The Truth About Low Testosterone (Part 2): Real Treatments, Fake Fixes

27:06The downside to pills is you have to take them twice a day, sometimes even more, and you have to adjust the dosing to get to the point where a guy feels good and his blood levels are reflected that he's in a good therapy state. Second thing is especially true in Santa Monica, where everybody's waify thin, that you have to take it with a little bit of fat. And so if a guy's on an intermittent fasting diet and he doesn't start eating until four o 'clock in the afternoon, your body won't absorb that because there's no fat in your gut to get into the lymphatic channels and actually get the molecule started to be effective.

27:42So you have to have a little bit of fat, not much, even a little bit of cream in your coffee, a little cream cheese on a bagel, something like that is enough. But ultimately there are some guys that absolutely won't take the pill because that's just not how they eat. So that's kind of the downside to it. But otherwise, it's very well-tolerated. They're easy. I've never seen levels go really, really high in guys and pills, and people feel pretty good. And there's about three different companies that have a pill that's on the market that is FDA approved. So that's another perfectly good way. In my practice, I do not have a large percentage of guys on pills, partially because it's hard to get authorized.

28:19There is a pill that is a cash-only model, so for about$165 or so a month, if a guy is willing to pay that, then that's a great system for getting good testosterone levels without really any risk and not worrying about transference from gels or the discomfort of injections. The wheelhouse, I would say, of my clinic, the number of guys that I see, especially just because a lot of guys see me once they've been to other clinicians and didn't get a good response to testosterone or the person didn't feel comfortable treating them, is going to be either injections or the long-acting pellets. And the injections are great because they last about a week.

29:02I can really predict where a guy's levels are going to be. And I can infinitely adjust the dosing just by teaching them how much to drop per injection. So my guys that are super motivated, they don't have a problem giving themselves a shot at home. They're also incredibly inexpensive. I can send them to any pharmacy or any mail-order pharmacy and really get therapy for 50 bucks or less a week. So even if they're paying cash, I can find injections that are very cost effective for guys if they don't have insurance coverage. And that leads me, I think, to the pellets, which, gosh, the pellets have been around pushing 50 years, believe it or not.

29:43But they come in two flavors. One is a compounded pellet where you go through a compounding pharmacy and you find a provider that inserts compounded pellets. And the advantage to those is they tend to be very cost effective. And the nice thing is that they last, from the insertion of the pellet, they last about three or four months before you have to go back in for another procedure. The other pellet is the only FDA-approved pellet. So I will say it by name because there is only one. It's called Testapel. And it's been in production, again, for decades. And the advantage of that is that it is FDA-approved.

30:21So you know that you're getting high scrutiny of the lab. You're getting a pure product. and most of the time insurance covers it. So that's the downside is that if you're paying cash for it, it's very expensive because it is a pharmaceutical, but most of the time we're able to get insurance coverage for it. And so for my guys that travel, I'm in a city where people travel all over the place. Sometimes they're going on set if they're a camera guy or anything in the film industry where they're going to be in Hungary or Atlanta or Turkey filming for three months at a time. Those pellets are great.

30:55They don't have to travel with any needles. They don't have to travel with a couple gallons worth of testosterone gel or bottles and bottles full of pills. They just come into my office a couple of days before they head to LAX and fly off to parts unknown. And they're in great shape for three to sometimes even four months in between the pellets. So that tends to be a really popular form of testosterone placement in my practice. What is the process like of coming off a testosterone treatment? Why would you want to? That's the question. I sound like a cheerleader. I think the truth is that most of the reason that guys discontinue testosterone, one is that it is a great form of male birth control.

31:37So if I see a guy that is on testosterone and wants to initiate a family or maybe have more kids, if he's in between, then we have to get those guys off testosterone in order for sperm production to pick up again. So let's talk about that first, because that requires its own special treatment. And that is, we have to reverse the effect of testosterone that is prescribed, so ejected or swallowed or gelled, on the pituitary gland. So what happens if I put a guy on testosterone therapy of any kind, his pituitary gland will shut down not only testosterone production, but sperm production. That's the way it works.

