The Dr. Hyman Show - Male Menopause, Low Libido, And Testosterone Replacement with Dr. George Papanicolaou

Starting point is 00:00:00 Coming up on this episode of The Doctor's Pharmacy. If you're just looking at testosterone alone, then you're going to potentially miss the root cause of the problem. And so just replacing testosterone is never a good idea. Hey everyone, it's Dr. Mark Hyman here. I want to talk to you about how I make time to read all the books on my list. I love books and I'm constantly reading at least two to three at any given time. And when I get really busy, I turn to audiobooks. My love of learning, reading, and listening to audiobooks has been critical in my ongoing journey to become the happiest, healthiest version of myself. And one of my favorite activities is

Starting point is 00:00:38 getting in the car with my wife and going for a long drive while listening to one of our favorite books on my Audible app. I always revisit my favorite classic, Walden by Henry David Thoreau. This book made such an impact on me and the way I view the world that I love to listen to it over and over again. I take away something new every time I return to this book and Audible makes it so easy to do. They have thousands of titles to pick from and their app is super easy to use. And you can download everything to your phone or your tablet to listen to while you're going for a walk or cooking or going for a drive. Today, Audible.com has a special offer for the Doctors Pharmacy listeners. That's you.

Starting point is 00:01:15 You get two free credits for books when you sign up for your 30-day free trial. Just go to audibletrial.com forward slash Dr. Hyman. That's audibletrial.com forward slash Dr. Hyman. That's audibletrial.com forward slash Dr. Hyman. That's just D-R Hyman. All right, now let's get back to this week's episode. Welcome to Doctors Pharmacy. I'm Dr. Mark Hyman, and that's pharmacy with an F, F-A-R-M-A-C-Y, a place for conversations that matter. And if you have had issues with hormones, this conversation is going to matter to you because it's with my colleague and friend at the Ultra Wellness Center, Dr. George Papaniccolo. And here we are at the Ultra Wellness Center in Lenox, Massachusetts.

Starting point is 00:01:55 We're appropriately socially distanced. And we are going to talk about a number of cases today. And one of them is going to be about hormones. It's a big issue. George has joined our practice a number of years ago. He's an incredible physician, a big man with a big heart. He's been a functional medicine practitioner for years. He worked on the Navajo reservation, and he's just an extraordinary dude who I love having in our practice, and we are going to talk about hormones today and all things hormones. So, to the doctors pharmacy podcast Mark it's always a pleasure so you know

Starting point is 00:02:29 hormones is a big topic right and you know we talk about hormones and men hormones and women and there's a lot of hormones right there's sex hormones like testosterone estrogen progesterone there's thyroid hormones insulin stress hormones and there's many many other other hormones. But we're going to focus today on guys who have a problem that's very common, sometimes referred to in the media as low T or low testosterone, which is a pandemic out there. And it causes so many different issues. Other people call it andropause or male menopause. But if you're a guy listening to this, whether you're 30 or 40 or 50 or 60,

Starting point is 00:03:11 this could be happening to you and you just don't know it and it makes you feel like crap. And you are often misdiagnosed, misunderstood, and suffering with fatigue, muscle loss, low sex drive, and lots of other problems. So, George, tell us a little bit about how we think about this in traditional medicine and how that contrasts with how we approach hormone imbalances in functional medicine. Well, you hit all the hot spots. Did I say your thunder? Yeah, yeah, yeah. Again, you know, I mean, it's...

Starting point is 00:03:44 Yeah, you stole my thunder, yeah. Yeah, you hit all the hot spots yeah yeah yeah again you know i mean it's it's yeah you stole my thunder yeah uh yeah you hit all the hot spots you know men men we always when we think about hormone replacement you know we're always thinking about women but believe it or not i have more men asking me about hormones than i do women and i think there's some reasons behind that i think there's women still have a great deal of fear about hormones because the media for so many years would publicize the relationship between hormones and cancer and so women are very reluctant men on the other hand are now starting to experience hormone issues and it's becoming more of a popular conversation and as you said the media talks about it and men are living longer um and

Starting point is 00:04:27 they're starting to experience difficulties with is all the things you just said fatigue uh mental uh this clarity brain fog uh libido lack of motivation uh erectile dysfunction and they want to get help with that and why shouldn't't they? We want to live vital lives. The difficulty is in the diagnosis. So that's where we run into our first difficulty. So how is this treated in traditional medicine, or is it? Well, that's the point. The diagnosis piece.

