The No.1 Reason Men's Testosterone Levels Are So Low Today | Dr. Sara Amirmehrabi

The conventional primary care doctor may test your testosterone and that's about it. Right. If they think it's above 300, you're fine. I hear that a lot and it's really sad because it's not fine. Just because the entire population's testosterone is dropping doesn't mean that it's okay.

Exactly.

People are suffering.

Exactly. And I'm so glad you bring this up because these ranges are out of control. I mean, a normal range being somewhere between 300 and 1000, it's too broad for me.

Welcome back to the Dr. Joy Kong podcast today. I'm so happy to have Dr. Sara Amir Mehrabi back here. Now we're going to talk about male hormones, which of course is equally important to female hormones, which we covered last time. So Dr. Sara is passionate about optimization of health, prevention and longevity and she specializes in hormone therapy. So I'm really looking forward to tapping into her expertise today. So you know how to optimize your hormones. Okay. Dr. Sarah, so happy to have you back.

Hi, Dr. Joy. Thank you so much for having me back. It's a pleasure to be here.

Yes. So are you equally passionate about male hormones as female hormones?

Oddly, yes. Testosterone is actually one of my favorite hormones on the face of the planet. If it could be in the water, I would love that. It's something very near and dear to my heart and just the way it makes people feel and the difference I see in my patients lives, I have a lot of respect for it.

When did testosterone become an important hormone like in the medical world?

Testosterone for men, at the very least, this has been something, at least for the past 40, 50 years that has been used in treatment to help men feel more optimal, prevent, you know, diseases like insulin resistance, high cholesterol, dementia and Alzheimer's. So it's been around for quite a while. I know. You know, there is this whole camp where bodybuilders were kind of abusing it, but even still there, there are, there is that camp out there with the bodybuilder group that we can learn a lot from them in terms of, you know, how not to go too high, when to cycle off. So they do know a lot. Surprisingly some of them are PhDs that have contributed a lot to the. That's even surprising for me in a sense. Just because they didn't go to medical school doesn't mean that they're not aware of the benefits and how it can really help the recovery and performance and just overall mental well being.

So I assume initially testosterone was used medically. Right. For People who are deficient.

Yes, yes. So you know, how do we know that a patient is deficient? Right. It's based on a collection of symptoms that the patient is coming in with and of course biochemical lab work. So we have to look at labs, see what's happening within the body. But yes, initially it was for that in men, just to help with energy, mood, reducing belly fat, improving muscle mass, really helping with focus and concentration, libido and erectile quality. Those tend to suffer as testosterone drops due to aging. So lots of these factors came into play in order to start treatment for these men.

What is the ideal range of testosterone for men?

Somewhere between 700 and 1000 is where we like to see it.

And where are most men at these days? Let's say men between the age of 30 to, you know, 70.

Interestingly enough, the past, you know, 10 years I've been seeing a drastic drop in.

Even within 10 years?

Even within 10 years, especially the past five years. I mean men as, as early as age 26 are starting to, we're starting to see lower and lower levels in the two, three hundreds. Um, but on average we want it somewhere between seven hundred and a thousand is where I like to see optimal levels. Um, some other docs out there might drop down to 500 to a thousand, but minimum, on average, 700 is where I like to see it. And that's where men start to feel really? Really.

I'm curious to see how, what's the proportion of men that actually meet that, that level that you like to see.

The seven hundred to a thousand? Yeah, yeah. I, you know, I think over the 10 years I've been doing this, I've, I've maybe run into four or five men that came in with outstanding levels without enclomiphene citrate, without hcg. So nothing, nothing to boost their testosterone either exogenously or endogenously. And that was surprising for me. And I asked them, well, what are you guys doing? And they're like, well, I don't eat processed foods. I make sure I get outside. They monitor and manage their stress. I think the latest guy that came in his was in the thousand range. He was actually one of your patients here at Chara. And I asked him, what, what are you doing? He's just like, well, I'm active, I spend time with my family, I spend time outside, I regulate my stress. And he was on some really good peptides, like, you know, some anti inflammatory peptides, like a BPC157, maybe a little bit of growth hormone. Stimulating peptide CJC 1295 and epamorlin combination. Not even kiss Peptin to help this guy out. So there was nothing.

