Huberman Lab - How to Optimize Your Hormones for Health & Vitality | Dr. Kyle Gillett

Starting point is 00:00:00 Welcome to the Huberman Lab podcast, where we discuss science and science-based tools for everyday life. I'm Andrew Huberman and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine. Today my guest is Dr. Kyle Gillette. Dr. Gillette is dual board certified in family medicine and obesity medicine

Starting point is 00:00:22 and practices out of a clinic in Kansas and via telemedicine. He provides full spectrum medicine, including hormone health, preventative medicine, obstetrics, which is the branch of medicine and surgery concerned with childbirth and the care of women giving birth and pediatrics. I first learned about Dr. Gillette from a podcast of all things and was immediately struck by the breadth and depth

Starting point is 00:00:43 of his knowledge on all things, hormones and hormone optimization. As you'll see very soon today, Dr. Gillette can teach you how to optimize your hormones using behavioral tools, nutrition, exercise-based tools, supplementation, and hormone therapies if those are appropriate for you. There are many professionals out there, there, including many medical doctors, of course, talking about hormone health.

Starting point is 00:01:06 What really sets Dr. Gillette apart from the pack is his ability to understand how the different factors that I described before, nutrition, supplementation, exercise, and hormone therapies, how those interact with one another, and the safest and most rational ways to approach hormone optimization. During today's episode, you will learn

Starting point is 00:01:24 how to optimize your hormones, not just testosterone and estrogen, but also prolactin and other hormone pathways that impact your mood, mental health, and physical health. Dr. Gillette is also an avid educator about hormones and other aspects of health. He does this on zero cost to consumer platforms,

Starting point is 00:01:40 such as Instagram and other social media. On Instagram, he is Kyle Gillette MD. That's K-Y-L-E-G-I-L-E-T-T, no E at the end, MD. So Kyle Gillette MD on Instagram, and he is Gillette Health on all other platforms, including LinkedIn, Twitter, YouTube, TikTok, and Facebook. If you go to his Instagram or his other social media, you will learn

Starting point is 00:02:02 a lot about hormone health, about the latest science impacting obesity and metabolic health. He is a wealth of knowledge and again, he's providing all that information at zero cost to you, the consumer. What you are soon to hear is a conversation between me and Dr. Gillette

Starting point is 00:02:17 about all things hormones and hormone health and hormone optimization. We dive deep into mechanisms, but we are clear to establish what each word or set of concepts mean. So if you have no background in biology or even if you do, I'm sure that you'll come away with a wealth of valuable knowledge.

Starting point is 00:02:35 We also talk about specific protocols related again to lifestyle factors, nutrition, supplementation, and where appropriate hormone replacement therapy. I know there's a lot of interest about these topics. Dr. Gillette is very thorough about addressing both male and female issues and addressing hormone health for people at all stages of life. I'm sure that you will come away from this episode with the same impression that I did,

Starting point is 00:02:58 which is that Dr. Gillette is an extraordinarily clear communicator, and that he has tremendous compassion for his patients and that he has a deep love of understanding biology and medicine in ways that can benefit you. Before we begin with today's episode, I want to emphasize that this podcast is separate from my teaching and research roles at Stanford. It is, however, part of my desire and effort

Starting point is 00:03:19 to bring zero cost to consumer information about science and science related tools to the general public. In keeping with that theme, I'd like to thank the sponsors of today's podcast. Our first sponsor is Athletic Greens. Athletic Greens is an all in one vitamin mineral probiotic drink. I've been taking athletic greens since 2012,

Starting point is 00:03:37 so I'm delighted that they're sponsoring the podcast. The reason I started taking athletic greens and the reason I still take athletic greens once or twice a day is that it helps me cover all of my basic nutritional needs. It makes up for any deficiencies that I might have. In addition, it has probiotics, which are vital for microbiome health. I've done a couple of episodes now on the so-called gut microbiome

Starting point is 00:03:57 and the ways in which the microbiome interacts with your immune system, with your brain to regulate mood and essentially with every biological system relevant to health throughout your brain and body. With athletic greens, I get the vitamins I need, the minerals I need, and the probiotics to support my microbiome. If you'd like to try Athletic Greens,

Starting point is 00:04:15 you can go to athletic greens.com slash Huberman and claim a special offer. They'll give you five free travel packs, plus a year's supply of vitamin D3K2. There are a ton of data now showing that vitamin D3 is essential for various aspects of our brain and body health, even if we're getting a lot of sunshine, many of us are still deficient in vitamin D3.

Starting point is 00:04:34 And K2 is also important because it regulates things like cardiovascular function, calcium in the body, and so on. Again, go to athletic greens.com slash Huberman to claim the special offer of the five free travel packs and the year supply of vitamin D3K2. Today's episode is also brought to us by Inside Tracker. Inside Tracker is a personalized nutrition platform

Starting point is 00:04:54 that analyzes data from your blood and DNA to help you better understand your body and help you reach your health goals. I've long been a believer, in getting regular blood work done for the simple reason that many of the factors that impact your immediate and long-term health can only be analyzed from a quality blood test.

Starting point is 00:05:10 There are a lot of blood and DNA tests out there, but a major issue with many of them is that you get numbers back about levels of hormones, metabolic factors, lipids, et cetera, but you don't know what to do with that information. Inside Tracker has solved that problem by creating a personalized dashboard. So you take your blood and or your DNA test,

Starting point is 00:05:29 you get the results back, and, where certain values might be too high or too low for your preference, you can click on that and it will direct you immediately to lifestyle factors, nutrition, supplementation, et cetera, that can help you bring those numbers back into the ranges that are ideal for you.

Starting point is 00:05:46 So it not only gives you information about where your health stands, it gives you directives as to how to improve your health. If you'd like to try InsideTracker, go to insidetracker.com slash Huberman to get 20% off any of InsideTrackers plans. That's inside tracker.com slash, Huberman to get 20% off. And now for my discussion about hormone health and optimization with Dr. Kyle Gillette.

Starting point is 00:06:08 Dr. Gillette, welcome. Thank you for having me. Well, I'm super excited to talk to you because I found out about you on a podcast, and it immediately became clear that you are an encyclopedia of knowledge about hormone health for men and for women across the lifespan. So I have many, many questions. but before we dive into those questions, I'd love to just get a little bit of your background

Starting point is 00:06:35 in terms of your medical training and what your particular orientation is toward treating your patients. And how do you think about this whole landscape that we call hormone health? What is a hormone? How do you envision people managing their hormones? If you could just kind of fill in a few of those blanks for us,

Starting point is 00:06:54 I think a lot of people would appreciate it. Absolutely. So I'm dual board certified in family medicine and obesity medicine. I've kind of tailored my training in order to provide what I call a balanced approach to total health, which includes body, mind, and soul.

Starting point is 00:07:12 I recently saw a podcast with Joe Rogan and Mr. Beast, and Joe asks Mr. Beast, how do you become such an amazing YouTuber and have all these great clickbait videos and how did you become good at it? And it turns out he just became obsessed when he was a teenager. and that's essentially how I've tailored my education as well.

Starting point is 00:07:34 I've become obsessed with optimal human performance, their body, their mind, and even their spirit. So I attended med school at the University of Kansas, which is one of the few med schools that still emphasizes full spectrum care. They emphasize exercise as medicine. They emphasize food as medicine, of which I was active in both of those interest groups. In residency, I was active in a lot of mindfulness curriculum, and then also things like walk with a dock where you emphasize preventative medicine. That's something that we've kind of got

Starting point is 00:08:05 away from and that niche led me to hormone health. It didn't really start as hormone health, but it's a very important component of health in general that many people don't emphasize. Great. Well, this idea of preventative medicine, I think, is starting to really take hold in the general population, especially given the events of the last few years. People realize that they are showing up to health challenges at a bunch of different levels and with some people feeling very robust, other people feeling back on their heels. When someone comes to you as a patient, what are some of the first things that you want to know about them? I mean, obviously, you want to know their blood pressure, you want to know something about their mental health and family

Starting point is 00:08:46 history. But in terms of hormone health, what are the sorts of probe questions that you ask and what are you looking for? And I ask this because I'd like people to be able to ask some of these very same questions for themselves. Yeah. So when you do a physical exam and a history, you have a lot of different parts. You have your history of present illness if they have a complaint. Maybe the patient doesn't have a complaint. In that case, things like their social history and their family history are extremely important because that gives you an insight into their genetics and an insight into their hormone health. So a patient will tell me, oh, I'm doing okay, but it helps to ask them, well, how are you now? Let's say the patient is 50. How are you now versus when you were 20 and what has changed? So I've gotten a question a lot. How do you get your doctor to order a better lab workup or to even include your basic hormones? And there's no magic answer to that. But what really helps is you tell them, you know, my energy is not as good as it used to be. My focus is not as good as it used to be. My athletic performance is not as good as it used to be. So you don't have to have to have.

Starting point is 00:09:53 have a pathology in order for a lab to be indicated, you just need to have that pertinent symptom. I think that's going to be really helpful because for many people, the idea of getting a blood test to look at their hormones just seems like such an enormous hurdle to get over, and many doctors won't prescribe them. And would you say that it's using the approach you just described, that it's equally effective for men and women, or do you find that for one reason or another that men and women have different challenges and advantages in trying to access their deeper hormone data? Yeah, it's slightly different. With women, there's a lot more objective data. So if they're having menstrual irregularities or, you know, if they're going in, if they're not having a period,

Starting point is 00:10:40 if they're having too heavy of periods, then those are things that they talk about very frequently with their doctor. Men are more hesitant. So men really want to know what their testosterone is. but at the same time, they really don't want to tell their doctor how their libido is or how their energy is because it's almost like they feel less masculine or they feel less like a guy when they say that, even if they're just talking to their doctor about it. Yeah, I think that that raises a really important point, which is that the whole discussion around hormone health is a bit of a barbed wire topic because in many ways when we hear the word hormone, we think testosterone and estrogen, we think notions of masculinity and femininity.

Starting point is 00:11:22 And of course, testosterone and estrogen are present in all sexes, right? All chromosomal backgrounds. And just to varying degrees and ratios. But it also raises all these issues about sexual health that it's kind of interesting because I'm surrounded by medical doctors in my lab at Stanford. And the more physicians that I surround myself with, the more open is the discussion around sexual health and reproductive health. But in the general population, I think some of these topics are a little bit taboo or against kind of barbed wire.

Starting point is 00:11:52 And so I think that people are seeking a lot of this information on YouTube and through communities that may or may not be very educated about the actual biology. So along those lines, you know, we could probably assume that hormones are changing across the lifespan, I think, right? Certainly from childhood and puberty and onward.

Starting point is 00:12:10 If you would, I'd love to just kind of take a snapshot of what you think everybody should be thinking about or doing to optimize their hormone health, male or female, in the, let's say in their 20s. And then maybe we could migrate that to their 30s and 40s. But before that, could you just tell us what everyone should be doing for their hormone health from puberty onward? Yeah. The law of diminishing returns applies. So doing a little amount of what I call lifestyle interventions over a long period of time is going to be far more helpful or efficacious than doing a lot and then doing nothing or doing a lot and then doing nothing. So I talk about the big six pillars. The two strongest ones are likely diet and exercise. For hormone health,

Starting point is 00:13:02 specifically resistance training is particularly helpful. For diet, caloric restriction can be particularly helpful, especially with the epidemic of metabolic syndrome that is continuing to on go in this country and in developed countries in general. So those are the two most powerful. So number one and number two are diet and exercise. For the last four, I have a little bit of alliteration. So there's stress and stress optimization that has to do with cortisol, that has to do with your mental health, that has to do with societal health and collective health of your family as well. when you're a member of a family or even a very close friend, trying to achieve optimal health together is very important.

Starting point is 00:13:47 It's the same thing with nicotine cessation. It's the same thing with hormone optimization. If you do it as a household unit, it's far more helpful. So after stress, you have sleep optimization. Sleep is extremely important, especially for mitochondrial health as well. And then you have sunlight, which encompasses anything that's outdoors. So you move more, you have cold exposure, you have heat exposure. That's sunlight.

Starting point is 00:14:12 And then the last one is spirit. So that's kind of the body, mind, and soul. If you have all the other five, they're dialed in completely, but you don't have your spiritual health, whatever you believe, then that's going to profoundly impact your body and your mind as well. Yeah, and we're definitely going to touch into this notion of spiritual health because I think for some people that might draw connotations of certain things that may or may not be accurate, but I know a number of academic laboratories that are focused on this and a number of,

Starting point is 00:14:43 not just functional medicine clinics, but research clinics and hospitals throughout the country that are achieving some really interesting data, not just in people that are quite sick, but in healthy people that are trying to further optimize health. So we will definitely touch back to that. If you would be so kind as to maybe give us a little bit more, more detail about some of these other areas. So when people hear diet, I immediately think, okay, now we get into the combat around vegan, plant-based, carnivore, et cetera. But I think that my general view of this is that most people should probably be eating as

Starting point is 00:15:19 few highly processed foods, highly palatable foods as possible, which doesn't mean eating foods that don't taste good, of course. But what other sorts of things do you recommend in the realm of diet? And then I also want to know about caloric restriction Because my understanding is that a caloric surplus can actually support certain hormones like testosterone So how does one combine caloric restriction and still optimize hormones? But what would you say is it a really terrific way to think about an approach diet? Yeah, diet should be an individualized approach.

Starting point is 00:15:51 So if you have a car, each car is made different and requires a different sort of fuel, whether it's a race car, whether it's a diesel truck, they have different fuels for different performance outcomes. So if you're trying to tow something or you're trying to go fast. So it's the same way with athletes. It's pretty well studied the more intra-workout carbs ultra-long-distance athletes take. In general, they do better.

Starting point is 00:16:16 I think they've studied this in cyclists quite often. It also depends on your genetics. So you can have a genetic polymorphism and you metabolize carbs and sugar better. even when they're unopposed by fiber. How does one determine whether or not they have such a polymorphism? I mean, I'm an omnivore, so I do eat some high-quality meats, not in huge quantities, but I also eat vegetables and starches.

Starting point is 00:16:39 I feel fine. I've never done an elimination diet. I think I did a very low-carb diet once, and all it gave me was a lot of psoriasis and poor sleep, so I backed off. I probably didn't do it correctly, but I know a lot of people that do quite well on a very low-carb or zero-carb diet. Yeah, particularly,

Starting point is 00:16:56 those who are at risk of cancer because you have less glucose that can be easily uptaken into cells and then also people with autoimmune diseases they tend to do well on our on lower carb diets yeah but yeah as far as the how do you know basically you can use your biofeedback how you're feeling to guess what you tolerate well or you can just get genetic testing which can be fairly expensive but most of all it requires a physician or someone who knows how to interpret the test accurately. And if someone had the means or would you say that getting regular blood testing is a good idea? And if so, what is regular blood testing? Is it every three months?

Starting point is 00:17:36 Is it every six months? Of course, the backdrop of life is changing too, stress levels, et cetera. Yeah. Every three to six months for preventative purposes, at times you need blood tests at faster frequencies than that. and then you should also get a blood test when you're fasting and when you're not fasting. So if you're looking for damage to the beach, you don't just look at low tide. You look at high tide and you see what's happening at high tide as well. It's a great way to put it.

Starting point is 00:18:03 And in terms of general recommendations around exercise, I mean, I'm of the mind based on the data that I've seen that almost everybody should or everybody should be getting 150 to 180 minutes minimum of zone two cardio per. week that kind of could continue while having a conversation, but with if one were to exert any more effort, it would have a hard time getting the words out, at least that, right, for cardiovascular health and general brain health and musculoske skeletal health plus resistance exercise. Is that more or less the contour of what you recommend? Yeah, that's more or less the contour. The more you're doing your zone two cardiovascular exercise, the slightly less important a long duration of caloric restriction is. Interesting.

Starting point is 00:18:50 And that brings us to caloric restriction. So it's very clear that caloric restriction can allow one to lose weight, right? This is the classic Kiko, C-I-C-O, calories in, calories out. We are not disputing calories in, calories out. Somehow that always has to be stated 50 times in any forum because of whatever follows, people I think will anchor to and assume that we don't mean that. But I know you and I both agree on calories in, calories out, as a fundamental law of thermodynamics.

Starting point is 00:19:18 But it's clear to me that, based on what I've read, that when one is in a slight caloric surplus, that hormones like testosterone can be optimized, but is that true for somebody who's showing up with excessive body fat? How does this all work? Because body fat is manufacturing enzymes that convert testosterone to estrogen. So in other words, how does someone know

Starting point is 00:19:40 if they should use caloric restriction or avoid caloric restriction? Yeah. Here's how to parse that out. So before I delve into the details a bit more, I should say as a board-certified obesity medicine physician, obviously the laws of thermodynamics apply. And then in addition to that, there is nothing special about intermittent fasting or chloric restriction or exercise when it pertains to losing body weight in general. When you do lose weight, about 33% of that is lean body mass and about 10% of fat cells. you know, adipose cells are actually lean body mass as well, because it has proteins and water and things like that in it too. So the reason for exercise and the reason for caloric restriction

Starting point is 00:20:27 in general, including intermittent fasting, is health reasons. That's how you increase your health span. It's not necessarily going to make the weight on the scale change, but that doesn't matter as much. It's been fairly well studying in both mice and humans. It's much easier to study in mice. So that's a precursor to are six types of people, the ones that care about my studies and the ones that care about human studies. But if you chlorically restrict mice by 40%, then they can have improved testosterone parameters, but only if they're obese to start. And it appears to be that same way in humans as well. So the easy way to think about it is if you're obese or you have metabolic syndrome, caloric restriction will improve your testosterone. There has been a study, and they talk about all

Starting point is 00:21:14 these studies in a systematic review from the Mayo Clinic proceedings in March of last year. And they note that there is a study in young healthy men and they chlorically restrict them and their testosterone does decrease. So if you're young and healthy and you don't have metabolic syndrome, then chloric restriction will likely decrease your testosterone. That clarifies a lot for me and I believe it will clarify a lot for other people as well. And I'm delighted that you pointed out this distinction about intermittent fasting, not being the only way to achieve caloric restriction. There are a number of young, healthy or older healthy people I know who like using intermittent fasting, even if they're not trying to lose weight for a couple of reasons. Some believe that it might extend lifespan.

