What Your ED Is Really Telling You About Your Heart, Blood Sugar & Hormones - Urology Roundtable

22:05Dr. Gabrielle Lyon:If you're interested in trying Body Health Pre-Workout, which I highly recommend, go to bodyhealth.com and use the code LION20 to get 20 % off your first order. I have another, maybe it's a little bit controversial. And I mean, it's not really, you know, we're all friends. But if we are seeing obesity, and it's not a treatment for type 2 diabetes, right? At least for women, we don't go, you have type 2 diabetes. If I had to make a decision of your first line intervention, and I had to choose between two drugs, GLP-1 and testosterone, it's never going to be testosterone right um we see i am not sure that we are going to get a handle on obesity and metabolic syndrome we do have an increased use of glp1 but as a provider and as someone who's trained in nutritional science i don't know if we're going to get there that means some individuals are probably going to be more likely at an earlier age willing to look at testosterone.

23:08Dr. Gabrielle Lyon:And then this becomes kind of a dance. Cause I remember when I had a patient and they were in their twenties, they went to urology and this was in New York city. They went to urologists and the urologists didn't want to treat that 20 year old with testosterone because he didn't want to affect his lifelong fertility. So how do we then normalize making decisions at to what age would you actually begin treatment with testosterone? When it's low, but they were in their 20s and there was like but was it low it was low it was low i mean it's like mo was saying i mean if they had uh low thyroid if they had uh problems with diabetes you would treat it so why are you not treating the low testosterone i mean we've shown that you can you can prevent them from affecting their sperm production we know that but the fertility his points well taken is fertility aspect is extremely important you know 20 year olds if you want to put them on lifestyle lifelong medication is a long time for a 20 year old right so the reality is there may be other ways to do it and you could do lifestyle modification but also lifestyle modification helps each one helps individually but uh but but sometimes just weight loss will make it but you can't it's hard to sustain that's what i'm trying to say you say mr smith i need you to lose 20 10 percent of your body weight he may lose it but he may gain it back again and sometimes these patients need to use the testosterone in conjunction with the lifestyle modification to get the best outcome That's what I think, because I think it gives them, it gets them to the gym.

24:34It keeps them in the gym. Yeah, I agree. It gives them a different mindset. Yeah. And so I think, you know, lifestyle modification is great, but sometimes you need something to get them started. And testosterone really does help. Yeah, but you're not touching the elephant in the room. The elephant in the room is the GOP-1's loss because it causes a significant decline in muscle mass, right? And that's important, right? Because if you restrict your caloric intake, you're not going to only lose fat, but you lose muscle. And some studies will say up to 30 % muscle mass. Well, that's a problem, particularly if you're older and you get sarcopenia, right?

25:04There are now new companies coming out making GLP-1 plus SARMs or medications to raise T-levels. Why are they doing the combination? The combination because they're hoping that the T-levels going up will increase muscle mass in that patient that's losing muscle mass with the GLP-1. Yeah, I think, you know, the bottom line is food is too delicious. Yeah. You know, that's why 95 % of all. Speak for yourself. I'm not going to die. I guarantee you. That's why 95 % of diets fail. So I'm very in favor of GLP-1s. And I think there is a danger of sarcopenia with extreme quick weight loss, but it can be mitigated.

25:43Protein intake, exercise, sleep, right? There's powerful trials showing that if you're sleep deprived and you lose weight, it's mostly muscle. But if you're sleeperplete, you're sleeping adequately, you lose much, much less muscle. Right. So all these are protein. So important. Yeah. Yeah. Sleep, protein, exercise, all of all the pillars that you need. But just the GLP one alone. Yes, I would be worried about muscle mass loss, but you don't give GLP one in isolation. You tell the patient, listen, I want you to get 100 grams protein a day. I want you to work out with resistance ring at least twice a week.

26:17I want you to focus on sleep. Yeah. And then you won't have that, you know, extreme muscle loss. when people lose a lot of weight, they also lose muscle, even if it's not from GLP-1s, if it's just from starvation, for example.

26:27Dr. Gabrielle Lyon:Are you seeing an improvement in testosterone with the use of GLP-1s because of the improvement in obesity? Yes. T-levels do go up. Clinically significant? Clinically significant and sustainable. In other words, when the GLP-1s were not around, they would lose the weight, then they would gain it. Then they'd lose the weight and now it's sustainable weight loss and the T-levels stay up. So why would it be sustainable once they stop the GLP once if they stop the GLP ones and then and they gain the weight back T levels start going back down again right right so but these patients stay on the GLP ones I have most of the patients I saw on GLP ones go on maintenance dose so they get to their desired dose the level of weight and then they say I'm not I say 85 % of patients gain every pound back if they stop unless you've changed your lifestyle modification most patients say doc keep me on a maintenance dose oh do we know do we know what I know I'm I'm asking a question I know the answer to, and that is, do we know the long-term effect of staying on GLP-1s for years?

27:28No, but we do know the long-term effect of being obese for many years.

27:32Dr. Gabrielle Lyon:And what about low testosterone? Can we touch on some of the perhaps a little bit unknown consequences of having low testosterone? And then maybe before we do that, defining what is actually low. Yeah. I mean, there's a definition that's with the community. It's 300 nanograms per deciliter. I disagree. I think most of us disagree. There are patients who are at 320, 350, 390 who are symptomatic that may benefit from testosterone therapy. You can't have one number for everybody and say that everyone below this number must feel bad. Everyone above this number must feel good. There should be some kind of range.

28:06And quite frankly, if you give a patient a three-month trial of the medication and they don't get any better, then you could argue maybe this is not for them. But if they do feel better, then you could consider. So my threshold is a little bit higher than the 300. I may go up to almost 400 in patients, particularly if the 40 is low. Talk about the tertiles from the AUA guidelines. Yeah, so I'll give you an example. So the AUA puts out guidelines. The guidelines say that the patient should be between 450 and 600. That's what you're shooting for. So a patient came into my office the other day and said, Dr.

28:38Kira, what range should I be in? I said, according to the AUA guidelines, you should be between 450 and 600. He said, that's great. I'm at 390, so can you raise my levels? And typically, you're supposed to say, well, no, you've got to be below 300 in order for you to put you on T to put you into the normal range. That makes no sense.

28:55Dr. Gabrielle Lyon:That makes no sense. Really, the cutoff should be the lower limit of the range you're trying to get them in. So the cutoff really should be theoretically 450 if that's where you're trying to put them. But I think another thing that patients don't realize, and a lot of the primary cares don't realize that, although the FDA has approved 0.5 as a drug dose with a commercial testosterone product. Can you explain to me what you mean, 0.5? Well, there is a commercial product, FDA approved, and its maximum dose is 0.5, 100 milligrams a week. Testosterone? Yes. I see. And the thing about that, if you give that to somebody and you measure their testosterone two or three days later, it's over a thousand.

29:39Yeah. So, I mean, this business of looking at endpoints, you have to decide, are you going to look at the Nader before their next shot? Yes. Are you going to get it in the middle? Right. And I am not one that's hung up on numbers because I am treating a patient with symptoms. Yeah. How long have you been in practice? I'm not going to tell you.

30:00Dr. Gabrielle Lyon:more because what I've noticed is, um, and there, I think that there's a natural trajectory of a clinician. When I was early on in my practice, I was a stickler for the number. Like this is the number and it takes 20 years of practice. Wait, but it takes 20 years of practice for me who, you know, I still am uncomfortable if it's outside the number, but then maybe if I've been in practice 40 years, I'm much more flexible, but that means there's a huge cohort of physicians and most importantly, primary care, the first line of defense, they're going to feel very uncomfortable if someone comes to them and go, doc, you know, I'm at four 50.

