. And some individuals have very low sensitivity receptors, meaning they would require higher levels of testosterone. 300 would be the cutoff, but it depends on where you go and what country. The cutoff in other countries is lower. It's an arbitrary number. You also have to look at how people feel. And it's funny, one of the things aside from just looking at the testosterone level, the diagnostic criteria for low t would be two levels in the morning with 300 or less 290 nanograms per deciliter but what if this person also is starting to have erectile dysfunction is starting to have fat deposition fatigue depression i was looking at one study 92 of men that were depressed also had low t It's not surprising.

7:44That's no, it is. And actually it's not surprising makes that it's a good point because if someone has low testosterone, how are they going to want to exercise and eat well? Yeah. It's tough. In your great interview you had with Dr. Morgan Taylor, he talks about that, that last what like 5%, that motivation that people have in testosterone gives them. The other piece of it though, that I thought was interesting. I wanted to ask you about is what about the health concerns? Because again, I've got young kids. I want to be around for them. Is taking exogenous testosterone going to put me at greater risk for prostate cancer or things like that?

8:20There are very few areas in medicine where the myths surrounding the concepts and the way that we practice medicine have been devastating. The hormone area is probably the biggest area where we have failed people. For years, we castrated men because there was this belief, as Abe spoke about, that testosterone caused prostate cancer. Yeah. For 30 years or more, they castrated men. Can you imagine? No, I don't want to. And testosterone has been around for a long time. The first testosterone has been used since the 1930s. 30s. Because of this myth and this thought process that testosterone caused prostate cancer, it really created a snowball effect, meaning testosterone therapy has not been routinely used.

9:14You do not go to your doctor when you have depression and they don't typically measure a testosterone level. Testosterone replacement therapy is really critical for a number of reasons. If you have low testosterone, it makes you at a greater risk for cardiovascular disease. If you wait, wait, wait, wait, stop that. Yeah. Wait, wait, wait. I've always heard that it puts me at greater risk. Like what about my cholesterol? And I'm like that. So you're telling me it's protective? It is. It is protective. And that's where the Traverse trial came. They did a trial called the Traverse trial and it did not increase the risk of cardiac events.

9:50Wow. Again, total myth. And if you have erectile dysfunction, you are at a greater risk for heart attack or stroke. So I'm hearing I shouldn't be concerned about testosterone replacement therapy. It could actually be protective. It could actually not put me at greater risk for some of these disease, cardiovascular health, prostate cancer, et cetera. It could actually be protective against some of these. I would be concerned if you were walking around with low testosterone. I would be concerned that you were going to have a bone fracture. I would be concerned that you're going to have heart disease.

10:23I would be concerned that you are at a greater risk for obesity and diabetes. Wow. You touched a little bit about the sexual health component. Why take testosterone? Like, why not just like Cialis or Viagra? Well, erectile dysfunction, just going back to erectile dysfunction, can predict a heart attack within three to five years. Wow. I don't care about if your penis is shrinking. I care about if you are going to die from a heart attack. And a stroke within one to two years. An individual who presents with erectile dysfunction, obviously there's psychogenic components typically when guys are younger, but if a 40-year-old male is having problems with an erection, we have to think about cardiovascular disease.

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11:41If you've ever wanted to feel part of the inner circle, this is your invitation. Join us at foreverstrong.supercast.com or through the link in the show notes. And I don't want to marginalize this or make fun of it, but it reminds me of the gauge on a car. Yeah. Right. And the overall health of a man, if I were to give you one marker, it would be testosterone. The one marker for overall health and wellness for a man and his morbidity, mortality, his risk of heart disease would be testosterone. Why is there this stigma with it? I mean, hearing this from you, but I've had a lot of other physicians throughout my career in the military moving around and having it.

