The Ultimate Guide to MAXIMIZING Hormones & MAINTANING Fertility

The difference between blood work of someone on TRT versus Enclomiphene is trt. Their LH and FSH levels, as we talked about, are going to be near zero because you're shut down. Your testicles are going to shrink and you're dependent on it. If you go off of it, you're going to feel pretty bad. With enclomiphene, your LH and FSH levels actually typically go up because it's essentially telling the body, hey, you don't have estrogen producing more. It actually makes your testicles bigger. Ironically, the studies that show the higher dosages, it actually increases testicular volume. Total motile sperm count, which is a key fertility marker, actually goes up. So it makes you more fertile as a man and it generally doubles testosterone. The other advantage is there's no dependency. If you just stop taking it, you'll just go back to your baseline levels. You won't be shut down like you will with trt.

I am here Dr. Cameron Sippa, and he's the CEO of a company that's got a pretty cool name, I think, Maximus, which is not the backup website for the movie Gladiator, although I did hear there's a sequel coming out. It is an online medical clinic. Maximus is an online medical clinic and they do health and hormone optimization. I've exchanged a lot of emails back and forth with Dr. Cameron Seppa, who is not only a doctor but a serial health tech entrepreneur. He has been involved with a number of different startups, but Maximus is his new baby, or relatively new baby online medical clinic that's focused on men's health and hormone optimization. And I wanted to get deep into the field of all things testosterone optimization, fertility management, estrogen, all of those things that I think more guys need to think about before they just stick a needle into their right butt cheek. So all of the Shownotes are going to be@BenGreenfieldLife.com Maximus Podcast. If you want to check out cam's website, it's BenGreenfieldLife.com Maximus to make it easy for you. So, Cam, welcome man.

It's a pleasure to be here with you. I've been a fan of your work for years and it's fun to be able to have this conversation.

Yeah, I've got all sorts of juicy questions, dude, but I'm just curious, do you have some kind of pain to purpose wounded healer story where you had severe hypogonadism and couldn't get it up or build muscle or recover or something like that? Or you just Interested in this from a medical standpoint?

Yeah, it's a great question. I think origin stories are really important. And the origin story of Maximus. Well, there's kind of two parts to it. I'll talk about. One was I ran across this statistic that said that testosterone and sperm count have dropped 50% in the last 50 years. And I thought that was quite remarkable. Not that many people were talking about it.

It's the plastics. Plastics, man. Same stuff that's making the frogs female, right?

Absolutely. Endocrine disrupting chemicals, as you point out, and our food, water and plastics. The interesting thing is when you look at the studies, you know, obviously there's an association between obesity and metabolic syndrome, which I've been working on for over a decade. The first company that I helped start, Omada Health, essentially created online weight loss programs to help people avoid diabetes and heart disease. Helped a million people lose 10 million pounds and cut kind of one of the key originating factors, which is just being overweight. The problem is, even when you control for weight, there are still thin people like you and I who are affected by endocrine disrupting chemicals. Our fathers and grandfathers essentially had twice the testosterone levels that we did.

Yeah, yeah. And by the way, I don't think it's just plastics. Yeah, we're. We're not lifting heavy stuff and building fences and rock walls outside. We're not getting sunlight. Relationships have suffered from social media and porn. The food quality has shifted slightly more towards the higher carb, lower fat type of scenarios. We're not getting the building blocks. It's kind of a cluster, isn't it?

Absolutely, yeah. It's a multivariate problem. But I think the endocrine disrupting chemical is certainly a large and hard to control factor because it's hard to avoid anywhere. So that's been a huge contributor. In the other part of it, though, is that sperm count's gone down 50%. And in fact, if it continues to do so, theoretically society would hit sperm count zero by about 20, 50. I don't think we'll all not be able to reproduce, but I think we're seeing essentially fertility problems on the rise. In fact, 50% of idiopathic infertility, which has no known cause, is actually male cause nowadays. And so that's kind of the interesting challenge. Obviously, the gold standard treatment for if you have low testosterone is injectable TRT or testosterone replacement therapy, downside of which, of course, is when you replace your testosterone exogenously or externally, it shuts down your endogenous or internal production, and it makes you infertile, essentially. TRT is a male contraceptive. And so it fixes one half of the problem in terms of the testosterone problem, but it actually exacerbates or worsens the fertility problem.

Right, and just, just real quick, why is that? Like, can you explain the mechanism behind why when you inject testosterone, it basically makes you less likely to have a baby? Because some people would almost think the opposite. Right. You're going to have a bunch of libido and go out there and populate the planet.

Yeah, it's a great question. So there's something called the HPG axis, the hypothalamus pituitary gonadal axis, where essentially the hypothalamus produces a hormone called GnRH, or gonadotropin releasing hormone, which stimulates the pituitary to release two hormones. One is lh, or luteinizing hormone. The other is fsh, or follicle stimulating hormone. FSH stimulates the gonads or the testes, where the word testosterone comes from, to produce testosterone, FSH stimulates the gonads or testes to produce sperm. And so what happens is when you're getting exogenous testosterone, it creates a negative feedback loop up at the hypothalamus and pituitary. And so the brain thinks, I'm getting enough testosterone. You know, the body tries to maintain homeostasis or balance. Right. And so it shuts down the production of GnRH. If you actually do your blood work, your LH and FSH basically go to near zero. So you can tell you're essentially shut down. And so as a result, there's no signal going to the testes. And what happens, essentially the testes, because there isn't sort of gas in the gas tank. It's almost like having a dead car battery. So they're not producing, they actually will atrophy, they'll shrink. Most people will notice essentially a decrease in what's called testicular volume, the size of the testes.

Right, right. The famous ball shrinkage.

Exactly. So it's basically analogous to what type 1 diabetics do who are insulin dependent. Right. Their pancreas can no longer produce insulin, so they inject it exogenously and it's life saving. But the analogy that I make is most people aren't type 1 diabetic. Most people are pre diabetic. They're on the type 2 diabetes spectrum. Right. Which is what my first company worked on. For those people, they should really, to your point, go focus on diet Exercise, sleep, maybe take a low dose of a metformin or a glucose reducing agent and really focus on changing their lifestyle rather than hopping on insulin. Insulin is really the treatment of last resort for uncontrolled type 2 diabetes that I used to see when I was.

Working at the va. And unfortunately, sadly, it's also an easy way out. There's a lot of people going to the Cheesecake Factory with their insulin syringe.

Exactly. Instead of obviously reducing their carbohydrate intake. I think injectable TRT is analogous. It is, there's definitely a place for injectable trt, but increasingly, I think if you talk to clinicians, including the top urologists and med school professors in the country, who are my colleagues and advisors, they really think TRT should be a treatment of injectable TRT should be a treatment of last resort because you're essentially going to become dependent on it for the rest of your life.

Okay, got it. Now backpedal here just a little bit because I think what you were explaining there regarding the hypogonadal issues and the LH and FSH relates to two ways that testosterone can be low. There's primary and secondary hypogonadism. Do I have that right?