30:43Dr. Gabrielle Lyon:I feel like crap. Let's say I'm living in the middle of Idaho and I, you know, I am in a very rural area, you know, no offense to anyone from Iowa, but maybe it's a rural area. And then it's unfair that both the physician, because we all, if physicians look back and go, gosh, I really wish I would have treated that patient. And then 10 years later, this patient goes through life, and then it becomes 20 years. And then finally, the patient gets treated when the doctor's caught up. Yeah. But it's very different than putting someone in the normal range at the upper normal and then sustained super physiologic levels.

31:16Dr. Gabrielle Lyon:What's the danger of super physiologic? Well, there's a lot. Erythrocytosis, there can be cardiotoxicity, cardiomegaly, ventricular hypertrophy there's been increased mi risk i mean he's done more work on this anyone i know we're gonna we're gonna talk so i mean he's i mean and so but that's it sustained super physiologic levels i accept that if i give someone injectable that there'll be a transient increase in physiologic levels at the beginning and then it goes down pellets it'll go up a little bit slightly higher above and then it'll come down but to sustain super physiologic levels i personally get concerned i mean there's been very good data that you've presented right but But I also think we do get too caught up in the numbers.

31:50And I think those of us, like you say, that was a great point. The longer you're in practice, I think the more you realize that it's not as important as the patient's symptoms. Because that's why you're treating them to begin with. But I have a patient with Kleinfelder syndrome, which is a problem with testosterone. They do not make high levels of testosterone. He's a football player in college, right? So we had to get permission to treat him because he's playing football, which we did. Because, you know, he has a genetic abnormality. He should be treated. So we were treating him with, I don't know, maybe 0.75 a week.

32:28He's huge, you know, like 6, 10, and, you know, 3, 20. I mean, just a big football player. Is 0.75 enough? Well, wait a second. Okay. So then I get a letter saying that I am over-treating the patient. he should only be on 0.5. I said, what happened? I mean, this is after three years of treatment. His parents say, well, somebody new entered the council, whatever they use for the athletes. And I said, I will bet you it's an endocrinologist. It turned out it was an endocrinologist. No one has ever looked at this person. They're just getting a report with a number, and they think the number's too high.

33:08I mean, we know there's biological variability. between humans, right? Somebody's T at 400, they're going to feel great. Other people are going to feel horrible. This is a fact. Whether it's testosterone sensitivity, whether it's the free T and not the total T, there's all these factors that can make you different how you feel. Maybe there's a content is, but I feel like every man should know what their testosterone level is when they're at their peak in their life. When they're 25 years old, they're healthy. They get their baseline T. So yes, I felt amazing when I was 25 with a testosterone 450.

33:41That's a very powerful piece of information. Because if your T is 450 at age 55, it's very unlikely that that's the problem if you're feeling off. If, however, your T is normally at 650 when you're 25 and now you're coming in at 400, to your point, yeah, it's probably low. Another thing that I think we overlook is a patient's weight, body size. I mean, there's a lot of literature on treating people with higher doses because they weigh more and they're bigger. Right. You know, someone, you know, a 150 pound man does not require the same injection as a 250 pound. I mean, they're different. You're right.

34:17And we don't pay enough attention to that. I don't think when we see patients. Do you? I do.

34:23Dr. Gabrielle Lyon:I do think about it. And then I think about this idea that actually I've learned from you guys over at Baylor is this idea of CAG repeats. And in my mind, when I think about obesity, so in skeletal muscle, there's this anabolic resistance. So muscle becomes resistant to this normal stimuli and less efficient. It's less efficient at recognizing utilizing amino acids and protein. And also, and this might be a little controversial, but obese muscle, when fat is infiltrated, it's not as responsive to exercise. There's myosteatotosis. Well, that makes sense. It does make sense. And then that makes me think about the receptors and testosterone, where it's this fine balance.

35:07Dr. Gabrielle Lyon:And I don't know the answer. I'm hoping that you guys can shed light on it for me that if someone is obese, do they require more testosterone to then feel the effect or even get the effect? and i'm sure you worry about estrogen and this um just this dance but is there to say this succinctly a change in the amount getting to the muscle from the with the utilization of testosterone do they require more in obese patients i think it's two different topics so one topic is the sensitivity of the testosterone receptor so it's called the cag repeat so in baylor when i started with Dr. Lipschultz, we started doing this, we do it today.

35:47We take the blood, we send it to the lab, and they give us the sensitivity of the angina receptor. If the CAG is greater than 27, the angina receptor is insensitive, and we show that those patients need more testosterone. Makes sense. It's less than 27. It's sensitive. They need less testosterone. And we're all different. So everyone has their own CAG repeats. So that's different. What you're referring to is the acquisition of obesity. And obesity in itself has many mechanisms in why it shuts down the tea. It aromatizes, increases leptin, increases cytokines. Each one of those take a hit directly on the pituitary and the testicle to shut down the ability of the amount of tea we make.

36:23So you have to give those patients more tea in order for them to compensate for the loss. On this side, when they're insensitive, you've got to give them more tea because they need to be at higher levels to feel the benefit. So they're a little bit different, but both categories need more tea to feel better.

36:37Dr. Gabrielle Lyon:And this creates a huge, I want to say red tape, because providers might not feel comfortable with the dosing. Can we touch on how, and you guys have talked about this quite a bit, but the idea of how do we determine a dose of testosterone? Because you don't necessarily look at all the numbers. but oh i look at the numbers to start treatment but my point is i don't follow the numbers in terms of what i'm going to do when he returned my patient returns in three months i'm going to see how he feels that's my most important guidance is the patient symptoms not the blood test so i have to push back on this just a little bit is that for example i don't feel comfortable increasing the dose of testosterone over 200 even if a patient comes to me and I'm not a urologist, if a patient comes to me, and even if I suspect Cagri, it's because for the general population, it's not as easy to get.

37:36Dr. Gabrielle Lyon:And I remember I have this patient who's a part of Homeland Security and I am only willing to provide 200 milligrams of testosterone because it's outside my comfort zone. And I know that he needs more. Because that's your problem. No, it's your problem because I'm sending him to you. But I mean, I do not have a problem. Would you do that? I typically don't. But I'm not looking at the amount I'm prescribing. I'm looking at the blood level. So I'm looking at the blood level. And so if the blood level, typically you're right, at 200 milligrams a week, I don't need to go any higher. So you're right.

38:15But if for some patients are eating it up faster, metabolizing it faster, and he needs to go higher, potentially. but the reality is it depends on when you're looking at the level. Testosterone is a game. Whenever you check the blood in relation to when you give the medication, you can make that level look like whatever you want. And that goes for anything, a palate, an injectable. I check in, give someone an injection today and check the blood tomorrow. It's very different than when I check it in a week before they give the next injection. So whenever I tell the residents, when you check a blood level, right underneath that, you write when was the last dose given on whatever you're giving because that's going to change the level.

38:53It's very important. But to that point, what we're seeing, what I'm seeing now is more patients are dividing the dose and more patients are microdosing. Microdosing has become very popular where the patient takes, let's say we're going to give them 200 milligrams. They divide it by seven and they do a sub-Q injection every day or they divide it into three. Because I'm seeing fewer side effects. I agree 100%. And the whole reason is you drop the erythrocytosis rate because you're not spiking. And that's helpful. Some people have shown a drop in hypertension rates. You drop the mood swings. So it's a little bit of a hassle, but I think it's so much healthier.

