Speaker 1 0:00

It’s okay before we start,

Dr. Gabrielle Lyon 0:03

and then is there a mechanism of action, testosterone and hyperglycemia, testosterone and blood glucose control? It’s is there an independent mechanism that indirect, indirect, okay,

Speaker 2 0:16

testosterone increases, muscle muscle decreases.

Dr. Gabrielle Lyon 0:18

Okay, so it’s not something on a receptor, like on the floor, can

Dr. Gabrielle Lyon 0:23

I just get first and last names real quick?

Dr. Gabrielle Lyon 0:27

Gabrielle Lyon,

Speaker 3 0:29

Larry Lub Schultz,

Speaker 4 0:30

Toby Kohler,

Speaker 2 0:31

Molieve Kira.

Speaker 1 0:33

Perfect, we’re recording all cameras. Audio is

Dr. Gabrielle Lyon 0:38

good. Well, this is the first ever roundtable, and we have Dr. Larry Lipschultz, Dr. Toby Kohler, and of course, Dr. Mahakara. Welcome.

Speaker 3 0:48

Thank you. Great idea.

Dr. Gabrielle Lyon 0:50

Well, it wasn’t mine. I have a great team. We are going to talk about, as you can imagine, as you can imagine, we’re going to talk about, we need to talk about penises.

Speaker 3 1:04

Oh my god,

Dr. Gabrielle Lyon 1:04

I know. And no, and it’s funny, we joke about this, but there is a disconnect between the science, men’s health, and ology, and of course the public. I think that there is quite a big disconnect, but you guys are changing the narrative, and also I think even more importantly, changing the science. So, with that being said, I have a few questions of my own.

Speaker 3 1:30

Good.

Dr. Gabrielle Lyon 1:30

When I was in residency, we weren’t even testing for hypogonadism for testosterone, and I did a fellowship in geriatrics. This was something that, when you think about sarcopenia and muscle mass, I wasn’t – we weren’t even looking at. Was there a moment in each of your residencies, and obviously this is the way back when, because I’m sure it shaped to where you are now, that you got wrong,

Speaker 3 1:56

but we got wrong.

Dr. Gabrielle Lyon 1:57

I know it’s a bad word, but that you got wrong in your training, because even right now there isn’t an ease where a patient goes to their doctor and says, I have low libido, I have erectile dysfunction, I have low muscle mass. There isn’t this ease of conversation, as opposed to, you know, I’m having headaches or I’m having shortness of breath.

Speaker 3 2:20

Yeah, but you have to look at the time. I mean, right now, I think it is fairly common. When I was training, it wasn’t – people didn’t talk about it at all. So, I think it’s different now for you guys, because you’re younger and you’ve been brought up in the practice where you do talk about it.

Speaker 2 2:38

Yeah,

Speaker 3 2:38

I don’t think it’s a taboo topic, and there’s so much in the media about testosterone and hypogonadism. I think it’s for sure.

Dr. Gabrielle Lyon 2:50

What about your both of your experiences?

Speaker 5 2:52

Yeah, go ahead, please. Well, he

Dr. Gabrielle Lyon 2:55

trained me.

Speaker 2 2:55

Sorry, I learned everything I learned was from a father situation, but we learned a lot along the way. Look, the past 25 years, we learned about the fact that, you know, patients who come in with low energy, low libido, rectal dysfunction, we were taught check a T level, but the reality is that same patient comes into a psychiatrist, they check for depression and only depression. That same patient walks into an endocrinologist office, they just check a thyroid, right? So we’re all in our silos, and we’re now learning that no, we should be checking TSH, check, make sure they don’t have depression, check at T level, so we’re broadening our scope. What could be causing these symptoms? We learned a lot about side effects. We learned about erythrocytosis. Now we’ve learned about estradiol. When we were training, we thought men don’t need estrogen, women have estrogen. Let’s bring it down with some Arimidex. Men absolutely need estrogen. They need estrogen for libido and sexual function, and we know it’s a mistake to shut them completely down, but we didn’t know that back then. So our education has really evolved over the past 25 years,

Dr. Gabrielle Lyon 3:51

and it still takes quite a bit of time to then get out to someone who is perhaps trained like me in family practice.

Speaker 2 3:56

Oh yeah,

Speaker 3 3:57

I think family practice is our biggest problem in terms of, you know, educating primary care doctors, because space.. well, they never had it in their training, and it was.. it’s just changed so much, as Mo said. So, I mean, I think, you know, a lot of my patients come in and they’ve been inadequately treated by their primary care doctors, but I think it’s changing.

Dr. Gabrielle Lyon 4:20

Well, I’ve had, actually, the same experience, because, and Dr. Kohler, you talk a lot about, and you, I remember this. I watched a lecture that you did at the Andrology Society, where you talk about Chad,

Speaker 4 4:31

okay?

Dr. Gabrielle Lyon 4:32

And I’m not usually good at names, but I remember Chad, and there was this evolution of the idea of testosterone, the testosterone culture, and where I’m going with this, in the 80s there was like a roid culture, and this discolored testosterone and testosterone replacement, both in men and women, but in terms of in your training, so I’m sure there’s been an evolution from what you,

Speaker 4 4:58

for me, testosterone. Norna has been guilty until proven innocent, instead of the other way around.

Dr. Gabrielle Lyon 5:05

Guilty until proven

Speaker 4 5:06

in terms of causing bad things, right? It’s like, for some reason, the preponderance of the evidence has to be, we have to prove that it’s safe. And there was this switch that got flipped eight years ago, when you know the work of Huggins, and some, you know, based on one patient, it’s amazing the work of one patient has changed how testosterone was a wonder drug and essential and vital for both men and women to being, you know, characterized as the devil or fuel for the fire, and so through my career, when I was at the VA in training, and we still worried about testosterone making prostate cancer worse, but it’s so interesting about how long it takes like ideas and medicine to evolve. Because when I was a resident, fourth year, I heard Abe Morgentaler speak for the first time. He’s like, actually no, it’s the opposite. Looks like testosterone may actually be totally safe, or actually even helpful for prostate cancer. This was for me 25 years ago, and every year it diffuses a little bit more, but the vast majority of people are still afraid of this prostate cancer testosterone myth, even though it’s completely debunked with excellent science. Just takes a while to get out there.

Speaker 2 6:16

I think Dr. Kohler nailed it. You asked why family practitioners do not prescribe it, they’re still reticent, it’s fear. It’s fear that it causes prostate cancer. It’s fear that it causes worsening of BPH symptoms. It’s fear that it causes cardiovascular events, heart attack, stroke, and PE. Right, that’s the fear we know today. That’s not true, but that takes time to get the word out. You still ask primary care physicians, why don’t you prescribe? I don’t want to give my patient a heart attack. I don’t want to give my patient prostate cancer, but those are myths. Those are not.

Dr. Gabrielle Lyon 6:45

There are myths. I will say that when I started in clinical practice, I was terrified, and I knew that they needed it. I need, I knew that they needed both men and women, and I would call mentors, and I would call other people, because I had not learned anything about it, and there’s risks if you don’t treat, and I just want to mention one other thing, is that people consider testosterone a lifestyle drug.

Speaker 2 7:12

Originally, that was right in the 280s up to the 2000s with a lifestyle drug, meaning something nice to have, but essentially it’s not. It’s essential, it’s an essential hormone for men and women, right. And we know that men with low testosterone levels are much more likely to have a heart attack, non-negotiable. Men with low testosterone are much more likely to suffer from depression, non-negotiable. More likely to break a bone, osteopenia, osteoporosis associated with anemia. You show me another blood test that’s associated with so many medical conditions in men. There’s no other blood test. It’s the best marker for men’s overall health,

Speaker 3 7:44

and you know, you have to be careful, though, about throwing out the term lifestyle drug and saying, well, we don’t want it associated with that, because there’s nothing wrong about changing your life, which testosterone can do. And I think the idea of a lifestyle drug gets a little bit punitive or something, but it does change your life, of course. So, I mean, I don’t have a problem with saying it is a lifestyle drug, but it changes your life. It’s not a like icing, it’s very essential,

Speaker 4 8:13

and you know, as humans, we get older, there are invariable changes that we’re all fighting against, right? And, like, these things I’m wearing right now, like my eyes were just fine 20 years ago, but now I can’t see anything, and nobody gives a second thought to getting a prescription for glass and seeing better, and so to demonize testosterone is like, well, it’s low, we shouldn’t fix it, because it’s kind of fighting the natural aging process, or however you want to think about, I think it’s completely wrong,

Speaker 3 8:40

and that’s what everybody’s doing now. They’re fighting the, you know, it’s all about not aging.

Speaker 2 8:45

Any other hormones, if your thyroid was low, you replace your thyroid. If your cortisol was low, if your insulin was low, there any other hormone – women, estrogen is low, we replace the hormone,

Speaker 3 8:55

right?

Speaker 2 8:56

Right. But why can’t we replace? I

Speaker 3 8:57

don’t like the word replace.

Speaker 2 8:59

Yeah,

Speaker 3 9:00

and I think that’s gotten way off course, because we’re not replacing testosterone, we’re using it as therapy, and we’re making it more normal, but men always have testosterone unless they’re castrated, women don’t, they stop making estrogen, and I think that TRT, the female was the HRT, and now we go to TRT, but I don’t think it really is. I say this all the time, but it’s never going to change, but I don’t like the term TRT

Dr. Gabrielle Lyon 9:29

when it comes to perform performance enhancement. So, if we’re talking about lifestyle medications, and why is this so important? Because if we don’t talk about the elephant in the room, which really is the stigma. It’s not any longer what testosterone does. I mean, you are all still clarifying and teaching the science, but the stigma is so heavy. It’s a Schedule Three medication with ketamine, and but if, if we’re really going. To unpack that and make it accessible for both the patient and the provider, where you know your patient doesn’t come to me, and then I put them on testosterone, well, not yours, but proverbial patient comes to me and I put them on testosterone, and then they go to their cancer doctor, or they go to another physician, and the other physicians, like, I cannot believe this doctor put you on testosterone, and hence you see patients under treated. So, just understanding that the relationship between testosterone and then normal life versus performance enhancement,

Speaker 4 10:32

and you know it’s interesting, he makes a distinction between if I drive up my tea naturally, I eat better, I exercise, I focus on sleep. I mitigate stress. I accept the fact that stress is like a powerful force of my life that’s going to help me, not necessarily a bad thing. If I do all those things, my T goes up and nobody says you’re doing something crazy, right? But there’s some of us where the testicles are kaput, they’re not doing the job anymore, just like the eyes aren’t seeing anymore. Sometimes it needs to be replaced. It’s very reasonable,

Speaker 3 11:08

but you’re not replacing it well, implementing it.

Speaker 4 11:11

Okay. Well, you’re normalizing it.

Speaker 3 11:12

Yes,

Dr. Gabrielle Lyon 11:13

there was something else, also very surprising. These are just a couple numbers, and I stand to be corrected. Number one, there is this idea of age-related decline, so age-related hypogonadism, and then when I looked up some of the numbers of testosterone deficiency, so I would love to kind of clarify, age related decline, is there a normal age related decline versus deficiency, and then is it true that five to 6% of men are diagnosed with, depending on their age, low testosterone? That seems very..

Speaker 3 11:51

I just don’t understand why has there never been a study looking at decades and average T.