Yes. Yeah, that's a really important differentiation and that's analogous to essentially the type 1 and type 2 diabetes. So in primary hypogonadism, the testes essentially no longer function correctly, just as in type 1 diabetes, the pancreas no longer functions correctly. So basically, no matter how much LH or FSH stimulation you're getting from the pituitary, if your primary hypocannadal, your testicles are not able to essentially respond to that signal and they're essentially shut off. For those folks, injectable TRT is absolutely the correct solution because, yeah, your testes no longer work.

Right. There's. There's no feedback loop to shut down.

Exactly right.

And with, with primary, what's the reason that something like primary would happen where the signal isn't even being sent? Is that just a bunch of stress? Is that being born with some kind of genetic issue or what causes that?

Yeah, sometimes people have testicular injury, testicular cancer, or other sort of very major medical problems. It's actually uncommon. I wouldn't say the majority of folks actually have primary hypogonadism, just like the majority of folks, probably single digit percentages, have type 1 diabetes. It's much more the type 2 diabetes and secondary hypogonadism. Secondary hypogonadism, you're still, the testicle's still work, it's just that they're not as responsive. Just like in type 2 diabetes. Your pancreas still works. It's just that you're insulin resistant and your body's not responding to the insulin as well, just like the testicles aren't responding to the LH and FSH as well. So you're getting the signal, but it's not producing as much testosterone, it's not producing as much sperm, generally due to poor lifestyle and health, which is unfortunately, as you point out, ubiquitous these days.

So how would you test for primary versus secondary hypogonadism? Would it be someone who's not on testosterone and you're measuring their LH and FSH levels, and if they were not on testosterone and those levels were low, that could give you a clue that they might have primary?

Yeah. So in both cases, both individuals would have low testosterone. Right. Now, traditionally, what people do is they do look at the LH and fsh. And so sometimes people who are primary hypogonadal have very high LH levels. And so they'll use that because it's like the pituitary, you know, the testicles aren't responding, so it's almost like trying to send, you know, more gas in order to turn it on. We find, however, that's not a perfect prognostic sign of whether you're primary hypogonadal. I think the best way to actually know conclusively is, is to actually put people on a serm. So traditionally there's something called the Clomid challenge. So Clomid is a selective estrogen receptor modulator, or cirm. It basically not everywhere in the body, but in selective places, including at the hypothalamus level, blocks the estrogen receptor. It's an estrogen receptor antagonist is also an agonist as well because it's two different drugs, technically speaking. But basically what it does is it tricks the body into thinking, I don't have enough estrogen or estradiol that's derived actually from testosterone, and so the body will produce more testosterone in response to.

It because estrogen is being blocked. The body thinks, okay, I need to make more estrogen. And the only way that you can efficiently do that as a male is to go through the testosterone pathway.

Exactly. So you'll produce more testosterone. So Clomid has been an FDA approved drug since 1967. It's used for female fertility and it's been used off label for men's infertility actually for many Decades as well. It works pretty well. And what will happen is if you are secondary hypogonadal, it will restart your system and get you to produce more testosterone. If you're primary hypogonadal, it won't work. And so you can do this pretty efficiently. You do that for like a week or two and you can tell if you're responsive. Great. Your testicles still function, essentially. And then you should probably figure out ways of increasing your endogenous or natural production. And if you don't, you can go right to injectable trt.

Okay, and you call that the Clomid challenge?

That's typically what's been called in the, in the academic research literature when we've analyzed LH and fsh, by the way, in terms of what predicts treatment response to a serum, it's actually usually when people. It's not when their LH is too high, contrary to popular opinion, it's when their LH or FSH are below one or they're almost zero. Those folks, essentially, they either have had a testicular injury, their testicles aren't working, or they've been suppressed because they've been on injectable testosterone so long that they're essentially no longer able to really produce.

Oh, so you can basically self induce primary hypogonadism absent of something like testicular injury, from using something like repeated testosterone injection, for example.

Yeah, that's kind of the irony of trt, right? Is it essentially can induce primary hypogonadism. Now, not always. There are some folks who, they go on it and when they decide, hey, it's time to have a baby, they can go off of it and they can recover. There's a little bit of individual variability in terms of that. And you can use, in fact, a CIRM or HCG to restart the system. It does work, but basically, in clinical observation, it depends on how long you are on CRT and what the dose was. Because if you were on it for too long and too strong, essentially, then it may not totally come back. That's why conservative clinicians basically tell people, if you at any point in the future would like to still have children, it's probably not wise to mess with your fertility. In fact, Jim Hoatling, who's on my podcast, basically argued that really, like, if you're under 50 or you still want to maintain your fertility, you should consider other options before jumping on injectable testosterone.

Okay. Yeah, it kind of reminds me of coffee, but much more serious. Coffee, paradoxically, can induce sleep issues because you get yourself to a state where you really only feel fully awake when you've had your cup of coffee. And then once you stop your coffee, you start to get all sleepy and it takes a little while to reset those receptors. But unfortunately, as you were just explaining, with testosterone, it can be much more serious and take a much longer time and you might feel a lot crappier coming off it unless you're introducing some of these things like Clomid and HCG to help. How long do you typically see that men are on testosterone before they start to create some of those potential issues for it being really hard to get off it?

Yeah, it's really hard to say because it is individual. And like I said, it also depends on the dosage involved. You know, more commonly, if it's kind of true medical TRT or HRT, you know, people are taking 100, 120 milligrams of typically a testosterone ester a week. These days you're seeing sort of sport trt, which is, I think a euphemism for more bodybuilder levels, where people are taking 200 milligrams plus they're certainly getting super physiological levels that are not achievable by any natural human being. And when you're, when you're pushing the boundaries of that, it's way more suppressive and it can induce it a lot faster. So it could be months, it could be years, but it depends on all those variables that I, that I mentioned.

Okay, and what if someone were saying cycling, and I'm actually curious not only if someone were cycling testosterone going on and off it, is that a common practice that would allow you to more easily come off it if you wanted to, say, have a baby? And then outside of that, just. Do you recommend cycling testosterone in general whether or not you want to maintain fertility?

Yeah, it's a great question. We get this question asked a lot about do I need to cycle? And cycling really comes from the bodybuilding world and their experience with anabolic steroids. Right. And testosterone, technically speaking, is the original anabolic steroid. It's just the one that our body sort of endogenously produces. People would typically go on these sort of 8, 12 week cycles of very, very strong, very harsh, very suppressive anabolic steroids, which not only cause the testicular shutdown, shrinkage and fertility, but, you know, mess with people's lipids and increase their risk for cardiovascular disease, which is why, like a lot of bodybuilders, obviously, you know, sort of die of heart disease in their 40s. And 50s. So they would, they would recycle this to try to mitigate the effects. Now for fertility purposes, as you're discussing, yes, theoretically speaking, if you cycle testosterone, went off of it in order to let your body recover, and then went on, you know, sort of a serum or an HCG that could theoretically prevent testicular atrophy. Right. From the testicles, you know, shrinking and being offline now, I think actually it's kind of an old school approach, kind of this going on and off, just like sort of the bulking and the.

Cutting that people do kind of reminds me of creatine. Right. The advice with creatine used to be, yeah, take 20, sometimes 30 grams a day for one to two weeks and then cycle down to five. When in fact, by taking five grams for about a month, you're going to get your levels topped off and keep them there anyways without cycling or loading or cramping or diarrhea or all the other stuff that happens when you load.