Starting point is 00:22:03 I think that's still a bit of an open question. It's a bit of a hard experiment to do because the control group is, no one wants to be in the control group, as I say. It does in mice. Right, exactly. Captive audience. Exactly. And the other feature of it that's a little bit tricky is that many people like intermittent fasting because of the mental effects, the clarity of mind that they feel during fasting,

Starting point is 00:22:23 the increased pleasure in eating when they finally do eat. And here I'm referring to intermittent fasting of the sort where eating windows are anywhere from 8 to 12 hours a day, not extended fast of 24 hours or more. So the question, therefore, is for the health, the lean enough person, right, non-obese person, is intermittent fasting a bad idea in terms of hormone health, is oscillating between this period of kind of feast and famine within a 24 hours a problem if one is getting sufficient calories to maintain weight? Yeah. So if they're in a caloric maintenance, then it's not going to be, it's not going to be deleterious. It's not going to be

Starting point is 00:23:06 bad for their hormone health. There's a couple different hormones that we can talk about. We can talk about testosterone, we can talk about DHEA, which you usually go hand in hand. And then we can also talk about growth hormone, which is not a steroid hormone, but it's a peptide hormone. So it's a chain of proteins, amino acids that are put together instead of a sterol. Think of sterile hormones as coming from cholesterol. So intermittent fasting, you do get a little spike in growth hormone after you eat, but you also get a huge spike in growth hormone, a more significant, less negligible spike overnight and that is improved if you are intermittent fasting.

Starting point is 00:23:49 So it's probably going to help your growth hormone and subsequently IGF1 levels, which will help more in older age groups than younger age groups. And I like to eat dinner. So for me that means sometime around 6 or 7 o'clock, sometimes 8 o'clock. I confess last night because I was working late. I ate pretty big.

Starting point is 00:24:09 I was basically my only meal of the day. At 10 o'clock, that's a rare thing for me. Can I still achieve a high degree of growth hormone output if I, let's say, I avoid food in the two to three hours before going to sleep? Or does one have to be very deep into a fast in order to achieve the increase in growth hormone? There's still pretty good growth hormone output, even if you eat two or three hours before you sleep. it's just the law of diminishing returns. The longer you go, you get slightly more and slightly more. Great.

Starting point is 00:24:40 And I know a number of people think of growth hormone in the context of the exogenous growth hormone and the fact that that can in some cases be associated with cancers. I've been asked many times before, can the increase in growth hormone from things like saunas or intermittent fasting cause levels of growth hormone that are so high that they cause cancers? my impulse is to say no, that seems like it's not likely to happen, but I should probably verify that statement with you. Yeah, so quite unlikely. I think about growth hormone and especially IGF1. And there's actually an IGF1 and IGF2, but I think about it in terms of endocrine IGF1,

Starting point is 00:25:22 mostly IGF1 that's synthesized in the liver and released in the liver versus IGF1 that's released. Classically, an example of this would be your IGF-1 levels increase after resistance training or exercise. And that's more of like paracrine or autocrine, and they have more local action. So that IGF-1, it's pretty well studied that if you just give people IGF-1, it's not going to, at physiologic levels, it's not going to improve their body composition. However, that IGF-1, that's autocrine and paracrine, just working in those local tissues and muscles, is likely part of the reason why you get a improved body composition response after exercise. I see. And just to clarify for me and for others, what can we say are the major functions of IGF1 and IGF2 that are distinct from just growth hormone?

Starting point is 00:26:16 Are they just kind of the active form of growth hormone, the kind of the pickax end of the assembly line? So they have a much longer duration of action. I believe the half-life of IGF-1 is several days, almost a week, whereas growth hormone has an extremely fast half-life of only hours. So growth hormone acts significantly on the liver to produce IGF-1. So it's around in the serum in the blood long enough to where it's producing an effect pretty much all the time. Very interesting.

Starting point is 00:26:54 Well, and then your other pillars, stress, you know, we've talked a lot about stress on this podcast before and tools for managing stress. Sleep, obviously, is a big one. I think, you know, if nothing else, I will either put people to sleep with my podcasts, certainly not this one, but my solo episodes, or hopefully convince people that sleep is the foundation of mental and physical health and performance. Are there any aspects of hormone optimization that can improve sleep? I know sleep can improve hormone optimization. but are there any aspects of hormone optimization that can improve sleep? And for people that are suffering from this common syndrome of going to sleep and then waking up at three or four in the morning, we know that can be associated with depression. But are there any hormonal indications that might lead to that kind of situation? Yeah. There's three big ones.

Starting point is 00:27:44 The first one is not super common, but it's a very direct correlation. If you have a growth hormone deficiency, a true deficiency, whether you're an adult or a child, then your sleep is likely going to be affected. And let's say you're a child with growth hormone deficiency. Once that is replaced with therapy, your sleep is going to get significantly better. The second one that's a very common scenario is if you're having what's called vasomotor symptoms of menopause or vasomotor symptoms of andropause, which are also applicable. And that's where your progestogenic activity, so your main progestogens, are progesterone and then pregnant alone,

Starting point is 00:28:27 and then five alpha, three alpha, progesterone. Where are those manufactured in the body? So they're manufactured in a few places. In men, they're manufactured some in the testes, in the latex cells. In women, they're manufactured in the ovaries until menopause. And then they're also manufactured in the adrenal glands. So if you're in, if you're pre-adrenalposal,

Starting point is 00:28:52 where your adrenal glands are still working fairly well, usually still have a decent amount of progesterone around, and this can be measured too. So after menopause, women make progesterone from their ovaries, or sorry, from their adrenal glands. If that progesterone crosses the blood-brain barrier, especially if it's 5 alpha and 3-alpha reduced, so it's modified a little bit, then it is both a GABA agonist, which helps sleep, just like GABA does, gamma-amino-butyric acid, the main inhibitory neurotransmitter, of which lots of things work on.

Starting point is 00:29:27 Alcohol works on GABA as well. GABA-Pentin also works on GABA. Migraine medicines, many of them work on GABA. Benzodiazepines and also non-benzos. So an example of a benzodia would be Xanax. An example of a non-benzo would be Ambien. So those all work on GABA. So GABA is also helped by the progester,

Starting point is 00:29:50 progestogenic activity as well. That's why a lot of women in menopause feel like their sleep is much worse is because they have lower activity of those progestogens. And for men in so-called andropause, low testosterone is that also one of the causes of poor sleep? Low testosterone can lead to poor sleep, but my third scenario is actually, if a man begins TRT, then they develop poor sleep because of sleep apnea. It drastically, raises the risk that somebody is going to have sleep apnea. And then a lot of people, especially when they first start it in the first month or two, it puts them into this hypersmpathetic state because they have overactive androgen receptors, especially after a long time of being hypogonatal.

Starting point is 00:30:37 Then they have a physiologic dose of TRT, and that causes the sleep issue itself. Interesting. I have a lot of questions about TRT testosterone replacement therapy. I should just mention when you say it increases sympathetic activity. You don't mean that taking testosterone increases sympathy for others. It may in fact do the opposite, although it's very clear from my discussions with my colleagues on the endocrinology side and also with the great Dr. Robert Sapolsky

Starting point is 00:31:09 that increasing testosterone merely exacerbates existing features of people. So the jerks become bigger jerks, kind people become even more kind in general. But I want to get into TRT in depth. But it's very interesting to hear that testosterone replacement therapy increases the risk of sleep apnea. And I want to make sure that I ask that,

Starting point is 00:31:31 is that also the case in people that are using TRT who are not hypogonadal? Because in the classic situation, as somebody isn't making enough testosterone, they're below 300 nanograms per deciliter on the chart, they go in and take TRT. But many people nowadays, let's be honest, are taking doses of testosterone.

Starting point is 00:31:48 even though they are in the sort of standard range because the range is so large because of other symptomology. Is that right? Yeah. I do love the analogy that Dr. Sapolsky had about monks taking testosterone and making them more and more generous. So that does appear to be what testosterone usually does is it exacerbates, if you will, what you're previously like. So it's not going to change you as a person. But if you're eugenaddle before you start testosterone, you see. Meaning you have normal testosterone and then you start TRT or self-administered TRT, steroids, however you want to look at it, then your risk of sleep apnea still goes up in a dose-dependent fashion. So the higher the dose, the more risky.

Starting point is 00:32:35 With the sympathetic and the parasympathetic nervous system, the sympathetic is the fighter flight nervous system. The parasympathetic is the rest and digest. So if you have too much fighter flight and stress can cause that too, then you're not going to rest as well at night. I want to touch on testosterone and women because there is testosterone and women. I'd like to know where that testosterone comes from, which tissues. I'd like to know whether or not testosterone replacement therapy makes sense in women. I'm hearing more and more about women using testosterone. And I'd like to know whether or not knowing a woman's testosterone, for her to know her testosterone

Starting point is 00:33:12 is of equal, less than, or more value than knowing, for instance, progesterone. and estrogen levels because I think there are a lot of misconceptions about the roles of testosterone and women. For health optimization, testosterone is just as important to know. For pathology prevention, for example, breast cancer, osteoporosis, estrogen and progesterone are more important to know. So when you're thinking about women, women think that they have such a tiny amount of testosterone because you test it, most people test a free testosterone.

Starting point is 00:33:44 So testosterone that's unbound, which is by far the, the, smallest proportion of testosterone. Any androgen is bound by lots of different steroid binding proteins, but the ones that are most pertinent are called SHBG or sex hormone binding globulin. And that binds the androgenic steroid, for example, Dht or dihydro testosterone. It's associated with prostate enlargement, associated with male pattern baldness. It binds that the most strongly. And then it binds testosterone next most strongly. And then it binds things like, like androstinidione or DHA, dehydro, epiandrostrone. And then it binds the estrogens, the weakest, like estradial.

Starting point is 00:34:28 So if you look at the total amount of testosterone, women actually have almost all women, not all women, but almost all of them have significantly more testosterone than esteradial. But it's because it's in different measurements. So esterdial a lot of time is, you know, grams per mill, as opposed to nanograms per deciliter. So women have more testosterone than estrogen and significantly more D-H-E-A than either.

Starting point is 00:34:58 Interesting. Do women make dihydro-testosterone? Yeah. And where does this testosterone come from? Because they don't have testes. Yeah. So most testosterone and women that are pre-minopausal can come from thika cells, T-H-E-C-A. So thika cells are cells in the ovaries

Starting point is 00:35:15 that can produce testosterone. And a lot of people have actually heard about hyperthecosis, not the term itself, but a lot of Olympians that are, their chromosomes are X, Y, they're females, and they're not taking any PEDs. Wait, they're X, Y, but they're females. Or sorry, they're X, X, X, yeah, thank you. So they're X, X, they're not X, Y. And they have never transitioned or been on any sort of hormone replacement or testosterone, but they naturally produce a huge amount of testosterone.

Starting point is 00:35:47 testosterone as much as many men. And some of these women, I believe they were from Botswana, were banned from competing in the Olympics in certain distances. I believe they were banned from the 400 meter and 800 meter because their natural testosterone was deemed to be too high. So they mistakenly thought that they were using steroids? They actually knew they were not using steroids. They knew it was their thika cells were just genetically gifted, I suppose, and they still made them change distances. Wow. So one or two of these athletes changed to, I believe it was the 3K or the 5K. And they still did quite well, but it was not their best event. Interesting. Yeah, that's turning out to be a very interesting

Starting point is 00:36:27 and controversial area of this notion of hormone therapies and natural variation in hormones on different chromosomal backgrounds. Fascinating, we should probably do a whole episode about that because it's very much of the times. So men and women both make DHD. I'd like to ask about D.HT in men. we hear about testosterone and men and free testosterone and being the unbound form, of course. But dihydro testosterone, where does it come from in men? What is the cascade of events that takes testosterone to dihydro testosterone? And what are some of the quote unquote positive and negative effects of here I'm only referring to endogenous dihydro testosterone?

Starting point is 00:37:12 And in fact, I'll make it very clear whether or not I'm talking about taking about taking something or one's own natural production. Here we're just, I think up until now, we've just been talking about natural production. So tell us about DHT and men. It's such a powerful hormone during development, obviously. But what is it doing? DHT is a very androgenic hormone. So whether you're talking about DHA, which is a mild, a weak androgen, or testosterone, which is a relatively strong androgen, or DHT, which is a very strong androgen, they bind to the androgen receptor in both men and in women. So the effect of all three of those is mediated by the androgen receptor. There's a couple different beta esterdial receptors and a alpha estertyle receptors,

Starting point is 00:38:00 but there's only one androgen receptor. Intrigingly, it is on the X chromosome. So men get their androgen receptor gene from their mother. Women get one antigen receptor gene from their father, one from their mother, often the one that is more sensitive to androgens and people with PCOS, that's the one that's active. The other one is methylated and inactive. Can I just pause you once? I say, sorry to interrupt, but I have to ask this question before I forget, and I know a number of people are probably wondering, I've heard that whether or not one develops male pattern baldness, whether or not a male develops male pattern baldness, just to be very precise, you could get some information about that

Starting point is 00:38:42 by looking at your mother's father and that would be in keeping with what you just described that the X chromosome, which of course is handed off through the mother, is carrying the genes that encode for the number and distribution of these androgen receptors that DHD will bind to because of course, I think as you'll probably tell us,

Starting point is 00:39:00 that DHD is responsible for male pattern baldness and beard growth. Is that right? Should I look at my grandfather on my mother's side to determine what I'm likely to look like in terms of my DHS? t-ness, is that a word? Yeah, it's the best guess that you can make purely from phenotypes. Now, you can measure your genotype and, you know, get a better idea of that.

Starting point is 00:39:20 Assuming that it's true male pattern baldness, it's related to the gene transcription of the androgen receptor. So I like to think of it as how much of this androgen receptor gene is activated by any androgen. So if you have an extremely sensitive gene, which usually means you have very few celsius, C-A-G repeats, which is basically just a certain C-A-G encodes for a certain amino acid. And if you have very few of the repeats, then your antigen receptor gene works better. Think of it as a corollary to Huntington's disease, where if you have very few called trinucleotide repeats,

Starting point is 00:39:58 then it's not as severe as a disease. But after you get more and more C-A-G repeats, which, by the way, in the population you're getting more and more C-A-G repeats, So it's a natural selection of process that has been ongoing for a variety of number reasons. But anyway, if you have more repeats, the net gene activates in the cytoplasm and moves to the nucleus and causes gene transcription more often and hair loss more often. Does that mean that we're seeing more hair loss now due to elevated levels of DHD than we were 50 years ago? Probably not. The hair loss 50 years ago, well, not 50 years ago, but 500 years ago, was probably more significant because on average 500 years ago, people were more sensitive

Starting point is 00:40:48 to androgens. So there's a syndrome called Androgen Insensitivity Syndrome AIS. And that syndrome was related to when men who have the copy from their mother who is a carrier, their AR gene or androgen receptor gene is completely insensitive. So think of it. It doesn't have it. It's not related to the CAG repeats, but think of that receptor as just not working at all. So there's a continuum. So everybody's receptor works a little bit better or a little bit worse. And the better your receptor works, the more likely you are to have male pattern baldness. To zoom out from this, but still keeping an eye on D.HT, what do you like to say? all women and all men do to optimize Dht.

Starting point is 00:41:38 And here I'm talking about regardless of age. So we're still in this from puberty onward phase. We haven't yet micro-dissected out decade by decade, which we will do. But what do you like to see people do to keep D.H.T. in check. But before you tell us that, could you tell us what positive things D.H.T. does when it's in the proper range? Yeah. So D.H.T. helps a lot for, the same reason why testosterone helps.

Starting point is 00:42:02 It activates the androgen receptor gene. It helps effort feel good. So it can be motivating. So that's how it's active in the CNS. It also is active in cardiovascular tissue. So if you look at someone that has heart failure or if someone has cardiac hypertrophy, the level of DHD can matter

Starting point is 00:42:23 because it's also binding to the antigen receptor in the mildcardium or in the heart itself. So you think of the classic bodybuilder heart. It's an easy example to make. They have very thickened muscle. Their muscle is very strong because they're pumping blood, often with high blood pressure.

Starting point is 00:42:42 And that Dht and the testosterone and any DHT derivatives like mastrone or oxandrolone, prima bolin, also bind to the heart, and they cause even more hypertrophy or enlargement of that muscle tissue. So then let's say the person stops and they're recovering

Starting point is 00:42:59 and they're trying to have cardiac remodeling, which is where you take a very thick heart. And cardiac remodeling is important in a lot of different cardiac pathologies. But if you give them finasteride or deutasteroid, which inhibit the enzyme that converts testosterone to dh-hty, so making less activity at the androgen receptor gene, they have cardiac remodeling and their heart health improves. I see. So for the non-bodybuilder, the typical woman or man or younger or older, what sorts of things support D.HT. And thereby heart health, presumably D.HT. is involved in some of the other things that testosterone is famous for in both men and women, things like libido, as you mentioned, making

Starting point is 00:43:43 effort feel good. So motivation, drive and vitality. I guess it's be the general phrase. What sorts of things support D.H.T? What sorts of things create problems for D.H.T.? There's lots of dietary changes and supplementation that you're probably doing right now that's affecting your dh t you mean me personally well every everybody all of the listeners um because let's say you have a diet high in plant polyphenols many of those inhibit the enzyme that converts testosterone to dh t could um could you give us an example of of one of those um either in supplementation form or in food form curcumins certain curcuminoids depending on the structure will inhibit the enzyme called five alpha-aductase that converts testosterone to dh-hth.