39:29The patients like it because a lot of men get very tired with intramuscular injections because it's painful. And it's much less painful with sub-Q. And with the pharmacies I use, they'll send the patients a larger needle to draw it up and then a smaller needle for them to inject. so they're kind of on the same page and you can drop the dose so 80 so whatever you give im you only have to give 80 sub q and get the same blood level you get the same level the i do want to touch

39:58Dr. Gabrielle Lyon:on the risks of testosterone replacement and really where you were talking about was super physiological dosing and in my mind if you do im technically they would then get a quote super physiological dose once a week. Transient. Transient though. It's transient, but still over time, it's kind of like if I'm eating a cake, I don't know. I know you like cake. If I'm eating a cake once a week, it's like a good listen because you're sitting next to me so I get to pick on you. Thank you to Timeline for sponsoring this episode. Time isn't just about how long you live. It is about the quality of those years.

40:39Dr. Gabrielle Lyon:It's having the energy you need to move through your day without fatigue. The strength to pick up your kids, your grandkids, who knows, someone else's kids, and the clarity to show up as your best self. Now, that kind of strength does go deeper than muscle. It starts with your mitochondria, the energy producing engines inside your cells. We've learned about mitochondria, I don't know, in our fifth grade science class. And here's the reality. As we age, those mitochondria decline. In fact, it's one of the key hallmarks of aging, and it directly impacts strength, recovery, and overall how we feel.

41:14Dr. Gabrielle Lyon:One of the ways your body protects itself is through mitophagy, which helps clear out damaged mitochondria and replace them with healthier ones. And you're thinking, okay, so why is she talking about this? Well, I use Timeline powered by MitoPure because it contains urolithin A, which is a molecule backed by over 18 years of research and multiple human trials, it works at the cellular level to support mitochondrial renewal. It's not a quick fix or a stimulant. It does support your body from the inside out over time. And if you've been considering trying it, it's a great time. Timeline has just lowered their price and you can get an additional 20 % off your first month when you go to timeline.com slash lion and use the code lion, lower price, same science, bigger biceps.

42:06Hey, living longer doesn't mean living less vital.

42:11Dr. Gabrielle Lyon:But even if it's transient, is that without risk? Well, there is some risk because the spikes do cause an increase in erythrocytosis. Which is? A higher increase in red blood cell count, right? So hematocrit goes up. And then theoretical risk if it goes above 54 there's a theoretical cardiovascular risk i use the word theoretical because i have patients in dengar and that's exactly right um hemoglobin hematocrit are above 52 easily and this is called secondary erythrocytosis and there's never been there's been only one paper to show that secondary erythrocytosis increases the cardiovascular rinse this is out of the university of miami other than that there's no data to support this all this data comes from the polycythemia vera data which is a blood discreation it's different Yeah, it's a cancer.

42:52It's very different. But we've extrapolated the polycythemia veridata to the general population, which is a mistake, saying, oh, if you have a high hematocrit, you're more likely to have MI. So I think that that data is evolving, but there's not great data on secondary erythocytosis causing cardiovascular events. So I think that's important to keep in the back of my mind. I've been trying to figure out that number that people want. Like, what is too high? What's the level that's too much? A couple things to think about. So I looked at 100 ,000 men at Mayo Clinic over the last 20 years, and it's actually pretty rare to physiologically exceed 1 ,000 nanograms per deciliter in healthy men.

43:32It happens occasionally. In testosterone? Yes. Testosterone levels above 1 ,000 naturally is pretty rare. Naturally. Naturally. Naturally, right? Okay, so that's an interesting tidbit, right? So if you think, well, if very few men get above 1 ,000 naturally, it's intuitive to think that an average level of testosterone should be below 1 ,000. The other thing to think about is, okay, well, what about people like really super physiological? We know a lot of bad things happen, heart attacks, these kind of stuff.

44:02Dr. Gabrielle Lyon:Is there a number? Well, the data is not great. There's only seven trials where they look at men getting T levels higher than 1 ,800 consistently. And they have a lot of the things that Mo talked about. acne, heart disease, changes in lipid profiles, problems with sperm production, these kind of things. But the bottom line is the FDA uses 1 ,800 as the safety cutoff. 1 ,800? 1 ,800 for trials. So when you're doing testosterone trial, if you exceed 1 ,800 at any point, you're up. That seems a bit high. It's generous, right? But they're taking into account the fact this is a one-time level, not an average, right?

44:43So, you know, I think a T-level in the 500 to 800 range, in my read of the literature, is reasonable. Especially for one of these people who are very insensitive to testosterone. If you have the keg repeats, if you have all these other mechanisms going on. So that's my read of the data. That's just an opinion. But that 1800, what he's saying is it's in a trial. So they allow for someone, it's 5 % will go above 1800. That's not allowing it to go to 1800. They have to titrate it down. So if you're trying a new drug out and just learning more about it, but they're not saying that's acceptable. That's like the hard stop.

45:21It's a hard stop. We don't really have a hard stop yet, right? But you know something? I see a lot of athletes, and they take testosterone for, you know, whatever, what were you calling it before? Performance enhancement.

45:35Dr. Gabrielle Lyon:Performance enhancement. I was wondering if you were going to say it. And I send them to the cardiologist at some point. I have not had a single cardiology problem identified in these guys. Not one. Is it a length of time then? I mean, it could be. They're younger guys, right? And I haven't done it yet, you know, at five years. But they don't stay on these performance-enhancing drugs for long term. I think the men who stay on testosterone long term are the older patient with classic symptoms of low testosterone. But the ones who are doing it, performance enhancement, I think it's fairly transient.

46:14But again, I have not seen anything. And I measure lipids and I measure hematocryl and I measure CMPs regularly on all these people.

46:22Dr. Gabrielle Lyon:It seems odd that an athlete would come in and think about performance enhancement. And again, we're not talking about super physiological levels, but then they go, oh, my sporting career is over. I'm going to go off of testosterone. It just seems a bit counterintuitive. And maybe it has to do with the FDA restrictions. So there was recently a removal of the black box warning with the Traverse trial. And you were involved in the Traverse trial. I'd love to hear a bit about that. Yeah. Can I just say one thing? And that is when these people are no longer doing whatever they wanted to do for which they wanted to hire.

47:04Testosterone, I will talk them down. I will not continue high dosing. What do you consider high? You know, over one cc.

47:13Dr. Gabrielle Lyon:Over a high, okay, so 200. 200? Yeah. A week, okay. Yeah, the Traverse Trial is interesting because it's like before 2010, numerous studies showing men with low testosterone levels much more likely to have a heart attack. Numerous studies showing that. Numerous studies before 2010, those below 300. Were more likely to have increased mortality, were likely to have a heart attack. Also, numerous studies showing that if you give testosterone, it may decrease the risk of a heart attack before 2010. 2010 to 2014, four studies come out suggesting that you may have an increased risk. Three of these studies are not randomized, no placebo, no control.

47:52They're retrospective database studies. 2015-2014, the FDA has a meeting and they decide that there may be an, it's inconclusive based on these four studies, whether testosterone increases the risk of cardiovascular events, and they strongly recommend a large study called the TRAVERSE trial. The largest randomized placebo-controlled trial, 5 ,246 men, took us six years to do it, very expensive trial. What did it show? No increased risk in heart attack in those men taking testosterone. And it was a gel, don't get me wrong, it was a gel versus placebo. But there were sub-studies, no increased risk in BPH, no increased risk in prostate cancer, A slight improvement in depression.

