SPEAKER_03 0:00

And welcome back to another episode of Vitals and Values. This is a fun and unique episode, passionate for me, because it's something I'm currently going through. I thought this would be an incredible time and opportunity to, because I just made a post on social media talking about uh I've been on hormone replacement therapy of testosterone for the last about six months. It's been a four-year kind of process for me, five-year process into getting onto TRT. And I thought this would be a great opportunity to bring on Dr. Treesenberg to talk about testosterone, TRT. Uh, and we're gonna talk a little bit about peptides at the end, but not going too much into the weeds. Uh, but this, funny enough, I've known Dr. Treisenberg from before even getting into uh hormone replacement therapy because about 15 years ago, my father and I went on a golf trip to northern Michigan, and Dr. Treesenberg was there. And uh so yeah, it's a fun opportunity to bring him on here. And so thank you for taking your time to kind of share your knowledge on hormone replacement therapy and a little bit of peptide conversation.

SPEAKER_02 1:12

Oh, I appreciate it. I appreciate being here.

SPEAKER_03 1:14

So, first and foremost, tell me about your past. Uh, what's your what's your history in medicine, and uh let we'll start from there.

SPEAKER_02 1:20

Yeah, I um sort of Michigan born and raised and uh went to Michigan State undergrad med school, ended up doing an internal medicine residency in Detroit, Michigan. Um then went to University of Michigan and did two-year fellowship in infectious disease, which was awesome. I really loved my experience there. Um so I came to town to Grand Rapids, I've been here ever since, and for 25 plus years, I practiced infectious disease in the hospitals, uh, bugs and drugs, we called it. And um it's pretty intense. You're seeing a lot of really sick people day in and day out. I will admit um over time I got a little burnout, to be honest. And um was division chief for a little bit there, uh, which was not my favorite thing. I'd rather just take care of patients, to be honest with you. But then Bill, uh Dr. Baer, who's a friend of mine, called me and said, you know, I started this new concierge medicine practice. I'm looking for a partner, and what do you think? And I thought, well, it's a little change, but uh I made the change about eight and a half years ago, so I've been doing concierge medicine, and uh I love it. I really love it. It uh you're all familiar with it, but just the focus on access to care and more of a wellness um preventative health concept. Um I uh have really enjoyed it. And through that time, I've gotten a lot of experience with hormone replacement therapy, mostly for men, but females too. So then I had a couple uh people come up to me and ask me to be medical director of a local men's health clinic, and I got the okay to do that. So I've been doing that for a few years now, and I I love that too. I can see that we're really helping people, and and uh that's been a great experience.

SPEAKER_03 3:30

Awesome. I mean, real quick, just to kind of unpack that a little bit, because I find that fascinating. From you're seeing the sickest of patients, and it's day in and day out, I'm sure uh someone comes in with an infectious disease, you save their life, and then by how what was that dynamic change of going from that to like building relationships inside of concierge medicine, really kind of working with the patient? What how is that dynamic for you?

SPEAKER_02 3:53

It's a little different. I mean, you still build relationships with patients in infectious disease, but lots of times those are short-term, as you mentioned. So not always, you know, sometimes you see people long term. So that that is a bit of a change, and then just going back to primary care. But I couldn't ask for a better partner to do that with. And not only is he a really good internal medicine doctor, he's also a pharmacist, so that helped a lot. I didn't realize how many diabetes drugs there were when I went back in the uh primary care, and so it was a big change, but you know, the thing about infectious disease is um you are seeing a lot of sick people, and towards the end, uh I was noticing that a lot of the people I was seeing were super sick, some of them dying. And I I think that over the years it kind of wears on you a little bit, to be honest. Um I love infectious disease. I really do. I I miss it a lot, but I really thought it was great for me, and I really love spending more time with people and getting to know them. That's one of the great things about concierge medicine, is that you get to spend more time with people and um so I and the preventative health, I love that. Uh I love precision medicine, preventative health. I love that stuff. So it's been uh a little difficult initially, but a really good transition for me.

SPEAKER_03 5:29

Well, and speaking of uh Dr. Bear, uh uh back in the like talk about talk about leaving from a different type of practice and having that same experience. My brother saw Dr. Bear back in the day before before he got into concierge. And when that whole thing happened, dad was frustrated too, because he's like, gosh, he's such a good doctor. And now he's you know he's gone doing other things, and it's like uh my brother loved uh uh yeah, I'm gonna bring it up. So first time uh obviously when they started their medical practice and this all came up and relationships between us started happening, um, between this and exponential health. Um, all of a sudden I was like, oh, Billy Bear? And I knew Dr. Bear as Billy Bear, because that's how dad called uh Dr. Bear was Dr was Billy Bear. And even Rob said Billy Bear. And Lara looked at me like, Billy Bear.

SPEAKER_00 6:21

We use more professional terms simply. Yeah.

SPEAKER_02 6:25

He doesn't mind, obviously.

SPEAKER_00 6:27

He's a great guy. He was very uh he was an inspiration for me in starting my practice because he had done it before. And so it's good to learn from. And so when you started doing more primary care, is did it naturally evolve into doing more testosterone? Absolutely.

