Dr. Gabrielle Lyon 00:02
Doctor Tobias Kohler, welcome back to the show. And I have to say, your episode was one of our most watched episodes, and for a number of reasons, you said that the penis is the most sensitive biomarker a man has.

Dr. Tobias Kohler 00:37
Yes. Well, first of all, thank you for having me back. It’s quite an honor, and yeah, I still believe it’s true. The penis is the check engine light, the canary in the coal mine, whatever saying you want to utilize. Because in order for it to function on all cylinders, your body has to be willing to give resources there, as you know, if you’re sick, if you’re not feeling well, if you’re stressed, the body shunts resources towards the brain. Right. So first of all, it means you’re overall healthy. You have to have excellent blood supply. You have to have normal nerves. You have to have excellent psychological and psychiatric health. And if any of these things, your hormones have to be on point. If any of these things are missing, it won’t work.

Dr. Gabrielle Lyon 01:27
You know, we are hearing a lot of information in the women’s health space right now, which is long overdue. But you and I were talking before the camera started, and you had mentioned something in terms of number one, men die, right? They die earlier than women. But also, you had mentioned something about the way in which we look at men’s health.

Dr. Tobias Kohler 01:52
Yeah, so you know it’s just a fact that the average man in the United States lives to age 76, and the average age a woman dies is 81, so women, yay, they get to live five years longer. That’s for a variety of reasons. Another thing to remember is that if we were to look back in time, if you compare how long men live now, at age 65, what their mortality is at age 65, it’s identical to what it was in women 50 years ago, meaning that essentially longevity for men is 50 years behind the times. That’s from a number of reasons, but if you look at the top 10 leading causes of death in the United States, the men are winning in nine of the 10, and the only one that women are winning in is, can you guess?

Dr. Gabrielle Lyon 02:46
Well, you told me, so it’s Alzheimer’s. I’m not so sure if I’m supposed to act dumb, because I don’t need any help with that. But when you say winning, you’re talking about chronic disease. Yeah,

Dr. Tobias Kohler 02:57
I’m talking about, you know, it’s the bad type of winning. Right, we don’t want to win at that. Yeah, you definitely don’t want to win at dying earlier, and so we have a problem with men’s health overall in the United States and in the world, and it’s something that I think needs to be addressed. It comes from a variety of reasons, right? Number one, men are a lot less likely to seek healthcare than women. They’re 33 percent less likely to even go to the doctor in the first place. Number two, men are much less likely to talk to their friends or family about any medical problems that they may be having. You know this, the phrase “I’m healthy as a horse. I haven’t seen a doctor in so long.” That’s not a good thing. It’s a bad thing. The other thing that’s different is, you know, essentially when kids go to pediatricians, girls get handed off to the OB/GYN doctors, and boys get handed off to, most often, no one. So there’s this period of time where men learn not to go to the doctor, 10, 20 years, and these are the prime years where we can do screening, we can do education, we can prevent things like, you know, suicide, which is four times higher. At what age

Dr. Gabrielle Lyon 04:15
group in men? At what age group?

Dr. Tobias Kohler 04:17
Well, all comers in terms of suicidality. You’re much more likely to die from suicide because men typically choose much more

Dr. Gabrielle Lyon 04:28
aggressive, aggressive

Dr. Tobias Kohler 04:29
solutions, so to speak. There’s a difference in mental health acquisition, and you know, that’s why I think it’s something that needs to be worked on, and I’m very excited to see that currently there is a bill on the floor, which is for an Office of Men’s Health.

Dr. Gabrielle Lyon 04:51
Which, I didn’t know that they didn’t have an Office of Men’s Health. You said something I just want to point out. You had said that the winning, that the guys are winning in a number of diseases that kill them, heart disease, and what are the other ones that are

Dr. Tobias Kohler 05:11
cancer, you know, accidental deaths, you know, you name it, kidney disease, everything,

Dr. Gabrielle Lyon 05:17
and then women have a higher rate of Alzheimer’s. But the other statement, you know, again, the landscape and the education, is it that we don’t know enough about men’s health versus women’s health, or is it sexual health overall? And when I say sexual health, is that the hormone domain of both men and women?

Dr. Tobias Kohler 05:41
Well, I think there’s definitely a lack of knowledge and understanding of sexual health for most people, in both men and women. And men and women have obviously unique needs, whether it’s hormonal stuff, whether it’s pregnancy-related, whether it’s, you know, sexuality, whether it’s addiction, right? Men are much more likely to become addicted to stuff. But there should be a government office which looks at the top unique needs of either gender and fixes it. And you know, the Office of Women’s Health started 30 years ago. Since then, cardiac mortality in women has gone way down. There have been other countries that have started an office of men’s health. Ireland, they’ve had an unbelievable decrease in cardiac death and cancer deaths in Ireland because of this initiative. Brazil also has done this, so it’s doable, and it’s doable in such a way where if we actually copy what the Office of Women’s Health did to improve the health of women, I think we can get a similarly successful approach in men. And the person who would help spearhead this would be Admiral Brian Christine. He’s a urologist. He’s a friend of mine. He and I were on committees together 20 years ago, and right now he’s the Assistant Secretary for Health. And so the current bill that’s in the works has bipartisan support, both Democratic and Republican support, and it would put Dr. Christine in charge to organize how we’re going to address public health in a cogent, systematic, fair, and effective manner.

Dr. Gabrielle Lyon 07:30
It’s very exciting, and Admiral Christine is also a friend. He’ll be coming on the podcast. It is the golden era of hormone, I don’t want to say hormone replacement, but I think hormone acknowledgement, and just overall health and wellness. And it’s time. It’s time because it’s been quite taboo. I know that, you know, Dr. Larry Lipshultz was on the show, and I know that he feels that it isn’t as taboo, but it still is controversial, even when we talk about, does, for example, estrogen cause breast cancer? Does testosterone cause prostate cancer? Even though we know that testosterone doesn’t cause prostate cancer, there is still a very slow drip to the rest of the general population as well as primary care providers. In this Office of Men’s Health, what will be the beginning initiatives? How do you imagine? Or I don’t know if you guys have discussed what that actual approach would look like, if it mirrors the female approach.

Dr. Tobias Kohler 08:37
Well, I don’t want to speak for people much smarter than me in this area, but it would make sense to start triggering screening, right? I mean, people look at screening in such a strange way. I had my first colonoscopy last year. Yay! You know, but, you know, I got the results back, and they said, yeah, you got one polyp, not bad. Come back in seven years. And actually, they said come back in three to seven years. And so I talked to my friends about it. They said, oh, so you’re going back for another colonoscopy in seven? I’m like, no, I’m going in three. Right. So, you know, you have to take responsibility for your own health, and, you know, I want the screening tests. I want to check my PSA early. I want to get to this stuff before it becomes a problem. I want to turn medicine for men from, you know, a reactive event to a proactive event. Again, you have to, you know, there’s this term, agency. You take control of your own action. You are driving your own car. You are the CEO of your own body, and there’s a number of things you have to do to get it initiated. An Office of Men’s Health would be one, but also, you know, doing things like just understanding how your body works is another. Number one, right. Number two, finding your voice, asking your physician, why this test, can I get a second opinion, what are my other options? Having the courage to do that is not easy.

Dr. Gabrielle Lyon 10:13
No,

Dr. Tobias Kohler 10:14
you know. And then, of course, the last thing is to actually take action so that you’re driving your own bus, and you’re doing what’s best for you, not based on a statistic or an average. You know, ultimately, we’re all not just the mean or median of a 1,000-person study. We’re us, individual people, so we have to decide for ourselves what’s best for us.

Dr. Gabrielle Lyon 10:35
And with that, last time you were on the show, again, you dropped the line that the penis is the most sensitive biomarker a man has, and the Princeton IV Guidelines came out shortly after. Can you give us the headline?

Dr. Tobias Kohler 10:47
Yeah, the Princeton IV Guidelines are a group of cardiologists, urologists, some endocrinologists who got together and wanted to look at, specifically, in this case, the link between the penis and the heart, and the three big take-homes are: erectile dysfunction definitively predicts heart disease, and is the most effective predictor in young men that we have. Right? Say that

Dr. Gabrielle Lyon 11:15
again. The

Dr. Tobias Kohler 11:15
most effective predictor of having a heart attack that we have is erectile dysfunction, especially in younger men. So a trick question that you might get asked as a medical student is, “What’s the most common sign or symptom before you have your first heart attack?” The answer is nothing. Some people just drop dead because they never have chest pain, they never have shortness of breath. But we do have this incredible marker, which men are very sensitive to, which is that if the penis is failing in the bedroom, yeah, there’s a blood flow problem until proven otherwise. And the evidence is so strong, so significant, that now in those guidelines we say, listen, if you’re a young man with problems with erections, you should strongly consider getting a coronary calcium score. This is a gated CT scan of your heart, which looks at calcium, which, again, is very, very good at predicting heart attacks down the line. Last but not least, in the Princeton IV guidelines, we talked about treatments for problems with erections, and also how, you know, Cialis may be, you know, protective against heart disease. So jury’s still out there, but man, what a powerful thing to have a drug that not only helps with erections, not only helps with peeing too often and going in the middle of the night, but also may be cardioprotective. So jury’s still out, but my personal opinion is I think these drugs are actually protective.

