How To Treat Erectile Dysfunction Without The Little Blue Pill | George Papanicolaou & Mark Hyman

See, all that blue pill does is fix that end problem, right? It fixes that let's just make sure we get the erection and we maintain it. But there's reasons why we get there. Hi, everyone. Just wanted to let you know that this episode contains some colorful language. So if you're listening with kids, you might want to save this episode for later.

Welcome to the Doctor's Pharmacy. I'm Dr. Mark Hyman, and that's Pharmacist Lynne F-A-R-M-A-C-Y, a place for conversations that matter. and if you're a guy listening to this or you're a woman who has a guy, you better listen up because this is about a very common problem that's known as ED, otherwise known as erectile dysfunction, which is a very, very common problem. We're going to get into that. And today our guest is none other than Dr. George Papanicolaou, who's one of our key physicians here at the Ultra Wellness Center, is an extraordinary physician, is doing great work here, and we are just so excited to talk about this topic. Aren't we, George?

Thrilled. Absolutely thrilled.

It's a little uncomfortable, but I guess we're gonna have to get into it because we're doctors and we're professionals, so we can really talk about it. So, George, this is a big problem. Guys are having trouble. Women also have a lot of sexual dysfunction. We're gonna maybe cover that on another podcast. Today, I wanna talk about male erectile dysfunction with you because it's such a big issue. The lucky accident of a failed drug experiment for a blood pressure drug led to the development of Viagra, which I talked about on a podcast with Dr. Luis Ignarro, who is the discoverer of nitric oxide, which is a little molecule that causes your blood vessels to dilate. And, that's how Viagra works. It was meant to be a blood pressure pill, but it didn't work so good, but it worked better for the side effects that the guys got. And, all of a sudden, it was a blockbuster pill. like Blockbuster, which means that people needed it. So tell us about the history of this whole story and the prevalence, how common it is, and what is going on? Why are we seeing such an epidemic of this?

Well, I'll say one of the key things was in 1998 when Viagra hit the scene, it really opened the door for men to have an opportunity to talk about what had been going on for centuries, and that was erectile dysfunction. So, great Viagra was awesome. Not only did it work, but it opened the door for that conversation because 10% of men under the age of 40 have erectile dysfunction. And by the time you're 70, you have a 60% chance of having erectile dysfunction.

70 or 60?

No, 60% chance by the time you're 70. By the time you're 70 of having erectile dysfunction. So, that's a lot of people having erectile dysfunction. People's sex lives are not over at age, you know, 50, 60, or 70. There are men that come to me wanting to have prescriptions for Viagra at age 70. And I always tell them, I'm not giving it to you unless I get a written note from your wife.

That's not gonna go well. Actually, yesterday, I was doing a consult with a patient who was 87 years old.

Yeah.

Who's still having sex with his wife.

I plan on it.

Yeah, I'm going at least to 100. I don't know.

It's getting better as time goes on, so why stop?

That's exactly right. So, this is a very common problem. From a traditional medicine point of view, there really wasn't much of an approach to this beforehand. We had some really coarse and crude treatments. Talk about what the traditional approach to erectile dysfunction has been other than the Viagra, Cialis, and Levitra category of drugs, which now are pretty widely prescribed and do work and help people.

Yeah, so prior to Viagra, there were some fairly primitive approaches to it, like vacuum pumps and revascularization because vascular issues, endothelial dysfunction is a key part of what causes erectile dysfunction.

So in English, you're basically saying that you get hardening of the arteries in your penis, which makes it not so hard.

Right, but that hardening of the arteries, not only reduces blood flow, but there's this endothelial dysfunction and it's in the endothelial cells that nitrous oxide has its effect. So what are endothelial cells? Endothelial cells are the cells that are lining the blood vessels that are inside the penis.

So throughout your entire body, you've got these lining of all your blood vessels and it's a very active lining. It does all kinds of things, including regulate the dilation and the blood flow and lots of other things, inflammation, and nitrous oxide is a key key regulator of that.

Very key.

And that's what goes wrong. And one of the reasons why that men tend to get this decreased blood flow in the penis that leads to these erectile dysfunction.