Yeah. And logically speaking, if you're taking something that you probably need to cycle, it's probably not that good for you in the first place. So, you know, I think the smarter and more cutting edge approach is to always try to maintain your own endogenous production or your natural production of testosterone. And that's really where the SERMs that I mentioned earlier come in. In terms of they used to be basically only used as what's called PCT or post cycle therapy. Right. So after you've done a cycle, as you mentioned, of testosterone or a steroid, people would go on Clomid or another serum in order to restart their production. They take very high dosages of it, 25, 50 milligrams. The problem with Clomid is it's really two stereoisomers or what's called mirror molecules, just like your left and your right hand. One of them is N Clomiphene and.

The other one, Zoo Clomiphene.

Right, exactly. That one's basically an estrogen. It acts just like estrogen. It's an estrogen agonist that actually binds to the receptor. The problem is when men take high dosages of Clomid, it will increase their testosterone because the enclomophine is working, but they're basically taking it with an estrogen. And so they'll get moody, cry at movies, they'll get emotionally labile. And that's why Clomid has generally been only used for shorter durations when people trying to get their wife pregnant or they're doing their post cycle therapy. Because men, even though their testosterone is higher, they don't feel great on Clomid because of the estrogenic, essentially, side effects that are happening.

Okay, so just real quick to clarify. So I'm keeping up here. Clomid is a selective estrogen receptor modulator. And when you take it, you are modulating, or in this case, even blocking the estrogen receptors in such a fashion that your body produces more testosterone in the hopes that it might get converted into estrogen for that estrogen that something like Clomid is blocking. Right, Correct.

Yes.

And then the problem is, because Clomid has zoo Clomiphene as one part of Clomid, you're dumping a bunch of extra estrogen into the system simultaneously and creating side effects like mood swings, I don't know, man boobs, getting weepy during chick flicks, stuff like that.

Yeah, I mean, it won't induce gynecomastia. Interestingly, the man boobs that you mentioned, because cirm, ironically, because they generally do block estrogen, are actually used as a treatment for gynecomastia. So Raloxifene, for instance, is an example of a serum that's actually prescribed when people have gyno.

Okay, so the enclomiphene is balancing out the zoo clomiphene.

Yeah, exactly. At least when it comes to gyno, because it does bind to actually the estrogen receptors in the nipples. But, yeah. Now here I would say low to medium doses of Clomid are safe and effective. And in fact, there's a study that was published where they put people on it for. They track people over three years. And the scientists basically concluded that Clomid, which is the branding for clomiphene citrate, is essentially a safe and effective treatment for hypogonadism. There's actually zero adverse offense in the trial that caused people to drop out. And so the problem is usually people overdo the dosing and then they get too much of the estrogenic effects. Now, there is a superior approach, which is a pharmaceutical company came along, realized that, you know, this problem was happening, and they purified Clomid. So they got rid of the zoo clomiphene isomer that was causing most of the side effects and which what only remained is enclomiphene. Right. The estrogen receptor antagonist. And that's actually what, you know, was almost the genesis of Maximus in that I realized this is an incredibly effective drug. It was kind of used in private practices that are more on the cutting edge of stuff like you're doing for hormone optimization, and it's incredibly effective. On average, enclomophene can increase testosterone, usually between 1.5 to 2.5x. So essentially, we can double testosterone levels.

Without being on testosterone, without being on.

Testosterone, just one daily pill. So it has huge advantages over TRT in that one. First of all, you don't have to inject yourself. It's literally an oral medication that's bioavailable and it stimulates your own natural production. So the difference between blood work of someone on TRT versus enclomiphene is trt. Their LH and FSH levels, as we talked about, are going to be near zero because you're shut down, your testicles are going to shrink and you're dependent on it. If you go off of it, you're going to feel pretty bad. Within Clomiphene, your LH and FSH levels actually typically go up because it's essentially telling the body, hey, you don't have estrogen, produce more. It actually makes your testicles bigger. Ironically, the studies that show the higher dosages, it actually increases testicular volume, it increases fertility. Total motile sperm count, which is a key fertility marker, actually goes up. So it makes you more fertile as a man, and it generally doubles testosterone. The other advantage is there's no dependency. If you just stop taking it, you'll just go back to your baseline levels. You won't be shut down like you will with trt. So it's a lot safer of an option because it's not a lifelong option. Obviously, you can choose to take it if it's benefiting you, but you're not dependent on it. And so the huge advantages for guys under 50 or anyone who wants to maintain their fertility or have kids, it's a really great option because it's not that drastic, kind of lifelong decision that you need to make. And, you know, you can prescribe it to men as young as 18 because it doesn't mess with their fertility and in fact, it enhances their fertility.

How much bigger are we talking, by the way? We're not getting into, like, teabagging when you use the bathroom type of territory, are we?

There is actually a poster presentation I believe is presented at, like, a urology conference, and they found that it was a statistically significant increase in testicular volume.

So I want to talk a little bit more about clomiphene because I have more questions about it. But you also mentioned hcg. Why wouldn't you use hcg? Because didn't you say you could use that to either increase testosterone, increase fertility, or both.

Yeah, HCG is a viable, but it's kind of an incomplete solution if you actually think about what HCG is. HCG is essential, essentially synthetic lh. Right. So oftentimes when people are taking trt, as I mentioned, they shut down their natural endogenous LH and FSH production. So you can replace your LH with synthetic H lh, which is essentially hcg. So if you really think about what HCG is, HCG is LH replacement therapy, just as testosterone is testosterone replacement therapy. So what it can do is it can maintain some of that testicular volume, function and fertility if you're on trt. The problem, though, is the FDA has now considers HCG a biologic. It can no longer be compounded. It's very expensive now and it's harder to get. And so it's less commonly used, unfortunately, because of the cost and the scarcity around it. The other part of it, though, is it doesn't replace fsh. You'd have to actually take another compound, which I believe is HMG and which is even harder to get, even more expensive. And now you're basically injecting three different compounds, testosterone, hcg, hmg, to replace testosterone, LH and fsh. And so you can do it. It's very. I don't actually meet a lot of people who take all three. Maybe they'll take the third one if they're trying to maintain their fertility in the future. But it's kind of an onerous solution. That's why it tests. Enclomiphine is kind of elegant because through one medication, you're maintaining your body's own natural LH and FSH production and it's producing its own testosterone. So it's simpler, essentially, especially for people who don't want to inject.

Now, you mentioned something important. You were describing hcg. You said it can no longer be compounded. For people who don't know what you mean by that, can you explain how this compounding and compounding pharmacies work?

Yeah, it's a great question. Most people are familiar with sort of traditional retail pharmacies. These are the CVS and Walgreens of the world. These. They essentially will provide you with manufactured, either generic or on brand medications. But these are things that are essentially standard medications and standard dosages, right? Like you might get a, I don't know, 20 milligrams of Viagra. But if you wanted a custom dosage of it, your doctor would actually have to write a prescription to a compounding pharmacy and Say, hey, maybe for your size and weight, or you don't have that much Ed, you only need 10 milligrams. And so if you can't kind of break the pill in half or you need a custom dosage like 7 milligrams, you get a compounding pharmacy to produce that in either a customized dosage. It could be a customized combination of two different medications, or it could be a different delivery system. Some people, for instance, have trouble swallowing pills, so they might give it to you in a liquid or a dropper form that's more easily consumable. So essentially, compounding pharmacies produce customized or personalized medications that are a lot more adjustable in terms of meeting people's needs.

