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The Shocking Link Between Erectile Dysfunction and Heart Attacks with Dr. Mo Khera

Episode 97, duration 1 hr 42 mins
Episode 97

The Shocking Link Between Erectile Dysfunction and Heart Attacks with Dr. Mo Khera

Renowned expert Dr. Mo Khera sheds light on common sexual dysfunctions in both men and women, emphasizing the startling connection between erectile dysfunction and heart attacks.

We delve into testosterone, exploring why low levels might not always warrant treatment and the importance of considering symptoms alongside testosterone levels for therapy decisions.
The conversation extends to female sexual dysfunction, stressing the significance of addressing common symptoms and a woman's unique concerns.

Dr. Khera speaks to the role of testosterone replacement therapy (TRT), providing in-depth insights and dispelling myths about increased risks of prostate cancer and heart disease.

Join us in this eye-opening podcast where we tackle the often neglected topic of sexual health in relation to your overall wellbeing.

The Shocking Link Between Erectile Dysfunction and Heart Attacks with Dr. Mo Khera

In this episode we discuss:
– The role of testosterone replacement therapy (TRT)
– Providing in-depth insights
– Dispelling myths about increased risks of prostate cancer
– Heart diseases

00:00:00 – Understanding Sexual Health and Exercise’s Role in ED

00:07:52 – The Intersection of Urology, Andrology, and Quality of Life

00:15:10 – Testosterone Therapy: Myths, Realities, and Prostate Cancer

00:22:42 – Addressing Female Sexual Dysfunction and Hormone Balance

00:30:17 – Optimizing Men’s Health with Testosterone and Lifestyle Changes

00:37:37 – The Impact of Diet and Exercise on Sexual Function

00:45:24 – Maximizing Testosterone Benefits and Managing Risks

00:52:23 – Cardiovascular Health and the Misconceptions About Testosterone

00:59:45 – Fertility Concerns and the Effects of Lifestyle on Reproduction

01:06:54 – Exploring Alternative Treatments for Sexual Health

01:14:14 – The Importance of Preventative Health in Treating ED

01:21:18 – Strategies to Preserve and Increase Male Fertility

01:28:36 – Menopause, Testosterone Decline, and Women’s Sexual Health

01:35:20 – Emerging Therapies in Sexual Medicine and Maintaining Penile Health

 

Mo Khera

Welcome to the Dr. Gabrielle Line Show. Today I sit down with friend, mentor, and colleague, Dr. Mohad Khara. He’s a professor of urology at Baylor College of Medicine. He is a world leading expert in sexual health, sexual medicine, and andrology. He is the go-to on all things testosterone and libido. In this episode, we talk about the importance of a good and healthy sex drive, the four pillars for sexual health, and the difference between men and women regarding testosterone replacement therapy and how it impacts your sexual health. Dr. Mohad Khara, thank you so much for coming on the show. I am honored to be able to sit with you. You are arguably the world leading expert on testosterone and andrology. Truly a pleasure. Great to have you. Thank you. Tell me about what inspired you to be doing what you’re doing. And just to lay the foundation for people, you have published over 200 scientific papers, if not more. You are really leading the charge and transforming the way that we think about sexual medicine, the way we think about andrology. You are an absolute maverick. How did you get here? First of all, you’re too kind. But the reality is this. I look at two types of medicine. One medicine is in the business of saving lives. The other business is improving the quality of life. So what I do is improving the quality of life. You know, patients come to me, many are depressed, they’re anxious. You know, sexual dysfunction is not commonly discussed, but many, many people suffer from this condition and and they don’t want to talk about it. So what we do is we try to improve the quality of life. And you’re right. People don’t talk about sexual health. We talk about muscle health. We talk about exercise. We talk about cholesterol. Do you think that the reason that we don’t is because people are embarrassed or it’s a stigma or is it the thing that really impacts them so much that maybe there’s shame around it? There’s a huge stigma around it and many patients are very embarrassed to discuss this. I want to give you just an example. There was a survey that came out two years ago and it was given to over 1500 patients. And what they found in the survey was that 69% of patients said they don’t even know where to get sexual medicine healthcare. They have no idea. What was really surprising about this is that roughly 51% of those patients ever discuss this with a provider and less than half of the patients ever discuss it with their partner. So think about this. They’re embarrassed. Right. Yeah. So I call this suffering in silence. They don’t want to discuss it. Majority of patients who suffer from sexual dysfunction don’t talk about it. And it’s a major concern. You know when I think about overall health and wellness I think it’s important to define sexual medicine. What is sexual medicine? What is andrology? We’re going to talk all about hormone. We’re definitely going to talk about hormones. Everybody wants to know about testosterone for men and women. But what are some of the definitions that we can start off with of understanding? There’s so many components of sexual dysfunction. I’ll give you some examples. First you can think of erectile dysfunction which is the most common. We can think of low libido. Don’t forget that we have sexual dysfunction in men and women. It’s different. Right. So many men and women can suffer from HSDD, hypoactive sexual desire disorder. Parones disease which is an abnormal curvature of the penis when the penis is erect. Nine percent of all men suffer from perone disease. That’s a lot. Pretty significant. Yeah. In fact if you look at the statistics for erectile dysfunction 40 percent of men suffer from ED at 40 years of age. 50 percent at 50. 60 percent at 60. 70 at 70. 100 at 100. You live long enough. ED’s going to affect most men. So it’s a very very prominent common condition. But we don’t talk about it. Other conditions premature ejaculation. It affects 30 percent of men. The 30 percent of men suffer from that condition. Right. So low testosterone. We know that roughly 52 percent of men over the age of 40 will have low testosterone and many of these men will suffer from the signs of symptoms. 52 percent. Let’s pause. Yes. 52 percent of men will suffer from low testosterone. 40 percent of men by 40 years old have some kind of erectile dysfunction. Absolutely. Now let’s talk about that low testosterone for a second. Just because you have low testosterone doesn’t mean you’re a candidate for therapy unless you have symptoms. So you have to have signs and symptoms and a low testosterone level. Now if you look at how many men have signs and symptoms and a low testosterone level that number drops about 8 percent almost up to 10 percent over the age of 50. That’s still a significant number of patients who suffer from this condition. We don’t talk about it.

And when you think about for women what are the numbers for women? 43 percent of women over the age of 50 will have some degree of female sexual dysfunction. Now when you talk about female sexual dysfunction there are four components. So let’s talk about them. Low libido, arousal which means blood flow to the genitalia or the breast, orgasmic disorder and pain. So 43 percent of women. That’s significant. Now the key thing about female sexual dysfunction is that she has to have one of those components and she has to be bothered by it. Let’s say a woman comes in she says I have low libido but I don’t really care. Well then she doesn’t have FSD right. So she has to have signs and symptoms and she has to be bothered by the condition. 43 percent of women now realize that of that 43 percent of women that suffer from this condition only 9 percent of those women seek therapy and in those cases the remainder just suffer in silence. And how long have you been in practice? So I’ve been practiced now for 17 years. 17 years and you did something before. Yes so before I was an analyst I did my MBA. I was a healthcare analyst for two years in Boston and I didn’t like it. I just didn’t like it. I just felt like you know every day it was just a presentation and meetings and I just felt like it I just didn’t feel like I was making a difference. So I went back and took some more prerequisite classes in medical school for med school. My wife was in Boston at the time and she was going to medical school so I loved what she was doing and applied and came back to the University of Texas and finished my medical school. How did you decide on urology? For those listening urology is a combination of surgery. Really you can do anything. I think urology is one of the most important specialties that we have. It’s somewhat of a gentleman’s or gentle woman’s however you want to say it. Specialty you do surgical procedures and you take care of lifestyle. Yeah so hands down there is not a better better specialty than urology. Not one. Urology not only is taking care of patients medically but when they need surgery you are also the surgeon. It’s one of those very few specialties where you get to do both. So I don’t send out surgical cases. I do my own surgical cases and remember we’re in the business when you look at urology the best specialty in urology is sexual medicine by far. I know. In terms of improving the quality of life and many patients don’t know where to seek care but hands down by far the best specialty. And you’re not biased. I’m not biased but it’s incredible. How would one define andrology? So it’s really the study of testosterone and androgens and the effect those have on the body. So you know andrology is a subset of sexual medicine. So sexual medicine could be erectile dysfunction, peroneal disease, premature ejaculation. There are many conditions. Andrology is a subset because it affects many of those conditions but mainly the study of testosterone and how it affects the body. That’s fascinating. And have you seen the landscape change because we’re hearing a lot more about hormone replacement and testosterone. Not so much sexual health but over the last 17 years have you seen changes in the field? Absolutely. There’s been so much more discussion. So we’re much more open to talk about sexual dysfunction like we’re doing today. We don’t see that. I didn’t see that 15 years ago. And the reality is that patients now demand it. Right? They’re saying look I want a better quality of life. Right? I want to have a better quality of life and sexual dysfunction now has become more and more important. Now we do see a lot of clinics that have popped up that are offering therapy and that’s fine. That’s just a testament to the fact that more people are demanding care. But patients now want to have a better quality of life and sexual medicine is one way to improve their quality of life. Do you feel that there are still a lot of misconceptions out there about for example you’ve really led the way this idea of for many people they believe that testosterone causes for example prostate cancer. People also believe that testosterone is dangerous and can cause cardiovascular disease. What I think is fascinating about your work and you’ve done work in multiple domains in sexual medicine and andrology is you’ve really challenged some of these beliefs. And I’d love for you to speak on that because medicine is interesting. We get an idea in our head. I see we the collective medical societies and then we execute on that without challenging the underlying science just like the women’s health initiative. Yeah. Yeah. So there’s so much to talk about about testosterone and I think you let’s talk about prostate cancer. In 1941 Huggins and Hodges said that testosterone actually can increase the risk of prostate cancer. And from that date from 41 for decades we believe that testosterone increases the risk of prostate cancer. It wasn’t until the AU8 guidelines came out in 2018 and said look testosterone does not increase the risk of prostate cancer. That was a strong recommendation. So that’s important. So we used to believe for many years. But the paradigm has completely shifted. If you look now at how we use testosterone there’s now data to suggest that if you can give men testosterone and normalize their testosterone the risk of prostate cancer may be reduced. In fact men with lower testosterone levels may have a higher risk for prostate cancer. And there’s a wonderful study that came out in 2015 out of Huggins. Do you know how they treat men with metastatic prostate cancer? They give them high doses of testosterone. This is called BAT, Bipolar Androgen Therapy. And what this high dose of testosterone does it tricks the prostate from becoming insensitive to sensitive. Right. So who would have thought decades ago I’m going to use high doses of testosterone to treat men with metastatic prostate cancer. But it’s very clever as you increase the dose of testosterone and then bring it back down what you do is you trick the cancer from becoming insensitive to sensitive. And in one of the studies you see a 50% reduction in the PSA. 50% reduction in metastatic disease. Unheard of to give men high doses of testosterone with metastatic disease. So the paradigm is shifting completely and how we think about testosterone and its true effects on prostate cancer. Now let’s be fair. We don’t have a large randomized placebo controlled trial saying yet that testosterone is safe in men with prostate cancer. And that’s why the guidelines say you know we don’t risk benefit ratios not been established. But it’s interesting treating men with metastatic prostate cancer with testosterone. Amazing. It’s it changes everything. Yeah. In your practice what are some of the most frequent disease disease processes complaints that you encounter in both men and women? I see so many men and women for sexual dysfunction. So when I see men for sexual dysfunction I see a lot of men for erectile dysfunction right. So that’s a very common condition. And how would that be defined? So it’s inability to obtain or maintain an erection right. So inability to obtain or maintain. That’s the easiest way to define it. Some men can obtain the erection they can’t maintain the erection right. And the statistics are very similar to when I told you about low testosterone. 50% of men over these are 50, 60% over 60 same numbers. It’s amazing how many men suffer from this condition and we don’t talk about it right. So erectile dysfunction is a very common condition. Premature ejaculation right. So you know 30% of men will suffer from some degree of premature ejaculation which can be very bothersome to the relationship. The average man will ejaculate within seven minutes. Premature ejaculation most men will ejaculate less than one minute right. And there’s a discrepancy you know. So it’s very important to realize that men and women premature ejaculation can have a big impact on their relationship. How about Peroni’s disease? Seven to nine percent of men suffer from this. And what is the cause of that? So we I believe that so as men get older and as they start developing a mild erectile dysfunction

