[Music] all right team today's guest is Dr Peter AA he's a Stanford John Hopkins NIH trained physician who focuses on the applied science of longevity the extension of human life and well-being now his podcast is called the drive and it features topics including exercise nutritional biochemistry cardiovascular disease Alzheimer's disease cancer mental health and so much more and if you've been living under a rock that would probably be the only way you you haven't heard about or read his book outlived today he's joining us to talk about testosterone replacement therapy so ladies get your husbands get your brothers get your boyfriends in the room your dads men who approach me on the street in the elevator at work what do I think what do I think of trt well I got you the foremost expert on the subject matter drti is about to educate and power get excited keeping it real with Jillian Michaels welcome so great to have you here in person Dr AA so great to be here but I like I like Peter I know you say that and I I can't though can't do it yeah you got to do it but you're like the most accomplished sort of well-respected doctor in the country at the moment I don't think that's true but I still like Peter really okay well Dr Peter Peter Peter okay um so why this happens to me I don't know maybe because I get to speak to people like yourself on a daily basis I get questions mostly from men I can't figure out why they're asking me this I I don't know what it says about me about testosterone replacement and I find it funny I guess because it's I'm such an unlikely person to ask I would hope and I know nothing about it because it's not something I go through personally so if I can speak in an educated fashion it's CU I had something personal go on with it and then I sought out the information and I can usually say hey explore this explore that ask your doctor about ABC or D and generally the experts I get on I ask questions about things that I personally want to know about I can be sitting in a chair this was the this was the last draw on top of my producers here on the show uh my business partner ask me questions who's a man you just met I was sitting in the chair at Fox and Friends and one of the anchors was like what do you think about testosterone replacement and I was like I think you got the wrong guest so I need I have crowdsourced about a million questions for you and I apologize in advance I am under the impression that all jokes aside that we have a major crisis with guys in their testosterone levels right now and I've heard statistics that um okay 30-year-olds today have the same testosterone levels as a 60-year-old man did 30 years ago is this blown out of proportion do we have new information now that we're just testing more people or is this in fact an epidemic a crisis so it is true um to tone is lower today age per age than it was in the past um I can't speak to that exact statistic but I can tell you that um a 30-year-old man today has the the average 30-year old man today has the same testosterone as the average 50y old did prior to about 2,000 so it's certainly that statistic is plausible which is a little more extreme given that it's a longer period of time so it's a problem it's obviously something's going on then right yeah and I think the most probably the best explanation honestly has to do with body weight really yeah so um and it's not body weight it's fat Mass I didn't think you were going to say that at all I thought you were going to tell me like microplastics or something no it's most likely the most the most obvious candidate is is body weight right so as body weight and body fat go up uh men tend to aromatize more testosterone so they turn testosterone into estrogen more and as you do that two things are happening one is you're um you're obviously siphoning off your testosterone but estrogen also then increases the level of a a a protein called sex hormone binding globulin right that binds most of your testosterone so that really the only testosterone that is having its effect is the Unbound part of that so if you have a pool of a 100 units of testosterone somewhere between 97 and 98 of them gets stuck to this binding globulin and another one called albumin and the only thing that matters is the two or three that are not bound right so as you make more of that binding globulin and deplete your testosterone because you're making more estrogen all those things are going to drive to kind of a lower testosterone level and I think that that is probably the most likely explanation for what's happened over the past 50 years which is not to say there aren't other things that could be doing it um if I were going to point to a second thing I would probably point to the erosion of sleep um Quality sleep because we make these hormones when we sleep so if you're not getting high quality deep sleep you're not your brain pituitary in particular isn't making the hormones that tell your testes not your testes my testes to make more testosterone um so I want can you tell me first of all what are symptoms of low testosterone what does this look like for a man how do they know that they're experiencing it how do you not confuse it with something else if you're like well it's fatigue you know be anything no it's it so there's no clear diagnosis it's not like how do you diagnose high blood pressure or how do you diagnose diabetes where it's very clear and it's black and white and those things tend to be black and white because you use signs signs are objective things you measure symptoms are not symptoms are subjective so in that sense we have to look at the signs which are the numbers so the lower the testosterone level the more likely you would say that a person is is you know at risk of being what we call hypogonadal um okay that's kind of like hyp so hypothyroid I know about because it was some so so meaning the gonads aren't they're under functioning right that's just a technical name for low te is hypogonadal understood and um and so what are the symptoms right so so in a guy the most common symptoms would be low libido low sex drive okay uh um low energy low mood low muscle mass and poor recovery from workouts low energy sometimes even impaired sleep but now you can see it starts to get a little circular because lousy sleep can be causing the problem so if I were to sort of look at my patients who who are indeed hypogonadal and then who respond favorably to testosterone I would say the most common things that we see are going to be low sex drive uh low recovery from exercise and just overall low affect low mood but you know look there are lots of other things that can result in like well you know it depends on my day yeah it it's you you go through a stressful period or things are going wrong or a lot honestly situational would cause all that for me but it would be not that I again hold actually I want to go back to the part where you said in men yeah that threw me off what do you what is this look like in women I've never I've didn't even act it never crossed my mind yeah so contrary to popular belief women have far more testosterone in their body than estrogen uh about 10 times more actually so your your testosterone levels are 10 times higher than your estrogen levels okay they're still lower than mine they're on Tenth of my testosterone levels but the point is testosterone is still a really important uh sex hormone in women then why are we not talking about low testosterone and women then if it's the predominant sex hormone from what I'm taking away yeah because I mean I still think that most of the female characteristics are driven by estrogen and progesterone and so it when we do talk about hormone replacement therapy in women 80 to 90% of that should be about estrogen and progesterone but we do replace testosterone in women as well um and in that sense it's almost exclusively due to two things low libido hands down Far and Away the number one reason we would replace testosterone in a woman in a woman and then also uh and by the way all of this is in the context of low measurable testosterone so if a woman has normal testosterone and low libido we're not going to give her testosterone to androgenized her and make her more masculine right it's you you you you you measure low testosterone and on top of that you see you know she's saying look I my desire to have sex is non-existent it's been that way for you know years um and then that that might be sufficient