Inside Modern Hormone Therapy: Safety, Symptoms, and Smarter Telehealth

16:07Dr. Peter Fotinos:Well, I think that's a great, I mean, I know we're going to talk about estrogen too, because I think you and I have a very similar opinion of most of these testosterone clinics. They almost bake in anastrozole or estrogen blockers, what we call aromatase inhibitors, into their formula. One of the things is it does allow the testosterone injection to last longer because you're blocking the degradation of testosterone. So it makes the labs look good. but then you're losing two of the critical functions of estrogen in men, which is cardioprotective by elevating your HDL. And it's also, there's a lot more estrogen receptors on the surface of bone for bone mineralization than there are androgen receptors, right?

16:51Dr. Peter Fotinos:So if you're not got estrogen, so a guy walks around with a T of 1 ,500, you've just killed two of the reasons that testosterone is so effective in longevity in men.

17:00Dr. Jesse Mills:And there's some good studies where they've done, where they did DHT and testosterone and saw that they had very little benefit. And they were blocking the estrogen, but when they added back the estrogen, that's where they got all the benefits from testosterone and DHD. So it's not, you can't just isolate these hormones. They work together in a symphony, right? So when you do that, it throws the whole balance off.

17:22Dr. Peter Fotinos:You know, I always say that we're a highly conserved species. Our DNA is really efficient at using it. And so why would we continue to have the aromatase as an enzyme if we didn't need it, right? Or why would we continue to have dihydrotestosterone if we didn't need it? Or 5-alpha reductase, rather, if we didn't need it, right? So these are the enzymes that control the metabolism of testosterone. It's like whack-a-mole. You hit an AI, and then the DHT goes up, and then vice versa. And so I think it's great that you bring up that point. And that's another thing, again, Pearl, for the listeners is if you're going to one of these clinics and they're automatically starting you on an aromatase inhibitor.

18:03Dr. Peter Fotinos:I just saw a guy like that yesterday. He was seeing a telehealth guy in Miami that started him on testosterone and AI both and didn't make sense to him. And you know how he figured out that it was the wrong thing to do? You'll love this. Chat GPT. He went to chat GPT. He's like, because I told him that was the wrong thing to do. He said, oh, I know that. I put it into a search engine and said, don't just start an AI. Don't put on an aromatase inhibitor just because, right? So, hey, man, Dr. ChatGPT could be coming for us, Peter.

18:35Dr. Jesse Mills:I think they have a medical version of it coming out. It's open source.

18:39Dr. Peter Fotinos:Yeah, there's a couple in the Doximity. Yeah, but yeah, I don't know when we release that. So far, they're curated by our NPIs or our national provider numbers. So we don't, you know, we can't unleash Pandora's box quite yet, but yeah, crazy. So, yeah. So, you know, again, like the whole idea, right, is low testosterone, in your opinion, is it a normal part of aging? Is it a disease state? Do you let somebody get into a disease state, which is kind of what you got in with the guidelines? Like we don't treat somebody for low testosterone until their T goes below 300 nanograms per deciliter, and they have symptoms of low testosterone.

19:22So flip that paradigm for me. Tell me how you would look at somebody just on the testosterone side before we get into

19:29Dr. Peter Fotinos:female hormone replacement.

19:31Dr. Jesse Mills:So the first thing I do, and this is funny because I hear this all the time, you know, from doctors, what was the level? I want to know what's going on with you. What are your symptoms? If you look at the research as it relates to the analysis, the assays we use for testosterone replacement. And I did a lecture on this to my providers and stuff. And they are wholly, woefully not the greatest at indicating truly what's going on at the cellular level for these patients. You know, testosterone doesn't work in the blood. It works inside the cells. You mentioned the receptors, you know, estrogen is the same thing.

20:06Dr. Jesse Mills:Blood testing is very difficult to indicate that. It can give us a slight picture, but it doesn't tell us exactly what's going on inside the cell. What does is the patient's lived experience. What's going on with me? You know, my libido is dropping. My relationship's going away. You know, my energy is dropping. My sleep is having an issue. You know, my cholesterol is starting to go up. You know, I'm gaining fat in the middle. You know, I can't, I work out. I can't build muscle anymore. That's my first step because ultimately, and you can see this. I don't know if you looked at this. I don't know if the AUA is, I didn't look at any studies for the AUA, but I looked at the studies for the, there was a kind of an analysis on the endocrine society, how often they've changed the minimum level of testosterone.

20:47Dr. Jesse Mills:They've done it like five times in the last 12 years because they don't know there is no number. They don't know the number. Right. And it's kind of funny. You mentioned statins and cholesterol. You have one bad cholesterol. They're going to put you on a statin or try to put you on a statin right away. But you just mentioned with the testosterone, you have to have two levels of below 300 within a seven-day period done in the morning, right? Why? Why is it so restrictive? Because they don't want you on testosterone. That's what I see, you know. They're feared.