32:20And so I've got to figure out how to put jumper cables on the pituitary gland and get it up and working again. And thankfully, there's a couple of different ways to do. Well, there's three. And none of them, I should say, is FDA approved. One of them is au natural, so therefore FDA agnostic. In other words, I just say, stop your tea and come off it and give it a few months, and things will probably come back online. So that's not the preferred method for me or my patients because they're not going to be very happy. I mean, when guys come off testosterone, especially if they're well into that normal range and we start them on therapy for some compelling clinical reason, then they're going to have to start making really high numbers from zero to get back up to feeling well.

33:09So what happens? So what's the withdrawal of testosterone look like? Well, it doesn't take long for testosterone to get out of the system. So in other words, if it's an injection and you miss a shot after a week or two, you're going to be well under the normal level. If it's a pill, it'll happen after a day or two. Same thing with the gel. If it's those pellets, then obviously it takes much longer because they last so long. But eventually everybody hits bottom. and that bottom will look like they might get some night sweats, feeling kind of hot, cold intolerance, definitely some grumpiness, probably loss of morning erections that they were doing so well on for a while, definitely loss of libido, maybe even some weight gain if they don't turn around very quickly.

33:56And on a global physiologic health level, bone density will go down, their muscle mass will go down and all of these things take a little while to reverse. And so, so those are serious deals. And that's why I think your question at the beginning of our chat today was very important is that that would be a real bummer if I took a normal guy and over treated him. And he just said, I'm done. I'm quitting for whatever reason. He's going to feel crappy for quite some time, you know, maybe a couple months, three months even, and he may even have actually some medical concerning things happened to him during that time period.

34:33So that's the cold turkey method. I don't recommend it. There's no need for it. There are different ways to reboot that pituitary gland. And the two most popular are a injection, which is called HCG or human chorionic gonadotropin. And it's been around again for decades. And what that is, is essentially a maternal testosterone. So anybody that has ever been involved in a pregnancy and they do a pregnancy test or they go to the hospital or the lab and get a blood draw, that's what we're measuring is HCG levels. And what happens is that when a male fetus is developing, mom secretes HCG, which the male's body and testicles will recognize as testosterone that allows for testicular development and penis development, everything.

35:26That's sort of the beginning of differentiation of male into female phenotype or body type in utero. So we've known about this for decades. And so when we take somebody that's on testosterone, we put them on HCG injections. What we're essentially doing is we're inducing puberty again in these guys. And it's kind of cool because they feel better almost instantly. So if their testosterone is zero for whatever reason, whether it's from trauma, from surgery, or from going off testosterone therapy, as your question was saying, then we naturally stimulate their testicles to make testosterone based on this molecule of HCG.

36:12It is a peptide. And so your body will start to synthesize testosterone based on that interaction from that molecule. So that's pretty cool. And that works well. And it works within a few months to actually get sperm production back online. But testosterone levels go up almost immediately. So guys don't feel quite so horrible as they're recovering natural function. And eventually, if the goal is to get them to be not on anything, we start to back off on the HCG and see where their numbers really return to. The second that is even more used because A, it's cheaper, B, it's easier because it's a pill, is to take something called clomiphene.

36:53And clomiphene is a really fascinating molecule. We use it in women all the time as a fertility drug, and I use it in my male patients to stimulate sperm production. But that also works on the pituitary gland to tell the pituitary gland to make more testosterone and sperm and it does so through this crazy molecular pathway called selective estrogen receptor modulation. Many people have heard the term CIRMs and that's what clomiphene is. It's one of the early CIRMs. And the best way I can explain is that it gaslights the pituitary gland. So what it does is basically you take this clomiphene and the pituitary gland thinks, oh man, I'm not doing my job.

37:36And I got to make more LH and FSH, which are the only hormones that the testicle recognizes to help me make more testosterone sperm. And so basically by blocking the estrogen receptor at that level, the signaling to the testicle shoots way up. And that's another great way to restart testosterone production naturally. And as a side effect, it also restarts sperm production. actually. It takes longer. Guys don't feel quite as good on it for the most part for some nuanced reasons and hypothetical reasons in terms of what estrogen does in a male. But for the most part, it's a very effective way of restarting therapy.