12:28And not one of them has ever talked to me about testosterone. We're like, have it checked. They're like, you're young, you're healthy, you're exercising, you're fine. it's a great question and individuals are really misinformed there's always been a stigma with sexual health i believe that that's part of it and because of the perceived risks of testosterone replacement therapy that have been out there and then of course you bring in this idea of steroids that people are afraid well you mentioned steroids yes i want to ask about that because you know, I hear testosterone replacement therapy and then I look at like a bodybuilder online and it's like talking about their own steroids.

13:09Where does that line, it seems that line's blurry. Like where is it at? Is that the whole, Matt and I were talking about this, is that the whole natty or not? That's the natty or not, like the Kenny KO thing they do. The natty or not. The conversation is totally wrong and misleading. We make testosterone. The idea of steroids and testosterone replacement therapy being one end of 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 supra 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.

13:50An 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 are there is risk what's 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.

15:00But 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? Following question of that, what if you are done having kids, let's say, and you're just wanting to feel good and, you know, kind of regain some of that 23-year-old vigor. What risks are to that individual? 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.

15:42But 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, you 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 TOT. 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 the data, let's say 40%, 25 to 40 % of men in their 40s have low testosterone.

16:43Roughly 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. So even, because that's my next question, you have somebody who's overweight or obese. We know that that obesity is probably contributing to them having low testosterone. So you wouldn't just have them lose weight, you would do it concurrently or would you try to have them lose weight?

17:29Great question. Honestly, personally, I would have them do it concurrently. Here's why. When an individual has low testosterone, it's setting them up for issues later on. And as a physician, my perspective is, does lifestyle matter? Yes. But come in and treat it. If 92 % of men in this one veteran study had depression and low T. Now I'm asking a depressed person, potentially depressed and obese, to give them another three months with how they're feeling. I would say I wouldn't feel comfortable doing that. Of course, diet and exercise, we have to do those pillars. But it's not like women. Women go through menopause.

18:12Tax day, New Year's, Christmas, it's coming. Menopause is coming for women. But for men, it's not true. Men can maintain the same level of testosterone again certain things change but to have a man suffer in silence for absolutely no reason and know that it's something that is treatable i think is a huge mistake we have to go in there we have to treat it's not to say that again diet and exercise we know and sleep are key i was looking at one of uh some data looking at five nights of poor sleep decreases testosterone by 15%. And then also you and I were talking that an individual can increase if they lose roughly 15 % of their body weight, they can increase their testosterone by 250 nanograms per deciliter.

19:04That's a lot. That would take someone from 300 to 550. But the same goes for if someone gains weight they would go from 550 down to well and i love that because you talk about the the reality of the motivation and the mental component that if you can start treating them they might actually have that motivation to start losing that weight they never lost whereas if we're assuming they're going to do something that they have not done before to get their testosterone back up now what about these testosterone boosters like natural like supplementation, Tonga, ashwagandha, how effective are they? It's not my first line therapy.

19:43And 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. 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.

20:24This episode is brought to you by Something Sweet. And it's not me. It's Manakora. Let's talk carbs. Specifically, honey. And no, it's not another nickname for my husband. I usually call him something else. People have this idea that carbs are bad. and that is simply not true. I use Manokura honey daily. Well-positioned carbs like Manokura honey, they have been amazing for my personal training. I think of Manuka honey, which is what it is, is a functional carbohydrate, not just the sugar. It's serving a purpose. It's not just adding empty carbs. Honestly, we use it anytime we need a natural sweeteners.

20:57The bees collect the nectar from the Manuka tea tree in New Zealand. It's very complicated. The nectar is them packed with bioactive ingredients and the honey that is produced has three times more antioxidants than your average honey. If you are looking for good honey and you're looking for something sweet, you can check out their website to learn more. Head to manicora.com slash Dr. Lion for$25 off your starter kit. So along those same lines, we talk about some of the alternatives. I also see a lot of influencers on Instagram who are not physicians talk about testosterone. on her but he 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 well um if you were looking to get your testosterone treated, would you have a criteria for people that you are listening to?