Okay, so if you have a compounding pharmacy making clomiphene, is it like a tablet or a capsule or. I'm assuming it's not an injection?

It's not an injection. It is very orally bioavailable. It's almost 100%. So it doesn't need to be injected. It absorbs pretty well. It can be taken as a capsule or it can actually be taken sublingually as a tablet. Just stick it under your tongue. It'll dissolve and gets absorbed that way.

Other side effects to enclomiphene all medications.

As you know, have side effects. The good news is the side effects for enclomiphene are rare. They're about 1 to 3%. They're mild, most common being headaches, dizziness, nausea. And they're reversible in that if you do run into them, typically you just need to adjust the dosage and they can go away. More is not always better, contrary to American, you know, opinion. So sometimes, if you like, increase the dose way too much. It can reduce libido and other things, but that's actually true of testosterone as well. It's really about maintaining that equilibrium or that homeostasis that I mentioned. The nice thing is, for instance, the compounding pharmacies that we work with can prescribe eight different dosages of enclomiphene all the way from 3.125 milligrams, all the way up to 25 milligrams. And find the right dosage that allows you to maximize testosterone while minimizing side effects. And usually the way you do that is you find what's called the med, the minimal effective dose. So what gets you the most bang for your buck without running into side effects? And the nice thing about the, you know, what we're doing now with telemedicine is you can start people on a conservative dose, especially if they're not hypogonadal. You might put them on half the dose that's been effective in the clinical Trials, which is 12 and a half milligrams. You can put people on, let's say 6.25 milligrams, see how they respond. If they get a nice testosterone boost. They're, they have twice as high levels. They're feeling pretty good in terms of their, their energy and their function. Great. They can stay on it. If they find, ah, maybe I'm at 1.4x, I want a little higher levels. They can type and they're doing well. They can titrate the dosage up to 12 and a half milligrams, see if they tolerate it well, adjust it up or down. And so it's really true personalized medicine, which is the way, as you know, medicine really should be practiced.

Yeah. And with enclomiphene, don't some people also combine it with testosterone? And if so, what would be the reason for doing that?

Yeah, it's a great question. So with injectable testosterone, it's so suppressive, it will shut down your LH and FSH by 90, 95%. Nothing really mitigates that suppression. People have tried, in fact, for years to combine injectable testosterone with Clomid, which is, like I said, been around for a long time. It doesn't negate the suppressive effects. It may be that HCG can negate some of the testicular volume issues and the fertility issues. Clomid a little bit less. So it's not as, not as effective?

No, no. I'm going to jump in here real quick. I just, I have to ask, when you're saying it's not as effective, is that based on, like, what you've observed in patients, or is there actual research that compares Clomid and testosterone with enclomiphene and testosterone?

This is from clinical observation of doctors who've seen patients on injectable testosterone and Clomid. It doesn't, it doesn't negate the suppression, essentially. And like I said, HCG doesn't totally negate it either. It just maintains some testicular function, but maybe not even to 100%. Kind of keeps the lights on, but it's not the same as your sort of natty levels, so to speak.

Okay, got it. But what you've clinically observed is that enclomiphene seems superior because you're able to maintain fertility without testicular shrinkage, even if you're also on testosterone, not injectable testosterone.

Like I said, injectable testosterone is still too suppressive. Now, here's the interesting thing. This is going to answer your question. There are other forms of testosterone now on the market. There is topical testosterone, which is typically a gel or cream that you can apply to your scrotum, your arms, your chest, that is suppresses LH or FSH by 50, 60%. There are intranasal forms like Natesto, where you can swab the inside of your nose, that are only suppressive by about 20, 30%. And there's actually new oral forms of testosterone. So, as you mentioned, testosterone is typically injected because it's not bioavailable. However, there have been advances in pharmaceutical science that make testosterone orally bioavailable. And the trick to that is it's typically consumed with some fat. Your fat is absorbed by your lymphatic system, and so it kind of piggybacks off of the lymphatic absorption in your intestines instead of your stomach and actually can be absorbed as a, as a pill or a capsule. So oral testosterone is still suppressive, kind of like topical. About 50, 60% suppression of LH or FSH levels, but it's not as suppressive as the injectable at 90, 95% suppression. What we've discovered, and we published clinical trial data, which you can read@maximus tribe.com is that when you combine enclomiphene with oral testosterone, it can actually mitigate the suppression. In fact, 100% of the people in our clinical trial maintained LH or FSH levels within the normal range, even though they're on exogenous oral testosterone, which should otherwise be suppressive.

Now, one thing that comes to mind a lot of times when we're talking about oral delivery versus transdermal delivery mechanisms would be some of the first pass liver stuff. Is there any concern about hepatotoxicity or anything like that with either oral enclomiphene or oral testosterone?

Yeah, great question. So let's start with oral enclomophine. Oral enclomiphene is not a steroid, and so it doesn't actually have liver toxicity. It is. It is processed through first pass liver metabolism, but it doesn't typically elevate liver markers, and so it doesn't have any adverse effects on the liver. Testosterone, unfortunately, gets a bad rap because back in the 70s, there was a form of it called methyl testosterone, which is a kind of a modified form of testosterone that had hepatotoxicity and obviously Oral steroids can be liver toxic. But this new form, this oral testosterone, like I said, it's actually designed not to get absorbed in the stomach. It gets absorbed and piggybacks off the lymphatic system. So it actually, for the most part, actually bypasses first pass liver metabolism and it doesn't have negative effects on liver enzymes. And we're sure of this, in fact, because not only do the studies show that, in fact there are three FDA approved forms of oral testosterone, they wouldn't have gotten FDA approved, obviously if they were harmful to your liver. In fact, there's some interesting emerging research that they may be used as a treatment.

For fatty liver disease. But we actually measure liver markers as part of our blood work. And so you don't have to take my word for it, we assess it before and after and make sure that it doesn't cause any elevations in liver enzyme.

Yeah, that's good. That's critical. Anytime you're working with a company is make sure you get your testosterone, your dht, your hematocrit, your liver. There's a lot of stuff to keep track of before you just get started on something like, like this. That's super important. Now the, the oral tea, you said you take it with a fat. How much fat are we talking? Is this like half a jar of peanut butter, an egg, you know, a little bit of olive oil in your smoothie, or what's the quantity?

Yeah, it's a great question. So first, the thing I wanted to clarify is that the testosterone that's actually used in oral testosterone is basically what we call native testosterone. Native testosterone is literally the same bioidentical testosterone that your body produces. It is unmodified or what's called un esterified testosterone. Testosterone that you inject is typically an ester you've heard of probably the term testosterone and Anthony propionate cypionate. These are essentially modified versions of testosterone that allow for them to have a longer half life. So you only have to inject it once a week rather than inject it every day, which is obviously an annoyance. However, they behave differently than the natural endogenous testosterone. That's truly bioavailable. I think a lot of people say that testosterone is bioavailable, but it's not. Not unless it's native testosterone. Oral testosterone and actually topical testosterone are really the only two forms that are true native bioidentical testosterone that's essentially chemically identical to the testosterone that your body naturally produces from its gonads. And so that's the form that's actually used in oral testosterone and we find actually works pretty well. Sorry. Now remind me what your question was about it.