Starting point is 00:44:32 Tumric. Yeah, turmeric. Black pepper extract. So if you, it's used often to increase bioavailability. It's also called biopurine. It's also a five-alphoriductase inhibitor. So, and on top of that, people have different genetics, too. So some people, there are five alpha-aductase enzymes.

Starting point is 00:44:52 There's three of them. They're on chromosome two, three, and four, I believe. But some of them are active in the same. the prostate. Some of them are active in the brain. So it depends on which tissue. They're tissue-specific enzymes that depend on how much dh-t you convert. Do you recommend that people avoid curcumin and turmeric for that reason? And is there any specific recommendations for men versus women? If a man or a woman, by the way, in women, a lot of times if you just ask your doctor for a dh-h-t check, it's the same units as in men. So it's essentially undetectable. So you have to

Starting point is 00:45:29 especially if they're on oral contraceptives, which is a different topic, their Dht is very likely undetectable, especially if it's free DHT. You can measure both a DHT and a free DHD. But if someone's DHT is already low or if they have somewhat insensitive androgen receptor via genetics or via lifestyle,

Starting point is 00:45:51 then I recommend they avoid bioavailable curcuminoids like bioavailable turmeric, black pepper extract, they might be a good candidate for creatine. Creatine, like creatine monohydrate can significantly increase the conversion of testosterone to DHD. Interesting. There's also a lot of really interesting data coming out now about the role of creatine as a brain fuel and maybe even as a cognitive enhancer over time. The data are still ongoing, but some of the studies in humans are pretty impressive, at least to me. I'm glad you mentioned this thing about curcumin and black pepper. I wish we'd

Starting point is 00:46:25 had this conversation six years ago because I had the experience of jumping on the bandwagon of the excitement around turmeric and I took a tumric supplement. It was a couple capsules of what I thought to be, and I think was high quality turmeric. And I've never felt as poor as I did in the subsequent few days. Flat line of, let's just say, everything that one would want to have in life, energy, vitality, just it was a cliff. And a friend somehow knew, that curcumin could inhibit five alpha ductase that converts testosterone to DHS, as you pointed out. I stopped taking it.

Starting point is 00:47:02 It was the only new addition to my diet and supplementation and things bounced back within about three, four days. But it was remarkable. I mean, I felt like garbage. And it was actually kind of frightening to experience the sharpness of that cliff. But I know that some people like turmeric for its anti-inflammatory properties, et cetera.

Starting point is 00:47:23 Sounds like people either need, to experiment or, and if they do, obviously, to approach that with caution, anytime you add or remove something, you need to talk to your doctor. You're a doctor, and I'm guessing that if one were to experiment, would you say that most of these effects of things like curcumin are reversible as they were in me, or is there any potential of permanent damage if people have been taking them for a long time? The effects are nearly always reversible. When you're talking about five alpha a ductase inhibition. So what tumor does, but stronger. The most common story that we hear is regarding a supplement known as Saw Palmetto, which a lot of older men take for their prostate

Starting point is 00:48:04 health, or fanasteride, which you can take for your prostate or your heart or your hair, or dutasteride. So if you're having side effects on these, then it's probably because of a couple different reasons. One can be your ratio of androgens to estrogens is off, and that needs addressed. Another one, can be, it's inhibiting the conversion of your progesterone to that other type of progesterone, the 5-alpha 3-alpha that we talked about earlier that's helping with your sleep and your brain and your calmness. And that's definitely in effect. Another one is depending on the type of supplement or med, they inhibit different isoenzymes of that 5 alpha reductase. So if they're just inhibiting 1 and 2, then that's going to be a different effect than if they're inhibiting 2.

Starting point is 00:48:53 and three. So Phanasteride does two and three. Sal Palmetto does one and two, and then deuteride does all three. The third one is active in the brain, and deutastoride inhibits that third one a little bit weaker in vivo, but strongly in vitro. So it's really hard to parse out. You can use biofeedback and experimentation. I do think with supplements, it's safe to experiment. The time that it takes to set in is usually about three months. So the risk of, and this is anecdotally, there's been lots of research published about if post-finasteride syndrome is real or fake. And it is real, but it's one of those things that's a combination of organic and inorganic disease, almost kind of like fibromyalgia, where it's definitely real and there's lots of things that you can do

Starting point is 00:49:42 to help with it, but it's very unlikely to occur if you stop taking your supplement or medication after you have side effects. Interesting. Well, I certainly feel better when I'm taking five grams of creatine monohydrate per day. I know most people take it for muscle growth and tissue repair and things of that sort. Mainly I think brings water into the muscle tissue, et cetera. But I take it for the brain effects and also because I like to think that it gives me a little bit of a dh t bump that I can actually see in my blood charts when I've done them. I know many people want to avoid the hair loss that can sometimes be associated with dh t levels going too high. And so I've been asked many times.

Starting point is 00:50:22 does creatine monohydrate cause hair loss, it would make sense that if creatine increases Dht and DHT, binding to the enderine receptor on the scalp can induce hair loss, that that would be the case. Is that true? Or are people just overly concerned about something that's trivial or non-existent? Each male, so yes, it can potentially add it. I don't like to say it causes it,

Starting point is 00:50:47 but it can be a little bit more fuel to the fire. So just like everybody has a different sensitivity of their androgen receptor, they have a different amount of gene transcription that is going to cause death of the follicle. That's an arbitrary threshold. So you don't really know until you start losing hair. And if somebody takes a little bit of creatine to increase their dh-hty, maybe for the cognitive enhancing effects or for whatever reason, and they notice a little bit more hair falling out in the sink, and they stop taking it. You said death of the follicle, which sounds very dramatic. Are those little stem cell niches that reside in the follicle, which hairs grow from, are those then abolished? Like there's no going back?

Starting point is 00:51:27 Or can you one rescue the hair? It takes months. If they're still there, the hair will come back. So the loss of the hair itself is a normal part of the hair cycle. So you have your antigen phase, your catagen phase, your tealogen phase, and then your hair loss. Of the stem cell niche in the hair follicle. Think of it like sharks have. teeth. So a shark loses a tooth and they have a new one that comes through or losing your baby

Starting point is 00:51:53 tooth and you have a new one. But your hair just always keeps coming through. So it's natural for it to die and lose. That's why when you start five alpha reductase inhibitors, often you have a big shed. So what happens during that big shed is all of these cells that are unhealthy, they immediately jettison that hair and they start making a much healthier new follicle. So all the hairs that are at the end of their telogen phase, then they have what's called telogen effluvium, which also happens after pregnancy, also happens in thyroid pathologies. So you shed it, a new one comes in place, and you think that you're having a horrible hair loss caused by your finasteride or whatever you're doing. And monoxidil does this too, but you're really just having a new, healthier follicle.

Starting point is 00:52:41 If you go a really long time, if you go a year, then those hairs might come back and they might not. So for simplicity's sake, if somebody is concerned about or is experiencing hair loss, male or female, what are their options of ways to offset that hair loss that are not going to negatively impact other tissue sensitive to DHD? And what I'm basically saying here is I could imagine taking a DHD inhibitor, a pill of some sort or an injection of some sort, and offsetting hair loss, maybe even stimulating more. more hair growth. It's clear that I'm not doing that, but I know people that do, but then experience some of the other negative effects of blunting D.HT. Reduced affect, reduced libido, reduced drive, disruptions and prostate function or even sexual function generally. So what can people do if they want to maintain or grow back hair, but they don't want all those other effects? What should they avoid

Starting point is 00:53:40 and what should they perhaps consider talking to their doctor about? Yeah, there's a whole host of options. I try to separate alopecia or hair loss into two different categories. Male pattern baldness or androgenic alopecia, also known as androgenetic alopecia, versus other types of alopecia, usually telogenofluviums. And if it's androgenetic alopecia or male pattern baldness, even if they're female, perhaps say a PCOS, something like that, then you want some sort of strategy to decrease the activity of that

Starting point is 00:54:15 androgen receptor. So women can get male pattern baldness? Absolutely. Okay, I'm going to have to wrap my head around that one, but okay. So there's a lot of different things that you can do that are topical. The most promising is called dutasteride mesotherapy. Essentially what it is, is it's very localized injections in areas that are prone to male pattern baldness, whether they're a female or a male, and it acts locally only, and you repeat these injections from time to time, it decreases the conversion of testosterone to Dhth just in the scalp. So that can avoid prostate effects,

Starting point is 00:54:51 and what are some of the negative effects of blocking DHT in females in the periphery, meaning not on the scalp or in the brain? But where is DHT doing its stuff? Yeah, so it's both DHT and then also that 5-alpha-3-alpha progesterone, which is called THP or dihydro-progesterone or tetrahydro-progesterone. So they're active in the central nervous system, but it's also just active, again, binding to the androgen receptor in a female as well, causing them to have that effort feel good motivation.

Starting point is 00:55:27 A lot of women that are sensitive to D.HT, because women can be sensitive to D.HT as well, feel very different when they start an oral contraceptive, not because it alters their dh t to a huge amount it does to some degree because the negative feedback inhibition and the pituitary and less produced in the ovaries but it increases shbg really high so because their shbgs are significantly higher their free dh t is way lower see how does a woman know if she has pcOS polycystic ovarian syndrome what are the issues with polycystic ovarian syndrome what can be done about I confess I was naive to PCOS.

Starting point is 00:56:10 That wasn't supposed to rhyme, but since it does, I do confess I was completely naive to it. And I started getting a lot of questions about it in various forums. And I think that's actually the reason why I initially approached you. I know you have treated a lot of PCOS. What age women should be thinking about PCOS? What's PCOS? Teach us about PCOS, please. Yeah.

Starting point is 00:56:34 So PCOS is polysystem. ovarian syndrome. And this is one of those conditions which is underdiagnosed. So its prevalence is much higher than we think it is. There's been a lot of studies and some studies say prevalence of 10%, some say 20%. It's not completely clinically penetrant. So most people don't know they have PCOS until they have infertility or subfertility. And is this, is PCOS happening at this frequency in 20-year-old women and 30-year-old women, N-40 and onward? Most women find out they have PCOS in their 30s, especially, it's on a spectrum or a continuum, like a lot of things, where you can have a weaker version or a very severe version.

Starting point is 00:57:16 What are the symptoms? There's a criteria called the Rotterdam criteria. And in the Rotter Dam criteria, there's a couple different ways that you can diagnose it. You're looking for androgen excess, insulin resistance, and you can also look for polycystic ovaries. You don't actually have to have polycystic ovaries or get an ultrasound of your ovaries to be diagnosed. If you have androgen access, for example, androgenic acne or hormonal acne, if you have hair growth, like a hair growth on the chin, it's called hercetism, or if you have, you know, like deep meaning of the voice, any symptom of too much male pattern baldness,

Starting point is 00:57:55 if you're female, that's a symptom of PCOS as well. Then you can also have insulin resistance. So this is obesity, it's pre-diabetes, a high fasting insulin. a Homa iR over two, a fasting insulin of over six. So if you have significant insulin resistance and also androgen dominance, that's a sign of it. Androgen dominance often leads to what's called oligomenorrhea. So if you're having more than 35-day intervals in between a period, or if you have less than nine per year, then that can be a sign that you have oligo, which means too little minnowiness. Menorrhea, which means mincease. So that's a very common sign of PCOS. If you have infertility,

Starting point is 00:58:43 so if you're under the age of 35 and you've been trying for more than a year, or if you're over the age of 35 and you've been trying for more than six months, then that can also be, it's a very common presenting complaint when somebody presents with PCOS. And assuming that a woman is doing all these other things is paying attention to the six pillars that you talked about earlier, diet exercise, caloric restriction in some cases, right? Not everyone needs to be caloric restricted. Stress, sleep, and sunlight, spirit. Assuming that they're doing all those things, what other things in the realm of diet or supplementation can help them avoid PCOS if they have subclinical PCOS or they have not developed it but don't want to develop it? Because it doesn't

Starting point is 00:59:25 sound like a good thing. Yeah. So depending on where they are, if they're very strong on the insulin resistance spectrum, then optimizing their body composition, decreasing their body fat, and treating that metabolic syndrome can help. So a lot of people ask, well, does everybody that's on, like, does everybody need to be on metformin that has PCOS? Not necessarily, but metformin is one of the tools that can help with insulin sensitization. Other tools that can help are anostatal. So myoanostatol is an insulin sensitizer. Its cousin, de chyrolanostatal, is a weak antihandrogen. A lot of types of anostatal have both of those in it. So depending on if you're a female or a male and you're on an ostetol, the type of an ostetol does matter. Yeah, this is a very important point. I just today I said,

Starting point is 01:00:20 I'm trying this new supplement, anostatal for its role and help perhaps enhance. sleeping even further. My sleep's generally pretty good. Lately, it's been a little bit off for a number of reasons. So I took it for the first time last night, and I said, I thought it helped, and just subjectively, and you said, what kind of anastatol is it? Because anastatol is a very potent androgen inhibitor. It turns out I was taking myoanostitol, which is not an androgen inhibitor. The type, the other type that you mentioned, which is an androgen inhibitor, is dechiroinostal. It's usually in a ratio of 1 to 25 or 1 to 40 in a much lower amount compared to myoanostatal. In a supplement or in the body?

Starting point is 01:01:04 In a supplement to help induce ovulation. But for women who have PCOS who might want to try and reduce androgen, then they would perhaps want to take a form of anastatol that reduce the androgen receptor activity, correct? They want both. So if you're a woman and you've ever talked to your doctor about getting on the oral contraceptive or sparranolactone, which is also an antaractal. antigen, but it happens to be a potassium sparing diuretic blood pressure medicine as well. Dechiroinostitol might be a better option. Dimm or diendomethane is another kind of weak

Starting point is 01:01:40 anti-estrogen, anti-androgen that a lot of women should consider as well. You mentioned oral contraception. I've done a few posts on these, let's just call them, they really are perceptual effects whereby it's been demonstrated inhuman several times now, and what it would appear to me to be very solid studies, where women that take oral contraceptives, there is both a shift in their perception of men, because these studies only looked at heterosexual, the sort of arrangements here,

Starting point is 01:02:13 where women who are on oral contraception, because it blunts some of the peaks and valleys of hormone output, no longer experienced the same peaks and valleys in their assessment of other men's attractiveness. So it sort of flattens their perception, so to speak. They still find certain men attractive and certain men unattractive, but the degree of difference is kind of mellowed out. And likewise, these data say that men perceiving women's attractiveness, they still see women on oral contraceptives as attractive. but a woman taking oral contraception eliminates this kind of peak in her attractiveness that men would otherwise perceive.

Starting point is 01:03:00 In other words, oral contraceptives are changing the way that we perceive each other, at least in terms of these male-female experiments. What is going on with that? Is that because oral contraceptives blunt the increase in testosterone that occurs just before ovulation? Or is it because of a complex cascade? What is going on?

Starting point is 01:03:20 I find this fascinating. Yeah. So there's differences in how you're, and I wouldn't use the word change necessarily, but alter the severity or alter the peak, as you said. So it's just like TRT is not going to change you as a person. An oral contraceptive will not change you as a person. It will just change your day-to-day peaks and troughs in libido and attractiveness. So one of the main effects of oral contraceptives, almost all of them have a synthetic estrogen and a synthetic progestogen in them. One common type of synthetic estrogen is ethanol esterdial. There's another new synthetic estrogen that's out there as well, but anecdotally that seems

Starting point is 01:04:07 to have even more side effects. So this ethanol esteradial is 100 times more potent than endogenous or bioidentical esterial in the liver. So it binds to the estrogen receptor in the liver. and it's going to increase sex hormone binding globulin, which secondarily, as you mentioned, decreases your free testosterone and especially your free DHD.

Starting point is 01:04:30 So that little testosterone hump that you get when you're a female that's ovulating, that's really flatlined. And it's already, it's a pretty insignificant difference. It's not negligible, but it's a little bit of a hump, and you have significantly less of that when you're on an oral contraceptive. And does that blunt the associated increase in libido

Starting point is 01:04:50 that normally would occur from that increase in androgen? Yes. Interesting. What about other forms of contraception, right? Because there's copper IUD, there's various implants, there's rings, there's a huge number of different forms of these. So what we're talking about is, as I understand it, is only the effect of oral contraception that impacts hormone output.

Starting point is 01:05:17 Is that correct? Yeah, there's a lot of other effects as well. For example, your choice of synthetic progestin will alter how higher platelets in SHBG go. It appears to be the higher your platelets and the higher your SHBG, the higher risk of a blood clot. So a lot of women know that if they're on an oral contraceptive and they're already predisposed to a blood clot or a venous thromboembolism in their vein, they have a blood clot in either their leg or their lung, then it can increase that chance. So you can choose a synthetic progestin that is not going to have as high of a response. But there's various pros and cons. Some synthetic progestins are weak antigens as well.