SPEAKER_02 6:42

I think um part of cancer medicine, as you're aware, is more of a wellness approach to to uh things. And so uh that just led to more discussions on um hormone replacement therapy, not just for males and females as well. And so it just naturally occurred. And uh it's really nice to see benefits of that in people and really have them sort of feel a lot better. Uh obviously it doesn't always happen. Um but you know, there's I I feel like there's this five percent rule in a lot of um I'm gonna talk mostly about men, but you know, this five percent where maybe they're just five percent short of uh being feeling the way they want to feel, and um and when you put them on hormone replacement therapy and you see those symptoms improve and their quality of life improve, uh that's a good feeling.

SPEAKER_03 7:43

In mine personally, uh the whole dynamic, uh tell me if this wasn't similar patients for you. It was 400 pound me, obviously kind of going into where we go into the process of why do people get low testosterone. When I was 400 pounds, my testosterone was tanked. Like it was not good. It was I don't know the exact numbers, but back when I was uh a kid, I would I actually was going to who's a pediatric endocrinologist out of core uh uh there was a doctor who started with an L.

SPEAKER_02 8:15

I can't remember my daughter. Um Woods, Dr. Woods. Dr. Woods. That's actually Dr. Woods, yeah.

SPEAKER_03 8:20

That's who it was. Dr. Woods.

SPEAKER_02 8:21

Did start with an L. You know, my buddies do tell me if I say it starts with an L, it does definitely start with an L.

SPEAKER_03 8:29

So Dr. Woods saw him, and then I still hadn't gone through puberty at like 16 plus. And so I did like two rounds of testosterone just to see if that would shock my system and brought it up a bit, and then that was it. And then I was in the low hundreds or whatever for years. And then after I lost the weight, I dropped 200 pounds. My testosterone naturally went up to around 700. And so it's like, great, this is this is awesome. And so I sat around 700 for four or five years, and then when I was about uh 2021, I started getting blood test, like just annual blood testing. You know, everyone wants to get their testosterone checked, and it was like 700, and then it was 500, and then it was four, four hundred. This is over about a four or five year time period. And I was going to my primary, it got down to like 300, and I'm like, I don't know. I just don't, I don't, I don't have ED, I don't have any of this stuff, but I just don't feel like in the gym and everything else that I'm at the same level and something just feels off. And going to my primary when you're that traditional medicine, it was like, well, you're not hitting the major symptoms, so you're still in a normal range. They didn't do anything of it. And then that's when I got connected with Charlie at game day, and he came in there, and then I was at 290 or something like that. And then we had the conversation, and I was like, All right, let's try this, let's see what happens. And I went into the process, because obviously, from my standpoint and understanding science, like placebo effect is real. And I was like, all right, I'm not like I'm gonna look, I'm gonna act like this didn't happen. I'm not looking for, I'm not looking for the secret bullet, I'm not looking for anything. I just want to see what happens. And within three to four days, I felt like the gym, everything felt a little stronger, everything felt better. I was waking up a little more energized, like just it, I remember calling Lara on it like three days later, and I'm like, I just feel better.

SPEAKER_01 10:25

Yeah.

SPEAKER_02 10:25

And so that could be that five percent, you know. You just uh so that that kind of does bring up a little bit, you know, what is low testosterone and um what level is low testosterone, and that's a little debated out there. So I think in the US a total testosterone below 300, I think in Europe below 350. Um, but there is varying uh opinions on that. Like there are some endocrinologists a little bit more hardcore who will set the number even lower than that, but I think and it's hard to know where they come up with these numbers, but I I would say less than 300, uh maybe less than 350. But you don't want to treat just numbers, right? And you also have to remember that the free testosterone is a better number, actually, than total testosterone, because the free testosterone is the amount of testosterone that's not bound to albumin or sex hormone binding globulin that is free to use. So a lot of times we will check both. We'll do a total testosterone, but also check a free testosterone. And I do think that's really important, especially if you're going to treat somebody for low testosterone. Um, but you know, to start with, a total testosterone is often used, and I would say less than 300, maybe less than 350. I know at the men's health clinic that we do, we rarely treat anybody if their total testosterone is above 500 as a baseline. That's sort of a cutoff. And then uh we can get in more into the free testosterone later if we want, but you know, you want to combine that with symptoms, right? So, you know, in a lot of medicine, it's uh, you know, treat the patient, not the numbers always. So uh the numbers are important, but you're looking for symptoms of low testosterone. You're not just treating based on a number. I mean, there are men who have testosterone levels of 200 and they're perfectly fine. They don't need testosterone. Um, so you're looking for the major things which decrease muscle mass is one of those. I think um, you know, you're not getting the results you used to get at the gym, you're losing muscle. So certainly decreased muscle mass is one of the major things that we see with lower testosterone. Fatigue. Um I hesitate a little bit on just fatigue because fatigue can be a lot of different things. So, you know, that's how they get people on the radio. Are you a male and fatigued? And, you know, um 99.9% of people say yes. But, you know, so fatigue alone, I don't usually use as a standalone symptom. I usually combine it with other things, but certainly fatigue can be seen in in men with low testosterone. Decreased sex drive is definitely seen. It's not uh you mentioned earlier about um maybe with erection erections. You know, testosterone is not necessarily an ED drug, but it definitely does help sex drive. It could help with ED a little, but its primary benefit there is more in sex drive. And then there's uh metabolic effects. Um certainly testosterone has some really positive metabolic effects. The other thing we sometimes see, just like we see with estrogen in females, if it's low, uh testosterone low in males, there's some brain effects. So we will see men who complain of brain fog. Um sometimes they have some depression, um, increased anxiety. Now, I I don't want to throw that all under low testosterone, but it is true that testosterone, as is estrogen, is a brain drug. So sometimes we do see symptoms of uh, you know, those kind of symptoms in men. So those are some of the major symptoms we're looking for, and kind of the number cutoffs we're sort of looking for. Um, but pretty much you don't want to just give somebody testosterone based on a level. You want to do it on numbers and symptoms.