Yeah. So for men who actually had that kind of level, they are taking good care of themselves.

Very good care of themselves. Yeah.

It sounds like it's probably less than 5% of men, which is very alarming, very alarming because supposedly for every, every drop of testosterone, testosterone level, there's a big, big impact on their cardiovascular health and on their longevity. Right. Can you break that down a little bit about just what kind of degree of a reduction and what kind of consequences?

Yeah, so with low testosterone, and this is, you know, respect to age related testosterone deficiencies, not, you know, something going on with the brain or something going on with maybe like a varicoseal or some congenital defect in one of their, you know, in the reproductive organ. So this is just age related that I want to, I want to touch on. But most men without the testosterone, we start to notice insulin resistance, which we all know in terms of longevity and health optimization. We don't want too much sugar accumulated in the blood. It can lead to peripheral neuropathy. Right. So numbness and tingling in the hands and feet, retinopath, so problems with our vision and just overall inflammation and, and really obstructing the microvasculature and the inner lining of our blood vessels so the endothelium. So we start to see damage there. And so with that, at the very least, insulin resistance is, is one thing that I like to use testosterone for. High cholesterol, low testosterone can oftentimes cause a skyrocket or, or allow cholesterol to skyrocket in the absence of it. So we see in studies profiling men who are on TRT or testosterone replacement therapy, three year later follow up study, we're seeing that total cholesterol reduced, HDL or the healthy cholesterol improved and LDL or the not so healthy cholesterol also reduced. So very heart healthy in that sense. Testosterone is also necessary for feeding the tiny vessels in the heart. So the microvasculature, oxygen and nutrients so really also helping with heart muscle contraction, you know, and, and when that's optimized, we, we start to see a really nice pump of venous return and arterial flow and, and we start to have blood flow to our cells in the way we want them to and, and replenish, replenishing them with oxygen and nutrients so they can function at their best. So that's more overarching as we kind of break down the rest of the benefits of testosterone, we see a lot of the quality of life tends to reduce in, in men with low testosterone. So we start to see men feeling moody, maybe they're feeling a little bit depressed, they're not as confident as they once were, they're irritable, and they don't know why, they can't sleep. So the next day they can't function. And then if you're, if you're not well rested right the next day, you're probably going to wake up just super groggy, you can't focus on your work, you're hungry. So now we start to see a little bit of weight gain that tends to collect around the midsection of the abdomen, that spare tire. And believe it or not, men care about their aesthetics and their appearance. We start to see with their workouts that they're not able to recover as quickly. And with muscle recovery, we need that to happen in order to build muscle. So it's not that testosterone directly stimulates muscle growth, but it does help in recovery and the ability to work out the next day so you can build more muscle mass. So these men, when they're low, they just don't feel like themselves and it starts to affect their personal life. So the amount of energy they have to interact with their children, that tends to plummet. And, you know, I've spoken to men who do have families, and that is a source of a little bit of regret for them that they can't spend time with their young kids and really nourish them through their young childhood and even adolescent years, they're libido maybe, maybe is a bit low and it's affecting their relationships, whether it's with, you know, whoever partner they have or their marriage, you know, their partner might feel undesired or feeling like it's their fault. And no matter what these men tell their partners that it's not you, it's me, that no one really wants to hear that. Right. So, no, as much as they tell them this, it puts a strain between the interaction in a partnership and in a couple. So compound that with the emotional side effects of erectile quality issues. So no man wants to, no man wants to walk around with the idea that they cannot, you know, achieve an erection. It's just something of the, you know, the 10 years I've been doing this, I've heard it all. And it's really a source of discomfort and a source of, how do I put it? Like a. It's a hit on their masculinity. They just don't feel like the men that they're supposed to be, if they cannot achieve an erection, which I understand. I mean, there's that psychological component. So that really.

Does testosterone actually affect the quality of the erection?

It can.

Okay, it.

Once we eliminate. Okay, is there high blood pressure that's in the. In that comorbid condition with the low libido, Is it, you know, diabetes or blood sugar regulation that's also lending itself to a reduced or, you know, faulty erectile quality? Once we eliminate that, then we can safely say, okay, maybe it was actually the testosterone. So lots of things that can affect men emotionally and mentally on that level, the confidence that the testosterone can bring. A lot of men tend to lose a little bit of that. That juice, so to speak, that they used to have in their 20s or 30s, when they'd go out there and, you know, nothing would bother them, problems would roll off their shoulders. They can take on mountains of responsibility and chaos and show up the next day as if it never happened. Also, one of the main reasons I love testosterone, you can just survive. Oh, it's not even surviving. It's. You can push through your daily life.