Starting point is 01:06:01 For example, there's one known as Slend, which is made from spronolactone. So some women are on spronolactone and that as well, which is made from spronolactone, which probably isn't particularly necessary unless they need it for a diuretic or hypertensive effect. I see. I'm just going to intentionally interrupt and I apologize, but specifically because I wanted to ask about, there is this notion that, you know, that oral contraception taken over long periods of time can disrupt fertility in ways that are independent of just the age-related decrease in fertility. Is that true? It depends on what you mean by a long time. Six to 12 months, it's possible. Past that, it seems. very unlikely. However, the persistently elevated SHBG can be present for quite some time. Wait, so if a woman takes oral contraception for six to 12 months and then stops,

Starting point is 01:06:58 will she essentially be where she would have been anyway in terms of her fertility at that age? Or are you saying that it can cause permanent damage? Her fertility would be equitable as if she had never taken it if she's certainly 12 months, but probably six months off. And what if she, I know of women that have taken an oral contraception for many years, are in addition to the age-related decline in fertility that occurs, that's inevitable. Of course, the slope is going to be different depending on the individual. But are they quickening the transition to infertility?

Starting point is 01:07:35 Probably not. You could make a case that because they've been an oral contraceptive, they may have been slightly more predisposed to insulin resistance and or lower lean body mass. But that's probably going to be a negligible difference compared to their resistance training and also their caloric restriction or chloric maintenance. And of course, there are also effects of having children. Yeah. Yeah.

Starting point is 01:08:01 I mean, on all these parameters, right? Because it's a major lifestyle shift, right? that obviously people contend with and have since the beginning of human time anyway. I want to ask some questions about male hormone therapy and male hormones generally. But before I do that, I have a couple of burning questions that I get very often that I'm just going to insert now. Marijuana, I've heard that it can decrease testosterone in men and women. I've heard that it can increase testosterone. Alcohol, I think there's general consensus that high alcohol intake, high barbiturate intake,

Starting point is 01:08:43 does in fact reduce testosterone. What about modest increase of alcohol? I'm not a drinker, so I'm not asking these questions for me. I don't smoke pot, I'm quite over. I just never really like marijuana or alcohol. They're not my thing. But many people want to know the answers to these. And the data that I've seen are very confused and conflicting.

Starting point is 01:09:02 So what about marijuana? Does it reduce testosterone to a significant degree or not? Cannabinoids itself, whether it's THC or CBD, are not going to reduce testosterone by themselves. If it's smoked marijuana, then it's very likely to increase your aromatase, which increases your estrogen. And, you know, it's rheumatizing from testosterone. So that is going to decrease testosterone. When you have an increased estrogen like esteridial, that's going to work on your pituitary to make less hormones that cause the release of testosterone. So you're going to have less LH and less FSAH. So it's almost kind of like opiates are well known to opiate agonists.

Starting point is 01:09:50 They're going to decrease LH and FSAH and subsequently testosterone. Smoked marijuana will as well. As far as alcohol, high alcohol will decrease. testosterone, as will any very potent GABA agonist, whether it's a barbiturate or a benzopine or a non-benzo or alcohol, they're definitely going to. Moderate alcohol, I guess it depends on what your definition of that is. I guess I'm being like a, like some people I know that don't seem to be alcoholics, at least by my, you know, assessment will have a glass or two of wine four nights a week,

Starting point is 01:10:25 which to me seems like a tremendous amount, only because I don't like. alcohol. I don't have a problem with other people liking alcohol, but I think for many people, that would be considered low or moderate intake. Yeah, I would consider that low intake. The American Heart Association for men recommends between one and two drinks a day on average. They recommend it. Yeah, so around one per week. Wait, so I'm making my heart less healthy by not drinking alcohol. Yeah, they recommend a very low amount of alcohol intake for men. For women, they recommend zero to one. So that's hard to interpret the zero to one. But the protective effect of alcohol, especially if it's a red wine with polyphenols in it, outweighs the deleterious effect.

Starting point is 01:11:13 Interesting, because I've seen some studies that point to the idea that even low intake of alcohol over a prolonged period of time might actually decrease brain volume or at least volume of particular brain areas. But of course, we don't know the consequence of decreasing the volume of a given brain area either. I mean, one could imagine. it's decreasing the size of one's amygdala and making them less stress, although there's no evidence to support that. I've been told that I need a drink many, many times, but I always reply to, I don't need to drink anything in order to speak my mind. So again, individual differences. Very interesting. So it sounds like smoked marijuana may, in fact, reduce testosterone or at least

Starting point is 01:11:49 increase the conversion of testosterone to estrogen. Correct. Okay. And with alcohol and gabab agonist, it's important to remember that it shouldn't be daily. So one drink of alcohol a day is actually very mildly immunosuppressive. So it's better to have two drinks of alcohol one day of the week and then two more drinks of alcohol another day of the week and then no alcohol the rest of the time. The same could be said even for supplements that have GABA in them. A lot of sleep supplements have gamma amino immunobuteric acid, which is GABA. Oh, sorry to intro, I occasionally take 100 to 200 milligrams of GABA in order to enhance sleep, but I do it maybe every third or four nights, no more than three or four nights a week. Yeah. That's perfect. Okay. So there's a lot of sleep supplements

Starting point is 01:12:32 that should not be taken daily. And GABA is one of them. Another one of them is tracadone. And melatonin is kind of arguable and it depends on the situation. But in general, if you're taking a sleep supplement, it should not be taken every night. The sleep supplements that I understand are okay to take every night or nearly every night are things like magnesium three and eight, apigenin, And if that's not true, correct me. I certainly take them every night unless I forget them back home and I'm traveling. Magnesium is one of the exceptions. L-thianine is also another exception.

Starting point is 01:13:09 Great. Well, then at least I haven't put anything into the world that's wrong in that category yet. And hopefully I won't. But if I do, I'll correct myself. So let's talk about testosterone in males. You see these headlines all the times now that testosterone levels are dropped. sperm counts are dropping, phenotypes of men are changing over time. And I can't quite follow the literature on that because obviously those are hard controlled experiments to do

Starting point is 01:13:39 because techniques change over time and sensitivity of techniques change over time. But regardless, I'm aware that a lot of people are considering increasing their testosterone by taking testosterone. A few years ago, that was considered steroid use. And it was, really extreme kind of stance. Nowadays, it seems like there's more discussion about it. First off, I'd like to know, does testosterone supplementation, and here I'm talking about prescription from a doctor, does it make one more prone to prostate cancer? That seems to always be the first question that comes out. Yeah, and there is a huge amount of misinformation about this too. So testosterone is not going to cause a prostate cancer. However, normal aging causes

Starting point is 01:14:27 prostate cancer and testosterone will grow your prostate cancer. So if you're a 80-year-old male and you have an autopsy, then there's at least a 50% chance that you have a prostate cancer. If you're 90 or 100 years old, there's at least a 90% chance. So for humans with a prostate, it's only a matter of time until you get a prostate cancer. So that begs the question, do you want to take something that's going to grow it for sure, once you have it. So it's an individual assessment, and it's important to follow things like PSAs as well. So a PSA of four or less, I mean, ideally you wouldn't be at four because that's kind of the upper threshold, is the simplest readout of whether or not there's excessive prostate growth. There's benign prostate hyperplasia where the prostate is growing, but it's non-cancerous, correct? And then, of course,

Starting point is 01:15:20 there are the symptomologies, like people have challenges of urination, they have sexual difficulties, etc. I'm always struck by the correlation that people draw between testosterone and prostate health and the fact that, or I should say the claim that testosterone makes prostate health worse because if you think about it, young males have high testosterone often, if not always, certainly often. And you don't see a lot of prostate overgrowth and cancer in young males. So something's going on here. How should we conceptualize this? So if you have a PSA of 3.9 and you're a 25-year-old male versus a 75-year-old male and you have a PSA of 5.9, the 3.9 PSA is significantly more concerning. So think of your prostate as taking cumulative damage from not only testosterone, but also estrogen and also growth hormone.

Starting point is 01:16:18 So that's why obese individuals have higher incidences of prostate cancer as well. It's because they don't have those cell checkpoints where your immune system takes a second and says, all right, stop replicating as fast, prostate cells. Let's see if there's any atypical ones, and then it finds those, and it prevents them from reproducing. That's why immunotherapy and cancer is so promising, it's because they can target these certain things. So the older male is going to have that cumulative damage happen already. And arguably prostate cancer is a normal, you know, with aging, you know, fast aging is abnormal. Very slow aging is normal.

Starting point is 01:17:06 There's a fine line to walk between those two. But there's a lot of things that can be done to decrease the turnover, decrease the inflammation, and decrease the congestion of the prostate over time. There's also a lot more than just PSAs that can be done. There's prostate MRIs and things like that that can look at the structure and the function of the prostate. So what should every male do to maintain the health of their prostate? And I realize that younger males probably aren't thinking about it at all.

Starting point is 01:17:31 Although it seems like nowadays I get these kind of what I call cryptic questions. I think women are more comfortable talking about their hormone and sexual health because of they cycle, because of menstrual cycles. they're used to fluctuations that sort of give them the experience of what it's like to have different levels of progesterone, estrogen, testosterone, et cetera. But I get these kind of cryptic questions, often in my direct messages, where what I think people are asking is, is there something wrong with my prostate? What should I do for my prostate?

Starting point is 01:18:02 These are often indirect questions for other aspects of their life where they're suffering. And I don't say that in jest, I think more direct discussion would be great. So what should all males do to maintain prostate health throughout the lifespan? Maintaining prostate health can be looked at similarly how you can maintain a good natural optimal testosterone. So you look for things that can hurt it. You don't necessarily look for one thing that can improve it or boost it. So for young males, those are prostateitis. So it goes hand in hand with epididymitis.

Starting point is 01:18:38 So different infections of the prostate. The younger the male is, the more likely it is related to something that could be sexually transmitted. But another very common cause is what we call gram-negative and anaerobic bacteria. The prostate is right by the end of the colon. So if you have chronic constipation or if you have colitis or even just an E-Colai overgrowth in the colon is very likely to cause an infection of the prostate. as well. What should males do to prevent that? Have a diet that has good, healthy prebiotic fiber, probiotics as well. Make sure that they're having regular bowel movements that they don't have chronic constipation, have good sources

Starting point is 01:19:26 of dietary fiber, which is also known as soluble fiber and enough insoluble fiber. Most people get enough insoluble or non-dietary fiber. So that can help prevent the chance of diverticulitis, which is another type of infection. It can also decrease the chance of colitis and decrease the chance of prostate infections as well. Are there any foods and or supplements that men should take or avoid? What about, you hear about Sal Palmetto,

Starting point is 01:19:56 yeah, supplements for or supplements that support or cause issues for the prostate. Yeah. If there's a strong genetic predisposition to enlarged prostates or even just really early prostate cancers that grow fast, then they can consider taking salt palmetto or even curcumin as an anti-androgen

Starting point is 01:20:16 as long as they're able to tolerate it. It's an individualized basis and depends on their history. As far as making sure that their prostate is not congested, there's an interesting correlation between having girls and having prostate cancer. Having their offspring. Yeah.

Starting point is 01:20:34 So if your offspring are females, then you're slightly more likely to have prostate cancer. There is some, there's hypotheses that link estrogen to prostate cancer rather than testosterone. So if you have hyperestrogenism, your prostate has more atypical cells. In general, the higher your C-reactive protein, which is the general marker of inflammation in your body, we call it CRP and the test order is HSCRP or high-sensitivity CRP. If your CRP raises up very high, if you have an autoimmune disease, like if you have a Crohn's flare, or if you have a lupus or an infection, or a sexually transmitted infection, or even colitis or even the flu, your CRP is going to raise significantly. You would detect in a blood test, of course.

Starting point is 01:21:26 Correct. Yeah. So you want to get a baseline CRP when you haven't had any of those things recently. and if your CRP is higher, you also have more female offspring. If your CRP is higher than your reactive oxygen species, which are causing mutations and atypical cell turnover in the prostate, are also likely higher. So you want to keep a very low CRP. Interesting. And what about blood flow and pelvic floor in general?

Starting point is 01:21:53 We should probably do a whole episode on pelvic floor. You know, there's so much interesting data coming out of the fields of clinical and research urology. I realize it's kind of the Netherlands of biology and medicine. People probably aren't thinking so much about this. But pelvic floor is obviously a confluence of a ton of vasculature, of nerves, and of course the prostate resides there, and of course the genitals and reside there as well. So I would imagine that one of the six pillars, you know, exercise, being able to maintain

Starting point is 01:22:25 adequate blood flow to those regions is key. What about just postural things? is people sitting too much, not hydrating well enough. You mentioned avoiding constipation. What are some other things, including medications that can serve to support the prostate over time and maybe even support pelvic floor in general, both in males and females, over time?

Starting point is 01:22:46 Absolutely. And this is something that's rightfully getting more and more attention. The way I explained the pelvic floor is your abdominal cavity, which includes your peritoneum or where most of your organs are, your retroperitoneum, your pelvic space. Think of it as a box and your abs are the front of the box. Your back muscles are the back. Your diaphragm is the top of the box. And your pelvic floor, that's where your port is to the outside world. Especially important. It has muscles as well. And you can do exercises. Pelvic floor physical therapists are becoming more and more utilized,

Starting point is 01:23:18 especially after childbirth, but in other situations as well, including by men getting care from urologists. So you want to both strengthen that pelvic floor and make sure that the tubes that are docked to the outside world are working well enough, but they're not too loose. They're not working too well. So there's a lot of medications that can be positives or negatives for your pelvic floor. We kind of talked about your gut and colon health in general. As far as your prostate health and as far as your bladder and urinary system health, you think about a couple different classes. So you have your phospho diastriases. You have your tadalophyll. Basically, this is going to help decrease congestion in the prostate. A lot of people take it for ED,

Starting point is 01:24:09 but it can actually help you decrease your... Did you define that? A lot of men take tadalophil, which generic is Cialis, has a much longer half-life than Viagra or Lovitra. It's half-life is almost a day. So you can take a very low dose of it. Instead of taking 20 milligrams,

Starting point is 01:24:23 you take two or two-and-a-half-month-month. So they're taking, you're saying that a lot of men take it for erectile dysfunction, but that at lower doses it may have served purposes for prostate health independent of erection. Correct. The most common scenario is if a male is waking up twice at night to pee, on average, it'll cut that down to once. So if they're waking up four times at night, then it can cut that down to twice at night. Just because you have easier blood flow, We used to use other medications like Flomax, which is Tamptuylosin. That's an alpha antagonist, so it basically binds to a receptor in smooth muscle,

Starting point is 01:25:00 and it helps relax that. There's several other alpha antagonists. And then you also have your medications that are hormonal like finasteride that a lot of people take for prostate health to decrease the enlargement of the prostate. The periorethral area or periorethral lobe, there are several lobes of the prostate. that tends to be especially enlarged in cases of BPH. BPAH. Prostate hyperplasia or an enlarged prostate.

Starting point is 01:25:29 And if you are able to shrink that area, then at that point it's just a plumbing problem and the urine is able to get by easier. My understanding is that now there's a growing, I don't want to say a movement, but the idea of taking very low dose, like 2.5 milligram or 5. milligram to dalafil even daily is becoming pretty common for many men who do not have erectile

Starting point is 01:25:56 dysfunction simply to either maintain or enhance prostate health. Is that correct? Yeah, that's correct. And are there, do you see any negative effects of doing that? There can be negative effects. It can lower blood pressure. So theoretically it can increase your chance of vasolvagal syncope. A lot of people take it as an alternative to pump because it kind of works similarly to citrillaise. or a different pump products in pre-workout. And it can certainly help with that. But if you're about to go do a deadlift where you might pass that anyway,

Starting point is 01:26:28 it can certainly increase the chance of that happens because you don't have that compensatory exercise, hypertension response. Could someone just take it away from exercise? They could. If you took to Dallafil, then that's going to be, has a long half-life. Whereas Viagra and Lovitra is just a few hours,

Starting point is 01:26:47 to Dallafil is almost today. Some interesting studies on Viagra have been done as well. It can potentially alter your rays and cones in your eye. So the usual recommendation for pilots that need to have red, green discrimination from very long distances with very small indicator lights is to not take Viagra. So I usually say if you're a pilot, that's your profession, perhaps hold off from that for a while. There's also studies with Viagra that significantly, which is also known as sylidinophil as the generic now, it can increase eyebrow hair growth. So potentially what it does is it helps vasodilate and relax the veins, especially in older men. And when those veins are relaxed, you have better blood flow. That's one of the proposals or theories behind why older men get the androgenetic alopecia more. You're having less blood flow in the scalp. So theoretically, it can also help prevent that.

Starting point is 01:27:48 So in theory, increasing blood, oh, because it increases blood flow systemically throughout the body, not just in specific tissues. Well, I find it incredibly interesting that, yeah, there are these online forums building up now around low dose to dahlphil, daily use of low dose to dallophil, again, not for sexual or erectile dysfunction,

Starting point is 01:28:10 but for sake of long-term prostate health. Is there any reason why women might want to date, low-dose todalophil. Todalifil is also a weak androgen receptor sensitizer. Kind of like L. carnitine, where the density of the available androgen receptors to bind

Starting point is 01:28:30 increases slightly. So there could potentially be a benefit from that, but most of the time it's used in men. Very interesting. We haven't really talked about testosterone and optimizing testosterone in males. assuming someone is paying attention to the six pillars,

Starting point is 01:28:51 there's a kind of a gap, as I see it, between doing all those things and TRT, hormone replacement therapy. And again, the R, the replacement in TRT is a little bit of a, in quotes nowadays, because a lot of people who have testosterone in that 300 to 900 nanogram per deceler range opt to take low dose testosterone anyway. My understanding is that there have been new movements in this area toward, for instance, not doing big, large doses injected infrequently, but rather low doses quite frequently, obviously prescribed by a doctor, monitored by a doctor, etc.