they start increasing the risk of having a buckling incident during sex. So let me give you an example. If a man has a hundred percent rigid penis he’s fine. He’s not going to injure himself. If he has a 50% rigid penis he’s not going to be able to penetrate in the first place. But he’s in trouble when he has a 90% 80% 70% rigid penis because of what’s going to happen is he’s going to penetrate and he’s going to buckle and injure the penile tissue. And when he injures the penile tissue what happens is you develop a scar. Now the best way I want you to think about this is if you have a balloon. And if I put a piece of duct tape on that balloon and I blow that balloon up what do you think is going to happen? It’s going to curve in the direction of the duct tape. That’s exactly what happens in terms of Peroni’s disease. And seven to nine percent of men in the world suffer from this condition. And these men tend to be more devastated. I mean they are truly depressed when you look at them psychologically to have this kind of curvature. And when the curvature is greater than 60 degrees they can’t penetrate. So it’s very devastating. Yeah. And then for women when you when you see women on the flip side what are their most common complaints? The most common complaint I see is low libido. Right. So many of these women have low libido but it can be multifactorial. So you can’t just say hey give them testosterone and the world is great. I mean we there’s many things. It’s her stress. It’s her relationship with her partner. I mean it’s her medical condition. So you have to take into account everything for her low libido. Many women suffer from pain with intercourse dysperunia. Right. So we talked about that earlier. Many women just have poor arousal decreased blood flow to the genitalia and they have orgasmic dysfunction inability to obtain an orgasm. So you really have to do a deep dive and figure out what is the actual cause. I firmly believe that lifestyle modification for men and women does help with sexual dysfunction. And I will repeat that over and over again. The four pillars are diet exercise sleep and stress reduction. Diet exercise sleep and stress reduction significantly help with sexual function in men and women. There’s something very interesting between the difference between men and women. If you look at a man typically a man typically has sex to reduce his stress. He has a very stressful day. He comes home. He just wants to have sex to reduce his stress. In women it’s the opposite. She has to reduce her stress in order to have sex. It’s a 180. So if I tell men if you want to have a better sex life with your partner reduce her stress. Do the dishes. No seriously. I reduce the stress. If you can reduce her stress you’re more likely to engage in sexual activity. For him it is for sex to reduce the stress. I could see where that would create relationship issues and probably one would have to treat both parties as opposed to treating one party. You nailed it. It is a couple’s disease. When I started my practice in 2007 I was so proud of myself. I was able to get these men these amazing erections amazing libido. Everything was great. They’d go home and they’d have no sex with. In fact the women were very upset. They said look we haven’t had sex in 10 years and now he wants to have sex all the time. It’s ruining our relationship. Right. And I thought to myself they’re right. I mean the reality is that you can’t raise one libido without raising the other or you’re going to set up for conflict. Right. So if you’re going to raise one libido raise the other. So very quickly I started getting into the field of female sexual dysfunction. I said to myself if I’m going to treat the men I’m also going to treat the women and raise the libidos together raise the sexual function together. Otherwise it’s a setup for conflict. You have been saving marriages for decades now which is which is incredible. Let’s talk a little bit about hypogonadism. Yes. And the signs and the symptoms the definitions and how one would go about treating that and what does the evidence show. Let’s go back to like the basic signs just the basics. Remember that testosterone in men 90 percent of testosterone in men is made from the testicles. 10 percent is made from the adrenal glands. Women are a little bit different. 50 percent from the ovaries 50 percent from the adrenals. Now there’s a signal from the brain and that signal is called LH which goes to the testicles and says come on let’s make testosterone. It’s like the gas. Right. So if someone has low testosterone there’s only two areas the problem can be from the brain or from the testicles. Either the testicles are not producing or the brain is not producing one or the other. So my job is to figure out where is it coming from. Number one. Secondly you want to be able to treat them and you want to understand that giving men testosterone can make them infertile. So many patients who go to these clinics that are 32 years old and they take the testosterone they come to me and say no one told me I could become infertile. Now I want to have a child. Well a little bit of an issue. Now we can reverse it. Right. But the reality is if you’re thinking about taking testosterone and you’re planning on having a child hold off you can use medications to make you make testosterone. That’s safe. I can use off-label chlamyphine citrate. I can use hcg. I can use things to make you make testosterone but do not give a young man testosterone if he’s planning to conceive and make sure he’s fully aware that if he does take testosterone it will shut down his natural production. Right. So I think that’s very important to have those discussions with the patients. But testosterone again is not only for men it’s also for women. I use a lot of testosterone in women and they also benefit equally as well as men. And I would say for libido women benefit more from testosterone than men do.