There's multiple reasons, but before we go on to that, I think probably is a good idea. Let me just review quickly because we're going to talk about nitrous oxide, we're going to talk about why Viagra works and other drugs like it. Essentially what happens is that you have the release of nitrous oxide.

Nitrous oxide. Nitrous oxide is laughing gas.

I'm just gonna call it NO, okay? NO. So you release the NO and then NO has its action on the endothelial cells inside the blood vessels of the penis. It also acts on the corpus cavernosum muscles. And so you get this simultaneous relaxation of those muscles. so blood can flow in. Those are the big muscles of the penis so that when they're full of blood, they actually start the erection and maintain the erection. And then you have the small blood vessels, nitrous oxide acts on those at the same time and causes those to constrict. So the blood that flows into the cavernous muscles then stays there as these small veins constrict. And that basically starts the erection and maintains the erection. Then what happens is you have, and that's called tumescence. Then you have detumescence when after the ejaculation, the penis relaxes. And that's when five phosphodiesterase breaks down the compound that was responsible for causing that relaxation and constriction. And when that compound breaks down, the small blood vessels relax and the penis relaxes and becomes flaccid. It's the five phosphodiesterase that gets inhibited by Viagra. So this is just a little lesson everybody listening, that's how it works. Viagra blocks the five phosphodiesterase, allows this-.

So basically it increases blood flow and makes the erections stay longer.

And because you don't get the breakdown of this thing called cyclic GMP, so that doesn't break down, that maintains the constriction of the small blood vessels. You can maintain, actually obtain an erection and sustain an erection for a longer period of time.

It's a good thing you have to remember all those chemical names when you're having sex, 'cause that would not go very far.

No, it won't. But that's what's going on. And so then what can affect, what are the things that affect that? So metabolic syndrome. So when you're thinking about people with ED, see all that blue pill does is fix that end problem. Right? It fixes that, let's just make sure we get the erection and we maintain it. But there's reasons why we get there. We get there because of stress and its impact on that very, very sensitive neurovascular problem, that neurovascular, and it's not a problem, that neurovascular symphony that has to occur for you to have your erection and ejaculation. So, metabolic syndrome, That's pre-diabetes. Which is pre-diabetes, which includes, you know, to make that diagnosis, you have to have obesity, dyslipidemia, which is just abnormal cholesterol, lipid, cholesterol, triglycerides, HDLs, you have to have hypertension. And one of the things is insulin resistance. And so insulin resistance is connected to endothelial dysfunction. When those endothelial cells aren't working, then the NO, the nitrous oxide is not gonna have an impact. and you're not gonna be able to start that erection. So, what do you treat? You can give the person Viagra, but since metabolic syndrome has so many of their impacts on their overall health and their health span and lifespan, it'd be better to fix that.

Right, okay, so let me translate that because that was really good. I think here's what's going on. Basically, people are eating lots of sugar and starch and crap in their diet, get pre-diabetes, which goes along with high triglycerides, low HDL, high blood pressure, belly fat, the whole thing.

Exactly.

And when you have this problem, which by the way affects every other American, and if you take out the kids, it's probably more than half the adults, right? So we've got 75% overweight, 88% metabolically unhealthy in this country. Most of those people have some degree of insulin resistance. And what you're saying is when you have this phenomena going on in your body, it damages the ability of the lining of the arteries to function properly so you can't get blood flow in your organs, not just in your penis, but in your heart and in your brain, which is why insulin resistance causes heart attacks and strokes and also dementia. So this is all connected. And in fact, the first sign of heart disease is probably having trouble getting an erection.

You're worried about your erection, but you know what? You better be worried about your heart and your brain because they're the ones that are really the target of what's going on.

Absolutely. And I think people don't realize that. It's not just a local problem. It's just a systemic problem.

Absolutely. And so- and that's one of the points I really hoped we'd make today because as important as erections are, it's getting those root causes that impact your overall health and then the cherry on.

Top of the pie is great erections. Yeah. And I think most people don't realize that our whole system is connected. And that's what's so different about functional medicine is that it's looking at the whole system. So, you know, most people don't think of your diet when you think about having sexual dysfunction, but that's the first thing we think about, right?

Right.

We do think about stress, for sure, that plays a role.