Speaker 2 11:58

I agree. So, we know that does go down, but you’re right, specific decade, decade by decade, it, we know it goes down, but aging alone does not cause the testosterone to go down significantly. A healthy 80 year old man is not going to have a significant decline in his testosterone below 300 if he’s healthy. When the patients develop diabetes, obesity, metabolic syndrome, the acquisition of comorbid conditions, that’s when you start dropping your T levels, right? So this age-related hypogonadism is a misnomer, right? Healthy patients should not have a decline. You’re right, 5.6% 6% of patients from the age of 30 and 79 are going to have low testosterone, diagnosed by low T and signs and symptoms. If you just look at low T, that goes up significantly higher, but low T signs and symptoms up to 20% of those patients never get treated. So it’s, it’s an important number to think about, but

Speaker 3 12:49

I’m not sure, I’m not sure about this, that it doesn’t decline with aging, because examining a lot of men with fertility concerns, you notice that as men get older, the testicles get smaller and softer.

Speaker 2 13:02

Yes,

Speaker 3 13:03

so I mean, and they could be very healthy guys. They just don’t have the same testicles as a 25 year old, so something’s changing. I mean, it’s.. and I don’t think they necessarily have to have diabetes or hypertension.

Speaker 2 13:15

2% per year, starting at 20. You’re right, so there’ll be a decline as we go on, but it shouldn’t be enough to throw them down significantly, unless they have some illness, like I agree, aging will drop it, but it’s not enough to make you severely symptomatic, unless you have something, and Toby Kohlers use this, I use it again, it’s collected, kind of like the check engine light, if you have ED or you have low T, check what else is going on because something is causing those to go down, right?

Speaker 4 13:44

We know we have a decrease in postal LH release when we hit 30s, and it goes down a little bit per year in men, but you can mitigate how bad it is for you, and you can certainly make it a lot worse if you don’t take good care of yourself, right? So there are some age-related changes. We’re not going to live forever, no matter what we do, unfortunately. But if we do all the right things, we can still have a super high T, super awesome erections in our 70s and our 80s, as long as we take good care of it.

Dr. Gabrielle Lyon 14:15

Does the idea of age-related decline, if we think about statistics, if 74% of Americans are either overweight or obese. 74% are going to have what I mean, that’s a comorbid condition, but if it is defined, and I know this is a little bit of nitpicking, but if we don’t have the conversation, it will remain age-related decline, and we are seeing 50% of adolescents and youth that are either overweight or obese. How do we imagine that if kids and people are getting obesity and other comorbid conditions earlier, then this in my mind becomes an essential treatment.

Speaker 2 14:56

Yeah, it’s there’s no question that every decade by decade. T levels are going down, and if you want match and look at obesity in the United States, decade by decade, obesity is going up at every age group, right? And weight increased fat increases the risk for having hypogona 10% you gain 10% your body weight, you’re actually drop 85 nanogram, you gain 15% your body weight, you drop 270 nanogram per deciliter, so it’s bidirectional, and so the GLP ones have helped, so you’ll lose weight. You actually can maintain and increase your T levels, but obesity has a bad, profound effect on T levels,

Speaker 4 15:31

and it’s a feed forward, or you know, reverse forward cycle. The heavier you get, the more fat you have, the more you convert your testosterone to estrogen, the less testosterone they have, the less energy you have, and you get more and more and more heavy, but so that’s the badness. The good news is, cut 10% of your weight, all of a sudden, boom, tea starts going up, more tea available for your muscles, for your energy, for your sex drive, and now you have more, and now you’re starting to make gains, and your tea gets better and better, so it goes both ways,

Speaker 3 16:00

but I think you know we have to face the fact that, look, you know, I am older than you guys. I hate to admit it, but I am, because I trained Mo, right? But I mean, my T has gone down, and I don’t, I don’t have any comorbidities, and I’m not obese.

Speaker 2 16:16

Yeah,

Speaker 3 16:16

so I mean, you know, it is what it is. You have to deal with it. I just don’t think you can say, well, if I do everything right, my T is not going to go down, it’s going to go down.

Speaker 2 16:25

Yeah, I think you can decrease the slope, right? So it’s going to go down, it’s just that, how fast is the slope?

Speaker 3 16:31

And mine’s gone down slowly,

Speaker 2 16:33

yeah, which, you know, good health,

Speaker 3 16:34

yeah, good health, but it’s still not what it was,

Speaker 2 16:37

yeah.

Speaker 3 16:37

And now the question is, if it is low. Should I be supplementing? I mean, do I want a tea of a 40 year old, or is it more, or should I have a tea of whatever age I am? Which

Dr. Gabrielle Lyon 16:52

I have a question. Why would there be a even a consideration that either you would or you want it? And what do I mean by that? Is if a 40 year old testosterone level, which again I realize that it’s not based on age, some people will have a baseline, and to be fair, many people listening only think about the total team, so if a free testosterone when someone is 40 is anywhere from let’s just pick number 500 to 700 and that’s normal for them. And as you get more mature,

Speaker 4 17:27

the

Dr. Gabrielle Lyon 17:29

idea that you would replace that of your 40 year old self, that there would be some hesitation.

Speaker 3 17:39

Why would there be any to

Dr. Gabrielle Lyon 17:40

me, as someone who has been a legacy, you know, provider and prescriber,

Speaker 3 17:45

right?

Dr. Gabrielle Lyon 17:46

Why would you even have a second thought?

Speaker 3 17:48

I don’t know. I, for a long time, I resisted, but I decided I wouldn’t.

Speaker 2 17:57

I agree with you. I mean, like, the reality is, if you knew that there was a drug, let’s call it Drug X, that decreases your risk for diabetes. t4 DM large study prevented the risk of progressing to type two diabetes and reverse diabetes. If you know there was a drug that helped prevent

Dr. Gabrielle Lyon 18:11

reverse diabetes. Oh yeah, can you say this again?

Speaker 2 18:14

So this was a t4 DM study, it was a study out of Australia, over 1000 patients randomized to either long acting testosterone or placebo over the fact of the time they found that these men who had testosterone actually reversed diabetes or prevented the progression of diabetes. Large study, one of the, we call it the big three, it’s one of our big three studies, t4 DM. So, if you know that there’s a medication that could potentially reverse diabetes or prevent the onset of diabetes, the medication could actually prevent or help prevent osteopenia, osteoporosis. Knew the medication actually helped with depression, you know that theoretically there’s some cardio protective effects, but we can talk and debate that. If you knew that, forget, and it also helped with muscle mass and preventing sarcopenia, and you were low in that medication, why would you not consider taking it?

Speaker 3 18:59

But I think

Dr. Gabrielle Lyon 19:00

I

Speaker 2 19:00

agree.

Speaker 3 19:01

I just always worry, wonder, worry whether or not people who are taking testosterone are doing so many other different things that they didn’t do before. I mean, they’re eating better, they’re probably exercising better, they care more about themselves, or they wouldn’t have taken the testosterone.

Speaker 2 19:17

Yeah,

Speaker 3 19:17

so it’s almost a self-selected group to become healthier,

Speaker 2 19:21

sure, but I’ll take it.

Speaker 3 19:22

Yeah, I understand that, but when you look at studies like that, I mean, do they control for every other variable?

Speaker 2 19:28

Yeah, t4 DM, you’re correct, was testosterone versus placebo, but both groups did lifestyle modification, yeah, exercise, but the T plus the lifestyle modification was much stronger than exactly

Speaker 3 19:39

modification, but I think I think if somebody has low tea and you want them to exercise as part of lifestyle changes to help with their natural improvement, then if you give them the tea first, they’re going to be more likely to exercise, so it’s kind of, you know, a self-fulfilling prophecy.

Speaker 4 19:55

Of course, you not only will you likely have more energy, be able to get up off the couch. But actually, if you do start moving iron, you’re going to see progress, and we’re like, get excited.

Dr. Gabrielle Lyon 20:06

I have another, maybe it’s a little bit controversial, and I mean, it’s not really, you know, we’re all friends, but if we are seeing obesity, and it’s not a treatment for type two diabetes, right? At least for women, we don’t go, you have type two diabetes. If I had to make a decision of your first line intervention, it’s and I had to choose between two drugs, GLP one and testosterone. It’s never going to be testosterone, right? We see, I am not sure that we are going to get a handle on obesity and metabolic syndrome. We do have an increased use of GLP-1, but as a provider and as someone who’s trained in nutritional science, I don’t know if we’re going to get there. That means some individuals are probably going to be more likely at an earlier age willing to look at testosterone, and then this becomes kind of a dance, because I remember when I had a patient, and they were in their 20s, they went to urology, and this was in New York City, they went to urologists, and urologists didn’t want to treat that 20 year old with testosterone because he didn’t want to affect his lifelong fertility. So, how do we then normalize making decisions at to what age would you actually begin treatment with testosterone

Speaker 3 21:20

when it’s low,

Dr. Gabrielle Lyon 21:22

but they were in their 20s, and there was like, but was it low? It was low.

Speaker 3 21:26

I mean, it’s like Mo was saying, I mean, if they had low thyroid, if they had problems with diabetes, you would treat it. So, why are you not treating the low testosterone? I mean, we’ve shown that you can, you can prevent them from affecting their sperm production, we know that,

Speaker 2 21:43

but the fertility, his points of all taken, its fertility aspect is extremely important, you know. 20 year old, if you want to put them on lifestyle, lifelong medication is a long time, 20 year old, right? So the reality is there may be other ways to do it, and you could do lifestyle modification, but also lifestyle modification helps, each one helps individually, but, but, but sometimes just weight loss will make it, but you can’t. It’s hard to sustain. That’s what I’m trying to say. You say, mr. Smith, I need you to lose 10% of your body weight. He may lose it, but he may gain it back again. And sometimes these patients need to use the testosterone in conjunction with the lifestyle modification to get the best outcomes.

Speaker 3 22:19

That’s what I think, because I think it gives them, it gets them to the gym, it keeps them in the gym.

Speaker 2 22:24

Yeah, I,

Speaker 3 22:24

you know, it gives them a different mindset.

Speaker 2 22:26

Yeah,

Speaker 3 22:26

and so I think you know lifestyle modification is great, but sometimes you need something to get them started, and testosterone really does help.

Speaker 2 22:34

Yep, but you’re not touching the elephant in the room. The elephant room is the GOP one is lost because it causes significant decline in muscle mass, right? And that’s important, right, because if you restrict your caloric intake, you’re not going to only lose fat, but you lose muscle, and some studies will say up to 30% muscle mass. Well, that’s a problem, particularly if you’re older. I think it’s sarcopenia, right? There are now new companies coming out making GOP one plus SARMs, or medications to raise T levels. Why are they doing the combination, the combination, because they’re hoping that the T levels going up will increase muscle mass, and that patient that’s losing muscle mass, the GOP one.

Speaker 4 23:08

Yeah, I think you know the bottom line is food is too delicious.

Speaker 2 23:13

Yeah,

Speaker 4 23:13

you know that’s why 95% of diets fail. So I’m all, I’m very in favor of GLP ones, and I think there is a danger of sarcopenia with extreme quick weight loss, but can be mitigated protein intake, exercise, sleep, right? There’s powerful trials showing that if you’re sleep deprived and you lose weight, it’s mostly muscle, but if you’re sleep replete, you’re sleeping adequately, you lose much, much less muscle, right? So

Speaker 3 23:46

all these proteins are so important. Yeah,

Speaker 4 23:48

yeah, sleep, protein, exercise, all the pillars that you need, but just the GLP one alone. Yes, I would be worried about muscle mass loss, but you don’t give GOP one in isolation. You tell the patient, listen, I want you to 100 grams of protein a day. I want you to work out with resistance ring at least twice a week. I want you to focus on sleep, and then you won’t have that extreme muscle loss. And when people lose a lot of weight, they also lose muscle, even if not from GLP ones, if it’s just from starvation.