38:14And I do something called the Clomid Challenge. Clomid is the old brand name for this. But the Clomifin Challenge is to put them on therapy. Usually after about three months, I stop it and I see what happens. And if their numbers recover, their pituitary gland wakes up and it's starting to produce good levels of LH and FSH, then I hope that their testicles start to produce higher levels of testosterone and sperm production goes up and everybody's back to where they were, no harm, no foul after this sojourn on the testosterone train. So that is why testosterone therapy, there's a bit of a myth that I hear all the time.

38:52It's not irreversible. So in other words, if I start a guy in T, a lot of guys say, Doc, I don't want to do this because, you know, what if I don't ever make it again and I'm going to have to be on testosterone the rest of my life? And I think I agree with you because I don't have a dog in this hunt other than taking care of you and making you better since I'm not profiting off of your testosterone prescriptions. that makes me so happy. If I can see a guy that, say, has low testosterone, but maybe is really overweight or not exercising or not sleeping well, or all of the classic eat, move, sleep paradigm of how to take care of yourself, if he's failing in those and I can get him on testosterone long enough that I can reverse that so that then he actually is doing it on his own, that's the best day in clinic ever.

39:38Because what I've done is I've empowered a guy through coaching and a little bit of pharmaceutical intervention so that we can actually eventually stop therapy. And that's a total win in the office.

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43:21I mean, speaking of myths about this that you're busting, here's another one. It's a rookie question, but there's something I've wondered about, and maybe listeners are too, and maybe people, when they come into your clinic, ask you the same questions. Is there a psychological, I guess I should say negative psychological impact of taking testosterone treatment? I guess I'm thinking about like essentially roid rage or something like that. Yeah. Polking out. Right. So it's interesting. You know, I say this a lot and I've done some expert witness work in the field too, but roid rage is actually a legal diagnosis.

43:56It's not a medical diagnosis. So in other words, like there's no level of testosterone that's going to turn the guy into Lou Ferrigno circus at 1981 or whatever. I was growing up watching The Incredible Hulk. It just doesn't happen. But the reason that myth started really is because a lot of this anabolic steroid rage that was going on in the 80s, a lot of those guys, and there's a couple of landmark key cases of bodybuilders, professional wrestlers doing incredibly horrific things, including murdering their families to get really dark really fast. Those guys were all on like crazy doses of cocaine as well.

44:35And so like, was it the Coke, you know, was it the Colombian marching powder or was it, was it just good old fashioned testosterone? So if you lay off the blow, then you're probably not going to get rage. But you do definitely have mood instability if you're not doing testosterone therapy well. So in other words, if a guy is on super high doses and then he comes off, that grumpiness, yeah, I can see how definitely men are much more irritable when their T levels are low, but not so much when they're really high. It certainly changed a little bit of our behavior, our prefrontal cortex, which is where things like the libido come in and decision-making.

45:15So guys that are on testosterone tend to be better, quicker decision makers. They get rid of that brain fog. And so all of that is certainly part of the psychological aspect of testosterone replacement is that a lot of guys will say, I just don't feel like me, or I've got this brain fog. I'm not thinking quite as clearly. And I will tell you that the reason urologists know this really well is because one of the treatments for guys that have advanced prostate cancer is to take away all their testosterone. We put them on pills and injections that will take their T levels to zero because that helps the prostate cancer or that stops the prostate cancer from getting worse or growing as, especially if we're combining it with something like radiation therapy.

46:01And if you look at those guys that have to be on temporary testosterone ablation, where they just, you know, they get their teeth thrown down to zero. They feel horrible when they're on this therapy. But then thankfully, a lot of times after six months to two years, depending on the treatment protocols, they're able to come back off of the androgen blockers or the testosterone ablators. And man, they feel great. And they're like, I don't know exactly what it was, but I just felt like I couldn't quite even finish sentences or thoughts. My mind was wandering. I was so grumpy. I just didn't want to be around myself.

46:37And so, so that's the extreme example. And those are great people to learn from because you know, then when you normalize their testosterone, either just through mother nature and they're coming off that therapy, or we actually start them on testosterone after their treatment, man, those guys are grateful. And all we're trying to do is get them back up into a nice normal range. And so, so yeah, I would love to pretty well kill the roid rage myth if we can today. Stops. Stops here, Jordan. Stops right now. Stops right now. Roid rage is not real. I can only imagine the people that are rolling their eyes at me and yelling at me right now, but I just haven't seen it.