Starting point is 00:05:00 It's really, the diagnosis requires you to have a low testosterone of about 250 to 300. Which is about what you see in the average 97-year-old. Exactly. So now a gentleman shows up with a- And what's the normal for a guy who's like 20, 30? It can be anywhere from 600 to 1,000. Yeah. So a guy shows up with a testosterone of 400, but he's not feeling

Starting point is 00:05:26 good. He's tired. He has no sense of wellbeing. He doesn't have erections. He doesn't have motivation. He's apathetic. And his, his testosterone comes back at 400. The doc says, Hey, you know what? That's pretty good for a guy who's 52 or a guy who's 48. What do you expect for a guy your age? Exactly. So that's the first problem. You don't treat the number, you treat the patient. And that's where I think we really focus on in functional medicine. And then the second problem is that when you do address testosterone, that's all that gets addressed. Let's just replace your testosterone.

Starting point is 00:06:00 And that's not how we approach it in functional medicine. It's certainly not in my approach. For me, it's all about the first thing we do is we dig into lifestyle. Because if you change lifestyle, most of the time, I can get that testosterone to get up to 600 just by changing lifestyle and addressing some comorbidities that might exist. So let's talk about that. What are the drivers of dropping testosterone in guys from a lifestyle perspective? And what do you do to address those?

Starting point is 00:06:32 Stress, nutrition, lack of exercise, poor sleep, too much alcohol, too much pot, bad relationships. The usual suspects. So you're saying stress lowers testosterone yeah my favorite study was this study where they they looked at guys who went to football games and they measured their testosterone before and after the game another study and and the guys whose team won their testosterone levels went up the guys whose team won, their testosterone levels went up. The guys whose teams lost, their testosterone levels went down. Particularly the ones that had been gambling. Oh, the ones that had been gambling.

Starting point is 00:07:11 I didn't get that far. That was in the fine print of the methods of the study. I didn't get that. But that is striking when you think about that. So your mental state has a huge effect on your hormones. So you mentioned also nutrition. Talk about that because I think that's something people understand. How does food affect your hormone levels, particularly testosterone?

Starting point is 00:07:30 Well, food is fundamental. It's the building blocks for everything that we need. So hormones require certain food macronutrients. You need really good healthy fats so you can have cholesterol in your system. So you can make, because cholesterol is a building block for testosterone so diet diet provides us the macronutrients we need to be the building blocks for creating hormones cholesterol is a building block so cholesterol is what actually testosterone is made from yes right so what about people taking statins they they could potentially statins can lead to low testosterone because you're going to drop your cholesterol levels.

Starting point is 00:08:08 And if you get them too low, you're not going to have that building block. And if you're under lots of stress and if you're not sleeping well, both of those are going to drive down your testosterone, imbalance where you're going to actually produce too much cortisol, which is going to demand the use of cholesterol because cortisol is also made from cholesterol. So you have this, this, you have this, this sync of cholesterol and it needs to be used to make your hormones. And if you're using it primarily to make cortisol, it's like the cortisol steals it away. It steals it away from being able to make testosterone. Like the cortisol steals it away. Cortisol steals it away from being able to make testosterone. So getting back to the nutrition piece, we do need those building blocks that come from eating fatty fish, taking a fish oil capsule if you don't, and then making sure you have

Starting point is 00:08:58 all the other nutrients that are required to make testosterone. It's very important. And what about what causes it to go down? Because that's what causes it to go up. In fact, saturated fats can help it go up. Right. Exactly. So what causes it to go down? Yeah. You know, sugar, you know, sugar plays a big role in creating inflammation. Sugar also will drive insulin up and that can have an impact on your testosterone levels as well. So having a diet that's going to be rich in whole foods, low in sugars, processed foods, will definitely be beneficial. So essentially what you're saying is that our diet plays a huge role in regulating our hormones.