Dr. Gabrielle Lyon 24:15

Are you seeing improvement in testosterone with the use of GLP ones, because of the improvement in obesity.

Speaker 2 24:23

Yes, T levels to go up. Yeah,

Dr. Gabrielle Lyon 24:25

clinically significant,

Speaker 2 24:27

clinically significant, and sustainable. In other words, when I, when the GLP ones were not around, they would lose the weight, then they would gain it, then they lose the weight, and now it’s sustainable weight loss, and the T levels stay up.

Speaker 3 24:38

So, why would it be sustainable once they stop the GLP ones,

Speaker 2 24:42

if they stop the GLP ones, then, and they gain the weight back, sea levels start going back down again.

Speaker 3 24:46

Right,

Speaker 2 24:46

right. So, but these patients stay on the GLP ones. I’ve most of the patients I saw on GLP ones going maintenance dose, so they get to their desired dose, the level of weight, and then they say, I’m not, I say 85% of patients gain every pound back if they stop. Up, unless you’ve changed your lifestyle modification. Most patients say, “Doc, keep me on a maintenance dose.

Speaker 3 25:04

But do we know? Do we know? I know I’m asking a question I know the answer to, and that is, do we know the long-term effect of staying on GLP ones for years?

Speaker 4 25:16

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

Dr. Gabrielle Lyon 25:20

What about low testosterone? Can we touch on some of the perhaps a little bit unknown consequences of having low testosterone? And then maybe before we do that, defining what is actually low.

Speaker 2 25:34

Yeah, I mean, there’s a definition that’s with the community – it’s 300 nanogram per deciliter. I disagree. I think most of us disagree. There are patients who are at 323 5390 who are symptomatic that may benefit from testosterone therapy. You can’t have one number for everybody and say that everyone below this number must feel bad, everyone above this number must feel good. There should be some kind of range, and quite frankly, if you give a patient a three month trial and medication and they don’t get any better, then you could argue maybe this is not for them, but if they do feel better, then you could consider. So, my threshold is a little bit higher than the 300 I make up to almost 400 in patients, particularly

Speaker 3 26:11

talk about the tertiles. Yeah,

Speaker 2 26:16

so I’ll give you an example. So, the AUA puts out guidelines. The guidelines say that the patient should be between 450 and 600 that’s what you’re shooting for. So, patient came to my office the other day and said, Dr. Kira, what range should I be in? I said, according to the AUA guidelines, you should be between 450 and 600 He said, that’s great, I’m at 390 so can you raise my levels? And typically, you’re supposed to say, well, no, you got to be below 300 in order for you to put you on to put you into the normal rights, that makes no sense, that

Dr. Gabrielle Lyon 26:44

makes no sense,

Speaker 2 26:45

really. The cutoff should be the lower limit of the range you’re trying to get them in, so the cutoff really should be theoretically 450 if that’s where you’re trying to put them,

Speaker 3 26:53

but I think another thing that another thing that patients don’t realize, and a lot of the primary cares don’t realize that, although the FDA has approved point five as a drug dose that they, you know, with it, with a commercial testosterone,

Dr. Gabrielle Lyon 27:08

can you explain to me what do you mean? Well,

Speaker 3 27:09

there is a commercial product FDA approved, and its maximum dose is point 500 milligrams a week

Dr. Gabrielle Lyon 27:18

of testosterone. Yes,

Speaker 3 27:20

all right, and the thing about that, if you give that to somebody and you measure their testosterone two or three days later, it’s over 1000 Yeah, so I mean, this business of looking at endpoints, you have to decide, are you going to look at the nadir before their next shot?

Speaker 2 27:37

Yes,

Speaker 3 27:37

are you going to get it in the middle?

Speaker 2 27:39

Right,

Speaker 3 27:40

I am not one that’s hung up on numbers, because I am treating a patient with symptoms.

Speaker 2 27:46

Yeah,

Speaker 3 27:46

and not

Dr. Gabrielle Lyon 27:47

everyone in practice.

Speaker 3 27:48

I’m not going to tell you,

Dr. Gabrielle Lyon 27:51

because what I noticed is there. I think that there’s a natural trajectory of a clinician. When I was early on in my practice, I was a stickler for the number, like this is the number, yeah. And it takes 20 years of practice,

Speaker 3 28:06

I think you’re right, but it

Dr. Gabrielle Lyon 28:08

takes 20 years of practice for me, who, you know, I still am uncomfortable if it’s outside the number, but then maybe if I’ve been in practice 40 years, I’m much more flexible, but that means there’s a huge cohort of physicians, and most importantly, primary care. The first line of defense, they’re going to feel very uncomfortable if someone comes to them and goes, ‘Doc, you know I’m at 450 I feel like crap. Let’s say I’m living in the middle of Idaho, and I, you know, I’m in a very rural area, you know, no offense to anybody from Idaho, but maybe it’s a rural area, and then it’s unfair that both the physician, because we all have physicians, look back and gosh, I really wish I would have treated that patient.

Speaker 2 28:51

Yeah,

Dr. Gabrielle Lyon 28:51

and then 10 years later this patient goes through life, and then it becomes 20 years, and then finally the patient gets treated when the doctor is caught up.

Speaker 2 28:58

Yeah, but it’s very different than putting love, putting someone in the normal range at the upper normal, and then sustained super physiologic levels.

Dr. Gabrielle Lyon 29:05

What’s the danger of super physiologic?

Speaker 2 29:07

Well, there’s a lot of erythrocytosis, there can be cardio toxicity, cardiomegaly, ventricular hypertrophy. There’s been increased MI risk. I mean, he’s done more work on this than anyone I know.

Dr. Gabrielle Lyon 29:15

We’re gonna, we’re gonna,

Speaker 2 29:16

so I mean, he’s, I mean, and so, but that’s a sustained super physiologic levels. I accept that if I give someone an injectable, that there’ll be a transient increase in physiologic levels at the beginning, and then it goes down, pellets, it’ll go up a little bit slightly higher above, and then they’ll come down, but to sustain superphysiologic levels, I personally get concerned, I mean, there’s been very good data that you’ve presented, right,

Speaker 3 29:36

but I also think we get, we do get too caught up in the numbers, and I think those of us, like you, say that was a great point. The longer you’re in practice, I think the more you realize that it’s not as important as the patient’s symptoms, because that’s why you’re treating them to begin with. But I have a patient with Klinefelter syndrome, which you know is a problem with testosterone. They do not make high levels of testosterone. He’s a football player in college, right. So we had to get permission to treat him because he’s playing football, which we did, because you know he has a genetic abnormality, he should be treated. So we were treating him with, I don’t know, maybe point seven five a week. He’s huge, you know, like 610 and you know, 320 I mean, just a big

Dr. Gabrielle Lyon 30:22

is point seven five enough.

Speaker 3 30:24

Well, wait a second. So then I get a letter saying that I am over treating the patient, he should only be on point five. I said, what happened? I mean, why did this? Is after you know three years of treatment, his parents say, well, somebody new entered the council, whatever they use for the, for the athletes, and I said, “I will bet you it’s an endocrinologist. It turned out it was an endocrinologist. No one has ever looked at this person; they’re just getting a report with a number, and they think the number’s too high.

Speaker 2 30:57

Yeah,

Speaker 4 30:58

I mean, we know there’s biological variabilities between humans, right? Somebody’s tea at 400 they’re going to feel great. Other people are going to feel horrible. This is a fact. Whether it’s testosterone sensitive sensitivity, whether it’s the free tea, not the total tea, there’s all these factors that can make you different, how you feel. Maybe this is contentious, but I feel like every man should know what their testosterone level is when they’re at their peak in their life. When they’re 25 years old, they’re healthy, they get their baseline T. So, yes, I felt amazing when I was 25 with a testosterone 450 That’s a very powerful piece of information, because if your T is 450 at age 55 it’s very unlikely that that’s the problem if you’re feeling off. If, however, your T is normally at 650 when you’re 25 and now you’re coming in at 400 to your point. Yeah, it’s probably low for..

Speaker 3 31:45

and another thing that I think we overlook is patient’s weight, body size. I mean, there’s a lot of literature on treating people with higher doses because they weigh more and they’re bigger, right? You know, someone, you know, a 150 pound man does not require the same injection as a 250 pad. I mean, they’re different. No, you’re right, and we don’t pay enough attention to that. I don’t think when we see patients, do you?

Dr. Gabrielle Lyon 32:12

I do. I do think about it, and then I think about this idea that actually I’ve learned from you guys over at Baylor, is this idea of CAG repeats.

Speaker 3 32:19

Yeah,

Dr. Gabrielle Lyon 32:20

and you know, in my mind, when I think about obesity, so in skeletal muscle, there’s this anabolic resistance, so muscle becomes resistant to this normal stimuli and less efficient, it’s less efficient at recognizing, utilizing amino acids and protein, and also, and this might be a little controversial, but obese muscle, when fat is infiltrated, it’s not as responsive to exercise. There’s myostatoes. It does make sense. And then that makes me think about the receptors and testosterone, where it’s this fine balance, and I don’t know the answer. I’m hoping that you guys can shed light on it for me, that if someone is obese, do they require more testosterone to then feel the effect, or even get the effect, and I’m sure you worry about estrogen, and this just this dance, but is there to say this succinctly a change in the amount getting to the muscle from the with utilization of testosterone, do they require more in obese patients?

Speaker 2 33:27

I think it’s two different topics. So, one topic is the sensitivity of the testosterone receptor, so it’s called the CAG repeat. So, in Baylor, when I started with Dr. Lipschultz, we started this, doing this, we do today, we take the blood, we send it to the lab, and they give us the sensitivity of the androgen receptor if the CAG is greater than 27 The androgen receptor is insensitive, and we show that those patients need more testosterone. Makes sense, it’s less than 27 it’s sensitive, they need less testosterone, and we’re all different. So everyone has their own CAG repeats, so that’s different. What you’re referring to is the acquisition of obesity, and obesity in itself has many mechanisms of why it shuts down the T, it aromatizes, increases leptin, increases cytokines, each one of those take a hit directly on the pituitary and the testicle to shut down the ability to the amount of tea we make, so you have to give those patients more T in order for them to compensate for the loss, on this side when they’re insensitive, you got to give them more T, because they need to be higher levels to feel the benefit, so they’re a little bit different, but both categories need more tea to feel better,

Dr. Gabrielle Lyon 34:28

and this creates a huge, I want to say, red tape, because providers might not feel comfortable with the dosing. Can we touch on how, and you guys have talked about this quite a bit, but the idea of how do we determine a dose of testosterone, because you don’t necessarily look at all the numbers, but

Speaker 3 34:50

well, I look at the numbers to start treatment, but my point is I don’t follow the numbers in terms of what I’m going to do when you return with facial returns in three. Months, I’m going to see how he feels. That’s my most important guidance, is the patient’s symptoms, not the blood test.

Dr. Gabrielle Lyon 35:08

So, I have to push back on this just a little bit. Is that, for example, I don’t feel comfortable increasing the dose of testosterone over 200 even if a patient comes to me, and I’m not a urologist. If a patient comes to me, and I, and even if I suspect CAGR, because for the general population it’s not as easy to get, and I remember I have this patient who’s a part of Homeland Security, and I am only willing to provide 200 milligrams of testosterone because it’s outside my comfort zone, and I know that he needs more.