unknown 14:56

Yeah.

SPEAKER_00 14:57

Do you talk to your men about do they ask why as my testosterone does that come up much?

SPEAKER_02 15:03

It comes up a lot, and uh it's surprising, right? We're you know, ED, rectile dysfunction is a little easier. It's like 30% of 30-year-olds, 40% of 40-year-olds, 50% of 50-year-olds. It kind of follows the decades. Uh and, you know, ED is um, of course, uh uh the silent majority out of there. It's not something that people like to talk about with their physicians, or they don't talk about it. So uh that's a little bit more common with testosterone deficiency. We do see it now in younger men. I don't know the whole reasons for that. Um some of it may be obesity, some of it may be microplastics in our foods and drinks, some of it maybe we're just checking it more often than we used to. I uh some of it may be diet-related, other diet-related factors, but definitely I think there's been a trend towards seeing it in younger individuals, even in their 30s, rarely below that. If you see somebody below 30 with a low testosterone, especially a really low testosterone, you have to think of um secondary causes. So you have to look for more brain issues where they may have a pituitary adenoma or some something wrong in the brain that isn't getting to the testicles to make um testosterone. But most low testosterone is primary, it's just testicular failure of producing it. Um so I don't know all the exact reasons, but those are some of those. It does go down with age, but again, not necessarily. I see some 70-year-olds who've pretty normal testosterone. And again, I do see 70-year-olds with lower testosterone, but no symptoms.

SPEAKER_00 17:01

So do you get a lot of men more asking about their testosterone, like, can we check it? I think, hey, could it be low? Or do you digest it more typically because of their symptoms?

SPEAKER_02 17:11

Well, uh at my practice, we do it as a yearly test on males, so it's automatically one of the yearly tests we do. And um it's best when you're looking at low testosterone. If if the initial test comes back negative, you want to repeat it, get an early morning specimen, that's the best time to check it. And again, looking at their free testosterone is important. Um so we do it annually in males uh over you know 40. Um at the men's health clinic, of course, it's more people coming in and curious and word of mouth and hearing things on the radio and uh their friends. Um it's more them looking to see where they're at because they don't feel they don't feel right.

SPEAKER_00 18:00

Yeah. I know you've only been in primary care for how many years, did you say?

SPEAKER_02 18:04

Yeah, so uh eight and a half now.

SPEAKER_00 18:06

Have you seen more use of testosterone over that time or do you think that's a good idea? Oh absolutely.

SPEAKER_02 18:10

Yeah. Definitely have seen um definitely have seen more use of testosterone. And not not just males, but also females.

SPEAKER_00 18:20

That's interesting. But I know we're not going there. We'll have to talk about that with somebody else. No, you mentioned the um uh checking free testosterone.

SPEAKER_01 18:29

Yeah.

SPEAKER_00 18:29

And I've like looked into this a little bit for some of my own patients. And isn't it I mean, my understanding is there's some ways to test that that are more accurate than others. And do you care which way you check it?

SPEAKER_02 18:41

Or there are, and I don't really care, to be honest. Uh there are some ways you can t check your testosterone levels that are a little bit more reliable. In the big picture, though, I I don't think it really makes a big difference. So there's there's a couple labs. We've run into this. There's a couple labs where if you order testosterone levels, they'll do your bioavailable testosterone, your free testosterone, your total testosterone, and they use a special radio assay that's really expensive, and I don't really feel that's necessary. Um but I do prefer to get a total and a free testosterone when assessing testosterone levels for sure. Because you will see people who have a relatively okay total testosterone with a really low free testosterone. The primary problem there is their sex hormone binding globulin is elevated because that tightly binds testosterone. And so their total will be okay, but their free is really low. And there's not much you can do about the sex hormone binding globulin. Um, but it is good to check both, at least initially.

SPEAKER_00 19:55

And if you start somebody on testosterone, what what's your kind of strategy for monitoring that or how what is your plan?

SPEAKER_02 20:02

Yeah, we do follow-up at six weeks. So we do their testosterone, we check a baseline estradiol, a PSA, a CBC. Once a year we do a full lab panel on them, check their lipids, uh, kidney function, electrolytes, liver function, etc., once a year. But the major things we follow in monitoring are their total testosterone, their free testosterone, their estradiol, and I can explain that. Um and then we will check a CBC because testosterone can increase your red blood cell count. You have to monitor that closely. And then we will um follow their PSA if necessary. Um so those are the main, and we do it typically at six weeks after we start, or if we make a dosing change. Then once they're on um seem to have decent levels, we will cut that to three to six months and monitoring things. Um we don't have uh but six weeks for any new patients or for dosing changes.