47:19I think obviously if you do really good evidence-based therapy, monitor your guys really closely to make sure they're in a good range, then I think that's the key. And the same. So if you're the patient listening to this, then yeah, you want to go to somebody that's keeping a close eye on your levels and making sure they're right in that wheelhouse of a good range. So those are all incredibly effective treatments for treating people whose numbers are definitively low. I'm sure, or I shouldn't assume this, but I would imagine that there are edge cases where you would give people a certain window of trying to make certain lifestyle changes.

47:54What are some of the most important things that people can do to try to elevate their T levels naturally? First of all, what you can't do, which is take supplements. So there are, despite the gas station, or even gosh, I mean, God bless. I love watching my Dodger games, but I won't call out any, uh, any necessary supplement company for fear of defamation, but, but yeah, they, there's really no clinical evidence. We've looked at this, uh, of going on things like ashwagandha or fenugreek or maca or any of these things, there may be other reasons for those supplements that I certainly wouldn't want to step out of my lane there.

48:35But in terms of if you take a supplement and you look at serum testosterone levels, nobody's ever had a randomized clinical placebo-controlled trial that shows that T levels go up. But are you ready for this? Now, just maybe think of something else. I love teaching this. to medical students and even other physicians. When we were talking about the gel therapy, I just love this because I think this is why supplements work. And I think everybody realizes this. So this is not earth shattering. But when we looked at the original clinical trials, not the original, but the second formulation of gel therapy, which goes back to, I want to say like the mid 2010s or so.

49:21And you, we had two arms. We had guys that went on the study that went on transdermal therapy with testosterone, and then other guys that were just smearing hand sanitizer on their shoulders every day, because they were in the placebo arm. So it feels like hand sanitizer kind of smells like hand sanitizer. And so you look at the guys that were in the treated group. And the number of guys that had a really fantastic response where their numbers went into the normal range was, I can't even tell you the number, 89, 90 % of guys that were on testosterone therapy, the treatment arm had really good appreciable improvements in their testosterone.

50:04So here's, do you know what the number is of guys that were thinking they were getting testosterone, putting on hand sanitizer with no testosterone in it every day. Do you know how much their testosterone levels went up? Just give me a guess. I can make a multiple choice if you want. 30%. Damn, you're so good. 38%. Really? Yeah. So isn't that crazy? So if I tell a guy, like a guy comes into my office and says, Mills, I need testosterone. I'm like, ah, I don't know, this guy, I don't want to give him testosterone. He's fine. I'm going to give him this hand sanitizer, tell him it's testosterone.

50:40Then after I lose my medical license for practicing unethical care, the guy comes in. I'm like, guess what? You went from 350 to 450, man. That's amazing. Congratulations. So that's why supplements work a lot of times is the placebo effect is real. So that's why you can say guys clinically improved for this, this, and this. Perfect. But give me a randomized trial where you show how much more they improved over placebo. Nobody wants to do that study. So anyway, that's it. So stay away from supplements that say they're going to boost your T naturally because either they don't work or some of them sneak testosterone into it and you're actually taking T whether you know it or not.

51:21So there's no regulation at that level. The FDA doesn't get involved in supplements. And that's a discussion for a whole nother podcast that I'm not sure I even want to do. But that is the deal. So that's what you can't do. So what can you do? So there's a lot of great evidence that weight-bearing exercise and any good physical exercise, if you stick to it and have a really good routine where you're doing something at least five days a week, can actually raise your testosterone upwards of about 25%. So, again, you're empowering yourself. You're probably changing your metabolism. And there's a really simple mechanism for why that works.

51:59And that is that if you're overweight, then your body will convert a reasonable proportion of testosterone to estrogen. And that lowers your total testosterone because what happens is that pituitary gland, that rate, I said this was going to be simple, I promise it will be, that regulates testosterone production, it responds to high levels of estrogen as well. And so it shuts down and the signaling back to the testicle goes down. So if you start to do physical activity, improve your metabolism, then all of the testosterone you are already making, it gets to stay testosterone and it doesn't go into estrogen and confuse the pituitary gland.