And that's for both men and women.

Both men and women. Yeah. So all of these things compound. And then all of a sudden you go from this man when he was in his 20s and early 30s that felt unstoppable to this almost like fragile and kind of almost moody. Moody, just not feeling like he can provide. And that's not what I want for our society, and that's not what these guys want for themselves either. So that was my. I think, in a way, this is my. My treating and, you know, using testosterone replacement therapy and helping these men out is just my way of kind of helping society out a little bit. Forging men.

Right, make better men, make happier women.

Yeah, exactly.

And what about the relationship between testosterone and cognition?

Yeah, I mean, without the testosterone, whatever, what, you know, we see is that the active receptors in the brain need testosterone. There are androgen receptors in the brain specific for testosterone. And when levels are low, we start to see difficulty with focus, concentration, recall. There could be a potential for. As men age, especially in their 50s, 60s, 70s, without, you know, repleting the testosterone, we could be at risk for dementia and Alzheimer's disease as well as. I mean, this is more pronounced in women as estrogen drops, but there is a small effect with men as well as endogenous T levels do go down. So what I have noticed after treatment in patients is that they are mentally more clear, their Endurance mentally increases. And so maybe they've had a full workday. And these, these, most of the men I've treated, they were corporate executives, high functioning, high achievers, law enforcement, firefighters. So guys that are under a lot of stress. And then these, these high functioning, high achiever guys and you know, law enforcement and firefighters, they're, they need to be on their toes mentally. And so what we've seen clinically is at the very least that they're brighter, sharper, and they can feel like they can problem solve more readily versus struggling prior to testosterone replacement therapy. So that's also a really nice advantage to navigate through our, our crazy world that we have.

Mm. Yeah. And testosterone really doesn't have to decline as we age. I mean, we know there are people who maintain really good testosterone level right until they're in their 80s, 90s, and they're all still having sex and having a good time in life. So it's not an inevitability. But what do you think is causing such sharp decline in men's testosterone?

What's happening right now is in our modern world, we have a lot of environmental pollutants, toxins. Stress has, stress is the number one trigger that can plummet testosterone levels. And I see men that sometimes, you know, we put them on treatment and they're not really noticing a benefit. And then I, you know, we deep dive a little further and realize that they need to manage their stress a little bit better, whether that's going outside, getting fresh air, breathing, you know, spending time with their family, checking out of work for a little bit, if possible. So stress is a big indication. And the stress can be emotional, mental, environmental, a myriad of things. There's also a lot of microplastics in our environment. Men's personal care products are contaminated in a sense, with phthalates, agents that basically can increase estrogen instead. So xenoestrogens. And when we see in men, especially with low testosterone levels, if their T is low and their estrogen is high, we start to see a lot more problems. And that's where the personal care products come into play.

I don't think there's enough attention about these things because people just grab it, they think it is sold on the market, it should be fine. And they, you know, they, they would rather not think about it, unfortunately. And I see women do that all the time too, spraying all kinds of stuff on their hair, their face and. Yeah, and without realizing how that's really jeopardizing their health and their happiness. So what can people do about this if they find out, I guess if someone has a little midsection, you know, energy is not as good. Maybe libido is dropp, maybe brain is not functioning as great as before. They probably don't know what's going on. Their heart, you know, that's usually silent until it's not silent anymore. So. But there's some other things that are a little bit more noticeable, a little bit moody. That may be a good time to talk to your doctor and really get tested. So I know there are different kinds of doctors and probably run different sets of tests. So if a person goes to a primary care doctor, do you think that they get adequate testing?