Speaker 3 35:40

That’s your problem.

Dr. Gabrielle Lyon 35:42

No, it’s your promise. I’m sending them to you,

Speaker 3 35:44

but I mean, the point.. I don’t have.. I do not have a problem,

Dr. Gabrielle Lyon 35:47

but you would prescribe me more. Would you do that?

Speaker 2 35:50

I typically don’t, but I’m not looking at.. I’m not looking at the amount I’m prescribing. I’m looking at a blood level, right? So, so I’m looking at the blood level, and so if the blood level typically, you’re right. At 200 milligrams a week, I don’t need to go any higher, right? So that’s you’re right, but if for some patients are eating it up faster, metabolizing it faster, and he needs to go higher, potentially. But the reality is depends on when you’re looking at the level. Testosterone is a game, you, whenever you check the blood in relation to when you give the medication, you can make that level look like whatever you want, and that goes for anything, a pellet, an injectable. I check in to give someone an injection today and check their blood tomorrow. It’s very different than when I check it in a week before they give the next injection. So, whenever I tell the residents, when you check a blood level, right underneath that, you write when was the last dose given on whatever you’re giving, because that’s going to change the level, right? It’s very important,

Speaker 3 36:44

but to that point, what we’re seeing, what I’m seeing now, is more patients are dividing the dose, and more patients are microdosing. Micro dosing has become very popular, where the patient takes, let’s say, we’re going to give them 200 milligrams, they divide it by seven, and they do a sub q injection every day, or they divide it into three.

Speaker 2 37:04

Yeah,

Speaker 3 37:04

because we’re seeing, I’m seeing fewer side effects.

Speaker 2 37:07

I agree, 100% The whole reason is, you drop the erythrocytosis rate, because you’re spiking, right? And that’s helpful. Some people showing a drop in hypertension rates, you drop the mood swings, so it’s a little bit of a hassle, but I think it’s so,

Speaker 3 37:19

but the patients like it, because a lot of men get very tired with intramuscular injections, because it’s painful, and it’s much less painful with subcu,

Speaker 2 37:28

yeah,

Speaker 3 37:29

and if you know, with the pharmacies I use, they’ll send the patients a larger needle to draw it up, and then a smaller needle for them to inject, so they’re kind of on the same page,

Speaker 2 37:39

and you can drop the dose, so 80% so whatever you give I’m, you can only have to give 80% sub q and get the same blood level,

Dr. Gabrielle Lyon 37:45

you get the same blood level. The I do want to touch on the risks of testosterone replacement, and really, where you were talking about was super physiological dosing, and in my mind, if you do I’m technically they would then get a quote super physiological dose once, once a week,

Speaker 2 38:06

transient

Speaker 3 38:07

though

Dr. Gabrielle Lyon 38:07

it’s transient, but still over time it’s kind of like if I’m eating a cake, I don’t know, you know, I mean like cake, if I’m eating a cake once a week on you, but um, if even if it’s transient, is that without risk?

Speaker 2 38:26

Well, there is some risk, because the spikes do cause an increase in rhythmcytosis,

Dr. Gabrielle Lyon 38:31

which is

Speaker 2 38:31

a higher increase in red blood cell count, right? Zymatica goes up, and theoretical risk, if it goes above 54 there’s a theoretical cardiovascular risk. I use word theoretical,

Dr. Gabrielle Lyon 38:39

yeah, because my patients in Denver, and they’re hemoglobin, matocrit are above 52 easily,

Speaker 2 38:46

and this is called secondary erythrocytosis. And there’s never been – there’s been only one paper to show that secondary erythrocytosis increases as a cardiovascular events. This is out at the University of Miami. Other than that, there’s no data to support this. All this data comes from the polycythemia vera data, which is a blood discretion, it’s different than the cancer test, it’s very different, but we’ve extrapolated the polycythemia vera data to the general population, which is a mistake, saying that, oh, if you have a high hematocrit, you’re more likely to have a MI. So the date, I think that that data is evolving, but there’s not great data on secondary rhythmcytosis causing cardiovascular events, so I think that’s important to keep in the back of my

Speaker 3 39:21

mind,

Speaker 4 39:22

I’ve been, I’ve been trying to figure out that number that people want, like what is too high, what’s the level that’s too much. Couple things to think about. So I looked at 100,000 men at Mayo Clinic over the last 20 years, and it’s actually pretty rare to physiologically exceed 1000 nanograms per deciliter in healthy men. It happens occasionally,

Speaker 3 39:45

but

Dr. Gabrielle Lyon 39:45

testosterone.

Speaker 4 39:46

Yes, testosterone levels above 1000 naturally is pretty rare

Speaker 2 39:50

naturally. Naturally,

Speaker 4 39:51

naturally, yeah, right. Okay, so that’s an interesting tidbit, right? So, if you think, well, if very few men get above 1000 naturally. Is intuitive to think that an average level of testosterone should be below 1000 Right, the other thing to think about is, okay, well, what about people like really super physiological? We know a lot of bad things happen, heart attacks, these kind of stuff.

Dr. Gabrielle Lyon 40:12

What is there a number?

Speaker 4 40:14

Well, the data is not great, right. There’s only seven trials where they look at men getting T levels higher than 1800 consistently, right, and they have a lot of the things that Mo talked about, acne, heart disease, changes in lipid profiles, you know, problems with sperm production, these kind of things, but the bottom line is the FDA uses 1800 as the safety cut off,

Dr. Gabrielle Lyon 40:38

1800

Speaker 4 40:38

1800 for trial, so when you’re doing testosterone trial, if you exceed 1800 any point you’re out.

Dr. Gabrielle Lyon 40:45

That seems a bit high.

Speaker 4 40:46

It’s generous, right? But they’re taking into account the fact this is an this is a one-time level, not an average, right? So you know, I think a T level in the five to 800 range in my, my read of the literature is reasonable, especially for one of these people who are very insensitive to testosterone. If you have the CAG repeats, if you have all these other mechanisms going on, so that’s my read of the data, you know, that’s just an opinion.

Speaker 2 41:15

But that 1800 and he’s what he’s saying is it’s in a trial, so they’ll allow for someone, it’s 5% will go above 1800 That’s not their lot, allowing it to go to 18. It’s a, they have to titrate it down, so if you’re trying a new drug out and just learning more about it, but that they’re not saying that’s acceptable, that that’s like the hard stop. We don’t really have a hard stop yet, but you know something, I see a, I see a lot of athletes, and they take testosterone, for you know, whatever. What were you calling it? Performance

Dr. Gabrielle Lyon 41:45

enhancement. I was wondering if you were going

Speaker 3 41:47

to say, and I send them, and I send them to the cardiologist at some point. I have not had a single cardiology problem identified in these guys, not

Dr. Gabrielle Lyon 42:00

one. Is it a length of time? Then

Speaker 3 42:02

I mean, it could be they’re younger guys, right? And I haven’t done it yet, you know, at five years, but they don’t stay on these performance-enhancing drugs for long term. I think the men who stay on testosterone long term are the older patients with classic symptoms of low testosterone, but the ones who are doing it, performance enhancement, I think it’s fairly transient, but again, I have not seen anything, and I measure lipids, and I measure hematocrits, and I measure CMPs regularly on all these people.

Dr. Gabrielle Lyon 42:34

Seems odd that an athlete would come in and think about performance enhancement, and again we’re not talking about super physiological levels, but then they go, “Oh, my sporting career is over, I’m going to go off of testosterone. It just seems a bit counterintuitive, and maybe it has to do with the FDA restrictions. So there was recently a removal of the black box warning with the Traverse trial, and you were involved in the traverse trial. I’d love to hear a bit about that.

Speaker 3 43:06

Yeah, can I just.. I just say one thing, and that is, what, when these, when these people are no longer doing whatever they wanted to do, for which they wanted the higher testosterone, I will talk them down. I will not continue high dosing, and people

Dr. Gabrielle Lyon 43:20

consider high,

Speaker 3 43:21

you know, over one cc

Dr. Gabrielle Lyon 43:24

over? Okay, so 200 200

Speaker 3 43:27

yeah,

Dr. Gabrielle Lyon 43:27

a week, okay,

Speaker 2 43:30

yeah. The trewich trial is interesting because it’s like before 2010 numerous studies showing men with low testosterone levels much more likely have heart attack. Numerous studies showing

Dr. Gabrielle Lyon 43:39

numerous studies before 2010 those below 300

Speaker 2 43:44

were more likely to have increased mortality, more likely to have a heart attack. Also, numerous studies showing that if you give testosterone, it may decrease the risk of a heart attack before 2010 2010 to 2014 four studies come out suggesting that you may have an increased risk. Three of these studies are not randomized, no placebo, no control. They’re retrospective database studies. 2015 2014 the FDA has a meeting, and they decide that there may be an.. it’s inconclusive based on these four studies, whether testosterone increases the risk of cardiovascular events, and they strongly recommend a large study called the Traverse Trial, the largest randomized placebo-controlled trial. 5246 men took us six years to do it. Very expensive trial. What did it show? No increased risk in heart attack in those men taking testosterone, and it was a gel. Don’t get me wrong, it was a gel versus placebo, but there were sub-studies. No increased risk in BPH, no increased risk of prostate cancer, a slight improvement in cardio depression. There was also improvements in sexual activity as well. So big trial, a lot of money spent on it. And based on the reverse results of the traverse trial, big day was it was february 28 2025 The FDA announced we. Now going to remove the cardiovascular warning from the labels. It was 10 years exactly later where they decided to remove the warning, so it took us a while, but it’s now off the label.

Dr. Gabrielle Lyon 45:10

Was that one of the biggest moments in your career? Huge.

Speaker 2 45:12

I remember exactly where it was, and I saw the thing come up, pop up on my feet. It was a big deal, because you know, we published the first paper in 2023 showing there was no cardiovascular events, and then it was silence for two years, and I thought, maybe I hope they’re gonna.. what if they don’t do anything? What if they don’t take it off? It was just silence. And then two years later, they announced, okay, yes, we will take up the cardiovascular morning.

Speaker 3 45:33

But I have to be the devil’s advocate in that. I’m not comfortable with the dosing on that study.

Speaker 2 45:39

Yes, so let’s talk about that, because people look at the range of 350 to 750 and they say, well, 350 is sub therapeutic. If you got someone at 360 it may be low, but what most people don’t realize is this is the only study where those numbers were the troughs, they weren’t the peaks, they were the troughs. So, if the T trial, which came out in 2015 2016 sorry, those were actually peak levels,

Speaker 3 46:02

so what? So, what was the average T level in the traverse study?