Dr. Gabrielle Lyon 12:38
It’s nice to hear that medications can be protective, as opposed to what we hear about medications, that the side effects are so tremendous. Something new that I would love to learn about is this idea of a ceramide biomarker, the cholesterol test that misses erectile dysfunction risk.

Dr. Tobias Kohler 13:01
Yeah. So ceramides are this ubiquitous protein that’s in lotions. You look at any lotion bottle; it’s going to say… “I buy those.” Right, but there are certain ceramides that are specific to different body parts, and there are some that are specific to the endothelium of the heart. And so there’s a bunch of different labs throughout the world that are trying to find the best kind of ceramide combination. Mayo Clinic has developed their own test, and it’s very, very good at predicting your rate of death from heart attack.

Dr. Gabrielle Lyon 13:34
So someone would go to their provider, or probably the Mayo Clinic. The Mayo Clinic is typically years ahead. Go there and say, “I would like a…” Is it just an overall ceramide test? It’s

Dr. Tobias Kohler 13:47
a ceramide blood test. It’s relatively inexpensive. It’s a test that you can have sent to the central lab at Mayo Clinic from any clinic, you know, in the world. So

Dr. Gabrielle Lyon 13:57
frankly, we should be doing that at Strong Medical.

Dr. Tobias Kohler 13:59
You know, some people would say it’s too young. The data is too early to say that. But again, I’d much rather be proactive than reactive. And when you look at men or women who have high ceramide scores, they’re much more likely to die of a heart attack. Now, what’s the beauty of this test? Cheap, easy, but it changes with behavior. So if I am unhealthy, I don’t exercise, I eat poorly, I’m 15 pounds overweight, but I turn things around, I buy a book like Forever Strong, I follow a plan, I check my ceramide again, it gets better. So it’s a test that goes from a score of zero to 12. 12 is like you’re going to the cardiologist tomorrow because you’re, wow.

Dr. Gabrielle Lyon 14:42
It’s that sensitive? Oh yeah, and specific.

Dr. Tobias Kohler 14:45
Well, I mean, essentially, if you can change your ceramide score from 12 to five, your risk of heart attack goes way down.

Dr. Gabrielle Lyon 14:53
What is the biggest way to move the needle on a ceramide test? Because it’s a byproduct. So, could you explain how we can think about ceramide?

Dr. Tobias Kohler 15:03
Well, I think it’s an overall marker of endothelial inflammation. So the likelihood that the blood vessels are going to get a rupture and then get sticky, and then you die from heart attacks because the body inappropriately clots off a big old artery in your heart, and then you don’t get blood to the heart and you die. So basically, it’s trying to assess the health of the endothelium, and in a sense, lipid levels kind of do this. But lipid levels wax and wane; they go all over the place, and they don’t change if I start to exercise.

Dr. Gabrielle Lyon 15:39
It takes, right,

Dr. Tobias Kohler 15:40
very… It’s kind of a static test, whereas ceramides is like, if I’m doing it, I can see the difference

Dr. Gabrielle Lyon 15:48
immediately? Immediately, or weeks, two weeks?

Dr. Tobias Kohler 15:51
Yeah, no. As soon as you are healthier, you stop releasing as much ceramide into the blood, and the level will go down. So I’m not advocating for checking your ceramide every month, but, like, check it at baseline for sure, and then, again, knowledge is power. If that thing is high, you’d better start to worry. And the study that we had was when we combined men with problems with erections with a high ceramide level as the second kind of marker of potential problems, we saw a much, much higher rate of premature stroke and problems, right? So a relatively small trial, but it was a powerful predictor of, you know, these potentially avoidable catastrophic complications of, you know, blood flow.

Dr. Gabrielle Lyon 16:30
And would you say that ceramides as a test, which I think is really profound because of the fast changeover, for example, well, we know Lp(a) doesn’t really change, but that’s a risk factor for cardiovascular disease. Apolipo-, you know, apoB can change, but it doesn’t change as quickly, if we’re thinking about prevention. And, you know, my husband goes to the cardiologist and he gets a calcium score. Would it be safe to say that the ceramide score would be a bit predictive? Because what I’m hearing you say is that the ceramide score will increase the likelihood of a plaque formation.

Dr. Tobias Kohler 17:13
Yeah.

Dr. Gabrielle Lyon 17:13
So

Dr. Tobias Kohler 17:15
both tests are great to predict heart disease. Yeah. One is a CT scan. Yeah. One’s a blood test. Again, it’s relatively young in its development and how we understand it, but super exciting, and I think something that I certainly take advantage of. Every guy that comes to my clinic with ED that I’m worried about, he gets it. And then if it’s above, in my hands, six, off to the cardiologist they go, and they get probably a more invasive stress test.

Dr. Gabrielle Lyon 17:45
There is this operating belief, and this is one of the ways in which muscle becomes dysfunctional, and this is really out of Shulman’s lab, and it talks about how diacylglycerol and ceramides increase in skeletal muscle and then create derangement. And I always think, how do we get a marker that shows that we’re being effective in, for example, our exercise, in an immediate feedback loop? So I would think, okay, we’re going to test a myokine. That’s totally unrealistic because your ability to squat, the way in which you contract muscle, is going to be different than mine. Let’s say I have unhealthy muscle and I’m not stimulating my tissue appropriately. We should be able to test not just from a contractile perspective, but from a metabolic perspective, how effective that exercise is. So when I think about ceramides, I think about muscle, and if it’s changing that quickly in blood, could that potentially give us an indication that our exercise is actually effective? I mean, going out on a limb here.

Dr. Tobias Kohler 18:56
Yeah, well, I’m not certain, you know, but we do know that ceramide levels will go down if you do exercise, right? So whether it’s a direct or indirect effect, I’m not sure. But again, the fact that we have a test like this readily available in modern medicine, I think that is the thing that we need to remember.

Dr. Gabrielle Lyon 19:18
I’m excited to see how that evolves, because I think that marker can change a lot of things because of the quick flux that I’m understanding that you’re saying. Because if someone comes in and says, “Well, I’m doing all the right things,” and this is not a genetically predetermined marker like Lp(a), then we should be able to say, “Well, actually, you’re not working hard enough.” And I know that that’s a little aggressive, and I don’t mean that to be condescending, that we’re saying, okay, oh, you’re not working hard enough. But I could say, hey, whatever the plan that you were doing in the gym, I get that something is better than nothing.

Dr. Tobias Kohler 19:50
Yeah.

Dr. Gabrielle Lyon 19:51
But it just makes me think about Chad. Your story about Chad, this patient that you’ve had that we talk a lot about as a representation of anabolic, you know, steroid use. Again, even I watch myself. Even I feel cautious in how I talk about it, and I’m a clinician and a science communicator, and I can only imagine that other people have that same experience if they’re not influencers. They really have to have these conversations, and so I always think, you know, if we’re putting in the time and the energy and the input, are we really putting it in the right places? Maybe people are not training hard enough. Maybe they are not doing what Chad does. It’s Chad, right? It’s not Chaz.

Dr. Tobias Kohler 20:36
It’s Chad. You got it. Yeah, yeah. No, I think you’re right, and it’s hard to know if you’re doing the right or wrong things because you can’t see yourself, right? It’s hard to be a good judge of wrong things. Think of people who diet and they swear they’re doing everything right.

Dr. Gabrielle Lyon 20:52
Right. Those are the people that I’m talking about. Right. And

Dr. Tobias Kohler 20:55
then all of a sudden they’re like, oh, I guess I didn’t remember to count, you know, those specific calories, or I didn’t realize peanut butter had so much fat in it, or whatever it is, right? So yeah, I think it can give us insights as to, are we moving the needle in changing physiology and reducing risk, with a very concrete test. I mean, I think it’s a very powerful thing to be able to say, and especially if, you know, you fall off the wagon, right? And you’re like, hey, last year we checked and it was three. This year it’s seven. What gives? Yeah. Now, probably there’s going to be some differences in weight, but maybe not. Maybe it’s just you’re not hitting the gym anymore. Maybe you decided that you didn’t eat fruits and vegetables anymore, or maybe it’s because you’re sleep deprived because you’re freaking out about some stress, right? So I think all these things play a role, but that’s why I’m so excited by it, because it potentially gives you a good starting point and a waypoint in the future to see if what you’re doing is effective.

Dr. Gabrielle Lyon 21:53
And you were the co-chair of the Princeton IV consensus guidelines on erectile dysfunction and cardiovascular disease, and essentially that’s what we’re talking about, as an early predictor. What do you hope to see in terms of outcomes for patients with these new guidelines?

Dr. Tobias Kohler 22:14
Well, many more people getting coronary calcium studies.

Dr. Gabrielle Lyon 22:18
Hard, so that’s hard plaque, right?

Dr. Tobias Kohler 22:20
Is

Dr. Gabrielle Lyon 22:21
there a world where they’re looking at hard and soft plaque?

