Optimize Your Testosterone
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Summary
In this episode, Dr. Kyle Gillette joins me to discuss testosterone and hormone optimization. Dr. Gillette is a family physician who specializes in hormone optimization, helping people have healthy hormones so they live a flourishing life. In this episode we discuss a quick overview of the different hormones that affect male health and how to optimize your testosterone. We then discuss what causes low testosterone in individual men, and how its decline in the general male population may be linked to both birth control and World War II. Finally, we discuss the risk and benefits of taking testosterone, and what young men can do to prepare for a lifetime of optimal testosterone and hormonal health.
Transcript
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Hey, this is Brett, we're taking a break from new episodes today, so we're rebroadcasting
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episode number 893, Optimize Your Testosterone with Dr. Kyle Gillette.
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We'll see you on Monday with a brand new episode.
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Brett McKay here, and welcome to another edition of the Art of Manliness podcast.
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When men think about optimizing their hormones, they tend only to think about raising their
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But while increasing T can be important, an ideal health profile also means having testosterone
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that's in balance with your other hormones as well.
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Today on the show, Dr. Kyle Gillette joins me to discuss both of those prongs of all-around
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We start with a quick overview of the different hormones that affect male health.
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We then get into what qualifies as low testosterone and how to accurately test yours.
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We also discuss what causes low testosterone in individual men and how its decline in the
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general male population may be linked to both birth control and the world wars.
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In the second half of our conversation, we discuss how to both raise testosterone and get
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rid of excess estrogen, including the use of some effective supplements you may never
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We then get into the risk and benefits of taking TRT, before ending our discussion with
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what young men can do to prepare for a lifetime of optimal T and hormonal health.
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After the show's over, check out our show notes at awim.is slash optimal T.
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All right, Dr. Kyle Gillette, welcome to the show.
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You specialize in obesity, but also hormone optimization, helping people have healthy hormones.
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And today I like to talk about hormones, particularly male hormones.
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I think when most people think about male hormone optimization, they think about testosterone,
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We're going to dig deep into testosterone today.
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But are there other hormones that affect male health that people often overlook?
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So even testosterone in and of itself, there's nothing unique about it compared to other androgens.
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Testosterone just happens to be the most well-known androgen.
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So there's DHEA, which is a very weak androgen.
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It's produced by the adrenal glands, which are small glands above the kidney.
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You don't have as much of it as testosterone, but it's vitally important for what's called
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secondary sexual characteristic development, like the deepening of the voice,
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growing facial hair, those secondary sexual characteristics, which are vital.
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And also, I think people often overlook estrogen plays a role in male health.
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Testosterone aromatizes and directly converts to estrogen.
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So the way to think about estrogen is the more estrogen, the better for your health,
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because it prevents things like heart attacks at a correct ratio to where you feel good.
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So we got to have some estrogen in there at the right balance.
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So SHBG is also known as androgen binding globulin.
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The liver makes most of it, but the testes also make some of it.
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And SHBG stands for sex hormone binding globulin.
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It most strongly binds DHT, and then it binds testosterone relatively strongly.
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And then estradiol, which is your main estrogen, even weaker than that.
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So think of this as regulating all of the hormones and keeping them more stable.
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The higher the SHBG, the more stable the level will be.
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Men produce a lot of testosterone during sleep.
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So the level is generally much higher in the morning.
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And you can actually have deficient levels of testosterone in the evening routinely.
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But normal levels in the morning, if you don't have enough SHBG,
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the most common cause of an SHBG deficiency is insulin resistance,
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which is often due to too many calories or too many carbohydrates and sugar.
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So what's interesting about all those hormones is they interact with each other.
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So if you raise the level on one, one might go down or up.
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So I think a lot of guys, they get too focused on,
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well, I got to increase this one thing or reduce this one thing.
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Well, if you do that, you're going to have these cascading effects that might not be optimal.
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I actually heard an advertisement from a TRT clinic this morning, and it said,
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new study shows that men with low testosterone are more prone to cardiovascular disease and early
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And I thought to myself, this is odd because they're implying that you need testosterone
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But of course, that is a logical fallacy because just replacing the testosterone without figuring
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out what's actually causing it in the first place.
