#274 - Performance-enhancing drugs and hormones: risks, rewards, and broader implications for the public | Derek: More Plates, More Dates

26:44So my patients, and probably most people listening to this are not bodybuilders, but I think there is a belief that growth hormone is the elixir of life. and there are no shortage of longevity doctors out there, which is why I bristle at the term when I'm looped into that group, longevity clinics out there whose basically sole intervention is giving you growth hormone. It's like, here's a bunch of supplements that are proprietary and whatever, and growth hormone. There are two responses to that. So if you look at the traditional medicine approach to that, what I call Med 2 .0, what you might call just sort of the evidence -based medicine guidelines.

27:25That group, which is the majority of medicine, would look at people doing that and say, that's the most dangerous, careless, unethical thing you could ever do. Those people are not doctors. Shame on them. At the other one, the spectrum, you have the people that embrace that point of view, which is like the other people are idiots. This is modern medicine. This is the future. We should all be on growth hormone once we reach a certain age. And I find myself on neither side of that because I simply can't come up with an evidence -based point of view. So my very naive point of view, which our acknowledge is naive, is given how many people are taking growth hormone.

28:02And it is quite ubiquitous, especially in sports, which I think we'll talk about. If there are really serious consequences to its use, even chronically, I feel like epidemiology you would give us that answer. So it's possible that no one's looking. It's possible that there is a signal there, but it's not large. It's possible that not enough people take it for long enough. There's so many explanations for why this isn't happening, but there isn't a clear signal. Conversely, I think that there are probably a lot of reasons why growth hormone chronically given exogenously, especially if it's kind of super physiological, could be problematic.

28:43For example, if you have a tumor that is growth hormon or sensitive to growth hormone, and it's already initiated, are you propagating it? So that would be kind of both sides of that. So let's go back to, tell people about what growth hormone is, where it comes from, what are the challenges of measuring it. Let's just do kind of a growth hormone 101. Yes, a growth hormone is, most people know it as like the primary hormone responsible for determining height as you grow and add a lessons, androgens are more sexual differentiation, maturation, but growth hormone and the subsequent growth factor production IGF1 will be a fairly significant determinant on if you grow to, I guess, like target height, whatever you could become.

29:25And it's pretty, during puberty, especially, pretty important for the proper development of your infrastructure, bone, et cetera, connective tissue. As you get into adulthood, it becomes one of those things where it drops significantly first off as you reach adulthood and as you get older, it drops precipitously as well. That kind of begs the question is this one of those things that you should be replacing to optimize function, fat loss, vitality, what have you. And it's tough because a lot of the proponents that assert such things have financial incentive. It's kind of hard to wade through the nonsense and kind of figure out what is the truth here.

30:04And it is often framed out to be like this fountain of youth elixir HGH. So it's so cost prohibitive. It's what all the pro athletes are using. This is the thing you need to be on to prevent any age related decline in, you know, own strength, your ability to burn fat as you get older is going to go down. So you need to be on a growth hormone, et cetera, et cetera. And at a bird's eye view, it's kind of responsible for the growth, broad spectrum growth of tissues as you grow up and then as you get into adulthood. It's not irrelevant, but it's far less important because you're not trying to push a human from childhood into adulthood essentially.

30:43And even when you have this push of exogenous growth hormone to manually manipulate your levels, after it's called epiphezial plate closure, there does not seem to be any benefit to be gained from enhancing like the length of bones, for example. You could still enhance bone mineral density to some extent and it seems to be, you know, you could enhance connective tissue integrity, it kind of depends on what your situation is and how IGF1 deficient or lack that are of you are, but it's not going to impact your height and adulthood. It's not going to really do anything other than regulate light -politic action.

31:21And how does it do that, by the way? Liberates free fatty acids into circulation. So it's kind of seen as the opposing hormone to insulin. Does it do that through lipoprotein light paste? Is it actually acting on a substrate with on the adipocyte? It seems to be driven through different baseline states that you're in, like if you have Garellen receptor agonism from being fasted, for example, a lot of people point to the literature on if you're deprived of calories. Oh, girl, the hormone goes up. There are different situations in which it will go up, deep sleep obviously, super impactful on if you're gonna have a release or not as well.

31:57But the main actions that I'm aware of at least in a state of growth hormone pulsation is kind of, the underpinnings are you are trying to liberate free fatty acids for utilization as substrate for energy or anti -catebolic action. So the actual like mechanism endomatically and whatnot. It's a bit fuzzy. What's the relationship then between G .H. and IGF and the liver? How does this all work? Because we don't really measure G .H. in people, right? Because it's pulsatile. So what are we stuck with as a proxy? Yeah, even if you inject G .H. a large dose of it, you will only see a spike in serum for a transient period of time and people who are trying to assess the quality of their growth hormone with the underground stuff.

32:46They specifically down to the minute to assess the quality of their stuff, but the best proxy for GH production endogenously seems to be widely accepted as IGF -1, which is after you produce growth hormone from the pituitary, there is action in the liver, but also pericure and autochroren action on muscle, especially if you are exercising, resistance training, but a lot of the serum IGF -1 is driven through liver production and has its own implications in terms of its effects that seem to be more intelligent in itself to some extent. Which is kind of counterintuitive, right? Because if IGF1 has intelligent properties which are promoting a fat storage and GH is promoting lipolysis, don't those act at odds with each other and how does one become more dominant?

33:38Yeah, it's this weird orchestrated feedback loop and these feedback loops are pretty in the body in multiple different hormone substrates will reduce in multiple different metabolites that then have negative feedback through different systems. And this seems to be no different if you have GH at a certain level, and it results in a certain amount of IGF1, you will have negative feedback that will then lower your production of HGH while the IGF1 is elevated. And as it declines, you have this decrease in inhibitory feedback that then tells your body, okay, now the IGF1 is not present and significant quantities, it's okay to release GH again.

34:17So it's this finely tuned balancing act in your body where your body has counteracting things. It's not counteracting, but it's like the balance between anabolic or anti -catabolic. Frankly, I don't even know how to elicit it like a super clear way that is completely accurate, but it seems to be, when one is high, the other one would be low and conversely in order to kind of maintain not necessarily at the same time, but to maintain a balancing act in the body. We have a real sense of how to dose, for example, testosterone or estradiol in the case of HRT for women, because we know what physiologic normal levels are during various periods of a person's life.

35:00And so if we're replacing testosterone to the level that we think is normal, either for your age or for some earlier age, we can measure the hormone, We administer it and we can do the calculation. Hey, this person has a lot of sex. Someone buying a globular or they don't or whatever the case might be. When people are administering growth hormone, and again, let's just talk about this through the lens of the context you're talking about it now, which is rejuvenation or longevity, the waist -basket term. How do they know? Because typically they're using about one to two units per day, isn't that the typical dose?

35:35Yeah, it depends largely on liver function too. with some people with compromised function or type one diabetics, for example, they could have super high GH production, but very low IGF -1 from seemingly lack of insologenic signaling because it also has a positive relationship with IGF -1 production. But it can be difficult because you could have a person on a ketogenic calorie -deprived diet model who has an IGF -1 that is on the low end of the reference range be manually administering growth hormone and be using a higher dose than would otherwise be necessary to get to high normal optimal function, put in quotation marks.

36:15That's the best proxy we have as far as I'm aware, is that serum biomarker IGF1, but there's not really a cut and dry way. So people would use the Z score presumably of their IGF1 as the output for determining how much GH2 admission. Yeah, my understanding is that regardless of its idiopathic short stature, GH deficiency, they would use IGF1 as a metric to kind of dial in the dose. So if your IGF1 is higher than the target, then you would dial the dose back accordingly, or if it's not high enough, then you would incur it accordingly. What did they target? A Z score of one to two, meaning one to two standard deviations above the mean is therapeutic, or just being above zero, for example, which means you're above the 50th percentile.

37:01The target, I think it's mainly just correcting, but as far as what is correct, I guess the reference range, if it's in the middle or the hind of normal, I don't recall off the top of my head, but it's something in the neighborhood of middle of a standard lab -corporate reference range as far as I know, could be off on that. Okay, so let's talk about the physiology of this. So you give GH, there's a feedback signal, because GH comes from the pituitary, but it's spoken to by the hypothalamus. So we're going to talk about this again when we talk about testosterone, of course, because that's a really obvious issue.

37:35What happens upstream of the pituitary, i .e. what happens to the signal from the hypothalamus to the pituitary to make endogenous, to make your own growth hormone when you take it from the outside? Does that get shut off as well? Yeah. The negative feedback that I spoke about briefly when you have elevated IGF -1, it will give negative feedback and there is an elevation, something called somato -statin, basically tells your body, don't make as much GH essentially. And there is different receptors, which gets a bit confusing as to how you produce the growth hormone upstream. There's the grellen receptor, which super confusingly is also called the GH receptor, I believe, it's also called.

38:17And then you have the GHRH receptor and the production of GHRH indoginously as well as the agonism of grellin receptors can both stimulate growth hormone and the way by which they achieve your end output can be different. That's why there's different drugs that target different receptors for actual elevation. Typically, GHRH drugs are coupled with GHRPs to get like a 1 plus 1 equals 3 effective sorts. But this is why also when you are fasted or malnourished, you could have significantly more output via the growl and receptor agonism. And this is the same growl and hormone that plays an important role in management of hunger.

39:01Yeah, so for people who don't know, growl and is like, I don't know if it's the primary, but I think it's probably pretty accepted that leptin and growl and are kind of like the signals that you're full -verse hungry. So growl and receptor agonism is what would tell your brain you're hungry. So, for example, if you gave somebody a really potent girl and receptor agonist like Ibu to Moran is a commonly orally bioavailable GHRP, you use that, even if you're not hungry, you'll want to eat your pantry, like it's insane. So, that compound plus a GHRH will seemingly have a downward pressure on some matastatin activity and simultaneously increase the output from the pituitary to produce more GH.

39:48So you can kind of like max out your endogenous production through these peptides essentially. But those are the primary mechanisms involved. Like those three things is the Grelan receptor, GHRH, and then also some out of statin as a negative feedback. So if someone is just taking exogenous growth hormone, how long would they need to take it before they would start to compromise their own ability to make endogenous growth hormone once they came off? I think it's pretty quick. IGF1 elevations are not instant in the serum. You would see GH spikes in a matter of minutes. Like it's very transient in your system, very short half life, but the downstream.

40:28IGF1 conversion can increase over days and then stay elevated for days. And this is why IGF1 is a biomarker has been asserted to be a potential way to catch people doping further out than the HGH isoform differential. I say, which is the current accepted gold standard test that they use, does IGF on the state elevated for a relatively long period of time. Let's just say a person's on GH for two years, and then they stop it. Does the pituitary go back to making GH? Yes, seemingly. It seems pretty flexible in that. In that sense, it's different than LH and FSH and the testee's making testosterone.

41:11Yeah, and the reason for that, I can't help but think there's because there's multiple actions of the pituitary. It's not going to atrophy in the same way I would think and this is just speculative. But for example, people always want to know if I take anabolic sort testosterone replacement for years, but I don't take HCG or I don't take these fertility drugs, will I be able to restore fertility in short order and it seems to be like I use it or lose it kind of thing, where not necessarily, but it's more difficult to restore fertility in somebody with like severely atrophied organs that has not had stimulation directly for years versus the pituitary does multiple different things.

41:53So I can only imagine that the maintenance of output of other hormones and things are at least maintaining its flexibility to some extent, but super speculative. Let's talk a little bit about the use of GH in restoration of tissue during periods of healing. So I think there's some accepted medical use for GH and burn victims, for example, right? So if a person sustains a significant enough burn, the body surface area is burnt, I mean, that's one of the most catabolic activities that human can sustain, and therefore the reversal of that is one of the most anabolic demands that a human can sustain as an adult.

42:31What about during orthopedic injuries? So you look at a person who's having either elective or emergency surgery for an injury. So we've had patients who have had injuries, so like a torn bicep. We've looked at the literature found, I would say, at best modest, evidence suggesting maybe for that person an eight week course of antibiotics, steroids and growth hormone can aid in recuperation. The few times we've done this, we've seen great outcomes, but that means nothing. So anecdotal, we'd have no contrapositive or opposite view there. What would happen otherwise? So do you have any insight either from literature or from just the underground world as to what the use of modest amounts of growth hormone would look like in periods of rehabilitation?

43:22Yeah, it's more anecdotal because like you said, you could find very... There's just no counterfactuals to any of these stories. Yeah, and oftentimes, is when I'm talking about this stuff, I want to say it's not necessarily founded in literature, unfortunately. It's kind of a mix of extrapolations, rodents studies, anecdotes and humans, stuff like that, which is unfortunate. I would love to be able to make hard -hitting factual statements every time I say something on this stuff, but with GH anecdotally, it seems to be quite effective in rehabilitation. I think that it is worthwhile and in a cute timeframe.

43:56like that's where the ROI makes sense in my opinion. So I do see people, but again, it's not like you have a control of that same guy with the injury not taking it. So we can only go by what you discerned to be a reasonable, I don't know, recovery period. And then, oh, it seems like it's recovering quicker than you would have expected. Good, probably good. I think I've been told just like year and a half ago, I had shoulder surgery and really this is an operation. I had been postponing for 15 years until it got to the point where I sort of had to have it. And I really was so hesitant to give up so much because of the size of the tear in the labrum.

44:37It was gonna be four months before I could really do anything again other than very light movements. My plan was to take, I did a little bit of homework and came to the conclusion that a certain cocktail of Nandralone and Growth Hormone was gonna be the best cocktail. So I found that so interesting that you didn't use a base of testosterone with the Nandralone because you could effectively wipe out your estrogen with that combination. Interesting. Well, I ended up taking it for a total of one week. Yeah, I know this. Yeah. I saw that you're a post on Facebook where you've mentioned how you're, I think you had a blood pressure elevation and also, but glucose went up.

45:14My blood pressure went up. My temperature was up at night. Now, in retrospect, what I realized is, I think I was sick. I think I actually got an infection. So I don't need anything to do with the hormones, but I felt so bad on the hormones that I was like, well, I'm definitely not doing this. So I'm the counterfactual, I suppose, for not having done anything, which of course means I still know nothing. I still have no insight into what this is, but I do find this interesting. And like you, I do find it frustrating that this is a question that isn't studied. Now, I understand that there isn't really a financial incentive to study this because of course, it's not something that is a new drug.

45:49Recompetent GH has been around for over 40 years now, hasn't it? Yeah, it was like cadaver derived in the 80s and then soon they went to recombinant, I think late 80s or 90s. Yeah, so over 30 years it is a shame because I've talked to many orthopedic surgeons and To a person they also the same thing which is I really wish we knew the answer to this question It would really be wonderful to study this rigorously and know Could we make a difference in the outcomes of patients by using these things in a very narrow opportunity. And the other question I guess I'm wondering is because I can't find a clear answer to this in literature.

46:25Do you have a sense of the use of growth hormone in osteophenia? Yeah. One thing I can say circling back to the justifying if it makes sense or not. I think there's certain things you can use to discern if it's a better idea like baseline IGF1 or you somebody who is in a ketogenic diet and you're trying to recover from an injury simultaneously or you calorie deprived. There are certain things that could otherwise be significantly influencing your recovery capacity from a growth factor standpoint that you may be able to manually backfill that for another person. Some people naturally have IGFs that are like top into their reference range or if you were acromegally, had acromegally, you would not use GH obviously.

47:05So it's definitely context dependent or if you had insulin resistance at baseline or something, there are certain things that may otherwise sway you in the direction of the ROI makes sense first not. I feel like that should at least be said so people don't think it's a total blind role of the dice. That's right. That's a good point. And let's throw the same caveat in there. So let's say we're talking about an individual with osteophenia or osteoporosis. Let's assume further, you're going to do all the normal stuff you would do. So you're going to do all the things you would do nutritionally with respect to vitamin D, calcium, amino acids.