22:07Speaking 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. It's peak one out of 11 people were on the Atkins diet. I can't believe it. That's crazy. 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.

22:45Doesn't mean that they are correct, but it does mean that they are popular. My perspective on influencers. Influencers, by definition, are there to influence. They are not experts. They should be, if they are smart, the best influencers are educated by the experts and then go and, quote, influence. The problem that I'm seeing is that it's like taking medical advice from a mechanic. Maybe you want that mechanic to read your MRI. Don't want that to happen. Don't want that. They might be confident. The question is, are they competent? The Dunning-Kruger effect, right? I believe you said that. Therefore, when I am thinking about who I'm going to go to and listen to, they have to be trained professionals.

23:34The 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 soundbite basically because of their ignorance.

24:15That'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? and that individual is listening to an influencer, they go on testosterone and they shut down their fertility forever.

24:54Then this person isn't able to conceive or in order to conceive, they're gonna have to go get sperm, you know, 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. And again, the people that are reckless have nothing to lose because they never worked 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, right?

25:29I am not, if I have an opinion, I will tell you this is my opinion. I will also tell you this is where the evidence is. This is where it's limiting. These are the things that we have to be cautious of. But I would say that the smartest people, the most impactful individuals have a scope of knowledge and they will tell you where that knowledge ends because there is intellectual integrity. Love it. The influencer hotline. I mean, what could possibly go wrong with the influencer hotline? What could possibly go wrong? Well, back to testosterone. Yes. And now we've agreed that it's pretty good stuff.

26:06What about the different forms of administration? So I'm looking to go on it. What's the best way to do that great question the first thing that you have to figure out is what is someone willing to do there are a number of different modalities as to how to get testosterone and there is testosterone intermuscular injections that would be in the shoulder or the butt there or the thigh but i don't recommend that there is why don't you recommend that because it i mean it hurts I don't know, but I've seen it. It seems like it hurts. There is testosterone sub-Q, and that's my favorite way of delivery.

26:45Sub-Q testosterone a few times a week allows for a steady state as opposed to a weekly injection. It gives you a high peak and a high trough. That's what you and Dr. Morgenthaler were talking about. He naturally discovered his patients started feeling bad at the end of two weeks, and he checked their testosterone, and it's because of that trough. So you're not getting that with the sub-Q? You are not. And also, one of the reasons that we monitor blood work so much is the elevated hematocrit, which is the blood viscosity can go up because of, in part, that big peak. If you are administering it through the week, sub-Q, you don't get that huge peak.

27:24And for someone who is a responder and seems to get elevated hematocrit, which is why people go donate blood, this could be an alternative, which i think is fascinating yeah there's also other ways of administering testosterone which people don't often think about intranasal i can snort it you well i wouldn't necessarily say snorting it but you can get it yeah put in your nose okay twice a day one to three times a day here's why someone would use that short acting you could use it before sex you could use it before a workout, it does not seem to have those same long blood lasting effects as an injection.

28:06Wow. Intranasal and also may affect fertility differently. Less impact on fertility. All testosterone you have to disclose must can affect fertility, but this seems to be a bit less. I wonder like cognitive function and brain, I mean, it's just from the proximity piece. Is there any, do you know if there's any literature on that? fascinating question i don't know but that is a fascinating question there's also oral testosterone that's lymphatically absorbed and that's kaizotrex typically you take it with a fatty meal what about my my liver it doesn't go through first pass metabolism all right there's also androgel if you have kids don't recommend that also i would say once someone goes to injections they have a really hard time going back so we have gel potentially patch but no one really uses that you have im injection sub q injection internasal and oral the sub q i just got to pinch my skin throw it in and we could probably show people how to use that it works really well for people what they have to look out for is depending on sensitivity they can get a reaction which is very itchy but seems to be the best way both men and women seem to really like that the best and so Do I have to mix that or can I just, can you just pull it straight out?