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Not that TRT is wrong, but you need to figure out what the cause of it is and then address it.
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And I hope we can talk about TRT because I know a lot of guys are thinking about doing it,
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or maybe they are doing it, and they might have questions about that.
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So there's two ways to measure testosterone, or two measurements of testosterone that I read about.
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One is total testosterone and free testosterone.
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So first, what's the difference between the two?
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And as a clinician, is there a particular number you focus on?
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So total testosterone is a total amount of testosterone, whether it's bound or unbound.
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When testosterone is bound, it in general does not bind the androgen receptor, which is on the
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And total testosterone includes a testosterone bound to albumin, which is the main protein in
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the blood, and also SHBG, which we talked about earlier.
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But free testosterone, or any free androgen, is what is going to be what is actually binding
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to the receptor, and then it takes it into the nucleus of the cell, and then it binds
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to DNA to cause what's called gene transcription.
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So the androgen receptor gene that's on the X chromosome is then mostly activated by free
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Oddly enough, sometimes I make the analogy of plumbing.
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So you have a pipe, that's your bloodstream that takes testosterone everywhere, and then
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you have different types of cells, for example, a muscle cell or a brain cell or a germ cell
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in the testicle or a somatic cell in the testicle, which we don't have to get into.
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But anyway, the free testosterone level can be very different in the bloodstream, which
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is where we measure it on a blood test, versus inside the cell.
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So it is possible to have symptoms of low testosterone because you don't have enough androgen
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in the cell but have a normal level in the blood, it's rare, but it's possible, and the
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opposite is possible, to have a low level in the blood but still have enough inside the
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cell that's free to be causing normal gene transcription.
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Okay, so just to recap there, total testosterone is made up of bound and unbound testosterone.
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Bound testosterone can be bound to albumin or SHBG.
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And then when it's bound to those things, it can't attach to the androgen receptor in
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And so it can't be, can't have those changes on the cell.
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Free testosterone, unbound testosterone is free testosterone.
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So as a clinician, when you do a blood test on a patient, like what number is more important
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Like which one are you going to be focusing on more?
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I think both are equally important for athletic purposes, for muscle building purposes.
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Usually that's more correlated with free testosterone level.
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However, symptoms and how you feel is usually correlated more with total.
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Insurance companies and academic societies usually put more weight into total testosterone,
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partly because free testosterone are often measured inaccurately.
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So often it's more accurate to calculate your free testosterone using your total testosterone
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And then you estimate what your free testosterone is.
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Some societies say low testosterone is often best treated if you have one have symptoms and
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then two also have a testosterone below about 400.
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And I tend to agree with the level of 400 with a caveat if you have significant symptoms
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and with a second caveat if you cannot improve that naturally in any way after identifying
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I want to dig more into diagnosing low testosterone because there's lots of commercials out there.
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You just mentioned one or these businesses popping up where you can just go in and get
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So you mentioned two things you look at to diagnose low testosterone.
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And if it's below 400, coupled with if the patient is reporting symptoms of low testosterone,
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we'll talk about the symptoms of low testosterone here in a bit.
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I think a lot of guys out there, they think it's a panacea.
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If you just take a test, you take the test and it says, oh, well, your T is at 400.
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Why isn't one blood test alone sufficient to diagnose low testosterone?
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In general, testosterone levels can have what's called outliers.
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It's the statistical phenomenon, but it's especially true of testosterone where you
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could check it one time and your testosterone that morning could be low because the last
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two nights you've had poor sleep and poor diet and other lifestyle factors.
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Males that are generally seeking a TRT prescription know this very well because there's various things
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that you can do to artificially make your testosterone level look low that morning.
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So in general, the recommendation is to recheck it two to three times after, you know, good
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night of sleep and normal diet and whatever you're doing normally, not after you've dieted
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down to 7% body fat to do an ultra marathon or bodybuilding show, then your testosterone is
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But when you're at a healthy body fat and there's not an artificial something else that
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is going to make your testosterone look low, there's a runner.