Dr. Tobias Kohler 22:25
Yeah, I’m not sure. But as far as the hard outcomes from Princeton IV, again, just the knowledge that these things correlate, that we should try to intervene earlier. When we look at risk calculators for cardiac disease, you know, it’s a bit cumbersome, but you have to go onto your app or onto the phone as a provider, or you can do it yourself, and you enter in your blood pressure, you enter your cholesterol levels, and you enter your age. And it turns out that age is the biggest thing in the model, right? So if you take anybody’s cardiac risk and you change it by five to 10 years, the risk goes through the roof. That’s like the most sensitive predictor, because we have these predictors based on these trials, which are very age-dependent cohort studies. I hope that future cardiac risk predictors will start to take into account erectile dysfunction as a risk factor, because there’s only one that does it so far, and it increases the risk, you know, on average by 10 to 15 percent if it’s a positive or negative. But if it’s severe ED, that’s a much, much stronger predictor of having a heart attack than if it’s mild ED, right? So now if you start to stratify by mild, moderate, severe ED, based on, like, how bad is the ED, how long’s it been going on, then we can further refine these cardiac risk calculators and come up with better advice as to how you should act.

Dr. Gabrielle Lyon 23:55
You treat men with testosterone, and I’m sure that you’ve seen the things floating out there about statins and a secondary decrease in testosterone because of their impact on cholesterol. I suppose, number one, is that true, and is it clinically significant?

Dr. Tobias Kohler 24:15
Yeah, I mean, I take a statin, and I think my T’s fine, right? I don’t have good evidence to say that these statins lower testosterone. I think if there is an effect there, it’s probably a minor

Dr. Gabrielle Lyon 24:31
one. But you’ve heard it, right? Yeah, of course. I also heard that

Dr. Tobias Kohler 24:34
statins, you know, maybe cause some problems with thinking, or myalgias, these kinds of things. But when I look at the data, people who take statins get less dementia. Hard stop. You know, when you’re born, your LDL is 50. 50. And so I spent, I was lucky to spend a half day in clinic with this guy named Dr. Kopecky. He’s like one of the world’s premier preventive cardiologists. You know, and so I had the luck to spend some time with him occasionally, and he’s going to be part of the Princeton V guidelines, by the way, which are coming. You guys already

Dr. Gabrielle Lyon 25:05
started number five? Yep. Okay. Yep.

Dr. Tobias Kohler 25:07
Yep. Much more focus on testosterone, much more focus on women’s health, and then evolving data, because the field is moving very, very fast. So that’s exciting. But what Dr. Kopecky says is, you know, you’re born with an LDL of 50. If you ever have had a cardiac event, so if you see something on a CT scan in the heart that looks like plaque, if you’ve had a heart attack, your LDL goal should be 50. That’s really low LDL.

Dr. Gabrielle Lyon 25:35
That’s very low LDL, because I’ve actually had Tom Brenna, who’s on the dietary guidelines, and he talks about LDL cholesterol, and the dietary guidelines really are, I don’t know how to say this, but they seem to be somewhat of a medical intervention. LDL above 130; those with an LDL above 130, it’s like 24% of the population.

Dr. Tobias Kohler 25:59
Yep, it’s true.

Dr. Gabrielle Lyon 26:00
But the guidelines are talking about reduction of saturated fat. This would be a nutrition plan. So if we were to just actually think about dietary interventions, who is it meaningful for? It’s meaningful for someone who has a cardiovascular risk, especially when it relates to LDL cholesterol and cholesterol.

Dr. Tobias Kohler 26:22
Yeah, the average LDL, I believe, of somebody who has a heart attack is 100, like 106 or something. So there are plenty of people with normal cholesterol that still get heart attacks, but we do our best to make it better. So the other thing that Dr. Kopecky taught me is that if you don’t have a cardiac calcium score, your LDL goal should be 100,

Dr. Gabrielle Lyon 26:45
which, which again is double what you

Dr. Tobias Kohler 26:47
were as a baby, yeah, but is clearly a lot lower than what I used to be at prior to starting this. Yeah,

Dr. Gabrielle Lyon 26:52
and then the question becomes, what’s the optimal goal? So we’re talking about the outcome for prevention of heart disease, but I’m sure it has a function, and that there is probably an optimal number, just like we think about, okay, here’s the optimal number for testosterone. I recognize that to each his own. For some people, it’s 600. For someone else, it’s 700. But there is probably a mean to an optimal range for… I, again, hate this word, optimization,

Dr. Tobias Kohler 27:22
yeah,

Dr. Gabrielle Lyon 27:23
as opposed to prevention of heart disease,

Dr. Tobias Kohler 27:25
right, right. Again, I would just continue to lean on diet, exercise, sleep, stress mitigation, and then, you know, GLP-1s. I think they are a good thing. They’re going to move the needle bigger than anything else we’ve ever had in terms of reducing cardiac risk.

Dr. Gabrielle Lyon 27:46
Do they have an effect on sperm quality or testosterone levels?

Dr. Tobias Kohler 27:51
Sperm quality, not that we know of.

Dr. Gabrielle Lyon 27:55
But there are receptors, from what I’ve read and learned. Yeah,

Dr. Tobias Kohler 27:58
but so far, no evidence that it’s going to cause any craziness, but it’s early. You know, we’re positive.

Dr. Gabrielle Lyon 28:06
What about, you remember, there was that study about metformin and its impact on spermatogenesis and fertility.

Dr. Tobias Kohler 28:12
Yeah, there’s no doubt that people who are on GLP-1s are going to have some benefits, because they’re going to lose weight and their hormones are going to be optimized. Their inflammation is going to be reduced, and likely their fertility is going to be better. And that’s what the preliminary evidence is showing. But it’s relatively early. But whenever we talk about risk to something, I think people often don’t think about, well, what’s the risk of doing nothing?

Dr. Gabrielle Lyon 28:36
Yeah.

Dr. Tobias Kohler 28:37
Right. It’s the same thing with, you know, if you have a hypogonadal man, and you’ve got some providers that are very worried about the potential risks of getting the testosterone back into the normal range. Well, we know that if we do nothing, the risks of heart attack, all-cause mortality, cancer are a lot higher than when we intervene. So we have to keep the baseline risks in mind as well. And as far as, you know, T levels and erectile function, weight loss helps.

Dr. Gabrielle Lyon 29:05
You had said something that I’d really like to dive into a bit more, and it was this idea of supraphysiological doses of testosterone, and, again, this is going to be an extrapolation, and most women are not, I don’t want to even use the word abusing, but, again, I don’t even have the vocabulary to frame it up. They’re not necessarily abusing testosterone, because there are significant changes that would then happen, with lowering of the voice and these side effects. But for men that go on supraphysiological doses of testosterone, there are changes that happen, and you have looked at that and published data on those changes.

Dr. Tobias Kohler 29:46
Yeah, I think testosterone is like any other substance. If it’s a normal part of human physiology, too low is bad. There’s a range where things are good, and then when you redline, then bad things happen, right? So we know that people who really push the boundaries of supratherapeutic testosterone levels, several thousand, right? They have more than a normal T level. Let’s just arbitrarily say 500. We’re talking about people that are pushing 2,000, 3,000. Do

Dr. Gabrielle Lyon 30:21
you get worried? And I know that this is going to be a tricky answer. Do you get worried at 1,000?

Dr. Tobias Kohler 30:30
Kind of. I’m not certain. And no

Dr. Gabrielle Lyon 30:35
one would be certain, right? Right. There isn’t data that would say. My answer

Dr. Tobias Kohler 30:40
is gonna lean on people checking their T levels when they’re young, okay. So back to the fact that, you know, the boys that become men don’t have a primary care doctor for 20 years, if not more. What if we checked their testosterone level when they were 25? They’re healthy. They can eat poorly, and they still stay thin.

Dr. Gabrielle Lyon 31:06
It’s very annoying, right?

Dr. Tobias Kohler 31:07
Right. And they’re basically in the best shape of their lives. Their T level at that point, when they’re healthy, is a very important number. Most of the time, it’s going to be 500 or so, right? There are some published T levels per decade of life, and it does go down. There

Speaker 3 31:26

are.

Dr. Tobias Kohler 31:26
Yeah, there are. There are, and, you know, it’s something like 480, 460, 440, and I was trying to look at this big cohort of Mayo Clinic data to try to get it into the much more geriatric ranges, because we got it, like, between 20 and 40 in a small, small study, but it’s well done. But I’m trying to figure out what it is for the 20s, 30s, 40s, 50s, 60s, 70s, 80s, 90s, using many, many, many patients, and still working on it. But the bottom line is, it’s pretty rare to get above 1,000 naturally, right? So considering that as a kind of max upper level of normal is a very reasonable thing from my perspective. I don’t claim to have all the answers, but when I look at the science, you know, the guidelines will tell you to shoot for a level around 500. It’s very easy to remember. 1,000 is probably running a little too hot, because we do have very strong evidence that if you’re running at 2,000, 3,000, you get cardiovascular disease, and

Dr. Gabrielle Lyon 32:23
I want to pause here, because this is really good education for the patients listening to us and the doctors who are going, wait, from an anabolic steroid perspective or performance enhancement, there are reasons why these things happen. And I’ve learned this actually from you, that there is cardiac remodeling, that there are things that happen, that I would love for you to pause and explain, because there are providers and also patients who have to understand this, rather than it just being kind of, well, you’re going to get cardiovascular disease if your testosterone is 1,000 over two years, because it probably takes more time. But again, you’ve got 20-year-olds that are growing up in the online culture and the YouTube space, where it has unintended consequences.