enough reason to use testosterone but other other things would be also kind of real difficulty putting on muscle mass got it so all right now what if I have low testosterone but I don't have symptoms should I still take it supplementally are there any long-term dangers to low testosterone and is there a threshold for too low so I kind of thought obviously this is crowdsource question but I don't fully understand the free te the can you explain the blood work numbers I thought we could start with that so people even know what they're supposed to tests they're supposed to ask for what the numbers are supposed to be what the like TSH free I don't get it yeah so um when we do it we're going to look at everything so we want to see total testosterone okay free testosterone I'll explain what that is okay FSH which is follicle stimulating hormone LH which is luteinizing hormone estradiol we always want to check estrogen levels in men as well I thought you were talking about follicle stimulating hormone you can check in only women though correct oh men what follicle no FSH and LH men and women have the exact same hormone but for men the follicle is basically the sperm right oh my God I thought it was like when the ovary produces it that's what it's doing in wom idea so both so again we so we go back an idiot I swear to God I just this a girl thing if we go to the very very top um in the in the brain you have something called the hypothalamus yes okay the hypothalamus makes a hormone called gonadotropin releasing hormone it makes that hormone that's the master regulator it makes that hormone in response to how much estrogen it senses and a little bit and women got it yep so so if you have so it's a feedback loop so if estrogen is high or testosterone is high the hypothalamus makes not very much gonadotropin releasing hormone okay so when it makes abundant amounts of G&R it signals to the pituitary also in the brain to make two more hormones lutenizing hormone and follicle stimulating hormone LH and FSH okay those two hormones signal to the testes to make testosterone wow now there's more Nuance to it because when you talk about spermatogenesis which is the creation of sperm you actually have two slightly different responses to the LH and the FSH because they're hitting different cells so they're hitting different cells within the testes but for the purposes of um testosterone production you can just think of it as both LH and FSH stimulate the production of testosterone in response to the pituitary saying go ahead and do this in response to the hypothalamus telling them to do it now we can't measure GNR okay so what so we can't go that far Upstream but we can measure LH and FSH which tells you if there's a problem that so so yeah the first question you're trying to and that's why I'm sort of opposed to let's just measure everybody's testosterone and think we know the answer because if testosterone is low you still have a fundamental question to answer which is is it low because the testes can't make it that's called primary hypogonadism or is it low because the brain is not telling the testes to make it that's called secondary hypogonadism got it okay so so what numbers are the most important out of all those hormones because it's like like you said you could have X amount of testosterone but if it's bound up yeah only a few or effective um I don't want to forget to ask you like how you know which one which of the two so I I want to make a note uh okay so now I'm at the doctor and what numbers do I want to see yeah so the part of the problem here is again the the the physiology here is much more complicated than most doctors appreciate so first of all there's another variable involved which is we don't so so there's something else we can't measure that's the most important thing of this whole thing but we can't measure it and it is what is the saturation of testosterone on What's called the Androgen receptor okay so when we just take a step back what's a hormone a hormone is a molecule that binds to a receptor and creates a downstream effect physiologically right I that's not the technical definition but just so people understand like what does testost appreciate the the L term that we need that here yeah so so what testosterone does in spe in particular is it enters a cell it goes into the nucleus of the cell where DNA is it binds to something called an androgen receptor and when it binds to the Androgen receptor it's a transcription Factor so you know when people say like well how does testosterone make you stronger give you bigger muscles it does so by driving DNA transer destion right tells the DNA to do XY or Z right so that's why if you give a person c yeah but and if you give a person testosterone and they sit on a couch they're not going to get bigger and stronger they have to be in the gym nothing's going to happen nothing going Happ it's only going to respond to the stimulus and what it does is it heals quicker and quicker and quicker so as much as we love to bash on the athletes that cheat by using testosterone you have to understand like the only thing that testosterone did was enable them to train a lot harder and recover much quicker but it's doing it through this testosterone Androgen receptor or t complex now we can't measure how many Androgen receptors we have so oh my God so somebody could arguably seemingly have low testosterone however their receptors are extremely effective so they may have no symptoms and need no replacement therapy and go even one step further from that you can take two people with the same testosterone level one of them has relatively few endogen receptors one of them has many the person with few is already saturated meaning all's going to be like chill out which might and by the way if you if you give them more testosterone you'll raise their testosterone but you won't change anything because you have nowhere else to put it whereas this person over here who has low testosterone has lots of Androgen receptors they are not saturated when you give them more testosterone their testosterone goes up but more importantly you have more testosterone that has now bound to the Androgen receptor and they actually reap the benefits okay so all of this is to say it's a kind of empirical process you know you can be as scientific and wonky as you want and I certainly like to be but at the end of the day sometimes you got to bite the bullet and say dude your testosterone is 300 nanograms per deciliter which is really low that's like you know for a guy my age that would be about the 10th to 20th percentile okay and your free testosterone is appropriate or equivalently low meaning it's about 2% of that so it's 6 nanog per deciliter um you are describing a whole bunch of symptoms that seem to line up with hypogonadism why don't we figure out the right way to replace you which we can talk about and in three months let's re-evaluate when you have higher testosterone do you feel better and if the answer is you know doc I don't feel any different then I would say it's probably not worth being on testosterone conversely if after you know three months he you know his testosterone goes from 300 up to 900 and his free te has a commensurate increase from 6 to 18 and he says not bound testosterone that is able to get into so that's what that means that free te I'm with you which is estimated not measured we can talk about that if you want God how annoying there's a mathematical formula to estimate free tea based on the concentration of testosterone estrogen sexor binding globulin and albumin so so if that guy says oh my God like I wake up with morning erections now I want to have sex again I'm crushing my workouts my mood is better we would say bingo let's stay the course that was worth it got it I got it can you I didn't fully answer your question which is if you were asymptomatic and low what should you do and I would say um my general want is to do nothing but occasion Al continue to probe and find out are you sure you're you know what's your how's your muscle mass how are your workouts are you getting stronger any of those things and if and if we're kind of ambivalent I would say let's just do a trial and see how you feel and be quick to eliminate it if if you're not feeling demonstrably significantly obviously better okay um you had also said forgive me that there were two things that could be happening um one is the the brain's not signaling to make the hormone