But there's alcohol. There's alcohol, you know, and one of the roles that alcohol plays is that when you're drinking alcohol, that itself is going to impact that endothelial function during the time of your use, and you're going to maybe that night not have an erection. Here's what happens. You can stop drinking and say, okay, that will fix it, but there's something that happened. You're gonna have a psychogenic response. It's called performance anxiety. And once you, for some men, once they have a failure, it multiplies itself. They get performance anxiety and it becomes a psychogenic problem. And there's a vast majority of men who have erectile dysfunction actually have a performance anxiety or psychogenic cause.

So basically just if it doesn't work once, you're going to be afraid it doesn't work every time and that's going to make the whole thing worse.

Yeah.

So that's a hard mental thing to fix. But the fascinating thing to me is that the phenomena around seeing this as a systemic metabolic vascular issue is so, is so important. And there's a lot of ways to address it that, you know, we're going to get into. And of course, there's a lot of ways to also address erectile dysfunction that are up and coming that are quite new, just far beyond Viagra, which we're going to talk about. I'm excited to talk about those things. But, but even in traditional medicine, you've got the vacuum pump, which is previagra, where you put a little ring around the base of your penis and you basically put a tube around your penis and you basically vacuum it all the blood in, which just doesn't sound like fun to me. And there's penile implants, which can work. There's Alprostadil, which is an injection or something that goes inside the urethra and the penis that can help. That's a prostaglandin. And there's revascularization, which is something I would love you to talk a little bit about.

So revascularization is essentially, you're having, as we talked about, hardening of the arteries. And it's two ways that can be done. Just like you have angioplasty stents placed in the heart, the same thing can be done for the penis. and that's one possibility.

So it's basically angioplasty for your penis?

Yeah.

Wow, that's incredible.

Again, these are very interesting, very interesting responses to the problem. And we're gonna go through other possibilities, as you said, we're gonna talk about stem cells and platelet-rich plasma. I always like to go back to the idea that, yeah, you can be revascularized, but why get there in the first place? Exactly. Right.

Right. You know, it's like you get a stent, but you got to fix your.

All of these things actually work. I mean, I, I've had patients of mine use the vacuum pump. I don't know how they do it. It works, doc. I love it. I've had people get penile implants. It works, doc. I love it. And they're pressing their testicle and they're getting their erection. And, you know, that's how, that's how the pump works. You know, they have the pump is inside one, one testicle, and you start pressing on it, and it. gives you your erection and it works. I've had men use the injections, they feel like 18 years old again. But they all have diabetes, hypertension, metabolic syndrome, and I can't get them to get to that underlying cause. So, almost sometimes when I not let them get their erections.

Well, let's talk about testosterone because there's this whole conversation out there about male menopause or andropause and this whole syndrome of low T or low testosterone. and I think part of it's gone to the extreme and there's a lot of bodybuilders use testosterone and I think it can be used inappropriately. But what I want you to talk about is why do we see the drop in testosterone as men age? Because I think this is really important. There are natural ways to raise testosterone. There are ways that we are living that lower testosterone. So let's get into talking about that, because you fixed testosterone, a lot of things get better.

A lot of things do get better. erections may or may not get better, testosterone can definitely have an impact on erectile dysfunction. It impacts the five phosphodiesterases we talked about earlier, and it also can have an impact on nitric oxide, and that can result in improved erections. And you asked me why do we see this drop off in testosterone? Well, there's this natural drop off in testosterone as men age. So after the age of 30, you're losing about 1% per year and over time that's gonna drop you pretty low, but that's not gonna do it all by itself.

Now I've seen many older guys with raging high testosterone levels.

Here's the older guys that don't have raging testosterones. Those are the guys that have sleep apnea, alcohol over, they drink too much alcohol, they have diabetes, they haven't learned how to manage their stress. Did I mention sleep apnea?

You did.

Yeah, I did. But that's a very important one. And so those are things that as you age begin to impact your body's ability to make testosterone. Yeah.