Dr. Tobias Kohler 33:17
Right. Yeah. Well, complicated answer, but first of all, you know, when I’m advocating for checking a baseline testosterone level at age 25, like, before I stick the needle in, or the phlebotomist does, I want to ask them, how do you feel? And if the answer is good, everything’s working, penis is working, all systems go, then that T is what you need to do well. And if the answer is horrible, then, well, it’s not really a true baseline, because you’re not at your optimal, right? So, oh,

Dr. Gabrielle Lyon 33:54
I like that.

Dr. Tobias Kohler 33:55
Right. So when you check your level at 25,

Dr. Gabrielle Lyon 33:58
regardless of the number,

Dr. Tobias Kohler 33:59
right? You want to know: Are you feeling well or not? And by definition, remember, to treat people with T, you need to have both symptoms and a biochemically low level, which you can debate what that level should be. But if they feel well from the get-go, and presumably they’re in their prime because they’re 25, that is a good baseline for them that you can use in the future. Now let’s talk about abuse. So you got a guy who feels well. His T is 500, but he wants an edge. He wants to get bigger, faster, stronger, faster, faster, twice. First of all, you know, when I ask guys like Chad, my friend, my testosterone expert, you know, what are the reasons why people will start these androgens? One of the common reasons is, I want to become a professional athlete. I want to win. Like, I want to have my fastball be 95 instead of 92, whatever it is. The problem with that thinking, though, is, like, if you’re not a good enough athlete in high school or college to already be elite without enhancement, sorry, you’re just not good enough, man. Right? You’re never going to be a pro because you’re just not good enough. You have to have so much natural talent to make it as a professional athlete unenhanced, and then you have to also be lucky enough to avoid an injury along the way to make it to the pros. But people who think they’re going to take a shortcut by using anabolics to get bigger, faster, stronger, remember, as soon as they stop, they’re likely to feel horrible and lose many of their gains. And if they get caught and they now have to perform unenhanced, they’re not going to be good enough, right? So this fallacy of, like, I want to become an athlete, I want to be a professional, make lots of money by using steroids, doesn’t work very well.

Dr. Gabrielle Lyon 35:52
You know, it makes me think about early on in my career. There were individuals that were coming in, and I didn’t quite know what to do with them, and ultimately I’d send them to urology. They would come in and they would say, “Doc, I started testosterone at a lower number.” Maybe they started at 75 milligrams a week. Then they increase it, and then they increase it again, and then somewhere along the line, it’s almost as if the higher the testosterone number gets, which is what they think they need, the worse they feel. And I don’t know if that is psychosomatic, or is there a downregulation of receptors that happens? Is there a sweet spot where we can teach people that, you know, I’m all about, you know, what do they say, nothing succeeds like excess, or whatever it is. Yeah, bigger, faster, stronger. But is there a point of diminishing returns?

Dr. Tobias Kohler 36:52
Yes, I mean, and, you know, people who use androgens or abuse them, they very rarely will recommend it to the general public, right? They’re like, yeah, don’t do this. It’s a very hard lifestyle, for a variety of reasons. Getting back to these initial reasons why people start. So athletics is one. The other one is kind of vanity: how you’re going to look, how you want to appear, and here, this is, I think, the most dangerous one, because steroids alone, without training, without dialed-in nutrition, you’re gonna get bulkier, but you’re also gonna get fatter, because you’re ravenously hungry. You’re taking all these calories in, and so achieving that aesthetic look of, I don’t know, pick a number, 12% body fat, six-pack, whatever it is you want, ain’t coming just from T. That’s coming from eating perfectly, from training perfectly. I mean, we haven’t figured out the training perfectly yet. We’ve got many good ideas, but I mean,

Dr. Gabrielle Lyon 38:01
or genetics. There’s a… exactly, genetics.

Dr. Tobias Kohler 38:03
Well, so, and you know, professional bodybuilders who are successful, oh yeah, they’re genetically sensitive to this stuff. They

Dr. Gabrielle Lyon 38:10
are. Two of our friends, Matt and I always joke, Mike O’Hearn and Phil Heath. Just these guys. Yeah, they work harder than anyone, but they are naturally extraordinary, and they cannot be compared to, I don’t know, someone who aspires to do that without the genetics. There’s probably a threshold for the amount of muscle someone could put on, and, you know, I am curious about this idea of androgen insensitivity. Do individuals that go into an abuse lifestyle, do they require, like… Because I know that testosterone is a Schedule III drug, just like ketamine, but it is not addictive per se. It doesn’t have withdrawal symptoms, which is interesting. It doesn’t have the definable withdrawal symptoms of increased heart rate, increased blood pressure, a number of things, depending on the drug. But if an individual continues to increase their dose, are they required… Is there a tolerance built, where they then must continue to increase their dose to get the same effect?

Dr. Tobias Kohler 39:24
I think there is, undoubtedly. You know, when we… Chad, his main reason,

Dr. Gabrielle Lyon 39:32
Chad, Doctor Toby’s making him famous over here. Yeah,

Dr. Tobias Kohler 39:34
yeah. One of his biggest contentions as to why not to start steroids is that, you know, you reset this set point in your brain. So if you’re acclimatizing to T levels of 2,000 over time, what’s a T level of 500 going to do for you? So essentially, you have this new set point where you expect your energy level to be 13 out of 10, your erections 11 out of 10, and now all of a sudden you take the T away and you feel horrible. And, you know, that’s a big problem for some guys when they redline so much they never feel as good as they want to, so they end up on lifelong androgen replacement therapy, which is typically higher than the average Joe who’s, you know, normalizing back into the 500 range. That’s pretty common. Is

Dr. Gabrielle Lyon 40:24
there ever a return to baseline?

Dr. Tobias Kohler 40:30
Maybe, but I doubt it. For the guys that really hit it hard, I doubt it. I think there’s always probably some irreversible sequelae, whether it’s in the brain or at the receptor level. Again, I can’t say with absolute certainty.

Dr. Gabrielle Lyon 40:44
And also, you can’t say with absolute certainty. No one is going to be… I mean, I am sitting across from the guy who runs men’s health at Mayo Clinic.

Dr. Tobias Kohler 40:53
Right.

Dr. Gabrielle Lyon 40:54
And the fact that we don’t know.

Dr. Tobias Kohler 40:56
Yeah.

Dr. Gabrielle Lyon 40:57
And have this kind of information. I mean, CAD repeats was the most novel thing that I had heard in a long time when it comes to how to have personalized medicine, and you can touch on that. But if you don’t know,

Dr. Tobias Kohler 41:11
yeah. Well, I just don’t want to come across as a guy that pretends he has all the answers. I’m just like, there’s so much that I don’t know, that I don’t understand. But all of us, right? Well, again, I guess the message here is, if somebody is certain, they’re usually wrong. Beware, except for

Dr. Gabrielle Lyon 41:29
protein, right?

Dr. Gabrielle Lyon 41:30
Except for that, I’m right, and we’re just going to carry on. I’m kidding.

Dr. Tobias Kohler 41:35
So yeah, it’s one of those things where I think medicine and interpreting science and data requires a certain level of humility, and I just don’t want to come across as, like, you know, stating that I think I have all the answers. I don’t. I try to combine what people who have experience in this domain tell me with what I read in the studies and literature. I want to point one thing out, too, which I thought was fascinating. So up until the early ’80s, even after the East Germans were winning in everything,

Dr. Tobias Kohler 42:10
you know, East German women specifically,

Dr. Gabrielle Lyon 42:14
the Helga

Dr. Tobias Kohler 42:15
people, people were denying the fact that steroids could help with, like, sports performance. It was absurd. Do

Dr. Gabrielle Lyon 42:23
you know why that was?

Dr. Tobias Kohler 42:24
I don’t know. And then they’re like, oh, I guess we should study it, right? So some beautiful trials were done in the ’80s where they’re giving guys, like, high-dose T, you know, 400-milligram injections, right? Really high, getting levels… Which

Dr. Gabrielle Lyon 42:39
someone’s listening to this, they’re like, oh shoot, that’s high. I didn’t know. Yeah,

Dr. Tobias Kohler 42:42
no, that’s shooting for levels of 2,000, approximately, like the average T level in these guys that were treated. These were normal guys off the street. They took them and they started giving them a really high dose of T, but they randomized the trial to an exercise, weightlifting program alone, no steroids; or steroids alone, no exercise; and then double placebo; and the last group, of course, is both exercise and steroids. And when you looked at bench press score and squat score, which I would, you know, say is the ultimate kind of predictor of how strong you are, those two huge muscle groups, right? The guys who exercised but didn’t take steroids had better results than the guys who didn’t exercise and were on this crazy dose.

Dr. Gabrielle Lyon 43:32
Wow, I’m actually surprised.

Dr. Tobias Kohler 43:34
Yeah, no, it’s true. So you need the stimulus, right? Now, of course, the magic of the study, where you see this crazy explanation as to why, you know, the Eastern Europeans were winning, is when you combine the lifting with the high-dose T, then the strength just goes through the roof. But I think it’s important to understand that the exercise initially is the stimulus that causes the change in strength, in physique, in functionality. And so why not focus on that, max that out, before you do anything that potentially can give you a heart attack, give you horrible deep acne for which you will have scars the rest of your life, will irreversibly maybe change your physiologic set point of what T can do. There’s all these negative sequelae that are reported for the people who are at the extremes. You can potentially avoid them just by doing kind of the normal stuff, which admittedly is hard.