and the other one is the the testes themselves are not making aren't capable of doing it can you figure out which one this is yeah now not always from the blood test but you can absolutely figure it out with your treatment so if um if I suspect that the problem is in the um in the hypothalamus and the pituitary somewhere in there I actually like to use um a hormone that tells that mimics LH okay and that hormone is called HCG which I'm sure you've heard of right yes so so just as women would use HCG as part of a an IVF cycle you can give men the exact same hormone because HCG is a mimetic of lutenizing hormone and one of two things is going to happen in the presence of HCG they're going to just start making tons of testosterone in which case you know the problem was here or they're going to have no response to it in which case you know the problem isn't in the testes if it's in the testes is it a different course of treatment yes then you have to go with testosterone got it yeah okay and if it's not you would just do HCG instead well again it depends on the guy you know there there are drawbacks to HCG so first of all it's more expensive than testosterone testosterone's Dirt Cheap right it's like basically the price of tic taacs um HCG is pretty expensive you know it's a fancy peptide okay got it uh secondly testosterone is a is a is an oil so it's e it's it's easy like you it doesn't have to be in the fridge a guy can travel with it there's it's it's not sensitive if you shake it nothing happens for HCG none of that is true it's expensive it needs to be refrigerated if you drop the bottle by accident you got to throw it out so so there's a there there's a little bit more baggage associated with using HCG so it's not ideal yeah there's also two pills one is called chopine or Clomid I know this only from IVF yes of course and then the other is encline which is a derivative of Clomid and they do something even different they block the estrogen receptor on the hypothalamus so what if you go back to the top of the the the thing if your hypothalamus can't see estrogen it says oh I need to make more testosterone to get more estrogen so it's another indirect trick it's a hack to tell the hypothalamus to make more gonadotropin releasing hormone to tell the pituitary to make more LH and FSH I am personally not a fan of these we do use it occasionally so much new on like does the regular do I'm jump no forget it hold on the obviously a regular doctor is not going to be able to determine this kind of nuance what kind of doctor should they be taking this information to a urologist yeah a really good urologist who specializes in trt is going to be a great person to help with this they're going to know the ins and outs of when is this one when is this the right treatment when is this the right treatment and and and and they're also going to be able to monitor for the side effects we haven't talked about that which but I'm sure you questions about that yeah so so you know you also want somebody who gets what the side effects are and knows how to manage them guys how often do you buy skincare products because they're labeled as clean or organic paraben free only to find out that there are aund other toxic ingredients in them that are damaging your skin your body your health and why is it so hard to find skincare products that are truly USDA certified organic well you know what the Search is Over okay Purity Woods has you covered I love these products they smell amazing my skin looks great they're easy to travel with and you don't have to worry and read every single thing on the label because you have an umbrella of Wellness you're covered all organic all clean Purity Wood's mission is to provide people with the cleanest most effective healthy aging and Longevity products available all their products are USDA certified organic non GMO free of anything artificial free of toxic preservatives and synthetic additives like pesticides chemical fertilizers dyes parabens and of course it's qualty free never tested on animals so guys turn back time on the appearance of your skin with Purity Woods aged defying dream cream Purity Woods is currently offering 177% off sitewide but we get an additional 10% discount for our listeners for total Savings of 27% just go to Purity woods.com Jillian or enter Jillian a checkout so for an additional 10% off your first order that's Purity woods.com p r i Ty y WOD ds.com enter the code Jillian for a total of 27% off your first order one of the things that I love so much about the way you practice medicine is so you know there are people that are just like well there's no evidence to Sugg just it doesn't whereas you know doctors like yourself look at the body as a complex system obviously and you're like well okay you know if if one plus 1 equals 2 surely we should be mindful of and I I think that's why people like yourself are so special because they allow and Empower regular people who aren't doctors to think things through and use their common sense and have an educated decision with the doctor that may not think the way you you do and I I don't ever want to undermine doctors but I talk to a lot of them and you guys don't all put your pants on the same way you know what I mean I don't even have pants on right now so for sure that's definitely true it's just there's a vast Divergence which you would see in any profession but when it comes to living dying the quality of your life that Divergence is pretty significant you know um and so I I just I love you so much for taking the time to explain that and and spelling it out for people and you're like well you know I just want to throw it out there but it's it's massively significant for for reasons that would would be ultimately potentially common sense to be concerned about um okay so if somebody is there's another one I'm 49 I'm doing everything right I exercise I eat well I have good sleep habits my uh testosterone is 362 with a free te of 5.4 and the question is I'm doing all these things right what could potentially be well I'm glad that the person asking the question called out something that I probably should have said earlier which is our first line is not to try any of these hormones it's to go back and do the basic blocking and tackling which is are you eating like [ __ ] um are you sleeping are you you know so like what are the things that are going to impair you are Define I'm sorry can you define eating like [ __ ] is eating like [ __ ] avocados and cashews but like three times as much as you should be eating so you're putting on body weight or you're not over eating but you're eating Diet Coke or you're what are you both of those I think would constitute poor eating right so I think I think first and foremost yeah anything that's in putting you in energy imbalance where you're gaining fat mass is going to be problematic got it but also just eating you know processed garbage food even if you're eating it at modest amounts okay I think the two things that probably have the greatest impact on the pituitary side of the equation are going to be poor sleep because again if you're not getting deep sleep you're going to have a hard time with that thing that I described about the making the hormones and then the second thing and I think in me personally this is the greatest detriment to to my low testosterone levels or the greatest driver of them is actually just cortisol so hypercortisolemia really yours yours I've always had super low tea okay so then what are your symptoms um yeah low libido kind of like blah mood okay but I I know a lot about you so so I mean you're you're ripped you're a and you're an Uber achiever um if you said mood you know you you've talked about kind of like struggling with with certain issues which is a different show you can listen to you know different shows of people but you've you've had a journey you know to become who you are do you think it's that then because not necessarily I mean I would say I would say that um that that you know in me personally it's not like in in well let me back up for a minute because I when I look at you a day I must have missed that episode of the drive well no actually so so six months ago I started taking HCG so I was my testosterone levels were actually about 300 nanograms per deciliter with a free tea of about five so that's like about the fifth to 10th percentile and I was like you know what let me do the experiment so in other words