Starting point is 00:09:40 Oh, yeah. So good fats are good for you, and even a little saturated fat is necessary to produce cholesterol. And our starchy sugary diet, which is about a pound a day per person in America of starch and sugar, which basically are the same interchangeable, flour and sugar, drives your testosterone down. And when you get high insulin levels from eating too much starch and sugar, that causes the deposition of belly fat. So, what you see is, it's this amazing phenomenon of these guys.

Starting point is 00:10:09 They get these big bellies, their testosterone goes down, they lose hair on their body, and they actually get man boobs. So, why does that happen? Dr. Because what's happening is that when you have that excess belly fat it's it's basically too much estrogen and estrogen but and we're gonna when i talk about my case we're going to talk about this when you have too much estrogen then estrogen drives something called sex binding sex hormone binding globulin so this is a it's a protein that carries your testosterone throughout your body. But the active testosterone is free. It's not bound. So when you drive your

Starting point is 00:10:52 estrogen levels up, then you're going, you know, by being overweight, you're going to, you're going to store excess estrogen in that belly fat. Then what's going to happen is, is that you're going to then drive down, drive up your sex hormone binding globulin. You're going to happen is that you're going to then drive up your sex hormone binding globulin. You're going to bind that free testosterone, and now you're going to start to experience the effects of low testosterone. Yeah. And also, testosterone gets converted to estrogen.

Starting point is 00:11:19 Right. And there's ways to block that conversion. There are. But the key is, it's so diet-related. So maybe getting your sexual function back has to do with getting your belly to go down. Absolutely. If you want something else to go up. Yeah.

Starting point is 00:11:33 And it's so true. What happens to men in our society is that they're working too hard, they're stressed out, they don't sleep well, then they eat in such a way that they're going to gain weight and all of those things are impacting their testosterone levels but it there's this combination to where cortisol as we talked about is going to steal you'll lose your testosterone there but also you begin to have other hormones that are involved so if you're again if you in we're going to talk about this in the case, if your thyroid isn't functioning well, there are some studies that show, and it wasn't really clear to me as I looked at the studies, and I don't think that they delineated it, but when you have

Starting point is 00:12:18 hypothyroidism, you can also have low testosterone. So you have to look at all, you have to look at all the hormones. Yeah, low sexual desire is one of the symptoms of low thyroid. Yeah. So you have to look at, when you think about testosterone in men, or they come in saying, hey, I think my testosterone's low, or I'm having erectile function issues, or I just don't, I can't build muscle mass in the gym. I think about testosterone, but I think about balancing all the other hormones. I start to look at the entire lifestyle package. Well, they're all connected, right?

Starting point is 00:12:51 It's like a big chicken wire. We learn about insulin, sex hormones, cortisol. They're all interchangeable. They're all interchangeable. They're all separated by a few different molecules that are regulated by different enzymes. And it's like a pinball machine. And which ones are going to go down, you don't know.

Starting point is 00:13:07 And if you're just looking at testosterone alone, then you're going to potentially miss the root cause of the problem. And so just replacing testosterone is never a good idea. And alcohol is another huge factor. When you see guys who drink and have, you know, quote, beer bellies, what happens to their bodies? They get this big belly. They get breast enlargement.

Starting point is 00:13:29 They lose all the hair on their body, so they look more like women. And it's because the alcohol increases estrogen production in the body. That's why alcohol increases the risk of breast cancer. But it has that effect in men as well. And when you help them cut out the alcohol, cut out the starch and sugar, increase the good fats, increase fiber, increase plant-rich diet,

Starting point is 00:13:49 these guys see dramatic improvements in their hormone levels without actually using medication. So that's always the first step is addressing these lifestyle factors, sleep, stress, exercise, diet, and sugar, alcohol. And the other thing that is fascinating is muscle.

Starting point is 00:14:07 It's a huge role. And one of the ways to boost testosterone... Is to exercise and build muscle. Yeah, strength training literally will build your muscle. And will build your testosterone levels. Yeah. So when we're talking about patients with low testosterone, it's always lifestyle first.