21:29Dr. Peter Fotinos:Cardiometabolic is one of the biggest health challenges in the U.S., and evaluating patient risk across multiple conditions requires careful attention. With so many testing options and guidelines, getting a clear picture of patient health can still be a challenge. LabCorp brings clarity. Our cardiometabolic testing solutions support early risk assessment and empower more informed decision-making, so you can focus on what matters most, your patients. Visit LabCorp.com to partner with LabCorp and simplify complex patient profiles. This episode is brought to you by Spreaker, the platform responsible for a rapidly spreading condition known as podcast brain.

22:05Dr. Peter Fotinos:Symptoms include buying microphones you don't need, explaining RSS feeds to confused relatives, and saying things like, Sorry, I can't talk right now, I'm editing audio. If this sounds familiar, you're probably already a podcaster. The good news is Spreaker makes the whole process simple. You record your show, upload it once, and Spreaker distributes it everywhere people listen. Apple Podcasts, Spotify, and about a dozen apps your cousin swears are the next big thing. Even better, Spreaker helps you monetize your show with ads, meaning your podcast might someday pay for, well, more microphones.

22:38Dr. Peter Fotinos:Start your show today at Spreaker.com. Spreaker, because if you're going to talk to yourself for an hour, you might as well publish it. Almost 30 years together, four kids and some of reality TV's most unforgettable moments, we know a thing or two about living life out loud. We're taking you behind the scenes in our new podcast, Between Us, with me, Heather Dubrow. And me, Terry Dubrow. Between Us isn't about perfect lighting or curated Instagram grids. It's the unfiltered, behind-closed-doors conversations you wish you could eavesdrop on. Equal parts smart, funny, and a little bit scandalous.

23:13Dr. Peter Fotinos:Every week, Heather will bring you an unapologetic take on the headlines, the trends, and the cultural moments everyone's texting about. And Terry will deliver insider beauty, health, and wellness insights you won't find on TikTok. Together, we'll tell the stories, spill the secrets, and share the hacks that keep life, marriage, and everything in between feeling fresh and fun. We may live in a gated community, but there's zero gatekeeping here. And plenty of, did they just say that moments? Listen to Between Us on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts. I went and sat on the little ottoman in front of him.

23:50Dr. Peter Fotinos:I said, hi, dad. And just when I said that, my mom comes out of the kitchen and she says, I have some cookies and milk. This is a badass convict. Right. Just finished five years. I'm going to have cookies and milk at mom. Yeah. On the Sino Show podcast, each episode invites you into a raw, unfiltered conversations about recovery, resilience, and redemption. On a recent episode, I sit down with actor, cultural icon Danny Trail to talk about addiction, transformation, and the power of second chances. The entire season two is now available to binge, featuring powerful conversations with guests like Tiffany Addish, Johnny Knoxville, and more.

24:33Dr. Peter Fotinos:I'm an alcoholic. And without this trouble, I'm going to die. Open your free iHeartRadio app, search The Cino Show, and listen now.

25:03Dr. Peter Fotinos:I think it is, and also is it, you know, the concern about overtreatment and, and, and I think I'll take you one step further. because just yesterday in my clinic, I saw a man who had, he was a power lifter in his mid, he was 47 when I saw him yesterday, but a year ago, and he had his testosterone checked, it was 800 about a year before that. And he was deadlifting 400 pounds. I mean, just a fit, fit guy, had a massive stroke and testosterone went down to zero for a while. It was in the ICU, was barely recovering because we also know testosterone we use as a biochemical surrogate for an inflammatory state.

25:41Dr. Peter Fotinos:So we know if you go into the, and we've done these experiments since the 1970s, if you go into an ICU and you take any guy's testosterone, it's going to be almost zero because it works as an inflammatory marker that we know that something's wrong with the system, right? Well, anyway, this guy had, thankfully he had a testosterone of 800 a while back. He's finally out of the hospital in rehab trying to exercise. and he had his testosterone redrawn and it was 350. And his wife is just this amazing advocate by his side the whole time. And he was told this guy, we knew his testosterone before his stroke was 800, comes in at 350 and he was told they can't treat him because it's above the guidelines.

26:24Dr. Peter Fotinos:And here's a guy that's in a wheelchair. He's trying to get his strength and his muscle mass back. And we know, we know a couple of years back his testosterone was 800. and it's, you know, so to me, that's, I don't know if it's fear. I don't know if it's ignorance, but I think it is exactly what you said is you treat the patient. You don't treat the lab value. And here's a perfect example of a guy that would benefit so greatly from testosterone, just in terms of trying to build some muscle mass, trying to decrease his metabolic syndrome because he was also putting on a lot of weight, not being active and used to be a power lifter.

26:57Dr. Peter Fotinos:So yeah, is that every day in your clinic too? Talk to me about your average patient. You see that you know you're doing the most good with?

27:03Dr. Jesse Mills:Yeah, I see everything. We have like military bases in the area. You know, in Fayetteville, we have Camp Lejeune and, you know, Fort Freedom now. So I take care of a lot of those military. Those guys, because of what they're putting their bodies through, their bodies, you know, when you exercise, your testosterone is going to go up, you know, that's physiologically, right? So they require more testosterone than the average person. I find those guys, and this power lifter, I bet you 800, is probably where he needs to be at most of the time, right?