47:37You're going to increase load bearing activity, particularly strength training. if necessary, you're even going to bring on phosomax and the type of drugs that may help in that regard. But if in the context of all those things, an individual has a low IGF one, do you think, first of all, is there any evidence that in that setting, GH administration will improve bone density? Yes, I can say with almost near certainty that that literature exists. Even if it didn't, I would say almost without a shadow of a doubt that it would be worthwhile, especially in somebody with low IGF. I'd have to circle back and make sure the literature was not rodent and extrapolated, but I'm pretty sure that anybody, especially with lower IGF, one, you kind of get into the discussion of, can you even sustain adequate bone integrity, especially in, I don't know, old age where you might have, like you're probably most prone to that to begin with?

48:33Like it's almost certainly justified, I would say, in that scenario. Yeah, it's interesting. I'd like to find that and maybe we can include that in the show notes. I feel like the last time I looked, I didn't find anything that suggested not doing it, but I didn't find something that was a slam dunk home run. You mentioned a couple of peptides. So let's talk about these peptides that are upstream. So I can't even keep track of how many there are. There's like CJC1295, Samorra Lynn, what are the others? on the GHRP side, the easiest way to segregate these is by GHRP, GHRH. So GHRP are the ones that act on grueling receptor, GHRH are the ones that look very similar to GHRH and act on that receptor.

49:22So that's the easiest way to segregate them in terms of categories. And then from there, they are pretty different in how they affect things. For example, Well, IPAMREL and is often used in these anti -aging clinics and whatnot. But sorry, the GHRP ones are also going to drive hyperfagia. Depending on the compound, this is the weird thing about it. So even if you are stimulating the Grelan receptor, the effects on appetite are quite different. So for IPAMREL and for example, despite the fact that that's the receptor it's working through and it is a Grelan receptor agonist, it does not influence hunger.

49:59to even any reasonable magnitude with the striking distance of MK677 Ibuda moron. That difference is literally like you eating 2000 more calories a day, not by choice, but you're just starving per patch. So it's almost like it's inducing Praetor -Willie syndrome or something, which is a condition where you have uncontrolled eating. Yeah, like the will powered necessary to avoid overeating on MK677. So what's the clinical use case for that? Is that used in AIDS wasting, cancer wasting, and things like that. Orally active, so adherence is much more reasonable to expect. The application, it's not FDA approved by the way, but it is for GH deficient children, I believe, and we've seen restoration of IGF to the top end of the reference range when using it, so going from, I don't know, like a low end IGF to a 200 to 300 or something.

50:51It's not gonna push you into super physiologic territory because it's working through your endogenous capacity, but you can kind of max out what your pituitary output potential is. So similarly to a HCG or something, you can kind of manually at least stimulate natural production to the upper threshold of your capacity. It seems to be efficacious in that, but not going to have a high application among adults who don't need an extra 2000 calories a day. No, but it also depends because some people maybe have low appetite and you want to gain weight or you're in a state of recovery and your appetite is suppressed from some other drug you're using because that's fairly common.

51:31Depends on the context. So what is the FDA approved indication for this drug? It is for GH deficiency and adolescents, I believe. Even though it's prescribed among clinics and whatnot, it's not, I don't even think it's achieved FDA approval yet. It's like in phase two or three. So how is this oral? How does this peptide survive the gastric environment? That is a great question, but it is the only one I know of that is often referred to as a efficacious option in this laundry list of GHRPs to restore IGF1 to high end normal. So how the actual pharmacokinetic profile looks, all I know is the half -life is like 24 to 36 hours.

52:13And it must just be enterically coded. It's not hepatotoxic from what I remember. It's got to be something that it just survives through coding, like you said, or something of that nature. Any other GHRP's that are worth discussing? Yeah, I think IPemarellin is probably the one most prescribed in clinics, and that one seems to be probably more targeted in the outcomes you'd want to see out of like a growth hormone releasing peptide in that you get enhancement of sleep, doesn't make you hungry really, even though it operates for the same receptor pathway, definitely increases IGF1. It is, is FDA approved.

52:54I believe it might be for lipodistrophia. It might be Tessa Moralin. But these are the two eye pemeralins, the primary one that is prescribed. And then there's a bunch like JHRP6, JHRP2, which significantly impactful and hunger. JHRP6, probably the worst one. That's what bodybuilders use when they reach a bottle neck of food intake can't eat anymore. They will MK677's around the clock with GHRP6. After you inject it, it's like you can modulate acutely when you're hungry. So if you had a eating contest to win or you were going out for an all -you -can -eat buffet or you're just a bodybuilder who can't eat your 5 ,000 calories a day, that's when you would be.

53:31You'd see it's like disgusting, as I'm saying it. No, I just, I mean it's, uh, yeah. There's so much to unpack there. But IPemrallin is the one that is prescribed most often the other one. And that's a daily injectable. Yeah. And so is that used by athletes and bodybuilders? Yeah. Fairly often. Is it cheaper than growth hormone? Yes. Yes. Depending on if you get the growth hormone under ground or not, through pharmacies certainly, but there are generic growth hormone preparations that are pretty cheap now. Well, you could get a hundred IUs of pretty high quality HGH from China for 150 bucks. By comparison, what would that cost at a pharmacy?

54:13I'm trying to think. Thousands? Yeah, I mean, it's insane. Yeah, especially if it's like a big brand name. Like, back in the day, people would go to AIDS patients and convince them to sell their serostin. That's what bodybuilders used to do. Okay, so when the GHRH side, who were the big players? Testimoralin and Somoralin, but I would say Testimoralin probably more commonly. Somoralin seems to just... people just don't really get the results they want out of it. And it's more anecdote than any kind of literature that points to it being sub -efficacious. But Testimoralin plus IPemoralin is kind of the primary combo utilized in clinics especially nowadays.

54:53So they combine them. They'll combine Testimoralin with IPemoralin. Yeah, typically. And there's also, there's like the CJC 1295 and there's with drug affinity complex, which is basically extends the half -life significant length. And CJC 1295 is which one of these? GHRH receptor. And then there's a shorter version of it. It's like mod GRF 129. These are not FDA -approved compounds. These are literally the Wild West of compounds. Samorra linen, Tessamorra linen are FDA -approved, I assume? Yeah, some of them have, I know one of them in particular is approved for lipodistrophy, and there are some unique applications in which some of them have FDA approval, but most of them, the GHRP6, GHRP2, Hixor and I believe, and a couple of the GHRHs on that list do not have FDA approval.

55:44And MK677 as far as I know is like, off label prescribed. It's kind of weird because there's no company that makes a branded, you know, FDA approved version of it, but then compounding pharmacies will still make it. There's a lot of questions as to, well, what are the standards that go into making it then and are you just ordering it from China similarly to an underground lab? Yeah, there are no standards. I mean, there are no standards. That's the whole point of compounding, right? Is they can make anything. I mean, at this point, the real question is, where is the line between, if something has a grasp designation as general regarded as safe by the FDA, you can sell it on Amazon.

56:18It's an over -the -counter. What's the most potent, grass thing out there's probably DHA. In other countries, DHA is, I think appropriately treated as a hormone. I think it's a scheduled one in Canada. Is it really? Really? Wow, interesting. Why? I don't know, because actual steroids are not as as regulated. That's amazing. Yeah. Yeah, but in the US DHA, amazingly, is over the counter. So that means it has a grass designation. I'm guessing that CJC 1295 does not have a grass designation. So that means you cannot sell it without a prescription. but yet it doesn't have an IND. It's not an investigational new drug.

56:54It hasn't gone down the pathway of an approval. I think it's just sort of in this gray area. Some of them are abandoned. It'll be like a drug that was in a pipeline. So maybe there was an IND and it got scrapped. Yeah, so it's like sometimes is it financial? Is it lack of efficacy? Is it some like in some cases, there's a drug called Carderain, it's a PPR Delta Agonist, which is actually pretty good results on lipid management. It's kind of like one of those exercise mimetic drugs, but when you look at the metrics that it improves It looks great But then there is some rodent study It was like every dose of carderine Resulted in cancer in these rodents and then I guess the response to that was a public outcry of you know worry concern et cetera, and I just no Reason why publicly it got scrapped but it's weird because it was like preclinical rodent literature sure, supposedly cause like to get canceled after it was already in phase two in humans.

57:52So it's like some of this stuff and cardorine is prescribed through clinics too. But yet all the rodents who took it got cancer? Yeah, every dose. I mean, that would be disconcerting. Yeah, for sure. Okay. So again, talking about this through the lens of I have one patient by the way who came to me having been prescribed some oral and from the outside. I asked him to stop because I was like, look, I'm not going to take over the prescription on that because I don't know anything about it. So he did. And like, I don't know, a year, a year and a half later, he's like, look, I really want to be back on this.

58:27I've just never felt the same since I was on it. You know, it just gave me such a feeling of vitality and hit a lot of reasons why he felt it was the thing to be on. And I said, look, man, I'm not going to be that guy who says no, just to say no, but I need to understand this a little bit more. And I think we need to think through one of the risks and benefits of this. And so we kind of negotiated this back and forth for six months where I said, look, I guess if we do a bunch of really good cancer screening and can convince ourselves that you don't have cancer, you know, we do the Pranuvo, we do a gallery blood test, check a colonoscopy, like basically to the level of detection of our modern technology, you don't have cancer at the moment.

59:09I'll be happy to find an an endocrinologist who's more comfortable with the dosing. And we did. So we found a great endocrinologist and she was like, okay, and he went and saw her and she's prescribing it to him and he's as happy as can be. There's not a judgment around this. It's, I'm genuinely curious. I still can't make sense of would you want to be on Somoral and Testamoral and it sounds like you're saying test is better than Somoral and her, but that again could just be anecdotal versus growth hormone. And then of course, I never really understood the stacking where you would start to stack both compounds.

59:39So, do you get the sense that hitting both targets, both receptors is better than just using GH? Does it give more specificity? One thing you could say for certain is when you push endogenous production, you are fulfilling the full production of all spectrum of variants. So there's different kill adult and iso forums of HGH and they detect it in doping. And these variable molecular weight, growth hormone outputs that you get from the pituitary, We don't know why they are put out in different formats, essentially. Like for all we know, they have different actions in the body that may not be facilitated by the recombinant straight, like 22.

1:00:21So when you take a recombinant HGH, you are telling your brain, don't make more essentially. So you are actually losing the production of those other variants and you were relying entirely on this one. So what the implications are of that from a health perspective or a performance, what have you. Obviously we can manually push your IGF to superphysiologic, which you will not be able to do with the endogenous kind of up regulators of sorts with the peptides. And you can kind of manually just choose where you go with it. So there's certainly a case to be made just like with testosterone. It's like, oh, why would you use a GNRH agonist or why would you use a SIRM or why would you use an aromatase inhibitor?

1:01:01We'll have you in modulate these upstream pathways when you You could just take the straight hormone and manually pick where you land. And oftentimes I could need the reasonable answer, especially for somebody who wants like a very targeted end goal and knows exactly where they want to land on their IGF or doesn't need or potentially as worse output relative to the input of those peptides because again, it's working off your natural capacity. So there's definitely potential pros and cons. You can, if you have good functioning, entire hypothamus pituitary, all the output is satisfactory from an infrastructure standpoint to output natural hormones at an adequate level.

1:01:41The natural peptides may be useful and you know you're getting all the variants of all the kilobalt and molecular mass variants, but with exogenous, it's just like, you know, exactly what you're getting. You can manually choose what you're getting out of it. and I think it's more could be reserved for people who don't have the natural output that they are trying to get out of the peptides. They don't respond that well. Or there's just more data too. So is there kind of an analogy here where taking growth hormone, exogenous common growth hormone, is like taking testosterone, whereas taking the peptides is like taking clomid.

1:02:18Yeah, I would say with exception that you're not blocking negative feedback, you are positively modulating it. Correct. Climate works by creating a block. Yeah, so it would be like analogous to probably an HCG and recombinant FSH or more like a HCG probably, or combined HMG or something. What does the literature say and what does the non -literature say about the role of GH alone, not in combination with anabolic, in terms of its capacity to help build muscle and oxidize fat. The literature is so sparse on being able to say without a shadow of a doubt that it is going to enhance muscle growth potential and performance especially.

1:03:08There are very few studies that really show a clear enhancement of athletic performance. So I think what is clear in the literature is the body recomp effects. You do gain lean mass. Part of that presumably is water retention. You do lose fat mass, right? Yeah, and for like lipodistrophy if you're able to, I don't know, liberate free fatty acids and be able to actually improve your utilization of substrate. You could absolutely improve your body comp fairly significantly with it. But when it comes to actual protein synthesis muscle accrual, it's very wishy washy. And certainly not something that you should hang your hat on as the reason why you're taking it in my opinion.

1:03:56So from a muscle growth and athletic performance perspective, the jury is out in terms of if it does anything significant enough to justify its use. Bodybuilders will claim to high heaven that it's something. It's an expensive fat burner and some think it's actually quite useful and they notice huge changes. but it also very much depends on your response from a fluid dynamics perspective. It can definitely increase sodium retention and things that you may interpret as muscle growth. That may just be volume. And with that said, the muscle is how much water at the end of the day. So is that to be ignored from a cosmetic perspective, it certainly looks to get on a body -building stage.

1:04:33You might not have the function. Yeah. So you may not get enhanced force production outcomes like you would be seeking from like a true and a ball of agents, but it doesn't improve cosmetic appearance of muscle almost certainly and can help you improve your body composition, especially if you time it well with. Because if you just use it and liberate free fatty acids and sit around and do nothing, you could just redistribute that and not necessarily get the benefit out of it that you're seeking. So do you think that the liberation of fat is the more reproducible finding of GHUs? Oh yeah. You know that's happening when you use it for sure and you will become acutely insulin resistant as a result of that too So based on that knowledge when is the ideal time to take it?

1:05:18Do people take this once a day twice a day? Depends on the dose because if you're using a very high dose and it also depends on your lethargy from it. It is very Lethargy inducing you could feel sleepy all day if you're blasting a high dose of it. What would be a high dose like what you were taking six to eight? Yeah, I would say when I took it, it was mostly in the two to four. Are you range? I only did six to eight for like a very short period of time. Even that, the lower, lower, but still pushed me to like a 500 IGF was lethargy inducing for me personally. For how long? Man, that was so long.

1:05:55I had tried it for full durations of cycles, so you know, upwards of a few months was probably the longest I had taken it. Did you have lethargy the whole day or was it just like if you took it in the morning you'd feel that way till noon Then you had to work out in the afternoon to get around it What the dose as I was using and splitting it up the way I was it was Pretty around the clock. Why is that it seems to have a very Intertwine connection with sleep. So you have your biggest GH pulse when you're getting to sleep and people find seemingly pretty positively correlated with aging, you have a decrease in IGF and seemingly deep sleep metrics also decrease precipitously too.

1:06:38And I think this is the biggest case to be made on potential attenuation of cognitive decline as its impact on sleep if you're somebody who gets significant enhancement in deep sleep metrics. However, you want to track that. I can't imagine you can extrapolate from there that it's helpful for somebody who has, If you have a crashed IGF and you have horrible sleep as a result of it, there's clear literature to show that IGF deficiency will impair sleep. So if you're able to correct that to some level, the minimum effective dose, you don't need to push it. But you're saying with a higher IGF, you were more lethargic.

1:07:11You would think that you'd be sleeping better based on that argument, right? Yeah, probably. It's also gets conflated with bodybuilding diets too, because typically when you're using it, you're in a calorie surplus trying to gain a bunch of muscles so you could definitely like conflate those findings a bit, and it is anecdotal. But in general, people using peptides even and growth hormone will often find that their sleep is seemingly enhanced, like it's deeper, more restful. And yet they're more lethargic during the day. Is it possible then that the GH is inducing too long asleep? So you sleep a lot at night, but then it's carrying over to the day.

1:07:48Like there's a hangover of sleep? Potentially for sure. Like it seems to be a hormone that is quite it rejuvenative during your sleep. And I can't imagine not that I really read into like ancestral history or how your body functions relative to the ancestors that much. But it's like the time you are trying to recover and rest the deepest having the highest spike of GH. Like it seems to be, I think it's something you could at least extrapolate as a interesting anecdote. Nonetheless that I can understand why I might be tired when the deepest point of rest is also the time that this is simultaneously the highest endogenously.