Starting point is 00:14:24 And managing all of that. So the first things I'm going to do with my patients are the things that we've already discussed. And it's going to be get them exercising again, get them meditating to reduce their stress and their cortisol levels, get them to avoid alcohol as much. And you know what? That's not what they come in for. They don't come in for me to tell them to do that. They want the magic. And they want a testosterone injection or a testosterone gel. And that's not where I start.

Starting point is 00:14:52 And in the end, for a majority of the men I work with, they're much happier because by changing all their lifestyle factors, they're much more satisfied and they're much healthier. There's a lot of beneficial side effects. Huge side effects to improving all of those things. They get weight loss, increase energy, better sleep, happier, all that stuff. Just by getting them to meditate. I very much believe in the benefits.

Starting point is 00:15:24 The data on meditation and its impact on your body, your overall health is huge. So I've probably, every male patient that comes into my practice has that conversation with me. And they're just shocked that we're talking about meditation when they come in for all the issues they come in with. And I identify stress as a major issue. And I tell them about meditation that will drive their cortisol down and that will help them improve the testosterone levels

Starting point is 00:15:50 in and of itself so so tell us about this patient you had who came in with you know fatigue and and he was overweight uh what what what what was the story with this patient and how did you approach him because functional medicine is is a very different approach you know like you said it's not just here take the testosterone it's looking at all the variables that could be impacting a patient and affecting their hormones whether it's toxins whether it's their gut whether it's nutritional deficiencies whether it's their diet stress all these factors we look at comprehensively in functional medicine that's what we do at the ultra-volume Center that's why you have so much

Starting point is 00:16:24 success we're not just a knee-jerk, oh, you have low testosterone, give testosterone. It's a comprehensive approach to deal with all these variables. Right. So this gentleman came in, he was experiencing fatigue. As you described already, he was having adiposity around his waist and also in his breast tissue, and he had been working out. And he'd already been to a physician who had given him tissue, and he had been working out. And he'd already been to a physician who had given him testosterone, and he was not getting the clinical benefit that he wanted. So when a patient like that comes in, we begin to go through everything. We go through the lifestyle, we go through previous treatments, and we go around our matrix, which is that tool that we use that identifies the way we think about overall health in a patient.

Starting point is 00:17:09 And we don't treat the symptoms. We treat the systems. So in this particular patient, I immediately identified that he was a busy executive, 52 years old. He was understressed. He was a little bit overweight. And he had been on testosterone. And he brought me some lab values and his testosterone had gone up but his his free testosterone was really low that's the active that's the active testosterone testosterone so i started it so in other words

Starting point is 00:17:39 you're saying is a guy could have a normal level if the doctor let's say you check the normals let's say 300 to 1,000. Yeah, he was about 550. So it's 550, which seems pretty good. But if you don't check the level of active free hormone, you're not really knowing what's going on. Right. And if you don't check these other tests you're going to talk about, you don't really know what's going on. So tell us about how that works.

Starting point is 00:18:00 Yeah. So when you see that, you're like, well, that's interesting. So the test that I do included something called a Dutch profile. A Dutch profile just doesn't tell me about the total amount of testosterone. It also tells us how you metabolize your testosterone. And as you mentioned earlier, Mark, that you convert your testosterone to estrogen. And there are some men that naturally convert their testosterone very efficiently, too efficiently, into estrogen. And so they're over-aromatizing. And you can see that on the Dutch profile. You can see that the results show you that pattern. He was an over-aromatizer.

Starting point is 00:18:47 And so when he was being given testosterone, he was converting a lot of it into estrogen. So he was actually taking testosterone. Yeah, at the time. He came in with testosterone. He was taking testosterone when he came in, and he actually gained more visceral fat while he was taking it. So it sort of backfired. Yeah, it backfired totally.

Starting point is 00:19:04 He was supposed to build muscle. This is very interesting this is very that's why i brought up this case this is a great case because you know if you just go to a regular traditional doctor even you get testosterone they'll just give you testosterone they won't look at all these other variables i'm like well i don't know why you're losing muscle and gaining fat and growing boobs and losing hair on your body right so it was an interesting case because what hadn't been tested was his sex hormone binding globulin hadn't been tested. And his estrogen had not been tested.