48:33There was also improvements in sexual activity as well. So big trial, a lot of money spent on it. And based on the results of the reverse trial, big day. It was February 28th, 2025. The FDA announced we're now going to remove the cardiovascular warning from the label. So it was 10 years exactly later where they decided to remove the warning. So it took us a while, but it's now off the label.

48:57Dr. Gabrielle Lyon:Was that one of the biggest moments in your career? Huge. I remember exactly where I was. And I saw the thing pop up on my feed. It was a big deal. Because, you know, we published the first paper in 2023 showing there was no cardiovascular events. And then it was silence for two years. And I thought, maybe, I hope they're going to, what if they don't do anything? What if they don't take it off? It was just silence. And then two years later, they announced, okay, yes, we will take off the cardiovascular warning. But I have to be the devil's advocate in that I'm not comfortable with the dosing on that study.

49:26Yes. So let's talk about that. because people look at the range of 350 to 750 and they say well 350 is sub-therapeutic if you got someone at 360 it may be low but what most people don't realize is this is the only study where those numbers were the troughs they weren't the peaks they were the troughs so if the t trial which came out in 2015 uh 2016 sorry those were actually uh peak levels so what so what was the average t level in the traverse study average increase in the t level was 147 nanogram per deciliter but this was at the trough so we didn't publish the peak level you have it we can look at it we still have the data yeah but those were the troughs so everyone looks at say kira 360 that's so terrible i say if it was a peak yeah i agree that's a trough yeah but there's not as many peaks and troughs with topicals because you do it every day and it's constant these were not injections

50:21Dr. Gabrielle Lyon:Do you prefer, as a provider, I mean, most providers, at least I can speak for myself, prefer injection. Is there a reason someone would use a gel or you used a gel? Was it just ease of access? Well, it was also the sponsor. So the sponsors were basically gel sponsors, and so we used their formulations. But I agree with Dr. Lipschel. I mean, gels and injections are different. So you have to be very careful in using the injection, the gel data, to be apples to apples for injection data. but if you talk about prostate cancer it's safe because the reality is we talk about a saturation point so again if you put someone above 250 i don't care pause on that the saturation point most people listening to this don't really understand that component the saturation point of um prostate or psa right yeah the prostate acts like a sponge it takes up all the testosterone that it wants and finally it's saturated then it doesn't care how much more you raise the testosterone in the blood it's not going to change the psa it's not going to change the prostate volume and so when you uh we think the saturation points around 250 in the anagram per deciliter roughly meaning if someone has because one of the biggest um restrictions for primary care is i don't want to give you testosterone because it's going to cause prostate cancer right right that's changing Don't you think?

51:41Even on the Traverse Trial. So the Traverse Trial actually showed 5 ,246 men, no increase in high-grade prostate cancer, regular prostate cancer, or BPH. Big study. Vandamized placebo. But remember, if you take someone whose testosterone is 150 and you put them on T, that PSA is going to go up. You better believe it. It's going to go up. Right? If his testosterone is 290 and you put them on T, PSA is really not going to go up. You're above the saturation point. Right? So if you're on an injectable or a gel, we've gotten beyond the saturation point on both. So I'm not really concerned when it comes to prostate cancer and BPH.

52:15Cardiovascular is a little bit different. An injectable can cause higher erythrocytosis, potentially higher hypertension. So there could be some parameters that are not apples to apples. I think the traversal gives you a good idea, but it's not exactly the same with an injectable.

52:29Dr. Gabrielle Lyon:And can we just say one more thing? So in nutritional sciences, when a study is funded by an organization, whether it's a beef company or the Dairy Council, there will be very good science. And instead of looking at the science, people will say, well, there's funding behind that. And I don't know if it's like that in the world of andrology and pharmaceuticals. Is it? Yes. It is. I mean, quite frankly, without the funding, we can't do the great science. And so I wanted to hear you guys. respond to that. That's the issue. This traverse trial would have never happened without the funding. Now, the way the funding works typically, it's an unrestricted grant to a group of scientists that do the study.

53:09But yes, the money comes from an industry to help support the trial. I don't remember in that study whether it was whether the brand was announced or incorporated. No, it wasn't. But AbbVie was the major sponsor and we had other sponsors as well. But again, all the money went to a central repository at the Cleveland Clinic and that study was done with nine investigators. And wasn't at that time all of the topicals generic? I don't remember because it's 2015. Well, they are now. They are now. So, I mean, you couldn't have profited because your brand was not out there being advertised.

53:50Dr. Gabrielle Lyon:But it's a big misunderstanding with the general population and even people that are very interested in science. And then the researchers, because there has to be money for funding. And ideally, it is given to and provided to excellent scientists and excellent physicians. And the data is the data. And that becomes really important. Is it unethical to not treat with testosterone? So from what I've read is that if someone has low testosterone, there's an increased risk in, for example, high-grade prostate cancer. Mm-hmm. So you think, I think the word unethical. To not treat. I don't know whether the word unethical is the right word.

54:35It's uneducated. A little too heavy. Well, I mean, yeah, but it's not ethics, you know, when you're treating patients. It's what's right, what's wrong, what's, you know, the currently acceptable way to treat, standard of care. I think right now most people would treat. Yeah. But I think we, knowing what the three of us know now, I would say, look, if it was a loved one, my brother had low T, and I'd say, look, I really want you on this, not just for your sex drive or libido, it's for your overall health, and I really want you on this. But how about if he has no symptoms? Well, I agree. So it depends on how low is low.

55:09It's clearly under 200. That's a really good point.

55:13Dr. Gabrielle Lyon:That's a really good point. That's why I worry about testosterone screening. People are all talking about testosterone screening. And if they start screening, when do you treat? Do you treat because the number's low-ish? Yeah. you know you'd have to be it has to be well thought out yeah i agree when you're going to treat i think if you're severely hypogonadal and i use under 200 yes i consider that severely happy then i worry and it usually it's pretty rare that someone under 200 is not symptomatic so let's be fair but the reality is i worry about what's going to happen to you exactly osteopenia osteoporosis what cardiovascular risk i worry about lipid profile so i was in that case say look i realize your levels are low and you may not be symptomatic but these are the things i'm worried about But it's pretty rare for someone to be below 200 and not sent to mouth.

55:59I know, but I just saw a professional baseball player comes in, T's are consistently under 200. Yeah. And he doesn't really have significant symptoms. Yeah. But, you know, I worry about him. I worry. First of all, he was very thin. Yeah. And I just don't think he had enough muscle mass. Practically speaking from a patient perspective, if you go to your provider and you have symptoms, your testosterone is low or borderline low, it is totally reasonable to seek a second opinion if that physician or care provider is uncomfortable writing for testosterone. I know, but how many patients know that? I mean, you know that.

56:37Yeah, but that's why we're saying these things, right? I mean, you have to take the initiative and be like, listen, this doesn't seem right to me. I'm going to get a second opinion or ask them, you know, I understand you're not comfortable writing for testosterone. Could you please refer me to someone who is? And there are plenty of people to do that, But you have to kind of take the bull by the horns and say, listen, I don't feel well. And this is the blood level. If you're not willing to give this to me, can you send it to someone who is more educated about it? Let me give you another, playing the devil's advocate, low T centers.

57:07I don't know what it's like where you live. Here, they're on every corner. And they will treat anybody. I've never seen anybody who was turned away by a low T center. So then you have to ask yourselves, I mean, is this right? Is this a license to hurt people? I mean, there has to be some judgment. I think they've gotten a lot better, though. But you're right. A lot better. But initially, but now, because now, you know, just you worry about screening, elevated prolactin. Did you check the prolactin? You're talking about really infertility. The education initially was a little worrisome, but I think it's gotten a lot better.