And with the men when you start them on hcg or enclomaphene or clomid do you expect to get a certain percentage rise in free testosterone if you say I’m going to give you 3000 IUs of hcg a week. I expect your testosterone free in total. I don’t know the percentage that it increases to go up by 300 points. Is there some kind of expectation that you have? Yes. So remember this when you’re using medications to raise a man’s natural testosterone you are dependent on his ability to do it. Some men can some men cannot as they age they’re less likely to. So I tell the residents it’s like putting fuel in the car. You can put all you want the car will only go as fast as it can. Right. So the younger men tend to respond better. So typically what we do is we use hcg or clomid citrate but at some point at some point the body says I can’t do it anymore. I can’t make any more testosterone. But younger men tend to respond. I like to use clomid citrate it’s off label it’s used for women for fertility but what it will do is it goes to the brain increases something called LH and FSH that goes to the testicles and the man can start producing his own testosterone. Now there’s I’m a little biased. I believe that clomid can do something called the discrepancy effect. 40 percent of men in my opinion roughly will have an increased number in their testosterone but they don’t feel it. They say doc I know my number went to 800 but I don’t feel it. And there’s a reason for that. The way clomid works it blocks estrogen receptors in the brain and men need estrogen for libido. So they have a bunch of estrogen sitting around. They can’t see it. You take that same man and put him on testosterone. He’ll say OK now my libido is back. So some men who take clomid will not feel that improvement in in libido. hcg doesn’t depend on the brain. It goes straight to the testicles and starts producing testosterone. The problem with hcg it’s pricey. It’s an injection. It’s invasive and it’s pricey but it works. And prior to making the decision of putting someone on clomid or hcg do you look at do you like their LH and FSH numbers in a particular range before you say OK this person is going to be a responder. So for example the people listening blood work is now highly accessible to individuals and maybe they’ll go on inside tracker or maybe they’ll go on some way to get their their blood work that’s direct to consumer. Could they and also we have lots of physicians and health care providers listening say OK well the LH and FSH are three or under three versus say 10. How do you decide. Great question. So remember as the testicles start to fail your LH and FSH go up right. So the higher the LH and FSH the less functioning the testicles are. LH is a good marker of the testosterone production. FSH is a good marker of your sperm production right. So in men so as I go up this let’s less functional. So in men if the LH and FSH are high typically hcg and clomid will not work right. And the number you want to think about is 7.6. It’s a good number. It’s been shown that that’s kind of the cutoff. So if his FSH and LH are 10 15 probably not going to work the best. It may have some mild benefit but not really work that well at all. So in those cases what you want to consider is a third medication again off label. It’s called an astrozole or rhemaex. It’s been used typically for women with breast cancer. And what it does is it blocks the conversion from testosterone into estrogen right. So essentially instead of making the man make more testosterone you’re preventing him from losing what he’s got right. And so we use a lot of a rhemaex or an astrozole in those men who have elevated LH and FSH. So it’s important you’re right. Look at the LH and FSH. If it’s high giving them more hcg or a clomid will probably not work. If it’s below it will work and we typically use clomid off label. You do. And when you start with an astrozole the dosing is relatively low. We spoke about it’s different than what people think or a lot of the TRT clinics are giving individuals one milligram three times a week. That just it has negative effects on bone density. You nailed it. So this is very important. I used to think that testosterone was the key driver for libido and sexual function but there are many studies that have shown that it actually it’s the estradiol. It’s the conversion from testosterone into estrogen which gives that man that libido and improvement in sexual function. This was the Finkelstein study. And so what we know now is if you block a lot of the estrogen these men will complain of low libido. So I call it the sweet spot. You don’t want the estrogen too high but you don’t want the estrogen too low. I personally like to keep it between 30 and 50 in the sweet spot. So when I first started my practice I thought estrogen was for women. Testosnose for men. I’m going to give them a lot of an astrozole and shut them down. And it was a big mistake. Right. And now what we do is we manage it. We give them a half milligram once a week just enough to get them from high back into the normal range. And that works really really well. So getting those men in the normal estrogen level is very important. Estrogen is extremely important for men. It’s not just for women. It’s extremely important for men particularly when it comes to sexual function. It’s very important. That’s relatively unknown. Individuals listening probably have never thought about estradiol for men for sexual function. You’d mentioned it you really like to see the range between 30 and 50. Is there any evidence that above 50 would be a problem? There’s I think that there can be an adverse. The main one is gynecomastia. Right. So as the estradiol level goes up men can get breast tenderness. And I’ve seen personally that I see men typically can get some mood lability as well when the estrogen goes up so high. So what’s the point of keeping the estrogen so high. Why do I need I have beautiful wonderful medications that can bring them back into the normal range. My only request is not to shut them down because in the old days we said just give them a milligram a day. They don’t need it. The reality is they do need it. So if someone’s high just bring them back to normal but don’t shut them down. We also need it for bone mineral density. So men also can get osteopenia osteoporosis and taking away their estrogen particularly for two years or longer can result in osteopenia and osteoporosis. That’s that’s really important when you think about again what you talk about these overall pillars of health and these lifestyle factors when you are replacing testosterone. So typically when they’re young you don’t like to do it for people that want to have children fertility issues. Again you said that it can be reversed. Over time I know that I’ve read many of your papers that there’s a certain strategy. You start them on hcg to help and then if that doesn’t work you would consider also adding in Clomid. I am curious about the dosing of Clomid and we’re talking about Clomid. Is there a place also for in Clomidine? Right. And how do we dose Clomid? People ask can you be on it for five years at a time? Right. So Clomid is a dose I dose it every other day and the reason I dose it every other day is because if I dose it every day seven percent of patients will become resistant to the drug. We call that Tachyphylaxis. It’s roughly seven percent. We don’t see Tachyphylaxis on Clomid if you dose it every other day. N-Clomaphene is not FDA approved so never made it through the FDA but if you think about Clomid it has something called a cis and a trans isomer cis and trans isomer and the trans isomer alone is Clomaphene. Right. So Clomid has cis isomer and trans isomer. N-Clomaphene has just the trans isomer. It’s a shorter half-life and we did a recent publication an abstract that we presented showing that patients typically have less side effects and they may have more benefit with the N-Clomaphene but still not FDA approved. It’s compounded typically but Clomid is readily available. It’s a fertility drug for women that we use off label in men and the dosing again is every other day but Clomid as I mentioned can have that negative effect where some men will come back to me and say I have no desire for sex. I have a low libido and I know my number says 800 but I just don’t feel it. So I explained to patients before I give them the medication okay you may have this effect if you do we’ll switch you to HCG but if you don’t great it’s cheap it’s effective and it’s commonly used. And it can be used every other day. Do you start them at 25? Do you start them at 50? How would a provider or a patient or a person listening go and speak with their provider about that? Yeah so I typically do 50 milligrams every other day. Now some patients say look doc I can’t remember every other day. Sometimes I do one day I forget the other day I say fine take 25 milligrams a day which is half a pill and you may become resistant 7% chance. 