How much peanut butter?

Oh, look at that. Okay, so there's studies that show, for instance, if you Compare Oral Testosterone Undecanna 8, which is an ester, it does require fat absorption. Studies that use native testosterone, which is the form that we use, do not require as much fat in order to be bioavailable. So even if you take it without any fat, it will still increase your testosterone levels. So it does not require fat. However, if you take it with fat, it will enhance the absorption. Studies show that typically you need about 30 grams of fat in order to maximize the bioavailability, which is not a lot.

It's like just like 2, 250, 300 calories.

From there, I literally eat an avocado and half a cup of kefir or Yogurt, and that's 30 grams right there.

Okay, yummy. So with the oral and the transdermal, you're basically doing something far different than injecting once a week. You're taking a small amount, I'm assuming, by the way, is the oral twice a day or once a day.

You can actually. That's the nice thing about it. You can flexibly use it however you like. A lot of people will take it once a day in the morning with their breakfast or lunch, whatever their kind of fatty meal is. That's the other thing too. It's like you don't necessarily need to go out of your way to eat fat. Best thing to do is just eat it with the meal that you're having.

Yeah. So you don't have to put, you know, like ghee into your breakfast cereal. You can just wait till the first fat containing meal, which might be lunch.

Exactly right. If you're eating your eggs, which you should be having anyway, because, you know, eggs have cholesterol. Cholesterol is essentially the steroid backbone in which all your hormones are produced. You have to consume some fat. Right. In order for you to produce your own hormones. So you consume it with that. It will work if you take it once a day. Um, so the half life of the reason that oral testosterone is not very suppressive is it has a shorter half life. It will typically peak at about three to four hours, and it'll be out of your system generally within eight hours. Now it can induce quite a high peak. We found in our studies that oral testosterone in conjunction with enclomiphene will increase your total testosterone levels by about 2 to 5x and your free testosterone levels by 3 to 7x. So it can peak quite high and then go back down. And then that is enough to essentially stimulate the androgen receptors and induce anabolism, the muscle building and all the beneficial qualities of testosterone. Now, some people, because they want to feel it a little bit more in the afternoon or evening, you can split up your dosages. You can take it breakfast, lunch, breakfast, dinner, or one tablet per meal if you really want to spread it out. The nice thing is you have the flexibility in conjunction with your physician to kind of do what works with your schedule. If you're more of a morning workout person or an evening workout person and you want to try to piggyback it off to maximize your testosterone levels while you're working out.

Got it. I know I said it earlier.

And it could be inaccurate, so I should run it by you. I mentioned that taking testosterone might increase your libido and make you want to go out and have a bunch of babies. But is it true that testosterone doesn't have a real big impact on libido versus strength, recovery, vitality, sleep, performance, things like that?

It does. It's just that it's. Testosterone is not the only hormone, as you know, that impacts libido. Testosterone and estrogen or estradiol is also really important for libido. You don't want estradiol to be too high or too low. It kind of needs to be in a kind of a Goldilocks zone. And it also varies by individual. Some people actually feel quite good on having high estradiol levels, which is why increasingly within, in sort of the injectable testosterone world, doctors are not prescribing aromatase inhibitors or AIs like anastrozole as much. They used to always. Because one of the problems with injectable testosterone is it tends to aromatize or convert into estrogen, estrogen or estradiol at a very high level. And so even though it's jacking up your testosterone when you inject, your estrogen levels can get quite high too. That can mess with your libido. And so they'd give you an aromatase inhibitor to try to control it. And. But you got to be really careful about that because you do need some estrogen. It's important for your bone mineral density, it's important for your mood, it's important for your neurocognitive function.

Yeah, I was going to say a lot of guys get on AIs and they get brain fog because estrogen or estradiol specifically is so critical to brain performance.

Yeah, exactly. And so increasingly, the better thing to do is just lower your TRT dosage so your estrogen is not out of control. The nice thing about both topical and oral testosterone and is it actually preferentially metabolizes into dht, which you mentioned earlier. DHT is an androgenic hormone. It's responsible for puberty development, development of facial hair. It's kind of the aggressive hormone and is implicated in libido as well. And so because it preferentially converts to DHT over estradiol, you typically actually don't need an aromatase inhibitor when you, when you take oral and topical testosterone versus injectable testosterone. The other really interesting thing is dht. The, the natural, the body's natural androgenic hormone is essentially a natural aromatase inhibitor. It's the way the body naturally regulates its own estradiol. So if your DHT levels go high, it essentially keeps your estrogen or estradiol levels under control. In fact, in our clinical trial, even though, like I said, we were increasing testosterone by 2 to 5x free, testosterone by 3 to 7x, estradiol levels actually stayed the same, if not slightly lower. And that was because of the increase in dht. And in that case, DHT can't, can actually increase libido. In fact, when we did before and after measures of a measure called the Q Adam, and we specifically asked, you know, how is your libido before treatment? How is your libido after treatment? About 70% of people reported actually improvements in libido and erections being on this oral testosterone plus enclomafene protocol.

Now, doesn't DHT though, isn't it associated with male pattern baldness or increased PSA or prostate issues? If it gets too high, yes.

Now, if you read too much of the Twitter sphere, there's a lot of back and forth about whether that's true.

I'm a Reddit guy.

But yes, it can. If you are already prone to androgenic alopecia or bph, Right. Benign prostate enlargement, essentially. So in those folks, it can exacerbate it. So what we tell people is basically, if you're already losing your hair, you have to be mindful. Now, the good thing about enclomipine, if you're just talking about enclomiphene monotherapy, if you're taking it by itself, it actually maintains the same T to DHT ratio. And so even though your testosterone is going up and your DHT is going up with it, it's relatively balanced. And so we find it's actually pretty hair friendly, if you will. Doesn't seem to cause a lot of shedding or hair loss in folks with oral testosterone. It definitely converts more to dht and so the balance between T and DHT becomes a little skewed in those folks. If you're not prone to balding, you're probably not going to start balding. If you're already losing hair, then yes, it can exacerbate hair loss, it can exacerbate acne because DHT can stimulate the sebum production in your skin, the oily production of your skin.

Never seen that at a bodybuilding show ever.

Yeah, and for sure. And it can, it can enlarge the prostate. Now the good news is oral testosterone compared to injectable testosterone does not increase PSA as much, does not increase hermatocrit as much, and does not increase blood pressure as much. It's probably because it's a short half life and it doesn't kind of redline your body. But in those folks who are predisposed to and sensitive to kind of DHT increases, you can take a low dose of a 5 alpha reductase inhibitor, which most people know as finasteride or Propecia, or there's Dutasteride or Avodart. Those are the brand names of it. What that does is it basically blocks the conversion of testosterone to dht. And so you can kind of have your cake and eat it too, in that if you're taking an oral or topical testosterone and you're concerned about the increase in DHT, adding a 5AR inhibitor will not only block the conversion of DHT, but it actually increases testosterone even more because it's not conversion converting so much to dht.