27:32Dr. Peter Fotinos:That's my thought, exactly.

27:34Dr. Jesse Mills:So I find that, you know, that's one of the things I do see a lot of, you know, PTSD, you know, with the military guys, because a lot of that centrally affects the ability to produce these hormones. So, but no, I see a lot of ex-athletes, a lot of military. I see, you know, the average, I mean, I have a truck driver. He doesn't exercise, but he's so active all the time, all the time. He's losing weight tremendously. He's building muscle doing that while on the testosterone. Yep. You know, he's sitting in a truck most of the time, but when he gets out, he does stuff, you know, to the truck and everything.

28:10Dr. Jesse Mills:Yeah. He's phenomenal. I've seen diabetic 12 hemoglobin A1C12, which is uncontrolled, right? Twice normal. And he was on an insulin pump. He was a type 2, but put on an insulin pump because he was so brittle, right? And they started him, I started him on hormones and we got him down to 5.4 on his hemoglobin A1C, you know.

28:31Dr. Peter Fotinos:Which is incredible. Yeah, it's incredible.

28:33Dr. Jesse Mills:And I'm not going to take it away from him. He dieted and exercised too. You have to do those things.

28:38Dr. Peter Fotinos:Do the work. Yeah, that's exactly right. Yeah, I mean, when I look at this is that I look at the relationship with the patient is that you're going to give them the tool, but they have to do the work. And I think that's exactly right, especially for somebody that has, by definition, a sedentary job of doing long-haul trucking and also poor circadian rhythms, right? So one of the things we know that is such a risk factor for hypogonadism, low testosterone, is poor sleep patterns, not regenerating your LH surge in the morning. And so they're the kind of guys that you have to deal with them where they're at.

29:12Dr. Peter Fotinos:And also in the military, I don't know if you see this too, but traumatic brain injuries and my ex-NFL players, 70 % of guys that have a TBI, traumatic brain injury, are going to have secondary hypogonasm or the pituitary stops getting the signal from the hypothalamus to generate. So those are the guys that we really have to screen for because if you have a 70 % chance of finding pathology in a guy that had a pretty significant head injury, the good you can do for those men is immeasurable.

29:41Dr. Jesse Mills:Yeah, I had a military, a young guy, 20s, got, blew up in an IED and basically his testosterone was one of the lowest I've ever seen was 162.

29:52Dr. Peter Fotinos:Wow. Yeah. Yeah.

29:53Dr. Jesse Mills:I mean, and they weren't going to treat him. Yeah. Because they were afraid, you know, and this is the VA. I'm not trying to say it was all primary, but, you know, they don't treat them, you know.

30:03Dr. Peter Fotinos:Yeah. Yeah. And those are guys that need MRI head imaging as well to make sure that their pituitary is there. They don't have an adenoma or some other causes. So, yeah, I mean, I love it. We're very simpatico here. I think we're trying to say that there is a room for hormone replacement at any stage. But talk to me a little bit about what's happening on the female side, estrogen replacement. What's new out there that you noticed since the FDA has come back and said, hey, guess what? Maybe we do need to look at HRT again for women. So how has your practice changed since some of those guidelines or at least some of those recommendations has changed?

30:39Dr. Jesse Mills:Hasn't changed a bit. I've been doing this for the last 20 years. I finally said I feel vindicated seeing them removed. Right. I'm like, yes, you're right. Estrogen doesn't cause breast cancer. A 23 % reduction in incidence of breast cancer and a 40 % reduction in breast cancer mortality. I mean, what else do you want? That was the Chablowski study. Right. That was one of the authors of the WHI. They followed the patients for 28 years afterwards. you know, and they, they showed that, you know, and I was like, yes, thank you. And that was with primarin too. That was with the synthetic estrogen.

31:17Dr. Jesse Mills:It wasn't even with estradiol. So we know if primarin can do it, we know for sure estradiol can do it, right? Because that's the natural hormone in the body, right? Yeah. It hasn't changed. I mean, I still, I mean, progesterone, I give the women, testosterone, speaking of testosterone, when you mentioned how we kind of don't treat people based on like our expectations. For example, we don't think testosterone is a female hormone, but in the lifetime of a woman, testosterone is the most abundant hormone.

31:46Dr. Peter Fotinos:Yeah.

31:46Dr. Jesse Mills:And the only time we give the diagnosis, and this is, I get pissed at this and I tell my wife laughs at me when I do this. The only diagnosis medically that we should be giving women testosterone is hypoactive sexual desire disorder. Right. That's very misogynistic. Yeah. You're saying that a woman that doesn't have muscles. You're saying that a woman doesn't have breasts. You're saying that a woman doesn't have a brain. You're saying, you're saying, oh, it doesn't have a heart. All you're thinking about is that's only going to help her with sexual desire. That's the problem, you know? And I get mad at it because I put women on testosterone because it's, they were, they need it, you know?