SPEAKER_03 21:10

That's I mean, that was like my my exact experience when I was at game day, was like one of the things I respected in the process was it took four months to get me to like high clinical normal. Where because it was a very progressive process. Okay, you're still at this, let's raise it by um 0.5 just to kind of work through the milligram. I was at I was raising because I was at because I was doing I'm doing subcutaneous bi-weekly. Okay. Um or twice a week.

SPEAKER_02 21:39

Right.

SPEAKER_03 21:39

And um, and I was at 35 twice a week, and then 40 twice a week, and now my sweet spot's forty five twice a week.

SPEAKER_01 21:48

Right.

SPEAKER_03 21:48

Is what I'm at. But uh I love the process of like, all right, every six weeks, let's check the blood, let's see what's working. Instead of just throwing to what would be probably high, the the perfect spot to be, work up to it to make sure. Sure, nothing goofy happens with estradiol and all that kind of stuff.

SPEAKER_02 22:03

Yeah, I agree with that. I think there are some clinics out there that are more cookie-cutter in what they do, and you don't want to do that. You want to take the individual under account. So when you do that initial dosing, you know, um how much do they weigh? What's their age? You're going to use less than elderly people, obviously. You're going to use more if somebody's overweight. So you have to take in a lot of um things into consideration in that dosing. And it's always best to kind of start a little on the conservative side, you know, and monitor and go up. Also, you know, men, we always think more is better, honestly. It's like we're just in ground with that. But honestly, with testosterone and a lot of other things, more is not necessarily better. So some people really want to push their levels, weight really high. And so we have some cutoffs of where we say, no, that's uh you're you're getting too high with it. That's not what we're interested in doing. We're trying to optimize your health and treat your symptoms, not have you be a you know, uh bodybuilder necessarily. So we have our limits as to how much we'll push it.

SPEAKER_03 23:18

When like Lara had a patient that was getting his testosterone from like China or something.

SPEAKER_00 23:24

Well it was Janna, but yes. Oh yeah.

SPEAKER_03 23:26

And woe.

SPEAKER_00 23:28

It was off the charts every time. Like, okay, maybe this is not the best idea.

SPEAKER_02 23:34

Yeah, it's um it's not, you know, so that brings up kind of the side effects of testosterone and you know, with um you you really have you know, testosterone's a little complicated. It really is. It's uh f first of all, you know, you're kind of making if it works and it improves your symptoms and you feel better on it, it is a uh it's a long-term commitment that you're making, you know, where and you and it's also you have to follow your lab, so there's some time investment in that. So that's that's one thing. Um also a big caution is in younger people who want to have children, you uh have to be incredibly careful with giving them testosterone, and um, because when you give testosterone therapy, it will go up to your brain, it will cut off your FSH and LH, where the two hormones that go down to your uh testicles and produce sperm and um give you testosterone, so you cut those off. So one of the side effects is you won't make as much sperm and your testicles can get smaller. That is a possibility. There are ways around that a little bit to help protect that. But you have to be incredibly careful. And yeah, we have some young men come in who are in their 20s, and uh, first of all, you have to look for secondary cause, but also putting a younger person in their 20s or 30s on testosterone, if they want to have more children, is not necessarily the best idea in the world. Um now, some of them don't want children, and but uh you have to be very careful there. It's we um are real hesitant to do that only under certain circumstances. Um so that is something you have to remember is fertility, and that can be reversible. Once you go off, it takes uh about three to six months to recover, but not always. Sometimes it could be more of a longer-term shutdown. Um, you know, two of the major things that people worried about in the past is worsening heart disease and prostate cancer. So there's a big trial. There's been several trials, but there's a big trial that came out uh a couple years ago now, I guess, the Travers trial that showed that there really wasn't any increased risk of prostate cancer or heart disease. Now, if you abuse testosterone and you drive your levels incredibly high, you know, you could run into some issues with heart issues. But at normal replacement doses, that does not seem to be an issue. We still are we still check a baseline PSA on patients, a prostate test. And if it's elevated, we get okay from their primary care or a urologist before we use the drug. But the Travers trial did not show any increased risk. But in somebody who's had prostate cancer or has an elevated PSA, uh, we still get approval from urology typically. Um and then there's hair loss, you know.

SPEAKER_03 27:00

That was actually a big concern of mine.