1:08:27So if I'm manually creating at least half of the conditions that are associated with when I would otherwise get the deepest sleep, maybe I can manually induce that myself if I'm deficient or what have you. But as far as timing and the justification for it, it depends on if you were trying to use it for liposis or if you were trying to use it to a hand sleep or what the conditions are because you are going to be suppressed at a certain level regardless. So oftentimes the logic would dictate at least in my opinion that you would probably put part of your dose before bed, given that you're not going to get the same output when you're using exogenous GH.

1:09:06So if I'm using, let's just say all of my GH in the morning and then I'm going to exercise to try and use the fat. Yeah, which is not a bad idea. There's definitely a, at least I I think a justification that part of that dose or potentially all of it when your IGF1 or GH output is suppressed that you would actually allocate your dose to pre -bed. So it depends on goals too. And if you notice an enhancement of sleep or not, but you can say without a shadow of a doubt that feedback loop will suppress your natural output. You're not gonna just get the best of both worlds. And so would you say more people today would be using the two receptor approach, the two peptide receptor approach rather than GH?

1:09:49Is that a more common approach today? I think among those in the clinics, for sure, because it's less cost prohibitive, that's what I think. But in the underground bodybuilding world, they're typically pushing super physiological IGF -1 levels. That's their goal, that's what they wanna get out of it. So they typically try and find pharmacore GH, and if they can't get it, they will go generic, if they also can't afford it, and that's what they're doing. They're pushing IGF to 500 and more. Yeah, typically. Like that, it would be a minimum adequate amount for performance enhancement, quote -unquote performance enhancement, would be deemed higher than what is naturally achievable based on typically a lab corporate reference range is what most people would utilize.

1:10:33Let's detour for a moment just to talk about bodybuilding before I want to kind of go back and talk about antibiotics and then maybe this will be a nice dub tail into it. So in my gym, I have a lot of pictures of bodybuilders and nice black and whites that I enjoy. And there's just a real clear difference between Frank Zane, Arnold Schwarzenegger, Sergio Oliver to Jay Cutler and Ronnie Coleman. And I don't know when that jump took place. Maybe Leigh Haney, maybe Dorian Yates, but somewhere in there, there was a real transition in physique. Not to debate which of those is the best. I think everyone can have their own preference for which era of physique was their favorite.

1:11:14But if you sort of think of the things that can impact your physique, genetics, okay, that's not changing. Nutrition and knowledge of nutrition, that's clearly evolved. Training and knowledge of training, that's clearly evolved. Drug use, that's clearly evolved. And then maybe just even injection. I've talked to bodybuilders today who say that they're actually injecting compounds in their muscles to alter the shape. They're injecting like fats into muscles to actually create some sculpting. So that again, that's probably something new. Let's put that one aside. Of the three evolution of training, evolution of nutrition, evolution of drugs, how would you rate the relative balance of those three for the difference of a 1970s physique versus a physique today of the best bodybuilders in the world?

1:12:01Probably drugs at the top, almost certainly. followed by, I would say nutrition probably, and then training at the bottom. How much emphasis on each of those, like 50, 40, 10? That's tough, because these get scrutinized to hell, because it's like, I'm gonna put a number on it. People will be like, how do you think diet is only 20 %? Yeah, yeah, yeah. A lot of these things don't live without the other, so you could definitely lean heavier and say, well, if you eat nothing, the drugs aren't gonna do anything. So, I would say just in order of importance, If you did perfect diet, perfect training with all of the modern knowledge that we have now, your ceiling for muscle growth potential could be as much as 50 to 100 pounds lower as a natural, depending on height, depending on genetic response.

1:12:48By the way, I don't want to forget on the GH stuff. One thing that is interesting is even in acromegalic patients, the incidence of death seems to be cardiovascular significantly more than cancer incidents. So if there's anything to discern from actual human literature, significantly chronically elevated IGFs into even 40 years old, these individuals are dying from congestive heart failure and things like that. And that's really interesting. So not even atherosclerotic disease. I have to look into this. Actually, that's a very good point. I should look at the acromegally literature. One of the interesting things is how much fluid retention they hold and the stress that has on the heart, too.

1:13:27Yeah, that's very interesting. They also probably would be, I'm guessing maybe more prone to aortic dissection because they probably have larger connective tissue, things like that. Yeah. Okay, so you're putting drugs at the top of the list and then nutrition and then training. I think it was the order you had them in. So let's talk about the drug use. So I've spoken to 70s bodybuilders and if they're being honest with me and I have no reason to believe they're not. You would think. Yeah, like what have they cared? I was shocked at how little drug use was going on back then amongst the best of the best.

1:14:01And we're talking like one to 200 milligrams of testosterone a week, eight weeks at a time, eight on eight off, eight on eight off. In other words, they're basically taking TRT. Yeah, they're not telling the truth. Okay, so that's your view. Most of them, almost certainly or not, when you're saying you're taking a borderline, female HRT dienable dose, it's like back then that's what it was prescribed for, or like muscle wasting and old age or whatever, some of the old like sepidionable ads are hilarious by the way, but those dosages are almost impossible to wrap your head around producing outcomes that they are like you might as well have stayed natural at that point.

1:14:44So I too bought into the idea of oh they seem to have consistent stories, they seem to of all taking one shot of Primo week and one to two dianna ball or what have you. And it's just not an outcome that you see as reproducible ever in those dosage quantities. So maybe on the hyper extreme outlier scenario, you might have a guy who a total weekly dosage of a few hundred milligrams across everything he's using. He may hyper -respond and get huge, but I would say the majority of the guys competing at the Olympia level were still, like I've heard of people slugging debol by the bottles. even back in the 70s.

1:15:20Yeah, it's just certain people are more outspoken about their abuse than others seemingly, and it seems like the ones that are outspoken are more like this guy Pete Grimkowski. I don't know if you've heard of him before, but looked incredible, but the guy used thousands and thousands and thousands and milligrams, and I can understand why you would arrive at that logic to take that because there was nothing to tell you otherwise. So if you're competing against the guy at the highest level and there's relatively high stakes, You see a guy like Arnold getting movie roles and stuff. It's like the peak of achievement as a bodybuilder back.

1:15:53Then you couldn't do social media. It couldn't do anything. You would try and emulate presumably what he was doing or something of that nature to think that you're not going to escalate your dose past one to two dionibol in a shot of Primo or what habit or a shot of Nandrolohn because you didn't want to hurt yourself. It's like, shut up dude. Yeah, I feel like I saw a video kind of recently of Tom Platt's discussing. He's changed the story. Yeah. With that said, his original breakdown was relatively conservative still, but he's done public presentations about drug use back in the 80s, 90s. And you could tell he was pretty reserved even back then.

1:16:30He handled the situation very delicately. You could tell he was picking his words carefully as he spoke. But more recently, he came out and said his dose was like, I don't know, a third of that or something. And it's like, okay, maybe like, you know, in 40 years or something, I don't expect you to remember exactly what you took But the Savior peak dose was one third of what it was. I don't know like I just I just don't really believe you Well at the other end of the spectrum I've spoken to one bodybuilder who and I couldn't believe it But he said at one point he was up to are you ready for it?

1:17:04Yeah 50 grams of testosterone Brownie in a week. That's not there's no way. You would not inject that much. I was like, how is that possible in running of injections? How are you managing? I think a lot of people just don't know what they take to. Oftentimes you just ask people on TRT even, what's your dose? Well, it's like, you know, a pathos. We noodle with patients between 100 and 120 milligrams a week. Like literally, we will make movements that fine. 20 milligrams a week. Yeah, I think a lot of people that just go by, oh, my doctor told me to take this much of a syringe and then they kind of just remember some rough number, but oftentimes they don't know how many milligrams per milliliters what they're using is, they don't know what their dosages, they just take some scheduled protocol and they stay on it for years and then they don't even know what they're doing.

1:17:55But 50 grams is like, it's impossible. You would have to dedicate your life to injecting essentially. That would be your full -time job just sitting there pitting like five to ten C .C. barrels of tests all day. Oh, God. Given how remarkable the physics were in the 70s at the top of the food chain in the Olympia, would you agree with me that something dramatically changed in the late 80s, early 90s? Yeah, and it seems to be the emergence of growth hormone and insulin abuse, as well as the escalation of drugs to an even more extreme magnitude and the availability potentially granted they were prescribed readily seemingly, but people also seemingly push the limit more and there's the emergence of underground lab preparations and things of this nature.

1:18:42So my understanding at least is, and there's no literature to document, oh, you know, this dosage equated to this. And therefore this is why it happened, but it seems to be dose escalation of antibiotics to some extent, but more so the implementation of growth hormone coupled with exogenous insulinius. They're using insulin because of how anabolic it is. Well, the goal is what they think it is. And obviously if there's terminology that may not be exact on that, but it's like what they believe it's doing is shuttling a super physiologic amount of nutrients into the muscle because also when you take GH, you are acutely insulin resistant.

1:19:22and so need a little insulin to overcome that. Yeah, they're almost like doing both things at the same time as the goal. And often when you're using really high doses of GH, fortunately this isn't as problematic in replacement dosages, so I don't want people to extrapolate out, oh GH equals chronic insulin resistance necessarily, but at the dosages people are using, they could induce diabetes essentially, like you could end up a diabetic from just your GH abuse, and oftentimes to relieve stress off the pancreas in the beta cells, they will use exogenous insulin so you don't have to produce as much endogenously to actually acclimate the amount of carbohydrate intake and just overall nutrients because these diets to maintain a 300 pound of physique you're pounding 5 ,000 calories a day sometimes.

1:20:07So the introduction of growth hormone with all of its benefits presumably, which we've talked about, it's funny because right as we finish talking about how it's not progressing, Now, the thing that causes the 20 to 30 pound lean mass jump is supposedly GH and insulin. It's interesting to say the least, but continue. Well, I was gonna say, so we have that issue going on. You've also talked a little bit about, so my belief used to be all this GH and insulin use is why we're seeing these big abdomens on not just bodybuilders, but also on athletes. So you'll see track and field athletes who are insanely muscular, insanely lean, but they have huge protruding abdomens that do not appear to be fat because you still see a six pack ripped on top of it.

1:21:01But from the side, they look pregnant. And again, the thinking was, well, is this just organomethally? Are there organs just getting bigger? Now you've talked a little bit about an alternative hypothesis. Yeah, I think it is multifactorial, but there is seemingly, I think the largest cause of it now is significant distension caused by the excessive food intake and the result of significant gastrointestinal issues that result from the absurd diamodils because to get that many calories in, get that much protein carbs off in, especially peri workout when you're using insulin and you need to make sure you don't go hypoglycemic in your workout, they'll be slamming like 100 to 200 gram shakes that have hydrolyzed way in the branch cyclic dextrin plus amino, plus creatine, plus glutamine, plus of this.

1:21:55And oftentimes, they're essentially in a state of like I'm sure you've had a cheat day where your stomach was incomparable to days when you're fasting, for example, it's a massive difference. It's fasting, you could do a vacuum and see completely invert your stomach almost versus when you have a giant cheat day and just go off the rails, you couldn't keep your stomach in for the life of you. You have to be flexing just to keep it not looking like you have a gut when you're sitting down. That is a perpetual state of reality for bodybuilders who weigh that much to sustain that food intake and the physiques that they have because it's not a normal amount of muscle to hold so it requires a not normal amount of food to accommodate the nutrients required to grow further or even like sustain it.

1:22:38Good example of that as Ben Pekulski. He makes, I think, more health -focused content now, but he's a former high -level IFB pro. I think he won the Arnold Classic even at one point, and one of his biggest criticisms was his distended gut. And you know, for certain, the guy was using all the same drugs everyone was using at the high level, but he was able to reverse it seemingly in a relatively short period of time in his latter part of his career, by reducing his food intake significantly seemingly, and he actually showed up one year later with a vacuum on stage, which is a vacuum for people who don't know.

1:23:18I don't even know if I could explain it, but it's like you suck your stomach in, and it creates like an almost like an inverted, it kind of goes in, you can see your ribcage and like your serratus lines and stuff. And most bodybuilders wouldn't be able to do that nowadays. No, no, that's a big notable differentiating factor of 70s and 90s bodybuilders. The amount of people that could do a vacuum dramatically, so many code in the 70s and it looked great and in the 90s you'd be hard pressed to find somebody who has like an aesthetic vacuum. Except for presumably natural bodybuilders are more likely to or.

1:23:49Yeah, yeah. They don't have the food demand. Yeah, it also depends on what they're eating as people've got issues could have issues to. but it's more common in people who are pushing food extremely hard. And then the drugs on top of that, like when you have hyperglycemia chronically, you might have impaired intestinal motility and like all these things that could compound the issue, significantly. So I think you have people with SIBO and bacterial overgrowth and all the stuff that can influence the distinction that is kind of like a congregation of bad digestion, in saying amounts of food, poor choices of food that don't agree with your body, because it's simply the only way you can get the cal reason to meet the demand of the muscle, et cetera.

1:24:31But anyway, Ben Pukulski, he showed up with less muscle, but he had completely reversed his gut distension. So it seemed as if the food was a large dictator of, okay, to get the biggest physique you ever got, you had to eat some diet that was not conducive to the most aesthetic, non -distended appearance. And if he had organ growth, is it reasonable to assume that he could have reversed that? It is another example of something that's very frustrating to me. This is knowable. Literally, take the bodybuilders, throw them into an MRI scanner, you can get organ volumes on everybody. And we could compare that to controls and also look at them off drugs, on drugs, all that stuff.

1:25:12So again, it's just an example of so many of the questions that we have here that we're not getting resolution to are knowable. It's not like we're asking is their life outside of the solar system. We're never going to know the answer to that. One thing I can say is on autopsy bodybuilders that did die young or what have you oftentimes now with social media, those results are released publicly and people dissect them and what not. You learn things from bodybuilders that have died that you might have not even known because not that long ago, 10 plus years ago, people were saying where are the bodies known dying from steroids, etc.

1:25:43But there are guys dying with hearts three times the size of what they should be. So there's certainly organ enlargement systemically for sure. So we could say that, I don't know if it's necessarily pushing on the stomach wall to actually cause. I see what you're saying. But I can say with near certainty there is organ growth for sure. I just, again, multifactorial. Maybe it's part of it. It's a great point. So let's talk about the death of bodybuilders. And we're gonna, again, I want to come back and do a long discussion on to anabolic steroids. There was a bodybuilder that died kind of recently, right?

1:26:16Yeah, yeah, that was a shocking one, too. He's 30 years old. One of the biggest social media influencers, too. What was his name? Joe Lindner. American or German. German, that's right, yeah, yeah, yeah. So with him, the scariest part was he was one of the guys who was doing all the right things, at least from a blood work standpoint. point. So he would get blood work done literally every two months, if not more frequent and was very, very rigorous about trying to oversee his health status and his blood work wasn't perfect, though, is but it certainly wasn't somebody who should be dying at 30 years old regardless of back in the day or not that long ago, even it would be unheard of for somebody to be dying.

1:27:00If he wasn't a massive bodybuilder by industry standards for fitness where we have this work perception of what is big versus not. He was like probably like 50 pounds off of what you would consider a top level open class bodybuilder who would compete with Ronnie Coleman or something. So he was more of like a jack fitness model by fitness industry standards and less drug use significantly less drug use less food intake. He was always in a calorie deficit shredded year round. The guy did lots of cardio at least like 10 ,000 plus steps a day, eight clean. Like there was no reason objectively, at least why he should die at 30.

1:27:41And what are the known circumstances of his death? So apparently his, and this is the thing that's, I don't even know if you're gonna want this in the podcast dude, but it's he got apparently the vaccine and two boosters on top of it I believe? Might have even been more, but after he got it done, apparently he went and saw, he got his blood work done just routinely, and they saw supposedly that the blood they pulled out was like really coagulated and weird looking and I forget exactly his terminology but he literally did a podcast maybe a week or two before his death how he got a blood test on and they were telling him that he needs to get a plasma pharesis to clean his blood because it was so messed up from the Vax so he did it twice apparently and then supposedly his D dimer went back down because it was super elevated in his blood work and they said he was fine now and he cleaned his blood and reintroduced it back into circulation.