Dr. Gabrielle Lyon 44:29
Well, also, I’ve been thinking a lot about this, the idea that we have to exercise. There’s, in my mind, an exercise deficiency syndrome. It’s an abnormal stimulus. So it’s just like taking a multivitamin. If we ate a variety of foods and we had good, healthy soil and we picked something and then we ate it, we probably wouldn’t have to take a multivitamin. If we lived a life that involves picking heavy things up and were largely less sedentary, we wouldn’t have to have artificial exercise. And that’s, I suppose, a long-winded way of saying it would be really interesting to see what it would look like for those that lived, you know, a very physically active life. You know, I look at my dad. You watch and you go, ah, well, number one, I’m not even making fun of them, but I might. But now I can’t run. But you go, oh yeah, I see where you get your genetics. And yes, and this guy, again, I hate to go visit him because then I have to walk four hours. If it’s less than four hours, we have to walk, right? He’s a very unpopular host, because getting groceries and going to the airport is just terrible. But I suppose if we lived in an environment where we weren’t so outside of our element and deficient, then perhaps we wouldn’t require these replacements. No.

Dr. Tobias Kohler 46:02
Yeah. Well, you know, I don’t know if you’re familiar with Michael Easter’s work. I am, you know. So, that guy’s awesome. I love his books. I love how he thinks, and, you know, the 1% rule, right? When you go, I don’t know, you’re in the mall and there’s the escalator and the stairwell, and they’re right next to each other. Everybody knows it’s better to go up the stairs. Everybody knows it, but only 1% do, right? So it’s that kind of mindset to kind of have the fitness happen. I totally agree. You know, we have so much less physical activity and motion. All our meetings are online now.

Dr. Gabrielle Lyon 46:40
Like, could we potentially dose testosterone lower if there was a certain threshold of physical activity?

Dr. Tobias Kohler 46:46
Well, I don’t think we’d need T in the first place if we had normal physical activity, right? It’s almost like

Dr. Gabrielle Lyon 46:51
a compensation for the inactive lifestyle.

Dr. Tobias Kohler 46:54
Absolutely, 100%. Because when you’re inactive, you get obese, and then your T goes down.

Dr. Gabrielle Lyon 47:00
Do you see… Because, again, a lot of guys come to you that have potentially abused steroids. You talked about the risk of cardiovascular remodeling. What are the other risks? What I’ve also seen is high, high hypertension, just at baseline, like alarming hypertension. And I also have to say that it’s not just testosterone alone. So it’s a combination, if you care to speak about any of that, it’s a combination of testosterone plus anabolic agents that are potentially, say, not even meant for a human.

Dr. Tobias Kohler 47:35
Right. Oh no. I mean, people who are really trying to get as huge as possible, it’s never just one agent, right? It’s like 10 to 15 agents, right?

Dr. Gabrielle Lyon 47:49
Is there a threshold… I guess a better question: let’s say a guy was like, okay, I’m gonna take testosterone, and I’m gonna be completely reckless with my health, and I’m gonna take 400-plus milligrams of testosterone a week. Will there be a cap to how much stimulus that person can get on muscle with testosterone alone?

Dr. Tobias Kohler 48:11
My understanding is that the muscle is essentially boundless in its ability to respond. I have also seen that. Yes, the muscles keep getting bigger and bigger and bigger. The tendons and ligaments, maybe not so much, right? And the other thing that makes the data tricky for understanding the true risks of androgen abuse is not only these multi-drug cocktails, you know. So, you know, you’re not just talking about T anymore, which we do have some studies on, but all these other agents, I don’t know, thyroid agents to help lose weight, you know, aromatase inhibitors to drive up T and lower E, sometimes diuretics, you know, all these kinds of things, all these things together. And then I think if you’re willing to take a cocktail of eight to 10 things, and you are benching some absurd amount, and you pop a pec or a shoulder, whatever, you’re not going to be very shy about taking Vicodin or some other kind of strong pain medication so you can get back to the gym. So you get this polypharmacy too, where now the data gets confounded with these other agents that people are willing to take, and other kinds of risky behaviors that people are willing to take. When you look at the data on the WrestleMania participants, right, their risk of cardiac mortality is something like 100x that of the general population, because, again, it’s kind of this rock-and-roll lifestyle, and these things kind of gang up on you. And then, by the way, weight gain was a big predictor of mortality too, right? Imagine

Dr. Gabrielle Lyon 49:48
that, even if it’s muscle gain. Is it because of the stress on the heart?

Dr. Tobias Kohler 49:51
Well, yes, there are definitely conduction abnormalities with increases in heart size, which typically, in some studies, have been reversed. I was going to ask. Some… Yeah, some get better, but

Dr. Gabrielle Lyon 50:03
is it because it atrophies? This is very interesting, because I know people that love to run marathons, and you think about the increase in cardiovascular size, and maybe that you shouldn’t run more than nine miles a week. Again, I don’t know the number, because I know, maybe you know, people that run a lot more than that. There is cardiovascular hypertrophy,

Dr. Tobias Kohler 50:25
and then kind of remodeling and normalization in some; in others, you know, they die of a heart attack before it gets the chance to remodel.

Dr. Gabrielle Lyon 50:34
Terrible. But can you reverse… Is the hypertrophy different from anabolic use, anabolic steroid use? And again, we’re saying anabolic steroid use is testosterone that causes cardiomegaly.

Dr. Tobias Kohler 50:50
Yeah. Again,

Dr. Gabrielle Lyon 50:51
I want to be very careful because these are medical terms. Cardiomegaly means one thing.

Speaker 4 50:56

Yep. Versus

Dr. Gabrielle Lyon 50:57
cardiovascular hypertrophy, which probably is within a normal expected range for activity.

Dr. Tobias Kohler 51:05
Yeah, I think maybe a different way to look at it is it’s not only the change in heart size, but it’s the change in heart structure that affects electrical signaling. And, you know, a lot of people that drop dead from steroid abuse, it isn’t a typical MI. It can be, because your lipids can be adversely affected, and there are case reports of people just dying with crazy high lipids. You know, they use steroids. But most often it has to do with an arrhythmia, right? So a problem with the electrical signaling. You go into V-fib, and it’s lights out, right? So there are good studies from, you know, countries where steroids are legal, and they show definitive changes in electrical cardiac signaling. And, you know, if you combine high-dose steroids with, I don’t know, 500 milligrams of caffeine for your pre-workout, and then a little bit of bad luck, maybe it’s over. So that’s one of the risks we take. And, you know, getting back to this thing about vanity, wanting to look good, like acne, horrible deep cystic acne. It’s like 50% of people who really use a lot of steroids. So, again, that’s really kind of counter to the look you’re after.

Dr. Gabrielle Lyon 52:19
Yeah.

Dr. Tobias Kohler 52:20
Right. You want to look good taking your shirt off, but, like, you don’t look good because you’ve got this horrible cystic acne, or a receding hairline, you know, or other types of changes that happen to your facial structure. You know, sometimes very noteworthy in women. You know, you mentioned voice changes, which are irreversible. Right. Same thing with clitoromegaly in women. Women on high-dose testosterone, the clitoris permanently enlarges and never goes back to its size. So, you know, when people are kind of randomly deciding to start this based on information from social media, you really have to be careful.

Dr. Gabrielle Lyon 52:58
Yeah, and some of these changes, like you’re mentioning, are absolutely irreversible. But the reversible changes are what… If we can get to people younger that are potentially on an abuse trajectory, if they are using, even abusing, testosterone, because there is testosterone abuse, just as you pointed out, do we know what the dose would be where we’re like, okay, we’re starting to see cardiovascular abnormalities? Would we think, okay, blood pressure is first, or is that because of mass? How do we think about this? Again, in my mind, what would be the mechanism of action, and then the threshold where we would be like, okay, we need to really make sure that we get this person early, because in an ideal world we prevent

Dr. Tobias Kohler 53:43

1. Yeah.

Dr. Gabrielle Lyon 53:44

But, you know, I think back to when I started my career, and I was seeing bodybuilders that were coming in, because, you know, there’s always an influx when you open up a practice of various individuals, and where I was living in New York, there was just a higher population, and these guys were bigger, and also their blood pressure was just uncomfortably high. Would that be a precursor to… Obviously, you’re going to be like, okay, well, we have to pay attention to this. Or is this something where, like, okay, because your blood pressure is high, we know that your heart is pumping. You’ve already been doing this for a year. We’re moving into two years. If we don’t do something about this, you’re at a 10 to 20% risk for an arrhythmia, something like that?

Dr. Tobias Kohler 54:29
Yeah, I think the scary thing is that we don’t have that number. All right, it’s a little bit of the randomness. There’s the person who, you know, Grandma Betsy or whatever, who ate bacon and drank a fifth of, totally, you know, bourbon every day, and she lived to 100, right? And you’re like,

Dr. Gabrielle Lyon 54:43
“What’s the secret to health?” And she’s like, “Smoking.”

Dr. Tobias Kohler 54:46
Right? You’re like, “No.” So, but yeah, it’s smoking

Dr. Gabrielle Lyon 54:49
and onions.