So I just want to emphasize something you said there. It's so important. You said diabetes, but this whole pre-diabetes insulin resistance thing is the biggest reason. So here's the deal. The bigger your belly, the lower your testosterone and the smaller your [The hah ha ha] the more belly fat you have, the lower your testosterone is. And people don't understand that. And then you mentioned alcohol. And the reason alcohol is such a problem is that it increases a hormone converter called aromatase, which is an enzyme that converts testosterone into estrogen. estrogen, which is why you see guys who are drinking lots of beer and alcohol have man boobs and have big bellies and lose the hair on their chest and lose the hair on their legs so they become more like women and they have very high estrogen levels. So, you people are shocked to find that out. So, you're basically becoming like a woman the more alcohol you drink.

Absolutely.

And I think those two things are really important for guys to understand because if you are struggling with erectile dysfunction, it's a big deal for people and they don't understand that it's directly related to what they're eating. Now, in addition to the fact that eating starch and sugar will lower your testosterone, what are the things that actually might increase it from a dietary point of view?

Mark, it goes back to one of the books you wrote, Eat Fat, Get Thin. So now I'm gonna tell you this. The name of the book can now be, the one that I'll write will be Eat Fat, Get Hard.

Oh gosh, this is getting to be a racy podcast. We gotta put explicit warnings on this one.

You know what? They should have known getting us together this was gonna happen. So, yes, fat. Because fat actually, you know, we've talked about this before, has cholesterol in it. Cholesterol is not a bad guy. Cholesterol is really important foundational molecule for building hormones and one of them is testosterone.

That's right.

So eating good healthy fat is going to allow you to have that precursor molecule to maintain high levels of testosterone as long as you're doing everything else right. Sleeping well, managing stress, and limiting your alcohol use. 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, I promise. And all you have to do is go to drhyman.com/picks to sign up. That's drhyman.com/picks, P-I-C-K-S, and sign up for the newsletter and I'll share with you my favorite stuff that I use to enhance my health and get healthier and better and live younger longer. Now back to this week's episode. So let's talk about sort of a functional medicine approach to addressing this because at a high level and then wanting to get into some cases because from a functional medicine perspective we look at a lot of different things to try to identify why this person is having erectile dysfunction and or low testosterone which often go together. So, when someone comes in complaining about what are the kinds of things you think about and what are the testing things that you look at?

So, first off, I want to make sure that I make the right diagnosis. So, I always like to emphasize the fact that when people come to my office, I'm going to get a timeline of events. So, I'm going to want to know everything that's happened in pretty much throughout their lifetime. how they were born, early eating habits, early traumas and stressors in their lives, disease patterns, antibiotic use, medication use, trauma, all of those things create a timeline. And once you have that timeline, you can then begin to piece together a narrative that leads you to the root cause or causes of their disease. So it can be easy for a person to come in and tell me, I have erectile dysfunction. It started like three months ago when I tried to have an and I didn't have when I was with my girlfriend, and ever since then, I've been having a problem. Well, oftentimes, it's not as clear as the patient thinks it is. And by asking them a long history, I start to find out that maybe that wasn't the key turning point, that he was slowly building up because of other issues, maybe because of alcohol use, maybe because of a family history of dyslipidemia, and he has really high cholesterols and triglycerides and maybe early vascular disease. It's really important to make sure we get to all those and not be biased by a patient opinion or what to identify. So I really like to emphasize when we're talking about functional medicine, we're talking about a detailed timeline. And then we're talking about using the matrix. And that matrix is basically a paradigm we use that looks at systems and not symptoms. It takes your conditions and it attaches them to your various systems. So your cardiovascular or your immune system or your GI system where we break foods down and we assimilate and we absorb. We want to know how all those stories you're telling me, how all those symptoms you've had, how all of the lifestyles you have are impacting those systems because they all work together to get your body to work the way it's supposed to.

So, you have to deal with all those things. Inflammation, like you mentioned, that can affect- Inflammation and the thiol function, right?

You know, toxins, mercury, lead, talk about it. impact the endothelial mitochondrial function. I mean, those are major things. And just as a quick aside, it's not a matter whether you have heavy metals, it's a matter of how much you have and how good you are detoxing. So I also want to know about your exposure to toxins. So that's how I start.

So when someone comes in to see me, I also think very similar to you, and I go through the matrix, but things I'm really focusing in on I'm looking at, you know, what is their diet? Are they eating an inflammatory diet? Because anything that causes inflammation will damage the blood vessel lines and can affect blood flow, which is processed food, fried foods, you know, lack of protective foods that are anti-inflammatory those are really, really important. And I'll really dig into about looking at insulin resistance. Does this person have pre-diabetes we look at insulin levels, we look at things.