1:28:40He would be good. He made a long trip to the US. I actually met him for the first time like a couple of weeks before his death and then when he flew back to Thailand, which is a really long flight and yeah there's clotting risk associated with that on top of all the other things, which is speculated to be something that's another variable. But he got back seemingly fine. And then apparently a few days after he got back, he was complaining of neck pain. His aunt supposedly died from aneurysm in her neck. That is what we have been told we have yet to see a autopsy report in his situation. But his girlfriend at least reported that his aunt died from the same thing and had aneurysm in her neck.

1:29:25In her necker in her head, it was apparently neck specifically, which I would think is unusual. Yeah, I won't even speculate without an autopsy. I think, again, tragic, obviously, that hopefully an autopsy shed light on that. I mean, it's not difficult to know if someone dies of an aneurysm on autopsy. Would you scope that out with like a pernovo scan before you even? Yeah, that's actually one of the reasons we really do like whole body MRI is the The incidence of aneurysms you'll see on a whole body MRI is about depending on the series. I mean, somewhere between one and seven cases per thousand.

1:30:00Now not all of those are aneurysms that pose risk, meaning they're not all aneurysms that if left alone would ultimately rupture. But a number of those require intervention. So we've probably in the last seven years had two patients. If you think about how small our practice is, two patients who have had incidental captures of aneurysms that were, in one case large enough, in another case, growing quickly enough to a large enough size that they needed to be coiled preventatively. So the aneurysms that typically kill people are in the head behind the stomach. Those are the ones that you kind of want to look out for.

1:30:38Also as far as if he had a deep vein thrombosis, which would certainly be a risk factor on a long flight, that could obviously kill you with a pulmonary embolism, again, very easy to diagnose on autopsy. So by the way, what's your current flight stack? So I don't fly that much anymore. And when I do, most of my stack is around sleep. What I'm thinking about when I'm flying is how do I eliminate jet lag? So I went to London a few months ago. So you don't control for like clotting potential anymore. I take baby aspirin, although the literature suggests that it's not necessarily helpful against DVT.

1:31:18I used to take something else. Neidokines. Yeah, that's right. I used to take that for DVT. Nowadays, I just use compression, hose, hydrate like crazy. And basically, I've got straight legs, most of the flight, because I'm like laying down. Honestly, I think like hydration probably plays a greater role than most things. At one point, I was like so ridiculous. I was taking low -vanox injections. So, low venox is like an unfractionated, it's like a type of heparin basically. But after one time I took it where I injected it and hit a blood vessel and had like the biggest bruise on my head. And I was like, oh, this is just not worth the hassle anymore.

1:31:54Most of my effort really focuses around how to not get jet lag, which I've turned into a science. I'll have to ask you about that later. Yes, yes. I can go to eight hour time zone away, be a hundred percent functional. The minute I get off the plane, get right into routine and rhythm. But traditional bodybuilder deaths, like this was a bit of a unique one because a lot of people, well, until the autopsy comes out, no one really knows. It might be that this is just a tragic death in someone who also happens to bodybuild and it might have nothing to do with it. In general, what I've seen from the autopsy's available and some pretty young bodybuilders, it's almost always a cardiovascular issue.

1:32:31And not necessarily atherosclerotic, but more cardiomyopathy type. Yes. Yeah, so like left blood pressure unchecked and had heart function just Destroyed essentially and hearts that are way larger than they should be I don't know if you've ever heard of rich Piana But he was a very famous and influential bodybuilder in the fitness industry and he died in his 40s with I think it was like a 660 gram heart and then Dallas Macarver probably the most notable one he was like a mass monster by I .F .B .B. Pro standards, which is like one of the guys on the Olympia stage who's actually the biggest of the guys on that stage His heart was like 860 grams or something and I think an athlete heart is like what one third of that or something Maybe a bit more than that.

1:33:20Okay. Yeah Mike Menser died young as well. Didn't he? Yeah? He had known a thrice chlorosis didn't he have she was also and I don't want to speak at a term but I've heard he was pretty into M -fedamines on top of that. So he was like stimulant abuse on top of potential anabolic exposure. I do think that that's one of the difficult things to ascertain with respect to bodybuilding is so much polypharmacy. Well, it's the polypharmacy and there's also like there's the psychological component that's very difficult to disentangle that's part of the profession. So let's go on and talk about testosterone and androgens in general.

1:33:56You've already thrown around a lot of names that are going to be foreign to people. But before we get into the different antibiotic steroids, you want to just do a quick review of the relationship between the hypothalamus, the pituitary, lating cells, sirtoly cells, what's the whole relationship between those hormones, testosterone production, and maybe we can even talk about DHT, androgen receptors, and estradiol for that matter. So the body has a pretty, it's complicated, but it seems to be pretty well regulated way to know how much hormone to produce based on needs and tissues, especially too.

1:34:35So your hypothalamus will create something called gonadotropin releasing hormone. Just like the name suggests, this is the hormone that goes to your pituitary tube, actually stimulate the production and release of gonadotropins. the banana tropins are the hormones that work on your gonads to produce testosterone, as well as assist with spermatogenesis and sustain fertility. So, the banana tropins that come out of the pituitary, they elevate upstream and GNRH as well in response or lack thereof to adequate and there's so many to lesser magnitudes, but primarily Androgen Receptor Activation and Estrogen Receptor Activation.

1:35:18And then there's also some stimulation of progesterone receptors that causes negative feedback as well among other things too. But the primary that are to be noted probably for this discussion, Androgen Receptors, Estrogen Receptors. When those are satisfactorily or in an adequate amount stimulated it will tell your brain okay we have enough testosterone as well as DHG and estrogen that we don't need to make more essentially because we have a satisfied amount of estrogen receptor activation in the body so we need to clamp down and not make as much hormones because we don't want to have too much so that will give negative feedback to the hypothalamus pituitary testicular axis to not produce as much G &H and LHNFSH until those levels fall to where there's a need to make more hormones.

1:36:09So it's this like, finally tuned system where your body regulates how much it assesses how much it needs, waits until it needs to produce more, and then it produces more. So the top of that is the GNRH stimulates the tertiary output of LH, luteinizing hormone, which acts on the latex cells in the testes, and follicle stimulating hormone that acts on certainly cells as well. and this is, we'll definitely get into that email you sent me about fertility and whatnot. Those will go down to the testes and stimulate the production of inter -tisticular testosterone, as well as assist with the production of sperm and maintenance of fertility.

1:36:48So, those levels, I think that's probably a good summation of how you end up with testosterone, probably. So then, what's the fate of testosterone? The fate of it in terms of metabolites. Yeah, like once it gets out there, how much of it is converted into estradiol, DHT? Yeah, and this is where a lot of people who neglect lifestyle and diet don't realize all of the backhanded consequences of being too obese or something like that. You could have, for example, aromatase strongly expressed in adipose tissue. So if you are too obese, and this is problematic, especially in adolescents too, if you have a disproportionate amount of aromatase expression because of how fat you are essentially, you could otherwise be producing more estrogen than you would have if you were lean telling your brain in an indirect way that, hey, we have enough estrogen so don't make more testosterone because I used testosterone to make more testosterone.

1:37:48And I probably should have prefaced this with testosterone converts primarily to two hormones through the five alpha to reductase edinzyme, five alpha reductase to DHD dihydrotestosterone, which has a significantly greater potency for binding and transcribing activity at the endersin receptor and estrogen, estridial, that will be the primary estrogen receptor agonist in estrogen receptors around the body. So those two hormones regulate kind of a balance of androgenicity and estrogenicity in the body. And it's like a finely tuned system. And this system is also regulated by binding proteins produced by the liver and the differential between, you know, like females versus men.

1:38:35It also works in the same way. It's just the difference in how much of these hormones are produced is quite different. And also the binding proteins to regulate that you stay feminine versus you have like a masculine profile. So ultimately the balance of free androgen to free estrogen in the body is almost the thing essentially that dictates if you are feminine versus masculine, you could flip, flop back and forth almost manually if you really wanted to. We see this in bodybuilding where females will literally masculineize themselves to hell in order to win a show by using super physiologic amounts of drugs.

1:39:09And also in people who are trying to transition from male to female or vice versa. And some of these changes are permanent, of course, on the masculinization front. If you have a deep voice, it's almost certain that you're not gonna get it high after going on female hormone therapy, but at the end of the day, this is kind of like the primary hormones to understand as far as the spectrum of androgenic male to estrogenic feminine like. It's not a female hormone because they exist in both sexes, but DHT, the primary androgen that dictates androgenicity and sexual differentiation and maturation. Testosterone, they mean anabolic hormone and drives a lot of the neurology, kind of the psychoactive effects.

1:39:51And then estrogen is kind of like, it's a big balancing act essential. So let's again, just make sure people understand the difference between endrogenic and anabolic because we will come back to this more and more with other compounds as we talk about the profile. Well, this one has slightly more endrogenic behavior. this one slightly has more antibiotic behavior. Yeah. So the Androgenicity or Androgenic activity of a compound or your endogenous hormones is essentially how masculineizing it is. So dihydro testosterone, the five alpha -reduced metabolite testosterone is the most Androgenic hormone in the body and can significantly inhibit estrogen's activity even in RNA transcription at the receptor slightly.

1:40:37It's very potent than what it does. To frame how important it is, you could have a male if you wiped out DHT before puberty. Basically, that's how you end up with a micro -piness, essentially. You have individuals who will not undergo full maturation unless you have the presence of this hormone. If you took a male before puberty and just put him on detasteride or finasteride, and zeroed out his DHT with making no change on his testosterone, you would have the same amount of muscle if not slightly more, but that's debatable, but no temporal recession, probably not as much acne, not as much body hair, micro penis, he would be probably visibly male.

1:41:18And male? Probably not as deep as it should be. And we see this in pseudo -hermaphrodites that have a mutation in the gene that encodes for five alpha -reductase. So this is kind of the advent of these enzyme inhibitors and how we even discovered how they work and whatnot. But DHG, the most endergenic hormone in the body, the most masculineizing testosterone, still very masculineizing too. And estrogen on the opposite side of the spectrum, zero masculineization, very feminizing. I think that's the easiest way to summarize. So we talked a little bit, and I've discussed this on many previous podcasts, but just in case folks haven't listened, right?

1:41:53So testosterone or DHG make their way into the cell, into the cytoplasm where they bind to the endergen receptor. to your point, DHT does so with far, far greater affinity. I mean, it's on the order of one order of magnitude, more, maybe 20 times more binding efficiency to the endogen receptor. This new complex of testosterone or DHT bound to the AR makes its way into the nucleus where it acts as a transcription factor binding to DNA and imparting on it effectively transcription translation. That's how we make stuff. It's how we make proteins. So that's how it impacts muscle protein synthesis.

1:42:29You guys, one thing I should have said is androgenic, because you did actually ask me this, is not anabolic. So androgenic masculinizing, but does not necessarily equate to muscle. So you could have severe masculinization with a relative absence of actual muscle growth or translation to, I don't know, bone integrity and what have you. By the way, how important is DHT postpuberty? Seemingly, it depends because from a cognitive health perspective, from a balance of estrogen standpoint, from a vasodilation in the penis standpoint, there are certain things where you could say it's pretty critical, but then there's also, you could just as easily say, it's not necessary or mandatory.

1:43:14Like you will survive and likely thrive just the same with a lack of DHT almost entirely. A lot of people will demonize five alpha reductase inhibitors and justifiably so in some cases, but even when you look to literature that compares placebo versus finasteride versus due test ride, side effect profiles are pretty similar even. Yeah, due test ride, finasteride being two drugs that block five alpha reductase. Yeah. Used initially for reducing prostate size because DHT disproportionately drives prostate growth, but also used, I would say, used more for hair loss now. But yes, and we have talked about this on two podcasts previously about post -fenasteride syndrome, which is a debatable idea.

1:43:58In other words, there is not a clear consensus in the urologic literature about even the existence of this, let alone the prevalence, let alone the reversibility of it. All of these things are really unknowns. And actually, it's created quite a bit of a conundrum for us because we have a number of patients who take finasteride or deutasteride for hair loss and with your stance on five alpha reductis inhibitors. Yeah, I mean, look, I think I'll be honest with you. I never really paid enormous attention to it until about a year ago. I think right now our stance is I probably wouldn't start somebody on it.

1:44:37So in other words, if a person has BPH, We're not going to manage that anyway, but a urologist has far better tools to manage BPH than five alpha reductase inhibitors. So I feel pretty strongly that if you're presenting with BPH, you should not be on a five alpha reductase inhibitor. It's like if someone came to me and said, my apo B is too high and I gave them a biolacid sequester in circa 1981. I mean, it's just not necessary. There's no upside. If you're talking about it from a hair loss perspective, again, not something I obviously know much about, I would say, and they're gonna go and see a hair doctor who's gonna try to give them 50 different proprietary compounds, which by the way, want to come back to that in a second.

1:45:19I would encourage them if they've never taken it before not to because I think there are enough other compounds, oral monoxidil, topical monoxidil, topical five alpha -reductase inhibitors, PRP, transplants, I think there are enough other tools that you can do to avoid the small but not necessarily zero risk of something going wrong in terms of sexual side effects that in the worst case might not be reversible. What about you? What do you think? I think that several of the drugs you just said have either comparable side effect profiles like topical finasteride. You end up with the same burden of 5 alpha reductase inhibition systemically despite the effect that it's marketed otherwise.

1:46:03Topical do -tastride is interesting because it may have some capacity to stay local, especially if you do mesotherapy. I wasn't aware of that difference. Yeah, it's thought to be the molecular - So it's just hydrophobicity? It's more the molecular mass of the drug. So there's this like, it's like an arbitrary rule, but if the molecule is greater or less than 500 Dalton's, I believe it is on the top of my head, it's been a while since I've revisited it, but there is a lesser or greater ability to actually absorb it and get systemic circulation and distribution of across the body. With due to astride, it's like, I think it's like 600 or 700 with finasteride.

1:46:42It's like 300 or 200. I don't think that systemic monoxidil is necessarily a benign drug. And the other thing is, nobody really can give an explanation for what the right dose is. If you look at people like a low dose monoxidil. Oral monoxidil, it's insane. So I don't like to be in the business of prescribing things for which I don't have a great understanding which is why I'm not in the business of treating hair loss. Not because I don't think it's something worth addressing. If it bothers someone, but I think the bigger issue is, it would be really awful if in trying to treat a cosmetic condition like hair loss, you induced a devastating consequence on your endocrine system.

1:47:20That's really where I find myself concerned. Now, it also appears that if you've been on finasteride for a long period of time and you're not experiencing any of these side effects, you're probably fine. So I also don't want this to turn into like someone listening to this who's been taking Propecia for 10 years who's never had an issue going like oh my god I got to stop this stuff the literature would suggest and there is a pretty good review Will link to that if you're gonna have these side effects you're gonna have them in about six months Yeah, in general when it comes to hair loss the problem is oftentimes the treatments if it doesn't actually interact with the AR or inhibit the potential for stimulation or agonizing the AR through DHT reduction or even systemic anti -androgen.

1:48:08It's not that I ever recommend that. You are essentially just putting a bandaid on the issue. So if you stimulate growth with minoxidil, you are still not preventing further loss. If you get a transplant, you are putting hair on your head, but you're not preventing further loss of your actual existing hair. So oftentimes it's like you're almost trying to a row against a current or something. And it's like you are continuously getting pushed back and eventually you're gonna get to a point where you have so few visible hair follicles just even left that are healthy that it doesn't matter how much you've been on a minoxidil or what have you.

1:48:42And oral minoxidil, it's definitely effective, but I think it should be reserved for people who have weak response, typically this topic seems to be far more tolerated, side effect wise and a lot more predictable with like hordes of literature and great outcomes. And there are ways to enhance that and also turn yourself from a non -responder to a responder, which we can get into. But, finasterite in itself, it seems to be, like I don't wanna try and come out and say I'm a proponent necessarily. I try to take a balanced approach to it, but the prevalence of side effects is not nothing, but it's quite overblown by the opposite camp that wants to assert that, Why would you ever inhibit a hormone that is the primary endogeneity rely on?