Not necessarily. And this isn't to put anyone to shame, it's just a primary care doctor. If they're not in the niche of hormone replacement therapy, they may miss a few things. I would really go to somebody who does this on a daily basis because it's not just about the low testosterone. It's also about looking at the rest of the hormones. Where is the estrogen at? Where are the brain signals at the FSH and lh? Where is the sex hormone binding globulin, globulin at? Where is even potentially albumin at? So these are b, these are protein chaperones essentially that you have to have. The lower the hormone levels we have, usually the lower the sex hormone binding globulin and albumin are. As we tend to ramp up in hormone replacement therapy, these numbers tend to increase. So we need a before measurement of these parameters and also checking your cortisol so it's multifactorial. I like to also check lipids and also check a hemoglobin A1C and an insulin. Because if we're not looking at that complete profile, we could be missing other things that are leading to these other comorbid conditions that could be causing inflammatory responses and stress in the body to lower the testosterone levels as well. So it's a whole person approach.

Right, right. Which the conventional primary care doctor, they're not trained in it, you know, they may test your testosterone and that's about it, Right? That's right. That's pretty much this. Well, you know, if they think it's above 300, there's a, you're fine. I hear that a lot. And it's really sad because it's not fine. Just because the entire population's testosterone is dropping doesn't mean that it's okay. Exactly. The people are suffering.

Exactly. And I'm so glad you bring this up because these ranges are out of control. I mean, a normal range being somewhere between three hundred and a thousand. It's too broad for me. You know, working in optimization and longevity and really wanting to get my patients the healthiest that they can be. I never want my patients in the lower or upper quartile, want them somewhere in the middle. And depending on how each person responds, we gauge the treatment accordingly. Some men don't need a whole lot of replenishment and treatment. I've gotten away with getting men to feel great with 40 milligrams twice a week. That's it. Some other men, I've needed to go a little bit higher. So it really just depends on the blood work, what we're doing with the other hormones and proteins that we need to work with, how the cholesterol and blood sugar are coming along and what their stress levels are like. So it doesn't have to be high. It's just physiologic repletion. And I think a lot of primary care docs scare men out of it because they're saying, oh, no, you have high cholesterol. If you get on testosterone replacement therapy, you're going to throw a clot and die of a heart attack. Well, yeah, I mean, if we're not, if we're not looking at why is the cholesterol high? Is this a stress response because it can elevate just from stress, or is it dietary? Do we need to intervene that way? Or, you know, what's. Basically, we have to look at the entire picture. There are ways to go about repleting testosterone in a, in a scenario where cholesterol is high because it actually treats that after three years according to studies. So it will come down. I think the one line I, I draw is if liver enzymes are elevated. So this is a new patient. If liver enzymes are high, and this is not because, you know, it was some sort of holiday and, you know, the patient's in is like, okay, I was with my family, you know, I had a few drinks, whatever. But if somebody's a, you know, pretty much an alcoholic and is consistent consistently drinking and it's affected as liver enzymes, we got to cut the, cut the alcohol. So I won't treat if we're not adjusting for that or if we have uncontrolled high blood pressure. That's not something I like to play around with. So we adjust for that first and then we move forward. So I think in a primary care setting, the high blood pressure, the high cholesterol setting in combination with testosterone is something that can Be scary to the doctors and then that trickles down to the patient and then I have to damage control and tell them no, it's, it's great for you long term, but we just need to take some, a few steps prior to treatment.

Yeah, yeah. So the cholesterol and blood pressure, I mean these are all kind of inflammation based, which has a lot to do with toxicity and diet and lifestyle.

Yes, yeah.

Of what they're doing with their body. They just do some exercise. Probably a lot of these things will get better.