That nobody really looks at traditionally. And I'll say the insulin resistance thing, I, I almost I would say eight out of 10 of my patients that come here to the Ultra Wellness Center don't just get a blood sugar or hemoglobin A1C. They primarily are going to get a fasting glucose tolerance test. It's the most sensitive way to uncover insulin resistance because insulin resistance can be hidden. You know, if we use the current standards that we have of a fasting blood sugar of 100, you know, that's not low enough. You know, it needs to be lower, you know, and so when you do a fasting insulin resistance test, basically a person fasts, and then after that fast, you give them 75 grams of sugar, and then you see how their body responds, how they produce insulin in response to that bolus of sugar. And if they're able to keep that blood sugar at a normal range at lower levels of insulin, we know that they have a very good carbohydrate metabolic glucose, an efficient way of managing glucose. But you're right, but if you see.

Someone who's able to manage their sugar and insulin, that's the key. But I've seen patients who, for example, have normal sugars, but their insulin are high. And here's the take-home point. When you go to your doctor, if you ask for a glucose tolerance test, good luck if you're gonna get it. But if you get it, they have to measure insulin. And insulin is something that most doctors don't measure. And you can measure fasting insulin, Right. Because most doctors don't even measure that. If your insulin's over five, you probably have an issue. And if your triglycerides are higher, HDL is low. So, I'm looking at all that. I'm also thinking about, you know, what's going on with their testosterone levels. So, I'll look at total free testosterone, I'll look at other markers. So, we get a really sense of what's their adrenal stress like. Do they have adrenal dysfunction?

Are they chronically stressed? We can look at things like DHEA or we can look at other saliva cortisol. And all the things you're mentioning, are not things that you will get through your primary care physician at Harvard Vanguard. It's just not gonna happen.

Well, you don't have to pick on Harvard. Pretty much anybody. I got friends at Harvard.

I love that.

But I do think you're right. And I think we're looking under the hood.

Yeah, we look under the hood and we have very specific tests to do that.

Someone said a functional regular medicine is like trying to diagnose what's wrong with your car by listening to the noises it makes. Functional medicine is basically looking under the hood.

We look under the hood, you know, and it's, and we don't guess, we test. And we happen to have really good tests at the ready. And so we can, we can really, you know, the glucose tolerance test is a conventional test we can get. And anybody can do that. It's just a matter of understanding the need for it. Then we do, you know, then we do, you know, we're looking at, at our lipid profiles, and we're not going to get into detail about this, but we don't use the conventional lipid profile. We use the NMR. and we look at markers of inflammation that you might not primarily see all the time being looked at, like oxidative LDL, how LDL is oxidized because of inflammatory states that you might be in. We look at CRP.

It's like rancid fat in your blood. Which isn't good for your arteries.

So we look at other inflammatory markers and these are critical, but we do advanced testing where we do a four-point cortisol test. as part of a profile that will also look at your hormones, estrogen, progesterone and testosterone, and tell us not only what your totals are, but going back to a point you made earlier, we can actually see if you're an aromatizer. On the tests that I look at, I can actually see the pathways in your particular physiology that are showing me testosterone being converted to estrogen and are you are you over aromatizing and producing too much estrogen? There are some men that naturally are over aromatizers. Now they may even come to me complaining about, you know what, I'm having a hard time with erections. And by the way, doc, I've always had this belly fat and I've always noticed I have like some boobs, always from when I was a kid. And then I do this test and I realize, you know, I can show them, well, this is why you just physiologically for genetic reasons are over and over aromatizer. So, we can, you know, there are things that we can do about that.

And that's- There's natural inhibitors of aromatase that block that conversion. There's even medications that do that, like Arimidex, which they use for breast cancer to prevent making estrogen in the body.

Exactly. So, there's a lot of tricks out there for us to do that. So, we do that. And so, as we work on those things, obviously we're gonna be helping them with their erectile dysfunction, but these are.

Not simple things to get to. And it's not just always a matter.

Of the little blue pill.