93% chance you won’t but if you get the 7% we’ll deal with it you know but again it’s a reality you can become resistant to the drug so we try to do it every other day. And how long could someone stay on that if they’re getting good benefits? Great question. So you can be in as long as your testicles can produce you can be on it right. So at some point so the testicles tend to atrophy we undergo apoptosis one to two percent every year starting in your 20s. So the longer you live this greater cell death than the testicles eventually they will stop producing and your testicles will say I don’t care how much clomid you give me I’m done. I’m out. I’m out right. At that point you make the switch over to testosterone. Now typically though I if a patient is not interested in fertility and they’re a little bit older it makes more sense for me to start them on testosterone supplementation because I think they tend to feel better on exogenous testosterone and it’s a lot cheaper a lot cheaper. And there are different forms of testosterone there is now an oral form I’d love for you to break down testosterone replacement and and the forms. Yes so there are so many when I first started there’s essentially gels and injections and patches. We don’t use patches anymore. I was like there’s patches? Yeah patches you know androderm there was one patch that was actually placed on the scrotum they thought would be better now than those androderm not commonly used because 37 percent of patients would get a very bad skin reaction you have to take the patch off every day. Now the gels are very commonly used but the problem with the gels is that they’re dependent on skin penetration. So let’s say I put a gel on your body and you get zero skin penetration you get nothing. Let’s say you get 10 percent that’s great if someone gets 80 percent that’s even better so we’re so dependent on skin penetration. So there’s numerous others injectables are very popular. And before you move on the gels they so someone would not be able to know going in is it based on skin type? Right so so everyone’s skin is different and some patient’s skin has better penetration than others. But but one important thing about the gel you mentioned you bring up you can get transference. If you have a baby at home or a pregnant wife you do not want to prescribe a gel to that patient because of the risk of transference. So I think you got to be very careful but because of the variable absorption the poor penetration in many cases most patients as long as they’re not needle phobic like the injections because you can do them sub-q. Now they are the ones you get like testosterone, nandate, incipientate are off label sub-q but they’re meant to be intramuscular but there was a medication called xiostead that came out several years ago. And xiostead essentially is just a spring with testosterone and nandate in it and and it’s meant to be sub-q. And typically when you inject someone sub-q you have you can use less testosterone about 20 percent less you know. So if I have to use 100 milligrams I am in a patient I can use 80 milligram sub-q. The starting dose for the xiostead the sub-q testosterone nandate is 75 milligrams. So testosterone injectables are great. There’s long-acting injectables we have in the United States. We have Avede which is a 10-week long-acting injectable but most people like the short-acting because they’re cheap because you can get it from a compounded pharmacy and you can get cipinate or nandate are the most common. Now I tell the residents how do you know between cipinate and nandate how do you know which one to use. I say think of C for child E for elderly right and kind of use the number 50 to 60 years of age because if you at cipinate has more sodium retention it’s more anabolic so you can get more swelling and a slightly longer half-life. Anandate is less anabolic and less sodium retention. So I typically if I give a 75-year-old man some cipinate he’s going to make it from swelling in his feet more edema. So I try to give the older patients an anandate the younger patients cipinate but these two medications are fantastic and quite frankly you can use them interchangeably slightly because half-life’s relatively the same if you run out of an anandate for someone young and you can use cipinate but very effective very cheap if you get from a compounding pharmacy and we have our patients inject sub-q. I think sub-q works far better and I think they should inject twice a week and I have them inject on Sunday and Thursday and the reason being is because they peak in 24 hours. So if you inject Sunday you’re ready for Monday. If you inject Thursday you’re ready for the weekend right. So I do half dose I split it otherwise I have these huge peaks and troughs if I don’t split it and I just like to have a much smoother graph. When you do sub-q does that change the conversion to estrogen is there less estrogen conversion or estradiol conversion is there are there other mechanisms that make the person be able to use less. The absorption is better there’s no the only key thing is we you can use less testosterone but there’s no other kinds of conversion remember the most of the conversion is when you see on the skin right but this is beyond the skin you’re going into the fat but we feel that I’ve seen that better absorption of the medication it doesn’t have matter if it’s an anandate or cipinate better absorption systemically when you use it sub-q. So that’s why you use less dose and that’s why the starting dose for zyostead is 75 milligrams where most people are taking a hundred milligrams I am that little conversion. So if you’re using sub-q just remember you’re going to get better levels and you may need to go down a little bit on the dose to compensate patients love sub-q much better than I am it’s easy you know if you’re not using zyostead which is an auto injector you can draw it up yourself yeah you can inject sub-q and you can do it sunday thursday very very effective very cheap and very patients are very happy. And what percent just in general what percent of testosterone gets converted so for example if someone comes in and their testosterone is 300 they feel like crap their free testosterone is low do you say well I’m going to start you on 150 milligrams I expect your testosterone to bump up to x and I don’t know 0.6 or 6% will be converted to estradiol yeah so this is the way you want to think about it everyone’s different but if you look at testosterone 0.3% is converted into estrogen 6 to 8% is converted into dihydrotestosterone so those are the numbers you want to remember now it can vary because obesity fat cells contain a substance called aromatase and aromatase eats the testosterone and converts into estrogen so in patients who are obese they tend to have more conversion into estradiol but the good way to think about is 0.3% for estrogen 6 to 8% for dihydrotestosterone now what’s the problem with that conversion if you have too much estrogen you can get gynecomastia right and I also believe that patients have too much estrogen can get some mood lability as well if you have too much dihydrotestosterone you can get milk powder balding baldness right for men and women so how do the drugs work like propetia and these medications they block the conversion from testosterone to dihydrotestosterone I’m not a big fan of these medications yeah I do not I do not believe the use of men and women should use this medication I think it has significant negative side effects and some work can be permanent you know so but that’s how it works so essentially if you have a patient who’s getting too much estrogen what you can do is you can put them on a low dose an astro salt estrogen blocker and when you block that conversion estrogen comes down and their testosterone goes up so you can work around it but I think it’s very important to follow the testosterone and and estradiol and DHT in these patients and is there a number of DHT that you like to see well I try not to shut it down I try not to mess with their DHT at all you know I really feel that the what I’ve seen with irreversible sexual dysfunction suicidal ideations terrible side effects with setting the DHT down I don’t believe in doing that so I will not prescribe medications that shut down DHT which would be propetia and finasteride I will not so but I’ll do a workaround and so there are medications that you know patients will go for hair transplant or they may look at because the main thing is hair loss right right that’s the main thing that’s what they worry about right just had a conversation with a woman who her testosterone was low yeah but she really struggled with hair loss yeah and she wants to go on testosterone she needs testosterone yeah and she’s already on oral minoxidil things you know looking at her copper her iron what would you do in a situation like that so oral minoxidil is very good you can use a 1.25 milligram to between these are off label but it does help remember that you just tell the patient when you use oral minoxidil you’re going to lose some hair first and then it’s going to come back right there’ll be a dip excuse me there’ll be a dip the second thing you want to let them know is that you can use topical minoxidil also it doesn’t have the oral that can be very helpful but I really do not want to give them medications that will mess with their androgens orally particularly like propetia I just feel like it can have a negative adverse effect look I’ll just I just tell you so we did a study I got looking at propetia in men that the effects of something called post-phonasteride syndrome and in my study there were 25 men that came to me from all over the world they came from South Africa Scotland everywhere to be in my trial because when they took the finasteride they had negative adverse events not only sexual dysfunction but they also had depression low libido poor cognition and in my trial during my trial two patients committed suicide oh my gosh because it’s increased suicidal ideation and so I am very adverse to giving patients finasteride I just feel like because remember in medical school we were taught that testosterone at propetia the medications block the conversion from testosterone