32:22Dr. Peter Fotinos:Yeah. Well, so, you know, 2006 or so, I think was when J &J had a product for women for testosterone therapy. So 20 years ago, didn't pass. Do you think that that chip has sailed? And now I'm going to tell you my thought on this is that because of people like you and other people that are a little bit more progressive, proactive, testosterone therapy, especially for women is cheap, right? I mean, it's like 10 cents a day. And so is there ever going to be a company that's going to go in front of the FDA to try to do the studies to get FDA approval for a drug that's going to make them 70 cents a week?

33:07Dr. Jesse Mills:Before we talked about, you know, them reversing the estradiol and estrogen, because they did estradiol last year and they did estrogen premerin this year, black box warning. And then now they had that council or that special experts panel on testosterone. Yes. I never in a million years thought we're going to have anything like that. So before that, I would have said probably never because of the fear of hormone. You see a lot of the stuff that they use now for, you know, postmenopausal therapy as far as hot flash nights. Oh, it's not hormonal, you know, and now they have some non-hormonal testosterone, not testosterone, but things that increase the libido.

33:44Dr. Jesse Mills:So they're using their marketing, the non-hormonal. Right. Right. But since they've changed that stuff and we're showing that these hormones, you know, are more and more safer than what they've been saying in the past, I think we may see it. There may be, you know, how it's not necessarily the medicine in the actual device. It's the actual way that it's delivered. Sure. Right. Yeah. They may be able to they may be able to make money off that and make it more profitable. But with compounding, which is what we use mostly for women. Right. Right. They have to. Yeah. I don't really like doing injectable testosterone in women because the dosing can be really hard to deal with or work with.

34:26Dr. Peter Fotinos:Such a small amount, right? It's about a tenth. I mean, just in general, is that about a tenth of what you would give a male is what you give a female. So it's hard to get that syringe down to, you know, 0.1.

34:35Dr. Jesse Mills:0.01, whatever you try to.

34:37Dr. Peter Fotinos:Right. Well, I think you hit it. That's an interesting thought is that if they turn it into a vehicle FDA approval where it's, you know, a spring-loaded injector or some kind of sub-Q. pellet, you know, something like that, that, you know, that has a device delivery, then there may be a dog in the hunt. But honestly, I think it's always going to be off label. But I think as long as we have the information out there, and again, shouting back out to the listeners that you probably can find a provider in your area that is comfortable giving testosterone replacement to women, but that's going to jump me right into the next part of this, which is what I really want understand is talk to me about your telehealth practice.

35:16Dr. Peter Fotinos:I mean, how, because I think one of your things that you've done is you've, you've leveraged your, your expertise and your passion, as well as, you know, I think you're responsible prescribing into, into a platform that does allow access to care. So, you know, I, I, in my practice being in the state of California, especially now that, that I'm limited by telehealth platforms, since I'm only licensed here to see people in California. It's still amazing. I can see somebody that's a 14-hour drive away from my office and still do a lot of good for them without a physical exam. But I still think that we could probably do more, but I also think there's limitations.

35:54Dr. Peter Fotinos:So yeah, talk to me about your journey to do that and tell me how you've done this so that you are providing as close to in-person care as you can at the level that you do in your clinic.

36:05Dr. Jesse Mills:I'm very excited about Excel Medical. Um, it's there, we have some growing pains, you know, we're, we're, we're not a tech company. What I told you is we're a medical, uh, clinic, um, pretty much put together by medical, you know, doctors and people in the medical field and use technology to deliver. Most of these other companies that I'm seeing, they're tech people that basically hired medical providers for rent, right? A lot of people don't have any experience. I mean, I looked, interesting enough, I looked at all the kind of the chief medical officers and the medical directors of these clinics that are supposed to be hormone specialists.

36:47Dr. Jesse Mills:And they're doctors that have very little hormone specialty, especially in the field that they're practicing. They don't have any experience, really, to be honest with you. Most of them are just regular doctors that I guess they're using their license or they have experience in medical business that they're using for that position. So that kind of concerns me. And I've told Dr. Broody, who's my medical director, I said, we need to definitely let people know that we know this stuff. This is what we know. So initially, Revita was going to be about 100 clinics. Okay. And we found that scaling and franchising and doing all that kind of stuff wasn't working.

37:29Dr. Jesse Mills:You know, we had three clinics here in Charlotte. A couple were key mad spaces, right? Right. It was very difficult to scale this. And, you know, a lot of it is when you start this in an area, you won't get a lot of people initially, no matter how much you market. Most of our patients in a brick and mortar clinic are referrals. You know, we tried marketing different ways. It's just difficult. Thanks to Leif, who's our chief strategy officer. He started off as our chief marketing officer. He was able to find a way to scale on the Internet. We started off as an ED company, you know. And then when the COVID waiver came, we were able to kind of switch our gears to doing testosterone because that's what I was most comfortable doing, you know, and that's what I know.

38:23Dr. Jesse Mills:So we didn't realize, you know, we were sitting in my clinic in Charlotte. We had like a back area where Melixel was working out of. We get our first 10 patients and we're, oh, my God, we're doing a great job and stuff like that. But now we're up to 22 ,000 patients full time. And we've seen over 100 ,000.

38:44Dr. Peter Fotinos:So that's a lot of scale.