100% exercise, you know, eating, eating foods that don't come in a box or a bag. I mean, I think that's the most important thing. Hydration. And again, stress control, being outside, interacting for, for those men who aren't in a relationship, go out and meet women, interact. Even though you know that interaction with women, it's, it's a 10 minute temporary boost to testosterone, but at least better than. Yeah, it's just 10 minutes. Even post coitus, it's 10 minutes and then it fades. So I was, I was looking into their research and because I was curious, I was like, oh, does this build over time? It doesn't, it's just for that moment. But it's better than not. So at least these men can feel that drive in a natural way, like a quick little boost. And you know, direct exogenous treatment isn't the only way to go about this. So there's, there's three major forms of, of treatment to increase testosterone. There's straight testosterone, which will give you numbers that, you know, you can only imagine. You can go as high as you want. There's no limit. It's going to shut down your FSH and LH so your brain signals. But you can go as high as you want. Now for, for men who are not looking for preserving fertility, that's great. I mean, do we need to go in the high 3 thousands? No, but. Right. We don't need to do anything excessive. It's just a physiologic repletion dose is what we're looking for. But so that's the beauty of the, of just straight testosterone usually comes in a scipione or an anthe. It's got a longer half life. You only need to inject twice a week, smaller amounts just to, you know, prevent oscillation of feeling great. The testosterone metabolizing out and then not feel so great when you need your next injection. So that twice weekly is really nice for stability. Then there's other delivery forms like oral testosterone, like Katrix, this is. You have to take it twice daily. Usually the dosage goes from 200 to 400 milligrams a day. But I don't know any man that's going to take this twice a day. So that compliance could be an issue. But it keeps you within that physiologic range and it prevents any spikes in the testosterone. And that could preserve your fertility a little bit more readily. You won't really get to above 600 or maybe even 550 with that oral version. The other newer version out there is intranasal gel. Testosterone next and on, I believe. So that one, it's. We don't really see a lot of compliance with it because it is a gel substance. So it kind of gets a little sticky in the nostril.

You're spraying this gel.

You're spraying, you're spraying this gel. It's 11 mgs each nostril three times a day. So you, you, you get. I don't know who's gonna do this three times a day. So most men, after a week, they're just done with it. We find that women have an easier time dealing with this. They're more apt to continue with the intranasal spray.

It's also three times a day.

Also three times a day. Likely it's going to be a lower dose for women. Men have eight times more testosterone than we have. We still need it as women. But the men, compliance is an issue with the intranasal also, like I said, it's a little gel. Like, if they can find a way to aerosolize it more cleanly, I think that might be a really great route. But we'll see what happens. And then the other delivery form is, you know, if a man is looking to preserve his fertility and. Clomiphene citrate or Clomiphene citrate. Clomiphene citrate, you have a potential of increase of triglycerides, which I don't really like to use that a lot. I've seen it maybe a couple times. And then there could be a side effect of blurry vision. Mostly what we see is N clomiphene citrate being used. And that will not shut down the message from the brain to the teste. Your FSH and LH still remains, sperm count still remains high. So that's an option for men who are looking to conceive and want to maintain their fertility.

What's the mechanism of.

So the, yeah, the enclomiphene and enclomiphene citrate they block estrogen at the level of the hypothalamus. So at that point the brain is freaking out saying, okay, where's our estrogen? Because in men, testosterone converts over into estrogen. So when the brain senses that, it sends out gonadotropin releasing hormone, which then sends out false follicle stimulating hormone, fsh and then lh, that FSH and lh, the LH will give the testosterone, increase the testosterone, and the FSH will help with the sperm count. So that's how the mechanism of action works there. In a nutshell, it's kind of similar to hcg, right? Yes. Okay. Yeah, and I was going to touch on that next. So the hcg, that is a synthetic LH or synthetic luteinizing hormone. And that will still, you can still get really high levels with just HCG if you dose high enough. So you're still risking suppression. If you're dosing, for example, you know, 1500 mgs three times a week, that, that can be used, but you're, you're still gonna elicit enough testosterone to shut down the FSH and lh. So in that case, the clomiphene or enclomiphene is the better delivery form or the oral Kaiserx just to maintain sperm count. The other option, I think, for men to really think about in terms of fertility is just take it easy, dose that high, even if you're on exogenous straight replenishment of testosterone. Because I have had patients conceive quite successfully with dosages of, you know, even 25 to 40 mgs twice a week with exogenous testosterone, cipione, and then we supported them with small amounts of HCG concomitantly. So it wasn't a standalone treatment. It was so not monotherapy, but dual therapy with testosterone and hcg. That seems to be the chef's kiss to maintain sperm count and then also give these guys the tea that they need in a delivery form that's easy for them twice a week. The dosage with the HCG kind of want to stick to anywhere from 250 to 500mgs twice a week to maintain the signaling from the brain to the testy and not shut that down. And that's how I've always.

So out of all these therapies, is it only testosterone that can have the potential of making the testes shrink? If you're enjoying this content, please like and subscribe to this channel that will help us to create more content like this for you in the future.