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His name is Nick Bear, and he also is doing a bodybuilding show.
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And I saw that he got his total testosterone checked and he's a healthy guy.
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I'm not sure what his baseline testosterone is.
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And his total testosterone was right at 100 before his bodybuilding show.
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So that was obviously secondary to the caloric deficit.
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That wouldn't necessarily count as a testosterone reading that you could put stock in assessing
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But for most people, they probably won't be in a scenario like that.
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But it is important to get at least two readings.
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If you've been sick before, then maybe just postpone the blood test by a week.
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What symptoms are you looking for to diagnose low testosterone?
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So it could be anything from depression, anxiety to low libido is certainly classic.
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Low muscle mass is not really one that we look for.
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Testosterone levels that are naturally produced are not as correlated as people would think with
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body composition and muscle mass and athletic performance.
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So it's not uncommon to see a pretty high level athlete have a total testosterone of, you know,
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let's say 450 and let's say someone that has very low muscle mass and maybe even 20, 22% body fat to have
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But other things that you would look for seriously is, for example, erectile dysfunction, sexual health in general, sperm production.
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So if there's a patient that is having even subfertility, just a little bit of trouble getting pregnant,
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that individual should certainly have a test of his testosterone as well.
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So with low libido, how does a guy know if he has low libido?
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Because that seems like it'd be pretty subjective.
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Libido obviously has a lot of psychosocial factors as well.
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And a lot of times when you're testing these patients, you've known the patients for a while.
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But if they're telling you that it's low relative to what it usually is and no other factors of change, for example,
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you know, they've been married to the same person for five years.
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They're not actively going through problems in the marriage.
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There's not something else that would be affecting the libido.
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So that would usually come up in the social history.
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When you do a history and physical on a patient, it is important to dig into the social history to make sure
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there's not something else that is affecting the libido.
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So besides low libido, maybe lack of drive, what are the consequences of suboptimal male hormone levels, like chronically?
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Is it going to affect your cardiovascular system?
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If someone is significantly hypogonadal for a long time, they're at much higher risk of osteoporosis,
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which leads to bone fractures and even mortality as well.
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They're at higher risk of neurodegenerative disease, likely largely due to low estrogen.
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If you don't have a lot of testosterone, you're probably not converting a lot of it to estrogen.
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And if you're not doing that, then you're also at risk of cardiovascular disease.
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Estrogen is very cardioprotective and helps with the production of good cholesterol to help take cholesterol out of the plaque.
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So they've done studies and you look at one group of people that have true hypogonadism, which is generally two levels under 264 or so.
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And then one group you give TRT and then one group you don't give TRT.
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You would think that the group that you give TRT would have a shorter lifespan because androgens do cause excess production of quote unquote bad cholesterol.
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They do increase a particle called ApoB, which is the most important one to watch for cardiovascular risk.
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But the group that you give TRT actually has less heart attacks and strokes.
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Right, because what you were saying before, the testosterone creates estrogen and then the estrogen protects the heart.
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So let's talk about the causes of low testosterone.
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So excess calories, excess carbs, insulin resistance, high fasting insulin leads to the liver not producing SHBG.
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So you might be producing a decent amount of testosterone, but it's being metabolized so fast that it's difficult to use.
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The second most common, I think, is sleep apnea or obstructive sleep apnea.
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Obviously, that kind of goes hand in hand with metabolic syndrome, but often it goes hand in hand with PTSD.
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I saw a study on young men that had just gotten out of the military and they had been diagnosed with PTSD and they tested them all for sleep apnea.
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And something like 80% of them had sleep apnea and they were all under a BMI of 25.
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So there's certainly a lot of stress component as well.
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The limbic system includes places like the hypothalamus and the amygdala and downstream to that is the hippocampus and the amygdala.
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And that's some of the places of the brain that are involved in sleep regulation and breathing.
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So the theory is that apneic episodes don't just come from having a huge neck and excess body fat, but there are other factors like trauma at play.
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And when you have a patient with severe sleep apnea, they have a score called an AHI score.