Now would I be incorrect to theorize that if you're doing a big injection of testosterone once a week that flood, that big surge in testosterone versus like a once or twice a day small spike, which I think might more closely mimic the natural diurnal variation that would occur in a man anyways when it comes to testosterone. But that big spike, would that potentially cause even more concern about over aromatization, PSA issues, hematocrit issues, et cetera, because it just seems like a lot all at once that doesn't occur in a natural scenario.

Absolutely. It's not mimicking the natural biorhythm. So you definitely get much more spikes in estradiol, dht and yeah, so people can sort of develop issues with increases in their hemoglobin and hematocrit Right. Which is called polycythemia. And so sometimes you'll hear about people on injectable TRT actually having to donate blood because their blood is getting so thick and increases obviously your risk of heart attack and stroke. The risk of polycythemia on oral forms of testosterone is extraordinarily small. It's like 0.003%. In a study that I was looking at now we still monitor hemoglobin, hematocrit, just in case, because there's some people who are just almost like high to begin with. Like if you're living at very high altitudes, your body naturally produces more, more red blood cells and produces more hemoglobin. So we just make sure no one's getting too, too high. But yes, I think the reason it doesn't cause as many side effects is to your point, your body has a natural rhythm of testosterone in which basically.

Very early in the morning you achieve kind of peak levels of testosterone. It goes down as you kind of wake up into the afternoon and it elevates again into the evening. So there's that natural sort of 24 hour rhythm of testosterone and in, in which it's re released in sort of this pulsatile manner. Testosterone is really not meant to be redlined all the time. The, the reason that we're doing that is just because to your point, it's more convenient to inject once a week. So you get this huge surge. Your testosterone is actually super physiological. It can be, you know, well above a thousand, sometimes two thousand plus, and then it will kind of coast and go down over the course of the week. So that by the time you're on day seven and you're ready for your next injection, you're at your so called trough levels, your peak in your trough levels. So you feel really great. When you get that initial testosterone surge, it's almost euphoric, which I think sometimes gets people a little addicted to it, psychologically speaking. And then they don't feel as good by day seven, which is why increasingly you're seeing a move towards actually people injecting more frequently. They'll eject daily to every other day, so they're getting less of the highs and the lows. Downside is you got to inject every day and every other day and you feel like a human pin cushion.

So you guys are testing maximus, obviously. I know you do some testing to monitor values. You talked about supraphysiological values of testosterone. But let's say somebody comes to you, what are you looking for when it comes to deciding whether or not their testosterone is low or their free testosterone?

Yeah, so our advisors always say we treat people, not numbers. The treatment or the designation of hypogonadism based on testosterone values is highly problematic because the reference range as I mentioned earlier, has actually shifted. Usually super physiological testosterone back in the day was considered a total testosterone over 1200. But because it keeps dropping over the last couple decades, some of the recent lab reference ranges, which is usually between the second and a half to 97.5 percentile, have dropped to almost 900. I think I saw one that was like 827 is considered high, which back in the day was almost like normal for an athletic male. And so what is considered low is honestly kind of arbitrary. And there's in fact there's published research papers that prove that because what is low for, you know, a 20 something year old male is probably very different than low for an 80 something year old male. These are not even age referenced samples.

You mean they're not age reference? Like if I go to a Doctor and I'm 80 versus when I'm 20, they're looking at the same chart.

Exactly. The reference range for a lab is based on 18 to 80 something year old men and also people who are really sick. As you know, 88 of people have some form of metabolic syndrome, 70% are overweight or obese. And they're comparing their normal testosterone levels to yours, which is a healthy young athletic male should be totally different. So it's a bit of a joke to use, you know, standard reference ranges in the sick care system, as I call it, in order to be diagnosed with low testosterone or hypogonadism, as we discussed, typically you have to have a total testosterone under 300, which is right around the second and a half percentile. That's obviously a shitty way of doing a diagnosis because what if you're third percentile, you're, you're at 301. Technically you don't have hypogonadism anymore. And then the other problem is we didn't talk about the difference in total and free testosterone. Total testosterone is the total amount of testosterone in your system, but it's not necessarily bioavailable in order to bind to the androgen receptor because it gets bound to these two different molecules, one being albumin, the other being SHBG or sex hormone binding globulin. Free testosterone is the unbound testosterone that's actually free, like a lock and key to bind to the androgen receptor free Testosterone is more associated with clinical symptoms like libido, energy, all the things that we're talking about. So most clinicians who are experts in testosterone actually pay attention to free testosterone. You can calculate it pretty easily. If you've measured total testosterone, you have albumin or shvg, you can calculate essentially what's your free testosterone. So that's essentially what we do.

Oh really? How do you calculate that? For some reason I thought you just measured the actual free T, but it's a ratio type of thing. With shbg you can.

The problem is a lot of the measures of free testosterone are not accurate unless it's done by an LC Ms. Test which is more expensive, takes longer to run, etc. There's something called the vermulin vermuleon equation. So if you basically have, even if you just have total testosterone and shbg, you can plug it into a little online calculator, it'll calculate your free testosterone and it's actually pretty accurate. There's a lot of clinical validation for that.

Kind of makes logical sense because sex hormone binding globulin would bind total testosterone and if it's high, you're going to have less free testosterone. So I'm assuming this calculation is based on big data or something like that.

Yeah, large cohorts. And yeah, to your point, high SHBG means lower free testosterone, low shbg, higher free testosterone. So what we do, and this is really the innovation is it's obviously kind of a pain in your arm to go to a quester labcorp and get a huge needle stuck in your vein. Now it's great because you can measure 100 biomarkers, but it's inconvenient to do. And so what we've done is we partnered with a medical device company that's actually gotten these FDA approved. This is what the device looks like.

It's holding it up. For those of you watching the video, check it out on YouTube or BenGreenfieldLife.com Maximus podcast.

Yeah, it basically looks a lot like a CGM and it works in a similar way. You just stick it on your shoulder. There's a big red button, as you can see here. You press it and it actually uses micro needles, so they're very small and it's virtually painless. Like I would say on a, on a one to ten pain scale, it's like a maybe a two. So I have friends, in fact, who are blood phobic, will pass out of the sight of blood. They can do this test while they would have a Lot trouble, A lot of trouble. With a traditional blood test. You can literally do this in the comfort and convenience of your home in five minutes and it'll draw out. I'm showing this on the camera, basically, for those who are listening on audio. It's about half of your pinky's worth of whole blood. This is whole blood that comes from capillary blood. And it's mailed off to a lab via next day air via FedEx, and then it arrives in the lab in the wind within two days. They can analyze your total testosterone, your shbg, calculate your free testosterone, and then measure other key markers, including your estradiol, your lh, your fsh, your PSA that you mentioned, your hemoglobin, hematocrit, your, and your liver enzymes like ALT and ggt.

Oh, so you're getting it all from that once. Like it's like the staples easy button, that red button, you know, that begs the question though, because a lot of these companies that do the at home lab test testing, they got the, the little cards and you prick your finger and sometimes it bleeds and sometimes it doesn't. You gotta milk it like a cow and wait and get X number of drops and sometimes, you know, relance at your finger to get it to start bleeding again. But is there a reason everybody doesn't just use the little slap it on your arm thing you just showed us?