Starting point is 01:29:34 Is that generally what you like to see in your patients if they're going to take this route? if they're a hypogonatal patient whose benefits outweigh risks of TRT, then you want to have a nice, even, steady state. It's not going to be exactly the same as producing pulsatile testosterone release endogenously from your own body. When you have a steady state, you don't have a peak or a trough. And when you have a peak, that's when the androgen receptor gene is overactive. That's when you get more erythropoitin or EPO release.

Starting point is 01:30:08 and that leads to a lot of the side effects of thick blood, so higher hemoglobins and hematocrats. And then when you have a crash, you don't feel good. So it's definitely not optimal. There's a lot of ways to get around this. So when you're doing testosterone replacement, if you're someone that needs it, you can have different types of esters or you can do topical testosterone. So the ester is basically something that's attached to increase the biological half-life. The most common ones are cypionate and antheid. There's also a very short-acting

Starting point is 01:30:43 propionate, which has almost no clinical relevance. And there's also very long-acting ones, decanoate and undecanoate and different mixtures of all those. So if you're someone who has a very, very low SHBG, you're going to have trouble of regulating your serum testosterone in the long run. If you do it topically, then the testosterone is absorbed, hopefully bound to SHBG. And then a lot of you reapply twice daily or once daily, but you have lots of variations. So for most people, especially for people who can't absorb it well, that's not going to be a great option. So injections would be preferred? Most people end up injecting because they have either side effects from too high, too low or just too much of a varied dose when they do topical.

Starting point is 01:31:27 There's also a capsule with a special lymphatic absorption. So it's not being absorbed through the liver. It's not hepatically metabolized, but it's absorbed through the lymph. And it's essentially testosterone undecanoate and then put into a capsule. So, and that's taken twice daily. It has fairly steady half-lifes, but you have to take it at specific times the day. So that being said, and it's new enough to where there isn't a huge amount of data on it, but it is FTA approved. So it is brand name now.

Starting point is 01:31:59 It's called Jitenzo. But the injectables, in general, the lower your SHBG, the longer of an ester you one. because when you inject it, whether it's intramuscular or subcutaneous, just talk to your doctor about the risks and the benefits of those. Subcutaneous has slightly longer active half-life because the esterases take a longer to reach that cypunate or an aster to cleave it. So most men, a lot of people ask me about like what a usual dose is. For most people, it would be a total of about 100 to 120 per week for an actual replacement dose.

Starting point is 01:32:34 Milligrams. Milligrams. 120 to 100 milligrams per week, administered two to three times per week. And you're not, so you're saying dividing that into two or three, right? Because I'm sure there's a bunch of people out there are thinking, oh yeah, 100, three times a week, which is actually quite, quite high dose. Yeah, there really does seem to be a shift toward spreading these dosages out into, you know, dividing them into two or three smaller doses.

Starting point is 01:32:58 And then along those lines, five, ten years ago, it was common to hear about inhibiting estrogen through aromatase inhibitors. Nowadays you hear, and I think it's true, at least by my read of the literature, that inhibiting estrogen can disrupt ring function, can cause connective tissue issues, and even can cause reductions in libido. So a lot of people think that estrogen,

Starting point is 01:33:23 if you crash estrogen, that basically libido goes up, but actually the opposite is often true. You don't want estrogen too high or too low. Is that correct? And for that reason, do you shy, shy away from people taking aromatase inhibitors?

Starting point is 01:33:38 Yeah. Very few people truly need an aromatase inhibitor. There's almost always lifestyle interventions. It can just depend on which gene, how active your aromatase gene is. Some people's aromatase gene is very active. A lot of times these individuals have pubertal gynecumastia, which is breast tissue growth in males, even despite no other risk factor.

Starting point is 01:34:02 Even if they're lean, Some people get it if they're lean. I remember growing up, there were a few kids that got mild cases of gynecumastia that were transient. It's sort of like they developed gynecumastia and then it went away. Often it's unilateral on one side too. So growth hormone a lot of times is the fuel to that fire. Oh, interesting. Yeah, there were a couple kids.

Starting point is 01:34:24 I mean, they took some teasing because back then there wasn't online discussions about hormones and things like that, but then it would seem transient. And the people I'm thinking of were actually lean individuals, so they weren't overweight, which of course can cause gynecomastia because adipose fat tissue can convert testosterone into estrogen. So it sounds like except in special cases that avoiding aromatase inhibitors is probably going to be a good idea. There's several other ways that you can control your estrogen and keep it at a healthy level, which you do have to check. There's a lot of patients who assure me that their estrogen is going to be sky high,

Starting point is 01:35:01 and it's actually very low and vice versa. But calcium deglucrate is a supplement that can help with estrogen control. What's a typical dosage of calcium deglucrate? 500 to 1,000 milligrams. But is there the risk that if someone's estrogen is in normal range and they take the supplement that their estrogen will go too low? Is it that potent? It's not that potent.

Starting point is 01:35:22 It's not near as potent as an aromatase inhibitor. So it helps with excretion and also the sensitivity of the estrogen receptor itself. It kind of like helps out compete it. Some people also take dim or different cruciferous vegetable. They get them from cruciferous vegetables like kale or broccoli. And that is both an anti-estrogen and an anti-androgen. So if you're on TRT and you're on that, then you're probably just on too much TRT. Yeah, I remember a few years ago I had a friend, and it truly is just, it's not like I have a friend thing.

Starting point is 01:35:57 because I'm very cautious about which supplements I take. I think people might get the impression that I'm very cavalier about this, but I'm not. I always alter one thing at a time. I talk to physicians. What I suggest other people do, I actually do and have done for a long period of time. And I recall wanting to take dim,

Starting point is 01:36:14 because I thought, well, back then you hear, okay, reduce estrogen. My estrogen levels weren't out of range, so they were fine, but I thought, well, what would the experience be of bringing those down? But someone I know is quite informed in this area, I said, yeah, exactly what you said, which is that dim can reduce estrogen, but also testosterone.

Starting point is 01:36:30 So I just never opted to try and take it. I do want, we're sort of erring in this direction, but we went straight from the six pillars to TRT or to what some people now call sports TRT, which is basically code language for saying, taking exogenous testosterone, even though one doesn't need it, to get into a semi-superphysiological range

Starting point is 01:36:51 or a high-end like 900 to 1,000 nanogram per deciliter range. And people always point out, I should mention that, oh, well, in certain countries, the high end range is 1,200 nanograms per decilater in the U.S. It's 900. And so if you're 1,200, are you really super physiological? All that aside, I neglected to ask about that gap in between where individuals could think about supplementation, meaning non-prescription approaches to increasing testosterone. And here we should probably also talk about things like, is it true that ice baths increase testosterone or not? Lifestyle factors that go beyond the same. six pillars for increasing testosterone. If you could comment on those, that would be terrific, supplements that are useful. And it'd be wonderful if you could mention where some of these same practices and supplements might be useful for women as well as men

Starting point is 01:37:39 to increase testosterone for all the reasons we talked about earlier. Yeah, so this is where a true individualized approach comes in. When you're talking about what dose of TRT you should be on, one thing to keep in mind is the law of diminishing returns. Quality of life is, is a subjective thing, and it's different for each person.

Starting point is 01:38:00 So some people are more willing to give up a little bit of athleticism or body composition. Some people are more willing to give up, or not willing to give up, libido or sexual health. And as we mentioned earlier, everybody's androgen receptor is less or more sensitive. So you can make a case that if somebody's androgen receptor is half as sensitive as somebody else,

Starting point is 01:38:24 the person with the less sensitive receptor does need a level of 1,000 or 1,200. There's no great way to know that. And you can alter the sensitivity for antigen receptor or things like L. Carnotene and Tidalophyll, as mentioned. And we'll definitely come back to El Carnotene because I'm really intrigued by the data on L. carnitine, both for women and men in terms of egg quality, sperm quality, fertility, and a bunch of other interesting effects. So we'll come back to al-carnatine. But a lot of how you feel the biofeedback or subjective I feel like this comes from the ratio. of your androgens to your estrogens.

Starting point is 01:38:59 And a lot of that is lifestyle. So if someone's also on HCG, that could upregulate aromatase as well. HCG, you might want to just, human chorionic gonadotropin. Yeah. Used to be found in pregnant, it's still found in pregnant women's urine.

Starting point is 01:39:12 Still found in pregnant women. But used to be, believe it or not, there was a black market for pregnant women's urine before this stuff was developed synthetically. So in other words, what we're saying is men typically would buy pregnant women's urine

Starting point is 01:39:26 through black markets in order to get the HCG in order to get the testosterone-enhancing effects of HCG. So in other words, men were using pregnant women's urine for HG. I do not want to know how they got it into their body. Let's just skip to what you were going to say next instead. Yeah, so that's HCG. There's a lot of other things that upregulate estrogen. Alcohol significantly increases aromatase.

Starting point is 01:39:51 So if you're very sensitive to estrogen, then you probably shouldn't even consume the two glasses three times. a week. High fat meals also upregly than aromatase. So if you're on a ketogenic diet, but you have hyperestrogenism, then you should take care with that as well. All kinds of fats are just saturated fats. I'm not sure if it's just saturated fats, but fat definitely increases both fat in your body and consumption of a high amount of calories increases of rheumatoidase. So it's the ratio of testosterone and estrogen. I don't want to break your flow, but since we're talking about fat, I have to ask since estrogen and testosterone are both

Starting point is 01:40:26 synthesized from the cholesterol molecule, I've heard that ingesting some amount of saturated fat can be useful because of the way that cholesterol can serve as a precursor to these molecules. Now, I once said on a podcast that I like butter so much I occasionally eat pats of butter. Somehow that got misinterpreted to mean that I eat entire many pats of butter. I'm telling like one or two pats of butter here and there and I have no guilt or shame about it. My blood lipids are in great shape also, so I feel good. Is it possible that people who are ingesting too little of saturated fats could directly or indirectly reduce or somehow disrupt the proper ratio of testosterone to estrogen in men and women? It's theoretically possible, but it probably doesn't happen in developed countries, just like it's theoretically possible to have not enough omega-6 fatty acids, but that probably does not happen in developed countries.

Starting point is 01:41:22 So I don't need the butterpats, but I'm going to do it anyway. curious. Yeah. Okay. Grass-fed butter has good omega-3 content as well. So grass-fed foods in general, you know, it's not the end-all be-all and everybody doesn't need grass-fed foods, but they are one of the only sources of healthy trans fat. So a naturally occurring trans fat comes from ruminants. So ruminants, I think of like cows. And the rumination in the different stomachs can change your omega-3 and omega-6 to trans-linolinic and trans-linoleic fatty acids. Which are healthy for us. Yeah.

Starting point is 01:42:02 So it's actually omega-3s and omega-6s that just happened to have a trans instead of a cis- isomer. So, and these healthy trans fats would be found in ruminant cheese and milk and butter from ruminants and the meats. Yes. So, and for people who are following a purely plant-based diet or, you know, or or mostly plant-based diet, are they at risk of not getting enough of certain types of fats or other nutrients

Starting point is 01:42:29 to maintain that healthy ratio of testosterone to estrogen or not? If they're a vegetarian, they're probably not at risk. If they're a vegan, they very well could be at risk. Most vegans are aware of this very acutely, and they'll supplement with algae or they'll supplement with other sources of healthy fats. I see. So the takeaway that I'm drawing from this is that less so than getting saturated fat,

Starting point is 01:42:59 it's key to get these healthy trans fats from ruminants or the food products of those ruminants, as well as to get proper amounts of omega-3s. And to be clear, you don't need any trans fats. It just happens that those omega-3s and omega-6s are in a trans isomer. I see. Okay, so that's nutrition. What other supplements can support healthy testosterone to estrogen? ratios. Anything that alters aromatase can support healthy testosterone to estrogen. And your

Starting point is 01:43:32 testosterone to estrogen ratio, think about it as how much estrogen activity do you have at the beta estradial receptor and your alpha estradial receptor. How would I know that? So it's hard to tell, but depending on what you're eating, if you have a lot of plant-based diets or polyphenols, many of these are beta-estrile receptors. People know about turkestrone and also beta-ectosterone, which are two ecsteroids that are beta-estrile receptor agonist. So they activate the beta-estradial receptor. So if you have a very low amount of estrogen naturally, you're probably a better candidate for it. For taking to turkestrone or ectosterone. I've never tried them, but I know my understanding is that they work tremendously well for some people and not at all for others. And so

Starting point is 01:44:20 just simply has to try. But in promoting the activity of this estrogen receptor, is there a risk that Turkestrone or ectosterone could cause some of the, quote-unquote, problems associated with increasing estrogen activity? Like reduced libido, water retention. Water retention? Yes. Reduce libido, probably not. Closing growth plates in the bone. No, because that's the alpha esteridile receptor. I've talked before on a couple of podcasts. about Tonga Ali, which is this Indonesian herb. I guess it's also made and found in Malaysia, but it seems to be the Indonesian variety of Tonga Ali

Starting point is 01:45:00 that's most effective for potentially for reducing sex hormone and binding globulent and thereby freeing up testosterone. Whether or not the effects are through that pathway, through another pathway, a lot of people report improvements in things like libido and maybe androgen-like phenotipotene, types, right? Feeling more vital, et cetera. And of course, some of that could be placebo, correct? But what are your thoughts on Tonga Ali? And please challenge my statements about Tonga Ali

Starting point is 01:45:29 if they're incorrect. I'm not looking for validation here. I just really want to know what your thoughts are on it. Do you ever recommend it to patients when men, women, one or the other? Yeah. So Tonkat, Ali, or Long Jack, it has multiple mechanisms of action. And there have been several placebo-controlled studies on it. Some of them show decrease in SHBG. At least one of them did not show any change in SHPG. However it is, it does act on aromatase very weakly, probably not so strongly that you would have to be concerned of hypoestrogenism. So it reduces aromatase and thereby can reduce estrogen? Correct. Okay. It's also a weak, it's not a serm, so it's not a selective estrogen receptor modifier, but it's probably an urm as well or a non-selective estrogen receptor modifier.

Starting point is 01:46:22 And that should help with decreasing negative feedback inhibition of esterdial in various locations and also increasing testosterone. Interesting. Yeah, the dosage that I've been using for years now is, I think it's 400 milligrams taken once a day, typically early in the day because it can kind of have a mild stimulant, in fact, very mild. And I know that some of the products out there recommend dosages that are much higher. Anytime I've taken more than 400, I don't feel very good.

Starting point is 01:46:52 I don't know how to describe it other than it's just a little over stimulatory in terms of makes me kind of, it's like drinking too much coffee. So that's interesting. And so would women ever want to take Tonga Ali for any reason? Yeah, absolutely. So there's a lot of women that have hyperestrogenism. and unlike adrenal fatigue or andropause, there's actually ICD10 codes for hyperestrogenism. ICD10 codes?

Starting point is 01:47:20 Yeah. That's doctor speak. Yeah. So there's codes to where your doctor can actually diagnose you with something. So if you go to your doctor and you say, I have adrenal fatigue, they can't diagnose you with that. Or if you say I have andropause, they also can't diagnose you with that.

Starting point is 01:47:34 But if you say you have hyperestrogenism, the most common complaint that comes with it is endometriosis, which is overgrowth of the land. of the uterus. And those people could potentially, I think that's one area where we might see Toncat supplementation more and more,

Starting point is 01:47:54 because not only does it decrease aromatase, like we mentioned, testosterone and females is higher than estrogen in females. So a lot of females get estrogen from aromatization as well. Peripheral estrogen is sometimes what we call it, because it's not directly produced in the ovaries, but they could be good candidates for Toncat, if that's the case.

Starting point is 01:48:12 Very interesting. And my understanding is that people should be looking for sources of Indonesian Tonga Ali in particular. Correct. Another interesting application is essentially a, I'll call it a PCT, but essentially what that means is, PCT means how defined it is post-cycle therapy. Physicians love acronyms, scientists love acronyms, military love acronyms. Yeah, PCT, post-cycle therapy. So this would be people coming off hormone therapy or steroids. This would actually be for women that are coming off of their birth control pill. Because perhaps they can help lower that SHB. back to normal, which is sometimes persistently elevated, and then it can help prevent the subsequent hyperestrogenism that happens. Does Tonga Ali need to be cycled? When I first started taking it, I would cycle it. I would do a three, four months, and I would take some time off. Now I've just been taking it

Starting point is 01:48:57 continuously for years. And I should say I do blood work to check my liver enzymes and everything else, and I don't see any reason for me to cease taking it. Yeah, probably not. There's been human studies on both Toncat and Fedosia. And full disclosure, I did help design Derek's new testosterone optimization supplement, which has both Fedosia Arrestrus and also Toncat Ali in it. Yeah, let's talk about Fedogia separately in a moment, but if, let's say someone is only taking Tonga Ali for whatever reason, but do they need to cycle off? Likely not, but I would just to be safe because it does both affect your aromatase and it's an estrogen receptor modifier. And what would be a reasonable cycle off? So how long to take and how long to

Starting point is 01:49:47 stop before taking again? Yeah. There's a couple different protocols that you can do, but 11 months on, one month off for Toncat is pretty reasonable. Now, I guess this is, we'll talk about this later too, but if it's combined with Fedosia, the protocol that I would do is three weeks on, one week golf. So that's Tonga Ali. But I'm curious what your thoughts are on Fidogia Grestis, this Nigerian shrub or this extract from Nigerian shrubs that, at least in my experience, in my read of the literature, has the potential to increase testosterone and probably other hormones as well by way of increasing lutenizing hormone, something that we haven't really talked about much up until now. What are your thoughts about Fidoja Grestes? What are your

Starting point is 01:50:33 ideas about the proposed mechanism or mechanisms and where might this be useful for people on or off hormone replacement therapy? Yeah, Fadoja Agrestis has just reached a point where we have enough evidence to we know it probably helps both with leutinizing hormone release, which stimulates latex cells in the testes to produce more testosterone, and probably with LH receptor sensitivity as well. which is a good combination of the two. It does come from the Nigerian shrub, but there is not quite enough evidence

Starting point is 01:51:11 for me to be able to say that's safe for somebody to take this all the time, which again, full disclosure, that's why I recommended that we recommended for people to cycle this supplement. So three weeks on, one week off, that's likely safe. The only toxicity studies in general are in rats and in humans it looks quite safe.