Dr. Tobias Kohler 54:49
I wish there were an easy answer to that question, but there’s not. That makes it tricky and dangerous. And do

Dr. Gabrielle Lyon 54:57
you think we’ll ever have that? Because we have, you know, dosing for… We could be like, okay, at this dose a statin’s going to do this, right? Is that fair to say? At this dose, heparin’s going to do this?

Dr. Tobias Kohler 55:08
Well, again, biological variability. All humans are different. I don’t know if we’re going to get that number. It’s a tough one. I mean, when we look at the trials of what happens to men, there’s only seven right now where, like, the T is consistently at 2,000 or higher.

Dr. Gabrielle Lyon 55:26
Only seven trials? Yeah.

Dr. Tobias Kohler 55:28
Well, because most of these experiments are being done off the books, right? So the data isn’t great, and it’s confounded, like I said before, because of differences in other abuses and lifestyle changes. And getting back to those WrestleMania people, it was the weight gain that happened after they stopped training. So they were used to eating 3,000 calories a day,

Dr. Gabrielle Lyon 55:54
3,000, probably 6,000,

Dr. Tobias Kohler 55:56
whatever the number is. It’s a lot to

Dr. Gabrielle Lyon 55:57
talk about.

Dr. Tobias Kohler 55:58
Yep, and then you stop the training, and all of a sudden it’s all, you know, fat mass you’re gaining instead of maintaining your muscle mass, and then you really start to have problems.

Dr. Gabrielle Lyon 56:07
And people might be like, Gabrielle, why are you harping on this steroid testosterone issue? And the reason is because I think it’s the way of the future. With the increasing use of GLP-1s, we are going to be on a trajectory, and I think you and I are very much aligned on this, that we are going to trade, as robust as that sounds, obesity for sarcopenia. And then the question becomes, what kind of agents do we have? But what is the safety profile of what is going to be needed? Because, you know, when I think about the aging population, at 74, can we start a 74-year-old male on testosterone? You’d probably say, yeah, sure. But if he’s sarcopenic, what is the realistic amount of muscle, healthy muscle, that he’s going to be able to build, versus if we accelerate sarcopenia to an earlier age, a sarcopenic phenotype of youth, which I believe is gonna… it has to happen. How do we begin to think about treatment protocols in this younger generation that is going to be sarcopenic? And people might be like, “Gabrielle, that’s stupid, because sarcopenia is a disease of aging.” And I would say, “Well, it’s a disease of aging because of what we know now, but that’s through the framework of the frail elderly.”

Dr. Tobias Kohler 57:32
Yeah, yeah. There’s plenty of people that are the so-called skinny fat. Absolutely. And

Dr. Gabrielle Lyon 57:36
what is that? That’s sarcopenia.

Dr. Tobias Kohler 57:37
Yeah, that’s sarcopenia there. And, you know, there’s really good data that looks at surgical outcomes by body metrics, muscle-to-fat ratios, and if you get a surgery with this muscle-fat ratio, you’re likely to do very well. However, the opposite is true when you don’t have any muscle, right, at your core. So,

Dr. Gabrielle Lyon 58:00
what do we do about thinking about agents? Is there utility for some of these anabolic agents?

Dr. Tobias Kohler 58:08
Well, in the absence of, you know, people being able to exercise, I guess yes. But again, I just want to go back to these foundational things you talked about: walking and carrying things, right? Rucking is becoming very popular.

Dr. Gabrielle Lyon 58:22
I bet you my husband could rope you into the Bataan Death March. Seriously, he just did this recently. I’m gonna have to remind him, and he will, yeah, rope you. So I

Dr. Tobias Kohler 58:31
mean, like, just get more active, man. It’s like, park your car farther away from the grocery store. Just take the initiative and start doing these things. I mean, maybe I’m naive to say this, but, like, again, you should be able to steer your own health in the direction that you want it to go, with the right understanding and the right, you know, confidence to ask for help. That’s very important, and then to develop an action plan and follow it.

Dr. Gabrielle Lyon 59:00
And one of the things that I know you deal with a lot is erectile dysfunction, and with erectile dysfunction is vascular disease. With vascular disease, is it safe to say there is scarring of the penile tissue, of Peyronie’s disease? Is that a fair pathway?

Dr. Tobias Kohler 59:16
Yeah. So Peyronie’s disease, by definition, is a scarring of the penis. Most notable when your penis starts to bend in a direction, right? So, last episode we talked a little bit about how men can lose penile length, which made you the most popular guest

Dr. Gabrielle Lyon 59:33
in the history of popular guests, because you said men could lose, like, half an inch. Yeah,

Dr. Tobias Kohler 59:38
yeah, yeah, and it’s a use-it-or-lose-it organ. Whether it’s from… everyone

Dr. Gabrielle Lyon 59:43
immediately tried to find a sexual partner, right? Radiation

Dr. Tobias Kohler 59:45
or diabetes. So the people who actually lose length of their penis, they get uniform scarring. So the penis is still straight, but it’s shorter. Peyronie’s disease is simply scarring of one portion of the penis, and the penis always curves towards that side: up, down, left, right. Most often upward, it turns out. And that typically happens from a trauma to the penis, which people don’t notice, at least we think it does, and that happens as a result of problems with erections. So Peyronie’s disease is intimately tied to ED, because you get these microtraumas in the penis, and your body inappropriately scars this soft, fleshy tissue and turns it into a scarred area, and so you get a new curve.

Dr. Gabrielle Lyon 1:00:26
Is there anything someone could do if they are suffering from the initial… If someone is thinking about this and they’re like, “Oh, well, I don’t know,” and maybe I’m younger, so this person hasn’t fully developed Peyronie’s, are there signs and symptoms to look for?

Dr. Tobias Kohler 1:00:43
Yeah, so Peyronie’s disease has different stages. So the initial stage, the active phase, involves pain. That’s how it hurts. And then, like, if you watch yourself get an erection, the area that fills out last in your penis, that’s where the scar is forming, because literally the blood can’t flow there anymore because that tissue is scar. And so, like, as a man’s getting an erection… like, we test for this all the time in the doctor’s office. We do an office erection test, and, like, yep, there’s the scar, and then that part finally fills out, and then it curves towards exactly where that went. So I’d say to the man who has pain, either a new penile deformity or a new onset of curve, that’s Peyronie’s disease. It’s not cancer. It’s not an STD.

Dr. Gabrielle Lyon 1:01:26
That’s good for people too. Yeah,

Dr. Tobias Kohler 1:01:27
yeah. It’s pretty rare to get, like, a painful condition of the penis that’s cancer, and it will take some time to get better. And sometimes it will get better. Sometimes it’ll get worse. But what I would say to that person is, number one, if you’re gonna have… like, you’re at risk. You’ve proven that you can get Peyronie’s disease. So now, are

Dr. Gabrielle Lyon 1:01:49
certain people at risk and others are not?

Dr. Tobias Kohler 1:01:51
Yeah, I think they’re more predisposed. Like, people who have Dupuytren’s contractures or other kinds of fibromuscular scarring diseases are more likely to get Peyronie’s disease.

Dr. Gabrielle Lyon 1:01:59
Meaning, I want to just pause, because there’s providers that listen. What if someone has, like, a rheumatological condition or something with connective tissue disease? Are those individuals

Dr. Tobias Kohler 1:02:13
undoubtedly… they’re going to be at… Dupuytren’s contracture being the most common thing we’ve seen, in the hands, and so men who have Dupuytren’s are much more likely to get Peyronie’s. Let’s say, to those men, their job is to make sure they have 10-out-of-10 erections when they’re having sex, because, again, it’s this microtrauma, which most often happens in men whose erection is not quite as good as it should be, that leads to the Peyronie’s disease.

Dr. Gabrielle Lyon 1:02:36
People ask a lot, and I see this as a search: Viagra versus Cialis, which is better?

Dr. Tobias Kohler 1:02:43
Depends what your goals are and which medicine you can tolerate. So I write for a lot of Cialis, because it’s kind of set-and-forget-it. You take it typically once, whenever you want, during the day. And it used to be called the Weekender in France. I thought that was a bag. Yeah, Weekender. It basically gave you an erection that was much more functional over the course of the weekend. I’m not saying they had an erection for 40 hours, because they didn’t. No, because

Dr. Gabrielle Lyon 1:03:09
that would be priapism. There you go. Then people would say, maybe you’re on trazodone, and it’s a medical emergency.

Dr. Tobias Kohler 1:03:14
Right, right. So the one

Dr. Gabrielle Lyon 1:03:16
question I got right on medical boards. So yeah,

Dr. Tobias Kohler 1:03:19
I’m sure you got many more right. Cialis also has the advantage of treating urinary symptoms. Oh,

Dr. Gabrielle Lyon 1:03:25
how does it do that? A

Dr. Tobias Kohler 1:03:26
bunch of different proposed mechanisms, but essentially increasing blood flow to the bladder and making it less

Dr. Gabrielle Lyon 1:03:32
I have read that

Dr. Tobias Kohler 1:03:32
kind of spastic, and then also this potential cardioprotective effect, protecting the endothelium, which is

Dr. Gabrielle Lyon 1:03:39
super cool.

Dr. Tobias Kohler 1:03:40
Yeah, it’s amazing. It really is amazing.

Dr. Gabrielle Lyon 1:03:43
Combine Cialis with beetroot juice.