Because there's a, there's a lot of unethical and pseudo scientific companies basically that are out there. It's much cheaper to do the dried blood spot test. We actually looked into it.

Oh, it's cheaper. Okay.

It's cheaper. Yeah, there's, there's some companies out there that for 45 bucks you can do this little milk your finger dry blood spot test, which by the way, 20, 20% of men can't even do it because their fingers are so callous.

Yeah, no, I got super callous. I gotta get in the sauna to do it. I gotta heat my body up in the sauna and then I can't even. This is gonna sound super unhygienic, but I can't even use the Lancet. It's not deep enough. I literally have to use an insulin syringe and plunge it into my hand to get the blood to come out. Now I realize I've got, I've got very thick, my whole family, all the men in my family, these big sausage fingers. But yeah, it is a little annoying.

Yeah. And so, yeah, it has a 1 in 5 failure rate. So it's just a terrible user experience. You have to do this multiple times. So it's hard to even get the blood out in the first place. And the problem is when it gets on the card, it's prone to key issues because it's going off. You know, it can.

It's mailed regular mail. And so if it's hot where you are, or the postal carriers, the temperature's off, it can mess with the reading. And so dried blood spot testosterone tests are not very accurate.

That's what you call the cards, dried blood spot.

Yeah. If there's any company that's out there, if you're researching companies, salivary testosterone and dried blood spot testosterone, even though there's big companies that are selling them online, are just not accurate. And we know this because we tried it, because obviously it's convenient to just spit into a tube. And these tests are. The dried blood spot tests are cheaper, but they're just not accurate. And if you're obviously trying to have an accurate assessment of your health and whether these treatments are working, you need an accurate blood test. And so this is best in class technology. Like I said, it's whole real blood and it's clinically validated. It's just as reliable and valid is essentially going to a Quest or a LabCorp. And so if people are not using this, I would not trust that company. Basically.

Yeah. I mean, there is that Dutch test that does all the different metabolites and does melatonin and a whole bunch of other stuff via dried urine, but that one's pretty expensive.

Yeah, I think that's. I've heard of that. It's not a lot of, like, more naturopathic doctors are using that. I wouldn't say it's super accepted in sort of traditional clinical.

It's not. I think you can get a ton of data out of it. I think you can get more data out of it than saliva or blood, but again, it is spendy, so that's a downside. But I think it is a good test.

So, yeah, what we do with the Tasso, just to wrap this up, that's.

Called the tasso, the blood one you held up. T, A S, S, O. Yeah.

That we use. So we measured, obviously at baseline, and then the doctor will look at your numbers, but also your symptoms. And so you can technically be what's called eugenadal, meaning your normal testosterone. But like I said, that could be third percentile, it could be 50th percentile. And so that's less important as your symptoms. If you're saying, I used to have great energy, I was happy, had great libido, but now I'm falling asleep in the afternoon or after dinner. You know, I don't have the PEP that I used to have. And I'm having symptoms of low testosterone. And your numbers are maybe not optimal. You still can be a good candidate for especially the type of treatment that we provide with enclomiphene, oral testosterone, or the combination thereof, because it's maintaining your natural production and your fertility. So it's not that, oh, my God, this is a drastic treatment of last resort where I got to be on this for the rest of my life and shut off my own production. With this, you can really do more optimization or performance enhancement because it's a lot safer, essentially, than the old school, just injectable approach.

Right. And I can still meet with a doctor and get lab tests and everything. The only downside is, of course, insurance wouldn't cover it because I'm not hypogonadal. Right.

Yeah. I mean, I think insurance is a scam in this country because, like I said, they're in the business of denying care, not providing care, and they'll only provide it to people who are. Are really drastic, below the second and a half percentile. We're a cash pay, basically, private practice.

Another good reason to have an FSA hsa.

Yeah. Which we do accept. So we, you know, obviously you can get at least the tax savings from doing so. And, you know, the plans that we have, if you're committing for a year or more, it's typically 100 to $200 a month. Clomiphene is 100, 100amonth. Oral testosterone with the Clomiphene is 200amonth. So it's actually pretty reasonable.

No, that's not bad. I know some people would pay $100 a day for how they feel on testosterone when their testosterone is low. You mentioned eggs, and we're joking about peanut butter. And he talks about the avocado and the kefir that you have. It kind of makes me think you hear a lot of people talk about the pregnenolone steel, how if you have really high cortisol levels, your pregnenolone levels plummet and all your hormones drop because pregnenolin is like the mother building block from cholesterol of all the other hormones and just backpedaling here for a second back to what delivery mechanism you choose to increase testosterone. Why couldn't you just give somebody pregnenolone?

Yeah, it's a great question.

Pregnenolone and DHEA are precursor hormones. Right. They're technically neurosteroids. So as you pointed out, when you consume cholesterol, it gets metabolized into pregnenolone, which is considered the mother, grandmother, grandfather, whatever analogy you want to use hormone. And that converts into other hormones, including dhea, testosterone, estradiol and the whole steroidal cascade. The problem is the body kind of chooses how it converts pregnenolone into the rest of the hormones, so it typically actually doesn't increase testosterone on its own.

In men. And same thing with dhea. DHEA actually preferentially converts to estradiol, so which is why it's not actually a preferred option, unless for some reason you're trying to increase your estrogen. The major benefits of pregnenolone is it turns into another neurosteroid allopregnanolone, which is kind of a GABA agonist. GABA is obviously kind of the calming anti anxiety receptor system. It's literally what alcohol works on, which is why people kind of chill out, obviously, when they drink.

Have you have your glass, your glass of evening pregnenolone.

Exactly. So pregnenolone typically is taken to enhance mood, so it has mood and energy enhancing effects. Interesting. It also may improve sort of visual acuity, kind of makes the colors and life brighter. But so when people are on trt, by the way, that's the other thing that people don't appreciate. And you know, I'm a psychologist and some psychiatry professor, so I really care about neuro hormones and cognitive function. When you shut down your LH or FSH production, you're also shutting down your neuro hormone production. So your pregnenolone and DHEA plummet. And so not only, as I said, do you have to take testosterone, maybe hcg, maybe hmg, but they're also putting people on pregnenolone and DHEA to backfill to your point, the neurosteroidal cascade, when you're on enclomiphene or enclomiphene and oral testosterone, because you're maintaining your natural LH and FSH production, you're also maintaining your natural pregnenolone and DHEA production. So you're not getting those neurocognitive impairments or deficits. Now, we still sometimes provide pregnenolone just to give people a little extra mood and energy boost to kind of optimize levels, but it provides kind of further benefit, essentially.

Oh, interesting. So, so you can do. So you could theoretically do like pregnenolone with Enclomiphene or pregnenolone with enclomiphene. And to start, like oral testosterone.

Yeah, and it's, it gives, like I said, it's more of a supplemental boost. It won't increase testosterone levels, but like I said, it for some people, it enhances mood and energy levels.

Okay, got it. You know, a lot of these, you know, clinics, because you see them a lot, right. I even heard them called pill mills.

Right.

You know, all these places where you fill out questionnaire and do a lab report and then you get on your testosterone subscription and you're kind of like, you know, just swiping your credit card every month for the rest of your life. So I think some of them get a bad rap in terms of what you guys are doing. You know, if you could sum up how you would differentiate yourself from the standard pill mill, how would you do that?

