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

29:37I'm in public. I can't pee my pants. And so you learn this continence. 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 all of a sudden 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 visit urologists is for urinary incontinence not only stress incontinence from when you cough or sneeze you lose urine but this urge incontinence 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 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 it cardioprotective in women these are questions that need to be answer with a randomized control trial if a woman was taking cialis in the indication would not be i suppose it would be off-label for overactive bladders yep yep it could be an indication 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 risks benefits of this therapy and then you decide if it's right for you just like many other things in life.

31:02So 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. 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.

31:38However, 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?

32:18Well, 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 dr lion on top of their site-wide sale and save up to 40 off just head to cozy earth.com slash dr lion that's cozy earth.com slash dr lion 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.

33:05You'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. I'm like, right now we're in preparation for a geriatric decathlon. This is Peter Atiyah's concept. It's amazing. So you've got to be really healthy now. So muscles does so many things. And your book, Forever Strong, talks about the metabolic capacity as one of the biggest organs humans have to control insulin sensitivity, to control inflammation.

33:40And 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 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.

34:39Anything 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 this show because who doesn't want better erectile function and better penis? his 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.

35:19But 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 erections. So we should lean into this fact and get people to be healthier because yes, sexual function is very sensitive to overall 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.

35:54Is 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's organ of longevity versus my definition. Do we know, is there a dose? A study by Zhang et al., I think from last year, 2024, they looked at the and Hanes 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 erectile dysfunction by 20%, 300 minutes by essentially 40%, something very close to that.

36:39So, you know, intensity and duration as it gets higher, you get improvements. There is a, eventually you plateau. It's like if you do a thousand minutes, you're not going to get perfect erections, but even a modest amount of exercise, really move 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.

37:14Older men, this was fascinating but not surprising. Sarcopenia was linked to 2.7 times greater risk of moderate to severe ED. Both those studies are excellent in that a lot of them are self-reported studies and where 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?

37:50Testosterone is essential to a certain point, right? So if you have normal testosterone and you give more testosterone, there typically isn't an added benefit, right? So a mistake you'll make is like assuming if somebody comes in with a normal, you check their T, it's normal, but they have problems with erections. By giving the testosterone, that typically doesn't fix the problem. Remember, the main etiology of erectile dysfunction is probably a vascular blood flow problem. 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?

38:23Well, 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 a 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 good care of yourself, your tea will stay normal. There's data where people who look healthy in their 70s and 80s, their testosterone is way higher than people who look unwell.

39:04My dad. He's really low. Yeah. Let's just throw Nate Dog 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 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.

39:42So 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 great erections, you're probably pretty healthy. Oh, 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's snoring, my cell is there like, yo, gee, we're tapped out.

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41:46And how many tomatoes were thrown at your face and how that you probably had three friends and one of those included a sibling and maybe a parent. Oh my God. So, well, listen, thank you for that. And yeah, 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 my patient's best interest and with open communication and discussion of what the potential risks were.

42:27So 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. In my head, I was going to be a professional hockey player. And it turned out I could play at a decent level. I played freshman at Harvard, which is a good school to play at 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.

43:03And he said, how are you doing? I told him, actually, I'm not doing that well. I don't know if I should, you know, just stop college, you know, just drop out. And he said, why don't you come work in my lab? You might like it. His name was David Cruz. And he changed my life and put me on a track from age 19 to here I am 50 years later. It's unbelievable. And so he had a reptile lab and he was interested in sex, hormones, and the brain. And so the first project, I worked on these little American chameleons. They're all over Florida. If you've been there, you see them everywhere on the walls, on the sidewalks, inside your hotel room sometimes.

43:45Terrifying. And you put a male in the cage with the female and they have this bright colored flap of skin that comes out. It's called a dewlap. And the male sees the female, the dewlap comes out and their head bobs really quickly. It's almost like the male's going, yeah, yeah, yeah, yeah, yeah. Like he's interested. The female does a little stately pushup that says, okay, buddy, what you got? And then the male comes closer and repeats the behavior, and then they mate. So if you castrate the male, which means removing the testicles, which was the first procedure I ever did in a lizard, in anything, not knowing I was going to go to medical school, let alone become a urologist.

44:25But 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 dewlap would come out, head would bob up and down, yeah, yeah, yeah, and they would mate.

45:16It was the most amazing thing. And so my first publication on testosterone is in 1978, and that was the start. And then when 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 into practice and I start dealing with men with sexual problems. And some of these guys were desperate. How did you choose urology? Well, it wasn't obvious. I didn't know anything about urology really. I was in general surgery and I loved operating and I thought surgeons had, if you'll forgive the expression, the biggest balls in the hospital.