like I'm not I I I I sleep really well I eat well I do all of that stuff my stress could be lower or and or I could manage it better but I kind of gave up on figuring out a way to like make cortisol vanish in my life so I was like all right I'm going to first try HCG and see is the problem here or there and it worked I mean within 3 months my testosterone went from 300 to 900 and my free went from like 5 to 16 so now I'm probably at the 80th percentile for my age that's incredible but it was stress you're saying I that's my only conclusion so he we answered the first question was the problem here or was it it was primary it was primary brain sorry sorry I'm sorry it was secondary oh my okay I'm with you brain not test that's what we're following and and more importantly after my testosterone normalized I just I did feel so much better really oh my God yeah I just felt so much better so much less irritable so much more chipper um you know felt great in the gym um I haven't done a dexa scan in the last six months so I it's it's hard for me to say if I've put on muscle mass maybe I have a little bit I'm not sure okay um so it's stress I think in my case that's my that's my conclusion why was my testosterone 300 when I clearly have the potential to be at 800 or 900 what's Too High by the way well it depends um I would you know again we don't really know is a short answer but we know what the 90th and 99th percentile is and we know we know what the numbers are so so kind of 99th percentile would be about like 1,200 wow yeah that seems super hot but you know I've also spent a lot of time around bodybuilders and I am endlessly interested in hearing their crazy regimens for insane amounts of test testosterone use and um just to give you some perspective if I wanted to get my testosterone level to from 300 to 8 or 900 using testosterone right I would probably be using 80 to 100 milligrams of testosterone a week okay okay bodybuilders are routinely taking a th000 milligrams a week so so it's like you know you're just getting so so well that's you know one we call Super phys What's the diff is that not steroids though like what is one of the question testosterone is a steroid so is this steroid use um do you know what I'm saying like you know how like oh Schwarzenegger did steroids so so did steroids like is this I would there's such a stigma to that though well this is medicine yeah no Ian it's all the same [ __ ] well it depends on what you're trying to identify so if I were still competing in like Master's cycling and swimming I technically wouldn't be I mean I guess I would have to to technically get a medical use exemption because HCG is a water usada ban drug full stop really absolutely I mean so is DHEA by the way which does nothing to your testosterone if you're a man so it's like that's a low bar but the point is okay I couldn't be I couldn't be a professional athlete using this technically really got it correct okay so testosterone is an anabolic steroid HCG is not an anabolic steroid clomin is not an anabolic steroid but they are drugs that increase your testosterone and therefore they would be banned by W and us okay now when bodybuilders and athletes are using quote unquote steroids they are generally using far more sophisticated drugs than just testosterone yeah CU like why do I hear Winstrol and anavar I mean I've heard this for 20 years kicking around G 30 years kicking around gyms in La I never paid attention to it because the truth of the matter is and you we'll talk about this in in a female second but I you once made a joke and and when we did our podcast together um first time and you go you know I love the way people kind of like they they they fall into this accidental muscle growth and these women are afraid to live but I do get big like a dude and I'm this tall and I was like and I was like that's me like I'm the one that unfortunately can be very masculine very easily so I like I don't even want to touch creatin even though everyone's like it's to it's so good for you I'm like no thanks I'm 5 foot nothing and I can look like a dude in 5 seconds so I know nothing about it but for years yeah so so there are lots of other synthetic steroids that um come with various improvements on the original right testosterone is the original there's actually two Originals testosterone and dihydrotestosterone DHT those are the two we naturally make got it dihydrotestosterone has the notable advantage of being far far far greater in its binding Affinity to the Androgen receptor so it's much more potent has the drawback of doing a couple of things guys don't like one it hair loss and two it increases the size of the prostate because again it has that much much higher affinity for the Androgen receptor got it so we can park it as an aside one of the things that some people advocate for doing when giving testosterone is also giving a medication to block the transition or the pathway from turning testosterone into five into DHT via an enzyme comp 5 Al redu my dermatologist put me on spironolactone to to block that yeah spirolactone is different no spaone is fantastic in women um because women are more willing to take the hit of androgens can't give it to men because it is so anti-androgenic wow soy wouldn't take it because it's going to tank his testosterone okay okay well then I want to get into like that but the other drugs that you mentioned if you're talking about about cazol andand testosterone I don't understand well so again these these and this is like a super human you know oh well on testosterone Joel we can only get this big but on this you can turn into a Mac Truck well it's just it's just what what's the what's the how are you hitting the receptor profile and and and so for example like oxandrolone has a big Advantage for athletes right I mean again it has no clinical use okay but for an athlete it does what an what alxander loone does is disproportionately increase strength to size oh think about that what athlete doesn't want to be stronger without getting heavier think about track and field think about cycling think about swimming that's a great drug if that's the way you want to cheat understand I see what you're saying okay so so there testosterone is also very it's it's very androgenic and very anabolic those are two different properties of what that means by the way androgenic and anabolic anabolic is growth that's what most people think of Muses right but androgenic is more mascul masculinizing right and they're separate of course I guess they're related but they're separate and so you can tweak the hormones more in the direction of one or the other and obviously testosterone being the base you know natural hormone is is pretty significant in both but you can move to hormones that are much more anabolic and much less endogenizing and so um in the in the world of synthetic hormones which really doesn't factor into medicine outside of AIDS and burn victims where we do and when I say we I don't do this but but doctors who are doing that will use some of these synthetic hormones to really try to boost and and by the way it's a lot less relevant now because the drugs that we use to treat people with HIV are so good that we just don't see the number of people that are decaying into you know really really AIDS wasting stuff but in the 80s and 90s was on all these like HCG HGH sorry tons of stanazolol a drug and their stomachs would swell and it like was something to do with it okay got it I I understand um so can is it also safe just to wrap up this synthetic hormone piece is it safe to assume the side effects of things like that would be far more concerning than the side effects some trt well I mean truthfully we have less of an understanding because it's less studied really right so we know so much about testosterone because it's an FDA approved drug FDA approved hormone we it's been around since the 50s and there are tons and tons and tons of studies like we can we can speak out the Wazoo about what's the relationship between exogenous testosterone meaning testosterone you give and prostate cancer heart disease disas acne hair get get to all don't get to that I got all of those question by side effect question so and we know it because we can we've done all the experiments but when it comes to these synthetic hormones that have really Niche uses we don't we certainly don't know in a broad population now I will say this I am almost positive that the FDA somewhat