SPEAKER_02 27:02

Yeah, hair loss can occur mostly on the scalp area. Uh acne. We do see increase in acne with testosterone therapy, usually at higher doses. I think I mentioned that your hemoglobin can go up. Actually, there are some people who benefit from testosterone therapy just to get their hemoglobin up. If they have chronic low anemia, uh you can use it to bump their hemoglobin up and they'll feel they will feel better. But you have to watch that carefully. You don't want what we call polycythemia, where uh somebody gets a really high hemoglobin, they have a slightly higher risk of blood clots or other things happening. So we have ways to try to avoid that or treat that. Uh estrogen. So testosterone is converted to estrogen. And so in men, when you replace their testosterone, there's a chance that their estrogen levels will go up. So we measure their estradiol. There's sort of a sweet spot there. So you kind of want their estradiol to testosterone testosterone level ratio to be about 3 to 5 percent. Above that, they can have symptoms of high estrogen, including decreased erections and um some more moodiness, actually. And then if it's low, if it gets really low, they can have the same type of symptoms as well. So there's a sweet spot there that you have to monitor. As I said, it gets a little, you know, it is complicated. And then you're talking typically injections once or twice a week. Uh there are creams out there. I don't feel that they're as reliable as the levels you get. And sometimes the pharmacy will change where they get it, and so the levels vary more. So I'm not a big topical treatment patient unless somebody really insists on it. You also have to be careful that if you use it topically, you're not transmitting it to your partner. Um and there are pellet therapies, so that's where they do a local incision in the buttocks area and put pellets in, and that's done about every four months. Uh again, not a huge fan of that. You get a little bit more, you know, your levels get really high and uh harder to control with pellets, but some people prefer that, especially somebody who's away from home a lot. You know, you have a truck driver who's gonna be gone a lot, and they might say, I just want to do the pellet therapy. But prop the best way really is to give shots, either intramuscular or sub Q uh once to twice a week is usually what we do. And that seems to work best. Um some people prefer sub Q because they want to use a smaller needle, some some people prefer IM, you know, but sub Q has a little bit lower or a little bit slower peak. Um but they both work okay. Uh most patients we try IM first, but if they don't tolerate it, we can do sub Q. Uh so you know, we talked about some of the side effects. Um in that study, the Traverse trial, there were two things that were increased slightly in men on testosterone replacement therapy. One was a really slight increased risk of blood clots, just like estrogen can do with females. So if you have somebody who's had recurrent blood clots or pulmonary emboli uh caution, caution. And then the other thing we they saw a slight increased risk of is atrial fibrillation. Not sure why that really is the case, but there was a slight increased risk. Also, um it's very important if you're on testosterone therapy that if you have sleep apnea that you treat that first, because testosterone therapy can worsen sleep apnea. So overall, uh it is complicated. First, you're making a long, you know, kind of a longer-term commitment. Um monitoring is um a challenge. Administering it can be a little bit of a challenge, and there's some potential side effects that we discussed. Um so it is it is a commitment, but we also see a lot of reward from it, you know, in patients. So it's important that they understand all the risk, though, as in anything in medicine.

unknown 31:48

Yeah.

SPEAKER_02 31:54

We do, and or or uh or at the men's health clinic. We have a lot more time. Uh I that is one of the when I say the silent majority, it's not just a uh ED that is testosterone too, but it's a challenge because you know medicine's changed a lot from primary care um practices that people own to corporate medicine. So a lot of people, you probably know this, a lot of people who come to concerning medicine like their doctor, they just don't like the sys system. There's some good that comes with corporate medicine, but you know, the bad things are people are limited to how much time they have, 15 minutes for a regular visit, uh half hour maybe for a physical. And sometimes you know, the men's health type stuff gets ignored. And doctors are bad at bringing it up too, you know. They're uh so there is a silent majority out there, to be honest.

SPEAKER_00 32:54

Well, definitely when I was working in the corporate medicine field, if men brought it up, I was like, I didn't really know that much about it. And I'm like, uh, you can go to a urologist. Yeah. And that was the end of it. Yeah. So being able to be in concierge now and learn about it more and be able to use it and have that conversation is I agree.

SPEAKER_02 33:10

Yeah. It's uh it's it I agree with that completely.

SPEAKER_03 33:15

Well, that was a thorough, solid. I mean, to be honest, fantastic. The the fact that you went into uh a couple of the different clinical trials, you hit it without even I I had the notes up because I it's important talking points. You you hit it perfectly, which was talking about again.

SPEAKER_02 33:29

I guess I should look at the notes.

SPEAKER_03 33:31

Oh no, you're good that goes to show you how well you know what you're doing, because I was gonna bring up the fact of um the cardiovascular risk and this and and the newest studies on that, and you just hit it.

SPEAKER_02 33:41

You know, um one of the things I think is important as well is that you know, not everybody responds to testosterone therapy. Uh, you know, their symptoms don't get better. So, you know, typically you're talking about giving it a three-month trial to see if it helps or not. Um course, that may be a little longer depending on what levels you're getting from your testosterone. So you want to be at a therapeutic level for you know, two to three months before you really say. But we do see people who do not respond, and that is that's either their symptoms are due to something else, uh especially fatigue, of course. But uh there is a another factor, is that there we all have different androgen receptors in our blood, and so and those you can't measure, what you're you know, what uh how many androgen receptors you have to let the hormone work. So some people vary in their androgen receptors, it's not something we can measure, and that also can be a reason that people don't respond to hormone therapy. But um you need to give it a long enough trial at a good dose and levels. Um but you know, we do see that. I mean, not everybody responds.

SPEAKER_00 35:04

Would you say the vast majority do?

SPEAKER_02 35:06

I would. I would say over 70 percent.

SPEAKER_00 35:10

Okay.

SPEAKER_02 35:10

Yeah. I think um but I would say 10, 20 percent roughly probably don't have, as you know. Um and that is what it is, you know. There's something else typically going on, and um we do measure their thyroid levels as well as part of this to make sure that's not way off. Yeah.