to five high to five alpha reductase has a negative effect and it blocks the conversion to DHT but we weren’t taught about the other 12 pathways we were taught about that one little pathway testosterone DHT you give a finasteride it blocks the conversion but the other pathways are extremely important because they block the conversion to what we call neurosteroids in the brain and allopregnanolone which are responsible for depression anxiety so some patients that are taking this will say I have anxiety depression suicide ideation many countries have put on their package insert increased suicidal ideation if you take finasteride in the US we haven’t yet right but many countries have already said that so I think it’s very important that patients know finasteride can have a significant adverse effect mentally and with depression that it’s really important you guys if you are taking propetia or a finasteride this might be something to really obviously I’m not we are not your physician but really consider removing from your plan there are better options yes that’s safe to say yeah for DHT that is more anabolic yes it’s more anabolic than testosterone it’s really important is there a number a target number that you like to see for men 80 or 100 or is it again very variable yeah it’s for it’s 40x so like testosterone DHT is

40x but I don’t like shutting down their DHT for the reasons I mentioned before pea show right do you want it higher is there a target my target is typically on the T I look at the T level and the T level typically is 300 to a thousand now if a man comes to me in in some uh your physicians say he’s at 400 he’s normal that’s not you know it may not be normal for him the reality is we did this wonderful study several years ago looking at something called the sensitivity of the androgen receptors these are called CAG repeats right so that’s on my list I’m so glad you brought it up so the higher the CAG repeats of 27 or higher if it the higher the CAG repeats the more insensitive the androgen receptor is and we showed several years ago that those patients who have more insensitive receptors need more testosterone makes sense if you have more sensitive receptors you may need less testosterone so how can you assume that every man the cutoff right now is 300 above 300 is normal and it seems like it keeps getting lower well in some cases right so and we’ll talk about that every man if you’re above 300 you’re normal if you’re below 300 you’re you’re you’re not normal that’s not true every man has his own cutoff every woman has her own cutoff so if the range is 300 to a thousand what we found is if you put the patient in the upper quartile of normal then most of the patients have met their cutoff number so if a patient comes back to you and his number is 450 or 500 and he says doctor I still have symptoms the response should not be well you’re in the normal range so let’s find out if something else is going on the response should be let me raise your testosterone even more in the normal range because some patients will continue to see benefit right that should be the response and same with women as well so I think it’s very important to realize it’s not one number if it’s all it’s a range and you sometimes need to take patients into the upper quartile of that range to see symptomatic improvement and if someone has a CAG repeat and they’re insensitive they’re androgen insensitive typically providers will not go over 200 milligrams of testosterone weekly is there but what I’m hearing you say is potentially people might need more and they just don’t feel it would that be reasonable to say absolutely so some patient we’re all different right genetically we’re all different some you can’t assume that everyone’s going to feel great at a certain number and certain patients will we all feel great maybe you this gentleman over here needs an 800 some men just need 400 and they feel great and it gets a little deeper you got to look at the free testosterone also because if the SHBG is elevated we should definitely talk about that but but it is not one number fits all right everyone is different and every man and woman have their own cut off and you just want to get them above their cutoff in order for them to see symptomatic improvement and I’m not saying you have to go sue super physiologic but if someone doesn’t feel it if they have their very androgen insensitive and you’re they’re on what we would consider the max dose of testosterone so the max dose of testosterone um and correct me according to the guidelines would be 200 people wouldn’t go well don’t go on the dose go on the number of their blood tests right because some patients I need to put them at 200 just to get them into the normal range like it just varies right so the some patients will need 250 200 150 it varies I’m I’m looking at their blood tests and I’m also looking at two other things I’m looking at their risk of erythrocytosis so if someone has too high of a red blood cell count there is a theoretical cardiovascular risk if it’s above 54 right so testosterone increases the red blood cell count right so for everybody well do some people respond differently and there isn’t erythrocytosis right but it depends on the formulation you use so we published a study looking at all different types of uh formulations if you give someone an injectable in our study it was 68 chance of having erythrocytosis if you gave someone an appellate it was 35 chance of getting erythrocytosis if you gave him a gel it was 12 chance the aural which we’ll talk about but it’s nice it’s five percent chance so much less so much different right so if a man comes in and he’s saying look my red blood cell count keeps going up what I have them do is I have them donate blood that’s one option or you can have them decrease the dose most of them don’t want to decrease the dose so we have them donate blood and we typically have them donate one pint separated by a week to drop that blood count because most men don’t want to stop the medication but if another option another smart option is okay injectables have a 66% chance of erythrocytosis I was going to switch you to an oral I drop it down to five percent and he doesn’t have to donate blood so often now some men don’t like oral they like the injectables and the way they feel but it’s that peaks and troughs that causes the increase there is a theoretical increased cardiovascular risk if someone gets above 54 on the blood count so that’s why we want to stay away from that now I just want to be fair it’s I want to stress theoretical I just want to stress theoretical because up to you until 2022 before that year there was not a single study to show that secondary erythrocytosis meaning if I give someone testosterone and their blood count goes up they’re at a higher risk for getting a cardiovascular event that was never shown it was only shown in patients with polycythemia vera which is a blood cancer right that shows if someone has polycythemia vera and their blood count goes up their increased risk for having a cardiovascular event that was never shown never shown with testosterone there was one study at the university of Miami and showed a one percent difference mild but this was a database retrospective study saying that maybe there’s an increased risk so just be very clear testosterone is theoretical risk if that blood count gets too high but how do we reconcile that because again you said it’s a theoretical risk when you administer testosterone depending then the erythrocytosis would be something that we would expect I think that there’s the hematologist I’m not sure that they I think that they have guidelines that they are not necessarily concerned I don’t know if to some degree you know there are they I think that you know the numbers what you want to remember is 54 above 54 we ask our patients to donate in fact at 51 I ask my patients to donate blood because why am I waiting to the trouble number of 54 just preempt it do it ahead of time right and some guidelines will state that at 52 don’t start the testosterone so thematica it’s above 52 don’t start so we will live within the guidelines and that’s fine I’m happy to live within the guidelines you feel obviously they’re important because they set the standard of care they set the standard of care and so what you can do is very simple if you have someone on injectable and he’s getting erythrocytosis switch him to an oral switch him to a gel maybe switch into a pellet and it drops it or they can continue to donate they can donate blood and keep their levels low and some men are perfectly fine with that now remember this some patients this is very important some patients that keep donating actually have underlying obstructive sleep apnea they have us and we catch it right because and it’s manifesting now because they’re taking testosterone you send them for a sleep study they have sleep apnea you treat the sleep apnea guess what they start to stop getting the erythrocytosis with their injectables right and so we can unmask a lot of sleep apnea just by putting these men on testosterone injectables that’s really important I know that you really believe that sleep is important for overall health cognitive function sexual health do you think that there’s a risk it because they’re in the guidelines that if an individual’s he hematocrit goes up and we ask them to donate blood it could probably I mean it does it lowers their iron stores and so again we’re functioning within the guidelines but do you think at some point that those guidelines are going to be re-evaluated well they are so one that’s going to be re-evaluated is the cardiovascular risk so the cardiovascular risk uh was in the guidelines and they were in the 2018 testosterone guidelines but you should I got to tell you a little bit of a story so here’s the story here’s a story I love a good story for decades for decades we gave men testosterone and the studies would show that men with low testosterone levels were much more likely to have a heart attack that’s interesting molly schor’s in 2016 one of the first to show men with low testosterone more likely to get a heart attack many prospective studies after that and then there was this concept that maybe if you normalize a testosterone it potentially could decrease your risk for heart attack but in 2010 to 2014 there were four studies that came out saying that if you give men testosterone you will increase the risk of having a heart attack three of those four studies were retrospective non-randomized database studies so some limitations so the FDA in 2015 said look we want a well-designed trial to make sure that testosterone does not cause a heart attack in fact we’re going to put a warning in the package insert saying that it could increase the risk of cardiovascular events and until you give us this trial we’re going to leave the warning so this trial was called the traverse trial an amazing trial the largest randomized placebo control trial in men looking at does just over 5,000 men 5200 men big deal it’s right it’s a big deal yeah and we never had massive and so i was one of the investigators in this trial and basically helped design this trial and we basically not only looked at cardiovascular risk but we decided if we’re going to do this trial we might as well look at other things as well so we looked at the risk of prostate cancer or high grade prostate cancer then we looked at five other domains we looked at risk of diabetes we looked at bone fractures looked at sexual dysfunction we looked at anemia in these trials as well and so the gist of the story was this is that when we did this trial 50 to 50 200 men randomized to testosterone gel or placebo 45 to 80 that’s right 45 to 80 and that’s important because there was a trial before this called the t trials and the t trials only looked at men over the age of 65 right but this trial looked at all men above and below 65 years of age where do they find no increased risk in cardiovascular events that’s really important no increased risk so this is a multi-center randomized control trial over 5 000 men between the age of 45 to 80 yes no increased risk of cardiovascular disease on testosterone and we did something very interesting we only selected patients who were at high risk i know right it’s an extraordinary study we’ll link it yeah extraordinary yeah think about it in order to be in this trial you either had to have cardiovascular disease meaning cerebrovascular disease cardiovascular disease or you had to have risk factors for cardiovascular disease diabetes hypertension so these patients were already at high risk for having a heart attack right and in that study and even despite giving them testosterone we saw no increased risk of cardiovascular events now you should know about three little exceptions in the study we did see a slight increase a slight increase in those patients who had uh renal insufficiency very tiny we had a slight increase in pulmonary embolism very slight from 0.5 to 0.4 0.9 so it was very tiny and and some so that i think that’s very important to realize that there were some slight curve balls but at the end of the day no increase in cardiovascular events now look at all the other studies that came out of this it was it was fantastic we saw that there was no increased risk in prostate cancer that’s very important we saw that there was no increased risk in bph or lower urinary tract symptoms it’s in the package insert if you give a man testosterone make sure you follow his urinary symptoms because it could get worse that’s not true that’s not what we saw in fact most of the studies not the traverse trial most of the studies show that long-term testosterone in men either have no effect on their urinary symptoms or an improvement in their urinary symptoms because testosterone can be a strong anti-inflammatory for the prostate that’s a lot of a lot of reconsiderations that we have to think about from the patient population to provider because just number one people will say well i can’t go into testosterone i’m afraid it’s gonna affect my heart right i don’t want to go into testosterone because i’m afraid it’s going to cause bph and keep me up at night right these are right these are really important things that actually prohibit people from taking action to improve the quality of their life by the utilization of hormones we needed the traverse trial because when the traverse trial first started and the FDA talked about the risk of testosterone cardiovascular disease if you look at a graph the utilization plummeted in men it plummeted in the use of testosterone this was a fear that if they took it they’d get cardiovascular risk or any kind of cardiovascular disease but how unfortunate because many of these men were benefiting from the medication but they stopped it because they were fearful that they may get a heart attack but they actually didn’t need to stop it because they were benefiting as well so that was those two were the big findings cardiovascular and prostate but there were other findings as well there was improvement in sexual function now there’s two types of sexual function there’s libido and actually erectile function testosterone as monotherapy still should not be indicated for pure erectile dysfunction it does help when someone’s taking viagra let me give you an example or cialis or these we call these bd5 inhibitors if a man says look i’ve been taking viagra and things have been great and all of a sudden my viagra stopped working if you check his testosterone and it’s low and you replace it 30 to 50 percent of men will say you know what my viagra is now working again because if i had testosterone work very well together but in the guidelines testosterone as monotherapy is not meant to be used for erectile function but it does help with libido in the traverse trial we did see a significant improvement in desire in libido what are the other things we saw we saw improvements in anemia that was very important as well we didn’t see any improvement