57:43But Larry, think about this also. They're doing a lot of now online tea. like like uh announced uh that they're selling kaisatrix you know so people can they don't have to go see a physician anymore they can do it on their app and it's asynchronous i put in information someone puts information my t shows up the next day uh at my house so you know that's another

58:04Dr. Gabrielle Lyon:venue that a lot of people are using who would you not treat with testosterone because you had mentioned that it raises blood pressure is it um clinically impactful so if someone has a low blood pressure or low blood pressure if they go from 110 to 120 still the normal range if they go to 120 to 130 because we know as age happens you know as a geriatrician we wanted to see blood pressure at 130 for peripheral um perfusion for cerebral perfusion yeah so who would we not treat I get very nervous about treating young men at a very early age if he's 21 years old for fertility and long-term having to be on the medication.

58:46So I would like to talk him out of it or see if I can use other medications, Clomid, HCG, something else, N-Clomid, just to kind of, you know, 21, those young patients, I'm resistant. So I think that's probably my biggest. I feel that testosterone, I personally believe, is cardioprotective. I think there's many benefits. So people say, oh, he has a lot of cardiovascular risk. Well, the Traverse trial was high-risk cardiovascular patients. Amazed, right? Yeah. And so, yeah, you had to have cardiovascular events or three of the eight cardiovascular risk factors. And I think it may be cardioprotective.

59:16So most clinicians say, I'm worried he has a bad heart. I don't want to put him on testosterone. I say, I believe the opposite. I'm worried if you don't put him on testosterone, it's going to make it worse. Well, there's a difference treating someone with heart disease versus preventive treatment. Yes. Yes. I mean, you're not going to be worried about preventive treatment. Now, I'm not going to prevent it, but she's saying, is there someone you're worried about? And someone say, I'm worried. Most people say, I'm worried about someone who has high-risk prostate cancer. I'm worried about someone who has increased cardiovascular risk factors.

59:43I say, I'm not. I believe the opposite. I think that testosterone also may be protective against prostate cancer. I think that, you know, the hypogonadal range is the danger zone. We call it the inverted U. Castrate may have some benefit. Ugonadal high levels of T have some protective benefit. I personally believe that. It's the middle zone, the hypergnatal range, which I believe increases chemical recurrence for prostate cancer, increases risk for high risk prostate cancer. So I really believe the same with cardiovascular disease. It's the inverted U. That's very important. And we're also now seeing drugs that stimulate the patient to make their own testosterone.

1:00:17Dr. Gabrielle Lyon:Like what? The clomiphene and its derivatives, like, you know, and clomiphene. So that, I think, is a good drug for younger guys. Easy. It's a pill. Use off-label. but still it helps raise natural testosterone, helps raise sperm counts. Yeah, I think it's a great drug. We all remember what a freshly cleaned room smells like. Straight chemicals, you know? As I think about it, I used to touch this stuff with my hands directly. And the more we learn, the more we understand the whole body burden of these compounds over time. We all have, frankly, enough to worry about cleaning products should not be one of those things.

1:00:55Dr. Gabrielle Lyon:And I remember when people thought I was crazy because I was really concerned about all of these cleaning products. I get it. The essential oils might not clean everything, but on the other hand, I'm not sure that we need these very aggressive cleaning products. And typical cleaning products use chemicals that leave synthetic fragrances and other endocrine disruptors as well. There's also harsh organic compounds on your countertop floor, your sheets that kids sleep on. These chemicals accumulate over time, forcing your body to carry that burden. And that's why in our house, we use Branch Basics.

1:01:34Dr. Gabrielle Lyon:Their premium starter kit uses one plant and mineral-based concentrate to replace every single toxic cleaner in your house. It has zero fragrance and zero endocrine-disrupting chemicals. It handles everything from our laundry to our kitchen counter without compromising our health. The only thing I wish it to different is if it would actually clean itself, but it doesn't. Branch Basics is available at Target, Amazon, and branchbasics.com. You can get 15 % off the premium starter kit with code Dr. Lion at branchbasics.com. That code is Dr. Lion for 15 % off. Can we touch on, if everyone is comfortable, just touch on peptides because that's kind of all the rage right now.

1:02:21Like what?

1:02:23Dr. Gabrielle Lyon:How are you touching on it? We are touching on it. I don't want to talk about necessarily the GLP ones, but the other peptides. I think they're going to become huge. Like CJC and Ipamorin. I think they're going to become because as far as we know, they don't have side effects that are worrisome. How does that make sense? Why? Well, they're protein hormones. They're acting, you know, they're attaching to the cell membrane. I don't know. So, I mean, why would they necessarily have bad side effects? I'm going somewhere with this. I'm just leading you into somewhere. Are you going to trap me? No, I was going to have you explain that, because this is my understanding, that testosterone is recognized by the body as such.

1:03:03Dr. Gabrielle Lyon:But these other peptides, these string of amino acids are not recognized, again, this is my understanding, by the body as that entity. Meaning it doesn't have downstream effects that would be negative. Did I explain that well? No. As far as I understand, they're naturally occurring substances. They're extracted from other fluids. CJC and epimoralin is a natural? I mean, I cannot tell you which ones. There's one that comes from the placenta. There's one that comes from gastric juice. The BPC is gastric juice extraction. I don't know all the other ones, but they are theoretically, Theoretically, they're called naturally occurring substances, and they have very specific action.

1:03:50It's not like you give somebody testosterone, it does many different things. Peptides are very specific. And I think the more specificity, the less chance you're going to have of side effects. And we're not seeing any yet, but I mean, it's way too early because the places that are making them, they're coming from compounding pharmacies, and not all compounding pharmacies are equal. So I think we have to be careful at this point in time. I agree with that. Prescribe it because we just don't know enough about their sourcing. But I think it's going to be something very big in the future. We use this word peptides very loosely.

1:04:26There's a lot of peptides. But the peptides most people are talking about are growth hormone peptides, or they're talking about BPC, which is a gastropin. That's what they're talking about. They're not talking about all the other peptides. GLP is a peptide. That's not what they're talking about. Incentives are peptides. Yeah, so when you say peptides, be specific. What are you talking about? We're talking about growth hormone peptides, gastric peptides. And these peptides, some of them are FDA approved. Some of them are not FDA approved. The ones that are FDA approved, for example, are sermolin, tesamolin.

1:04:55Dr. Gabrielle Lyon:Been around for a very long time. And if you have data, and if you look at the data, what do they really help with? The three things they help with are increasing muscle mass, decreasing fat deposition, particularly truncal fat, and actually can help with sleep, right? That's it. there's no benefit in sexual function. My libido went up when I took that CJC. No, there's no data. Now, it may have, but show me the data. But there are some that are theoretically oriented towards sexual function. Like bromelanotide, PT-141. Tell me about that. So bromelanotide is, well, it came out for women. Bylesi, it's for women, PT-141.

1:05:36But when people say peptides, they're not talking about bylesi. But you're right, there are sexual function. I do use PT. I do use it for men. Yeah, we do. It's off-label. It's very effective. But I think when people are doing peptides, they're not talking about Vileci. They're talking about, give me that CJC. Give me that BPC. Give me my epimoralin. And you have to realize that they're not FDA approved, and there could be some safety concerns. And if you look at the FDA website, they say that they're not intended for human use at this time. Fine. And so I just think that it's important to know that.

1:06:07It's from Orleans, FDA approved. Tessa Morland is FDA approved.