SPEAKER_03 35:37

It was one one of the last symptoms I had I didn't bring up on the original ones that I haven't had in months, which was I used to have this weird anxiety feeling at like midnight. And the only thing that helped it was like a deep late like eating binge. It was the only thing that helped it. And then Which isn't good, which is not a good compound. And um I haven't had that like anxious feeling at midnight for months. And that's great. That's that's awesome.

SPEAKER_02 36:09

You know, the other thing with testosterone therapy is uh, you know, you don't want to forget the lifestyle stuff, right? So it's not just take testosterone and your muscles are, you know. Uh they will. Your muscles will get better. Um, they they will, but you know, you want to combine that with good exercise, good nutrition. Um, I'm a big fan of creatine, five grams a day. I I think that to get the most out of you know, testosterone if you're using it especially for muscle mass and metabolism, etc. Um you you need to do those things as well. And that's important that people remember that.

SPEAKER_03 36:52

Absolutely.

SPEAKER_00 36:53

I feel like a big one that I see in a lot of men is poor sleep. Because I know that it has multiple negative consequences and yeah, it sure does.

SPEAKER_02 37:04

It's um, you know, the with the poor sleep is one just lack of total sleep, or two can be due to fragmented sleep, right, during the night from whatever cause, whether it's stress or restless legs or pain or um but a lack of good sleep is certainly a big factor, I think, in a lot of things. Sleep apnea also is a cause. Um so ideally six hours at least. You know, everybody varies a little bit, but I think we can pretty much say if you're getting less than six hours of sleep consistently, you're you're gonna have you're gonna have problems. And uh we can debate whether eight is necessary or not. But I think long-term, less than six is not a help healthy thing. There are people who say I can do it on four hours of sleep. There are those people. You know, and I understand, and some can. I mean, but um for the most part, six hours is where so I think that is a really important part of our health. It's one of the key pillars of um lifestyle medicine for sure. And uh, you know, there's a lot of wearables now have to asleep, and the only downside I see to some of those wearables is people get obsessed with it, so they are uh convinced that their watch is gonna tell them exactly how they're gonna do that day, and that's not always true. Um, you mentioned placebo effects, so that can happen with wearables as well. So they're good at diagnosing things and monitoring some things and making changes to see how it goes, but um, you know, when you have wearables, you want to be careful not to get too obsessed with them.

SPEAKER_00 38:57

They do like my garment.

SPEAKER_02 38:59

My daughter works for Garmin, so really nice.

SPEAKER_03 39:03

Well, it was like uh Lara's always taught always made that joke going, people that uh she sees that go, oh, I can sleep on less than six hours a day and I'm just fine. Lara's always like, until you're not.

SPEAKER_00 39:16

For a lot of people.

SPEAKER_02 39:17

Um Yeah, there's actually uh a lot of health effects from you know lack of sleep, not just physical, mental. You know, I think it affects people's mental health. Definitely.

SPEAKER_00 39:30

I agree.

SPEAKER_03 39:31

Well, perfect. Well, thank you for a thorough breakdown of testosterone replacement therapy, primarily in men, obviously, but I mean that's a lot of what this focus is.

SPEAKER_02 39:40

Yeah, we um we do use it in females. Uh they get the same things, right? Fatigue, decreased muscle mass, decreased sex drive. I think a lot of times it's used more in females for sex drive, but uh there are benefits to muscle mass and certainly energy levels too. Uh the one caution I have in females is you know, you need if you're going to get it from somebody, just make sure they know what they're doing, because uh there are side effects from testosterone therapy in females, and you really have to watch their levels closely. And as a general rule, the levels are that we use or the doses are about one-tenth of what we use in males. And if you overdo it in females, uh there are some major side effects that can occur. So you just need somebody who is really uh familiar with doing that if you're a female. Oh, 100%.

SPEAKER_00 40:40

And I know you want to touch on peptides. And I know I just had a patient come going to a men's health, he's going to a men's health clinic, getting testosterone, not the one you're with, but um, and he was also getting peptides from there. And so that conversation comes up frequently.

SPEAKER_02 40:57

Yeah, peptides are hot right now. I don't know. There's not much hotter than peptides out there.

SPEAKER_03 41:03

Um yeah, they are first question to go off of that is just like give me the the the top level. What is peptides? What is a peptide?