Speaker 3 1:03:46

Yeah,

Dr. Gabrielle Lyon 1:03:46
maybe a little whatever, whatever, arginine. Just

Dr. Tobias Kohler 1:03:49
yeah, I mean, like I said, I think in the future there will be medications, specifically cocktails, that will involve statins plus PDE5 inhibitors, probably

Dr. Gabrielle Lyon 1:03:58
statins for decrease in inflammation, or for

Dr. Tobias Kohler 1:04:01
overall cholesterol. It decreases inflammation, and then, you know, again, endothelial protection from the PDE5s. I think that’s probably a thing. There’s probably some pills already in development right now for that,

Dr. Gabrielle Lyon 1:04:13
which you may or may not be able to talk about, it sounds like, you know, getting to know you. And there’s something else that also was really interesting, and I learned it, and I want to be really careful to not be immature or unprofessional. But, again, you guys talk about penises all the time, as if I’m talking about weightlifting or, I don’t know, macronutrients. So, and I will say that there’s a robust amount of penis jokes in urology, having been married to one. Just a robust amount. But I think we talked about the penile implant. Why do I have an obsession with this? Because it’s so fascinating that, you know, we see plastic surgery as breast implants or various nose jobs. You name it, you can tweak it. Brazilian butt lift. And while not for cosmetic purposes, individuals can get a… it’s a medical intervention, right? A penis implant, or a penile implant.

Dr. Tobias Kohler 1:05:10
Yep.

Dr. Gabrielle Lyon 1:05:11
Now, with other body parts, like breast implants, it does destroy the tissue. It flattens out the tissue. I think that there’s also an effect when people get prosthetics placed in their glutes or other places, that when you remove those, there is damage to the tissue.

Dr. Tobias Kohler 1:05:29
Yeah,

Dr. Gabrielle Lyon 1:05:30
and I think I’m doing very well in my professionalism right here. But sometimes people have to have penile implants removed. And you said something to me that was shocking.

Dr. Tobias Kohler 1:05:42
Okay.

Dr. Gabrielle Lyon 1:05:43
Do you know what that is? I mean, I’m just gonna lay it out there without any jokes.

Dr. Tobias Kohler 1:05:50
Okay. That

Dr. Gabrielle Lyon 1:05:51
that you now have a dysfunctional penis. Like, your penis will not work.

Dr. Tobias Kohler 1:05:54
That’s correct.

Dr. Gabrielle Lyon 1:05:56
That’s a big deal.

Dr. Tobias Kohler 1:05:57
It is. However, you have to remember that men who get penile implants, penile prosthetics, they don’t get it until it doesn’t work anymore. Okay, so if a man is getting normal erections, it would be crazy. Crazy, it would be crazy, because you cannot change size

Dr. Gabrielle Lyon 1:06:15
or girth in that way.

Dr. Tobias Kohler 1:06:17
Nope, nope. As a matter of fact, you’re going to lose a little bit, and, you know, you’re never going to be as good as when you were 18, right? So that’s something I tell every guy I put a penile implant in. It’s like, if you get a knee implant when you’re 65, you’re never going to be as fast as when you were 25. Good analogy. Such a really good analogy. Why? Because you get knee pain. What’s the first thing they tell you? Exercise, physical therapy. You get ED. What do we tell them? Eat better, exercise. Your erections will get better. When that fails, you go back to the orthopedist to say, “My knee still hurts.” They say, “Okay, try these anti-inflammatories. Try these pills,” whether it’s, you know, glucosamine, whatever it is. What do we do for guys? We give them pills. Cialis, Viagra, Levitra. That eventually fails. Will

Dr. Gabrielle Lyon 1:07:05
it always fail, or not necessarily? The

Dr. Tobias Kohler 1:07:08
average is five years. So of all the men we put on Cialis or Levitra or Viagra, in two-thirds it will work; in one-third it will never work, because the penis is too sick in the first place.

Dr. Gabrielle Lyon 1:07:20
Okay.

Dr. Tobias Kohler 1:07:21
And of the men in whom it works, on average it will last five years if they have severe ED. So they already have cardiovascular disease, right? Or another problem that causes ED, neurogenic disease. Okay. So there’s different causes for ED, right? Maybe they had a surgery that caused damage to the nerves, like

Dr. Gabrielle Lyon 1:07:39
prostate surgery.

Dr. Tobias Kohler 1:07:40
Yes, that’s the biggest. We did

Dr. Gabrielle Lyon 1:07:41
not talk about that before we…

Speaker 3 1:07:43

Yeah,

Dr. Gabrielle Lyon 1:07:43
I let you fly out of here. We do have to talk about sexual rehab.

Dr. Tobias Kohler 1:07:46
Yes, absolutely. So getting back to the point here, when you take the pills, they work for most for five years, and if you keep that level of health, they will work forever. You don’t get immune to the pills. You don’t develop tachyphylaxis, fancy word for saying that. Do you ever get off the

Dr. Gabrielle Lyon 1:08:06
pills? Is it possible to

Dr. Tobias Kohler 1:08:07
Absolutely. Wow! If you turn things around to get healthier, you can get off of them, or if you recover from a surgery, so to speak, right? But then eventually, most guys will come to a point where the penis gets sicker and the pills aren’t good enough anymore. Go back to the knee analogy. Now what’s next? Well, I’ll give you an injection in your knee, right? Typically a steroid injection or whatever. For the penis in men, it’s a medicine that goes into the side of the penis, an intracavernosal injection, and it’s pretty good at giving guys erections that are usable in most men that have failed pills, not all, but most. And then eventually, either the guy is saying, “No, I don’t want to do this anymore,” and that’s quite a few men, or it stops working again, and then you say, “Okay, it’s time for surgery to fix it,” because this is the thing that’s going to for sure fix it. But it’s a surgery. It has the risks of surgery. And so the guy who gets the knee replacement, is he walking? Is he running a marathon the day after surgery? Of course not. He’s walking to the mailbox, maybe. And then a few months later, he gets used to it, and now he’s maybe jogging around the block. But he’s never going to be running the same 100-meter dash time that he was when he was 18. Similarly, guys get surgery. There’s a month recovery period. They start to use it. It’s a little bit goofy at first, and they get used to it, and then it’s the best thing since sliced bread for them. That’s what most patients who get it say. Like, 90 to 95 percent of men who get implants say this is awesome, I’d recommend it. But the point of this very long story is that, you know, we don’t do the surgery unless the guy wants it because it isn’t working, right? So the time when we think about surgery is when the pills fail, and either nothing works or guys don’t want the shots. And our guidelines used to say, “Yeah, listen, I’m not touching you with the scalpel until you do all these things.” Now we’ve changed our stance and said, you know what, whatever the patient wants. As soon as they fail pills, if they don’t want to mess around with these injections, which not many men do, they can get the surgery and they can do fine. So yes, when I put the implant in, if I take it out, it ain’t gonna work.

Dr. Gabrielle Lyon 1:10:12
No matter what, you cannot reverse it back. You can’t diet or exercise your way back.

Dr. Tobias Kohler 1:10:16
But it wasn’t working before I put it in. So essentially, they’re going back to baseline. And in terms of having to take it out, do you have to take it out? The only time you have to take it out is if it gets infected. That’s relatively rare. If it breaks, you can leave it in. Maybe you want

Dr. Gabrielle Lyon 1:10:32
to swap it out.

Dr. Tobias Kohler 1:10:33
If you want it, if you want it to work. Some guys say, “No, I’m, you know, I’m retiring from being sexually active.” Other guys say, absolutely, let’s switch it up, and we do.

Dr. Gabrielle Lyon 1:10:44
That is, again, I’d never heard that before, so I know that if I haven’t heard it, and I am immersed in the urology field… Yes. So, can we touch on sexual rehab?

Dr. Tobias Kohler 1:11:01
So we’ve got a lot of things that we know are going to cause problems with your sex life. Certain surgeries, in both men and women, which

Dr. Gabrielle Lyon 1:11:09
are

Dr. Tobias Kohler 1:11:10
well, particularly pelvic surgeries, any surgery that affects either the blood flow to the genitals or the nerves going to that area. And there are things we can do to help rehabilitate the nerves and the blood flow, or spare them in the first place, right? So-called prehab: before you do the surgery, you kind of optimize things so they take less of a hit. Again, the number one predictor of a guy having problems with erections after a prostatectomy, a surgery to remove the prostate for cancer, is how good or bad the erections were before they had the prostatectomy. But people with great erections, they’ll have to have this surgery because it’s a cancer that is threatening their life. And so you do a surgery, and sometimes there’s collateral damage in the vicinity of the prostate, like the nerves and the blood vessels that feed the penis. To make a long story short, those nerves either get temporarily or permanently injured, or those blood vessels, same approach. So the field has moved to the point where, well, we know there’s probably going to be some negative side effects from doing these types of surgeries. How can we help guys best recover as quickly as possible? And it involves using pills, using vacuum devices to help stretch the penis and exercise it, and that helps prevent loss of length of the penis. The shots that we talked about. And then if that fails, typically about a year after surgery, when we know the erections are kind of gone, they’re not coming back, we’ll do the surgery if guys want to fix it.