Starting point is 01:51:36 My understanding is that the toxicity studies in rats showed toxicity to the testicular cells. So that's certainly concerning, but that the dosages that were used or translating the dosages used to humans would lead to a situation where the dosages that humans would have to take would be very, very large. So the amount of, I no longer take Fidogia, but I took it at 600 milligrams per day for a long time. And I ceased taking it because I was experimenting with other things and I didn't want to confound those things, not because I had any negative side effects. In fact, I was monitoring blood work and other biological parameters that would have told me if there was testicular

Starting point is 01:52:18 toxicity and there wasn't. Let's put it that way. Yeah, I think it's extremely safe. And I'm just not convinced that there's enough overwhelming evidence for a long-term consistent administration. So do you recommend this to people who are not taking TRT? And do you recommend to men and women? Yeah. So if you have a really high LH, then there's probably a gonadal issue, whether it's heat damage to the testes, a vericoseal, a history of testicular cancer, your LH is going to be higher. So if your LH is already very high, increasing it even more is probably not going to help. However, if your LH is low, then obviously try to find out if is it low. Is it deficient or is it just a little bit low? If it's low and you don't have an issue with prolactin, you don't have an issue with

Starting point is 01:53:08 opioid receptor antagonism, and naltrexone can actually potentially help antagonize that to increase LH as well, especially in people recovering from opiates or likely even alcohol. So you're looking for a subclinical secondary hypogonitism, which is essentially, just think of that as low LH. So when people with that lower LH and their estrogen, you're looking for, you, estrogen is fine and their prolactin is fine, then Fedosia is a particularly good option. Interesting. So three weeks on, one week off for 600 milligrams Fedogia, 400 milligrams Tonga Ali, Indonesian Tonga Ali could potentially be good. And of course, everyone should always check with their physician, clear this, do blood work, et cetera. I would say, we don't just say that to protect

Starting point is 01:53:53 us. We say that to protect you, meaning that the consumer is very, very, very much. important. You don't want to fly blind with any of the stuff. You want to do blood work, right? That's the cash 22 with supplements is most of them are safer than medications, but the only difference between them and a medication is one's prescribed and one's not. And oftentimes with supplements, it's unclear whether or not what's listed on the bottles, actually what's in the bottle. But I think there are a number of reputable brands now. The other supplement I want to talk about in terms of testosterone augmentation is boron. What is boron thought to do? Does it actually do that? And do you ever recommend boron?

Starting point is 01:54:34 Yeah. So boron is actually an element. And you can find it on the periodic table. It's more plentiful and rich soils. So frequent farming can deplete the soils of boron. It's very plentiful in the Mediterranean area like Greece and Turkey. So a lot of people will just eat dates or raisins that are grown there. I thought you're going to tell me people eat dirt. But there are people who eat dirt. There are people who eat dirt. And there's a phenomenon. called PICA, right? Where people in a, and that's not a good thing. Often assign an iron deficiency. Okay. But they're eating grapes and dates that were grown in soil that has high amounts of boron. Yeah.

Starting point is 01:55:11 So boron can help regulate SHBG, but its effect is mostly acute. So it's unlikely to have a bad effect. So a lot of people take boron because it's probably not going to hurt, and it will lower SHBG even if it is for a short period of time. So I guess you can make a case that maybe cycling boron can help too. What sorts of dosages are useful for boron supplementation? Three to six milligrams once to twice a day. Oh, interesting.

Starting point is 01:55:40 So that's higher than the amounts that I've been taking. I've long been doing this cocktail of Tonga Ali. Again, I stopped taking Fidoja, but for a long time with Fidoja and boron, I think it was two to four milligrams per day, but maybe that could afford to go higher. Although my blood work is where I want it, thankfully. So circling back to Fidogia, Fidogia was attractive to me as a supplement because I saw increases in LH testosterone and free testosterone.

Starting point is 01:56:08 My estrogen stayed in check, but I also did not see a downregulation of LH when I would cycle off. Whereas with HCG, human cortionic gadatropin, which does now arrive in forms, not from pregnant women's urine only, but the synthetic forms that people inject, that as I understand it, can actually suppress

Starting point is 01:56:30 endogenous hormone output if one takes it for a long period of time. So why would a man or woman want to take HCG and what are the potential risks and benefits of taking HCG? Yeah, so HCG or human choreonic gonadotropin is actually very similar to Tsh. Diroids stimulating hormone.

Starting point is 01:56:50 Correct. So when a woman is pregnant, she produces more HCG, especially in the first trimester. When you take a pregnancy test, whether it's qualitative or quantitative, you see the HCG rise. And it actually doubles every 48 hours. So if you're five weeks pregnant, you can get an HCG level. And then two days later, five weeks and two days,

Starting point is 01:57:13 you can see your HCG and maybe it went from 500 to a thousand. So it precipitously increases. It does a few things. one thing is it prevents hypothyroidism or hypothyroxemia of pregnancy, which is one of the most common causes of miscarriage. It's also why if you have hypothyroidism and you get pregnant in the first trimester, you want to increase your dose from 25 to 40 percent to keep your free T4 high as much as possible. And the reason why you have to do that, as opposed to somebody who does not have hypothyroidism, is if you have hypothyroidism, then likely your thyroid will not respond to either TSA or HCG. So the increased HCG does not compensate for that.

Starting point is 01:58:03 So if you take HG, then it can potentially improve your thyroid function. So that, along with selenium, are likely the two best things that you can do for thyroid health. HCG and selenium? Yeah. I definitely make sure I get enough selenium by eating three to five Brazil nuts per day, which I very much enjoy the taste of all. also. Who should take HCG and can HCG suppress one's normal leutinizing hormone output? Yeah. It suppresses LH in a dose-dependent manner. So the higher the dose of HG you take, the more it suppresses

Starting point is 01:58:39 LH. A common dose for fertility. Fertility is usually why HG is prescribed. In men or women? In both. Is 10,000 I use all at one time, which is quite a bit. That's a tremendous dose. Yeah. In fact, some formulation, some brand names of HCG come in auto-injector pins to where you cannot even dose lower than 5,000 units at a time. Wow. But I know a number of people who take HCG to maintain testicular function while on testosterone

Starting point is 01:59:09 therapy or augmentation of some sort. Does it work to do that? Yeah. Some people are on HDG monotherapy. It can be slightly better on your leg. lipids than being on TRT. Oh, so people are using HCG alone as a kind of neither, sort of a hormone augment, indirect hormone augmentation.

Starting point is 01:59:32 Some clinics advertise it as a non-suppressive alternative to TRT, but it is suppressive of LH. But it could also increase estrogen pretty potently? Yeah. And is it true that increasing LH and or HCG can improve sensitivity of the genitals. And is that true for men and women? I've heard this anecdotally.

Starting point is 01:59:55 People say HCG makes sexual activity more pleasurable for people because of some, is it a direct effect on some of the nerve cells in the genitals? Yeah, so LH is also an agonist in the prostate

Starting point is 02:00:10 and in genital tissue in general. So it's a very common treatment for post-phenasteride syndrome or post-5 alpha ductase when you've blocked the conversion of DHD for a long time, it helps re-upregulate DHT. So someone who's been taking finasteride to prevent hair loss comes off, it feels, maybe because they felt lousy,

Starting point is 02:00:33 but then feels even lousier for reasons that you talked about earlier. And then they might use HG as a transition treatment to transition back to normal hormone health. Is that right? It's extremely helpful in many cases. Now, when you come off the HG, then you need to have a strategy of how to return

Starting point is 02:00:50 to your normal as fast as possible as well. But it will upregulate those five alpha reductase enzymes. You have in your genital skin, both scrotal skin and penile skin and perineum in general, you have, I believe it's called stratum lucidum. It's a skin layer that is very, very thin, but it has the highest concentration of five alpha reductase. So you have a lot of activity, and after you've been on something that inhibits the enzyme, the five alpha reductase, A.R enzyme in those tissues, then you do something else to upregulate those enzymes. Whether it's waiting and taking time, whether it's trying to dolephil, whether it's trying creatine even, or whether it's trying HCG. A lot of times those are the go-toes for post-finasteroid syndrome.

Starting point is 02:01:37 Any risks for women taking HCG on their ability to get pregnant or risk generally? Yeah. Obviously, it'll make any pregnancy test positive. So that's a very way. risk that some women don't know. So one could in theory fake a pregnancy test by injecting HCG. Absolutely. Interesting. I have no motivation to do that. I was just curious. Yeah. What about prolactin?

Starting point is 02:02:06 The simple version of this that I was taught, because I was taught mainly from the neuroendocrine perspective, was dopamine is a kind of close cousin of testosterone and also estrogen, for that matter, drives appetitive behaviors, including pursuit of sexual partners, sex itself, motivated behaviors generally. Then post-copulatory, post-orgasmic states are accompanied by a prolactin increase, sets the refractory period for mating in males, and maybe even in females as well, involved in milk letdown, et cetera. What are sort of the general contours of syndromes or things that people could be on the lookout for of having too much prolactin or too little prolactin. And I'm aware of a number of people who take dopamine agonis, altiracine,

Starting point is 02:02:53 capergolein, things like that to really boost their dopamine levels. And that isn't always a good thing, as it turns out. Oftentimes people will become kind of hyper dopaminergic. And so they have the drive to do all these appetitive things, you know, fill in the blanks. But they don't always have the ability because it seems just as testosterone and estrogen need to be in the proper ratios, dopamine and prolactin need to be in the appropriate ratios. How should we think about and perhaps act on our prolactin systems? Absolutely. The way I describe it is the dopamine wave pool.

Starting point is 02:03:26 So if you're increasing your dopamine too much, you're going to overflow, and then you're going to have that wave crash too much. So you want to have nice, even waves that are not going too far above the pool of dopamine, and prolactin will follow. So prolactin and estrogen are quite close cousins. estrogen upregulates a gene called the PRL gene or prolactin gene that directly increases prolactin synthesis. So prolactin is going to also inhibit the release of testosterone from the pituitary. So if you're using a dopamine agonist, then you're going to help decrease the prolactin

Starting point is 02:04:05 producing cells, including if you have a prolactin producing microadnoma in the pituitary. How common are those? Because I mean, I hear a lot about these, you know, hypogonadism or, and of course, that can be due to an issue at the testicles. Or hypogonadism could also be, of course, in like ovaryan syndromes. And then there's, of course, the brain side of it where the signals aren't coming from the brain. You're not enough gonadotropin, not enough luteizing hormone. And there are ways of teasing this apart through with an endocrinologist that are quite elegant, in fact, right? Using stimulating hormones.

Starting point is 02:04:37 Too much to dive into here. But how often does one actually have one of these pituitary tumors? I have heard that people that play a lot of high-contact sports, so boxing, football, people that headed the soccer ball quite a lot. Sadly, people whose jobs force them to take head blows for, you know, could be military. And so they were firing, you know, 50 caliber guns and the kind of woodpeckering of the brain inside of the skull. and construction workers or just a concussion can cause the pituitary to go malfunctional. Is that really common or is this something that, you know, is a rare like 1%. Yeah, it's extremely common.

Starting point is 02:05:19 It's another one of those conditions where a lot of people never know they have it. They just feel a little bit more fatigued. They have that high prolactin feeling all the time. Batuitary microadnomas can be non-producing as well. So your prolactin can be totally normal. or growth hormone and IGF1 can be totally normal. That's the second most common producing microadnomas is growth hormone, causing either acromegaly, which is growth of cartilage or gigantism.

Starting point is 02:05:44 This is the big brow. Yeah. So those are fairly common causes of adenomas, but a lot of people that have a very small adnoma, much less than one centimeter, it's hard to see on imaging, even if you have a contrast that specifically looks at the pituitary, and many people aren't symptomatic.

Starting point is 02:06:04 So it's one of those things along with PCOS and prediabetes that are much more frequent when it comes to prevalence, which is the amount, the percentage of people that have it in the general population. I'm glad you mentioned the dopamine wave pool. I know nowadays there's a lot of interest in augmenting dopamine. I know a number of people that do this through prescription drugs, Adderall, Ritalin, Modafinil, and those drugs, of course, hit many transmitter systems, but dopamine is certainly involved. people taking antidepressants like, well, butrin tap into that system. And of course, people are trying to inhibit prolactin and promote serotonin or reduce serotonin. To me, it all seems like a very delicate dance, right? I mean, to just imagine the arousal arc of for mating behavior, for sexual reproduction is such an elaborate dance between sympathetic drive and parasympathetic drive, even with across the span of minutes, right? I mean, I've talked about

Starting point is 02:07:02 this before on the podcast, that the arousal is kind of more parasympathetic. Orgasm in itself is a sympathetic response, a completely different set of neurons. And so where do you see people getting into trouble just trying to hit the gas pedal on dopamine? And where do you think there is a place for people who perhaps are experiencing low drive and motivation, not just sexual, but in general,

Starting point is 02:07:26 to increase the amount of dopamine circulating in their brain and body? How do you think about that, given this wave pool? analogy. Yeah, so it's important to parse it out and start with the least powerful interventions. So if someone's concerned about dopamine or maybe they have a slightly higher prolactin, then they eliminate things that could be increasing that prolactin. Such as. Cacian or gluten, which are mu opioid receptor agonists or any mu opioid receptor agonist in the gut. Casein, so milk protein?

Starting point is 02:07:58 Correct. Can increase prolactin? Correct. Interesting. In addition to that, if they need a pituitary MRI, then they should get a pituitary MRI. If they don't have an adenoma or if they don't have a high enough prolactin level to where they need an MRI, if they're having visual symptoms or if they're having olfactory symptoms with the nose, then it's more likely that they do that they do. But if they don't, a lot of times a prolactin under about 40 is not too big of a deal. they can take dopamine agonists that agonize that D2 receptor like P5P, which is essentially vitamin B6.

Starting point is 02:08:35 It's periodoxine 5 pyrophosphate and periodoxine is vitamin B6. So that can help 50 milligrams once to twice a day. Vitamin E can also help, especially if it's mixed to coferols. A lot of people have the high levels of vitamin E but low levels of the gamma form of vitamin E. so that can also help. Fascinating. I'm so glad you mentioned vitamin B6 and P5P. I have heard that one can shorten the refractory period after orgasm,

Starting point is 02:09:08 essentially to be able to have sex again, to be quite direct about it, by way of vitamin B6 blunting of the prolactin response, which turns out to be quite potent. But I've also heard that vitamin B6 can be neurotoxic, especially in the periphery, that it can cause peripheral neuropathies if it's taken at high doses, but that P5P is the safer form.

Starting point is 02:09:29 Is that true? It's pre-activated, so it does not build up. Think of it as an allegory to how folate can build up. It's not methylfolate, but it builds up, and it can increase levels of homocysteine. Or if you have too much vitamin B-12, another water-soluble B-vitamine, you can have too much methylmalonic acid or MMA.

Starting point is 02:09:52 So depending on what your enzymatic conversion is to the active form of the enzyme, often it's just safer to take the active form of the enzyme. Very interesting. Okay, well, at risk of going down every hormonal pathway and talking about supplementation lifestyle factors, I think touching on, as we have, testosterone and estrogen and now prolactin, I'd love to chat a little bit about Elkharnatine. We talked about this earlier, but I want to raise this discussion about Elkarnatine, not in the context of al-carnatine itself,

Starting point is 02:10:23 but in the context of fertility. Because my read of the literature is that L-carnatine can be very beneficial for enhancing sperm quality and egg quality and even rates of conception. What forms does L-carnatine come in that people can reasonably consider? Again, talk to your doctor, folks. What is it doing? And do we know how it's doing it?

Starting point is 02:10:48 And do you often use this in your patients? Yeah. So the way I think about L. Carnotene, and I'll try to tie this in with creatine and other things as well, is if your cell is an energy factory or a car, then L. Carnitine is the shuttle that helps get the fuel into the motor to use the motor. The motor is mostly due to lifestyle factors. So like, you know, your diet and your exercise. And the type of fuel itself is NAD plus. We don't need to get into NAD precursors or NEMN or NEMN or N-R or anything. And then the accessory fuel tank is your creatine phosphate. So creatine is your accessory fuel tank, your NAD status, which is largely determined by your REM sleep and quality sleep and exercise, along with supplementation as the fuel. The carnitine shuttle is carnitine palmitil coenzyme A, and that takes medium chain fatty acids. It takes different molecules of fat. You have two main energy sources other than ketones. You have your glucose or carbs. you have your fat or fatty acids.

Starting point is 02:11:52 And that takes it across the layer of the mitochondria so that it can be utilized. So it upregulates that. That's why things that have flagella in general, the flagella are going to work better, like sperm. Phlegela being anything, sort of the wavy little tendrils on cell types. Of which way, they're everywhere, right, in the gut too, right?