All right, well let's talk about this patient that you had and how you helped them. Because I think that, you know, he was this guy named John. I don't know if that was on purpose or not.

Did you call him John? No, no, I know. That was actual name.

I always change names to protect the innocent. Okay, good, I'm good. What was wrong with John and how.

Did you fix his erectile dysfunction? So, John is, you know, sort of your classic case that, you know, that comes to see me, you know, 56 years old, just not feeling were they up to par, but is being told by his doc after his physical, hey, everything's fine. But he says, everything's not fine. My erections aren't as great as they used to be. I can have them, but they don't last as long. It's not as pleasurable. I'm not sleeping as well. I don't have the energy I had. And I just get told that it's just part of aging. Well, he's also at the age where menopause is prevalent. And so, you start to think about these things. So with John, he's everything we just described. He's a little overweight. He's a very successful sales manager. He now has a very high-end job with the international corporation doing international sales training, spends a lot of time socializing, and that means that he drinks a bit too much. So we got some extra belly fat, we're drinking too much, and he's under an enormous amount of stress. He wants to retire early. He's very, focused on his retirement and making his bonuses so that he can save tons of money. And he's very proud of that. And the officers are talking. So what's the treatment for him? Well, of course, he says his main focus really was the erections. And he said, you know, he didn't.

Care that he was about to have diabetes. I just. That.

Hey, Mark, it's. I'm not making this up.

I believe you. That's what guys care about, you know, over and.

Over again. So it was just really a matter of just saying, look, let's work on your lifestyle before we condemn you to a lifetime of, you know, paying for a little blue pill. So you want to overall feel better and have erections, let's start working on it. So, you know, the first thing, you know, I got my, I got all the testing done, you know, I did a fasting glucose tolerance test, and of course, you had insulin levels, way above 40 at an hour and two hours, which is really very significant for insulin resistance. He was actually just on the board of being declared totally pre-diabetic. His hemoglobin A1C was 5.6, so 5.8 is considered pre-diabetic. But I told him for a second, all intents and purposes, you're pre-diabetic. Why do I do that? Because when they hear the word insulin resistance, they don't know what that is. But when they hear the word diabetes, they know what that is, and that's bad, right? So I purposely say that, I say pre-diabetic, all of a sudden I have leverage, well how do I fix that doc? Let's work on your diet. So we work on his diet. First thing we do is we, I put them on, you know, following, you know, what you've written about so wonderfully over the years is, you know, basically a cardiometabolic diet, we detox them, you know, we take out sugars, processed foods, gluten, dairy, alcohol, soy, you know, basically put them on a whole food, vegetable-based, clean diet, minus those things. Just that alone in the first six weeks definitely leads to, I feel better, I'm losing weight, I'm sleeping better. The second thing I tend to go after is stress, particularly in a man like that. So I tell them, by the time you come back to me in six weeks, I want you to have established a good stress management program, I'll get even more specific and say, I want you meditating. I want you meditating at least once a day. I'm a huge believer in the power of meditation to alter every part of your physiology and improve it for life and actually slow the aging process in many parts of our body, most particularly the brain. So I really emphasize meditation and stress. That's what I do with John. So John was a lifestyle change with nutrition first, followed by meditation. And then what else I do with him? Oh, yeah. So I added in some things early on. So fish oil, his vitamin D was really low. Vitamin D was like 17. Vitamin D is a very important precursor to all hormonal function. So we got his vitamin D up. We got his fish oils to reduce inflammation as he lost his weight. I gave him an adrenal adaptogen. to help modulate his cortisol because cortisol Ginseng, you mean? Yep. Yep. Ginseng. There is some rhodiola and Ginseng and Ginseng actually and rhodiola can have an impact on erectile function. So I was able to give him that. And after about nine months, we lost weight. His testosterone was his testosterone was low. It was in the low 400s. I we talked about testosterone replacement, but I really pushed him on Let's get diet, let's get stress, let's get sleep. We did those things and he felt better. And by the time we were done in nine months, with that particular process, his hemoglobin A1C had gone down to 5.1.

His blood sugar was way better.

So his blood sugar was way better. He had dropped 23 pounds, right? He was sleeping better. He started meditating. and his erections were a lot better. They weren't perfect, but they were, he said, Doc, they are tremendously better.