Dr. Gabrielle Lyon 1:12:45
And what percentage of… So someone has a radical prostatectomy. They had aggressive prostate cancer. They get the surgery. They recover, full remission. They move to the shots, right? This is kind of like the next step after pills: shots. What are the chances that they will be able to maintain an erection with just the shots? You know, just from a percentage standpoint. So if someone’s listening to this and like, oh my gosh, do I actually get the surgery or not get the surgery?

Dr. Tobias Kohler 1:13:18
Well, before I give you the specific number for surgery, you always got to pay the piper to treat the cancer,

Speaker 5 1:13:26

right?

Dr. Tobias Kohler 1:13:26
Unless you’re doing active surveillance, where you’re carefully watching the prostate cancer, repeating biopsies, checking the PSA blood test, which is a very legitimate way to follow it, right? Not all prostate cancer is the same, and not all of it merits surgery the next day. Some of it you just watch, and you die of something else. But presumably you’re treating a guy who has aggressive prostate cancer, where if they don’t treat it, they’re going to die, likely within the next five to 10 years. You’ve got different options. All of them hurt the penis,

Dr. Gabrielle Lyon 1:13:56
but you save the life.

Dr. Tobias Kohler 1:13:58
Correct, correct. So you’re making a trade, and there’s really no prostate cancer treatment that is an active form of treatment that doesn’t have consequences. Whether it’s taking away hormones, whether it’s giving radiation to the field, whether it’s freezing the prostate, whether it’s cutting it out and throwing it in a bucket with a prostatectomy with the scalpel, they all have consequences. Yeah, well, that’s kind of how, you know, you have to think about it. If you think of the anatomy, you’ve got a bladder, you’ve got a prostate, and then you’ve got the check valve, which controls urination, and you’ve got this urethra. You take out this prostate. You send it to the pathologist, and next to that prostate are the nerves and the blood vessels that are very important to help with erections. So there’s this collateral damage, but, yeah, you’re going to live a long time. The good news is we can fix it, right? But this whole rehab that we’re talking about is a series of things that the patient can do to take the initiative to maximize their chance that they won’t need the surgery, that they won’t need injections, that they’ll get away with just pills. So the number of men that get away with just pills is somewhere in the range of 25 to 50 percent.

Dr. Gabrielle Lyon 1:15:12
That’s a lot.

Dr. Tobias Kohler 1:15:13
Yeah, it’s reasonable. And again, especially if they’ve got great erections before.

Dr. Gabrielle Lyon 1:15:17
So basically, the younger they are, with less cardiovascular disease.

Dr. Tobias Kohler 1:15:20
Yes. Which

Dr. Gabrielle Lyon 1:15:21
would also make prostate cancer unusual in that age demographic. You would expect them to recover, so those would be kind of like the unicorns.

Dr. Tobias Kohler 1:15:30
Again, it’s like, if you’re optimized before you go into the surgery, just like we talked about, the ratio of fat to muscle before you go into the surgery is predictive. Your pre-operative function is very predictive of how well you’re going to do. Is

Dr. Gabrielle Lyon 1:15:42
that a newer thing? Because, again, as a geriatrician, I didn’t rotate with urology. I did rotate with female pelvic floor specialists, but that was that. There was not one patient that came in, seriously, that was on Cialis.

Dr. Tobias Kohler 1:16:02
Yeah, I think it’s the last 20, 30 years.

Dr. Gabrielle Lyon 1:16:06
I’m not that old, so, I mean, there should have been. So this is for urologists,

Dr. Tobias Kohler 1:16:10
right?

Dr. Gabrielle Lyon 1:16:10
Ah, but this makes me think: does general surgery do these radical prostatectomies, or is this a urology procedure?

Dr. Tobias Kohler 1:16:20
Well, colorectal surgeons have to think about this as well. You know, general surgeons who are doing pelvic exenterations or doing big, big surgeries, again, they should be considering it.

Dr. Gabrielle Lyon 1:16:34
But it’s not the standard. It’s

Dr. Tobias Kohler 1:16:35
definitely not the standard. But again, if you are getting a surgery, you know, I would say rely on your loved ones to help make sure you’re checking all the boxes that are important to you. You’re gonna have the blinders on: cancer, cancer, cancer, cancer. I’m gonna die. I’m gonna die. I’m gonna die. So that’s all you can think about. But we had talked earlier, on a different episode, about preserving your fertility, right? That’s very easily forgotten. And then all of a sudden, you’ve recovered from whatever cancer treatment you got, and you’re like, “Yup, time to start a family.” Like, uh-oh, too late. That ovary’s been radiated, or the testicle’s been exposed to chemotherapy. Definitely should have cryopreserved either tissue or sperm. Same thing for people going into surgeries. Like, how am I going to optimize my psychological health? How am I going to optimize my sexual health, or whatever else is important? But it’s very difficult for the patient who’s the patient to think of all these things. That’s why you’ve got to lean on your support network, your family, your friends, and your physicians. A good question is, like, other than cancer, what about this cancer treatment should I be thinking about? What have other patients experienced? What kinds of regrets have patients had who’ve had this surgery? Like, what mistakes did they make that I can avoid? It’s a very fair question, and I’d argue that a good surgeon, or a good practitioner that’s going to be giving you the chemotherapy or the surgery, the radiation, whatever, hopefully should be talking to you about these things. But at the same time, I think you should come in with a list of questions that are important to you to make sure you get them covered.

Dr. Gabrielle Lyon 1:18:20
Dr. Tobias Kohler, always a pleasure. You are both hysterical and deeply professional and capable. Is there one thing that you want to leave us with? You’ve left us with so many nuggets to think about, but I really feel like you’re on a mission to change, like you had mentioned earlier, men’s agency.

Dr. Tobias Kohler 1:18:40
Yeah, I want people to be proactive, not reactive. You’ve got to take command of your own health. Get an understanding of how your body’s supposed to work. There are so many resources available to you. Ask the tough questions. Write them down. Write them down ahead of time. Don’t leave the question, like, “What about this, doc?” as he or she is leaving the office. Come up with a game plan and then act on it. You know, you’re in charge of your own destiny. Take advantage of it. The human body is amazing. Before I go, I want to tell you a quick story. I have a guy who came to me because all of a sudden he couldn’t pee anymore, right? He was having problems urinating. He needed a catheter, and so normally when I see this type of person, I’m going to talk to him about a surgery to help open up the prostate so they can urinate without a catheter. Turned out this guy had really bad prostate cancer, like really bad, and when I checked his PSA, it was in the 1,000s.

Dr. Gabrielle Lyon 1:19:38
Oh my God! Anything

Dr. Tobias Kohler 1:19:39
above 50 means bad prostate cancer. This PSA was really, really, really high, and so by the time he came to me and was diagnosed, he had a giant prostate cancer mass in his pelvis. He was on the verge of having horrible complications from it, or even dying. This guy was a super successful physical therapist at Mayo Clinic, who took pride in lifting weights every day. That was his thing. And he also has a neurologic disease where he has an assistant. He has trouble walking on his own, but every day he hits the gym, and he’s doing bicep curls, he’s benching, he’s doing tricep extensions. And he says to me, listen, the thing that I fear most is not necessarily dying, but that if you treat my prostate cancer, I’m going to lose my testosterone. I’m no longer going to be able to be strong anymore. I’m not going to be able to lift, this thing that I’m so proud of, that I’ve taught my patients to do. And so I really had to negotiate with him, like, listen, man, if we do nothing, there’s probably going to be some really bad events where you’re going to need major surgery. There’s going to be problems with the bowels and all this kind of stuff. He’s like, all right, man, I’ll do it. I’ll start this treatment. And the treatment involved taking away his testosterone, right, which can be a treatment. So he was absolutely mortified of starting this drug, because he thought he was going to lose all his muscle mass. I said, “Listen, man, just because you don’t have T doesn’t mean you should stop exercising. I want you to lift as much as you can, just like you’re doing now. Just see what happens.” So I expected him to come back, and I’d say, “How you doing, man?” And he’d say, yeah, you know, I’m getting weaker, but I’m still active. And I’d say, good for you. This is what I expected to tell him. Turns out, he comes back to my office two months later, and he’s noticeably bigger. Like, he’s jacked all of a sudden in his upper body.

Dr. Gabrielle Lyon 1:21:35
Was he on creatine?

Dr. Tobias Kohler 1:21:36
I’m like, what is happening with you? He’s like, I don’t know, man, but I’m just hitting all my PRs. I’ve never been as strong as I am now. With zero testosterone. We intentionally took it away.

Dr. Gabrielle Lyon 1:21:47
Extraordinary.

Dr. Tobias Kohler 1:21:47
And why? Well, the answer is because his prostate cancer was so bad that he had so many pro-inflammatories, so many… his body was systemically shunting away from his muscle development just to keep him alive. See, all these inflammatory markers, these cytokines, were making him weak and shrinking his muscle. So with zero testosterone, this guy, I’m sure, is stronger than many, many men of his age, and he was so proud. And man, should he be! Wow. And so that’s the story. Like, the body is amazing. This guy got stronger with no T, just because he was dedicated and he practiced every day.

Dr. Gabrielle Lyon 1:22:26
Well, I am really grateful to call you a friend, and thank you again. The world is going to hear more from you, Dr. Tobias.

Dr. Tobias Kohler 1:22:35
Thank you.