52:40So good rigorous exercise combined with weight loss is a great way to naturally boost your testosterone. I will tell you probably the number one thing that sounds so easy and blissful and wonderful, but is probably the best way to naturally raise your testosterone is sleep better. So we know that when guys don't sleep, their pituitary gland doesn't sleep. And when the pituitary gland doesn't sleep, it stops sending the signal to the testicle to make testosterone. And so by just changing sleep patterns, and we're going to have to have some help teaching our audience how to sleep better, because as much as I love it and learn about it, we're going to bring somebody on that's going to teach us about that at some point in the future.

53:24That is the key thing, because when I look at a guy in my office that has low testosterone, I'm not just looking at their testosterone. I'm also looking at their pituitary levels. And the key one for testosterone, again, is something called LH or luteinizing hormone. And again, if you're going to your doc and you're talking about symptoms of low testosterone, it's a reasonable ask to say, hey, do you mind adding on an LH to this? Because that will be able to teach us, if it is the fact that the pituitary levels are low, that's a reversible cause of low testosterone. And one of the most common causes of that is poor sleep.

54:00So that's the two big ones. In terms of all of the little clickbait about these foods can improve your testosterone and all this nutrition. And really, there's not a lot out there. I think one of the ones that I chuckled at the other day that I clicked on, because I'm a sucker too, just like everybody else. And I'm a sucker with a high level of scrutiny. So I feel as if I'm doing this for my patients and my audience. But I clicked on it, and it was about sweet potatoes. And it's a really interesting thing because when you eat a sweet potato, your body just converts all of that over to carbohydrate and food and it's done.

54:35But the reason that that myth starts, I think, is that the way that most testosterone is synthesized, is made in this country, is through harnessing a molecule in sweet potatoes that looks a lot like the testosterone molecule, but it still has to be chemically altered to actually be testosterone. So you can eat 1 ,000 sweet potatoes, and you get 1 ,000 of those molecules, but unless you have the chemistry lab to convert that to testosterone, your body's not going to. But anyway, so yeah, I would stay away from foods that say that's going to naturally boost your tea because it just don't have a lot of data out there.

55:12So that's it. But I think the most important thing, and in fact, that's part of our guidelines, is sure, start with reversible causes. So if a guy is not sleeping, if they're dramatically overweight, they're not exercising, great. Right. Here's where I differ from the medical establishment to a certain extent is I don't know why we have to just do one or the other. Why can't we do both? And that's really how I practice. So if somebody is coming to me with all of the symptoms of low testosterone and I know they have reversible causes, I know that they need to sleep better. I know that they need to have better nutrition to lose weight and exercise more.

55:50But why can't I supplement that guy and get him on the right path? And I've been successful over 20 or so years of being in practice, of meeting guys where they're at, helping. And I always say I'm halfway a coach and then halfway an interventionalist. And the intervention is I will have no problem helping a guy with a prescription, with a testosterone management therapy, as long as they are doing something to reverse the underlying cause. Let's do it both, man. It doesn't have to be one or the other. Well, I think we've got to get somebody, a sleep specialist on that. Hell, yeah. That seems like the right way.

56:23No, I got a guy to go after this. Yeah, I got a guy. I think there's, there's a lot of really cool things that are simple, that are effective, that we can really get guys motivated to, to understand sleep and sleep better for sure. And, and then that's right. That, that would just be so amazing. And this is coming from somebody that did a decade of surgical training and slept two hours a night for six years in a row. And so I'm still catching up. I mean, I'm mid-50s. I've been out of training for over 20 years, and I still am catching up. And there's nothing as blissful of being able to sleep through the night.

56:58Sleep debt is real. It's real, brother. But that's it. I mean, I think so testosterone therapy, not that hard. the key take-homes are just make sure you go to somebody that is treatment agnostic. It's okay if they say, look, I think you're going to be better with this and here's why. Great. But if you're walking out of there, giving them a credit card and walking out with a bag full of whatever, just, you know, I'm cool with that because they may in fact have exactly the right therapy for you and it may be the right therapy, but just do your homework a little bit and make sure that that in fact is what is right for you based on what we talked about today.