38:45Dr. Jesse Mills:Yeah, it's, and I know it's crazy because the benefits that I've seen at my micro level, because I see about 450 patients at Revita, and I won't ever give that up. I told Craig, our CEO, I said, I love seeing patients. Yeah. You know, I'm always going to see patients. Right. And so to see the same benefits at that scale, and if not better, it was crazy, you know. And we check in with our patients. I know physically touching a patient is important, but I think more importantly is talking to the patient, letting the patient know they have a line of communication to you. If there's an issue, we can get it to the right person if there needs to be a right person.

39:29Dr. Peter Fotinos:Right. And so we typically, what I saw was very good improvements.

39:37Dr. Jesse Mills:The follow-up mimics my clinic. I see my patients every six to eight weeks. We send out our symptom sheet and communicate with the patient every six to eight weeks. It is automated. Eventually, it's going to probably be AI driven, but it is automated. Your refill is linked to that form that you have to fill out. So if there's a problem, we won't refill you. Or if there is something we need to adjust, we refill you at that point. If we need to talk to you, we'll get on the horn with you and talk to you.

40:06Dr. Peter Fotinos:See, that's what, yeah, you know, as Tribe Called Quest said a long time ago, I ain't no West Coast disser, but I do have to diss a little to say, this is my problem with some of these companies, like the guy from Miami, where it just becomes this auto-renew prescription without any check-in. And he, for example, I get a lot of guys that will say, yeah, I was doing great, but then my partner and I were starting to have a kid and I go in and get a sperm test and I have no sperm and nobody ever told me that testosterone is good birth control. and so it sounds like you've baked in checkpoints, which is actually bad for your bottom line, of course, right?

40:45Dr. Peter Fotinos:Because what you're saying is your checkpoints not only cost money or cost AI time, but you're also potentially jeopardizing a new prescription and everything like that. So I have to respect the fact that, again, in your clinic, it sounds like patient first, profit later, and you're doing the better you get, you know, you're going to increase that scale even more to really show still that there's a pretty good ROI for you in this, in this ability to reach way more people.

41:14Dr. Jesse Mills:Well, if you do it right and you piss somebody off, like, like you just said, like if you call somebody to be infertile, they're not going to go back to you. I'm sorry. That's right. Yeah. So, I mean, and we, like I said, we bake in a lot of these questions into our intake. So do you want to have children? Well, we need to know that if you want to have children, so we, you know, we may get a baseline sperm count on you. Or if we add Clomid, I know HCG is harder to get right now. I was doing a lecture on Clomid. It's a little bit better because you can still block sperm production with HCG because it can drop intratesticular testosterone at some point because of the lack of FSH.

41:48Dr. Jesse Mills:But that's typically what we'll see. But, you know, I like using HCG and Clomid. But I agree with you. Our biggest selling point with our company is that you get a dedicated provider that follows you through the whole period. You're not getting a Renadoc. You know, It's not like Uber where whoever car comes get you at that time. You talk to Kelly. You talk to Jennifer. You talk to whoever is your provider, albeit if they leave or they have to go or something like that. They're not longer with us. You'll go to another provider that you'll follow too. But you're going to get a dedicated provider, and they know your history.

42:21Dr. Jesse Mills:They're going to see everything. They'll make adjustments based on what you're telling you. From a click away, they can actually talk to the provider if they ever need to.

42:59Dr. Peter Fotinos:We'll see you next time. and empower more informed decision-making so you can focus on what matters most, your patients. Visit labcorp.com to partner with LabCorp and simplify complex patient profiles. This episode is brought to you by Spreaker, the platform responsible for a rapidly spreading condition known as podcast brain. Symptoms include buying microphones you don't need, explaining RSS feeds to confused relatives, and saying things like, sorry, I can't talk right now, I'm editing audio. If this sounds familiar, you're probably already a podcaster. The good news is Spreaker makes the whole process simple.

43:34Dr. Peter Fotinos:You record your show, upload it once, and Spreaker distributes it everywhere people listen. Apple Podcasts, Spotify, and about a dozen apps your cousin swears are the next big thing. Even better, Spreaker helps you monetize your show with ads, meaning your podcast might someday pay for, well, more microphones. Start your show today at Spreaker.com. Spreaker, because if you're going to talk to yourself for an hour, you might as well publish it.

44:26Dr. Peter Fotinos:Every week, Heather will bring you an unapologetic take on the headlines, the trends, and the cultural moments everyone's texting about. And Terry will deliver insider beauty, health, and wellness insights you won't find on TikTok. Together, we'll tell the stories, spill the secrets, and share the hacks that keep life, marriage, and everything in between feeling fresh and fun. We may live in a gated community, but there's zero gatekeeping here. And plenty of, did they just say that moments? Listen to Between Us on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts. I went and sat on the little ottoman in front of him.

45:04Dr. Peter Fotinos:I said, hi, dad. And just when I said that, my mom comes out of the kitchen and she says, I have some cookies and milk. This is a badass convict. Right. Just finished five years. I'm going to have cookies and milk at my mom. Yeah. On the Sino Show podcast, each episode invites you into a raw, unfiltered conversations about recovery, resilience and redemption. On a recent episode, I sit down with actor, cultural icon Danny Trail to talk about addiction, transformation and the power of second chances. The entire season two is now available to binge, featuring powerful conversations with guests like Tiffany Addish, Johnny Knoxville and more.