Starting point is 00:19:31 And he had been on the testosterone for almost nine months. And he saw these differences. So on the basic labs that anybody can get, I checked his estradiol level. I checked his sex hormone binding globulin. And his estradiol level relative I checked his sex hormone binding globulin and his estradiol level relative to his testosterone was elevated. His sex hormone binding globulin was also elevated and that's what was binding the free testosterone. And then when I looked at his Dutch profile, it all made sense. He was an over aromatizer. So this Dutch profile is a test we do at the Ultra Wellness Center.

Starting point is 00:20:01 It's quite different. It looks at how all these hormones interact, how they're metabolized, what's getting converted to what, where the imbalances are. This is not something you get where there's a traditional hormone test that you go to the lab and get. It's a saliva test. It's a saliva test. And it's a very effective test. And it made sense when I saw that picture. So that's the difference. Now, he had some other things going on, and that included his sleep apnea. But the main thing was is that all we needed to do was address this hormone imbalance. And to do that, we needed to account for the fact that he didn't aromatize really well. So you add in something, an aromatase inhibitor called anastrozole.

Starting point is 00:20:47 So I added anastrozole to his treatment plan, and that was going to make a difference. Now that was going to block his body's natural ability to so readily turn testosterone into estrogen. And because of his age and the urgency, because he was getting a lot of emotional stress over this, I added in a peptide. So I added in something called CJC-1297. And that actually helps you, along with Ipramoralin, that combination will help you lose fat and gain muscle. So we added that in for a three-month cycle. And he did extraordinarily well. He lost all that visceral adiposity around

Starting point is 00:21:32 his waist. Also, the man boobs went away. And he was feeling great, gained muscle mass, and he was extraordinarily pleased with the outcome. Amazing. So you you know, you talk about this anastrozole, which is a medication. It's used often in cancer treatment for women, for breast cancer, because it blocks estrogen production by the body. There are also natural ways to inhibit aromatase and to help with the excess estrogen. One of the ways that we deal with hormone imbalances is using foods and using even ingredients that are in foods that are powerful regulators of hormones. One of the most important things is a compound found in the broccoli family, the brassica family, it's called diindylmethane or DIM and that can be used in patients who are taking testosterone to

Starting point is 00:22:23 help affect the hormone metabolism into estrogen and limit that. Absolutely. You can also use biotin. Right. And so there's a lot of other things that can be taken. Yeah. Along with the hormone replacement to help mitigate. And I will commonly use DIM and calcium deglucurate

Starting point is 00:22:40 because they both increase the metabolism of estrogen. I use them in women, but I also use them in men, particularly a gentleman like this. That would have been an option. I chose to do something that would be a more aggressive approach. Yeah, this is definitely going to work faster. And then what about the method of testosterone replacement? Can you talk about the options for men,

Starting point is 00:23:01 about what kinds of available testosterone replacements there are, and what is the point at which you would initiate that? What's your decision on these patients of, okay, this is now the time to start? Right. So the first thing I do is, as I said before, is we balance out everything else. We do lifestyle factors, and we make sure that that's all in place. If after six months or so of lifestyle factor intervention, they're not improving, that's when we'll start talking about testosterone replacement. And testosterone replacement, you can do topicals, you can do injectables. And I tend to use the

Starting point is 00:23:40 injectables because they're very effective and very efficient. So how does that work? How do you do an injection? So injectables can be given IM, but recently... In the muscle. Which is in the muscle. And the research has shown that the sub-Q injection, meaning you just pinch the little fat around your waist, you inject right into that little piece of tissue that you have there, that's called a sub-Q injection. you can get absorption and elevation of testosterone just as effectively as i am so it's a very very simple that's an easier procedure oh it's very simple and you use compounded hormones you just get them at the regular pharmacy where do you get them so they can be you can get them in a regular pharmacy and you can get them compounded

Starting point is 00:24:19 the the most of the time the raw ingredient of testosterone is going to be very similar. It's the carrier molecule that might be different. So some pharmacies use grapeseed oil. I mean, some compounding pharmacies use grapeseed oil because there's some theoretic advantage of absorption. So when they compound it, it's going to be the same raw material. It's going to be the carrier that might be different. And so I use compounded when that's appropriate. Sometimes patients don't want compounded. It's a little more expensive. So we'll go with a pharmaceutical grade from the local pharmacy. And then we'll do sub-Q injections.