recently actually banned the sale of oxandrolone so I don't even know if oxandrolone is legally available um again that doesn't concern a lot of people who use these things illegally um but you know my two cents which is not just a public service announcement I think it is absolutely crazy to be taking any of these hormones in a in a manner that is not purely medically supervised I mean it just strikes me as uh playing with total fire and and I you just you do not want a guy in a gym managing your hormone regimen and but you know how often that happens no sadly it is you know how often and I think that's a it's a little bit of a um it's a bit of a failure on the part of the medical community for not explaining why that's problematic and where where I get worried is when I hear about these 30-year-old guys I see I got a 34y old brother all of his friends yeah and they don't understand the sterility risk which is once you start taking testosterone for a couple of years you may never get off it and you may never be able to have kids so you know I I just got asked oh if few months ago by the son of a friend of mine so he's 24 yeah and he's like man Instagram body you know you know just finished finished foot you know played football in college he's out and he's like look I've never taken a single drug in my life but I'm really thinking like should I be taking testosterone and I was like no are you freaking kidding me dude you're already jacked like do you even understand the longterm seli of taking this at as a 24-year-old I mean it is an absolutely crazy thing to do but I feel glad that he could call me and ask me that yes and kind of go around his his you know his dad maybe but um but I worry about the number of guys that in that situation would be like well I mean bro looks good tons tons and I and I blame Instagram and you know I didn't mention this part but I told you all these men ask me these questions these these kids who are friends with my brother that are like 30 to 34 or my you know my little engineer Jake who's same age range all their friends are doing it because the you know the the Bros on Instagram and I'm like guys I mean Common Sense will dictate it's a bad idea but you know to hear it from you they don't see it though they just see some guy who looks amazing and is stronger than them and the chicks think it's hotter and then they're just kind of like well why not and I I don't even know I'm like I don't know just common sense let's talk side effects then you know we've kind of alluded to them and this is everyone's biggest concern right because now if you're saying well listen hey you know you might be at whatever 362 and you don't have symptoms and maybe those receptors are doing amazing but I I'm still thinking to myself if I'm at 362 what does 900 look like yeah so I mean I've wondered this about as a girl I'm like well should I be doing this like I don't think I have problems but but everybody in my age is doing it so I can only imagine any human being would be looking for the up button especially those of us who are interested in health I mean I I look at you and you you are all the way out there you're like and I tried this and then I and then I just wanted to see if I could beat the keto with performance I mean people who are into Health tend to constantly look for an up button yeah what is the downside of this is there one yeah you always have to be mindful of certain things so I always like to try to make sure people understand the difference between physiologic testosterone replacement and uh non-physiologic testosterone replacement physiologic is what doctors should be doing you're deficient it's what we it's creating symptoms right you're 300 we're going to make you 900 we might use h CG we might just give you testosterone we might you know even use some of these other things great um in that realm the amount of symptoms I see are virtually non-existent but they boil down to the following you will occasionally see acne okay but it's usually in a person who had a lot of acne growing up so it's a person who just has the type of skin that is particularly prone to acne this is true in men and women for physiologic replacement that's the only reason I I try to block DH acne yeah um if a guy is genetically susceptible to hair loss and you're letting his DHD go up he's going to experience an acceleration of hair loss gotad um I can honestly tell you they want to know about heart attacks yes okay we'll talk about heart attack Ian the one of the gentlemen who submitted a question was like I do not want my balls to shrink like okay I'll ask about your shrinking balls we'll get to that um blood pressure in a susceptible man will also go up about 3 to Five Points all measurable though I mean nothing life-threatening we're not going to drop dead of a heart attack right but that said if I have a guy who is very very high risk for cardiovascular disease I'm going to be very gentle in how much testosterone I give him and I'm going to make sure I don't tolerate any increase in blood pressure you explain this connection like Kimbo Slice right just Beast I don't know anything about them okay does a monster Street Fighter just a beast of a dude a nice guy from what I knew of but you next thing you know drops dead of a heart attack a testosterone testosterone no idea he's definitely on [ __ ] maybe the artificial [ __ ] you're say but you hear it a lot right and then you're like well if I have a guy that has a risk of this I'm keeping a close eye on what's the connection I don't get what does testosterone have to do with heart disease um well I guess the bigger so so testosterone does slightly lower HDL cholesterol that doesn't play any causal role in heart disease so I'm not convinced that that plays any role I think that um the the slight increase in blood pressure again if you're a guy who's that close to the edge of the cliff can play a little bit of a role again it's all in the it's all in the it's all in the margins right this is not something that most guys need to be worried about now let's talk about everyone talks about it though Peter I swear to God well again you know it's like oh he was on testosterone even like hate to say this but even the the the guy that I worked with on Biggest Loser people would come up to and be like well you know was he on was was he on testosterone sure sure but we so first of all if it's the Biggest Loser guy he had an elevated LP little a this is well documented so there are lots of reasons why people have heart attacks testosterone replacement therapy is very low on the list furthermore this has been studied right we know it's kind of an urban legend then it is a very much an urban legend that testosterone does not increase the risk of heart attack there is one study that found the following it took a bunch of men who were you know modestly like sick these were not the healthiest Guys these are guys that were at reasonable risk of heart attacks to begin with put them on trt and what was interesting was within the first year of the study the men on trt had an increase a small but real statistically significant increase in the risk of heart attacks relative to the men on the placebo okay in the second year of the study but there was no mechanism for like I thought you were going to say they LDL went up or some [ __ ] no I again I think the mechanism is blood pressure it okay I understand I'm with you and then in the second year of the study the that difference vanished there was no difference between the groups and then by the third year of the study the men on the testosterone had a lower risk of heart disease the risk flipped so you're saying over time yeah over time the risk probably goes away but you're also probably weeding out the people who were the sickest early in the study got it wow that's that's my point which is like okay if if this is the cliff and you're here testosterone's probably really good so just stay here if you're here I kind of like to think twice before initiating trt that makes sense so you're taking all these different factors you're taking family history into place you're taking absolutely medical history I'm sorry into consideration yeah and also like I mean you know we have the technology to know how close a person is to the edge you're not going to do this in a clinical trial because it's too expensive but if you're literally talking to one patient you you know you could get a calcium scan