45:46Dr. Peter Fotinos:I'm an alcoholic, and without this trouble, I'm going to die. Open your free iHeartRadio app, search The Cino Show, and listen now.

46:10Dr. Peter Fotinos:is there a mechanism in terms of your data capture to know how many of these patients that are reaching out to you via the telehealth platform had tried to get therapy or try to get seen through a more traditional route and just didn't get any interest you know because as i you know Like you said, I would say about 30 % of my patients do not have a primary care. Actually, we did this math a while back. About 30 % don't have primary care, and I end up reverse referring. But most of mine is referral, either self-referral or referring from a physician, a lot within the UCLA network. In your experience, do these people have primary care physicians that didn't want to treat them?

46:49Dr. Peter Fotinos:or are they just like, I know I have low testosterone or I know that my perimonoposal state is not really being treated. Talk to me about that in terms of where you see growth in this market for both for you, as well as growth for you means access to patients.

47:06Dr. Jesse Mills:We think we're at the tip of the iceberg in this market because a lot of people are waking up and seeing this, that they, and a lot of primary care don't give it, like you said, don't give them these medicines. Do I get a lot of referrals from primary care? We probably do. I've heard some patients talk about that. I don't have the data offhand, but we do know that a lot of them come from other clinics, either their brick and mortar clinics or another, you know, telemedicine clinic because they didn't get the service or the care that they thought they should get. Okay. Mostly about 50 % of the patients that come to us will start the program.

47:42who starts and who's like, you know, my testosterone is 800.

47:46Dr. Peter Fotinos:I'm not a good candidate or, or yeah, let me talk to me about that. That's really interesting.

47:50Dr. Jesse Mills:Well, we do our, the way we look against symptomatology is number one. You know, I have a symptom sheet that's basically I put together. It's, you know, it's not based off the, the general ones that you can get that were surveys, but it's.

48:03Dr. Peter Fotinos:The Adam questionnaire is kind of the classic. Yeah. Yeah.

48:05Dr. Jesse Mills:The classic. And there's two types of Adam, right? There's one with a number and then there's another one, right? But this one we categorize based on testosterone deficiency, testosterone excess, thyroid deficiency, thyroid excess, cortisol deficiency, cortisol excess for men, and then we add progesterone and estradiol for women. And they score, it's basically a zero to three severity, zero being the no symptoms at all, three being the worst. So it's a span of libido and everything. And anything that's above a 10 in those sections is highly suggestive of of being low testosterone or low whatever thyroid.

48:40Dr. Jesse Mills:Then we kind of go into the levels and stuff. Anything below a thousand is what I try to shoot for is kind of indicative if they have symptoms. If they don't have symptoms, we're not going to treat them. So basically that's kind of how we look at it. You know, we don't treat men under 30 because of the high risk of, now at Melixcel, So, you know, at my Revita clinic, I've treated any age, pretty much above 20, basically. I don't treat, you know, teenagers unless they have PCOS and they're female with PCOS. And if I do treat that age, I usually give Clomid or HCG. I don't touch testosterone in that group because of the infertility.

49:19Dr. Jesse Mills:And plus, you know, there's just too high risk of having abuse. most of the people between 30 and 38, we typically will treat with Clomid just because a lot of those people are trying to abuse in some situations, you know, so we can filter them out. If they know what Clomid is, they know what HCG is and they're institutionalized or understand the kind of system that it is, they're going to say, no, I don't want that. And so we filter out a lot of the bad players too, that are there just to abuse it. Right. Yeah. A 50 year old or 60 year old is not going to try to go up trial for the football team or although I did see that movie with Chiklis I forgot the senior and he was 59 years old.

50:00Dr. Jesse Mills:That's right there you go this is possible but

50:02Dr. Peter Fotinos:you still had eligibility.

50:04Dr. Jesse Mills:Yeah I was flying I was in the plane coming back from that conference and I was like man this might be a fun movie to watch and I was like oh man I better be careful with a 50 year old right now so there you go but you know you're typically going to those guys are going to come to you because, you know, they have more fat in their belly area or their libido's off and they can't have their relationships off. And so those are the kind of people we kind of treat towards. So we have a lot of kind of fail-safes. We do look at the PMPDs for all our patients and they do them spot checks and they do them pretty regularly.

50:35Dr. Jesse Mills:Some states require you to do it after every prescription. So our providers do that. But none of these patients don't have a primary care. Our requirement is for them to be with a primary care.

50:44Dr. Peter Fotinos:Oh, that's great.

50:45Dr. Jesse Mills:Because if we don't have them with a primary care, then we're not a primary care clinic. We don't do that. That's right.