1:06:10Dr. Gabrielle Lyon:What are their, was it clinical indication, Tessimorlin for? HIV lipodystrophy. Yeah. And Sermorlin was for pediatrics for growth hormone deficiency. But if you look at the data on Tessimorlin, the studies are pretty good studies. Yeah. From when it was launched. And it's an injection. It's a daily injection. Yes. Tessimorlin. Yes. Is it cost prohibitive or covered by insurance? I think it's too expensive right now. I don't think it's expensive to make or source. So I think we're going to see prices come down on peptides. For a compounding pharmacy to make a peptide, it has to be under 40 amino acids.

1:06:48Tessamolone is 42 amino acids. So theoretically, it should not be compounded for human use. But you can buy commercially. If it's no insurance, it's about$7 ,000 a month. It's pretty expensive. The 40 amino acids is for classification as peptide versus a biologic. Yes. It doesn't mean that if it's a biologic, you can't make it or sell it. But there's stricter criteria for biologics than there are for peptides. In Europe, some of the peptides are sold as supplements. You don't even need a prescription. So I don't know what's going to happen here with peptides. I mean, there was a recent announcement that 14 were going to be approved for manufacturing under a new FDA ruling, but it's not yet actually done.

1:07:36So whether it will actually happen, I don't know. But Robert Kennedy did come out and say he was trying to get them approved.

1:07:44Dr. Gabrielle Lyon:And then the follow up with that, will there be more, do you expect more randomized control trials with these type of? If they get approved, it'll be easy. If you get approved, it'll be easy to get those trials up and running. Yeah, but the trials will be from people like you. They won't be from pharma. Yeah. Because apparently there's some reason why they can't copyright them. Or what's the word? What is the word when it's a drug? Patent. They can't patent it because it's a nationally occurring substance. And there's, so, you know, big pharma can't make money on it. And since studies are so expensive, who's going to pay for the studies?

1:08:22That's the big problem with peptides.

1:08:25Dr. Gabrielle Lyon:So this is a really interesting statement here. I'm just going to read it. It says, erections as medicine, the cardiovascular conversation. Did you make that up? No, I didn't. Which is why I'm making it because it's much better than anything that I could make that, quite frankly. It's a really important point. And that's what I think Dr. Kohler brought up this phrase I still use. It's called the check engine light on. Essentially means ED is not a disease. It's a symptom. It's a symptom of something bad going on, right? A healthy man should not have ED, right? ED could be because he has depression.

1:08:59That's a symptom of depression, depression of cardiovascular disease, a symptom of his prostate cancer, diabetes. It's a symptom of something going on. And your job is not just giving the virus and say goodbye. Find out what the problem is as opposed to just giving them the virus and say goodbye. In all honesty, I would bet the majority of men who show up and say, yeah, my erections are just not as good as they used to be. And you give them, you don't get a study on these men. Why not? Because it's cost prohibitive. Every man at a certain age is going to tell you his erection is not as good as it used to be.

1:09:33So if I talk about lifestyle drugs, I mean, then Viagra is becoming a lifestyle drug. Yeah. So, you know, and daily sales.

1:09:41Dr. Gabrielle Lyon:What do you mean lifestyle drug? Meaning there's, because in my mind, that would improve blood flow. So that would not necessarily be a lifestyle drug, but improvement. But the end point, what I'm talking about is what they're trying to get is a better erection. They're not, they don't have a terrible symptom. Well, yeah, it's a terrible, they can't get erections. But just to make it better, which is so often what the patient says. But we do investigate everybody who comes to me with problems with erections. We check a testosterone level, right? That's what we were talking about in the first hour here.

1:10:18We ask about a family history of a cardiac disease. If that's there, we do much further investigation. We typically check a cholesterol panel. We check a sugar. So these are all the kind of like other check engine lights that should be... I was thinking more of a duplex. Well, duplex ultrasound is certainly down the road. But if a guy comes to me with ED, even if it's... I'm just saying, he says, my erections are not as good as they used to be. It's not that he can't get an erection. And it's very subjective, I mean. Of course it is. However, it could very well be the sign of something going on that we should investigate.

1:10:56You know, there's powerful data. We know clearly that vascular ED, that is classically lack of blood flow to the penis, predicts heart attacks by three, five.

1:11:03Dr. Gabrielle Lyon:Say that again. So when you have blood flow problems to the penis that cause problems with erections, because sometimes it's psychogenic, right? It's not a true vascular problem. The penis predicts the first heart attack by three to five years. Okay? That is really profound. So we know that as a fact. Okay. But now there's even more data that shows that men, even with psychogenic ED, that is, the plumbing is fine. We do the Doppler that we just discussed to check the blood flow, and the blood flow is fine. But we know that men who aren't getting erections because they're anxious, because they're nervous, because they had a bad day, bad night, and now it keeps happening again.

1:11:40Those guys actually have more heart attacks, too. It's crazy data. But think about it. The average man thinks about sex 18 times a day. There's a study out of Ohio State in 2012. And if this person doubts they're going to get a good erection, that means they're going to get depressed and anxious 18 times a day. That is a setup for more anxiety, higher blood pressure when somebody cuts you off in practice, worse sleep. These are all a formula to set you up for other metabolic problems and disease. So I think erectile dysfunction should never be ignored and it always should be further investigated independent of the cause.

1:12:18So if you think about what he just said, so a man walks in with ED, he's 35 years old. So we know that if he comes in with ED today, 15 % chance he'll have, 15 % of those men have a heart attack or stroke within seven years. 15? 15 % within seven years. We know that he's three and a half times more likely to suffer from clinical depression, which you're not even touching on. And there's a 30 % chance he could have diabetes or prediabetes that you're missing. Now, let's say you do nothing and you just give him the Viagra and he did have cardiovascular disease or he did have diabetes and you picked it up five to 10 years later.

1:12:46That's five to 10 years of pounding on the vessels and which you could have picked up 10 years earlier. Now, if you think that young man, he has hypertension. You say, hey, I want you to go in and get screened for your blood pressure every year. You say, no way. I would have never gone at 32 years old to get my hypertension. But if he has ED, first thing tomorrow morning, he's at my door. And he's going to say, what's going on? So ED is a great way, a gateway for men's health to get them their blood pressure checked and to get their blood sugar checked. It is a gateway to bring men in. But I think it's a disservice when you have a particularly young man to say, here's your vodka.

1:13:22See you later. But that's what's happening in the world. That's what's happening. Because most of these patients are talking to their primary care. And they're saying my erections are not good. They give them Viagra. That's it. Right. We only see them when, I think the ones that we see are the ones that don't respond. So the primary care refers them. Or they don't get erections, which is a lot more severe than it's just not as strong as it used to be. But what an opportunity to actually screen and get baseline numbers in these patients. I mean, awesome. You see this guy, like when you're a young boy or girl, you see your pediatrician.

1:13:59What happens to girls? They get headed off to their OB-GYN doctor. What happens to boys? Nothing. Nothing. So they don't come to your office for 20 years. In the meantime, they have high lipids. They're pre-diabetic. Maybe they have a cardiovascular risk. And we're completely missing that. We talk about this. You know, I have this webcast. And we talk, Amy and I talk about the fact that no one is seeing the guys. I mean, the women have their gynecologists when they're going to start birth control or they start having periods and they go and they get checked. There's no place these guys are just floundering around until they're 30 easily because we see them as infertility patients, right?

1:14:38They've never seen anybody. And the culture continues. Like the phrase, I haven't seen my doctor in 20 years. I'm healthy as a horse. I mean, that's just lunacy. Who buys a Porsche and then never changes the oil, checks the air pressure, right? I mean, like, that's just crazy. The human buys this amazing machine. And screening, like, really helps to prevent heart attacks, you know, diabetes, et cetera, et cetera, et cetera. Yet there's this desert of men's health care that is completely existing. There's this phrase now, toxic masculinity, right? And these guys, you know, they say, man up, you know?