you know we saw improvements also as a sexual function we saw improvements in anemia but we didn’t see much improvement when it came to other conditions such as diabetes

that’s interesting because you would think it would improve skeletal muscle mass but if they’re not exercising it’s not right going to make a difference now there’s a big difference because there is a very famous study called the t4dm the t4dm study showed that if you give men testosterone it actually improves insulin resistance but in this trial it did not show improvement now the t4dm used a different medication they used something called libido which actually has high levels of testosterone gets them well into the superficial or normal range but in our trial if you were above 350 you were considered normal so if you have a testosterone level of 370 then some would say that’s really not high enough to see symptomatic improvement in insulin resistance so i think there’s some limitations with this trial to say did we see improvements we did see improvements in anemia makes sense if you give for someone testosterone anemia you know blood count goes up in the traverse trial but i think that’s very important to realize that there are a lot of benefits of testosterone it’s just not about sex right what about for women you know the the numbers for women are much lower if an individual is looking at their labs their free testosterone would be considered normal even if it’s one yes do you think that those numbers are correct my patients seem to do and feel much better yes when their free testosterone is higher than these lab values that that we’re looking at and it’s very clear yeah in women free testosterone is far more important than total testosterone and the problem is that her shbg can be completely variable so remember sex hormone binding globulin right and sex hormone binding globulin is bad so the higher the shbg the less the free tea right so what is the number one cause of elevating shbg birth control those skyrockets shbg now here’s the clincher yeah right but here’s the clincher the clincher is is that did you know that if a woman takes birth control pills greater than five years and then decides to stop many of her shbg levels will not normalize they’ll stay permanently elevated right so many years that in the package insert you’re reading my mind because i was about to say many years ago we tried to put it in the package insert and we couldn’t get it in because causing irreversible sexual dysfunction in women irreversible and because if the shbg stays high i don’t care what her testosterone is the free testosterone is going to be very low would there be any way to overcome that if you dose it high enough yes so the only way to win is to is to increase the total tea to overcome and you can have a higher free tea but most you have to be able to follow that follow the free tea in women not the total tea follow the free tea it’s very important so i think that you know women are a little bit different you have to pay more attention to the free tea you have to be careful on how fast and how much testosterone how much of a rise because she can get acne or facial hair right and so in men if you overshoot you can just bring it back down in women you start low and you move up very very slowly on those doses so do you like injectable for women’s up to i do so i think you know i think the transdermal don’t absorb very well and the way you want to think about the dose for a woman to men is it’s one tenth one tenth the dose now remember testosterone is off label for women in the united states why is that why yeah you know so they tried many years ago in trenzo was a patch that they were trying to get through the fda uh and just never got through the fda um i think it’s a shame because women benefit i think even more than men when it comes to testosterone supplementation let’s talk about bone mineral density for them libido cognition just overall well-being so um but it didn’t get approved so uh typically for women i’ll either use a testosterone pellet i’ll use a cream which is compounded because there’s nothing fda approved or i’ll use an injectable but most women will go to the pellet where they use the injectable and the way i use my injections is again a sub-q and you just have to dose it different and use typically one tenth the dose one tenth the dose and do you have any concerns being outside of range and this is more for you know both the listener and the providers do you have any concerns about that i think the main concern is for women i can start getting acne facial hair but what if they don’t have any of those side effects sure you are outside of the normal range yeah they feel great yeah the other thing i worry about is in terms of erythrocytosis right so there are some other things that can occur i typically like to keep them in range but the upper quartile of normal and just and this is i just pulled this up this is again the lab values are going to be different but this is 0.5 to 2.4 to 2.4 nanomoles per liter yes so small versus yes a male could be um again the total would be 300 to a thousand nanograms per deciliter or 10 to 35 nanomoles per liter yes but this is very important why are we so fixated on the number let me just put that out there for you so if you treat a woman for estrogen she says doctor you know i’m postmenopausal and i have hot flashes so i say sure ma’am i’m going to start some estrogen and so i don’t check her level she’s postmenopausal and she comes back and she says you know my hot flashes are better but i still have some i’m bothered by them i don’t check her levels we just give her a higher dose of estrogen why is this any different i mean to some degree you know we’re so fixed i completely agree with you yeah this is symptomatic improvement not a number right and i bring this up because let’s say a woman is at 2.4 just even from a medical legal standpoint you know that’s not enough for her and let’s say she’s still completely symptomatic you push her to double that yeah or and she has no erythrocytosis and feels so much better yeah i agree so we’re so fixated on the numbers and many times before i tell the patient their lab values i say how do you feel same you know i say how do you feel this doesn’t feel great because sometimes i say your levels are low he says well by the way i don’t feel that great i say no i want you to tell me how you feel first because that’s very important yeah and when for so for women you’ll use a sub-q injection you’ll which is or cream or a pellet or a pellet those are my three favorite so you know typically i will again this is off label but she will will compound at 50 milligrams per ml and she’ll start out at 0.1 ml once a week and it’s sub-q and it’s easy if she wants to do the injection i’ll compound the cream at four or eight milligrams per ml and that’s easy but you know the cream sometimes has poor variable absorption it seems that way it can be tricky it can be tricky and then a lot of them love the pellet you know and so they’ll come in once every four months for a subcutaneous pellet that’s placed on the side of the hip very effective and she’s autopilot she doesn’t think about it and so she likes it and what about alternative treatments for women who let’s say they have concerns about going on testosterone you know we’re talking about addy yes i would love to hear your thoughts on the alternative treatment yes so addy’s nice in the sense that it has no hormones right so if a woman says i have a history of breast cancer the beauty about addy is it doesn’t increase the risk of breast cancer right not like so basically addy increases dopamine in the brain you can increase norepinephrine and these hormones increase the desire for sex right uh so addy’s been around for a while um and many patients will use the addy and sometimes in conjunction with the testosterone to help with libido but what’s nice about addy it is FDA approved FDA approved strictly to increase a woman’s desire for sex and it can be very effective so several years ago i said to myself if addy is good enough for women why don’t i use it for men so i went to the FDA and i actually got an IND from the FDA to be able to get permission to give it to men so i have the only IND in the United States to give addy to men strictly to increase their desire for sex right because men and women are not that different if i increase dopamine in a man’s brain if i increase norepinephrine in a man’s brain he also wants to have sex right so addy is a great medication very effective there’s one other medication out there and before you continue yeah would there be any reason why someone wouldn’t go on addy well not really i mean there’s some side effects some nausea there are some side effects i tell patients to take half a dose every day for two weeks and then you can desensitize yourself and then go up to the full dose there’s a cost and some insurances don’t cover it but it’s cost pretty reasonable for three months you know so those are the some of the things and i tell patients if you if you if you don’t benefit after three months and don’t so it takes about three months yes great point because i said you don’t expect if you don’t see anything in a week don’t quit right right you give me three months at the end of three months if you see benefit great if you don’t we can move on but i do think that many men and women do benefit from it and because they because it works in a different pathway it works in the brain could you potentially use it in combination absolutely so that’s what works the best if you use testosterone and addy primarily for sexual dysfunction that’s what we’ve been it is very effective because it’s two different mechanisms right and not to mention it seems like addy has side effects that i don’t know if they’re they lose weight they sleep better there it seems as if there’s these other benefits so 100 so two other things that patients will talk about is weight loss and sleeping better and so many women say i’m in right you know increase sex weight loss and sleep better you know but those yeah but yeah but yeah but but again the those are side effect the main goal is libido now look i just want to be very clear addy is phenomenal but you have to also work at it too i mean it’s part of your relationship i can’t fix your relationship with your husband i don’t know you can do a lot of things but yeah but with addy i mean you have to work on it and you have to give me the four pillars give me diet exercise sleep stress reduction it’s a program and you can add the addy in and it works beautifully but if you think that i’m gonna take addy and everything’s gonna be perfect with no work you know really it’s really synergistic when you put the work in yeah and i just because you mentioned exercise there is a paper here effective aerobic exercise on erectile function systematic review and a meta analysis of randomized control trials could you mention the impact exercise has on sexual function yeah we published this just recently and um it’s really important so patients come to me and say look i don’t want to take a drug i don’t take a pill what can i do naturally to improve my sexual function and this was a study looking at exercise and it was a meta analysis we looked at 11 randomized placebo control trials looking at the effects of exercise on improving sexual function and what we found was that on average the iief which is a score for sexual function improved by about three points strictly with exercise alone and what’s very interesting is the more severe ed you had the greater the improvements you would see in sexual function just by exercise alone so i can’t stress the importance of diet exercise sleep and stress reduction i call those the four pillars you have to and all you and i both of us can do better on diet exercise sleep and stress reduction and every day when you wake up every night when you go to sleep ask yourself what am i going to do better on those four because to me those are the key what is the one you have to work on i know the one i have to work on i have to work on all four but i would tell you this i think that i can always do better i’m always hard on myself i have to do better on all four but um you know i think um stress reduction because stress is i mean it’s it’s what we do is high stress but you got to find ways to take time out and you know most of my ceos are really good at diet and exercise they go to the gym right that’s actually healthy easy part easy part but when it comes to sleep and it comes to stress reduction they’re lousy yeah they’re lousy and they say well i can because because of sleep in many ways is not in your control somehow you know and so it’s how you process so diet exercise we got it most patients most guys are lousy on sleep and stress you know now a lot of them are successful because they manage stress well like that’s how they got there but sleep is the tricky one you got to get the sleep down it is critical for overall success the the thing that’s so interesting here is we talk about healthy lifestyle how do we get people there and erectile dysfunction is a huge problem you published this paper that looked at the effect of aerobic exercise on erectile dysfunction right without medication right yes i mean realize that healthier people tend to be more sexually active and this study shows that lifestyle modification diet exercise alone can significantly reverse erectile dysfunction reverse reverse right and so that’s really important amazing that’s really important because most people say just give me the pill i say fine i can give you the pill but let me tell you something that you can do to actually truly reverse your erectile function see remember that ed is a progressive disease so what happens if i give a man viagra today it works fine but eventually it’s going to stop working and that patient will then go on to an injectable for penile injections eventually that stops working and then they go on to pivot a penile prosthesis so there’s a spectrum here right how common is that so ed affects 52 of men over the age of 40 it’s very common and i think another way to look at this is 40 of men at 40 have erectile dysfunction 50 of 50 60 60 you live long enough you’re going to get erectile dysfunction and so but it’s reversible ed is reversible and typically with lifestyle modification if you improve your lifestyle it’s significantly improve your erectile function most men say just give me the pill i say fine i’ll give you the pill but you understand that that pill is going to eventually stop working and we’ll have to go to a stronger pill and then we have to go to a penile implant and so so if you work with me we can prevent ed from occurring remember that ed is the first sign of a heart attack or stroke that is really important right so if a man gets ed today 15 of them will have a cardiovascular event within seven years that is really important it’s not just about sex those are big say say that again yeah this is a prostate cancer prevention trial if a man develops ed today 15 of them will have a cardiovascular event within seven years that’s important because ed is the first sign of a heart attack and there’s a mechanism is how can explain this the penile arteries are one to two millimeters they’re very tiny the coronary arteries are three to four millimeters the carotid artery can be six millimeters so remember from physiology if you get occlusion 50 of an artery you start seeing end organ damage so what are you going to include first you include the penile artery first then you’ll include the coronary artery then you’ll include the carotid so ed typically is the first sign that something else is going to happen right so that’s very important to realize that so we take ed as a first sign of a cardiovascular event if a man comes to me and he has ed and two cardiovascular risk factors we send them for cardiovascular evaluation just to make sure there’s not a cult cardiovascular disease i think that’s really important that men out there particularly young men if you have ed and there’s no other cause should be thinking is there something going on with my heart that could be causing this condition do you typically screen um you know when we think about the blood panels i know that you get astrodial testosterone free testosterone shpg hemoglobin hematocrit psa i’m assuming you still you still get a psa do you also look at say apo b absolutely so apo b is much better than all the other ones right so apo b lp little a and lp little a is a non-modifiable risk factor it’s it is what it is but apo b can be modified typically like to keep the apo b below 100 you can say 130 or 100 but these are great gauges to let you know what is going to happen in terms of a cardiovascular risk so i i like the way you’re going with this because um i think it’s very important to realize that the first sign of a heart attack in men could be his erectile dysfunction and that’s been shown as i mentioned earlier 15 will have a heart attack or stroke within seven years if a man presents to you with ed and he appears relatively if it’s not psychogenic you should ask yourself is this the first sign of cardiovascular disease

and we we take it very very seriously also do you there’s a whole push for these weight loss drugs do you also look at glucose insulin hemoglobin a1c because what i love about the way you practice and the way you think is it is not just unidimensional yeah we’re talking about erectile dysfunction but you have your four pillars you are discussing things on a broader scale and really more holistic right the impact of these weight loss drugs ozempic