on them which is a you know a couple hundred test and get a really good sense of what their risk is in addition to their lipids and their family history now to the testicular shrinkage absolutely correct this absolutely happens if you take testosterone with nothing else because the testes stop making testosterone else okay hold on sorry forgive me and just walk it back for one second so um I I I've often heard been concerned about and even like when you look at things like glp1 or whatever like well if you start taking it exogenously and get off it I would imagine that'd be one reason you might gain the weight back right your body might be like well I'm I'm getting this from the outside so I don't need to make it from the inside and you even explaining that whole process of the brain sensing it and then saying make it don't make it right so when you give a guy testosterone his FSH and LH will go to zero right because the brain's going oh it's good you have so much testosterone and estradiol that the hypothalamus says we have so much I'm going to stop sending the signal to the pituitary and there is literally unmeasurable levels of FSH and LH we call that full suppression okay this means I need to be on this for life or that comes back or we don't know depends how long you're on it the general why wouldn't I just stay on it forever yes I mean look it's again like not to sound like a jerk I think Dana White's been honest about this like I don't know how young Dana White is but if I'm 80 like why not yeah look is it what I tell a guy before we make that leap to actual testosterone is um let's be conservative and say that once you've been on this for one year that's very conservative it's probably two to three years but let's just say once you've been on this for one year you better be convinced you're willing to stay on it for life now again I think that's overly aggressive and very conservative but I just want to make sure that nobody's ever surprised like the poor guys in the gym who are taking this at 25 and then at 30 go I just got married I'd like to have kids and low lo and behold I can't now and you and this is the infertility piece because the the testies shrink up that's right they shrink up but they don't make sperm anymore correct at all yep wow you still make semen but you don't have the actual sperm okay so they still ejaculate right understood but there's nothing in there s so so you if you go on this you better be committed to yeah we're very very careful about how we do this and men who still want to reproduce and if if you still want to reproduce we're going to try to avoid doing anything and if we do anything we're going to use like smaller doses of HCG um as the as the preferred um hormone replacement therapy that's crazy now again to be clear there are ways around all of this right so the you know bodybuilders who actually the bodybuilders who are quite sophisticated know this right they do what's called post-cycle therapy so they'll take testosterone and a slew of you know other synthetic hormones for maybe three months and then they'll stop and then they'll take large doses of Clomid HCG and even synthetic FSH really really telling the testes wake up wake up wake up wake up they shake them they shake them they make their tea so now they have relatively low tea compared to what they did they still have high tea because remember they're shaking the hell out of their testes to make as much as possible and then when they need a bunch more hormone they go back on the synthetic plus testosterone they make you know they now have a huge amount they stop making it at all and then they just keep doing that cycle speaking of if we're out of that you know we're out of this this range that you said bodybuilders were taking I imagine there would be different side effects correct yes I think once you get into that level and I don't have a lot of expertise in that that's not medicalization now you are running so if you're thinking you're listening to you know Dr Tia and he's like no no you know this and that and these are the things don't worry about heart attack Etc but you're talking about bringing some to a normal level not taking them to subhuman I think all bets are off got it because we don't we simply don't know what we have no one's done this study so your anecdotes as good as my anecdote when you're giving a guy a thousand a day it strikes me as a bad idea yes Comm exactly my Common Sense tells me that can't be good right but I don't have data and your anecdotes and my anecdote are pretty much all we've got but but but but the common sense would be like this is not a normal human level in any scenario yeah as a general rule I think um when you go that far out of what's physiologically normal there are risks yeah and and again certain hormones um have far narrower windows in which they operate the thyroid hormone right what's what do you mean narrow window I apologize years of life or no no no no no meaning the band in which you have to maintain what's called U thyroid status is pretty tightly regulated understand your homeostatic levels of hormones of top to bottom is what you're talking about right so if you look at the three big hormone systems we might think of and there are more but the three big ones would be the thyroid system the sort of corticol glucocorticoid system and the Androgen system understood okay the one that is by far the most forgiving is testosterone by far wow so let's explain why testost sorry thyroid pretty narrow band if you're low or you're high and the ceiling and the floor are pretty tight you will absolutely know it there's no mistaking it okay the glucocorticoid pathway if you were really low Addison's disease or you were really high Cushing's Disease you will absolutely know got it right this is these are brutal states to be in you need to be within a Rel relatively narrow band understood even on the female sex hormone side estrogen and progesterone if you are really low we call that menopause you will know it okay and it sucks if you are really high meaning if you're a woman in whom we are replacing estrogen and progesterone and we do too much oh you will know it got it you will be the most miserable unhappy person okay there's something about testosterone and and I've never really thought about it biologically why this is the case where the upper bound to how high you can go is almost Limitless in terms of feeling but that still doesn't give me a lot of who knows X time down the road it could cause a certain type of just because just because we can get away with going 10x on testosterone and not notice it symptomatically of like I feel okay and by the way I'm sure there are some people like I wouldn't do it but boy I'm sure there are folks out there that if they injected 10 you know 10x the dose so a th000 milligrams of testosterone would feel horrible so I'm sure there's somebody out there who would who would be like oh my God you know that's what Roid Rage is okay yes understood but when we're talking about these physiologic doses like we just don't it's it's it's it's a pretty net positive for people okay this the final big thing that people talk about here is prostate cancer and this has been I think unambiguously resolved I've done I think three podcasts on this topic Alone um and we can refer people to that if they want the Deep di so I'll just give people the tldr yeah it'll all be in the show notes to explore more the tldr is testosterone um testost exogenous testosterone testosterone supplementation does not cause prostate can cancer um if you had an existing prostate cancer you probably wouldn't give somebody testosterone okay um unless meaning if it was a it was a metastatic you know a prosec that spread but I'll tell you this if you and this is really interesting I just had Ted Schaefer on my podcast to talk about this particular example because there was a trial called the the Traverse trial that came out last year that discussed this but he said look even if we have a guy with t with a low grade prostate cancer what we call a glein 3+3 this is a prostate cancer that you don't have to operate on because in its current form it's not lethal but you have to watch it very closely you're doing biopsies and MRIs you watch it closely because it could metastasize well it could become the form that will metastasize you want to catch it there and then remove the prostate okay got it so he said if I have a guy with low T