Yeah, it's a great question. And you know, I think it's analogous to, you know, seeing any sort of clinician or doctor. Unfortunately, there's a huge amount of variance in terms of the quality of clinicians in this country. And I can say that because I'm involved in training psychiatrists at the number three medical school in the country. They typically produce very high quality clinicians. And there's some people go to, you know, med schools in the Caribbean or no offense to those folks, but you know, where the quality can vary. There's some great place doctors who come out of those places and maybe there's some who, you know, were barely smart enough or sentient enough to get into U.S. medical school.

What do you call a doctor somebody made through medical school? Right.

Yeah. And I think clinics are the same way. There are some really high quality clinics and we obviously aspire to be. Now, I'm biased, but I'll tell you objectively why I think this is the case. First of all, we use board certified physicians and there's a lot of clinics who are just using nurses and NPs and there's nothing wrong with those folks. They can be really great. But you know, someone who has a doctorate typically on average is going to have higher level of education, higher level of intelligence, quality assistance, etc, and so I think NPS are great. We do use them sometimes, but they're ancillary in the care. They might be involved in writing your, you know, the renewal of your prescription, but you're always going to have a physician as part of your care team that's supervising your care. And I think that's just a really important thing. It costs more. We have to obviously pay doctors more. But I think it's just, you know, when it comes to your hormones, really, really critical. So that's the first differentiation. Second differentiation, you see a lot of clinics who weirdly make people choose their own dosages of enclomophene, which I think is just criminal, because how do you know what the amount is that you're supposed to take?

Check. Check this box. Yeah, check this.

And you're like, pick your own poison. And I'm like, you know, we actually have the largest nationwide prescriber of enclomiphene. We've been prescribing it for four plus years. Have, you know, in the, in the five digits, you know, patients and a lot of clinical experience with it. So we know based on your age, height, weight, bmi, your testosterone levels, and your symptomatology, where you should likely start on how to adjust it if you're running into side effects. You know, what the dose adjustments should be switching maybe to every other day versus daily dosing. So there is an art to medicine, and the physicians just need to be really experienced with these medications in order to maximize the outcomes. You can probably. I always tell people, why bargain shop with your health. I'm sure you could theoretically find it cheaper somewhere else, but you're gonna have to almost play your own doctor, which I think is, you know, kind of a shady thing. So if you're, if you see any place that's like making you basically choose your own, you know, dosages, it's. It's probably kind of a bad sign in terms of they're not really providing high quality clinical care. You may save a few bucks, but, you know, you're gonna run into more likely run into side effects.

In other words, don't get your testosterone off Alibaba.

Yeah, exactly. So I think that's the other thing. But the other thing I was going to say too is we're the only telemedicine company that actually publishes their data. Right. So the two protocols that I mentioned, in clomiphene alone and oral testosterone plus enclomipine, there are published clinical trials on our website that show our data. And so if you ask me, you know, Cameron, how does this protocol increase my sports performance? I'd be like, great. We've measured that on this protocol, and in terms of people who reported normal levels of functioning before treatment, 62.5% of people said they had normal to excellent levels of athletic or sports performance. That went up to 93.8% on oral testosterone plus and clomiphene. Right. That's a statistically significant finding. You can look at the data yourself and the methodology of our paper. And so it gives you increased confidence as a consumer or a patient that, hey, these guys are not only on the cutting edge of developing these new forms of treatment like oral testosterone, but they're actually measuring the outcomes. And I can have a pretty good sense of what it's going to do for me. I always tell people, look, it's not a panacea. It's not going to necessarily change your life if you're not doing the diet, exercise, sleep, all the other things that you need to do behaviorally. But you should have a good indication of what it's going to do and that we've actually tested this and have clinical data to back up, you know, our experience.

Yeah, yeah. As far as the FDA goes, you think that it's. It's going to be something that continues to be cool with the FDA using something like enclomiphene instead of Clomid or oral testosterone or do they even look at stuff like that?

Yeah. So the FDA does not approve compounded medications. So what they do is they do regulate compounding and that the pharmacies are inspected essentially by the fda. You have to make sure they're obviously sterile if they're compounding things like the GLP1s, the weight loss drugs, or injectable testosterone, because anything that's liquid in a vial needs to be manufactured, obviously, in a way that's very safe. So there's less regulatory oversight on the actual medications themselves. But increasingly, I mean, I can't predict the future, but I will say the. The laws around telemedicine have essentially been relaxing in that. Obviously, post Covid, we've come to a world in which we're zooming and the evidence generally shows that clinical care can be delivered just as well in person as it can online. And outside of, obviously, procedural care where you're doing an injection or a surgery on someone. I think the future of medicine is telemedicine. And so I think a lot of the states are essentially catching up and allowing the prescribing and fulfillment of medications. And hopefully, increasingly, you know, it will become more and more prevalent and won't be sort of blocked by too much regulatory oversight. Now, I will say there are certain classes of medication which are more Schedule 2 controlled substances. These are the Adderalls of the world, the opioid painkillers that have clear addictive qualities. I've been very public and against Those sort of telemedicine pill mills who were prescribing that WILLY Nilly on TikTok. The, you know, the FBI and the FDA kind of came down on those clinics that I think gave the whole field kind of a bad rap. But, you know, we started out very conservatively, right? Like we were only doing non controlled, non injectable stuff. And then now that we have essentially safe, controlled, safer controlled substances like oral testosterone that maintains your fertility, you know, we feel safe about, you know, prescribing that to, you know, a population that meets the eligibility criteria.

Well, that's fantastic because on my top 10 least favorite things to do is drive to the doctor or drive to the lab.

Exactly.

So save me a step. So the, the website, if you guys want to check out more about Dr. Cam and what he does, go to BenGreenfieldLife.com Maximus for the podcast Show Notes. And I'll include other podcasts I've done about all things hormones, testosterone, libido, etc. Go to BenGreenfieldLife.com Maximus Podcast. If you don't know how to spell maximus, go watch the movie with Russell Crowe and Dr. Kim. Thanks so much for doing this, man.

Thank you so much. It's a pleasure to be with you and hopefully we can do it again and talk about some of the new innovations that we're working on, including the topical testosterone. And we also provide obviously GLP1s and the first prescription pre workout, which is a combination of Tadalafil and Bardenafil, which I'd love to talk about more in the future.

Everybody loves to take Viagra before they work out. All right, man. Thanks for coming on, folks. Thanks for listening in. Have an incredible week. Do you want free access to comprehensive show notes? My weekly roundup newsletter, cutting edge research and articles, top recommendations from me for everything that you need to hack your life and a whole lot more. Check out Ben Greenfield Life. It's all there. BenGreenfieldLife.com See you over there. Most of you who listen don't subscribe like or rate this show. If you're one of those people who do, then huge thank you. But here's why it's important to subscribe like and or rate this show. If you do that, that means we get more eyeballs, we get higher rankings, and the bigger the Ben Greenfield Life show gets, the bigger and better the guests get and the better the content I'm able to deliver to you. So hit subscribe, leave a ranking, leave a review. If you got a little extra time. It means way more than you might think. Thank you so much.