somaglutide trisepatide what are your thoughts on them and how could those affect infertility sexual function so we’re studying those right now and i think you can have a positive effect so remember what does fat do fat contains something called aromatase it eats up the testosterone and converts it into estrogen so the more fat cells you have the less testosterone you have the more estrogen you have so basically we like to look at these levels losing weight i believe will help with fertility i think it will make a big difference i think losing weight will help with sexual function and so we have a trial right now looking at that giving you these medications like semaglutide to reduce the fat to see if i can see improvements in fertility and sexual function i think it’s gonna make a difference let’s be honest health it’s survival of the fittest darwinism healthier people tend to be more fertile right so healthier people tend to be more fertile um i want you to think of this in two ways there’s two ways to play this there’s offense and defense right offense and defense and um when you talk about offense you know i say okay i’m going to focus on the four pillars diet exercise sleep and stress reduction i’m going to do things to improve my body but defense is looking at what we call the four henchmen i got this from peter atia you know looking at the if you’re going to something bad is going to happen it’s either going to be cardiovascular disease it’s going to be either that diabetes metabolic syndrome it could be a cancer right uh or it could be neurodegenerative right there’s other ways that can get you so what we do something very silly we wait till we get the problem and then we treat i know i have a heart attack and now i’m going to go ahead and figure out how i’m going to improve my cardiovascular health right i’m going to wait till i get diabetes and then i’m going to try to improve my diabetes no the name of the game is prevention so prevention on the over here on these and then also on this side trying to go offense and defense at the same time very important and so we go hard on the patients you know we look at cardiovascular risk we look at apo b we could lp little a we look at their cholesterol levels um i look at apo e for neurodegenerative so you can look at that as well right you can look at um insulin levels in these patients so we go very hard on cancer screens as well um i like using the grail as well it helps me understand what else this patient could have yeah i was i would you know we had lunch the other day my husband was there it was it was great we were talking about what you were doing in your practice you mentioned the grail yeah uh which is fantastic and also um scans whether it was a pranova scan or ct yeah you are the first urologist that i’ve ever heard doing this um i think it’s important right because the name of the game is prevention right if i can catch something today why wouldn’t i i would only do what i do for myself so a scan so you can get an mri full body scan although it’s sometimes hard to get you can get a cat scan but some type of imaging again this is not standard of care it’s something that i think i offer my patients it’s progressive and it’s as you say offense it’s offense right i want to know what’s going on before it happens right and i think that that’s very important so we use the grail as well i think it’s very helpful to tell it’s 50 cancers that you may be missing that you can’t pick up today um so these are all things i can do this uh for cancer prevention right so focusing on the cancer the cardiovascular the metabolic the neurogenetic those are the four categories because again if you are going to die those are the four ways i can get you besides having a a car wreck or a plane crash but these are the four if you know that you would go heavy on those four and preventing those four from happening right and that to me is more the defense prevent find a way to prevent the offense is diet exercise sleep and stress reduction and when you put it together you got a great program you know you have a winning team what effect do you think that these drugs that back to the the weight management drugs have on sperm quality do you think that there’s any indirect or direct effect on sperm quality well we know some basics we know that patients who are healthier have better sperm quality that’s right survival of the fittest starwinism right healthier patients healthier people tend to have better sperm quality so i would assume and we’re doing the trial now that patients who lose weight would potentially have better sperm quality um and that’s what we’re studying right now so we’re looking at semen analyses in these patients um and we’re looking at testosterone levels in these patients and hormone levels uh and these patients uh to make sure that we see an improvement over time healthier people tend to be more fertile that’s just the way it is is infertility a big thing that you’re seeing so 15 percent of couples will have infertility it’s a lot we don’t talk about it 15 percent um and the majority of time 50 percent of the time uh it’s a it’s a female factor that’s true what percent time 50 percent of the time it’s a female factor 30 percent of the time it’s a male factor and then 20 percent of the time it’s both male and female so indirectly the males involve 50 percent of the time when they present for infertility but if you think about it and you know one out of seven or one out of eight couples will have problems with infertility that’s a lot of people it’s a lot it’s a lot of people and it’s emotionally really really devastating for people absolutely um what would you say if you were trying to preserve or increase fertility for men most important is lifestyle modification healthier men are more fertile period right so if you want to improve your fertility lose weight exercise alcohol consumption so remember that alcohol can actually cause damage to the testicles as well and typically when it’s about 40 grams of alcohol i was gonna ask you the yeah 40 grams so each drink that you take in alcohol is about 14 grams roughly so that that second drink probably okay that third drink is where you cross right so you want to watch the alcohol marijuana consumption so healthier people tend to be more fertile and so i tell men you want to become fertile exercise lose weight right less processed foods are very important as well right sleep remember that we men only make their testosterone when they sleep you don’t make you don’t sleep you don’t make your testosterone and endogenous testosterone is very important for sperm production let me repeat that so endogenous testosterone very important for sperm production exogenous testosterone makes you infertile right but endogenous so reversible yeah but reversible takes some time on average our study showed anywhere from three to seven months but we could do it three to seven months but there’s no guarantee that i can get you back to baseline right so i started out with 80 million sperm per milliliter i took testosterone i went down to zero and now i’m back to 30 million okay i have 30 million per ml but i’m not as fertile as i used to be but i am fertile right so just be very careful on the definition and for for men you know women go through menopause and then that’s it they they can’t have a child but for um men can they always produce sperm do they always produce sperm sperm production goes down as men age and we see that typically between 40 to 45 years of age you’ll start seeing a precipitous drop so it does go down uh so it’s not that you can always now there’s other ways to get the sperm i can always do a biopsy of the testicle and get the sperm if i need to if he’s not producing male fertility is pretty easy it’s only two things i gotta figure out it’s either they’re blocked yet or they’re not making it there’s only two options when i see these patients they’re blocked or not making it and so if they’re blocked i can unblock them if they had a vasectomy i can unblock the vasectomy right if they’re not making it it’s a little trickier so you have to figure out why they’re not making it what you can do to help them and many times you have to go in and do a biopsy of the testicle find the sperm i don’t need very many just need several yeah you know to one good one yeah get to one good one and um but again i tell the patients healthier people are more fertile i need you to focus on your quality and health very important and what about for women i think you focus primarily on men in your clinic when it comes to fertility do you work with women at all i work with women in the sense that i work with all the ivf centers here in houston and so when the couple are trying to conceive they’ll send me the male patient say hey we have an issue uh we can’t get this find the sperm he has no sperm on his ejaculate can you help us retrieve and that sense is where i work with the women for fertility do i work with women for female sexual dysfunction all the time all the time right but for fertility my main focus is improving the quality of the sperm and finding the sperm in these men um you know just uh circling back to women and sexual function you’d mentioned that their shpg goes up and both men and women right a male will and can always make testosterone and he can for example my dad my dad’s 74 he cringes every time i say it maybe he’s 73 we got his blood work done his total testosterone was 800 yeah his free testosterone was amazing and he again he’s an older gentleman who does all of the offensive pillars that you talk about for women and testosterone production does that always decline yeah so you bring up two important points the first one is that we were taught in residency in medical school of this concept called male menopause andro pause doesn’t exist it doesn’t exist i know it does not exist it doesn’t exist because what happens is as men get older aging alone doesn’t drop their testosterone level it’s the acquisition of comorbid conditions that drops their level so obesity fat cells eat up testosterone convert them to estrogen called aromatization right uh hiv aids hypertension all these conditions that you can acquire start dropping your T levels but if you look at healthy healthy 80 year old men they have normal testosterone levels it’s still in the normal range right so healthy men will maintain their testosterone but women are a little bit different so women will typically make 50 of their testosterone from the ovaries 50 from their adrenals and as she goes through menopause it’s a precipitous drop in her testosterone and her adrenals are starting to decline every year at 20 years of age so it is absolutely makes sense that her desire for sex goes down because the number one desire driver for sex in a woman is her testosterone level and at 55 years old when she’s post-menopausal there’s almost no testosterone so you can’t blame her for having low desire secondly she has vaginal atrophy she has pain so now she has no desire and she has pain within of course and you want to have sex all the time by felicia right so so come on but it’s not fair so if you improve the testosterone level if you use local vaginal estrogen therapy if you help her then it makes sense but to assume that a woman post-menopausal is going to want to have a great have a great libido doesn’t make a lot of sense yeah uh i absolutely agree with you you’d mentioned that there was a third drug we talked about testosterone we talked about addy and there was another drug yeah so there’s numerous drugs out there to help with low libido um addy uh was fda approved came out in 2015 um and was very very helpful and then the next drug is and you have to cut this because i just blinked what was it i had to do you use it yeah sometimes um it’s not addy because uh it is i’ll tell you in two seconds it is violecy violecy okay yeah yeah okay fine yeah um do you use so it’s violecy yeah it’s bremelanatide and it has no hormones and it goes to brain and it makes a woman really want to have sex wait what is this i knew this i mean a lot of sex and you can get it compounded so empower pharmacy makes it cheap she draws it up she injects the only side effectors and get nausea so we just great i’ll be ready to go but it’s totally fine so many women what they’ll do is they do it like in the afternoon because it affect last 12 14 hours okay okay wait and significantly increases orgasmic function of women okay time out yeah okay wait we gotta start over um okay i gotta hear because i’ve heard about melanitan too bremelanatide yeah what is it bremelanatide very similar yeah okay um right we talked about testosterone we talked about addy and there was another one it’s bremelanatide or violecy okay uh so this is fda approved also to significantly improve desire for sex and women so we have two drugs on the market one is called addy one is called violecy addy’s an oral pill that she takes every day violecy is an injection she takes uh typically several hours before sex now violecy should be taken no more than eight times a month and um but she doesn’t have to take it every day both have different mechanisms of action but both significantly increase the desire for sex and women gosh i mean it just seems like a combination of one or two of these things would be amazing for women and not have to suffer yes um the testosterone for women you’d mentioned that women after menopause i know that there’s some concern i’m not sure how valid it is after a 10-year window not wanting to put people on estrogens what about testosterone yeah so there’s been no data suggests that testosterone increases any kind of um uh cancers or malignancies in women so the fear that we have with estrogen and progesterone is that we can get uh ovarian cancer and we can get other kinds of cancers but that’s not been shown with testosterone and testosterone has been used for decades in women with no really adverse events remember the concept of testosterone in these women replacement is to put the woman who is low back into the normal range it’s not rocket science we’re just going from low back into normal um and the effects that i see in women on testosterone tend to be greater than we see in men i mean the libido goes up her energy goes up her muscle mass goes up cognition goes up again realize that it’s off label in the united states so many years ago they would try to get it through with a drug called intrinsic it is used throughout the world and on label in different countries but it’s off label so what you use in a woman is one tenth what you use in a man that conversion is very important and go slow you don’t want the acne or the facial hair because you can get very upset so it’s very very slow very slow but but it is effective and that we let’s talk about other benefits bone mineral density yes i mean uh you know we talk about estrogens for women for bone but testosterone there are many studies showing that the combination of testosterone and estrogen for bone mineral density is better than just estrogen alone improving her bone mineral density her cognition her skin i mean we can go on and on and it’s just very fortunate that it’s not FDA approved for women now but you can use it off label you can use it off label but just go slow the just remember one tenth the dose is how you want to remember it that makes sense yeah um the