1:15:18I'm having headaches. Man up. The father tells this kid, there's nothing wrong with you. And this is built into the society as we know it right now, is that guys don't, they think it's bad to go to the doctors because they're admitting there's something wrong with them.

1:15:33Dr. Gabrielle Lyon:So when girls start menstruating, they go to OBGYN, is there an age that, so for example, the normal age for erections to become more frequent is what? 14? 14? Yeah. Yes. 14. Puberty. Puberty. Is there going to be an indication where, okay, you've hit 14, you're a boy, we're going to send you for even baseline testosterone or whatever? How about just to talk about sexually transmitted diseases? Preventing pregnancy. I mean, there's no health education in the general education system right now, like there used to be. So they don't talk about it. I mean, no one talks to these guys. It's tragic. I think it's terrible.

1:16:16Dr. Gabrielle Lyon:Will there be, I mean, is that anywhere in the guidelines, what you were talking about? Screening? Yeah. No, but we're trying. When we went to the FDA back in December, we talked about the fact that every man over the age of 40 was what we thought about. Every man over the age of 40 should have a testosterone level screen annually. This is the best predictor of a man's overall health. And when we thought about it more, I think the number maybe should be lower. Yeah, I mean, I want my levels when I'm at peak performance. Yeah. 25. Yeah. Just pick a number, but certainly earlier than age 40, because again, when you're 45 and things start to fall apart, you have a reference point.

1:16:54And it may be too late. Also, the things that caused your problems at 45 could have been addressed when you were 25. It should be an annual screen. Yeah, and everybody knows what their cholesterol level is, right, if they're going to the primary doctorate. Nobody knows what their testosterone level is. But young guys don't go to primary care unless they're sick. Well, that's the problem. No, I know. That's the problem. But then again, you have to think about primary care. Primary cares are just inundated with patients. It's very difficult in Houston right now to get a primary care appointment.

1:17:24And they have 10 minutes per patient or whatever. It's a very short period of time. There's so many things to discuss. Yeah. It's such an important point you just mentioned, right? So the reality is it's like 18 minutes. My wife's primary care. She says, look, I got to go through diabetes, hypertension, hyperlipidemia, OSA. How am I going to get to ED and testosterone? You start with it early.

1:17:44Dr. Gabrielle Lyon:Yeah, you could start with it early. But she's like, well, then what if I can't get to diabetes? Right? Like, this is what I got. I got to get everything in. And I said to her, well, it's an important predictor. They could be suffering from other things. And she said, look, where did I get the training? I didn't get the training. And he put out an unbelievable paper several years ago. So I did only 50 % of medicine. What is it called? Well, LinkedIn. It was a journal. It was a couple of years ago where you and the Mayo Clinic put out an article showing that if you look at education, I think Dr.

1:18:12Hilo is the first author, showing that the only 50 % of medical students and residents got formal training. Fifteen or? Fifty. Fifty percent got formal training on sexual medicine, like how to, you know, sexual medicine and how to approach ED. Of those 50 % that got training, 50 % said their training was lousy. So how do you feel comfortable coming out talking about someone's erections when you got no training?

1:18:38Dr. Gabrielle Lyon:I mean, that's a really good point. And then to your point on primary care, before we even get to diabetes, hypertension, cardiovascular disease, perhaps when they're 18 or 15, I mean, maybe 15 is a little too young to get a baseline cholesterol and baseline testosterone level. I think it's really important. and we start early what about birth control so vasectomies how many you've performed over 2000 vasectomies yeah you're doing it in your living room how many I have no idea I mean when I was in the army I had to do five every Friday for two years I mean you know it's just he's done a tremendous many fellows over 130 fellows how to do them what about reversals he's done a tremendous amount of reversals 130 30 patients.

1:19:28I mean, a number of 30 fellows have been trained. A lot of them go out and they don't do it because they don't have the patient population. But we do a lot of reverse. I had three people come in yesterday for office hours to talk about reversals.

1:19:43Dr. Gabrielle Lyon:Is that effective? And is it a common procedure in general? It's not a common procedure because not that many people are trained. I mean, if we trained 120, 130, that's, you know, that's who we trained. I mean, you know, there aren't more. And people retire. And I think what's happening, though, I think there's been more, with more divorce, people are forced to change their mind because their new spouse is often younger. The woman's often younger. And she wants to have a family. He has two kids. and he will have the reversal so she can have a child. And I think that's becoming increasingly common with the high divorce rate.

1:20:26Is there something that men and women should know prior to undergoing vasectomies?

1:20:32Dr. Gabrielle Lyon:I don't think it's really discussed that much. I just think the message is tell them it's permanent. So stop coming to you for a reversal? No, I would love doing reversals. But I mean, the point is people should not be told this is a temporary procedure. They have to realize that it's hard to get it reversed because there's not that many people doing it. But don't you think you want to educate people when they come in for a vasectomy that it's not temporary? Yeah, two points also. His point is also you only want to go to the center of excellence. People who have high volume that know how to do this because sometimes you can do something more complicated like an epididymal vasostomy, which is more complicated.

1:21:09Why? It's a more complicated type of the procedure. And you don't want to go to someone who's doing one a year or two a year. You really want to go to someone at a high volume. And more importantly, if you're going to give one message out about vasectomy reversals, the sooner you do it, the better. If you come to me in three years or five years, the outcome is much better than you come to me in 20 years. Right. So that's a really important point. It's time dependent on outcomes. But people don't always know when they're going to get divorced. You know, so, you know, I think we have to just do it when they need it done.

1:21:39But we counsel them that the results are going to be better if it's been under 10 years.

1:21:45Dr. Gabrielle Lyon:Okay. You know, I was misguided. I thought it was a very common procedure. What? A reversal? Yeah. I thought it was very common. I think 6 % of all men who get vasectomy inquire about vasectomy reversal. And that's the number I remember. Okay. So it's not quite frequent at all. And when it comes to male infertility, I'm curious as if you all agree on the one cause. If you could pick one. I know you hate the one. I mean, he was the one who invented varicoceles because of the one who caused infertility as vapor. So it's probably the most common problem. And it's the most, and it's the, and it's the.

1:22:24What is a varicocel? It's enlarged veins around the scrotum, around the testicle.

1:22:28Dr. Gabrielle Lyon:Could someone see that or it's under ultrasound? So you can see it in some cases. We grade them as, you know, small, medium, and large or grade one, two, three. And the grade three, you can literally see. I'm sure you've seen patients with these large veins. I have, but I'm asking for that. For those guys out there. Is there anything? So I think that you have to remember that 18 % of all men, 18, have varicose veins of the testicle. But not the legs. It's the testicles. It's right around the testicle. And it overheats the testicle. And heat is bad for sperm production. Wait, because I don't actually know this.

1:23:07Dr. Gabrielle Lyon:So the varicocele causes an increase in heat production? Yes. Because it's retrograde flow and it sits around the testicles. So you don't have the blood leaving. It's just pooling there. Sounds painful. No, it can be. But I mean, that's not the most common thing we see. Okay. It's like a factory where, you know, the workers are making sperm and somebody like takes out the air conditioning and turns the temperature up 30 degrees. The productivity of that factory is definitely going to go down. Oh, that's cute. That's a great analogy. Yeah, picture these little men in there. So when he starts to smile, so he's very stoic, and then when he starts to smile, you know he's coming in with an analogy or something.