46:06And 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 urologist 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.

46:44So 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. Like 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.

47:23You give testosterone, you have prostate cancer. And of course, we were treating, get this, we were treating men with advanced prostate cancer by removing men's testicles, not lizard testicles, men's testicles. And this is part of why there's a misunderstanding, so much misunderstanding about testosterone and prostate cancer, which is, and I'll just tell you, 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.

48:16prostate 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.

49:00And most traditional nonstick 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 nonstick 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.

49:40If 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 modification. So let's be clear. I say, look, don't go for the pill. Go for the diet, exercise, sleep, and stress reduction.

50:18How fast will you see a change, you think, from erectile? It depends on how quickly someone is willing to put in the lifestyle modification changes, right? But we can see them over the course of 6 to 12 months if patients want to commit. There was a wonderful story 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 erectile function without pills. I mean, this is just without pills.

50:54So I say, look, the best way to do this is to lifestyle modification because it's not just your erections. Your overall health is going to improve. Unfortunately, most men say, just give me the pill. I say, fine. All right. But lifestyle modification makes a big difference. So but, you know, 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 booming. And what is that? So essentially, when I first saw this, this came out in 2010 by a gentleman named Dr.

51:28Vardy 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 erectile 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.

52:01And what he showed in that study was that those patients who did the shockwave saw significant improvement in erectile function. Since then, there's been a boom in the United States. 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. Oh, that's interesting. Where they'll use shockwave on the heart, induce trauma, and you get neoangiogenesis and blood vessels within the coronaries.

52:31So 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 a treatment. And if you buy a class one 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%.

53:08Is it really? How did you know that? What do you mean? It's 30 % to 40 % with this thing. So 30 % to 40 % of patients who get the Class 1 machine will say, I got the best erections I've ever had in my life. It's a placebo effect, right? But the Class 3 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, electrohydraulic, 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.

53:47There 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. The right machine and the right patient. If you're losing a class, the hydraulic, 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 it's not necessarily correcting the underlying cause. I mean, again, it's multifactorial.

54:20It'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 penile tissue. You're improving the cause. So basically, the body's 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 penile tissue is completely fibrotic, I can't get you from scar back to normal tissue. But if they're not fibrotic, you can actually reverse the ED process by using these. Now, there's stem cells that are 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.

54:58And 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 the third realm. There have been a few studies suggesting that may be beneficial. 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.

55:33And you just have to be very careful because this is a very vulnerable population. And they're willing to pay the money. So just got to be careful. And I just thought about this as you were talking, does the penile tissue 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.

56:11So 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.

56:46And 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, Tonga, 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.

57:26But 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. So along those same lines, we talk about some of the alternatives. I also see a lot of influencers on Instagram who are not physicians talk about testosterone. Everybody should be taking a testosterone. What are your thoughts on that? It goes something like this. And this is being generous. If you had abdominal pain, would you go to the dentist?

58:05No. 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, 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 at its peak one out of 11 people were on the atkins diet 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 doesn't mean that they are correct but it does mean that they are popular.

59:12My 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? Yeah. Therefore, when I am thinking about who I'm going to go to and listen to, they have to be trained professionals.

59:55The 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 of and research. Whereas that influencer, they're so absolute and they can give that soundbite basically because of their ignorance.

1:00:36That'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. It 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.

1:01:15Then 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. And again, the people that are reckless have nothing to lose because they never worked for anything in the first place. It's good. Good point. And why people should listen to your show to get qualified information. Also, it's not me, right?

1:01:51I 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. What can I expect if I go on testosterone in the next three to six months in terms of my body composition and muscle gain? Your vanity will not improve. But aside from that, you and I were talking about Bashan, his study.

1:02:27And there was a study design where it was 600 milligrams of testosterone and anthate weekly for 10 weeks. There was 25, I think it was 25, 50, 125, and 600 milligrams, which is a lot of testosterone and anthate weekly. 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 so you're telling me some exercise some testosterone replacement i could gain 13 pounds of lean muscle mass and i'm sorry it was 25 50 125 300 milligrams and 600 Would you ever go with high 600? I would not. And here's why.

1:03:15Okay. It's a great question. And 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? And when I say low, let's define less than 300. he might be an individual who has androgen insensitivity typically people do not measure CAG repeats you cannot go to the lab and get a CAG repeat the average person will never know if they have an androgen sensitivity or not receptor sensitivity or not what if and I you know looking back on my practice I had a guy who many many years ago came to me and he was taking probably 500 milligrams of testosterone a week.