That's so great, such a great story. And I think there are also other things that are out there that people are using. And I think, you know, when do you decide you want to give someone testosterone? Because that's a reasonable thing to do as guys age. I think there's some controversy about it, but it can definitely help increase desire, libido, function, pleasure, orgasm. So when would you decide to give someone testosterone?

So in his particular case, his testosterone it came up, it was 450. And like I said, things, like I said, nine months, he was better, but things weren't perfect. So, you know, we did at that point talk about testosterone. And that's when I use it. When somebody's done everything they can to really improve their lifestyle, manage their Metabolic Syndrome, manage their insulin resistance, you know, manage their hypertension, manage their stress, and their testosterones just aren't budging. That's what I use it. And so I did, I put John on testosterone.

And you can do it topically, you can do injections, there's pellets, there's a lot of ways to do it that a doctor can prescribe. And you have to monitor it and you also have to make sure you take the right supplements with it to regulate some of the things that happen around estrogen. So it's going to be a really effective treatment. But what's interesting is you can increase your testosterone significantly by fixing your diet, by adding more fats and decreasing the sugar and carbs. and reducing stress, alcohol, but also exercise is a very interesting thing that happens to the body when you exercise. You also can boost testosterone, but there's very specific exercises that can do that. Can you talk a little bit about that?

So the specific exercises that will do that, number one aerobic activity, number two high intensity interval training will definitely improve your testosterone levels. those are the two that I recommend the most for patients, a combination and weightlifting.

Why do you recommend weightlifting?

Okay. For multiple number of reasons. Muscle mass actually helps improve carbohydrate metabolism. Muscle is actually very important to you in the aging process. You need muscle to be able to move and function. So very important. And that's why, yeah, those are the main reasons why I prescribe exercise, particularly weightlifting. But the other side of that is that I prescribe testosterone to help men, when they're working out, to actually make the muscle gains. Because oftentimes they're working out, they're not making muscle gains. So testosterone can help them and benefit the muscle gain, which then helps them in dealing with their insulin resistance and their metabolic syndrome and to age more appropriately.

Absolutely. I think that's right. I think, you know, the testosterone can help for people, but it also, by just weightlifting and using heavier weights, you can literally build your own testosterone along with increased fat. Now, there's a few other things I just want to mention for people listening that I think are up and coming treatments, and they're still needing more research and investigation, but, you know, people are using stem cell injections or exosome injections, peptides, platelet-rich plasma. So these are things that actually are out there that are being used and to varying degrees of effectiveness. One of the treatments that I found really fascinating is shockwave therapy. This is an ultrasound shockwave therapy, which is applied on the penis with a little ultrasound device. They use a little lidocaine to anesthetize the penis 'cause it's a little uncomfortable. but it usually takes about 15-20 minutes. It's done over a period of weeks. And what it does is it helps to break down some of the stiffness of the arteries that are causing the decreased blood flow. So it can really increase the blood flow and vascularization. And it's been well looked at by research. So I think that's another interesting avenue. But I think for men listening and women who are married to men, this is a solvable problem. It's an embarrassing problem. There's a stigma about it. people feel anxious talking about it, but often it's a medical issue that can be sorted and solved. And sometimes you need to think a little bit out of the box, and it's just not as simple as just taking Viagra or Cialis. There's a lot more to it. And I think that's really the approach we take here at the Ultra Wellness Center is a comprehensive approach that looks at all the factors in someone's life that may be impacting their sex drive, their sexual function, and their ability to actually enjoy life. well on into their eighties and nineties. So absolutely. I think it's important. I was very inspired yesterday talking to a patient who's 87 and who's still having sex with his wife. And we're just talking about how to make it a little bit better. But that is possible if you pay attention to the quality of your health and deal with your lifestyle. So George, thank you so much for being part of the Doctor's Pharmacy House Call podcast. If you all have been listening to this and you love the podcast, share it with your friends and family, maybe not your mother. But certainly leave a comment. We'd love to know how you've managed through this difficult problem, if you've struggled with it, or how your partner has, subscribe wherever you get your podcast, and we'll see you next time on the Doctor's Pharmacy.

Thanks Mark.