50:51Dr. Peter Fotinos:Well, I think the message is that you provide a service that's probably unmet. You'd use the word tip of the iceberg. And there's been a lot of data over the years that if you look at pharma projections and industry insider data, it's something like 10 % of people that would benefit from hormone replacement are actually getting hormone replacement. So you're out there for the other 90%. and fulfilling a need in a responsible and ethical way. I definitely applaud you for that. And we also, we do a segment that I like to call You're Probably Gonna Be Okay. And I give you a scenario of somebody that's listening right now, I guarantee you probably more than one person that fits what I'm gonna give you.

51:30Dr. Peter Fotinos:And I want you to A, say if this guy's gonna be okay and then B, how is he gonna be okay? So it's a 55 year old guy. He has a hemoglobin A1C of 8.2. Maybe he doesn't even know that he has diabetes, so you'll have to unpack that for me, explain what those numbers mean to you. His total cholesterol is 280, so it's high. You can break it down to HDL, LDL, but bottom line is high blood sugars, high cholesterol, testosterone is 220. Does that sound like somebody you see once every 10 years or once every 10 patients?

52:02Dr. Jesse Mills:I see that a lot, more than once every 10 patients.

52:05Dr. Peter Fotinos:Exactly. So he's the average American. Is this guy going to be okay, and how is he going to be okay?

52:10Dr. Jesse Mills:So he's got metabolic syndrome. What that means is he has elevated sugar. He's got an elevated cholesterol, probably has high blood pressure as well. I'd like to see what his triglyceride levels are. I would like to see what his HDL. My guess is triglycerides are going to be up because of the diabetes, and he has a low HDL for the same reason. He probably has low testosterone because he has visceral fat, because he has an elevated estradiol through backwards aromatization from estrone, causing his testosterone to drop, which is causing his visceral fat to get worse because he's losing muscle. He's going to have to diet and exercise for sure.

52:45Dr. Jesse Mills:I tell my patients there is no, and this is why I hate some of these medicines that are out now. They give patients an excuse to not diet and exercise and still lose weight, you know?

52:56Dr. Peter Fotinos:And lose muscle mass with it. Yeah, exactly.

52:59Dr. Jesse Mills:And you know, you said longevity and you know the single most important thing for longevity is muscle mass, you know?

53:05Dr. Peter Fotinos:Grip strength, grip strength, muscle mass. Yes, muscle mass. Talk about it all the time.

53:10Dr. Jesse Mills:Yeah, so that's what we were. I don't know what the implication and that's going to be, but I have a feeling it's not going to be the greatest. The hemoglobin A1c, you want to be less than 5.7. He's 6.5 and above. He's probably, he is diabetic. So we got to get rid of the visceral fat. This is all a metabolic syndrome that's driven by the visceral fat. Every study that I've seen, as long as he gets treatment and he's exercising and diet, and I'm talking about HIIT training, aerobic exercise. I like intermittent fasting and I like keto-based diets. Some people, I know there was a doctor out there that wrote a book on the plant-based diet for heart health.

53:44I don't believe in much.

53:46Dr. Jesse Mills:I've seen the studies, maybe, but as long as you're losing visceral fat and then I would start him on testosterone, thyroid, depending on how old he is. He's 55, so above 40, I would check to see if his growth hormone is low because that helps with visceral fat. Make sure his estrogen's above 75. That's where I shoot for because that's where you get the best increases in HDL and best reduction in belly fat. The belly fat's the key. If you get rid of the visceral fat, if you can get rid of that, he's going to be okay. My typical American that wants to come and see me will probably be okay. Most Americans that don't diet and exercise and just want me to give them hormones, they probably will just cruise along until they die.

54:29Dr. Jesse Mills:They won't see the belly. And not be okay. Yeah.

54:31Dr. Peter Fotinos:That was like a board question I just threw at you. That was great how you unpacked it. You did such a good explanation for guys about exactly what you can do as a physician, what they can do to keep themselves healthy as well. So I think that's amazing. And, you know, I know how passionate you are about what you're doing. And I think it's passion to the point of starting a nonprofit. I'd love for you to talk to our audience about your advocacy work as well.

54:56Dr. Jesse Mills:So, yeah, I'm excited. I actually met a couple of the providers, doctors, and experts that are going to be on the society at this medical conference. Dr. Nikki Lovett, who's out of Fargo, North Dakota, with Firefly Medical, and I have put together the Society of Proactive Medicine. And our goal is to do guidelines, but guidelines that are based on the scientific evidence related to hormone replacement and not based on disease states, right? So we're going to give you this and this for this, and we're trying, and this is what you want to do. And it is for the public. It's for patients, but doctors can also look at it as well.

55:34Dr. Jesse Mills:Our goal is to educate patients and providers alike on the benefits of hormones and also give you the positives and negatives of it, too. We want to be able to tell you, hey, don't do estrogen blockers or, hey, you know, progesterone is safe. But if you're doing progestins, which are synthetic progesterones, they're not safe. if you're going to have to watch out for breast cancer and all these other things. If you want to get pregnant, you can't just use testosterone or not use testosterone at all, right? So we'll be touching on a lot of different aspects of hormone replacement, benefits of protecting against heart disease and metabolic syndrome and things like that.