1:49:27But similarly, why would you inhibit, I don't know, APOB or something? Like there is a clear outcome whereby there's benefit and when there is DHT and somebody who's prone to hair loss, it's hard to overlook that this is the primary thing dictating if you go bald or not. And some people that hair loss, some people care a lot more than others obviously. So I do think there's a difference because I think APOB serves no benefit. If someone created an anti -sense oligoneucleotide that knocked out APOB, all it would do is guarantee we don't have heart disease in our species. We would still be able to use all the HDLs in the world for cholesterol transport, which we currently use LDL4.

1:50:06But I think to take your analogy a step further, what you're basically saying is if a person cares as much about hair loss as they do about heart disease and by that logic, DHT is causal. Which sounds absurd, but let's just run it. I would posit that there are lots of people who care more about hair loss than heart disease. The psychological stress for some people is significant and should not be overlooked by the silliness of, oh, just shave it, bro. It's not a big deal. There's tons of successful people who are bald. It's like, yeah, sure. But, although, I think, I think there's a statistic that no bald person has ever been president of the United States.

1:50:41So there you go. So there's a couple of occupations. You've got to take off the list. Now you mentioned when you were going through your insane anabolic steroid use at a very young age, if you're in your early 20s, we're already starting to lose your hair. So how did you reverse that? Part of it was just dropping the dose significantly and eventually just going down to replacement therapy. But it was the introduction of five alpha -reductase inhibitor initially finasteride, and then thereafter I introduced a, and I wouldn't necessarily recommend this blindly, but a topical anti -androgen that's experimental and they've actually received FDA approval.

1:51:18There are some that are in the FDA pipeline right now that actually look promising and have safety data behind them and whatnot that I'm watching closely and hope one comes to fruition because these are essentially compounds that compete for the Androgen receptor locally but do not have systemic anti -Androgenic activity so you can maintain all systemic Androgen levels with just localized activity in the scalp essentially. So I use the topical anti -androgen coupled with a 5 alpha reductase inhibitor. Those were the main two needle movers for me. I also use a ketoconzole shampoo, but it's like a very mild anti -androgen.

1:51:53It's mostly just a good shampoo. But those two things and decreasing the burden of Androgen significantly were fairly effective at getting me not to baseline. Meaning you never regain, no, that's the thing with hair. That's the sketchy thing is even if you're trying to decide, oh, you know, maybe I should treat it, maybe I shouldn't. I'll think about it for a bit. it'll see if it gets worse. The visual representation of loss is typically not a parent's until you've lost a lot of ground because you could pull a handful of hair out of your head and see no different whatsoever. Once you finally notice diffuse thinning or recession, it's not something you've been looking for carefully because you've never dealt with it.

1:52:31So oftentimes once you actually notice it, picture or in heavy downlining or something, you've already lost 20, 30 % plus of your hair. and there's no guarantee that's coming back. So did you regain hair that you had lost with this protocol or just completely stop some regrowth but expecting yourself to get back to baseline where you had like 17 year old immaculate perfect hair. If you've been exposed to androgens at a level where you're visibly noticing it, it's relatively unlikely. So that's not to say it's impossible. Like if I took Menoxil as well as micro needle into a bunch of other stuff I could probably get a decent amount of the way there.

1:53:12But the longer you wait and let hair follicles miniaturize, the more permanency you are risking. So making back ground is way harder than preventing yourself from losing in the first place. It's almost like maybe analogous to building muscle when you're younger, so then you don't have to try and build it in old age when you have like animal ecosystems or what have you. Let's make sure we give people the names of these compounds you're using. So, finasteride is like the main primary 5 alpha. And you take a bit of 1 milligram of that daily? I take due -tastroid now. So, you take 0 .5 milligrams?

1:53:47Is that 0 .5? Yeah, I take 0 .5 a day. So that is a soft gel that essentially wipes out systemic DHT. And your DHT level is worse than a teenager girl. Yeah, it's terrible. But I see him okay. At least now. I think one of the guys with the highest IQs on the planet has been on due -tastroid for decades if that's notable for anyone. Okay, so then what else are you taking besides detasteride? Detasteride right now is the only thing I take more of convenience because a topical application schedule can be quite burdensome, but when you were doing that big salvage effort in your early 20s, what was the rest of the stack?

1:54:21Oh, it was topical application of something like a RU -5841. It was like a experimental anti -androgen. So I don't necessarily recommend people use RU, 5 -8 -4 -1, when there are actually alternatives with human safety data on the horizon. With that said, it's also hard to tell me, however many years ago, that weight, because you only have so much time, right? So I'm not going to sit around. And one of these things that have more safety data coming down the pipeline. It's coming called Kintor has a compound called Pyralutamide. and it seems to be pretty well tolerated and comparable outcomes of hair count increased to due to astride if I recall off the top of my head, which is pretty substantial, given that there are very few things that produce outcomes that are even make it worth taking another drug.

1:55:15Right now the most effective things are going to be five alpha reductase inhibitors and monoxidil on top of that, everything else is like. Little sprinkles on the cake essentially. Some people might get better benefit from PRP than another person or what have you, but in general the main meat and potatoes are going to be Minoxidil, Potentially micro -dodeling with minoxidil if you're not a good responder or have low cell -fo transphase enzyme activity in the scalp and the inhibition of free endrogenic signaling in the scalp whether you do that through five alpha reductase inhibition or anti -endrogen activity locally that's kind of up to you or some people are gonna couple both of them like I did but those are the main needled movers, ultimately.

1:55:55And then some people go super hardcore. And the most crazy hair loss reversals, you will see are always in men transitioning to women who use female hormone therapy. I would never recommend anyone do that, but it's a pretty interesting data set to like pull from. So estrogen and progesterone would promote hair growth. I mean, we do see it in women actually during HRT, especially progesterone can really thicken hair. But this is in women. I mean, I have no idea. I'm more talking about antiandrogen plus estrogen. So somebody transitioning would typically use a Cyproteronacetate by coludomide, something of that nature plus exogenous E2 or a synthetic estrogen.

1:56:31And the first two, which I'm not even familiar with are drugs that just block the energy binding to the endogen receptor. Cyproteron is a very potently anti -genadetropic, I believe. So it's like it will inhibit you from producing G &RH, it's effectively a chemical castrate. That's like a steroidal antiandrogen, and then there's the non -steroidal one. Any add is effectively chemical castration. The non -steroidal variant by colludamine seems to be a bit better tolerated. It's not as liver toxic, and it will actually raise your hormone levels on paper. Your test levels go up. It's just, you can't actually interact with the receptor because it's occupied by by colludamine.

1:57:09So it's like a silent androgen receptor antagonist. And those are like extreme options. is it like essentially irrelevant for anyone watching? So maybe I shouldn't have brought it up. Yeah, yeah. Let's go back to TRT then. So we've kind of established what's going on when you starting. Yeah, we're going to talk about that. I'm actually doing my blood again next week, so we'll see how far my levels have continued to fall. So I was going to actually talk right about that, right? Which is let's talk about quote unquote what's normal? I've never found a compelling table for normal levels of free testosterone that are stratified by age.

1:57:44You can find these data quite easily for total testosterone level, but I've only really seen data for broad chunks, pre -pubescent, pubescent, post -pubescent. Here are the percentile ranks for free testosterone, whereas for total I can show you by decade or something like that. Yes, it's worth putting some context to this, right? So a person's total testosterone is 800 nanograms per desoliter. Most of that is bound and sex and combining a lot of you in an album and probably do the lion's share of binding. And if a guy's got 2 % of that as free or unbound, that would translate to 16 nanograms per desoliter of free testosterone.

1:58:34That's estimated, by the way, it's not calculated. It's very important people understand this. When you go to the lab and you get a test done, they're measuring testosterone. That's direct measurement, by the way, we should talk about ELISA versus LCMS, but they're estimating the free based on the measurement of the binding proteins. So that's introduction of potential error number one. So you don't really know how much free testosterone you have. The other thing is you don't know how many androgen receptors you have. So you really don't have any idea whatever whatever amount of testosterone you have is saturating your engine receptors or not.

1:59:06Are you playing below your weight or above your weight? What do we know about the amount of total testosterone over time in a guy's life? I know that after it peaks, you will have a steady, as opposed to women where you see like a plummet after menopause for men it's more gradual and you can expect. I believe it's about 1 % drop in total tests per year with an approximate 2 to 3 % drop in free each year as well. So at the same time, you would have 1 % total T drop, 2 to 3 % free. It depends on age lifestyle, but in general, like post age 30, 35, you can kind of expect a little bit of a decline to start, but that's not to say I haven't seen 70 year olds with like 1000 total T sometimes.

1:59:55So you can certainly retain high level production. I don't want anyone to think, oh, now that I'm 45, my levels have probably dropped 20 plus percent at this point. I should probably get on TRT. Might not be the case. So those are kind of general numbers of decline that you can expect based on literature, but I think it's reasonable to assume that a lot of people can retain good production as well. It's just a matter of how well do you produce Just get out of tropins, how well do you respond to them at your testies? Because there is some level of function that declines with age two, even in response to the get out of tropins.

2:00:32And that's an expected outcome, unfortunately, but that's kind of where you get into the nuance of its TRT justifiable for this person based on the two -itary output, lifestyle, diet, nutrient intake, sleep hygiene, sleep apnea, etc. And then also actual testicular response. Because there's an argument to be made. if you have very good testicle response, like why would you ever be on exogenous TRT too, because you could top out your natural signal even. Is there an advantage to that? Before we get to that, let's talk about the rationale for TRT. So what do you think is the most compelling case for it, and how often are people expanding that use case?

2:01:09I think the most justified use for it is people who have primary hypochonetisms of that is When you have banana tropins going to your testes, but you're just not responding to them. So LH and FSH are, you'll see these as high in your blood work, but your total T is still bottomed out. Like that could be somebody who is, you should probably check, do you have a varicose seal, do an ultrasound of your testes, see where things are at structurally, functionally, et cetera, before you make any rash decisions because there could be something you're overlooking. And I do think a lot of people do overlook certain structural abnormalities that may otherwise be rectifiable, kind of depends, but typically testicular failure in response to adequate signaling would be the obvious more no -brainer versus if you had a low LH and FSH, maybe your testicles were fine, so why are you haphazurely getting on testosterone when maybe it's a lifestyle thing?

2:02:06And so typically when we see that pattern, the second pattern you've described, which is low testosterone, but in the setting of low LH and FSH. The most obvious things that usually show up there are poor sleep, basically high glucocorticoids, which can also suppress the pituitary. And you'd measure the glucocorticoids through like a Dutch test? Yeah, usually you're in actually. We used to use saliva long ago, but yeah, so using a Dutch test. Interestingly, those are not the easiest things to fix because people have to change behaviors, which is a lot harder than taking a medication. So, let's just say we go down the path of, we believe that TRT is the right thing to do, and we believe that it's primary hypogonadism.

2:02:49What do we know about the dose response of testosterone? And do we think that it makes sense to use fixed dosing and increased dosing or target to certain levels? Because again, most of the studies, and we might talk about the traversed trial, they kind of just use fixed dosing, which is at least for me one of the criticisms of that approach, by the way, is especially when you're using something topical and you have variable absorption. But what do we know about this? I think in general, if you're going to be treating with exogenous testosterone and accepted entry level dose, that is on average safe and well tolerated and will get you to a reasonable total T that provides symptom relief for the majority of people is I can't see a more logical start point.

2:03:33then for example like 100 to 120 megs a week or something of that nature and just seeing what happens to the guys total tea free tea. This could also be variable based on does he have a super high SHBG should be evaluating that because maybe he just has a low free tea instead of his total is fine in that case you could have brutal symptoms but your production is still good. It's just being bound up severely and why is that the case? Do you have like severe liver issues or something? So after you fleshed all that out and you determined the guy needs to, I would imagine a reasonable starting place is typically like 80 to 120 a week and then go from there, see how you responded to that.

2:04:11And any advantage to dosing it once weekly, taking that dose and dividing it by two and doing it twice a week, taking that dose and dividing it by seven and doing it every day, I don't necessarily know that like for example when patients come to you, I'm sure they're looking for the highest level of optimization hence, either with you. So maybe it's more reasonable to expect them to pin more frequently. I would say pin, I mean, inject. But there is a half -life with the drug depending on the ester chosen, typically testosterone ,cipinate will be prescribed, at least in the US, that's the most prescribed one, which is a half -life of 10 days if I recall off the top of my head, depends on the person, of course, where it's injected, blah, blah, blah.

2:04:52But that half -life you could extrapolate out So from that, okay, it's going to take 50 days to achieve steady state serum concentrations in the blood. And that's going to look on like a steroid platter. You could check online and see this kind of like spiking until all of a sudden there is the same amount of dropping of the drug clearing out of your system. You're getting an equal amount of spike backup. Like there is no accumulation of drug burden after you've achieved steady state serum concentrations. So the advantage to injecting more frequently, and this is going to be determined largely by patient adherence more than anything, because some people simply refuse to inject even more than I've seen some insane stuff where people will let themselves drop to literally hypogonadil territory and then remember, based on their dick not working, I'm gonna, okay, now I take my test.

2:05:46But in general, once a week is like bare minimum, I would say, but that's certainly not optimal. And I would say that two times a week, at least for somebody seeking good quality oversight, preventative medicine, whatever, if they're coming to you or to somebody who believes in the same things you do, twice a week I think is kind of minimum for decent, steady hormone concentrations. We've sort of arrived at the same conclusion that that's the sweet spot. We do have a couple patients who do daily injections. and interestingly, in these patients, we see much less for the same dose of testosterone.

2:06:23So you take 15 milligrams injected a day, which is actually very difficult to do. You have to be very thoughtful about what kind of needles you're using to actually get such a small volume in, but they will have much less FSH suppression, which suggests to me that the higher the peak, the more the FSH suppression. I don't know that there's anything physiologically relevant to that. But the studies, when you look at trough -level T levels, and I say trough, I mean like the lowest point of hormone concentrations after an injection, oftentimes these studies assessing dose response will look a week after your injection.

2:06:59So what you see in the literature isn't necessarily reflective of what's going to be and patients trying to optimize anyways, but what I see personally and in Maricalt and through all my blood work that I've seen over the years, et cetera. the more frequent you get, there's a diminishing returns for sure, but you can lower the aromatization spike and 5 alpha reduction by going more frequent. So if you have a bolus administration of 150 milligrams once a week, you are literally spiking your tea into super physiological territory acutely, and concurrently you are getting superphysiologic conversion to estradiol, DHT.

2:07:41You also have a very, very aggressive spike and free endogenic signaling, which can crank your sympathetic nervous system up, impair your sleep quality. Like, there's so many consequences. And you'll see more hematopoecis. So when I had Mocaera on here, he was talking about Natesto, which is the nasal formulation, which has such a short half -life that it's actually a TID dosing schedule. So it's seven milligrams of testosterone. I want to see somebody take three times a day for more than a year and still tell me it's cool and fun to take. So if you end up doing that for TRT, you're going to probably will not.

2:08:17But two interesting points with the test O. The first is they don't have the hematopoesis. So these are not people who were making too many red blood cells that you have to actually be careful of and have to go and get them therapeutically flabotomized to take blood off them as their hematocrit gets over 50. Secondly, it's a FDA formulation that women can use, because if a guy is taking seven milligrams in each nostril three times a day, clearly a woman could take one of those every other day. And by the way, it's sort of an on -demand libido tool for women in particular. So there are lots of interesting things around that.

2:08:55Also, they're doing a clinical study and we're sort of observing what they're doing. where women are using intravaginal use, one application of that intravaginally before sex to enhance orgasmic function. It's always desirable to have an FDA formulated product when you can kind of avoid the dark side of compounding is my view. I think the best way to conceptualize for the listener to why this frequent protocol or getting a more stable level, why is it result in a lower side effect burden? The closest you can replicate natural function, the more you you will replicate natural side effect profiles, which should be nothing if you are physiologic.

2:09:36So with Netesta, which is like in and out, acutely like so fast, you were not getting this huge spike to like 1500, 2000 antigen predestinator total T, if there is no situation ever in which your testes would just blast you once a week with a hammer of test and all of the associated metabolites and back end and consequences of that, that you would have little pulsations over the diurnal rhythm. And this is why you could test your blood as a natural in the morning when your testosterone is spiking and it's going to ebb and flow over the day. Your test level in the morning could be 300 nanograms per deciliter higher than later in the day.