Starting point is 02:12:11 Yeah. So those are going to work significantly better, and in general, your mitochondria are going to work better. So the worst your mitochondria are off the bat, the better, the better. going to be helped by the shuttle that shuttles them across. It also slightly increases the density of the androgen receptor as well. Is that a local effect? So if Al-Carnatines is injected into a particular muscle, will it increase the density of androgen receptors in that muscle?

Starting point is 02:12:35 Likely so. So how are people taking El-Carnatine? Their capsule forms and their injectable forms. Most people are going to be taking the capsule forms because that's all they're going to have access to. And then we should also ask, can you get El Carnatine from food? Yeah. So L-carnatine. El carnitine is just a combination of, it's actually a very small peptide. So glutathione is just three amino acids. L carnitine is the smallest peptide, too. So peptide is just a protein that has amino acids between two and about 200. And L carnitine is just two amino acids.

Starting point is 02:13:09 Amazing. So it's like a micropeptide. Yeah. So your body synthesizes enough. It likes to absorb the amino acids by themselves. And then if it puts them together, there it makes L carnitine. it's not very bioavailable if you take it. A lot of people will take L. carnitine,

Starting point is 02:13:24 L tartrate, or acol L. carnitine, and that's about 10% bioavailable. So if you want one gram or 1,000 milligrams of L. carnitine, you can take 10 grams of oral l carnitine. Is it, is the one gram, the typical dose you recommend, one gram per day? For fertility and androgen receptor upregulation. So that means taking 10 grams of the capsule form. Yeah.

Starting point is 02:13:46 So that's about 15 to 20 capsules. which is a lot. That is a lot. It can also potentially increase TMAO. Yeah, I wanted to ask about that because TMAO on your blood chart is, you know, when that's elevated, that's going to cause some concern. You taught me a trick, however, that one can take 600 milligrams of garlic capsule for the Allison. Is that what's called?

Starting point is 02:14:09 Allison is in it. It's like the name Allison, but with two else. Yeah. Okay. And that had a remarkable effect in reducing TMAO. So that's quite potent. And also, was it just coincidence that it really brought my LDL down as well? I'm not sure if the LDL is a coincidence, but depending on your gut microbiome or your microbiota, some microbiome beneficial bacteria will convert carnitine and also choline. So any coline precursor like alpha-GPC or phosphatil-serine,

Starting point is 02:14:45 they will convert them more or less to TMAO. So TMAO is something that you can get measured in a blood test and see if it's high or low. Some people might not even need Allison. Interesting. Some people do benefit from it. Interesting. Although I think it was you that also told me

Starting point is 02:15:01 that Allison and garlic can have positive effects on cardiovascular tone and blood flow generally. Is that right? Yeah. Okay. So it's 600 milligrams garlic in excessive amount or can I just eat garlic? I mean, I like eating garlic. Yeah.

Starting point is 02:15:16 Yeah. So, okay, so one could also just eat garlic. If one were going to take Elkhartinine in injectable form, how much of that is bioavailable? A hundred percent, if you inject it. It is in an aqueous solution. So it's bacteria, static water, essentially. So it's not in a carrier oil. So it's going to burn a lot if you inject it subcutaneously.

Starting point is 02:15:37 So it's going to be absorbed faster and more evenly and also just hurt a lot less if you inject it into a muscle. But one could then just take one gram per day injected or divide it up into a couple doses. Yeah, or 500. The minimally efficacious dose for injectables, probably around 200 when it comes to sperm motility, the androgen receptor upregulation. So it really depends on why you're taking it. In terms of fertility and in terms of blood test generally, I always say that if possible, either by way of insurance or by way of some other way affording it, it would be great for people to have blood tests to know what their hormone levels

Starting point is 02:16:21 and other levels of other things like metabolic markers and lipids were in their 20s, also in their 30s, also in their 40s. I think there's this idea that you only take a blood test when you have a problem, but then of course, one can't actually do the comparison that you mentioned earlier or state the comparison to one's physician

Starting point is 02:16:38 that things are changing over time. And it seems to me that basically everyone should get at least a once a year blood test. Is there the hope that insurance will someday just cover it for everybody? This will be standard care. I would think that everybody should know what sorts of things are floating around in their bloodstream and what they need more of and less of in life. I doubt it will ever be covered by insurance.

Starting point is 02:17:02 In many cases, you could make an argument that it's indicated. As insurance begins to cover more of the population for pathologies, the things like FSAs or HSAs or care, credit will likely cover this advanced testing, which it continues to come down and down in price. So it'll be affordable, but it won't be free. Got it. I'd like to shift gears slightly and talk about social interactions and relational effects on hormones. Something that I just find fascinating.

Starting point is 02:17:35 We touched on this a little bit earlier in terms of oral contraception. But now that we have the backdrop of what these various hormones do, some involvement in neurotransmitter systems like dopamine and prolactin and associated pathways. Prolactin, of course, being a hormone, not a neurotransmitter. But, you know, there's a phenomenon in human beings where people get very excited about a new partner. And that excitement, no doubt, is related to the dopamine system, among other systems. And that excitement can be maintained or can wane over time. And here I'm talking about attraction, but I'm also talking about just general excitement in the sense of novelty, because that's what dopamine is associated with.

Starting point is 02:18:13 Given that you work with human beings and they have lives and relationships and lifestyles and they have hormones and all these things interact, what are some of the ways that we could think about adjusting our relationships in order to optimize hormones as opposed to just thinking about how to optimize hormones for sake of our relationship because it's bidirectional, of course.

Starting point is 02:18:39 and this assumes, I should say, that one is already paying attention to the six pillars talked about earlier, that people are doing most things right. How should we think about relationships and hormones? Friendships, romantic relationships, new partners, long-term partners. Yeah, how do you think about this kind of stuff? Yeah. So if you have a new partner, then it is largely regulated by the dopaminergic system, which changes over time.

Starting point is 02:19:07 So people may have heard the saying that you have to go through a full calendar year with someone that you're in a relationship. Very good advice, by the way. So that you really know what to do and what not to do. But because you experience both of your families and the holidays and all the different situations. But I would argue until you have moved in together, had a baby, and then raised that baby, preferably breastfeeding, because that's when you get the prolactant spikes. you don't really gone through every stage in life yet. Now, you can't really do that with every person that you're considering. Well, some people do, but it can be quite costly in terms of time and finances and emotionally costly.

Starting point is 02:19:48 And then here I'm definitely not referring to any personal experience of having done all that many times over. But what would you suggest people do or think about as they enter a relationship or for people that are in long-term relationships where they feel like something has shifted, and indeed, those shifts may reflect the output of different hormone systems and neurotransmitter systems. It almost certainly has to be the case, right? Yeah. So just like women who spend a lot of time together, whether they're co-workers or whatever, a lot of times menstrual cycles will align. There is a lot of pheromonal and hormonal cross-talk, including prolactin between men and women. So spending 100% of the time together, this is why people think it's so hard to work together and live together.

Starting point is 02:20:36 They're around each other 24-7. You don't have the reprieve where you let that dopamine settle down and then you're excited when you see them again. A lot of guys know that if they've gone on a hunting trip or if they've gone on a trip for a long time, they come back and they see their partner and it's like a new, not quite like a new relationship,

Starting point is 02:20:54 but almost like a new relationship. And they have that excitement again. And purposely building that into every relationship can help significantly, especially if you choose to have a child or get pregnant or be breastfeeding because you just plan ahead for both of your prolactants to be high and both of your dopamine's to be low and both of your testosterone's to be low.

Starting point is 02:21:16 So there's a lot of planning that you can do. Essentially every relationship goes through a crisis. And that crisis is personal between the two of you and you can plan ahead and figure out a way, maybe it's not supplementation, maybe it's not even the amount of time you spend away from each other, but plan ahead to have good times

Starting point is 02:21:44 if you know you're about to go into a crisis. Got it. And so it sounds like time apart and time together, which is actually built into a number of cultures where men and women will purposefully avoid each other for some period of time, avoid physical touch and maybe in proximity, and then we'll reconvene.

Starting point is 02:21:59 And yet those are very stable relationships over time often. Is the inverse also true? For instance, for people that are in long-distance relationships, where they're only seeing each other three or four days a week or two days a week, does this explain the fact that some of those relationships can go on for a very long period of time without ever actually entering the, let's call it, the hyperprolactin phase of actually moving in together and et cetera, et cetera.

Starting point is 02:22:25 Like, in other words, is that a way in which people are spiking and trikeying and dropping dopamine that keeps them attached, this kind of elusive, this sort of, what is it called, I think it's called like a cat string. Like if you play with a cat and you move the string away, they'll keep reaching, but you throw the string on the ground and they're like, they're totally uninterested in it. Is that what's going on? Because that's a dopaminergic phenomenon, the cat string example. We know this experimentally. In those cases, the relationship hasn't really progressed, in many of those cases, past the dopamine spike, the fun initial stage, honeymoon stage, whatever you want to call it.

Starting point is 02:23:01 So it's almost kind of like a roommate. If you're looking for a roommate, if it was for college or after college or whatever, you can fill out forms and look for common interest. But until you're actually together a significant proportion of the time, you're not really going to know if you're going to be compatible or not. And is there evidence that the appearance of an infant changes, obviously there are going to be hormonal shifts? We know actually that for,

Starting point is 02:23:29 in both women and in men, there's a prolactin increase when couples are expecting a child. This is the, it's almost like a brooding phenomenon. You see this in birds where it's actually called brooding and it's caused by prolactin increase. But it turns out this also occurs in humans. And some people would argue this causes the dad bod phenomenon because it actually prolactin's involved in laying down a body fat preparing for sleepless nights. And presumably that spike in prolactin is there also to suppress sexual activity. because there are periods of time immediately near childbirth where sexual activity is not advantageous.

Starting point is 02:24:06 Yeah. You see a prolactin spike right after breastfeeding. So if you think about it, often when you have an infant, you'll breastfeed, put the infant to bed, and then immediately go to bed with your partner, which is not particularly conducive. It's almost like trying to have intercourse back to back. And it's very difficult.

Starting point is 02:24:25 Because of the, in the prolactin sense. Yeah. Low dopamine. ioprloctin. Oxytocin is also increased significantly to help with milk led down as well. So yeah, as far as brooding, there's definitely a human equivalent of brooding. Some humans call it nesting instinct, which is both helpful, but it's not necessarily a bad change in relationship. It's just a change. And as long as you know that it's coming, you're going to do better with it. just like any medication, if you are aware of the side effect

Starting point is 02:25:00 and then it might happen, then when it happens, it's not only less severe, it also happens less often. Very interesting. You tell the patient. Well, as a neuroscientist, I come from the framework that of course, hormones impact perception and behavior, but perception and behavior also impact hormones. I found this fascinating.

Starting point is 02:25:20 I also really like the example you gave of people taking time apart, but also these affiliative bonds that are, non-romantic bonds can serve as kind of a reservoir to replenish dopamine that is then released upon experience going back to one's partner or some sort of regular feature of home. Very interesting. And of course, this should exist on both sides. I'm guessing that from both the male side and female side, there's an interest in kind of separation and reunion as the theme. And I guess the frequency will vary for different couples in different situations. Yeah. And I don't want to make it.

Starting point is 02:25:56 seem like prolactin is all bad. So prolactin does help with the nesting instinct. It helps with breastfeeding as well. A lot of women are diagnosed with luteal phase defects, which is basically the phase after ovulation but before a period or giving birth. The pregnancy is kind of a prolonged luteal phase. And a lot of them will go on progesterone for this. Progesterone can also decrease prolactin. And prolactin is also helpful for them maturity of lungs and infants. So it helps the sphingomyelin to letch a thin ratio. So it can decrease, if your prolactin's too low through pregnancy, it spikes up very high during pregnancy, then it can lead to increased risk of respiratory distress of the newborn. Really interesting. Yeah, so we certainly don't want to paint a

Starting point is 02:26:40 picture where prolactin is the bad, bad hormone to avoid. It's without prolactin, none of us would be here, of course. It's so vital. I realized that earlier I raised the question about whether or not cold exposure could modify hormone output, in particular whether or not ice baths or ice applied to specific tissues of the body as people are doing one way or the other can change testosterone levels, estrogen levels. In other words, taking ice baths and cold showers increase testosterone and or estrogen. Yeah, so taking an ice bath or a cold shower or cold exposure in general, it's not going to correct a vitamin D deficiency or a metabolic syndrome. So there's a lot of things that it will not correct that are causes of hypogonadism or low testosterone,

Starting point is 02:27:29 but it will help acutely, specifically the application of cold to testes that are too warm. So if you have a varicoseal or if you have a little bit of a primary hypogonadism, which is where testosterone is not released by the testes, but your LH and FSAH, signals are sufficiently high, then you'll likely respond to cold exposure better. And there's actually undergarments that are designed specifically to help with fertility. And there's probably going to be more and more of that in the future. You just need to be careful not to get frostbite because it's a particularly bad spot to get frostbite. Noted. Could you define vericose seal? You mentioned it a few times. That's a varicose vein. Yeah. So it's essentially a varicose vein.

Starting point is 02:28:17 it brings warm blood and the venous flow or the flow back to the heart is not as good, just like in the legs, it can happen in the scrotum. Usually about 20 to 25 percent of people have one grade of varicoseal. There's grades one through four, one through five, and most people just have a very mild one, usually on the left side because the blood has to go through further to get back to the heart. And it raises the temperature of the testes. Temperature is the enemy of testes. So they like to be five to 10 degrees cooler than the rest of the body.

Starting point is 02:28:50 So our sauna is particularly bad for sperm production? They can be, yeah. When you say can be, how long could one safely be in the sauna? Would you want to go back and forth between the cold and sauna? Are there any data? If someone is having infertility, then I tell them to avoid all saunas empirically. If someone has, if they're not infertile, but they have a low sperm count, I also tell them to avoid.

Starting point is 02:29:19 However, it's mostly warmed water that can raise the temperature of the testes faster than the sauna. So hot tubs and things of that sort. Yeah, so a hot tub and a jacuzzi, those are enemies number one and number two of sperm. What about ice baths and cold showers for women? Any evidence that it can shift hormone output in women? Yeah, it can. It increases the activity. of the beta adrenergic receptors,

Starting point is 02:29:49 even in the central nervous system and the astrocytes as well. So it can do a few things. It can slightly decrease the drive for food, which astrocytes and beta adrenergic receptors have some medications that are weight loss medicines also do similar things. But it can be beneficial in women do.

Starting point is 02:30:11 But no evidence that it changes estrogen output in women, correct? Not that I know of. Yeah, me either. Peptides. A lot of discussion these days about peptides. Peptides, of course, just being strings of amino acids, as you mentioned. Very small ones, like two amino acids like L. carnitine all the way up to polypeptides, which just mean many amino acids.

Starting point is 02:30:35 There are so many peptides that we should probably just do an entire episode about peptides. But I think one of the reasons I'm hearing so much about peptides these days is that they are not called steroids. You know, the name steroids, I think, has come to be associated with anabolic steroids in the context of, you know, acne, testosterone rage, et cetera. But of course, testosterone, excuse me, estrogen is a steroid hormone, right? There are other steroid hormones, as we both know. But peptides are gaining increasing popularity. I am willing to go on record saying that you can be sure that many of the incredible transformations

Starting point is 02:31:12 that you see in Hollywood are the consequence of, peptide use, and I'd put my name behind that because I'm well aware of people that use these to prepare for roles, but athletes use them. And then everyday people are using them to, for instance, surmoralin, tessimorlin, ipomorlin to stimulate the release of growth hormone rather than taking growth hormone. BPC 157, which is essentially a synthetic gastric juice that normally repairs the gut, is being used to treat injuries. And there are other ones as well.

Starting point is 02:31:48 What can we say generally about peptides? Are they safe? Are they not safe? What about sourcing? And are there any peptides that you think could be a particular use for people? And we should probably also touch on peptides that people shouldn't go anywhere near

Starting point is 02:32:00 with a 10-foot pole. Yeah, definitely. So peptides are very heterogeneous. There's very dangerous ones and very safe ones. My favorite peptide is the original peptide, which is insulin. So insulin is a peptide, and, you know, less than 100 years ago, there was a scientist studying insulin, and at some point they saw that an animal had its diabetes cured by insulin injection. Less than a year later, they were injecting insulin into every type 1

Starting point is 02:32:34 diabetic because it was saving their lives. And yet insulin can kill you if you take it at the incorrect dose. Yeah. So just like insulin should be prescribed by a doctor, there is over-the-counter insulin rely on our NPH,

Starting point is 02:32:48 but ideally your insulin is prescribed by your doctor for your diabetes as it's life-saving. Peptides should be prescribed by doctors as well. And there's several that are FDA-approved.

Starting point is 02:33:01 So you mentioned a lot of different ones. Let's start with Tessamorlin. So Tessimoralin was recently FDA-approved for something called lipodistrophy. It happens where body fat is displaced into abnormal areas, often as part of AIDS or severe burns, things like that. And it helps redistribute this body fat and give people their quality of life back. Tessimorlin is a GHRH, which I kind of loop into the category of GHRPs, so growth hormone releasing peptides.