1:04:07And 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.

1:04:40Is 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?

1:05:17There 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 testosterone or not. If someone is low, they're hypogonadal, I believe that they should be able to be replaced. I am not concerned about the risks. I think the benefits outweigh the risks. Now, if we're talking about someone who is using agents to enhance performance and enhance physique, you are going to arguably trade risk for performance for vanity. Testosterone is a brain hormone.

1:06:03Yes, it also works on muscle and fat and all these other organs, but it's a brain hormone. Absolutely. Absolutely. So one thing that's interesting is that it's far... So 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 mean to take your job. Wonderful. No, no, you're doing great. But it's related. Forgive me, forgive me. Please. Yeah. 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.

1:06:46Right. We have to be able to rethink about these conversations. And because the ultimate outcome that we want is health and longevity. Right. And muscle. Yeah. Which is all part of the same. Exactly. Exactly. Exactly. So what if someone isn't low and if we were to define, but let's say they are on the lower end, 350. 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 it is it's certainly well within the normal range and that individual has no symptoms, right?

1:07:35They 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 who's upper end of normal, we often define as around 1 ,000, okay? So if you had a guy who's 900 compared to another guy who's 700, which they're both well within the normal range, they're going to have, on average, the same amount of libido. As a matter of fact, you could take the same guy. Let's say you could manipulate his hormones at 700 to 900. Nothing changes for him. Not erection, nothing. Because his testosterone is normal. The one area that does not seem to max out is muscle.

1:08:16Is muscle. And that's why the bodybuilders, the athletes who are taking anabolic steroids that are all versions of testosterone-like compounds, versions of testosterone, why they can have muscles on top of muscles on top of muscles, right? Right. So anybody that's on normal amounts of testosterone therapy, just trying to get them maybe to the upper, into the normal range or the upper end, or even if they might slip a little bit above it here and there, it's not a problem. I've, I've treated thousands and thousands of men. There's nobody who walked into my office looking like, um, just regular muscular who walked out like super built.

1:09:00You need to get levels that are 10 to 50 times higher in terms of testosterone equivalents to start doing this. 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 Winstraw. 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.

1:09:40And 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?

1:10:31I 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 when I told you about low testosterone. 50 % of men over these are 50. 60 % over 60, same numbers. It's amazing how many men suffer from this condition, and we don't talk about it, right?

1:11:07So 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 their 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, you know. So it's very important to realize that men and women, premature ejaculation can have a big impact on their relationship. How about Peyronie'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.

1:11:52So let me give you an example. If a man has a 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 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?

1:12:23It's going to curve in the direction of the duct tape. That's exactly what happens in terms of Peyronie's disease. And 7 % to 9 % of men in the world suffer from this condition. And these men tend to be more devastated. devastated. I mean, they are truly depressed when you look at them psychologically to having 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.

1:13:01So you can't just say, hey, give them testosterone and the world is great. I mean, there's many things. It's their stress. It's her relationship with her partner. I mean, it's her medical condition. So you have to take into account everything for her low libido. Many women suffer from pain with intercourse, dyspareunia, 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.

1:13:37And 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 in 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 I tell men, if you want to have a better sex life with your partner, reduce her stress.

1:14:19Do 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 could 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 couple's 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.

1:14:54They 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, right? 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, right? 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 setup for conflict.

1:15:28You have been saving marriages for decades now, which is incredible. Let's talk a little bit about hypogonadism. Yes. 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 science, 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.

1:16:11It'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 is 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.

1:16:43Well, 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 clomiphene citrate. 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.

1:17:15But 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 Clomiphene 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 in 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.

1:17:59When 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 clomiphene citrate. 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 clomiphene citrate. It's off-label.

1:18:36It'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, I'm a little biased. I believe that Clomid can do something called a 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.

1:19:12So 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 picograms per ml would be… Yeah, so that starts to be around the right place. Right. So the thing… And it's the person. The data around women and actual levels are less strong.

1:19:52Yeah. You know, and what's funny is that there, well, there's a whole other topic, so I hesitate to take you too far afield. But, you know, the world of endocrinology is based on blood tests of hormones. And to treat people who are too low or too high, right? Whether it's thyroid or whatever it is. In order to decide what's normal, you have to have a control population.

1:20:23and um and so for and 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 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, they're 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.

1:21:17And then what's funny about that is it is a central tenet of laboratory medicine that if you had, let's say, 100 individuals in your reference population, that the central 95 % of them are categorized as normal. That's how labs work. For any blood test you want, with a few exceptions, like where there's targets like cholesterol, all 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 have 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%.