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And if that score is very high, like 100 or 200, you almost always see deficient testosterone levels.
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Okay, so having metabolic syndrome, being overweight, sleep apnea, any other causes of low testosterone?
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Yeah, so theoretically, xenoestrogens could be a cause of low testosterone.
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These are also things like bisphenol A, also known as BPA.
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You might see BPA-free on water bottles from time to time.
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These do bind various estrogen receptors and are likely suppressive.
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By suppressive, I just mean they shut down the production of the hormones that lead to testosterone production to some degree.
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Heat damage is also kind of an honorable mention.
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Some people might be familiar with what varicose veins are.
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Varicocele is where there's varicose veins in the scrotum.
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And some people with varicocele can have venous cooling very well.
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The testes want to be about 91 to 92 degrees, where the body is 98.6 degrees.
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So if you can't keep your testes at 91 or 92, then you're going to have less testosterone production and less sperm production.
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And in the more severe cases, you'll have atrophy, which is shrinking because, think about them as factories.
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If you're not using the factory, they start to shut down.
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And besides these lifestyle factors, environmental factors, you could also have just an issue with your pituitary system, right?
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You might have a tumor or something in your pituitary gland that's dysregulating the release of hormones.
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I suppose that would be likely one of the more common, less modifiable risk factors.
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You can take supplements like vitamin B6 or like vitamin E.
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But a lot of times, pituitary microadenomas or even macroadenomas, basically, it's a small tumor in the brainstem.
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The pituitary gland is where you make a lot of different hormones, like growth hormone and like LH and FSH.
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But LH is the main hormone that's produced there that leads to testosterone release.
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So there's two different types of hypogonadism.
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So primary is where the testes are not functioning.
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And then secondary, think about it, it's two steps instead of one step.
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So the LH can be low in secondary hypogonadism.
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And if your LH is very low and a hormone like prolactin or IGF-1 is very high,
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then that might be a sign of a pituitary microadenoma, in which case you need an MRI.
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But LH mostly helps with testosterone production and mostly binds to the Leydig cell in the testicle.
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And FSH mostly binds in the seminiferous tubules and helps with spermatogenesis.
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So, I mean, listeners have probably heard reports that T levels in men have been declining in the past few decades.
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Do we know what's causing this sort of general decline?
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Is it just all these lifestyle, like people are getting fatter, they're not sleeping, they're stressed, and the stuff in the environment,
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is that kind of what we've decided is the cause of the lower T levels?
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The various causes that we've already discussed are likely the primary causes of what is causing declining testosterone levels.
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But I think there is another factor, and a lot of that has to do with what I'd call epigenetic drift.
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I might call it unnatural selection, where individuals with higher testosterone levels are no longer being selected for as early.
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And also, a lot of individuals are having kids later on in life.
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For example, in their 30s or even 40s, when you might have very different maternal and paternal hormone profiles.
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That's one of the reasons why I recommend if men are taking medications like finasteride or dutasteride,
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that they stop their finasteride 90 days before attempting conception.
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And they stop dutasteride, depending on what dose they are, usually six months before conception.
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By the way, spermatogenesis takes about 60 days or two months.
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That way, they have enough time to wash out before they start producing the sperm in the germ cells,
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so that they wouldn't pass down any epigenetic changes to potential offspring.
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Okay, so maybe the idea is that, again, this is theoretical, right?
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The testosterone increases aggression and risk-taking behaviors,
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and that's not as adaptive in our safe, high-tech, modern landscape.
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So men with lower testosterone might be more successful these days,
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And then when they have children, the men pass down his genes,
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and then his children have lower testosterone too.
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And that just perpetuates just lower testosterone in the male population overall.
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I've heard that, I read this somewhere, correct me if I'm wrong on this,
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that women on birth control, they're not attracted to higher testosterone men.
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Yeah, that is one of the major players of what I would call unnatural selection.