1:23:49Right, right. But anyway, so when a man comes to see you, the fact that he has a varicocele is not necessarily. Known to him. Well, it's also, yes, but it's also not necessarily the cause of his low sperm production. Because it could be true, true, unrelated. He can have a varicosele since 18 % of all men do. And he can have another reason for his infertility. But I think in general, most of these men will end up having their varicosele corrected because it is such a common problem with testicular failure.

1:24:24Dr. Gabrielle Lyon:Is it one of the causes of low testosterone and or erectile dysfunction in younger men? Low testosterone, yes. Yes. Yeah, low testosterone, not erectile dysfunction. Maybe indirectly, if testosterone goes down, but low testosterone, yes. The problem is that if you fix the varicoceles, you see about an 85 to 100 nanogram per deciliter increase, which some would argue is not clinically significant. That's not that much. Yeah, so if I started at 250 and you get me to 350, so it's not currently considered an indication. Like, you wouldn't fix someone's varicoceles to help raise their T to a normal level.

1:24:57People do. You do. I mean, let's be honest. They do, but I don't think it's clinically significant. But you'll know if a man checks his own testicles and one's really small and it used to be the same size as the other side. So there's something called testicular hypotrophy. The testicle gets smaller from that factory exhaustion thing, right? From those little men taking you in and out of the house. They're riding and the factory's actually getting smaller. I think you mentioned something very important. That was having men check their testicles. And they don't. And they should. But again, there's no education to young guys that, you know, between 25 and 35 peak years for testicular cancer.

1:25:38So, you know, I tell my patients, you know, once a month in the shower when everything's nice and rough, just make sure there's no lumps or bumps on the testicles. And if there is, come on in and we'll check it. It's really important. But they don't.

1:25:50Dr. Gabrielle Lyon:What is testicular cancer? What is the mean age? Between 25 and 35. It has a bimodal distribution, so in either young men below age 35 and then older men, like about 50 or 55. And then, you know, when a guy's feeling his own testicle, he has to know what's going on there. So there's this olive-like structure, and then there's this thing on the back. It's like a backpack. That's epididymis. It's where the sperm learned to swim, swimming school. But it has to be bigger than an olive. It's a very grande olive. I would add a big stone. It's a huge olive. So 20 cc's or so. Yeah. And then what you're supposed to do is gently roll the testicle between your fingers and learn what normal is.

1:26:33So the epididymis is back there.

1:26:34Dr. Gabrielle Lyon:What age should they start testicular exams? Twenties. 18 to 35. I would say young. 18 to 35. That's a big range. Yeah. 18 is where you start. What you're looking for is if you're walking down the street and you picked up a stone like a pebble. Right? It's jagged. It's hard. If that's living inside her testicle, you feel like, wait, there's an irregular border. It feels very hard there. That's cancer to prove otherwise. That's cancer to prove otherwise. This is very important. And we've all experienced seeing these guys who come in, nice guys, married, unmarried, and they've just, their whole testicles replaced by cancer.

1:27:14Because they just don't. I know, but they don't know. Or they, you know, but refuse to face the fact that something bad is. Early diagnosis of testicles? It was great. Always careful. Life-saving. I mean, 99%. You ask them to make a fist, and you tell them between the knuckles is exactly what a normal testicle feels like. You just press down. It's a normal testicle. The knuckle is identical to what a cancer feels like, right? You want to feel between. You don't want to feel the knuckle. That's a very simple way to tell someone what they're feeling in their testicle.

1:27:44Dr. Gabrielle Lyon:What is the lifelong prognosis if it goes undetected or untreated? It's high mortality because it can get metastatic very quickly. There are a lot of good drugs right now for the man with testes cancer, but you don't want to let it get to that point because the drugs as a group will cause infertility. And so you don't want to let it get so far that you need drugs. And you also need to know that you can bank your sperm easily and not expensively if you have to have treatment for testis cancer. And can someone still maintain fertility? Because it's not always, is it usually both? I don't want to say bilateral.

1:28:28Dr. Gabrielle Lyon:Is that the right term? Yeah, it can be. It can be. And one of our partners has a case coming up that's bilateral. But in those cases, you have to make a decision. You know, it's saving their lives. We do something called oncotesty. And oncotesty means when you remove the testicle, you work with the pathologist. They line out where the cancer is. they show you where the good tissue is. We take the good tissue out at that time and we go bank it and save it so they can do IVF later. And then we give the cancer to the pathologist, but it takes a team to get that done. There's a whole subspecialty of medicine called oncofertility, preserving fertility with cancer for both men and women.

1:29:05Wow. So often when patients start, when young patients are told they have cancer, first of all, survivability with people, young people with cancer is actually quite good. But you get blinders on, you forget about these things like fertility because you're just like focused on you need to get this treatment, you need to get this treatment. But there is always time to talk to an expert about this and say either bank sperm or do ovarian cryopreservation in women or potentially move around where the ovary is if they're going to shift it out of the radiation field. There's always time. It should be considered because if you don't treat it before the cancer treatment starts, it's too late.

1:29:42But Anderson is trying. They do have two women over there full time. Yeah. But it's mainly addressing the women. Yeah. But they send us their patients. They do. They do.

1:29:51Dr. Gabrielle Lyon:And I have one last question regarding this before we wrap up. With smoking cardiovascular disease or lung cancer, we know that there's a relationship. Do we know what the action item or the exposure would be for testicular cancer? Are there known exposures? There's none. Well, it's cryptorchidism, so if the testicle doesn't descend, that's a risk factor, right? But I can't give you a percentage on the smoking or if there's a correlation with the smoking and the testis. No, I don't think. There's no data on that. But I can tell you this. For infertility, men who are having trouble with sperm production, a huge area is environmental toxins.

1:30:35There's some excellent review articles just out recently talking about all the things in the environment. that theoretically can affect sperm production because you're making millions of sperm a day. And with rapidly turning over cells, they're going to be exposed to whatever is in the environment that can come in and halt that cell division. So, you know, a lot of the coal, people who live around coal mining areas, they are breathing in things that can affect their sperm production. uh talk uh think the soil fumigants um pesticides and alcohol yeah what what is that it's excellent once you got this terrible look no no i don't know i was actually thinking about the veterans

1:31:23Dr. Gabrielle Lyon:and i was thinking about the veteran community and infertility but taking it one step further i was thinking about testicular cancer and the veteran population i was you know that's a very interesting point because we're just starting to look at the burn pit yes the patients i mean exposures in terms of fertility because it's you know all the other things have been identified many things have been identified that are health issues but it's just your husband is starting to listen this is what we talk about and now you know people are like starting to look at this and the better population yeah and i think it's going to be a very important thing i i would agree with you gentlemen thank you so much for coming on if you would like to leave the listener or the viewer with one it could be a tip it could be a statement for their physician or as physicians the floor is yours i'd say low testosterone and ed are a marker of poor health and just don't ignore it if you have low t or ed look at what the cause is because it could be potentially life-saving and you have a wonderful ted talk on sex man so we'll link it at the bottom thank you I was there from a popcorn.

1:32:30One thing, and that is we've shown that poor sperm production, infertility, is a metric of a man's health. So men who have low sperm production, increased risk of all-cause cancer, earlier mortality, greater incidence of comorbidities. And, you know, that can't be overlooked as simply something for reproduction. It's a metric of health. It's very well said. You need to be proactive. You need to take agency for your own help. Don't be anxious, depressed, sitting on the couch. You are the CEO of your own body, right? Take care of it.

1:33:10Dr. Gabrielle Lyon:Well said. Thank you so much. Thank you. Thank you.