2:10:12It'll get fluctuates. So to expect that it's reasonable to jam yourself with an absurd amount of test in one go and then hang on that as it declines into your body and then crank it to the stratosphere again, it once a week, it's just not representative of the physiologic state whatsoever. So the more you can replicate that diurnal rhythm through the synthetic administration route, the culture you're going to get to a lower side effect burden. Like I've seen some guys that get kind of comastia from TRT dosages go to ED everyday dosing and get off their AI just to translate that into English.

2:10:54I'm sorry. So they make so much estrogen that they have to take in a Roman taste inhibitor to prevent them from getting breast tissue, kind of, comastia. And if they take that same dose and divide it daily, they can come off through a Roman taste inhibitor altogether. Yeah. And some people it's problematic because they will give feedback to their doctor or just give a judgment to what hormone therapy was like for them based on what is maybe not the right dose, but also just not even close to an ideal dosing regimen and injection frequency. When I got back into the practice of medicine and was learning about HRT, I couldn't find doctors who weren't prescribing anything different than every two weeks.

2:11:39That was the standard. Have you seen the Europeans sustinon? No, I have not. But the standard dose was 200 milligrams every two weeks. I remember going through Lewellen's pharmacology and looking at at the pharmacokinetics and being like, this is an awful idea. Any difference clinically between sipionate and ananthate. Obviously, one of the advantages of ananthate is there's a commercial product called Ziya Stead for people who are squeamish about injecting that comes in a preloaded pen. So we have some patients who just don't like the idea of having to draw up a syringe and they just kind of want something that's a little more turnkey.

2:12:18So, Ziya's dead, which is a slightly different form of testosterone. But clinically, I sort of remember at one point there was some difference that might be age specific, but I don't recall now. Ananthate is often thought to be a long ester, which it is relative to like propionate or phenoproponate, but it's kind of like an in between of sipionate and propionate. It's like a half life of, could be as short as four or a half to five days, I believe, of the top of my head, where a sippin' egg could be twice as long in some people. So it depends on your individual metabolism of the drug often. And also if you're pinning sub -Q or I .M.

2:12:57like you could bleed out the effect more. So I would say if you're injecting frequently enough, it's essentially irrelevant. The Ziosted protocol from the FDA is once weekly. We still recommend people do it twice a week. Just use a lower dose. The difference of what you're supposed to take versus using it, like obviously frequency is of a lesser concern than you walking around with no test. So if it's the difference between a guy taking it versus not, okay, take your once a week if that's what it's going to take, is the preloaded dose, can you modulate? You can't meter it. That's what's so annoying about annoying with the GLPs too.

2:13:33Yeah, it's such a racket. And I always tell patients I'm like, look, if you're completely cost -insensitive, I guess fine, but otherwise gettingcipionate in a jar is a fraction of the cost if you're just willing to be the guy that meters it out. But the enantheta, I think, only comes in three loaded doses of Ziya's stead. You also have less wiggle room if you're not happy with the output. I would assert with near certainty that you are not optimizing your hormone status if you are, I want to say optimize, I mean just dialing in the stability of it and the side effect profile and potentially quality of life as much as you could if you did a more frequent schedule, especially with the Nante.

2:14:11Meaning the more frequent you're giving it the better. Yeah. I think the diminished returns are, there's a significant drop off when you go from every other day to every day, but one week to twice a week, like I'd say there's a pretty dramatic difference that's worthwhile. Let's talk about the difference between sub -Q and I am. I have always advised patients to do sub -Q for the belief that it has, as you point out, kind of you bleed out the effect a little bit longer. I have to be honest, I don't think I've seen data to support that. I have seen, and I think this is an extrapolation, but I believe it to be true is when you look at sub -Q dosing, you'll notice the total T levels are higher, and then people take away from that.

2:14:53Oh, sub -Q is like, you get more out of your test, but the reality is is when they measure total test levels, it's often a week after your shot. You see, so it's just last longer. So I think you are almost giving yourself a sustained release through administering into the fat tissue rather than intramuscular, which is more readily absorbed, quicker, blood flow, et cetera. Just like if you did look at IV administration, it would be in your blood immediately. Not that you would ever do that, of course, but the difference in pharmacokinetic profile of IV to I am to sub -queue, like you can change the same drug dramatically in onset of action through that.

2:15:28You think that sub -Q is probably a better administration. I think once you get to every other day dosing, it almost doesn't almost matter. Yeah, but I think especially for people who are doing, and again, it depends on the amount, because if you're doing once a week, is that gonna be too much of a bolus to sit in stomach fat, depends on the person. But I would say especially for infrequent, you'd be better sub -Q ideally if the volume of oil isn't significant enough that it's creating lumps and stuff. Let's talk about aromatase inhibitors. There was a study that I don't think gets enough attention.

2:16:02I think it was 2014, might have been 2013 in the England Journal of Medicine, that looked at 10 groups. So it took a group of men, chemically castrated them, divided them into two. First half of them get an aromatase inhibitor, half of them don't. And then within each of those groups, there were four escalating doses of testosterone plus a placebo. So what you have are five groups times two, one with estrogen inhibition, one without, and five escalating doses of testosterone. So you end up with 10 outputs, which are ranging from low to high testosterone with high and low estrogen. And the outputs were body composition, mood, libido, a whole bunch of, you know, erectile functionalities, things.

2:16:46The punchline was you were better off with more estrogen and more testosterone. So the best outcome group was the high T high E group. Now the high E group wasn't that high. I'd have to go back and look how high the E was. I think it was probably in the ballpark of 50 pg per milliliter. But this was an important study because I think it suggested that estrogen is not the bad guy, right? I think there was probably a lot of people out there thinking, if you're taking testosterone, you need to be taking in a Roma taste inhibitor and while that might be true at some doses, I guess let's start with normal physiology and then I'm kind of curious to hear what the body builders are doing.

2:17:24Back in the day we thought that regardless of the dose of Androgen, you should lower your estradiol to 20 to 30 because it's in the middle of the reference range ish for a man and that's where you get the best. There was no thought of balance. It was kind of like, This is a bad hormone to have above the reference range even though our andurgins are literally like 10X the reference range. What would your testosterone levels when you were back in the heyday? I never got LCMS testing when I use my highest dosages So it would get capped at like 1500 or something, but it was you know in the thousands for sure But yeah with extra dial There is and I've seen these studies too where it shows neurotoxicity when you add it in versus you take it out and there's a protective effect.

2:18:11So like neurotoxic outcomes are higher when aromatase is inhibited and less neurotoxicity when it's taken out on the exact same input of testosterone. I think it's pretty clear at this point that there is a role of estrogen in the body not just from a cardiovascular standpoint but from a neurological standpoint too. There's like serotonergic activity. There is so many things that regulate mood as well. I think even like temperature control too is going to be variable based on that. It's kind of ties into the post -menopausal stuff, but for men it is certainly important and to crush it arbitrarily based on a reference range is kind of like old bro lore and I think most people even in the bodybuilding space are pretty aware now that estrogen is important for cardio and neuro protection.

2:18:58And I think another thing it's really important for is bone health. And by the way you asked me earlier about when am I ready to start my TRT protocol? I think I'm more troubled by the fact that my estradiol is so low because my T is routinely between about 300 and 400 nanograms per deciliter and my estradiol is never above 25 pg per milliliter, which is normal. That would be normal for such a low T. But to me, one of the big advantages of having a T of a thousand would be that I'd hopefully have an estradiol of 40. Not to derail, but five alpha reductase inhibition. When you don't have conversion to DHT, you branch off more T to estradiol and estradiol will reliably increase by 15 to 22 % on finasteride or dutastride.

2:19:47Some people who are very low aromatizers and have like a hyperendrogenic state, those people, that's where unique individual variability comes into the consideration for drug implementation. So a guy like that, even for actual quality of life, sometimes that like modulation. Interesting. Yeah. I'm actually gonna do both tests side by side next week where I'll do enzyme -based tests plus LCMS for DHT testosterone and estradiol. So I'll probably have a better sense of what they look like because we can talk about how often enzyme -based testing gets estradiol wrong. No, yeah, I've seen some brutal overestimations using ETLA when it was like single digit.

2:20:29Yeah, we've seen guys come back with estradiol levels of, we're using like say Boston Heart, which is using an enzyme -based system and they'll come back and they'll have an estradiol of 100. And we're like, this can't be right. And then you send them to LabCore and specify LCMS. They're at 31. Yeah. And this is especially important, I think, in, especially hypo -ganadil men who have relatively low estrogen to begin with, like actually identifying where it stands is pretty important for sure. Okay, let's talk a little bit about the other hormones. So for most of the medical needs, is there any reason to be considering a hormone beyond testosterone for male sexual hormone replacement?

2:21:13I think it depends on the person for sure. That's like such a general answer. Well, let's say this, if you're just talking about health benefits and not performance benefits, we're going to talk I'm sure about lots of others. And I'll give you one example. So way back, I used to be a little bit more liberal and creative. So one of the things I used to do was if guys had normal testosterone, the example used a minute ago, a guy who's got a testosterone of a thousand nanograms per deciliter, but his SHBG is a hundred for a guy is very high. And his His free tea is like eight nanograms per deciliter.

2:21:50So he's like eight tenths of a percent free instead of say two. You could use a very, very low dose of oxandrolone, and you could eradicate his S .A .S .B .G. because it has such a high binding affinity for oxandrolone. And of course, it also will inhibit. If you give too much, you'll inhibit testosterone production. So there's a very fine balance where you might give him like 10 milligrams twice a week, or three times a week of oxandrolone. You knock that SHBG down and you double his free testosterone. You haven't given him any testosterone. I don't do that sort of thing anymore. I feel like he's just not worth a hassle, truthfully.

2:22:28That's one example of an area where you can manipulate another part of the system without having to go beyond that. But if you maybe take examples like that out, if you're just talking about the use of these other steroids, what's the case? In some individuals, a adrenal hormone replacement sometimes may be justified, but it's going to be based on blood work. Can you say adrenal -dimein DHA? Yeah, so like DHA, if you have like a bottom DHA -S, maybe you would look to a DHA replacement. If you have low pregnant alone, that might make sense, but it's more for like neurological, cognitive, perceived quality of life effects, not necessarily because there's any evidence to support that it's necessary.

2:23:08In general, the main needle mover is going to be your test and how much it five alpha reduces or romanticizes into the two metabolites. And from there, you would never manually use more DHT. You would never, almost never probably manually use estradiol on top, although it's not impossible. So it's like upstream to that in the story of Genesis cascade where might other stuff plug in. I've seen progesterone use and men on TRT actually reasonably effective in sleep quality. How much progesterum? Like the same amount as women. One to 200 milligrams? You don't have any HBTA suppression because you're shut down anyway.

2:23:41So it can be impactful on quality of life because you get the downstream conversion to some of those neuro steroids that may be inhibited in post -phastride patients. I'd never heard of that. That's super interesting. Not a commoner. Why would it work in women and not work in men if you had like a reasonably low progesterone level? Yeah, you're not expected to have a sky high progesterone anyway, but it's some of the downstream neurosteroid metabolites that you make through 5L for reduction and whatnot that are very gabberergic and ansiolidic and can help certain people. And maybe that's useful for a specific guy who has a low SHBG and is in a state of high sympathetic drive on his test and needs to calm down or there are certain use cases that are more individual dependent for sure and not necessarily dictated solely by.

2:24:28It looks like lab resulted out and anywhere we just look for red and then replace it. I don't really know the history at all of anabolic steroids guessing testosterone has probably been around since the 30s or 40s, right? Presumably. Yeah, I think when it was first synthesized, remains up for debate maybe? It goes back nearly 100 years at this point. And so what was the first anabolic derivative of testosterone? The first one I can think of of some I had as dianna bull. There might have been like methyl test or something. I could be misremembering, but essentially what they did was they took the testosterone molecule and found they could finagle it, manipulate it in ways to create testosterone derivatives like dianna ball, methanidro stenolone, which is supposedly the breakfast of champions according to Arnold.

2:25:19It's one of his famous quotes. Bold and known is a very commonly used drug as well still. It was prescribed to horses, I believe, for a while. And then I don't think it ever had a human use. But that is a testosterone derivative as well. And there's other ones that came there after, like, halo testin, which I think famously, one of the presidents of the United States was on some aggressive dose of halo testin for, I figure what it was, maybe fertility or endogen therapy, but some of the protocols back then made almost no sense. Halo testin, and through there, they also found, Oh, if we take the five alpha reduced DHT, testosterone converts to DHT, you would take that DHT molecule, you can manipulate it and create more anabolic compounds that are tissue selected.

2:26:04Like the idea of actually tweaking and modifying it to begin with came from the utility clinically to implement in muscle wasting, in antigen sensitive individuals. So you're not gonna give a child testosterone who has, you know, like a burn patient or not can give them tests because you might masculinize the hell out of a female child, for example. So you have to come up with novel alternatives that are going to be anti -catebolic preserved tissue, keep somebody from wasting away in a state of filling the blank without causing extreme viralization. So the armistice of creating the best anabolic agent was from numerous pharmaceutical companies and came in array of compounds that you know now to be the dionibols, the bull denones, on the DHG derivative side, you had oxandrolones with a more refined, more recent, although decades ago at this point, Prima Bowlin, also a very refined one.

2:26:59It's a maternalone, Provieron, I think still used to actually to interact with SHBG. It's probably one of the most potent drugs at binding SHBG's, Mesterolone. But yeah, the ideal scenario would be you're trying to segregate the anabolic from antigenic activity, because testosterone is essentially equal, at least based on rodent studies, you would find an equal amount of anabolic activity and muscle relative to androgen -like activity and masculineization. So you would try and take the compound, manipulate it to give maximum anabolic outcomes with a relative lack of androgenic outcomes to create something that men, women, children, anybody could take for muscle wasting purposes and preserved tissue.

2:27:40And they never successfully did it, but an array of compounds. If sort of one to ten would be, let's just make this a scale up. So five is testosterone. So it is halfway between completely anabolic and completely androgenic. DHT would be closer to one. It's much more androgenic than it is anabolic. What is the furthest example you have that's closest to ten? Meaning the most anabolic premable, and probably? So one would think that that would be like the drug of choice if you're a body builder. It often is too. So typically men will take, I'm not saying that's the only drug because it depends on what else you're trying to get because sometimes the side effects as absurd as it sounds are desired.

2:28:24So with dianna ball for example, heavily water -retentive. So that could help cushion your joints when you're doing heavy lifting for example. If you have better leverages on like a max out, you're going to be better with more water retention around your muscle belly then if you or in your muscle belly then you would if you had like a dry compound that is not a substrate for a rheumatase and premable and is extremely refined and specific in its action. Like it's like a pure protein accretion compound with a relatively less burdensome and urgent profile. But the side effects of it, it doesn't interact with a rheumatase because it's a DHT derivative.

2:29:05So it's not a substrate for rheumatase. it does not 5L reduce into a bunch of different things too. So it's more predictable and it's outcomes. But that's not always the desired outcomes. Some people want to look cosmetically inflated with water. Some people want to lift more weight or prevent injury. And sometimes that water can be helpful. Depends on the person. But yeah, that's like skewing the furthest direction of anabolic relative to anrogenic. You probably have like premable and anavar. Yeah, and I remember, again, just sort of reading like anavar. are also highly prized among athletes.

2:29:38Technically, charms are actually even further if I was to give the most extreme anabolic relative. So let's talk about charms then tell folks what those are. I guess selective androgen receptor modulators, these were kind of designed. Some people might be more familiar with serms. You've talked about clomid, tomoxifen on this podcast before. Selective estrogen receptor modulator, so these will interact in a tissue -specific way with estrogen receptors in various areas of the body. So you might have inhibition of estrogen receptor activity in the breast for somebody who has breast cancer, for example, versus you would have pro estrogen activity in other areas of the body like bone, which is what makes the selective action of it desirable because you can actually sort of choose where you get the activity you want, but also don't impact the health of other tissues and other areas of the body.