1:22:16But 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.

1:23:10And 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 the world of, and those of, I'm not an endocrinologist, but maybe I play one on TV. But on the frustrated one. Or maybe on your show, The Sex Doctors. Yeah. He has a podcast. It's not a visual show, guys. He's like, yes. I'm maybe your lovely wife. Thank you. Yeah, my wife is a clinical psychologist, Marianne Brandon, is a clinical psychologist and sex therapist. We met at a sex therapy conference where I was lecturing. And so we have a lot to talk about. And so we talk about that in our show, the sex doctors.

1:23:53It's fun. The delivery mode for testosterone. So now we have Kysetrex and we just have various, you know, 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.

1:24:28In 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. Kaisotrex is one and the one that I have the most experience with. It's got the easiest dosages, by the way, of 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.

1:25:14So what's interesting is if I give somebody an injection once a week or every two weeks, levels go up. They usually go above the normal range and then they decline over days to a week or two. With the orals, you have to take them twice a day because the levels go up and stay up only for about six hours or so, four to six hours. They come down and then you got to do it again. 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.

1:25:59If 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, a little smaller.

1:26:38Most guys, if they're in married relationships or stable relationships, or they're over the age of 45 or 50. They don't care. The single guy who's out there dating might care some. And so there are ways that we can deal with that. But the orals don't seem to suppress those pituitary signals as much. And I think there's a study that's undergoing now looking at sperm counts. And I think that that's probably going to be positive. In other words, that the guys will still have sperm. Whereas with injections, usually we get guys down to zero or very close to zero. I read that the orals, there's maybe 20 % are affected.

1:27:19Their fertility is affected maybe 20 % as opposed to almost all the individuals taking. 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 a 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. No. 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 percent.

1:28:04slightly 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 hematocytes 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.

1:28:49So there now have been two large randomized controlled trials where often when people are anemic, nobody knows the answer. It's called unexplained anemia, right? You're not bleeding from anywhere. You don't have a genetic abnormality. The doctors say, we don't know, but it's not dangerous, so you're okay. And it turns out that testosterone is better than placebo in these trials at making people not anemic anymore. Amazing. Because testosterone increases the right 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.

1:29:32They 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.

1:30:16The Endocrine Society has helped everybody in this way. They're 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's 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. There's just, you know, it's interesting, right? Yeah. Especially when we're talking about, like what you said, patients.

1:30:59Yeah. And, you know, there's a, so in medicine, as I've discovered, there is a lack, often a lack of what I would call common sense. So it turns out that people who live at altitude have high hematocrats, 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.

1:31:50Right. 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? So the labs don't really make that distinction. That's why I say the normal range is usually between 38 and 50, and it applies to both men and women. But listen, I don't think that having a somewhat higher hematocrit does anything.

1:32:30The 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 hematocrites, because of testosterone, have been shown to have any problems at all.

1:33:07You have to attack diet and lifestyle early. It's much easier to raise kids. No, let me stop you there. Yeah. 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 in Clomiphene. Those are two ways that I would consider trying to increase testosterone naturally. Would I say saw palmetto or all this other stuff? I wouldn't. I would say sleep, train hard, eat better, have sex.

1:33:49Most important is lifestyle modification. Healthier men are more fertile, period. 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. I was going to ask you the joke. Yeah, 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.

1:34:24And 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 men only make their testosterone when they sleep. 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. But reversible. Yeah, but reversible. It takes some time. On average, our studies showed anywhere from three to seven months.

1:34:55We 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. So just be very careful on the definition. And for men, women go through menopause and then that's it. 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 between 40 to 45 years of age, you'll start seeing a precipitous drop.

1:35:31So 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've got to figure out. It's either they're blocked 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. 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.

1:36:00And many times you have to go in and do a biopsy of the testicle, find the sperm. I don't need very many. I just need several. Yeah, you know. Take one good one. Yeah, to one good one. 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 and say, hey, we have an issue.

1:36:35We can't find the sperm. He has no sperm on his ejaculate. Can you help us to retrieve it? In 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. But for 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 had 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.

1:37:09Maybe 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 this concept called male menopause. Andropause 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.

1:37:53It'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? 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.

1:38:30And 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 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 her course and you want her to have sex all the time. She's out. Bye, Felicia. Right. So come on. 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.

1:39:05But to assume that a woman post-menopausal is going to want to have a great libido doesn't make a lot of sense.

1:39:17to help Krank to squares