SPEAKER_02 41:12

So we can kind of so peptides just simply is a chain of amino acids that the body naturally produces. So insulin is a peptide. Um a lot of people don't realize that, but insulin is a peptide. All the new GLP drugs, uh, you know, the terzeptide, semaglutide, your mangero, your ozempic, your wigovie, all those are peptides. Um so what has happened is there's a lot of research into different peptides in the body, and there is a growing and huge library of ones that are being talked about and discovered and looked at for just about everything. It's hard to keep up with it, to be honest with you. Uh, there are some major peptides out there that um are available. I think the major ones that are being used are growth hormone uh peptides. Uh there's several different variations on that. It depends on what they do in the brain and how they work to increase your growth hormone. Um growth hormone. Now, growth hormone has some FDA indications for certain things, but in this setting, people are using it more for what we call optimization, right? They want to optimize their health. Um there's BPC 157, which is a little controversial. Just yesterday, the FDA had a panel meeting where they had put BPC 157 as a category two drug in the past, which was more restricted and they had a major warning on potential side effects. Um yesterday they voted on the panel to take it out of category two and make it available in state compounding pharmacies to make. So the restrictions changed yesterday for uh four peptides, and they're looking at three or four more today. So there's been some lightening of restrictions and a couple key peptides that are out there. Um there is uh one called GHKCU copper that's being used more for skin health. Um BPC157 is being used more for tissue recovery, injury repair. It's also a gut hormone, so it's helpful for gut health. Um, one of the issues with peptides, one of the warnings I would give people from this podcast. Is that, you know, there's two types of medicine out there at times. There's testimonial medicine and there's evidence-based medicine. And whenever you have testimonial medicine, which is somebody saying, I went on this drug and I feel better, versus evidence-based medicine, which is a study, you know, and people comparing to other things and saying, yes, this does this or it doesn't. When you have drugs that are more based on testimonial medicine, you just have to ask yourself, you know, some key questions, and that is uh what am I treating? You know, what what am I trying to accomplish with this? Um, you know, what are the side effects, potential side effects? And I'm I'm just worried that that in some places those side effects are not being uh taken into account by people. So I I do I would like to mention a couple of those uh just to people are aware. Um so you really need to think, and then you know, can you measure it? You know, sometimes it's best if you can measure something, not always though, but you know, versus a lot of these peptides are based on animal model, animal studies, not human studies. So there's a lack of detailed evidence-based human trials. So you just have to be careful and um look at some of those things. Um so one of the big categories is growth hormone. Uh, that will increase your muscle mass, it can help with sleep, it can um, you know, give you a little bit more energy at times. The interesting thing is that one of the down or one of the things you get with growth hormone is what we call insulin growth factor one. And you increase your levels of insulin growth factor one. When you're young, you want that. You want insulin growth factor. It helps with uh muscle mass and as you're as you grow, as you get older, you don't necessarily want a lot of insulin growth factor because it can theoretically, not really completely proven, but theoretically may um be associated with increased risk of malignancy. The other major side effect of IGF-1 is insulin resistance, so you'll get a little bit of increased insulin resistance uh growth hormone, also some fluid retention, uh carpal tunnel syndrome has occasionally been seen on growth hormone. So at least uh I think if you're over fifty and you're going to use um especially if you're over fifty, I should say, and you're going to use a growth hormone peptide, I think you should monitor your IgF levels. At least baseline and after, let's say, three months to see where they're at. I think that's important. Um so with growth hormone, you have to be aware of that. Also with BPC 157, which has become incredibly popular, and people do swear by it that it helps. I you always have to take into account also with testimonial medicine what's placebo effect and what isn't. But um BPC-157 will increase what we call angiogenesis, which is formation of new blood vessels, which in tissue recovery is great, um, but not in cancer. I mean, there's actually drugs that uh target angiogenesis in cancer. So again, I think you know, the risk of cancer really starts to increase after the age of 50, and the older you get, the higher the risk. Uh so I think you have to be careful, you know, over the age of 50 with with that. Um I certainly wouldn't use it in somebody who has cancer, definitely not. And I would typically use it short term, you know, so for like injury recovery, we'll do two months maybe, and um cycle it at the most. But I would say stay away from it from long-term use because of the potential side effects. Um I know we all see people who get cancer when they're 35 and they have colon cancer and it's horrible. I mean, it's really devastating. But the majority of cancers happen over the age of 50 is when the risk really starts to increase. Um the so those those are a couple big side effects I think people need to be aware about when they get into the, you know, those things and just use them wisely. Again, what am I treating? You know, what am I using this for? Um, and then are am I getting that benefit or not? You know, that's a and and what are the risks? I mean, those are really important questions to answer, especially in the days now of social media where anybody can get on and tout something, uh whether there's a study or not. And so um you always have to be careful there. I I always have an approach with patients, you know, first of all, sometimes they'll ask me about a supplement. I'll say, well, first of all, that's based on testimonial medicine, so you have to be aware of that. Um, you know, is it going to hurt you? You know, what are the risks going forward? What benefit are you going to get from this? And what's the cost too? I mean, cost is an issue, I think, at times. So um just some words of caution. I'm sorry, I I got carried out.

SPEAKER_03 50:03

No, it's honestly the way you state that that the there's two types of medicine evidence-based medicine, testimonial medicine. Sometimes, and I'm guilty of this, I lean very heavy on evidence-based medicine, and I almost make a condescending tone towards quote unquote test uh testimonial-based medicine. I liked how, like, no, testimonial place-based medicine has its place, but also understand it's not ones and zeros, and there's things, there's uncertainties in it. Yes. Not saying it can't be real, but you got to put into context. Exactly.