Starting point is 02:33:31 So it's only a couple amino acids different from endogenously produced growth hormone releasing hormone. So growth hormone itself is also a peptide. It's a peptide hormone, not a steroid hormone. So you have different somatotrophs, which are very similar to growth hormone. Another fun fact is that HPL, which is human placental lactogen, we love acronyms, right? Human placental lactogen is nearly identical to growth hormone. The growth hormone in pregnancy is not what causes the sugar spike and gestational diabetes. It's the human placental lactogen. So if you look at twin pregnancies, if they have two placentas or more placental tissue,

Starting point is 02:34:19 making more human placental lactogen, the risk of gestational diabetes is exponentially higher. So this HPL is only a couple molecules different from growth hormone. it is interesting that these different GHRHs and GHRPs actually have pretty different mechanisms of action. Grelin is also a hormone that's released when you're hungry. This is probably one of the reasons why you have more growth hormone release overnight, and there's a lot of peptides that are very similar to Grelin. So these peptides are not bioidentical peptides, but they just have a couple different amino acids change,

Starting point is 02:34:58 so they're almost identical. and they're probably going to be used in the future for growth hormone deficiencies, including in kids they've been studied. So if somebody wants to increase their growth hormone and output, in addition to not eating within two hours of sleep, getting good deep sleep, doing all the other things in the six pillars that you mentioned earlier, especially resistance exercise at some point earlier in the day, what are the risks and benefits of taking a growth hormone releasing hormone peptide?

Starting point is 02:35:30 like sermoreland prescribed by a doctor, of course. What should one be concerned about? How long could one take these? I've even heard that they can modify gene expression so that they really are changing your hypothalamus in very long-lasting ways. Yeah, there's definitely a lot of risk, tumor growth and cancer. So you look at a type 1 diabetic. They have very high incidences of various types of cancer. They have very high growth hormone, but low IGF1, paradoxically. So they would likely give you a similar cancer risk to a type 1 diabetic that has very high growth hormone. However, there are the benefits of it. You think of lipolysis, decreased body fat, increased lean body mass. A lot of those can, you can use other things to get those benefits. So then, you know, you don't

Starting point is 02:36:27 need growth hormone for those benefits, it just leaves cosmetic benefit, to which you can usually use topicals to get your hair and your skin and your nails. There's a lot of other things that you can do other than growth hormone. So a lot of people just don't need these GHRPs if they don't have lipodistrophy or if they don't have growth hormone deficiency. There is other uses of them, specifically in injuries. So I know that they've been studied. I'm not sure if it's in the military. We mentioned the woodpecker or the coup, contra-coo injury. So that can obviously... Halting back and forth,

Starting point is 02:37:02 the brain basically slamming up against the front of the skull. Yeah, football, heading the ball in soccer. Definitely people who use the 50 caliber and military, although that's a fairly small population. And I think anyone that's hit their head hard more than once. Yeah. We can talk about BPC-157 for a bit, GHK copper peptide for a bit,

Starting point is 02:37:24 TB 500 or thymocin beta 4 analog. And then we can also talk about brim melanotide, which is melanotan 3. They have melanotan 1 and 2, and then they also have melanotan 3 and 4. Yeah, let's talk about BPC 157 and melanotan, because I think those are the ones that most people are eyeing, so to speak. Yeah.

Starting point is 02:37:46 So BPC 157 is body protective compound 157. It's identical or bioidentical to gastric protective compound 157 that's produced in the stomach. So as you age, you get atrophic gastritis very often. That's why you have less intrinsic factor, which is kind of another peptide that binds to vitamin B12. That's why you can get age-related B-12 deficiencies. So that's one reason why you have more colitis, more diverticulitis as you age. You don't have that gastrop protective compound. It increases veg-f, vascular indifference. Vascular, end theelial growth factor, which basically makes your blood vessels grow more. So that's what causes

Starting point is 02:38:31 your body to form a blood vessel. So another medication known as Avastin, it's on the WHO's list of essential medications for cancer. So many different types of cancer, including colon cancer, you treat it with Avastin, which is a VEGF inhibitor. So if you have cancer or a high cancer risk, you probably don't want to be taking a medication. That's the exact opposite mechanism of action as your essential anti-cancer med. In other words, if you have cancer, you're at risk of cancer, avoid BPC 157.

Starting point is 02:39:02 Correct. A lot of people prescribe it for six weeks. And BPC 157, so brimelanotide, that is FDA approved for a hypoactive sexual disorder. Tessimoralin, that's also approved for lipodistrophy. Interestingly, another one of the melanotan is also approved for lipodistrophy and also a deficiency in the melanocortica receptor. So the receptor that receives the alpha melanocytes stimulating hormone, it's a very rare condition. It's also approved for that

Starting point is 02:39:34 because if you don't take it, then you get obesity. But BPC-157 is not FDA approved, but it is essentially standard of care at this point. I would say it's, you know, if you're not counting insulin or growth hormone as peptides. It's one of the most commonly used peptides. And anecdotally and in some clinical literature, it's fairly well tolerated for short periods of time. I'm not in the camp that everybody needs to do it two to three times a week or even daily for six weeks no matter what. The major benefit is when you're going to take it early on because it's going to allow your body to increase blood flow to the injured area. And the less blood flow it has, for example, ligaments have horrible blood flow, especially as people age, it's going to make a significant

Starting point is 02:40:23 difference. So I would wager that that Russian gymnast that Achilles healed in one month completely from a full rupture was likely taking BPC 157 or something very similar. Yeah, I'm willing to wager on that as well, a remarkable recovery. And so because it is prescription, there are non-prescription forms. My understanding of the non-prescription forms and the danger of going after non-prescription forms is that oftentimes they will contain what, they claim they contain BPC 157 in this case, but they are not adequately cleaning out the LPS, the lipopolysaccharide, which can cause inflammation.

Starting point is 02:40:58 In fact, in the laboratory, we use LPS to deliberately induce fever and inflammation to study systemic inflammation. So this is a warning to people, if you're interested in peptides, you absolutely need to work with a physician, in my opinion, get it from a really good compounding pharmacy

Starting point is 02:41:12 who will clean out, that cleans out the LPS. Because if you're buying it through a source that, you know, a lot of people, I don't want to name sources, but they're these common sources on the internet that everyone knows about. They're buying these sources. They'll ship it to anyone, essentially. But then the LPS is really causing inflammation. And many people experience a kind of mild fever or tingling from that when they inject it. And they're like, oh, I can feel it working. That's probably LPS action, which is not good for the brain. I don't know about the, on other

Starting point is 02:41:41 peripheral tissues. I haven't heard of people dropping dead from this stuff yet, but I certainly wouldn't want to be ingesting any LPS unnecessarily. So would you agree that you should work with a doctor? After all, you are a doctor. Yeah, definitely talk to your doctor about this and talk to them about the dosing regimen as well. So if they have you doing it for six weeks, ask them, why am I doing it for six weeks? Why not? Two weeks or why not, as soon as I feel better, can I just stop it? Yeah, there's a lot of good questions like that that you should ask your doctor. And if somebody's trying to prescribe you a bunch of different things, then see, is this what they prescribe everybody? Or is this individualized for me. There are peptides like GHK copper peptide, which is produced endogenously

Starting point is 02:42:20 in the liver more at younger ages. That's why the liver can regenerate fully is this. The GHK copper peptide helps. And if you're copper deficient, which not a whole lot of people are, but a lot of people that have had bariatric surgery are copper deficient. GHK copper peptide can help significantly with your nervous system. And it's also synergistic. So any growth agonist like thymus and beta of four made in kids in the thymus, which shrinks. That's another reason why kids heal really well. That and GHK is somewhat synergistic with BPC, but if you don't need all three, you don't want them. And if you don't need it for more than a week, you don't want it for more than a week. I really appreciate you saying that. I often say that sometimes the best dose of something to take

Starting point is 02:43:01 is zero. It's often the case that the best dosage is zero. You mentioned melanotan. There are several kinds of melanotan. I find it a little bit of a funny conversation because I first learned about melanotan from reading about peptides and discovering that people were taking, injecting melanotan to get tan because it's in the melanin synthesis pathway. They also discovered, this isn't an individual, this is reading about this in various manuscripts and peer-reviewed papers, that it could cause things like preopism, like a sustained direction that might be the last one that anyone would ever have because of damage to the vasculature. Also, women taking melanotan as a way to get tan and lose body fat.

Starting point is 02:43:45 So this sounds all very recreational. Are there any clinical usage of melanotan? So separate from the kind of extreme biohacking cosmetic world, which is really not the main focus of this podcast ever, more in terms of, you know, pursuing health optimization. Yeah. There's actually three FDA-approved indications,

Starting point is 02:44:05 Believe it or not. Not many people know about this, but there's three well-accepted indications. One of them is the hypoactive sexual disorder and more in women. That's for brimulanotide. So those are women that have essentially no libido whatsoever. But other hormones are in check. Yeah. Classically, it's before menopause. So those hormonal issues are not contributing. And when you give them this peptide, it's also known as PT-141. It helps significantly. A lot of times you use it in nasal spray. It goes straight into the central nervous system and act centrally. You can also inject it and you can also take it via troki.

Starting point is 02:44:43 Men and women take it. Correct. It's approved for women, but it can also help men. And it's relatively safe. The only relative contraindication that I tell people, and a lot of people say, oh, there's no side effects that I know of. But if you have a family history of melanoma or potentially have a melanoma and don't know about it, that's why I'm a big advocate of dermoscopy as well and regular skin.

Starting point is 02:45:05 checks, then theoretically it's going to increase that alpha melanocyte stimulating hormone, and it can grow that. So that's definitely not a good thing. So be very careful about long-term administration of it. It's also approved for lipodistrophy, which is the same exact thing as Tessimoralin, which I believe is also known as Evista or Agrifta. And then it's also approved for the rare genetic condition where your receptors or your melanocytes don't prove. And then it's also approved for the rare genetic a condition where your receptors or your melanocytes don't proliferate as well. So you usually have hypopigmentation. It's not true albinism, but it's associated with morbid, morbid obesity and very poor

Starting point is 02:45:45 outcomes from that in childhood. So it's used in kids, actually. Interesting. Well, peptides are a fascinating landscape, but thank you for that deep dive into several of them. We will probably return to you to talk about peptides again in the near-finding. future because I know there's a lot more there and a lot of interest. I want to talk about the sixth pillar. All right. So just to remind people you said diet, exercise, where appropriate,

Starting point is 02:46:13 caloric restriction, managing stress, sleep and sunlight are critical for everyone at all ages to manage and optimize hormone health. Then you have this sixth category, which is a really intriguing one, which is spirit, which is a kind of unusual thing to hear coming from a medical doctor, except that I have many colleagues and indeed our former director of the National Institutes of Health, Francis Collins, has talked about this notion of spirit. We've talked about belief effects on this podcast before with Ali Crum, how one's understanding of the things that they do and their world in general really creates an important effect on everything at the level of physiology, not just psychology.

Starting point is 02:46:55 So as a physician, how do you conceptualize this spiritual aspect and how do you talk to patients about this, given that people walking into your clinic presumably have a bunch of different religious and not a religious backgrounds. I'm sure some are atheists. Some are probably strong believers. How do you deal with that? And how should people think about this? Yeah, I believe it's, it is surprisingly well received. You wouldn't think at first glance that a patient really wants to talk about their spiritual health with their doctor. But the way I think about it and the way that it really is, is it's like a Venn diagram. And you have a body and a mind and a soul. and you can't have one healthy without the other healthy, even if your mental health is phenomenal,

Starting point is 02:47:36 and even if your physical health is phenomenal, the mental aspect of spirituality, if that piece is not there, then that's going to affect your body physiologically as well. And Ali Crum's done some excellent work. There's also been a lot of other studies regarding prayer. And I'm a Christian, I believe in God, and that gives me a lot of that resilience and motivation.

Starting point is 02:47:59 it gives me the cornerstone or the groundwork, how I can interact with life. And regardless of someone's an atheist or regardless of what someone believes as far as religion or the origin of the species, they can know that their spirituality is going to have a profound effect on their mental and physical health as well.

Starting point is 02:48:22 People like to compartmentalize it. So they like to talk to their doctor only about the physical health because it's comfortable to do that. They only talk to their pastor or a mom or, you know, reiki healer for their spiritual health, and they just talk to their therapist or psychiatrist about their mental health. But you need to bring all three of those things together. It's well known that interdisciplinary clinics lead to improved patient outcomes.

Starting point is 02:48:47 And that's just disciplines within medicine. So that's just doctors that are specializing in this or this. So this takes a step back in the upper part of that tree before you reach those. dichotomies or the split-offs. You have your body and your mind and your soul. So your spiritual health and your mental health and your physical health. So if you're in line in all three of those things, that builds the cornerstone for the rest of your health and the rest of your life. So if someone comes into your clinic and they say they're feeling one way in their body, they're feeling one way in their emotional life, you run their charts, you get their blood work,

Starting point is 02:49:23 and they're an atheist or they're agnostic. What are some of the sixth pillar practices that they can consider that are in keeping with their atheism or agnosticism? Because I have to assume that people who are in participate or feel that they belong to particular religious sect will have particular prescriptives from those religious sect that will direct them towards particular types of prayer. How would somebody who doesn't have a prescriptive coming to them from some other source,

Starting point is 02:49:59 what could they do or would they do? Yeah, so I certainly don't force prayer on anybody or anything like that. But it's my belief that being, especially being an agnostic, it's almost the hardest thing. Because if you're an atheist, then you have some groundwork and you have some spirituality, even if it has to do with the human spirit's interaction with the environment, things that can't be physically explained well, phenomenon like the work that Ali Crum does.

Starting point is 02:50:27 But if you're agnostic, you're still trying to find that. So I hope that everybody does find what they truly believe in as far as their own spirituality. But yeah, that's a personal journey. From a physician standpoint, and even if I'm friends with him as well from a friend standpoint, I don't like to push anybody in any specific direction. So I don't think that everybody should believe what I've

Starting point is 02:50:52 believe, and I don't feel like there should be any pressure for them to believe something different. So I think that there can be excellent physician-patient rapport, regardless of what we believe and what our backgrounds are. Yeah. That's wonderful to hear. I can say without revealing any names that I have close colleagues that in every bin of this spectrum, like hardcore atheists, hardcore religious in different domains, different religions. I don't know, I don't know if I know many, I'm agnostic as to whether or not I know any agnostic, I should say.

Starting point is 02:51:28 It's not something that people commonly discuss, but in the context of science and medicine, but it's starting to happen more and more. And certainly this issue of spirituality is one of the areas in which neuroscience is asking a lot of questions, like what spiritual experiences really are in terms of how they're grounded in the brain or not grounded in the brain.

Starting point is 02:51:46 I think it's a really interesting area, for discovery. And I appreciate that you bring it up and you bring it up in the non-pressured way that you do. I think that it will stimulate a lot of thinking, which is ultimately the goal of this podcast. Well, I have one final question that a listener insisted I ask. And it's a very straightforward one. It's not at all a curveball and not at all related to what we were just talking about. but it was the most common question when I told people that I was going to be talking to you, which is, is caffeine problematic for hormones? It's amazing. I received hundreds of the same question about caffeine. And since it's probably the most commonly used drug on the planet,

Starting point is 02:52:31 I know it's taking us back into the very practical, but in closing, we're not quite the area, but in closing, is caffeine having an effect one way or the other on testosterone, estrogen, or other hormones that is positive, negative, or neutral? Only if it affects your sleep. So it works on adenosine, and it can actually slightly improve allergies as well, but negligible effect otherwise. Great. Well, sorry to end on such a practical brass tax type of question, but I did promise to the listeners

Starting point is 02:53:04 that I would ask that question. Listen, I want to sincerely thank you. We covered basically an endocrinology textbook, a neuroendocrinology textbook's worth of information, a ton of practical tips in there. Where can people find out more about you? We will certainly provide links. And I guess the other question is, are you taking patience? I'm sure you'll hear that in the various venues where people can contact you. But where are you active in terms of public-facing work?

Starting point is 02:53:29 I'm active on Instagram, Kyle Gillette, MD. I'm also active on the social medias of my... brand new clinic, which is Gillette Health. That's at Gillette Health on Instagram or Gillette Health.com. Great. We'll provide links to those. And I should say that the content you've been putting out on Instagram is terrific because you actually point to specific studies and you put things into actionable context, which is very meaningful for me. Kyle, Dr. Gillette, I should say. Thanks so much for your time. I really appreciate it. I know the listeners will too. Thank you. My pleasure. Thank you for joining me for my discussion about hormone health

Starting point is 02:54:05 and optimization with Dr. Kyle Gillette. As you just heard, he is a treasure trove of actionable, clear information. And again, you can find him teaching more about hormones and other aspects of health on Instagram at Kyle Gillette. That's Gillette with two T's and two L's, but no E, Kyle Gillette MD on Instagram,

Starting point is 02:54:26 and Gillette Health on all other platforms. And if you would like more information about his practice, you can find that at Gillettehealth.com. If you're learning from, and or enjoying this podcast, please subscribe to us on YouTube. That's a terrific zero-cost way to support the podcast. In addition, please subscribe to the podcast on Spotify and Apple.

Starting point is 02:54:46 And on Apple, you have the opportunity to leave us up to a five-star review. If you have questions or comments about this or any episode of the Huberman Lab podcast, or if you'd like to suggest topics that you'd like us to cover or guess that you would like me to talk to, please put that in the comment section on YouTube. In addition, please check out the sponsors

Starting point is 02:55:04 mentioned at the beginning of today's episode. That is the best way to support the podcast. If you're not already following us on Instagram and Twitter, please do so. It's Huberman Lab on both Instagram and Twitter. And there, I cover science and science-based tools, some of which overlap with the contents of the Huberman Lab podcast, but much of which is distinct from the contents of the Huberman Lab podcast. Thank you once again for joining me for today's discussion with Dr. Kyle Gillette. And as always, thank you for your interest in science.

Huberman Lab - How to Optimize Your Hormones for Health & Vitality | Dr. Kyle Gillett

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