2:30:31So the same idea was kind of adopted for serums, and they tweaked and modified anti -androgen actually to make these compounds that would interact with the Androgen receptor in a way that was tissue specific and try and get pure anabolic activity with almost no androgenic. And proportionally, it's more successful probably than anabolic steroids, but the ceiling of anabolic activity seems to be lower. So when people use storms, they do not gain as much muscle as when they use anabolic steroids. And oftentimes in their quest for achieving a similar muscle -building outcome, the higher and higher the dosage gets, the less selective it becomes.

2:31:11So almost like certain, I don't know, beta blockers, for example, as you get higher and higher, they become less receptor selective and you get more like broad spectrum. What are the typical What are the most potent or commonly used serms? LGD4033, probably it's called a ligandrol. These compounds often get traded around companies so often that they have new code names every time I check. I think the most recent one was, I think it turned it to VK5211 by Viking Therapeutics was the last company I'm aware of who had it and I was in a phase 2 trial for hip fracture patients. It's Austrian, also known as EnoboSarm, was probably the most well -known Sarm, but it has not been FDA approved and seems to have not hit their target end points that they wanted, although it looked effective and oftentimes women who are trying to achieve like a physique to step on stage to try and like bridge the gap between not using anything and using steroids, they will go for something like an osterion, and they don't viralize themselves when they take it.

2:32:17It's funny. I always thought that was a sirm. I didn't know it was a sarm. These band compounds in natural bodybuilding? Yeah. And they're super detectable, because they're not supposed to be in your body at all. So how does one get these? Are these, if they're in phase two, compounding pharmacies, some of them make them? Yeah, that's true. I've heard some wild nutty stuff just like, oh yeah, I'm prescribed trend. How is your pharmacy made trend? Yeah, let's talk about trend. Where does that fit into? So that's actually classified as a steroidly -sarm, interestingly enough. So it was prescribed to women in the 80s, I believe, and was also used to beef up cattle and might even still be.

2:32:55But it is super anabolic, but it also has very odd, progestogenic activity. So it interacts with the progesterone receptor, causes severe night sweats, it's called trend sweats. It also has this weird side effect called trend cough. No one can be sure of what is causing it, but it's one of the only drugs associated with a prevalence of a severe coughing fit, like you're having an allergic reaction or something after you take it. So you inject it and you feel all of a sudden it's tightness in your chest and then within 20 seconds you're on the floor hacking up along for two minutes. I had a patient come to me a little while ago who was seeing some fancy doc in LA who had him on a pretty high dose of trend in GH.

2:33:39Again, there's always like, how do you get people off these things? Luckily, he wasn't on it for very long. Those compounds are more suppressive, too, because they interact with the progesterone receptor significantly. So it's like you get the negative feedback not just through AR, ER, but PR as well. So let's just kind of recap where you were on some of those. So did you talk about Deca and Andralund? Yeah, Deca is close to the more pure anabolic side. It's not near the selectivity of a Sarm at a therapeutic dose, but it is probably the interestingly enough, the only steroid that you can probably use at a dose that is will result in body, builder, level results without hair loss because it has unique interaction where it gets so complicated when you think of the pharmacology of this stuff because it's like it will five alpha reduce into a dihydronandrolone, which is almost no androgenic activity.

2:34:37So in the muscle where you have a relative absence of five AR, you will retain the anabolic properties of androlone where you want it, but then in your scalp, it'll five alpha reduce into this metabolite dihydronandrolone where it has almost no androgenicity. So you get like the muscle building without the hair loss. So, do body builders even take testosterone at this point? Almost always. So, why are the Hingt testosterone when they have all of these more designer and abolics that seem to have an advantage over testosterone in every way? Tostosterone is the base because it provides your estrogen -based layer of neuroprotection because none of these things provide aromatization.

2:35:18The only other compounds that could act as replacements for test are things that are potent and substrates for aroma taste too, but even then you get these synthetic estrogen metabolites that have less predictable activity. So for example, deball converts to methyl estridile, which the potency of it at the estrogen receptor, it's not as predictable. And your body doesn't really know exactly. It doesn't have as predictable of outcomes in terms of providing the base layer of what you want from like a broad spectrum, perfectly balanced endogeneity, converts to estrogen where you want it and in tissues, you know it protects the brain to some extent.

2:35:57Granted, superphysiologic dosages, you're a neurotoxic territory, certainly. You're not going to protect yourself with a base of test, but it's better than no test, for sure, or no estrogen. When you're saying it's superphysiologic doses, you mean superphysiologic doses of all of these other hormones? Yeah, because I guess there's no actual physiological level of them, but it's more just like the Androgen burden on your body is exceeding what it would be from a natural testosterone production standpoint. So what is a body builder? Let's just talk about an IFBP top 50 body builder in the world.

2:36:31What percentage of the year is he on some anabolic steroid? Oh, anabolic steroid, including testosterone. Yes, notably. 90 to 100%. They basically have accepted the fact that they've completely suppressed and lost any endogenous production for life and it's now just a question of how they cycle up the testosterone plus or minus the other antibiotic. Sort of. I've seen firsthand multiple bodybuilders who've been shut down for decades come off and restore natural function and they're using presumably FSH and some of them just HCG and just coming off the drugs and waiting long enough. But it begs the question, would they have been there had they not used the drugs until then?

2:37:13Is that just what is representative of where they decline to naturally or is it like a permanently lower ceiling potential because you've inhibited organ function for so long? You can't really say for certain. Do we have data on people who have been on anabolic steroids for five years or greater and the ability to forget spermatogenesis? Just regain endogenous testosterone production? Yeah, it's sparse, but it exists. The data are sparse or the frequency of people who do it is sparse. There's almost no literature on it. I believe there's a study that shows the recovery capacity and there are people who recover function.

2:37:49It's just relatively arduous if you don't know what you're doing too when it comes to post -cycle therapy, because you might have clearance of hormones and go to a crashed hypo -ganatal level that you're dealing with until you hopefully kick in, and can add atropans and hopefully respond to those well and hopefully restore production to a level that provides symptom relief. And that process isn't instantly to get the bleed these hormones of your system if you're using long acting compounds too, which most people are. So, there requires a lot of thought around bridging into your recovery and how you go about doing that.

2:38:23People have to be implementing as the androgens clear, they'd be implementing each, well, you'd hopefully be on HCG to begin with to preserve testicular function. Are these guys taking HCG the entire time they're on these other drugs to just maintain some testicular volume? Now it is, it's becoming more understood that it's probably important, but back in the day, and even me, I didn't do it because I was just told it doesn't matter, you will just recover fine when you want to, when you want to come off. I think more people are becoming aware though that stimulating activity in the latex cells is of reasonable importance almost certainly to retain and ease your transition back into recovery while you're on drugs.

2:39:04So at their lowest time throughout a year, they'd be on how much testosterone. They'd be only on testosterone and they would be on... Yeah, some people, they think that they're cleaning out by taking like a month off, but in reality, it's like the drugs have almost some of them work their way out of their system by then, but they've been on grams of stuff that's achieved steady state and you're just clearing 80 % of it or something. And then you've never actually gotten out of your system and recovered function, which could take months. So oftentimes they have either residual and origins in their system for the time they're trying to clear or most of them are staying on a base of TRT to bridge between blast phases, which are like your high exposure points.

2:39:45So those bridges though of TRT, typically it's not actual TRT. It's like fitness industry, TRT, where everyone's dose is 200 minimum. They cycle up during contests, obviously, professional bodybuilding is not tested, so the understanding is you're going to take anything and everything as often as you want. Do they take a more middle of the road set of compounds as they're bulking up and then move to the more pure andabolic less water retention as they're leaning out or there just must be so much nuance to this. In general, in an off season, when your goal is protein accretion, building muscle, they are using it as they still use a ton of stuff, but they will use less when they are preparing for a contest.

2:40:32And the thought is when I am trying to diet down aggressively, when I'm in a calorie deficit, I need more help. Yeah. Even though it's like what threshold is it to preserve tissue at the end of the day, typically a fraction of what they're using. but to build muscle, they will typically be using a base of testosterone plus one or two antibiotic agents in general. It's going to be a premable and an androlohn or something. And how many total milligrams? Because they're about one to one to one, right? No, it depends on the person, how sensitive they are to estrogen. Because there's also interaction with, for example, DHT derivatives, they also compete for aromatase, seemingly.

2:41:10I've seen people on the same dose of testosterone with and without a synthetic DHT derivative have significantly lower estrogen without an aromatase inhibitor. So they're actually lowering their estrogen input through competing for aromatase simply by using a synthetic anabolic on top. So it's like get them modulate that accordingly too. So it's like often times if you're a very estrogen prone individual or you get gynecomastia easily the male breast tissue development These are things you are concerned of when you are pushing your dosages to levels that your body cannot regulate on its own to prevent tissue formation.

2:41:51At TRT levels, most people will have no issues with gynecumacity development if they have a good protocol in place and they're not obese or whatever, but at super physiological doses of tests, not necessarily the case, but you might be able to modulate that activity down by actually competing for a rheumatase with your or premable in or your draw stand alone. And then you get to the progestins, like Nandrolohn, which seem to have like a additive effect, because progesterone receptor agendism seems to be a stimulation. It actually provides a stimulative input on breast tissue development too. Like there's other things besides estrogen that stimulate breast tissue.

2:42:28So you have GH also, an IGF -1 stimulate breast tissue development. Estrogen, progesterone, prolactin. These are all things you have to consider when you're using witch drugs. How do these guys navigate this? Not well, typically. Even at the pro level? Yeah, they just take random shit often. I mean, when you look at the guys on the Mr. Olympia stage, responding well does not equate to health often. There's multiple ways of skin and cat and you can still gain similar amounts of muscle with all these compounds in general, but the way you arrive there just might be more side effect burdensome or problematic in film the blank area.

2:43:05How many of these guys require surgery for gynecomastia? Most, they proactively do it to make sure they don't have to. Because one of the things that's brutal is guys who choose their drug protocol based on how gyno -prone they are to those drugs. So I've seen people use abusive dosages of aromatase inhibitor, serums, just to tolerate the androgen inputs. Some of the drugs that are substrates for aromatase, so it's like to use the drugs I need to gain the muscle, I'm going to get gyno development, which I can't have on stage because it looks cosmetically not pleasing and I'll get marked down for it.

2:43:40So I'm going to use aggressive Novodex and aromatase inhibitors while I'm using the Androgens to prevent gyno. So I can gain the muscle without the estrogen. But it's like you can just imagine the Androgenic signaling plus no estrogen. It's like a horrible constellation of negative problematic factors. It just seems like such a complicated regimen. I'm really surprised there aren't more health consequences of this. We see early deaths all the time in the bodybuilding world, granted we see early deaths in all places, but these individuals are at least, you can say, lean. They're typically following meticulous diets and training regimens, so at that point it's kind of just body weight and drug exposure, because their sleep is usually dialed to, at least as much as it can be relative to their related side effects.

2:44:26But yeah, when people say where are the bodies, I'm surprised we don't see more deaths. I think it just hasn't been as documented as it should be. There are a lot of people that you will never hear about because they're not a big name in the industry that had heart failure at 27 or something. Let's talk word about how you measure this stuff. So if you're taking testosterone, you can check testosterone. But which of these other compounds show up on a testosterone check? Many of them through immunosatesting. So if you use, for example, testosterone plus andandralone, it is derived from testosterone and often you will see a cross detection.

2:45:02So you might have an elevated testosterone level through a standard amino acid that is not reflective of your testosterone dosage you're using. And similarly, we see things like estrogen metabolites that are synthetic artificially inflating your estradiol on ECLA as well. And there are certainly a group of supplements that seem to aggravate this problem, although it's not been clear to me which ones. Agrivate, which the artificial reading of enzyme -based testing of estradiol. Yeah, yeah. There's certain things that you shouldn't take before a blood test, even like Piotin. Yes, Piotin being a good, like there's some basic stuff that really messes up readings.

2:45:45In general, if you're not getting liquid chromatography with tandem mass spectrometry, it's like the highest sensitivity of testing you can get for total testosterone. And free testosterone, this is something I haven't revisited in a while, but I recall equilibrium dialysis was the gold standard. And if you don't use those, you will end up with cross detection. I've seen on Immuno -Assa for total test and the calculation for free tests, numbers showing that I'm in the reference range for testosterone when I did Nandralone monotherapy, which for you, if you stayed on that decka, almost for sure your test would have ended up in the gutter, after dial in the gutter, and you would have just had an Andralone, there's no Andralone test, so you should have just had like a hypogenital looking testosterone profile in Estradile.

2:46:31But if you got the cheap entry level amino acid testing, it probably would have been, oh look at that, my test isn't rain still, I'm not suppressed on Andralone, I guess 100 Migs of Andralone isn't enough. That's a rough, yeah, yeah. Yeah, so that's like what some people might conclude. So it's very nuanced and it's not like your top to look for the stuff. Often most people aren't going to be prescribed this stuff to be in a way so it's a bit less relevant but in the bodybuilding world especially pretty important I would say to know especially where your estrogen is at thinking that you're good when you might have a DHT derivative competing for Romance and your E2 on paper looks in range and it's actually like crashed into single digits problematic brain damage cardiovascular disease bad bone loss.

2:47:13Let's talk a little bit about clomid and HCG. Maybe tell folks how they're used and we can talk about some of the pluses and minuses of each. Human -choreonic, genetotropin is presence in pregnant women's urine, significant quantities, and often it is pulled out as absurd as that sounds and purified because it can be used to stimulate the luteinizing hormone receptor similarly to what endogenous LH does. So it looks similar. Some people say it's a memetic essentially. I think it's the best way to put it. Like a mimics the effects of luteinizing hormone in the body. And this is why it is commonly used in fertility regimens for men, because you can essentially replicate the LH signal to your testes that may be suboptimal if you have Logan antitropanode output or non -existent if you have HBTA suppression from your exogenous testosterone using.

2:48:06So if you use TRT, you can pretty reasonably expect that your LHNF stage will go down to either non -detectable or close to there, depending on what you're using and the dose. And replacing that LH, I would say is of pretty high importance if maintaining fertility is important to you. So you will experience testicular atrophy if you do not replace the LH somehow, whether it's through recombinant LH, which is almost never used, or HMG, which is typically not used. Either the most cheapest, lowest barrier to entry, predictable thing is HCG. Which still is not that cheap, if you're using the brand -ded HCG as much more expensive as other sources.

2:48:50Clamp down on it recently too, in the compounding world. And then Clomid, I guess the primary clinical uses in women for fertility. for IVF prep. And men, it acts, this is how it works in women too, but it's just like for fertility purposes in men, it's a selective estrogen receptor modulator. So we talked about serums earlier, and I mentioned serums and how they use that idea for serums. It interacts with the estrogen receptor in either a positive or negative way, in that it could stimulate activity or prevent estrogen from binding to it and interacting and providing estrogen -related activity in certain tissues.

2:49:27and it's selective in the way it does this. So, Clomid has anti -estrogenic activity in the hypothalamus or tricks your brain into thinking it's estrogen deprived. So, the response to that is, we have low estrogen, so we need to make more testosterone to aromatize into estrogen. So, you up -tick your GNRH output to the pituitary, which will increase LH and FSH, which increases test, and then you can intervene with that compound to trick your body to make more tests, I think, as a best way to put it. And interestingly, I don't know if you want to go down the rabbit hole of N -clomophine versus clomophine.

2:50:01Clomophine has two stereo isomers, I believe. Yeah, one is basically a mirror image of it. Yeah, so it's like zoo -clomophine, an N -clomophine, an N -clomophine is seemingly the more selective and actually antagonistic in the hypothalamus. So it's kind of like doing the thing you want from the clomophine, whereas the zoo -clomophine is like anti -goodenated, like it's providing almost like a anti -androgenic type activity in a way that is not as selective as like a pure serum. So when you think serum, you're thinking something that antagonizes estrogen receptors purely in the hypothalamus, but then leaves estrogen activity everywhere else.

2:50:42Bone, integrity is maintained, cardiovascular, etc. Everything is kind of backfilled accordingly, except for right there in your brain where you want your brain tricked into thinking make more testosterone. So end -cholomephine, it also has a shorter half -life significantly less. I think it's 10 hours off the top of my head and zoo -cholomephine is like days or something. So the actual ability to maneuver the drug like pharmacokinetically too, if you have a bad side effect or something, can't even get off it as easily with cholomephine because you have this big chunk of it as zoo -cholomephine.