Starting point is 00:24:59 And what about the topicals? Can you talk about when you would decide to use topicals or why or i don't use topicals that often and the reason being is that they're uh they're just sloppy i'll just i'll just say they're there you need to use large quantities of them to get the concentration that you need you need to be sure to wash your hands after you've used it because you can actually by touching your child or touching your wife, they can actually absorb some of that testosterone. And I've had situations where women are beginning to have the effects of elevated testosterone because they're coming in contact with their husband's testosterone on their shoulder or what other location you may have placed it or if he didn't wash his hands appropriately, and they're in intimate contact. So I don't use gels that often. Because you can do sub-Q

Starting point is 00:25:50 injections, I primarily will use the sub-Q injectable form of testosterone. And there's other forms, right? Pellets. Can you talk about that? Oh, you can do pellets. So now, again, pellets- What is that? How do you do it? So they have to be placed on your skin, and they're usually placed for up to six months. They get replaced. The issue, well, there's no issue with pellets.

Starting point is 00:26:13 They work fine, but you don't have the ability to make any alterations in the testosterone concentrations. So if it's not enough, they're not experiencing it, you have to remove them, you have to put new pellets in. I find that using testosterone injectable is just, it's very flexible and it's very, very simple and easy and it doesn't involve the placing of pellets in the skin. Yeah. And in terms of the side effects of testosterone replacement, because it is a hormone and it can have adverse effects and there's concern about risk of prostate cancer, high cholesterol, heart disease. How do you address that? Well, I think the data on all of those are mixed.

Starting point is 00:27:02 When you look at heart disease particularly in relationship to metabolic syndrome and even diabetes actually taking if you have low testosterone which you probably will have in those cases actually there are studies that show replacing testosterone will improve your metabolic syndrome will actually improve your glycemic control it improves muscle mass yeah blood sugar, yeah. Exactly. So in that regard... But it can spike people's cholesterol.

Starting point is 00:27:29 Oh, you can. You can spike people's cholesterol. Does that mean they need a statin? No, it does not mean they need a statin. It's not something... I've seen some studies where it also lowers the cholesterol. So it's something I watch closely. It's not something I see that often.

Starting point is 00:27:49 And the other concern about prostate cancer is it's pretty clear in the data that testosterone does not cause prostate cancer. If you have prostate cancer, it's not something you want to be taking because it can accelerate the growth of the cancer. The issue that may arise. I've talked to some urologists at Harvard and specialists in prostate cancer. And a lot of times after prostate cancer treatment, men have low sexual function. And they're actually using testosterone replacement in some of these men when they're carefully monitoring them.

Starting point is 00:28:23 Yes. Yeah, absolutely. Yeah, I've read that in the literature as well and so there's there's a lot of safety behind testosterone and that's why I think men beginning to understand it's safer and they know it's an option and they want it and particularly when you start to combine it with the lifestyle changes and you combine it with the use of peptides which I mentioned you know men can regain a huge amount of vitality and, and really improve their overall experience of life in a very, in a fairly safe way. There's, there's no reason. I, I believe that as we age,

Starting point is 00:28:59 things happen to our bodies that we should and can account for. And I think it's a pretty low-hanging fruit for men to address these hormone issues and use things like peptides that are saccharoges for hormones that can actually increase muscle mass and decrease body fat as they're aging. Yeah, I think this's a really important point, George. We are living longer, although our life expectancy is going down as a country because of all the obesity and terrible disease, but we are seeing people living longer lives. And sometimes in order to live vital lives, there needs to be a little bit of extra support because we do decline as we age, but there are ways to mitigate that through the lifestyle interventions exercise is so important building muscle is so important

Starting point is 00:29:49 and that's why testosterone is so critical even for women testosterone is very important and i think that affects their sexual function or affects their muscle mass energy motivation mood and it's really an ignored aspect of hormone therapy in women i think it's just estrogen and progesterone. But women also need this. And I have many patients who use topical testosterone for women on the clitoris here at the Ultra Wellness Center. I mean, you don't apply it directly. They do it themselves. But it's a very powerful treatment.