The testosterone and sometimes in High doses, the hcg. But yes, that's a great clarifier because testicular atrophy is a thing. I mean men really care about this. I, I don't know any woman that cares or even looks. I mean, you know, but it's for them, it's a thing. I know. Now there's fat transfer to the testy.

Yeah.

Paul Turek, he's created this technique.

This doesn't sound right. I mean why would you put fat where it doesn't belong?

It's almost like a Brazilian butt lift for the testity. Yeah. I, I just don't understand. But it gives them the bulk, it gives them what they want. In, in case though for where I was listening out there, worse comes the worst. But yeah, the testicular atrophy is a real thing. So the guys on exogenous tea, so maybe they're on the testosterone cipionate or even the enantate. The ananthate's more of a, you know, it's more readily available in Europe. I know some guys can get it here but, but the Scipione is what we tend to have in the States. So layering that with a little bit of HCG dual therapy is the one thing that's going to prevent some of that atrophy. We've also found that it just helps men feel a lot better mood wise when that HCG signals a little bit of that natural LH release. So they're happier, they're feeling better. We've noticed that with the addition of the HCG as well, they're able to maintain their lean mass a little bit more readily and reduce their body fat a little bit more readily. So, so as far as the mood, that piece still needs some discovery in terms of what the HCG is doing there. But it's a, it's a, it's a benefit I'll take for, you know.

Yeah. And there's another form that's for testosterone that's really popular. Will be the, the topical. Right. The cream or the, the gel.

Yeah.

What, what do you, what do you think of that compared to the injections?

So the Androgel, it's. Yeah, I, I like the Androgel but it's more of a daily thing. So men need to apply it daily. It's got to cover a large surface area. So the problem with the gels is, is absorption. If a guy maybe has a lot of hair and they haven't shaved it, that we won't get the absorption onto the chest or wherever it is that they're applying. So shaving is going to be key. Sometimes exfoliation. If, if the guy's just gotten out of the shower and he's and is still not dried off, you know, he needs to be careful of, of when he's applying. So absorption could be an issue. I like to reserve the gels in, in cases of testosterone induced polycythemia. So testosterone will stimulate the kidney to secrete erythropoietin which then tells the, the bone marrow, hey, make me some red blood cells. So then the blood gets thick and we see an elevation in hemoglobin and also hematocrit on blood labs, which any doc doing this should be following with blood labs monitoring hemoglobin, hematocrit every three months. So I like to use the gel. If I find that exogenous testosterone supunate has caused that increase in the, in the blood cells and we see this elevated hemoglobin, hematocrit, then I'll drop down to a gel because it won't spike as readily. We have a little bit more control with the topical to prevent peaks the way we see in the exogenous direct injection testosterone.

So guys, it's just not as fast release.

Yeah.

Is usually absorbing to the fat layer. Right. And then slowly, slowly getting into the blood.

So that's one thing I like. But again, compliance is a key. I don't know any man that's going to really do that. The only, the only time I've really seen daily, daily applications medication.

Okay. I always think that's an easy way. You know, just in the morning before you go to work. Just.

It is, right?

It is just like you put moisturizer on, right.

It, it is, it is for, for a lot of people. I mean maybe we as women are used to it. I may, you know, but for men who can't tolerate the injections, for example, maybe they're getting welt or maybe they're just, they're just done with it and they don't want to feel like a pincushion anymore. Then we can transfer to a topical like a gel to give them a little bit of a break, which is always nice. And that's why I love having these different delivery forms. You can play around with it it and that's I think where the art of who's behind the replacement comes in. So you got to really find someone that knows what they're doing is in the know with the different forms, what the side effects are. I mean, you mentioned atrophy, hair loss is a potential side effect as well.

So are these reversible?

Great question. The atrophy is. The atrophy is testicular. Testicular atrophy is. You know, there are times where you can just take the testosterone away for a little bit, maybe add in some clomiphene citrate so the man doesn't crash. Right. And then you can maybe after the enclomophene spike, the FSH and lh, get them back on a regular kind of communication between the brain and the testy, and then maybe transition them to a topical, like a gel, and then maybe go back to the. The exogenous testosterone. I was seeing you smiling like that's a lot. I mean, this is a way to go around it, right, To. To make your patient feel their most comfortable. But, yeah, it's reversible within clomiphene citrate and even some hc cg. So different ways to go about that.