2:51:15So the idea and presumably creation of trying to get FDA approval on end -cholomephine was, because this is a more pure version of the drug that does what we want. And there's been at least one study that showed improved outcomes in women who took end -clomophine, but it never made it through FDA approval. But despite that, it doesn't stop people from prescribing it and people from using it. I don't think that's a sustainable treatment protocol for your entire life, probably, I think. The reality, and it's not as easy to adhere to, but I would probably assert that stimulating living exactly what you want to do directly with an HCG plus recombinant FHHS's superior outcome rather than perpetually inhibiting estrogen activity.

2:51:59There's no drug that's purely selective exactly where you want it is perfect. And that's the only issue I would also have with it where I think if you took two individuals and one of them you put on exogenous testosterone and one of them you put on clomaphine, they were identical in every way in terms of readout, equal testosterone, free testosterone, and estradiol. I think there's still an argument to be made that the guy who's getting it from exogenous testosterone has a better outcome because he's not getting the central inhibition of estrogen. So his libido is better, his mood is better, his sleep is better.

2:52:34Some of the mood dysregulation on Clomid wild. Yeah, I mean, we never saw this stuff, but again, I think we're a very small sample size. We're not running like a clinic on this stuff. And we're using microdoses compared to where I think people are going. If you're not asking those questions, you also might not get it. Even when people report that, these are often people who are on the precipice of hypogonadism already with very low quality of life as is, presumably to even get on the therapy, going on something and then noticing a decrease in vitality and notable anti -ethrogenic activity, you are going from a baseline that is not good to be in with.

2:53:17So it's like comparing that to the outcome of TRT, I feel like is often a misrepresentation just for the sake of your maintaining adequate function or you're maintaining the tisicular axis. At the end of the day, a thing that I need to maintain in perpetuity just for the sake of having an LH and FSAGES that comes from my batuitary. And so they're just manually doing it. Probably not if it's at the burden of permanently antagonizing one of the most important receptors in your body, I would say. Yeah, I think as a general rule, if you start to muck around with receptors in the brain, you should have a pretty good idea what you're doing.

2:53:52Let's talk a little bit about fertility. Let's compare a guy who's on testosterone versus a guy who's on HCG. If you're on a high enough dose of HCG, you're going to see FSH and LH suppression. Yeah, this is what I found. I had dug into this specifically based on that case that you mentioned. So what does it mean? So you've got two guys, one guy's on testosterone, one guy's on HCG and they both have a very high testosterone. They both have completely suppressed LH and FSH. Obviously in the case of the guy on high testosterone, his lady cells are doing nothing. In the guy on the high HCG, his lady cells are cranking out testosterone.

2:54:31own. But in both cases, there is enough testosterone being made that the pituitary has stopped making LH and FSH. So what happens to these guys when you stop testosterone? Let's assume they've both been on their protocol for several years. The guy who has sustained organ function is almost certainly going to have a smoother transition because he has maintained the natural function and output of the organ responsible for intertasticular testosterone the entire time versus the other guy has literally deprived the tissue so significantly that it's a fraction of the size. So trying to compare a guy recovering with testes half the size or less compared to a guy who has fully functioning testes that have been maintained.

2:55:21That guy just needs to discontinue and get rid of that feedback inhibition and he's likely going to return to natural function within short order pending his ganatotropin output from the pituitary satisfactory. So it's to be determined if that guy is gonna have adequate pituitary output given once you've other factors, lifestyle, et cetera, but probably that guy is gonna be okay. I would say the question then is why did that guy gonna HGD to begin with? because it's presumably because he had low LH output. So maybe if that guy got on with low LH output on HCG, because that's probably the main reason he would have, he's probably gonna go back to low LH output unless something dramatic has changed in his baseline lifestyle diet.

2:56:02And he's older now with less to stickular function just as a result of age. So there's that for sure that is a major factor, but he at least has more potential to recover to whatever his baseline was than the other guy, in my opinion, and who's gonna have a longer, more arduous road with. Okay, you have to have enough, you have to not only get the testosterone under your system to stop having negative feedback. Now you have to get the pituitary output back, hopefully to some satisfactory amount, which if your baseline was low, because presumably it was if you got on TRT, why else would you, unless you had like testicular failure?

2:56:36And that guy would have never got off test because that's the only option he has essentially. That guy is going to have to have enough LH output to stimulate him back to baseline testicle size to match the capacity of the other guy just from a morphologic standpoint. So I would assert that the HCG guy is almost certainly going to be better off than the test guy. Do you think that there's a way around it on the HCG guy if you dose him more frequently? Like you take the same dose, we typically dose HCG twice a week. So kind of starter dose would be like 750 units twice a week. Or 625, I think makes them at these years.

2:57:12I think 625 twice a week allows them to go whatever, eight weeks with a vial or something like that. And then generally we just stop. If you're not getting an amazing response at 2 ,000 twice a week, which we would never go above that, you're wasting your time and you're wasting money. Curious, by the way, what doses are bodybuilders using? Most aren't using it, but the ones that are typically, or even the ones that are using it aren't following like a literature recommended dosages, but at least from what I've seen to maintain intratusicular testosterone at 100 % while suppressed on exogenous endurgins, I think the dose is about like 375 IU every other day approximately.

2:57:54Okay, so not curtailing the endgages at all. But this is also assuming you're starting at full function and you're not trying to get back up from zero to 100. So that'll be a bit of a difference on that. That guy who was on HCG, I would assert probably have an easier transition for sure. But we can definitely get into the FSH suppression and the frequency of administration, that's what you ask. So if you pin more frequently versus twice a week, half life of HCG I believe is 24 to 36 hours off the top of my head. I'd have to double check. But if you are going to an everyday schedule, you're probably going to maintain more stable serum concentrations, so you're not going to get as aggressive spikes in light -accel activation.

2:58:39So you're going to have probably more representative of natural output of tests, but at the same time, if that level of test is satisfactory to achieve the hormone levels that your body needs from anandrogen and you should shut down. Yeah, then you should shut down. So the only way you wouldn't is either A, HCG was too low, B, your response to the HCG was too low, or C, your dosage frequency was so not ideal that you had little blips of time that you had deprivation essentially, and your body reacted to it, which is not an ideal outcome either. So the frequency thing, I think it's more so, I would recommend more frequent, probably, for just stability and side effect profile, but it's based on the adherence of the patient, how realistic it is that.

2:59:24Yeah, a couple more random things before we wrap up. We've been going a while and I feel like I'm about halfway through the stuff I wanted to talk about but there was one peptide we didn't talk about which is BPC 157. Do you know anything about that peptide? Yeah, yeah, one thing I shouldn't say before we get off the HCG though because you had that specific example of if FSH is suppressed, how do you know if the negative feedback is through the HCG Dose amplitude, etc. Versus the testosterone that comes from it. I found a really good study that was it used HCG at 4 ,000 I use in men who had normal guinattal function and those who were poor non -responders to HCG so you can discern from that.

3:00:03If it's the testosterone of the HCG. Yeah, but in addition, the people who responded, they used clomid on after. So this is the interesting thing. So it's suppressed FSH in the people who responded to the HCG, but not in the individuals who don't respond. So from that, you can discern it's not necessarily the LH interaction and more so the downstream androgen receptor activation and subsequent to that E2, estrogen receptor activation, the negative feedback. So that's pretty elegant. So that actually tells us that it's not that you've shut off LH. It's that you've ramped up testosterone that is turning the system down.

3:00:39Yeah, basically. Sorry, it's not that HCG is mimicking too much LH. Yeah, the LH receptor doesn't tell your brain, stop making tests. It's the testosterone output. Yep, yep, yep. And to confirm, they applied clomid in the responders to HCG2C if they could attenuate the FSH suppression and they could. So in that, you can assert that an estrogen is obviously a huge negative feedback regulator. If you can maintain FSH at baseline with a high 4 ,000 IU dose of HCG with pushing your total T way up and use the serum concurrently and prevent FSH suppression, it's like, okay, it's really downstream to the LH activation because it's literally the testosterone output and the estrogen, because you're still maintaining FSH with the same androgen signal and the LH receptor signal.

3:01:30So from there, you kind of then need to discern, okay, one thing I can say from the literature I've seen too is in -treatisticular androgenic signaling seems to be the primary determinant on sprobandogenesis far and above FSH receptor activation. So, one of the ways you can kind of conversely assess this too is finasterine, do task ride, reliably kill, don't kill, but it decreases significantly sperm quality. And count, it's something that is just reliably decreases all metrics of fertility from a semen parameters aspect. So, the intratesticular free androgen signaling seems to be the main dictating variable on per madogenesis and you can find even in people who have minimal or no FSH at all, getting them fertile on HCG only and maintaining it.

3:02:20Now there are certain people who don't seem to respond as well. Off -5 off -hybridic case inhibitor though or well still on. I'm just saying in general, like people who are on 5IR inhibitors, you're diminishing, your possibility of fertility almost certainly. So again, it's not just intertesticular testosterone, it's also presumably, and this is how you confirm with the five alpha reductase inhibitor applied is when DHT goes down, T goes up 15 to 22%. There's nothing changing about output of testosterone production other than DHT goes down when you have a five alpha reductase inhibitor. So if fertility goes down when DHT goes down, it's not just the testosterone.

3:02:56It's just broad androgenic signaling. So the more androgenic of environment you have, interestingly, seemingly is the main dictating variable. When DHT goes down testosterone goes up by how much? If it's finasteride, about 15%, and you are inhibiting upwards of at best if you use a 5 milligram proscar tablet for benign prostatocyper pleasure, you're getting a 70 % systemic DHT inhibition, which pushes your T an estrogen up by 15%, which is so interesting because regular T conversion to DHT is not that high. I mean, it's rarely more than 10%. So it's like you're disproportionately getting a bump in T to the inhibition.

3:03:38Yeah, yeah, and I'm sure this is probably something that I have to almost write out, but I'm sure if you get into the modulation of how much DHT is occupies SHBG, and then how much free testosterone there is. That's a free increase in testosterone, not total testosterone. But DHT also, the activity of it is going to be inhibited dramatically more proportionally to test because of its affinity for SHBG is like 5x. So I'm sure there's something there if I wrote it out, it would make more sense than me just trying to think all the way upstream but in general the takeaway that I've seen is having high Intratusicular endogenic signaling is the only thing that's mandatory for spermanogenesis and FSH receptor activation with some level of FSH you can still maintain or achieve spermanogenesis with minimal to almost no no FSH and in those individuals that still need a push, they either lack endogenic signaling or there's too much oxidative stress potentially.

3:04:37They need to utilize things like ubiquinol, NAC, I don't know, like sometimes supplements actually make a difference, quarantine, creatine, or get off their 5 -out for reductase inhibitor or amyriata things, but a little bit of FSH were competent on top of that base of ensuring you have adequate intertistic alerts to the australian can be the differentiating factor on fertility for a minority of people, but it's not mandatory. And at the end of the day, when I hear people talking about, well, maybe we should get back to, we should use Clomid instead of HCG because we're seeing FSH suppression.

3:05:09I'm like, I'm thinking a little bit of FSH. It's cost prohibitive, but it's probably a much better alternative. Yeah, what's the cost of recombinant FSH? It depends on the pharmacy, but I heard the other day there was a pharmacy in Texas that prescribes 1500 IU vials for like a couple hundred bucks, which to me sounds cheap. I've heard it's extremely cost prohibitive, and I think it depends if you're getting like gondol or if you're getting like which brand you're getting. A typical dose would be what? 50 IU every other day. It depends. You can go as high as 75 every day if you need to, but it's still significantly cheaper than growth hormone.

3:05:45Oh yeah, probably. I mean, everything is okay. All right, a word on BPC157, which is a peptide. Yeah. So, body protection compound, I think is what the acronym stands for, 157. It's like a peptide that's producing dodgingly in your gut and it seems to have some like angiogenic properties that can be useful for certain injuries, but it's like, I've seen some pretty remarkable improvements in like minor, not complete tears and certain injuries that are like of lesser. I'm not overly familiar with it to a point that I could say with any certainty that it's going to be efficacious for filling the blank thing, but it seems to be something that if I had an area with low blood flow, like a tendon issue or something, that's when I would be looking to something that's pro angiogenesis because it's like, I also worry about cancer cell proliferation from something that pro -growing blood vessels.

3:06:43So that is a concern with DPC for sure. And does it need to be injected locally for it to have maximum efficacy? So let's just assume you tear your rotator cuff. This was one of the bro myths we were taught back in the days and injected right into the injury site. And I now don't believe that to be the case. It seems at least the last I heard that you don't need to do that. Do we hold out any semblance for hope that we might get a study that would shed light on this? because how could we ever possibly know the counterfactuals here and how could we possibly disentangle the single user experience on all these things?

3:07:17I don't think so. I think it's something that so many people use at this point. I imagine you can't patent anything or make any money off of studying it. You'd probably know better than me off of pharmaceutical pipelines work, but I imagine it's kind of at a point where so many compounding pharmacies sell it. The problem I see mainly, I don't really think it's not good to use. I would probably use it if I had a minor injury to somewhere I needed more blood flow, but I do think a lot of people use it proactively far too often for something that is directly intertwined with increasing I think it's a veg F and is like super correlated with cancer growth.

3:07:54Like to me, that would freak me out people who are using it like preventatively. A lot of athletes use it as a preventative measure to avoid injury or rehabilitation when it's not necessary and I think that's overkill and risky as hell personally. I think because there are so many other things I wanna talk about that we should just wrap this up and hit a part two. Because we haven't talked about any of the stuff I wanna talk about around nutrition, around appetite, appetite suppression. Again, I think we've talked a lot about how body builders use drugs and I think for many people, that's a pretty foreign idea.

3:08:30But body builders also, I think, in a way, through their own very empirical study have really figured out the science of how to get lean and how to do it with the maximum preservation of muscle. This is something that I think most of them have dialed. They really do and that's why I can't imagine a demographic that better understands how to do that even if it's not necessarily the healthiest way to live. But I think we could all take a page out of the book if we're saying, you know, God, I could stand to be 10 pounds lighter. Wouldn't it be cool if I only lost one to two pounds of muscle in the process?

3:09:05When you see a guy with 50 pounds more metabolically active tissue demanding nutrients, starve himself to 5 % body fat and step on stage, it's like, okay, I can cut my calories by 300 or find some way that is more satiating to hit my goals. Like it's definitely something to take from that. Yeah, I want to dive deep into that. But I also think we could spend some time talking about ways that people can prevent themselves from being fooled by all the charlatans out there. But these people wouldn't be as popular as they are. They wouldn't be making tens, if not hundreds, of millions of dollars, if there weren't people who were falling for what they're talking about.

3:09:44So probably there's something to talk about as far as like, what are signs that maybe what this person is telling you might be too good to be true. Maybe there's a bit of a buyer beware. Anything else you want to add to around too when we do it, which maybe we can do in the fall or something? Off the top in my head, I think the fertility discussion, I think we kind of scratch the surface on what an ideal protocol might look like and things to be mindful of, banking sperm concerns that people might have getting on TRT beforehand, how to vet if you need it, even like criteria that would be worthwhile to know because discerning oftentimes people are told, especially at the clinics, oh, you're told these 400?

3:10:26That's low. Get on test. It's like you might have high AR content and expression. You don't know that you need more tests to actually achieve. I've seen some of the most jack guys I know. I have 450 totalties and feel fine. There's a lot of nuance that goes into that too and knowing, not just identifying content charlatans, but medical providers, even your own doctor potentially, knowing who is looking out for your best interest, educating yourself at a base level, I think is almost a necessity nowadays to wade through the nonsense, so I would love to dive deeper. Sounds awesome, man. I look forward to it.

3:10:59Derek, this was a ton of fun, and I look forward to continuing the discussion. Awesome. Thank you for having me. Thank you for listening to this week's episode of The Drive. It's extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members, and in return, we offer exclusive member -only content and benefits above and beyond what is available for free. So if you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of the subscription. Premium membership includes several benefits.

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