even if he has a glein 3 plus three I would still replace his te got it now I have to watch him like a hawk but we don't have any evidence that that is driving him to a glein 3 plus4 which is the operable one right the dangerous dangerous cancer of in fact what we know is the opposite right we know that low testosterone is a greater risk for high-grade prostate Cancers and that's it at the first that sounds like crazy you might be like wait should we be giving testosterone to prevent prostate canc that's that seems kind of don't know that we can I don't know that we can go that far but what it tells us is the most aggressive prostate cancers are quite Androgen insensitive that's actually what we're learning about the biology so just as we know in breast cancer if you're a woman and you have to get breast cancer hopefully a decision you would never have to make do you want estrogen positive or estrogen negative you want estrogen positive you do absolutely oh my God I would think estrogen negative no estrogen positive breast cancers have a far better outcome than estrogen negative breast cancers and similarly testosterone sensitive prostate cancer that is very responsive to testosterone that goes crazy with testosterone is very responsive to treatment you get a testosterone that you get a prostate cancer that thrives in a low testosterone environment that's a very dangerous prostate cancer okay so this is all another way of saying testosterone is not driving prostate cancer yeah but again you need to have a doctor who knows what hell they are doing and the because that's the key that there knows what the hell they are doing not some Los Angeles fancy [ __ ] Spa where they do trt right because another thing you to be careful of is if you give a guy a five Val per reductase inhibitor which is often done with trt you are artificially suppressing his PSA Now by a factor of about two PSA prostate specific antigen which is one of the tests we use to screen for a prostate cancer oh my God so you might miss it is what you're saying correct because it appears that it's not a problem hence artificially suppressing but it in fact is could be yeah so that's another reason I do not like suppressing DHT I like to let a guy's DHT go where it may and um and and you know actually have a a a true uncorrected PSA got it okay last thing on this we should say we should talk about estrogen it is really really important for guys to have normal levels of estrogen and the other uh thing that is really in Vogue and it's just infuriating to me is giving men estrogen blockers and the idea it's Bro Science is look dude hey you don't want estrogen and two anytime you take any of your testosterone to make estrogen which we already talked about is a problem for like the average guy but when you are supplementing with testosterone you unless the estrogen is getting really high you actually want that estrogen to go up and there was a study that was done about 10 years ago that actually looked at U this was in the New England Journal of Medicine actually so it was a pretty well done study and it looked at 10 groups so it took um it took a whole bunch of men and chemically castrated them so you give them a drug that prevents them from making testosterone and then they were randomized into two groups uh five different Placebo and four different doses of testosterone then with or without a drug called an asrol that blocks the conversion of testosterone to estrogen so now you have 10 outcomes okay right you have high low estrogen in five different doses of testosterone got it and the best performing group is the highest testosterone with the high estrogen High being 30 to 50 as an estradiol level take away being do not mess around with estrogen blockers unless your estrogen is absolutely through the roof and by the way if you're a bro in the gym taking a lot of it yes you have to because then you're going to get gynecomastia because your estrad will be through the roof but again that's not what we're talking I'm not interacting on that yeah we're not exactly we're talking about the average 40 year old guy like why is my number 362 instead of 900 right his Testo his estrogen by the way that guy who's 362 I promise you his estrogen's probably about nine is that high horrible so low very very low I want his estrogen that's another reason I'm giving him testosterone is I want his estrogen to come up that's another you could make an argument that his mood and libido are just as much in response to his low estrogen as his testosterone and so I want his testogen to be 40 I want his estrogen to be 40 myths around this [ __ ] Peter Mr you're crazy that's why I hate talking about it truthfully other than the odd podcast it's just drives me nuts but if you but if you don't then so many people are vulnerable to misinformation you know and and you we're talking about millions and millions and millions of men around the world so I appreciate it and then you know I kept you for a million hours on this subject matter but would you consider supplementing something like HGH with this I remember when I was 30 everybody was doing that in Los Angeles and at the time I was thinking if if I do this exogenously I think this will mess this up you know endogenously so no common sense always kept me away from it but it was a massive thing in La is this a thing now should should a thing it's still it's still a very popular thing should we do it I don't believe so no no no medical reasoning for it no longer the HIV is out of there equ yeah yeah no I don't think there is um medical the only medical reason for it and it's not something we see in our practice because we're not a Pediatrics practice but in kids that have really really stunted growth obviously growth hormone plays an important role and and it's a really important thing to be able to at least offer parents when their kids are projected to be incredibly short and you're still in the window of development got it okay but this is a by the way something that's becoming very bizarre and popular is there are parents now that are giving this is not common I don't want to blow this out of proportion but I'm surprised at the number of parents that come to me and say hey my kid's going to be six foot but love him to be 6'4 you know we're going to we're going to probably give him growth hormone you know he's eight years old but we just you know I really I want him to be a pro tennis player and at 64 he's going to do a lot better than 5'11 and I think that is not a great idea for wouldn't that be arguably potentially child abuse yeah it's interesting question I I I just I you know anytime I have been asked that question whether it be at a party or otherwise my my general advice is please don't do that that just strikes me as an awful idea right um and how would you live with yourself if there was some unknown consequence of that which again I'm pretty sure there's not because we know that you know you can give kids that are a very very short stature growth hormone and they end up just fine but but and maybe that's just me passing an ethal Jud but if you gave it to a young kid then wouldn't you potentially have the issue of them not making it themselves and that causing a problem later in life or you when Common Sense would dictate bad idea for a healthy child yeah the good news is if you're if you put good news on it is you wouldn't need to give them much to make that happen like when they're in that phase of development this is something you could do over a relatively short period of time and you would you would get a benefit but again I it just doesn't strike me as a great idea now what you're talking about is what you know this sort of more common idea of of growth human growth hormone as a longevity hormone well but here's the funny thing it's not even a great drug for body composition I've heard you say that it's not you didn't see improvements I guess or there like when you took it I think it was podcast you did with Lane Lane Norton Ed I remember you guys saying like a ironically like there was no improvement yeah if you look at the data I mean again we don't really have experience with it in our practice we don't have I think we I don't think we have a single patient taking growth hormone in our practice in fact I know we don't so this is not this is all my knowledge of GH is from um um basically the literature but the literature this has been studied quite a bit and at the end