blood work that you do and we talked a lot about sex hormone binding globulin

sex hormone binding globulin and that testosterone for men the production doesn’t have to decline precipitously doesn’t have to be drastic but sex hormone binding globulin goes up as individuals age what can we do about that if anything um i have tried certain supplements it doesn’t really move the needle the question is if we give boron or if we give x y and z does it actually have a meaningful impact i haven’t found it yeah the way the way the best way to solve the problem is if your shpg is fixed just raise the total t yeah it’s a math formula right so essentially if you want to have a higher free testosterone raise the total t above what you need to have a higher free t and it works there are things that can lower the shpg but the benefit um with the amount of work you have to do is not worth it just raise the total t and you’ll get there um that’s very it seems like a very straightforward easy answer but um people still really really struggle yeah but look at don’t get fixated on um the uh shpg numbers the numbers how does she feel how does he feel you know that’s the most important part everyone’s like well my number is not high enough so i must not feel good so therefore i don’t feel good that’s why i never let them know their value first i say how do you feel right they say i feel better it’s it’s basically every person has their own cut point we all do and i just have to get above your cut point uh to get you to feel better and that’s all doable um i know that i i want to honor your time so i know that we’re running out of time but are there certain common misconceptions that you would love to clear up whether it’s through sexual health um just anything in your domain that really needs to be stated you know we talked about prostate cancer we talked about cardiovascular disease we talked about propetia finasteride these are all so meaningful yeah are there any misconceptions there’s several so first of all we know now that testosterone does not cause prostate cancer right for decades we were taught that testosterone causes prostate cancer that’s been put to rest now we know that testosterone does not increase the risk of a heart attack with the traverse trial finally people say if i take testosterone i’m going to get a heart attack so that’s been a misconception those are two big things that i think people should know i think that people should also know that uh ed is the first sign of a heart attack right huge that’s really important if you look at that you know there’s something called the arterial diameter theory as i mentioned earlier you will occlude the smallest arteries first right and so ed will precede cardiovascular disease in many cases and so um if a young man presents to you with ed and no other risk factors i get concerned that i may have a cult cardiovascular disease and if they have two risk factors i will send them for cardiac evaluation so just be cognizant that ed could be the first sign of a further problem particularly cardiovascular that’s a really important point and you even um mentioned about infertility and alcohol i think people fail to recognize that and then the impact of marijuana or other drugs yeah they can so people use these recreationally but they don’t realize that they can have a significant impact i’ve never seen a great study to say how much marijuana do you have to smoke to have damage to the testicles we do know that in alcohol studies it’s typically 40 grams right so that tells you if i have more than three drinks i’m going to start causing damage to my testicles meaning that i can impair not only my sperm production but my testosterone production as well right so just careful in moderation if you’re going to drink um but you know these are all what we call gonadotoxins just be very cognizant of the things that can cause damage to the testicular tissue what are you working on now let me rephrase that what are you not working on i’m kidding but uh you’re very prolific when it comes to publishing and exploring questions that are going to have a meaningful impact what’s on the horizon so we have a lot you know i have a basic science a lab and in the lab i have some amazing people in the lab um looking at something called the cag repeat so we’re looking at something called the sensitivity of the androgen receptor and we talked about this earlier we found that those patients who have who come in and i raise their testosterone to 800 and they say doctor i still have symptoms maybe there’s something genetic going on why they still have symptoms and if you check the cag repeat if it’s long 27 28 it explains that these patients may need more testosterone to get symptomatic improvements we’re looking very very closely at that we’re still looking at shockwave therapy i think that you know there’s we didn’t talk about treatments for ed but some of the cool things we should let’s let’s talk about it you have time yeah so some of it so my favorite way to treat ed yes is lifestyle modifications let’s be clear okay i say look don’t go for the pill uh go for the diet exercise sleep and stress reduction how fast how fast will you see a change you think from erectile it depends on how quickly someone is willing to put in the lifestyle modification changes right but we can see them over the course of six to twelve months if patients want to commit uh there was a wonderful store by esposito she did a wonderful study randomized controlled trial two years lifestyle modification or no lifestyle modification in 110 obese men 55 in each arm she followed them for two years this was in jama and with lifestyle modification and weight loss they saw a significant increase in erectile function without pills i mean this is just yeah just without pills so i say look uh the the best way to do this is to lifestyle modification because it’s not just directions your overall health is going to improve unfortunately most men say just give me the pill right i say fine all right but but lifestyle modification makes a big difference so but you know the the key is here that if you can do the lifestyle modification most patients if they stick with it i see numerous other benefits as well and then the shockwave therapy does that shockwave therapy is blooming so essentially when i first saw this this came out in 2010 by a gentleman named dr vardy in europe and what he was doing was he was taking a device it’s a shockwave device essentially and shocking the penis it’s basically like a pulse electrical pulse what he showed was in those patients that got shockwave they were seeing improvements in erectile function now i’ll be honest with you when i first saw this i thought it was ridiculous it made no sense to me but it’s actually brilliant because what you’re doing is you’re tricking the body and you’re inducing a trauma state and when the body sees trauma the body is an unbelievable healer unbelievable healer so you’re telling the body i have trauma in the penis and what he showed in that study was that those patients who did the shockwave saw a significant improvement in erectile function since then there’s been a boom in the united states everywhere you look there’s shockwave devices and for for women too there have been also for women for sexual dysfunction for many causes but for sexual dysfunction and it makes sense this actually came out in the cardiac literature before it came out in the urologic literature and they’re still doing where they’ll use shockwave on the heart induced trauma and you get neoangiogenesis and blood vessels within the coronaries so we use it now in for you know for for ed but you have to be careful there’s different classes of drugs there’s class one some class three class one do nothing they’re pneumatic they don’t do anything but they make a click and so patients hear it and it’s a big business it’s anywhere from 500 to a thousand dollars of treatment and if you buy a class one drug anyone can buy a machine anyone can buy it and so you have to be careful because they don’t really do anything at all and if you treat someone for six treatments and they pay six thousand that’s very expensive it’s very expensive there’s a placebo effect is it 30 percent 30 to 40 percent is it really how’d you know that yeah it’s 30 40 percent with this drug thing so so 30 to 40 percent of patients who get the class one machine will say i’ve got the best directions i’ve ever had in my life it’s a placebo effect right but the class three ones are regulated and those machines have been shown to have efficacy in improving sexual function so using the right type of machine these are called electromagnetic electrohydraulic they’re very good machines and remember that not everyone sees improvement so remember that you know a lot of patients will i think mild to moderate see the most improvement but not everyone will because ed is multi-factorial there could be a second genic cause there’ll be a lot of other factors going on as well but right now those are not covered by insurance so it’s a cash business do you think they’re effective i do think they’re effective if you’re using the right machine and the right patient right the right machine and the right patient if you’re losing a class the electro hydraulic electromagnetic if you have patients with mild or moderate ed they don’t have significant fibrosis and scarring then you have a better shot but would it be it’s not necessarily correcting the underlying cause i mean again there’s it’s multi-factorial it’s multi-factorial but it’s improving the quality of the tissue and that’s really important because you’re bringing in new blood vessels into that penile tissue you’re improving the cause so basically the body is one of the best healers if i cause any trauma to your body your body can heal it it’s pretty clever except when it’s gone to the state of fibrosis if the penile tissue is completely fibrotic i can’t get you from scar back to normal tissue but if they’re not fibrotic you can actually reverse the ed process by using these now there’s stem cells that have out there we had the first stem cell trial in the united states for ed using a this trial was though using a FDA approved machine and we did find that there was some benefit in ed but it wasn’t sustained it was only about six months so unfortunately there’s not a randomized placebo control study with stem cells for ed yet yeah and that’s sad because that’s an easy study right but there’s not a randomized placebo there’s a lot of randomized placebo control trials for shockwave showing benefit and the last one is PRP so platelets is the third realm there have been a few studies suggesting that may be beneficial a recent one out of the university of miami showing no benefit at all so again be careful because a lot of these treatments are cash and you just have to be very careful because this is a very vulnerable population and they’re willing to pay the money so you just got to be careful and um i just thought about this as you were talking does the penile tissue atrophy it does with non-use for sure like any muscle and so where do you see the most atrophy in men typically around 52 years of age why 52 that’s an odd number it’s because that’s when women go through menopause right so as she goes through menopause and they stop engaging in sexual activity he will see more and more atrophy of the penile tissue he’ll develop something called venous leak so now the blood will come out faster than it goes in and so once you get venous leak then it’s harder to get an erection so really important to keep the penile tissue healthy as we get older do you think educating on this if you were to wave a magic wand

do you feel like your contribution would be to educate on this much earlier absolutely because as you stop using the penile tissue you can start developing fibrosis and scarring which i cannot reverse right so you want to keep the tissue as healthy as long as possible maybe you’re not having sex today maybe you’re not but maybe you will want to have sex in five years and if you don’t keep the penile tissue healthy today you won’t be able to have sex in five years so it’s really important to keep the tissue healthy yes well um that gave listeners a free pass to have lots of sex and they are very excited and hopefully have a great and willing partner dr mojicara thank you so much i encourage everybody listening to follow you i will include all of the links you are doing extraordinary work the world is so lucky to have you you’re too kind thank you