Starting point is 00:30:18 And it works. I know it works because women are always calling back for refills. And they're just happily referring all their friends for it. So I think there's a lot of ways to use hormones judiciously to do the right amount it's different than we think of the anabolic steroids like testosterone that bodybuilders use they use super physiologic doses these doses far beyond what is ideal for a normal level you don't want to get super levels you want optimal levels optimal levels right and't want to get super levels. You want optimal levels. Optimal levels. Right. And you want to make sure you're checking everything. So I always check the sex hormone binding globulin. I always check the estrogen levels just to find a gentleman like this that really needed an adjustment, needed to be on a aromatase inhibitor. There are some docs

Starting point is 00:31:03 that just put you on an aromatase inhibitor right There are some docs that just put you on an aromatase inhibitor right with the testosterone. Yeah, I usually do the natural versions. I'll use DIM, which is a supplement, and I'll use biotin. The other thing I think is worth mentioning is that for some people, there's an increased conversion to something called DHT, which is a dihydrotestosterone that can happen when you use hormone replacement therapy. And that increases the size of the prostate. So people are concerned

Starting point is 00:31:32 about enlarged prostates with this, and it can also increase cancer risk in some patients. So it's really about looking at everybody's individual hormones. And there are natural ways to affect the dihydrotestosterone too. Right. So with DHT in particular, so that also, and this is one of the concerns for women, is hair loss. You have increased DHT, which can affect the hair follicles and that can lead to hair loss. And that's why men get hair loss. And that's some of the drugs like Propecia are actually blocking DHT. They're 5-alpha reductase inhibitors. Yeah, to prevent the hair loss. Yeah, and so that's, you know, I'm generally, again, careful about that.

Starting point is 00:32:16 And on the Dutch profile, it measures DHT. So we can actually see if a person, you know, is going to be making too much of that and we can make adjustments um you know and as you brought up before there are things that we can use like propitia now propitia you know has some concerns in regards to um some side effects that can be permanent so we're careful with using that uh there's natural versions yeah there's natural which is basically an herb that you can take that helps to mitigate that conversion. And you can use that topically as well as in an oil.

Starting point is 00:32:50 So I'm a little, you know, I'm not, I use testosterone in women both clitorally and as part of their overall gel or that I'll create for them with their cream. But I'm somewhat careful about it because the hair loss yeah because the women the women that are coming in that need it are also going through menopause and they are they're naturally beginning to experience some of the natural aging that will thin out their hair and change their their hair growth cycle they'll have a shorter

Starting point is 00:33:20 antigen phase and so you have to be careful with the addition of testosterone yeah and we've done a number of podcasts dr bow and others on on hormone replacement and hormone issues in women which are common infertility pcos pms menopausal symptoms fibroids all these are signs of hormone imbalance and they manifest differently obviously in women and men and we use a very similar approach of looking at sophisticated testing that helps us navigate what's going on, not just doing a simple regular blood test. And at the Ultra Wellness Center in functional medicine, we know how to think through the complexity of human biology, and we can map out what's happening in each individual, and it's not a one-size-fits-all treatment. So, you know, it's the right medicine at the right

Starting point is 00:34:03 dose for the right person for the right amount of time. And it's really that personalization that is so key. And I think we have the ability to do testing to look at all these things, not just testosterone, but free testosterone, sex hormone binding goblin, DHT, estrogen levels, the pathways, aromatization, the saliva levels it's a very sophisticated way of looking at things that allows us to really personalize the treatment minimize the the dose and the risk but maximize the benefit yeah and again with this patient looking at the dutch profile that we use that also tells us about the adrenal glands yeah and again he was a man that was under a great deal of stress with his work at that particular time and you can see that when you looked at the adrenal function on his dutch profile you could see that his total his total cortisol levels were low his free cortisol levels were low which were evidence of chronic stress