of the day it does not really improve muscle mass it does reduce fat Mass slightly um people who patients who have come into our practice on it a lot of them will swear up and down that they simply feel better when they're on it and there might be something to that you know my view is um and I'll Never Say Never but I'm not going to take it until I'm until I've run out of other options got it you know like um and the other time when I think it might be reasonable is during recovery from certain injuries okay so I think I think there's probably a use case you know if you tear your rotator cuff um and you know you want to minimize atrophy while stimulating um regeneration part of your PT might include the use of it and and and I've I've certainly prescribed it in those settings for people that have had certain types of injuries um but this idea of HGH as a longevity Elixir the spa version of it I I don't I don't first of all I don't see any evidence that that's true got it um but at the same time I also don't like to demonize it and aize it to the point that the medical community traditionally does which is says this is going to cause cancer we also have no evidence that's true right right because this growth hormone would make cancer cells grow because it's a it's which is a which is a reasonable hypothesis but there's no evidence that it's true so I don't know if that's the case understood and and maybe you could make the case well growth hormone would have no impact on the initiation of cancer but it might propagate cancer so maybe if someone's listening to this and they're saying look dude I got to be on my growth hormone I would just say maybe that's an argument for for really having your cancer screening dialed in so that you know at least you don't have something visible that's going to propagate speaking of screenings if I'm taking testosterone I think you've wiped this one out um you you could take it forever arguably if you're within the safe range how do you need to do blood work how often do you need to do blood work to make sure you're in this this this band when you're when you're when you're starting it out I mean you know we we if we were going to put somebody on those hormones we would be checking their levels again Within you know two months got it um but once you're kind of at a steady state level um you you know you could probably check it Whatever frequency you're checking for other things it is important and again most doctors I would hope know this and I'm sure they do um but it's important for patients to understand the half-life of these things so when you're if a person's taking testosterone the typical dosing is like a once a week dose okay so typical dose might be 100 milligrams of testosterone cypionate once a week and I don't let me forget I need to ask you also in what form I should get that dose sublingual shots this all this [ __ ] so the most common dose is an intramuscular injection of this oil testosterone c a um but let's say I said okay well you're going to you're going to take 100 milligrams once a week um so you inject it every Sunday great well the day I measure is really important to tell me how much you've got if I measure you on Monday or Tuesday you're through the you're going to be through the roof if I measure you on Friday or Saturday you're going to be really low so I want to measure you on Wednesday if I give it to you on Sunday cuz that's about your average level now we when we have our patients inject testosterone we have them do it twice a week at half the dose and that Smooths out the curve a little bit so we would have a person do 40 or 50 milligrams twice a week perfect s and then you get smooth out does well because honestly a lot of patients don't want to do it it's now it's two shots a week instead of one back in the day people were doing one shot every two weeks they were doing 200 milligrams once a week probably once every two weeks but then you had this massive super phys ologic level then you came down to normal for about 5 six days and then you were actually very low and the drawback of that is there's sorry there's one other side effect I forgot to mention and it is it's very important because it's not uncommon um not common but not unheard of and it is a rise in hematocrit so testosterone will drive what's called hematopoesis what is that means it tells your bone marrow to make more red blood cells so you have to monitor bad guys who do testosterone sometimes have to give blood yes what's the downside to too many red blood cells if it gets if your blood becomes too viscous you run the risk of a blood CL too thick yeah that's what I had heard that whole blood's too thick and it made no sense to me I was like oh testosterone make you're blood thick that seems stupid and I just kind of thought it was some that's what it is I got it so the probability of that happening is higher when the testosterone levels get higher so if you're doing the every two weeks you get that huge Spike you're more likely to drive that excessive hematopoesis when we are giving it to guys twice a week we see virtually none of them needing to give blood got it okay have I left anything out of this conversation that we need to include well you said you want to talk about how to do testosterone all the different forms Sor yes which is the best uh I don't think there is a best I think testosterone cypionate is the tried and true way to do it that's the inject it yourself there's another testosterone it's identical it's just a different formulation of what binds it and it's a commercially available pre-loaded pen called zad so if you get a guy that's a total total needle phobe he doesn't want to be the one drawing it out switching the needle from a big needle to a little needle and putting it in he just wants a pre-loaded pen like OIC um then you would give him zad the cost is enormous it's a much more expensive drug even though it's the exact same drug it's just the in you more because they put it in a pen for you um but again for some guys that's like I don't care I just don't want to have to deal with the thing and I just want to carry my pen um so those would be your your big ones there is um a recently approved nasal version called nesto and it's an interesting drug we use it in females we don't use it in males okay um like we can talk about why but it's a much lower dose and but you have to take it three times a day oh well that's a pain in the ass I would even find that to be a pain in the for women you would never have women take it three times a day because that's a male dose so you have women maybe just take it well there you go once let's just say they're taking it for libido we would say look maybe take this before you want to have sex or before you think you would want to have sex it and so you get that hit of testosterone it's kind of like a little Viagra then for women to yeah yeah I mean in a in a weird way kind cool and there are two different uses of testosterone right so women are injecting it nasally and vaginally depending on what they're trying to Sol what the problem so nasally would be the the hypothesis this isn't known yet the hypothesis is that if you inject it nasally you're getting more of the um increase in sex drive if you inject it vaginally you're getting more the SE no more the sexual function orgasmic function we use estrogen for lubrication we use testosterone for um orgasm but again we'll get to that with women we'll get to that with women and then finally there is an FDA approved pill for testosterone um that comes in a form that gets absorbed via the lymphatic system so it doesn't destroy your liver normally you could not take testosterone orally these synthetic hormones there are some guys that are out there taking them orally because the liver filters it yeah the liver gets destroyed by these hormones got it but if but if you take them and you can bypass the circulation of the LI digestive system and you put in the bloodstream so the the drawback in my mind of these is they're far more expensive um and I just you know again we don't we don't typically end up having to use them because most of our patients who end up needing or wanting to be on testosterone um you know just fine taking the injection so I've left nothing serious out and for all the Nuance on this we go to the drive podcast um which I will link to thank you so much you're awesome appreciate keeping it real with Jillian Michaels [Music]