56:12Dr. Peter Fotinos:Peter, that sounds amazing. Well, I'd like to see how that progresses. And lastly, I always have to ask my guests, especially guys that are so invested in men's health, what is your daily non-negotiable? What do you have to do to be Peter Fettino's? What do you have to do every day? You know, I've gotten everything from meditation to prayer to music, but what makes you you that you have to do?

56:32Dr. Jesse Mills:Two things, if that's okay. Of course. Pray at night. Always in my mind, and it's because of my parents, you know, I'm Greek Orthodox and just sit there and, you know, ask for forgiveness for myself, my wife, protect my parents. And every morning I tell my wife, I love you.

56:52Dr. Peter Fotinos:Oh, wow.

56:53Dr. Jesse Mills:I know that's hard with the call that just came in. But it's great.

56:59Dr. Peter Fotinos:I was looking out for you, brother. I love it. Yeah, I do exercise.

57:03Dr. Jesse Mills:I do everything. You know, I work out. I mean, I do everything I preach. I even take four milligrams of estradiol from you guys. There you go.

57:12Dr. Peter Fotinos:There you go. Yeah. So, no, I think you should love your wife because we know that married men live longer than single men and married women die sooner than single women. And so we literally take the life out of our female spouses. So I too, I'm grateful for that every day. But man, you've done it all. Peter, this is so great to have you on the mailroom. You delivered, super excited to be your colleague and to continue to watch how everything grows, the advocacy you're doing as well as just the boots on the ground, taking care of our guys, especially taking care of our veterans and active duty soldiers.

57:46Dr. Peter Fotinos:So thanks so much. I look forward to seeing how things go. And yeah, maybe I'll hop on your podcast as well, and we'll continue the conversation over on your channel. But Peter, shameless invite, I know. But I'm looking forward to continuing our conversation.

58:01Dr. Jesse Mills:I might have another invite for you, maybe related to the Society of Proactive Medicine. There you go. I might have you talk to Nikki and Dr. Rosier and see if you might want to come on board and help us.

58:12Dr. Peter Fotinos:Well, let's see what develops. Thank you so much for your time. Stay warm out there in North Carolina. Jordan, put another sweater on, brother. It's going to get better.

58:20Dr. Jesse Mills:Another pot of water on the stove.

58:22Dr. Peter Fotinos:That's right. Have a great rest of your week, everybody. Look forward to seeing you next week. Take care.

58:52Dr. Jesse Mills:Let's talk about it Let's talk about it a minute The Mailroom with Dr. Jesse Mills was a production of iHeartRadio. It was executive produced by Jordan Runtog. It was edited, mixed, and mastered by Bahid Frazier.

59:09Dr. Peter Fotinos:And the theme was provided by Long Transit. If you like what you heard, please subscribe and leave a review. For more podcasts from iHeartRadio, check out the iHeartRadio app,

59:19Dr. Jesse Mills:Apple Podcasts, or wherever you listen to your favorite shows. This program is intended for educational and informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Consult your healthcare provider for any medical or other related questions or concerns. The views and discussions aired on this podcast are those of Dr. Mills and do not represent the official positions of UCLA or UCLA Health.

59:57Dr. Jesse Mills:We'll be right back.

1:00:19Dr. Peter Fotinos:with Carlos King. And yes, Drink Champs will be in the building. Plus, you know, we're going to have a lot of guests. So you need to join us. And we got the Black Effect Marketplace to pitch your podcast and everything you expect from the Black Effect Podcast Festival. Tickets are on sale right now. Go get yours at blackeffect.com slash podcast festival. Don't play yourself, okay? Pull up.

1:00:44Dr. Jesse Mills:Then she says, have you seen a photo of my son? And I'm like, who is this person?

1:00:49Dr. Peter Fotinos:Welcome to the Boys and Girls podcast. Arranged marriage is basically a reality show, and you're auditioning for your soulmate. And who's judging? Only your entire family? I sacrificed myself to this ancient tradition, hoping to find love the right way. And instead, I found chaos, comedy, and a lot of cringe. Listen to Boys and Girls on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts. Come check this. iHeart and TikTok have come together to create something new. I love it. Where the world of TikTok meets your playlist. Three words that will change your life. iHeart TikTok Radio.

1:01:26Dr. Peter Fotinos:The biggest hits across iHeart Radio. What's trending for you on TikTok? Tell me a sound that's better than this. iHeart TikTok Radio. Plus TikTok's most influential creators all in one place. Search for iHeart TikTok Radio, make it a preset, and stay connected all day. This Women's History Month, the podcast Keep It Positive, Sweetie celebrates the power of women choosing healing, purpose, and faith, even when life gets messy.

1:01:53Dr. Jesse Mills:Love is not a destination. You have to work on it every day.

1:01:56Dr. Peter Fotinos:Keep It Positive, Sweetie creates space for honest conversations on self-worth, love, growth, and navigating life with grace and grit, led by women who uplift, inspire, and tell the truth out loud.

1:02:08Dr. Jesse Mills:I have several conversations with God, and I know why it took 20 years.

1:02:13Dr. Peter Fotinos:To hear this and more, listen to Keep It Positive, Sweetie, on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts. This is an iHeart Podcast. Guaranteed human.