Speaker 2 46:06

Average increase in the T level was 147 nanogram per deciliter, but this was at the trough, so we didn’t publish the peak level, but

Speaker 3 46:13

you have it,

Speaker 2 46:14

we can look at it, we still have the data. Yeah, but those were the troughs, so everyone looks at, say, Kara 360 that’s so terrible. I say, if it was a peak, yeah, I agree, that’s a trough,

Speaker 3 46:24

but there’s not as many peaks and troughs with topicals, because, because you do it every day and it’s constant, these were not injections,

Dr. Gabrielle Lyon 46:34

was there? Do you prefer as a provider? I mean, most providers, for at least I can speak for myself, prefer injection. Is there a reason someone would use a gel, or you used a gel? Was it just ease of access? Well, it

Speaker 2 46:46

was also the sponsor, so the sponsors were basically gel sponsors, and so we used their formulations. But I agree with Dr. Luchts. I mean, gels and injectors are different, so you have to be very careful in using the injection, the gel data to be apples to apples for injection data, but if you talk about prostate cancer, it’s safe, because the reality is we talk about a saturation point. So, if you put someone above 250

Speaker 3 47:10

I don’t

Dr. Gabrielle Lyon 47:10

pause on that, the saturation point. Most people listening to this don’t really understand that component, the saturation point of prostate or PSA,

Speaker 2 47:23

so yeah, the prostate acts like a sponge, it takes up all the tests, and that it wants, and finally it’s saturated. Then it doesn’t care how much more you raise the testosterone in the blood, it’s not going to change the PSA, it’s not going to change the prostate volume, and so when you, we think the saturation points around 250 in the end of gram per deciliter, roughly,

Dr. Gabrielle Lyon 47:43

meaning if someone has, because one of the biggest restrictions for primary care is, I don’t want to give you testosterone, because it’s going to cause prostate cancer,

Speaker 2 47:51

right? Right, that’s changing to think, even on the traverse trial, so the traverse trial actually showed 5246 men, no increase in high grade prostate cancer, regular prostate cancer, or BPH – big study, randomized placebo. But remember, if you take someone whose testosterone is 150 and you put them on T, that PSA is going to go up. You better believe it, it’s going to go up, right? If his PSA is testosterone is 290 and you put them on T, PSA is really not going to go up, you’re above the saturation point, right? So, if you’re on an injectable or a gel, we’ve gotten beyond the saturation point on both, so I’m not really concerned when it comes to prostate cancer and BPH. Cardiovascular is a little bit different, right? Injectable can cause higher erythrocytosis, potentially higher hypertension, so there could be some parameters that are not apples to apples. I think the traverse light gives you a good idea, but it’s not exactly the same with an injectable,

Dr. Gabrielle Lyon 48:43

and can we just say one more thing? Because this is so in nutritional sciences, when a study is funded by an organization, whether it’s a beef company or the dairy council, people there will be very good science, and instead of looking at the science, people will say, well, there’s funding behind that, and I don’t know if it’s like that in the world of andrology and pharmaceuticals. Is it?

Speaker 3 49:07

Yes,

Speaker 2 49:07

it is. I mean, quite frankly, without the funding, we can’t do the great science.

Dr. Gabrielle Lyon 49:12

And so I wanted

Speaker 3 49:14

this trebuchet

Speaker 2 49:14

would have never happened without the funding. Right now, the way the funding works typically, it’s an unrestricted grant to a group of scientists that do the study, but yes, the money comes from an industry to help support the

Speaker 3 49:26

truck. I don’t remember in that study whether it was where the brand was announced or incorporated,

Speaker 2 49:32

but it wasn’t. But AbbVie was the major sponsor, and we had other sponsors as well, but again, all the money went to a central repository at the Cleveland Clinic, and that study was done with nine investigators, but

Speaker 3 49:45

didn’t, and wasn’t at that time the all of the other topicals generic,

Speaker 2 49:51

I don’t remember, because it’s 2015 so the well,

Speaker 3 49:56

they are now,

Speaker 2 49:56

they are now,

Speaker 3 49:57

so I mean, you know, you couldn’t have profited. Yeah, because you know your brand was not out there being advertised.

Dr. Gabrielle Lyon 50:04

It’s a, it’s a big misunderstanding with the general population, and even people that are very interested in science, and then the researchers, because there has to be money for funding, and ideally it is given to and provided to excellent scientists and excellent physicians, and the data

Speaker 2 50:23

is the

Dr. Gabrielle Lyon 50:24

data. Yeah, and not.. I mean, that becomes really important. Is it unethical to not treat with testosterone? So, from what I’ve read, is that if someone has low testosterone, there’s an increased risk in, for example, high-grade prostate cancer,

Speaker 3 50:40

so I think the word unethical to not treat.. I don’t know whether the word unethical is the right word, it’s uneducated, a

Dr. Gabrielle Lyon 50:49

little too heavy.

Speaker 3 50:50

Well, I mean, yeah, but it’s not ethics, you know, when you’re treating patients, it’s what’s right, what’s wrong, what’s.. you know, the currently acceptable, acceptable way to treat standard of care. I think, right now most people would treat,

Speaker 2 51:03

yeah, but I think we, knowing what with the three of us know now, I would say, look, it was a loved one, brother, my brother had low T, and I’d say, look, I really want you on this, for your not just for your sex drive or libido, it’s for your overall health, and I really want you on this,

Speaker 3 51:17

but how about if he has no symptoms?

Speaker 2 51:20

Well, I agree, so it depends on how low is low. It’s clearly under 200

Dr. Gabrielle Lyon 51:25

That’s a really good point.

Speaker 2 51:26

You know,

Dr. Gabrielle Lyon 51:27

that’s a really good point.

Speaker 3 51:28

That’s why I worry about testosterone screening. People are all talking about testosterone screening, and if they start screening, when do you treat? Do you treat because the number’s low-ish?

Speaker 2 51:39

Yeah,

Speaker 3 51:40

you know, you’d have to be it has to be well thought out.

Speaker 2 51:43

Yeah, I agree. When

Speaker 3 51:44

you’re going to treat,

Speaker 2 51:44

I think if you’re severely hypogonadal, and I use under 200

Speaker 3 51:48

yes,

Speaker 2 51:48

I consider that severely hyperganidad. Then I worry, and it usually it’s pretty rare that someone under 200 is not symptomatic, so let’s be fair. But the reality is, I worry about what’s going to happen to you exactly: osteopenia, osteoporosis, but cardiovascular risk. I worry about lipoprofile, so I was in that case. Say, look, I realize your levels are low, and you may not be symptomatic, but these are the things I’m worried about. It’s pretty rare for someone to be below 200 and not symptomatic.

Speaker 3 52:13

I know, but I just saw a baseball professional baseball player comes in, t’s are consistently under 200 and he doesn’t really have significant symptoms, but you know, I worry about him.

Speaker 2 52:26

I worry,

Speaker 3 52:27

first of all, he was very thin. I just don’t think he had enough muscle mass,

Speaker 4 52:31

practically speaking. From a patient perspective, if you go to your provider and you have symptoms, your testosterone is low, or borderline low, it is totally reasonable to seek a second opinion if that physician or care provider is uncomfortable writing for testosterone.

Speaker 3 52:49

I know, but how many patients know that? I mean,

Speaker 4 52:51

yeah, but that’s that’s why we’re saying these things, right? I mean, you have to take the initiative and be like, listen, this doesn’t seem right to me, I’m gonna get a second opinion, or ask them, you know, I understand you’re not comfortable writing for testosterone. Could you please refer me to someone who is, and there are plenty of people to do that, but you have to, like, kind of take the bull by the horns and say, “Listen, this I don’t feel well. And this is the blood level. If you’re not willing to give this to me, can you send to someone who is more educated about

Speaker 3 53:17

it? Let me give you another. You know, playing the devil’s advocate, low T centers. I don’t know what it’s like where you live. Here they’re on every corner, and they will treat anybody. I’ve never seen anybody who was turned away by a low T center. So then you have to ask yourselves, I mean, is this right? Is this, is this a license to hurt people? I mean, there has to be some judgment.

Speaker 2 53:39

I agree, I think they’ve gotten a lot better, though. But you’re right, but a lot better. But initially, but now they’re short, because now you know, just you worry about screening and elevated prolactin. Did they check that? You check the prolactin, they chuck talking about really infertility. The education initially was a little worrisome, but I think it’s gotten a lot better. But Larry, think about this. Also, they’re doing a lot of now online tea, like, like this announced that they’re selling Kaiser trucks, you know, so people can, they don’t have to go see a physician anymore, they can do it on their app, and it’s asynchronous, I put in information, someone puts in some information, my tea shows up the next day at my house, so you know that’s another venue that a lot of people are using,

Dr. Gabrielle Lyon 54:20

Who would you not treat with testosterone, because you had mentioned that it raises blood pressure. Is it clinically impactful? So, if someone has a low blood pressure, or low blood pressure, if they go from 110 to 120 still in the normal range, if they go to 120 to 130 because we know as age happens, you know, as a geriatrician, we wanted to see blood pressure at 130 for peripheral perfusion, for cerebral perfusion. So, who would we not treat?

Speaker 2 54:50

I mean, I get very nervous about treating young men at a very early age, if he’s 21 years old, for fertility and long term having to be on the medication. Patient, so I would like to talk them out of it, or see if I can use other medications, Clomid, HCG, something else, and Clomid, just to kind of, you know, 21 those young patients on resistant, so I think that’s that’s probably my biggest. I feel that testosterone, I personally believe it’s cardio protective. I think there’s many benefits that people say, oh, he’s, he has a lot of cardiovascular risk. Well, the traverse trial was high risk cardiovascular patients, right? Yeah, and so, yeah, you had to have cardiovascular events, or three of the eight cardiovascular risk factors, and I think it may be cardio protective. So, most clinicians say, I’m worried he has a bad heart, I don’t want to put him on testosterone. I say, I believe the opposite, I’m worried if you don’t put him on testosterone, it’s going to make.. well, there’s a difference, yeah,

Speaker 3 55:40

treating someone with heart disease versus preventative treatment.

Speaker 2 55:44

Yes, yes,

Speaker 3 55:45

you’re not going to be worried about preventive.

Speaker 2 55:47

No, I mean, we’re preventive, but she’s saying, is there someone you’re worried about? And someone say, I’m worried. Most people say, I’m worried about someone who has high risk prostate cancer. I’m worried about someone who has increased cardiovascular risk factors. I say, I’m not. I believe the opposite. I think that testosterone also may be protective against prostate cancer. I think that you know the hypogonadal range is the danger zone, we call it the inverted U. Castrate may have some benefit, you can add all high levels of T have some protective benefit. I personally believe that it’s the middle zone, the hypogonadal range, which I believe increases biochemical recurrence from prostate cancer, increases risk for high-risk prostate cancer, so I really believe the same with cardiovascular disease. It’s the inverted U. It’s

Speaker 3 56:26

we’re also now seeing drugs that stimulate the patient to make their own testosterone,

Dr. Gabrielle Lyon 56:31

like what

Speaker 3 56:31

the clomiphene and its derivatives, like you know, and cloma fene. So that I think is a good drug for younger guys.

Speaker 2 56:40

Easy, it’s a pill use off label, but still it helps raise natural testosterone, helps raise sperm counts. Yeah, I think it’s a great drug.

Dr. Gabrielle Lyon 56:49

Can we touch on if everyone is comfortable, just touch on peptides, because that’s kind of all the rage right now?

Speaker 3 56:56

Like,

Dr. Gabrielle Lyon 56:56

what we’re touching on it. I, I don’t want to talk about necessarily the GLP ones, but the other peptides, like,

Speaker 3 57:04

I think they’re going to become huge,

Dr. Gabrielle Lyon 57:06

like CJC and EPA, more.

Speaker 3 57:07

I think they’re going to become, because

Dr. Gabrielle Lyon 57:09

Tessa, more

Speaker 3 57:10

as far as we know, they don’t have side effects that are worrisome.

Dr. Gabrielle Lyon 57:14

How does that make sense?

Speaker 3 57:15

Why?

Dr. Gabrielle Lyon 57:16

Well,

Speaker 3 57:16

they’re protein hormones, they’re acting, you know, they’re attaching to the cell membrane, I don’t know, I mean, why would they necessarily have bad side of..