57:36But yeah, Jordan, I think that's it. Just like everything, it's not that hard. Let's keep it simple. Be very mindful of your own health and make sure that you're asking the right questions. I guess before we let this topic go, do you have a favorite success story involving treating low T, a patient who made big changes and really turned things around in a remarkable way? Oh, man, I can think of this one guy, so many. I can think of this one guy because of the way he phrased it. But he was a accountant, I believe, and a professional, but a sedentary job, but very analytical, came in with reams of blood work over the years, came in with his diet, his sleep habits, he had everything.

58:22and also that he was referred to me specifically for testosterone, but he advocated, says, I want to go see a real specialist. So I knew his primary doc, well, he was a good doc. He probably could have taken just as good care as I could. But, you know, this guy wanted to have somebody that really knows their testosterone. So I saw him and we had to saw it probably took an hour just going through all of the risks and the benefits and everything we just talked about today. And we started him on therapy. and I remember him coming back after three months. He had just, he lost about five pounds, but he had been going to the gym.

58:57But the most important thing about this man, I remember so vividly is he said, Doc, you got me out of the cave. I just felt as if my body and my mind was in a cave for years where I just, it was just dark and sad and I didn't have the motivation to just get out and start to really live my life and to feel good about the next decade and the next 20 years and the rest of my life. And I think what that speaks to is, yeah, he did the physical things that he was supposed to do, but the psychological impact, the mental health impact of a guy that has low testosterone, and he doesn't know why, that we can turn around just with simple therapy.

59:42And in fact, I remember this, he was just on the gel. So after all of the shenanigans, I just put the audience through about how I can do injections and pellets and all this stuff. I literally just wrote him a prescription and he went to his corner drugstore, but that got him out of the cave. So that was exciting. And I followed him for years and he just continued to get better and better and good begets better. And I think that's the thing is that testosterone is not the answer. And starting testosterone is really a fraction of what you have to do to overall turn around your life. But it's an amazing and it's an integral fraction.

1:00:18And again, I think it's, you know, everybody that comes in and says, well, I want to look like that guy in the Marvel Universe. Well, A, you know, we don't know what his testosterone status is. But B, you know, you got to spend some time in the gym and you got to definitely spend less time in the drive-thru to look like that guy. And so those are not the guys that are going to be success stories. We have to break it down and build them up and use testosterone as one tool in the box. It sounds like it's a good starting point, which is why it was a great starting point for this series. Yeah, good starting.

1:00:50It's just a great entry into the conversation about just how to optimize your life and how to reevaluate where you are. If you're 18 years old or if you're 88 years old, there's always something we can do. if you want to do it, to make yourself a little better than you were the day before. Incredible. It's all good. All right, guys. Well, this is another episode of The Mailroom. Dr. Jesse Mills here. So great to join Jordan Runtah again for a little sojourn into the world of men's health and what's hot, what's not, what you should be doing, what you shouldn't be doing, who you should be listening to, who you shouldn't be listening to, and everything in between.

1:01:32So have a great time. I'll see you next time. Let's get some learning done.

1:02:03Let's talk about it in the mailroom. 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. And the theme was provided by Long Transit. If you liked what you heard, please subscribe and leave a review. For more podcasts from iHeartRadio, check out the iHeartRadio app, 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 health care provider for any medical or other related questions or concerns.

1:02:48The views and discussions aired on this podcast are those of Dr. Mills and do not represent the official positions of UCLA or UCLA Health.

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1:04:17Taking ZEPBound with a sulfonylurea or insulin may cause low blood sugar. Side effects include nausea, diarrhea, and vomiting, which can cause dehydration and worsen kidney problems. Talk to your doctor. Call 1-800-545-5979 or visit zepbounce.lily.com. And now, another appliance triumph from our friends at Grand Appliance. With two dogs, every wash load came out covered in fur. I went into Grand Appliance looking for a fix, and they recommended the Maytag Top Load with PetPro Hair Removal System. They had it in stock and installed it days later. And you know what? It really works. Lint rollers are a thing of my past now.

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