SPEAKER_02 50:40

I um I do want to go back to the testosterone. I forgot to say one thing that in younger people with low testosterone, and I talked about the potential harm with um testosterone therapy, cutting off and you know, your sperm production, et cetera, some of the side effects. So there are medications that will actually um stimulate the brain to produce FSH and LH and therefore increase your testosterone levels and actually your sperm production. So you avoid that potential side effect. So you can increase people's testosterone without giving exogenous testosterone. So drug like Clomid uh is frequently used, or there's uh one similar to that. So they will they're not my favorite drugs in the world, and they don't necessarily give you the same bump up on your levels that you get with exogenous testosterone replacement therapy. But um for younger people who still want to have kids and they have you know symptomatic low testosterone, those are a definite option. Another one is HCG, is a compound that uh can do the same thing. It does a little bit differently, but it will again increase your testosterone. You're not going to get the same levels as you get, but you will not run into the fertility issues with that. Um I also failed to mention that there is oral testosterone therapy available now. Historically, oral replacement of testosterone or hormones has been somewhat ridiculous, to be honest with you, because it's broken down in the stomach and by the through the liver, and so it really doesn't do much. But they have new formulations that are better absorbed. Um, the oral testosterone I'd say is more expensive. It's not insurance approved, but it um it does help with fatigue a little bit and sex drive. It doesn't, you don't really get them the levels to help with muscle mass with oral testosterone. So if you're looking just for some help with fatigue and sex drive, oral testosterone might work, um, but it's gonna be a little more expensive. It's usually several pills twice a day, so it's not the easiest thing in the world to do. But that just brings up the fact that there's a lot of supplements that say, well, let's take this, take this supplement orally and it'll increase your testosterone. Not so fast. I mean, a lot of those things are just broken down and they don't work. I mean, I had a partner who worked with a local pharmacy and he was taking, you know, a handful of supplements for like three months because it was going to increase his testosterone level, and his testosterone level actually went down. So I I had to laugh a little bit, but um I would you know be careful with people pushing oral replacement therapy for testosterone. Historically, those things don't really work well.

SPEAKER_00 54:02

Excellent.

SPEAKER_03 54:03

Cool. Well, this was a phenomenal conversation. Thank you for giving us the I mean, honestly, the the it was it was fun because uh as you said from the beginning of this episode, like before we started, you're like, I don't know, we put me on a camera, I'm not gonna be able to talk well. You've I didn't have to like put you back on track with notes. You were locked in. Like that was a very congruent, well thought out podcast on TRT.

SPEAKER_00 54:27

It's like he's done this for a while.

SPEAKER_02 54:29

Yeah, I um I I actually really like it, and I've learned a lot, you know, being uh part of the men's health clinic. And we really strive there to do what's best for people and do it the right way. You know, that's the key, is you want to do things that are um the right way. And um so yeah, it has become a passion of mine a little bit. And I uh honestly I'm on twestosterone replacement therapy myself, uh full disclosure. And I have been for about six years, and it's been uh really helpful in me as well. Yeah, I've I've really uh um done well at it.

SPEAKER_00 55:06

I do feel like in primary care there's so few things that we can actually like do this and it causes an improvement in symptoms in a short period of time. So testosterone is one that does that, which is nice.

SPEAKER_02 55:19

You're right. And there's a lot of medicines we use that are important, but people don't feel it, right? Like a blood pressure medicine, you know. Obviously, we try to avoid using at our practice, we try to avoid medications as much as possible. And most of our patients want that. Um, but you know, occasionally you have to take a blood pressure medicine, and you're not gonna feel a whole lot different typically. So it is somewhat rewarding. Infectious disease was a rewarding that way, because we give somebody an antibiotic and they'd get better, and you'd be I'm gonna die, I'm gonna ride the downward fever curve to glory. Uh but uh yeah, it is nice.

SPEAKER_00 56:01

Yeah, I guess your practice of infectious disease is the one field that does have some of that.

SPEAKER_02 56:06

Yeah, it does a little bit, which I did like that.

SPEAKER_00 56:09

Yeah. Um awesome. Anything else, David?

SPEAKER_03 56:12

Well, it was a pleasure. And uh hopefully as uh as you move towards the next week, we can get out and hit some hit some golf balls together.

SPEAKER_02 56:18

It's gonna be great. Uh I need to improve my game a little bit. Well, me too.

SPEAKER_00 56:23

I'm with you.

SPEAKER_02 56:23

Did you know she hit a hole in one last year? You did. Her first year golfing. Nice.

SPEAKER_03 56:28

I still have yet to have one.

SPEAKER_02 56:30

Yeah, I just went on a golf trip and one of the guys got a hole in one, so that was pretty cool. Um, I've seen about three of them. I've never had one. I've never had one.

SPEAKER_00 56:37

I said a patient tell me she has five. What? Five. And she's like, I'm not even that good. It's all luck.

SPEAKER_03 56:43

Oh my gosh. It's pretty good.

SPEAKER_00 56:44

Her husband only had two, so he was smidge irritated like you were.

SPEAKER_03 56:49

I remember when when okay, in the moment it was electric. When it happened, like we were excited. Afterwards, I was like, I'm super happy for you. I'm kind of pissed. I did that. All right, beautiful people. Well, hopefully, you got some great value out of this episode. If you have any type of specialty you would like to have on here in the future, um a physician in town or a specialty on questions or anything like that, we'd love to help facilitate that for you. And so comment down below anything you guys have. You guys have a phenomenal week, and we will talk to you later.