Dr. Gabrielle Lyon 57:25

I’m going somewhere with this. I was leading you in somewhere. You

Speaker 3 57:28

trap me,

Dr. Gabrielle Lyon 57:30

explain that, because this is my understanding, that testosterone is recognized by the body as such, but these other peptides, the string of amino acids are not recognized again. This is my understanding by the body as that entity, meaning it doesn’t have downstream effects that would be negative.

Speaker 3 57:52

Well,

Dr. Gabrielle Lyon 57:53

did I explain that well? Or,

Speaker 3 57:55

as far as I understand, they’re naturally occurring substances. They’re extracted from other fluids.

Dr. Gabrielle Lyon 58:05

CJC, no comorin is in.

Speaker 3 58:06

I mean, I can’t.. I cannot tell you which ones. There’s one that comes from the placenta. There’s one that comes from gastric juice. The BPC is gastric juice extraction. I don’t know all the other ones, but they are theoretically. They’re called naturally occurring substances, and they have very specific action. It’s not like, you know, you give somebody testosterone, it does many different things. Peptides are very specific, and I think the more specificity, the less chance you’re going to have of side effects, and we’re not seeing any yet. But I mean, it’s way too early, because you know the places that are making them are they’re coming from compounding pharmacies and not all compounding pharmacies are equal, so I think we have to be careful at this point in time.

Speaker 2 58:51

I agree,

Speaker 3 58:51

prescribe because we just don’t know enough about their sourcing, but I think it’s going to be something very big in the future.

Speaker 2 58:57

You know, we use this word peptides very loosely, there’s a lot of peptides, you know, so every, you know, but the peptides most people are talking about are growth hormone peptides, or they’re talking about BPC, which is a gastrophied, that’s what they’re talking about, they’re not talking about all the other peptides, GLP is a peptide, that’s not what they’re talking about, and the insulin is a peptide, yeah, so when you say peptides, be specific, what are you talking about, we’re talking about growth hormone peptides, gastric peptides, and these peptides, some of them are FDA approved, some of them are not FDA approved. The ones that are FDA approved, for example, are Sirmalin, Tessma, one,

Dr. Gabrielle Lyon 59:30

been around for a

Speaker 3 59:31

very long

Speaker 2 59:31

time. And if you have data, and if you look at the data, what do they really help with? The three things they help with are increasing muscle mass, decreasing fat deposition, particularly truncal fat, and actually can help with sleep, right. That’s it. There’s no benefit in sexual function. My libido went up when I took that CJC. No, there’s no data to support now. It may have, but show me the data,

Speaker 3 59:54

but there are some that are theoretically ori. It towards sexual fall,

Speaker 2 1:00:01

like Bremelana tide, PT

Speaker 3 1:00:02

140 yeah. So, brown melanotide is well, here it came out for women, by

Speaker 2 1:00:09

Lisi, it’s for women, PT 141 But when people say peptides, they’re not talking about by Lisi, but, but you’re right, there are sexual fun.

Speaker 3 1:00:15

I do use PT one, I do use it for men,

Speaker 2 1:00:17

yeah, we do, it off labels very effective, but I think when, but it’s different. Yeah, they’re not talking about my Lisi, they’re talking about give me that CJC, give me that BPC, give me my Epomorelin. And you have to realize that they’re not FDA approved, and there could be some safety concerns. And if you look at the FDA website, they say that they’re not intended for human use at this time. Fine. And so I just think it’s important to know that Sermorelin is FDA approved, Tessa Moreland FDA approved. What

Dr. Gabrielle Lyon 1:00:44

are there? Was it clinical indication Tessa Morelin for

Speaker 3 1:00:48

HIV

Speaker 2 1:00:48

lipodystrophy, and Sermoreland was for pediatrics for growth hormone deficiency.

Speaker 3 1:00:53

But if you look at the data on Tessa Moreland, the studies are pretty good studies from when it was launched, and it’s an injection, is a daily injection. Yes, Tess Marlin,

Speaker 2 1:01:03

yes. Is

Dr. Gabrielle Lyon 1:01:03

it cost prohibitive or covered by insurance?

Speaker 3 1:01:06

I think it’s, I think it’s too expensive right now. I don’t think it’s expensive to make or source, so I think we’re going to see prices come down, yeah, on peptides

Speaker 2 1:01:17

for sale. For a compounding pharmacy to make a peptide, it has to be under 40 amino acids. Tessa Morelin is 42 amino acids, so theoretically it should not be compounded for human use, because it’s above that. But if you can buy commercially, it’s not no insurance, it’s about 7000 a month.

Speaker 3 1:01:34

It’s the 40 amino acids is for classification as peptide versus a biologic,

Speaker 2 1:01:41

yes, it

Speaker 3 1:01:41

doesn’t mean that if it’s a biologic you can’t make it or sell it, but there’s stricter criteria for biologics than there are for peptides in Europe. Some of the peptides are sold as supplements, you don’t even need a prescription, so I don’t know what’s going to happen here with peptides. I mean, there was a recent announcement that 14 were going to be approved for manufacturing under a new FDA ruling, but it’s not yet actually done, so whether it will actually happen, I don’t know, but Robert Kennedy did come out and say he was trying to get them approved,

Dr. Gabrielle Lyon 1:02:19

and then the follow up with that, will there be more? Do you expect more randomized control trials with these type of..

Speaker 2 1:02:27

if they get approved, it’ll be easy. If you get it approved, it’ll be easy to get those trials up and running,

Speaker 3 1:02:31

but the trials will be from people like you. They won’t be from pharma. Yeah, because apparently there’s some reason why they can’t copyright them, or what’s that word? What is the word when it’s a drug patent? They can’t patent it because it’s a nationally occurring substance, and there’s so you know, big pharma can’t make money on it. And since studies are so expensive, who’s going to pay for the studies? That’s that’s the big problem with peptides.

Dr. Gabrielle Lyon 1:03:00

So this is a really interesting statement. Here, I’m just going to read it. It says erections as medicine, the cardiovascular conversation.

Speaker 3 1:03:09

Did you make that up?

Dr. Gabrielle Lyon 1:03:10

No, because it’s much better than anything that I could forget, quite frankly. Yeah,

Speaker 2 1:03:17

it’s a really important point, and that’s what I say. Dr. Cole brought up this phrase I still use, is called the check engine light on. Essentially means ED is not a disease, it’s a symptom, it’s a symptom of something bad going on. Right, a healthy man should not have ED, right? ED could be because he has depression, that’s a symptom of depression, depression of cardiovascular disease, a symptom of his prostate cancer, diabetes, it’s a symptom of something going on, and your job is not just giving the vibe and say goodbye. Find out what the problem is, as opposed to just giving them the vibe.

Speaker 3 1:03:50

In all honesty, I would bet the majority of men who show up and say, “Yeah, my erections are just not as good as they used to be, and you give them.. you don’t get a study on these men, because it’s cost prohibitive. Every man at a certain age is going to tell you his erection is not as good as it used to be. So, if I talk about lifestyle drugs, I mean that you, Viagra is becoming a lifestyle drug. Yeah, so you know, and daily Seattle

Dr. Gabrielle Lyon 1:04:18

lifestyle drug, meaning there’s because in my mind that would improve blood flow, so that would not necessarily be a lifestyle drug, but improvement.

Speaker 3 1:04:28

Well, but the end point, what I’m talking about is what they’re trying to get is a better erection. They’re not, it’s they don’t have a terrible symptom. Well, yeah, it’s a terrible that they can’t get erections, but just to make it better, which is so often what the patient says,

Speaker 4 1:04:45

but we do investigate everybody who comes to me with problems with erections. We check a testosterone level, right, that’s what we’ve talked about for the first hour here. We ask about a family history of cardiac disease, if that’s there, we. Do much further investigation. We typically check a cholesterol panel, we check a sugar, so these are all the kind of like other check engine lights that should be.

Speaker 3 1:05:09

I was thinking more, more of duplex. Well,

Speaker 4 1:05:12

duplex ultrasound is certainly down the road, but if a guy comes to me with ED,

Speaker 3 1:05:17

I’m just saying he says my erections are not as good as they used to be. Yeah, it’s not that he can’t get an erection, and it’s very subjective. I mean,

Speaker 4 1:05:25

of course it is. However, it could very well be the sign of something going on that we should investigate. You know, there’s powerful data. We know clearly that vascular ED, that is classically lack of blood flow of the penis, predicts heart attacks by three, five. Say that again. So, when you have blood flow of problems to the penis that cause problems with erections, because sometimes it’s psychogenic, right? It’s not true vascular problem. The penis predicts the first heart attack by three to five years. Okay, so we know

Dr. Gabrielle Lyon 1:05:54

it’s really perfect,

Speaker 4 1:05:55

so we know that as a fact. Okay, but now there’s even more data that shows that men even with psychogenic ED, that is, the plumbing is fine. We do the Doppler that we just discussed to check the blood flow, and the blood flow is fine, but we know that men who aren’t getting erections because they’re anxious, because they’re nervous, because they had a bad day, bad night, and now it keeps happening again, and those guys actually have more heart attacks too. It’s crazy data, but think about it. The average man thinks about sex 18 times a day. Study out of Ohio State in 2012 and if this person doubts they’re going to get good erection, that means they’re going to get depressed and anxious 18 times a day. That is a setup for more anxiety, higher blood pressure when somebody cuts you off in practice, worse sleep, these are all a formula to set you up for other metabolic problems and disease. So, I think erect child dysfunction should never be ignored, and always should be further investigated, independent of

Speaker 3 1:06:54

the cause.

Speaker 2 1:06:55

So, if you think about what he just said, so a man walks in with ED, he’s 35 years old, so we know that he comes in with ED today, 15% chance he’ll have 15% of those mental heart attack or stroke within seven years, 15, 15% within seven years. We know that he’s three and a half times more likely to suffer from clinical depression, which you’re not even touching on, and there’s a 30% chance he could have diabetes or prediabetes that you’re missing. Now, let’s say you do nothing and you just give him the Viagra, and he did have cardiovascular disease, or he did have diabetes, and you picked it up five to 10 years later. That’s five to 10 years of pounding on the vessels, and which you could have picked up 10 years earlier. Now, if you think that young man, he has hypertension, you say, “Hey, I want you to go in and get screened for your blood pressure every year. You say, “No way, I would have never gone at 32 years old to get my hypertension. But if he has ED first thing tomorrow morning, he’s at my door, and he’s going to say, “I, what’s going on? So, Ed is a great way, a gateway for men’s health to get them their blood pressure checked, and to get their blood sugar checked. It is a gateway to bring men in, but I think it’s a disservice when you have a particularly young man to say, “Here’s your vicar, see you later.