Starting point is 00:34:57 yeah so we had that conversation so i can replace his testosterone but if and i can i can do all these manipulations to make sure that it works right. But if I don't reverse his stress, I am not doing that man a service. That's right. He will not feel well. So with him, we talked about meditation, and we also gave him an adrenal supplement. These are herbs, they're adaptogens that help the adrenals function better and between functioning adrenals that got his cortisol levels appropriately up but not too high

Starting point is 00:35:32 taught him how to meditate he was a far he this this guy was he was not just happy about his testosterone he was happy about the new lifestyle that he was adopting because then he got into yoga right and then he had a different community now a different community you know and a new blood and new stimulation in his life brought him greater life satisfaction yeah I think that's true so so this is just a recap you know many people suffer from hormonal imbalances and guys tend to have declining hormones as they age and even young guys i've seen young guys as young as 20 who eat a crappy diet are stressed have low testosterone

Starting point is 00:36:12 levels and poor sexual function so it doesn't mean this has happened to seven-year-olds it can happen to anybody along the spectrum so i think it's really important to understand we take a comprehensive approach we look at lifestyle we look at the role of nutrition and hormones, exercise, stress, sleep, environmental toxins. And we look at a complicated panels of hormones to help understand what's happening for that person. And then we apply the first things first, which is food and lifestyle. And then we can modify using nutritional supplements, herbs. And if we need to, we'll use hormone replacement therapy, but we use the minimum dose possible, applied in the safest way possible, in a way that we track and follow. And that's what's so unique about functional medicine. It's not just a knee-jerk response to, oh, you have low testosterone,

Starting point is 00:36:55 take this, or you have hormone sickness. It's really understanding the whole picture. And that's what we do at the Ultra Wellness Center. That's what's so special about our practice. We have a group of incredible physicians, nutritionists, physicians assistants who've been working together for a long time. We have probably over 60 years of collective experience in functional medicine. And we now are doing all virtual visits. People want to come virtually. They can do it on Zoom. It's great. You can come here if you want in person, but we are also now adapted to the new environment of telemedicine. And so it doesn't create a barrier to entry. We'd love to see you here and share this story with your friends and family and it's been great talking to you george we're gonna be back again uh you you have the number two podcast on the

Starting point is 00:37:35 doctor's pharmacy which is amazing you know all the people you had you are number two right below walter long ago on aging so congratulations on that. I appreciate it. And I just think you're just a fabulous guy and physician and a privilege to work with you. And for those listening, if you enjoyed this podcast, please share with your friends

Starting point is 00:37:53 and family on social media. Leave a comment. We'd love to hear from you and hear your story about hormones. And please subscribe wherever you get your podcasts. And we'll see you next time on The Doctor's Pharmacy.

Starting point is 00:38:16 Hey everybody, it's Dr. Hyman. Thanks for tuning into The Doctor's Pharmacy. I hope you're loving this podcast. It's one of my favorite things to do and introducing you all the experts that I know and I love and that I've learned so much from. And I want to tell you about something else I'm doing, which is called Mark's Picks. It's my weekly newsletter. And in it, I share my favorite stuff from foods to supplements, to gadgets, to tools to enhance your health. It's all the cool stuff that I use and that my team uses to optimize and enhance our health. And I'd love you to sign up for the weekly newsletter. I'll only send it to you once a week on Fridays, nothing else,

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Starting point is 00:39:21 This podcast is provided on the understanding that it does not constitute medical or other professional advice or services. If you're looking for help in your journey, seek out a qualified medical practitioner. If you're looking for a functional medicine practitioner, you can visit ifm.org and search their find a practitioner database. It's important that you have someone in your corner who's trained, who's a licensed healthcare practitioner and can help you make changes, especially when it comes to your health.

The Dr. Hyman Show - Male Menopause, Low Libido, And Testosterone Replacement with Dr. George Papanicolaou

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