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Another interesting unnatural selection, I suppose,
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if you look at, not very recently, but the World War,
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but especially wars that, even if a war has a draft,
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the individual that has higher testosterone and also more sensitive androgen receptors,
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so this is probably true throughout all of human history,
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you would, and this obviously cannot be proven scientifically,
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but theoretically, that individual would be more likely to volunteer
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to go to the front line or to very risky positions.
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And if that male passes away at age 18 or age 19,
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What you're saying is that men with very high testosterone,
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and in doing so, that may take them out of the gene pool
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And there's more opportunity for that sort of risk-taking
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during big global conflicts like the World Wars, right?
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they lose the chance to reproduce and pass on their genes,
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and then that just contributes to the declining testosterone in men in general,
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and that's going to have echoes through the generations.
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we just have selection factors going on in the mating market as well.
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Yes, and it's not like it's an be-all, end-all,
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You select for high testosterone or you select for low testosterone.
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There's a lot more psychosocial factors at play,
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but we are certainly seeing that there's likely a decline in testosterone
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maybe things like xenoestrogens are playing some part in this,
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is it like keeping your laptop on your lap sitting down a lot?
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directly over your scrotum is certainly not going to help.
00:23:14.060
I suppose someone could prove this at some point.
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and they've randomized two groups of usually college students.
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And one group they have where basically like a sock
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around their scrotum that has something really warm in it.
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So they warm up the scrotum artificially to 98 degrees
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And in the individuals that don't have varicocele,
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So that did not affect their testosterone production
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However, in individuals that already have impaired venous cooling,
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for example, with varicocele or varicose veins,
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Let's talk about optimal levels of testosterone.
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and if you're experiencing low testosterone symptoms,
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I say that word a lot because health is individualized.
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and we have different growth and development past that as well.
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an optimal testosterone level is between about 500
00:25:00.920
So a lot of times their free testosterone is only 20 or 25.
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top-in endogenously naturally without medication.
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I mean, you mentioned there are athletes who are at 450
00:25:16.400
So if you get a blood test and it's below 500 a little bit,
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then I'm worried about the pituitary or the brain.
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then I'm worried about the health of the testicles.
00:26:13.180
So you have estradiol, which is your main estrogen,
00:26:27.260
which converts testosterone to estrogen, by the way.
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Beyond that, I'd like to, if pertinent, do an exam.
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When you're essentially adult growth and development
00:27:17.500
So if their prolactin is just a little bit high,
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It basically helps you excrete it through your stool.
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you're going to be primarily doing lifestyle changes, right?
00:28:07.580
and a lot of times your testosterone production
00:28:21.740
And occasionally I'll utilize very short courses.
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or maybe two weeks of selective estrogen receptor modifiers,
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that you're trying to stimulate endogenous production.
00:28:42.920
Besides diet, exercise, sleep, managing stress,
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Are there ones that you recommend for just any guy
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who maybe they don't have any problems with their testosterone,
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Are there ones that you like and that are safe?
00:29:00.520
Creatine, five to 10 grams a day would be a great start.
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to make sure that they're binding up extra estrogen
00:29:44.420
if you take boron for a very long period of time.
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because they tend to be relatively high in boron.
00:29:59.020
There's another something I've been hearing about lately,
00:30:00.500
Tunggat Ali, I think that's how you pronounce it.
00:30:06.740
So Tunggat's active ingredients are Uri peptides,
00:30:14.760
because it upregulates a couple different enzymes
00:30:23.060
And it looks like the cause of the mixed results
00:30:25.580
is sometimes people have great activity of those enzymes.
00:30:51.660
that are also upregulated by insulin and IGF-1.
00:30:57.920
or if you're trying to lose weight or body fat,
00:31:12.660
that was pushed for increasing testosterone levels.
00:31:24.300
there'll be an enzyme called alkaline phosphatase.
00:31:33.080
the more likely you are to have insufficient levels
00:31:37.280
That's why when I have input to various companies
00:31:39.820
designing a supplement to optimize testosterone,
00:31:49.860
Think about trying to optimize your testosterone
00:32:44.140
At any point when the risks outweigh the benefits
00:40:32.980
And that might be one of the most common causes
00:41:04.540
That makes something like a calcium deglucrate.