Speaker 3 1:07:59

But that’s what’s happening in the world, that’s what’s happening, because most of these patients are talking to their primary care, and they’re saying, “My erections are not good. They give a Viagra, and

Speaker 2 1:08:09

that’s it. We

Speaker 3 1:08:11

only see them when I think the ones that we see are the ones that don’t respond, so the primary care refers them, or they don’t get erections, which is a lot more severe than it’s just not as strong as it used to be, but what an opportunity to actually

Speaker 4 1:08:26

screen and get baseline numbers in these patients. I mean, awesome. You see this guy, like when you’re a young boy or girl, you see your pediatrician. What happens to girls? They get handed off to their OB-GYN doctor. What happens to boys? Nothing, nothing. So they don’t come to your office for 20 years. In the meantime, they have high lipids, they’re prediabetic, maybe they have a cardiovascular risk, and we’re completely missing. And we

Speaker 3 1:08:51

talk about this, you know, I have this webcast, and we talk, Amy and I talk about the fact that no one is seeing the guys. I mean, the women have their gynecologist when they’re going to start birth control, or they start having periods, and they go and they get checked. There’s no place these guys are just floundering around until they’re 30 easily, because we see them as infertility patients, right? They’ve

Speaker 5 1:09:14

never

Speaker 3 1:09:15

seen anybody, and

Speaker 4 1:09:16

the culture continues like the phrase, I haven’t seen my doctor in 20 years. I’m healthy as a horse. I mean, that’s just lunacy. Who buys a Porsche and then never changes the oil, checks the air pressure, right? I mean, like, that’s just crazy. The human buys this amazing machine, and screening, like, really helps prevent heart attacks, you know, diabetes, etc. etc. etc. Yet there’s this desert of men’s health care that is completely,

Speaker 3 1:09:46

but there’s this, there’s this phrase now, toxic masculinity, right? And that’s these guys, you know, it’s they say, “Man up, you know, I’m having headaches, “Man up, into the father tells this kid, “There’s nothing wrong with you, and this is. Built into the society as we know it right now is that guys don’t, they think it’s bad to go to the doctors because they’re admitting there’s something wrong with them.

Speaker 4 1:10:10

Yeah, well, again, if I buy a Porsche, I’m not just gonna drive it around and not take care of it. Now, should

Dr. Gabrielle Lyon 1:10:15

there be an early, so when girls start menstruating, they go to OBG, you know dying is there an age that so for example the normal age for erections to become more frequent is what

Speaker 2 1:10:29

more dream like

Dr. Gabrielle Lyon 1:10:30

yeah 14 puberty what is there going to be an indication where okay you’ve hit 14 your boy we’re going to send you for even baseline testosterone or whatever.

Speaker 3 1:10:42

How about just to talk about sexually transmitted diseases preventing pregnancy? I mean, they’re not.. there’s no health education in the general education system right now, like there used to be. So they don’t talk about it. I mean, no one talks to these guys. It’s tragic. I think it’s terrible.

Dr. Gabrielle Lyon 1:11:00

Will there be? I mean, is that anywhere in the guidelines? What you were talking about

Speaker 2 1:11:05

screening?

Dr. Gabrielle Lyon 1:11:06

Yeah,

Speaker 2 1:11:06

no, but we tried. When we went to the FDA back in December, we talked about the fact that every man over the age of 40 was what we thought about. Every man with age of 40 should have a testosterone level screening annually, because the best predictor of a man’s overall health. And then we thought about more. I think the number maybe should be lower.

Speaker 3 1:11:22

Yeah, I mean, definitely. I

Speaker 4 1:11:25

mean, I want my levels when I’m at peak performance.

Speaker 2 1:11:28

Yeah,

Speaker 4 1:11:28

25

Dr. Gabrielle Lyon 1:11:29

Yeah,

Speaker 3 1:11:29

just is to

Speaker 4 1:11:30

pick a number, but certainly earlier than age 40, because again, when you’re 45 and things start to fall apart,

Speaker 3 1:11:36

and it may be too late.

Speaker 2 1:11:39

Yeah,

Speaker 3 1:11:39

also the things that caused you problems at 45 could have been addressed when you were 25 It

Speaker 2 1:11:45

should be an annual school.

Speaker 4 1:11:46

I mean, and everybody knows what their cholesterol level is, right? If they’re going to the primary care doctor, nobody knows what their testosterone level is,

Speaker 3 1:11:53

but you young guys don’t go to primary care unless that’s the problem. No, I know that’s the problem, but then again, you have to think about primary care. Primary cares are just inundated with patients. It’s very difficult in Houston right now to get a primary care appointment, and that you know they have 10 minutes per patient, or whatever. It’s a very short period of time, and so many things to discuss.

Speaker 2 1:12:15

Yeah, it’s such an important point you just mentioned, right? So the reality is it’s like 18 minutes. My wife’s primary care, she says, ‘Look, I got to go through diabetes, hypertension, hyperlipidemia, OSA. How am I going to get to ED and testosterone? Right, you start with it early. Yeah, exactly. I mean, like, but she’s like, ‘Well, then what if I can’t get to diabetes, right? Like, I got this is what I got, I got to get everything in. And I said to her, ‘Well, it’s an important predictor of their.. oh, they could be suffering from other things. And she said, “Look, where did I get the training? I didn’t get the training out, an unbelievable paper several years ago, so I did only 50% of what is it called. Well, it was a wood journal, it was a couple years ago, where you and the Mayo Clinic put out an article showing that if you look at education, I think Dr. Hilo is the first author showing that the only 50% of medical students or residents got formal training,

Dr. Gabrielle Lyon 1:13:03

15 or

Speaker 2 1:13:04

50, 50% got formal training on sexual medicine, like how to, you know, sexual medicine, and how to approach ED. Of those 50% that got training, 50% said their training was lousy. So, so, how do you feel comfortable coming out talking about someone’s erections, when you got no training,

Dr. Gabrielle Lyon 1:13:23

I mean, it’s a really good point, and then to your point on primary care, before we even get to diabetes, hypertension, cardiovascular disease, perhaps when they’re 18 or 15, I mean, maybe 15 is a little too young to get a baseline cholesterol and baseline testosterone level,

Speaker 2 1:13:42

think it’s really important. Yeah,

Dr. Gabrielle Lyon 1:13:43

and we start early. Yeah, what about birth control? So, vasectomies, how many you’ve performed over 2000 I mean, your vasectomies in your living room, how many

Speaker 3 1:13:55

have no idea. I mean, when I was in the army, I had to do five every Friday for two years. I mean, you know, it’s just we do them. I mean, it’s not even.. he’s

Speaker 2 1:14:04

done a tremendous taught many fellows, over 130 fellows, how to do them.

Dr. Gabrielle Lyon 1:14:09

But what about reversals?

Speaker 2 1:14:11

He’s done a tremendous amount of

Speaker 3 1:14:12

130 patients. I mean, 130 fellows have been trained.

Speaker 2 1:14:16

Yeah, and

Speaker 3 1:14:16

a lot of them go out and they don’t do it because they don’t have the patient population, but we do a lot of reverse. I had three people come in yesterday for office hours to talk about reversals. Is

Dr. Gabrielle Lyon 1:14:28

that effective, and is it a common procedure in general?

Speaker 3 1:14:34

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

Dr. Gabrielle Lyon 1:15:12

Is there something that men and women should know prior to undergoing vasectomy? I don’t think it’s really discussed that much.

Speaker 3 1:15:20

I think I just think the message is, it tell them it’s permanent, even though we

Dr. Gabrielle Lyon 1:15:24

stop coming to you for a reversal.

Speaker 3 1:15:25

No, I love doing reversals, but I mean, the point is, people should not be told this is a temporary procedure. They have to realize that it’s hard to get it reversed because there’s not that many people doing it. But don’t you think you want to educate people when they come in for a vasectomy, that it’s not temporary.

Speaker 2 1:15:43

Yeah, two points. Also, his point is also you only want to go to the center of excellence. People who have high volume that know how to do this, because sometimes you can do something more complicated, like an epididymal vasostomy, which is more complicated. It’s a more complicated type of the procedure, and you don’t want to go to someone who’s doing one a year or two a year. You really want to go to someone at a high volume, and more importantly, if you’re going to give one message about per second reversals, the sooner you do it, the better. If you come to me in three years or five years, the outcome is much better than you come to me 20 years, right? So that’s a really important point. It’s time dependent on outcomes,

Speaker 3 1:16:16

but people don’t always know when they’re going to get divorced, and they only, you know, so you know, I think we have to just do it when they need it done, but we counsel them that the results are going to be better if it’s been under 10 years.

Dr. Gabrielle Lyon 1:16:30

Okay, you know, I was misguided. I thought it was a very common procedure,

Speaker 3 1:16:35

but

Dr. Gabrielle Lyon 1:16:36

I thought it was very

Speaker 4 1:16:37

6% of all men who get vasectomy, inquire about vasectomy rehearsal, and that’s the number I remember.

Dr. Gabrielle Lyon 1:16:45

Okay, so it’s not quite frequent at all. And when it comes to male infertility, I’m curious, as if you all agree on the one cause. If you could pick one, I know you hit the one,

Speaker 2 1:16:59

he was the one,

Dr. Gabrielle Lyon 1:17:00

yes,

Speaker 2 1:17:01

invented varicoceles, because of the one who caused infertility paper,

Speaker 3 1:17:05

so that’s probably the most common

Speaker 2 1:17:06

problem,

Speaker 3 1:17:07

and it’s the most, and it’s the edits, it’s enlarged veins around the scrotum, around the testicle,

Dr. Gabrielle Lyon 1:17:13

could someone see that, or it’s under

Speaker 3 1:17:15

sound, so you can see it in some cases, we grade them as, you know, small, medium, and large, or grade 123, and the grade three, you can literally see, and I’m sure you’ve seen patients with these large, you know,

Dr. Gabrielle Lyon 1:17:29

asking for that, or those guys, is there anything?

Speaker 3 1:17:33

So, I think I think that you have to remember that 18% of all men, 1818, have varicose veins of the testicle,

Dr. Gabrielle Lyon 1:17:42

but not the legs, it’s the testicles,

Speaker 3 1:17:43

it’s right around the testicle, and it overheats the testicle, and heat is bad for sperm production, hence,

Dr. Gabrielle Lyon 1:17:50

because I don’t actually know this, so the varicocele causes an increase in heat production,

Speaker 2 1:17:55

yes,

Dr. Gabrielle Lyon 1:17:56

it,

Speaker 3 1:17:57

because it’s retrograde flow, and it sits around the testicle, so you don’t have the blood leaving, it’s just pooling there.

Dr. Gabrielle Lyon 1:18:04

Sounds painful.

Speaker 3 1:18:05

No, it can be, but I mean, that’s not the most common thing we see.

Dr. Gabrielle Lyon 1:18:08

Okay,

Speaker 4 1:18:09

it’s like a factory where you know the workers are making sperm, and somebody like takes out the air conditioning and turns the temperature up 30 degrees. The productivity of that factor is definitely gonna

Dr. Gabrielle Lyon 1:18:21

go down, that’s

Speaker 3 1:18:22

cute.

Dr. Gabrielle Lyon 1:18:22

That’s a great analogy.

Speaker 3 1:18:26

Picture these little men,

Dr. Gabrielle Lyon 1:18:27

so he’s very stoic, and then when he starts to smell, you know he’s coming in with an analogy,

Speaker 3 1:18:34

right? Right. But anyway, so when a man comes to see you, the fact that he has a varicocele is not necessarily

Dr. Gabrielle Lyon 1:18:41

known

Speaker 3 1:18:42

well, it’s also, and yes, but it’s also not necessarily the cause of his low sperm production, because it could be true, true, unrelated. He could have a varicocele, since 18% of all men do, and he can have another reason for his infertility, but I think, in general, most of these men will end up having their varicoceles corrected, because it is such a common problem with testicular failure.

Dr. Gabrielle Lyon 1:19:09

Is it one of the causes of low testosterone or erect and or erectile dysfunction in younger men?

Speaker 3 1:19:16

Low testosterone, yes,

Speaker 2 1:19:18

yes, yeah, low testosterone, not erectile dysfunction, maybe indirectly testosterone goes down, but low testosterone. Yes, the problem is that if you fix the varicoceles, you see about 85 to 100 nanogram per deciliter increase, which some would argue is not clinically significant. It’s

Dr. Gabrielle Lyon 1:19:32

not that, so

Speaker 2 1:19:33

yeah, so if I start at 250 and you get me to 350 so it’s not currently considered an indication, like you wouldn’t fix someone’s varicoceles to help raise their teeth to a normal

Speaker 3 1:19:42

people, do let’s be honest, they do, but I don’t think it’s not, I don’t think it’s clinical, yeah,

Speaker 4 1:19:47

but you’ll know if you, if a man checks his own testicles and one’s really small and it used to be the same size as the other side, so there’s something called testicular hypotrophy, the testicle gets smaller. Sure, from that factory exhaustion thing, right? So those

Speaker 3 1:20:03

little men taking,

Speaker 4 1:20:04

yeah, now they’re rioting, and the factory is actually getting smaller. I think

Speaker 3 1:20:08

you mentioned something very important, that was having men check their testicles, and they don’t, and they should, but again, there’s no education to young guys that unit between 25 and 35 peak years for testicular cancer, so you know, I tell my patients, you know, once a month in the shower, when everything’s nice and around, just make sure there’s no lumps or bumps on the testicles, and if there is, come on in and we’ll check it, but really important, but they don’t,

Dr. Gabrielle Lyon 1:20:36

testicular cancer, what is the mean age

Speaker 4 1:20:39

between 2535 has a bimodal distribution, so in either young men below age 35 and then older men, like above 50 or 55 and then you know when you’re when a guy is feeling his own testicle, he has to know what’s going on there, so there’s this olive-like structure, and then there’s this thing on the back, it’s like a backpack that’s epididymis, that’s where the sperm learn to swim, swimming school, and so it

Speaker 3 1:21:03

has to be bigger than an olive,

Speaker 4 1:21:04

so it’s a very grand, it’s a huge olive, so 20 cc’s or so,

Speaker 3 1:21:11

yeah.

Speaker 4 1:21:11

And then what you’re supposed to do is such a gently roll a testicle between your fingers and learn what normal is, so the epididymis is back there, that’s what age

Dr. Gabrielle Lyon 1:21:20

should they start testicular exams?

Speaker 3 1:21:23

Twice,

Speaker 2 1:21:24

18, something, 18

Dr. Gabrielle Lyon 1:21:25

to 35 That’s a big, that’s a big range. Yeah, 18 is when you start.

Speaker 4 1:21:31

What you’re looking for is if you’re walking down the street and you picked up a stone like a pebble, right? It’s jagged, it’s hard. If that’s living inside her testicle, you feel like, wait, there’s an irregular border. It feels very hard there. That’s cancer proven otherwise.

Dr. Gabrielle Lyon 1:21:47

Yeah, that’s cancer. Very important.

Speaker 3 1:21:50

And we’ve all experienced seeing these guys who come in, nice guys, married, unmarried, and they’ve just, their whole testicles replaced by cancer, because they just. they just don’t, I know, but they don’t know, or they, you know, but refuse to face the fact that something bad. Early diagnosis

Speaker 4 1:22:09

of testis cancer is great,

Speaker 5 1:22:10

always

Speaker 2 1:22:10

true.

Speaker 4 1:22:11

I mean, 99%

Speaker 2 1:22:12

make a fist, and you tell them between the knuckles is exactly what it normal testicle feels like. You just press down, it’s normal testicle, the knuckle is identical. What a cancer feels like, right? You want to feel between, you don’t want to feel the knuckle. That’s a very simple way to tell someone what they’re feeling in their testicle.

Dr. Gabrielle Lyon 1:22:29

What is the lifelong prognosis if it goes undetected or untreated?

Speaker 2 1:22:34

It’s high, high mortality if you, it gets, because it can get metastatic very quickly.

Speaker 3 1:22:39

There are a lot of good drugs right now for the man with testis cancer, but you don’t want to let it get to that point, because the drugs all will, as a group, will cause infertility, and so you know you don’t want to, you don’t want to let it get so far that you need drugs, and you also need to know that you can bank your sperm easily and not expensively, if you have to have treatment for testis cancer,

Dr. Gabrielle Lyon 1:23:06

and can someone still maintain fertility? Because it’s not always, is it usually by both biomorthy bilateral, is that the right term?

Speaker 2 1:23:15

Yeah, it can be. It can’t be. And one of our partners has a case coming up that’s bilateral. In those cases, you have to make a decision, you know. Do you have it’s saving their lives. Well, we do something called oncotesy, and onco testing is when you remove the testicle, you work with the pathologist, they line out where the cancer is, they show you where the good tissue is. We take the good tissue out at that time, and we go bank it and save it, so they can do IVF later. And then we give the cancer to the pathologist, but it takes a team to get that done.

Speaker 4 1:23:43

There’s a whole sub specialty of medicine called oncofertility, preserved fertility with cancer for both men and women, right? So often when patients start, when young patients are told they have cancer, first of all, survivability with people, young people with cancer is actually quite good, but you get blinders on, you forget about these things like fertility, because you’re just like focused on need to get this treatment, need to get this treatment, but there is always time to talk to an expert about this, and say either bank sperm or do ovarian cryopreservation in women, or potentially move around where the ovary is, if you’re going to shift it out of the radiation field, there’s always time. It should be considered, because if you don’t treat it before the cancer treatment starts, it’s too late.

Speaker 3 1:24:28

Now, Anderson is trying, they do have two women over there full time, yeah, but it’s mainly addressing the women,

Speaker 2 1:24:34

yeah, but they send us their patients,

Speaker 3 1:24:36

they do, they do.

Dr. Gabrielle Lyon 1:24:37

And I have one last question regarding this before we wrap up with smoking, cardiovascular disease, or lung cancer. We know that there’s a relationship. Do we know what the action item or the exposure would be for testicular cancer? Are there known exposures?

Speaker 3 1:24:58

There’s not. There’s

Speaker 2 1:24:59

cryptocurrency. Doesn’t show up if the testicle doesn’t descend, that’s a risk factor, right, but the, the, I can’t give you a percentage on the smoking, or if there’s a correlation with the smoking and the testicle,

Speaker 3 1:25:09

no, I don’t think there’s no data, there’s no data on that, but I can tell you this, for infertility men who are having trouble with sperm production, a huge area is environmental toxins. There’s some excellent review articles just out recently talking about all the things in the environment that theoretically can affect sperm production, because you’re making millions of sperm a day, and with rapidly turning over cells, they’re going to be exposed to whatever is in the environment that could come in and halt that cell division, so you know, the a lot of the coal people who live around coal mining areas, they are breathing in things that can affect their sperm production, tox, think the soil fumigants, pesticides,

Speaker 2 1:26:00

and alcohol, yeah.

Dr. Gabrielle Lyon 1:26:02

What is that?

Speaker 3 1:26:04

It’s excellent. She got this terrible look.

Dr. Gabrielle Lyon 1:26:06

No, no, I don’t. So I was actually thinking about the veterans, and I was thinking about the veteran community and infertility, but taking it one step further, I was thinking about testicular cancer in the veteran population. I was,

Speaker 3 1:26:17

you know, that’s a very interesting point, because we’re just starting to look at the burn pit patients, I mean, exposures in terms of fertility, because it’s, you know, all the other things have been identified, many things have been identified that are health issues, but it’s just your husband is starting to look, this

Dr. Gabrielle Lyon 1:26:36

is what we talk about, and not young people

Speaker 3 1:26:38

starting to look at this in the veteran population, and I think it’s going to be a very important thing.

Dr. Gabrielle Lyon 1:26:44

I would agree with you, gentlemen. Thank you so much for coming on. If you would like to leave the listener or the viewer with one, it could be a tip, it could be a statement for their physician or as physicians. The floor is yours.

Speaker 2 1:26:57

I’d say low testosterone and ED are a marker of poor health, and just don’t ignore it. If you have low T or ED, look at what the cause is, because it could be potentially life-saving.

Dr. Gabrielle Lyon 1:27:08

And you have a wonderful TED talk on sex span, so we’ll link it at the bottom. Thank you. I was there, front row, it’s popcorn.

Speaker 3 1:27:16

One thing, and that is, we’ve shown that poor sperm production, infertility is a metric of a man’s health. So, men who have low sperm production increased risk of all-cause cancer, earlier mortality, greater incidence of comorbidities, and you know that can’t be overlooked as simply something for reproduction. It’s a metric of health.

Dr. Gabrielle Lyon 1:27:41

It’s very well said.

Speaker 4 1:27:44

You need to be proactive, need to take agency for your own health. Don’t be anxious, depressed, sitting on the couch. You are the CEO of your own body, right? Take care of

Dr. Gabrielle Lyon 1:27:57

1. Well said. Thank you so much.

Speaker 4 1:28:00

Thank you. Thank

Speaker 3 1:28:00

you.

Dr. Gabrielle Lyon 1:28:02

Okay, I want to get you out on time. You guys did a great

Speaker 6 1:28:04

job,

Dr. Gabrielle Lyon 1:28:05

I know, but I want to make sure he has to leave, so we

Speaker 3 1:28:08

right.

Dr. Gabrielle Lyon 1:28:08

So now this is more casual. We have a couple questions. Killed it. You can go.

Speaker 2 1:28:12

Yeah.

Speaker 3 1:28:15

Hey,

Speaker 2 1:28:15

thank you. Have a good time. Thank you for that. Thank you so much. Thank

Dr. Gabrielle Lyon 1:28:20

you.

Speaker 3 1:28:20

And, oh, I was here on time for you guys,

Dr. Gabrielle Lyon 1:28:22

and then we can do the strong seat. It’s behind the curtain, the proverbial curtain. What are we doing now? There is a, so there’s strong C questions that are behind, like it’s more casual, like how you doing. It’s just people ask questions. You guys did a great job.

Speaker 3 1:28:50

When do they ask questions?

Dr. Gabrielle Lyon 1:28:52

We drop in our community.

Speaker 3 1:28:54

What

Dr. Gabrielle Lyon 1:28:54

we drop it in the community,

Speaker 3 1:28:55

and

Dr. Gabrielle Lyon 1:28:56

you’ve got questions. I’m not gonna tell you the question beforehand.

Speaker 3 1:28:58

Oh, you’re gonna surprise

Dr. Gabrielle Lyon 1:29:00

us, like so. so, for example, there’s one who’s 35 and he’s talking about, as a matter of fact, his erection is not working, and he wants to know, is that normal? No, it’s not.

Speaker 3 1:29:14

It’s not normal.

Dr. Gabrielle Lyon 1:29:16

You guys did a great.. what a great..

Speaker 3 1:29:18

So, when do you head back later on this evening, yeah, you know, at least the guys are back to work here

Dr. Gabrielle Lyon 1:29:26

at

Speaker 3 1:29:27

the airport. Yeah, it was awful.

Dr. Gabrielle Lyon 1:29:30

It

Speaker 4 1:29:30

was the first time ever I did.

Speaker 3 1:29:32

You didn’t fly out during that all

Dr. Gabrielle Lyon 1:29:33

day. I only experienced it one time.

Speaker 4 1:29:36

I did clear, you know, I’ve cleared TSA, nothing. I just went right through. There was no, there was no idea anymore

Speaker 3 1:29:42

what airport

Unknown Speaker 1:29:43

in.