For the hair loss.

The hair loss, yes. As if you catch it early enough and pull back on the dosage and then add some oral minoxidil and then use maybe some natural herbs like a combination of a saw, palmetto, nettle, rupigium. They'll work on both alpha and beta receptor of the 5alpha reductase enzyme. And I use this often. So we block that conversion to dihydrotestosterone, which is what's responsible for thinning of not only the follicle, but then over time, after regrowth, it becomes shorter and thinner, shorter and thinner, and then we start to see the baldness. So.

I see.

But I think the oral minoxidil is a great place to start, you know, just to preventative. And if men are. If men are a little concerned with, you know, I just got a hair transplant. You know, clearly I'm going to start a little bit on the error on the side of caution and maybe do a topical gel and then make sure they're on the oral minoxidil. And definitely, you know, a 5 alpha reductase blocker. It doesn't have to be herbal. It can be a finasteride as well or a dutasteride as well. So we can go pharmacological route as well. It just depends on how serious the condition is and how. How scared the man is that's in front of you.

There are a lot of nuances.

A lot of nuances.

And so which brings us to side effects of the hormone replacement. So. So the. The testicular atrophy, the hair loss, and. And tell us A little bit about other potential side effects that people may end up noticing.

Yeah. So, I mean, I think the biggest, biggest thing out there is gynecomastia. So nipple tenderness, breast tenderness, and then eventually, if, if, you know, the estrogen goes uncontrolled. So that's how the gynecopacia forms. It's too high estrogen. Man boobs. Yeah. So there's the man boob situation, and then the. How. How will you know? Right? Or how would a man know that this is what I'm going through. So he might just be going through his day, and then all of a sudden, you know, the brush of his T shirt or a towel might cause some tenderness to the nipple. That's. That otherwise wasn't there. The nipples can become pink, puffy, enlarged, and maybe pointing downward. That's when we've gone a little too far in the game. They're also maybe, you know, seeing water retention in the hands, feet, or face. Now we're, we're kind of getting outside the gynecomastia realm. That's just more dealing with the man boob situation, which is a result of high estroge. But they may also start to notice puffiness in the hands, feet, or face. They may notice feeling a little weepy or emotional from triggers that normally wouldn't trigger them, and then maybe a little bit of bloating in the abdomen. And that's when we know, okay, your estrogen's out of control. Let's dial it back. Let's, you know, try to clear whatever estrogen is out of the way. I like to use herbs like, or. Or supplements like diandol, methane and indole. 3 Carbinol. These are normally found in foods like kale, broccoli, cabbage, bok choy, cauliflower, Brussels sprouts. So if we can't use food as medicine or concomitantly use food as medicine with the dim i3C. And then if I need to, I'll throw in some anastrozole. That's the generic form of Arimidex. So those are, you know, pharmaceutical estrogen blockers. Sometimes I use all three. Just depends on how deep in the hole we are. So that's kind of how. How the signs and symptoms of the gynecomastia, how we can mitigate for that. The other is the hair thinning and hair loss discussed. The other is just feeling angry or irritable. It's interesting that, you know, all these years it's been, you know, testosterone has been the culprit and you know, for testosterone being so calming and so stabilizing and just the most magical hormone on the face of the planet to get through your life.

So you have your favorite.

I have my favorite. It's just. You can just. You feel like a superhero when, when you have the right amount of testosterone, but it's not in. According to a 2023 meta analysis, it's not really the testosterone, so it's the estrogen. Because we have receptors in our brain in the amygdala, which is, you know, our fear, fear area, emotional control area, and the prefrontal cortex. So our area of impulse control. So what we find is that there's a ton of estrogen receptors in that area. So if we're now all of a sudden having a flood of estrogen in this, in this man, his brain in those areas are gonna register that those estrogen receptors are gonna latch on. This guy's gonna start to become a little bit irritable, a little bit weepy, and a little bit aggressive, especially if he's had a history of it in the past. So we're starting to see that science is a little more nuanced now when it comes to, oh, testosterone as the aggressor, not necessarily could be the estrogen. And so that's what we're seeing according to this 2023 meta analysis.

And how does testosterone leads to elevation of estrogen?

Great question. So, yeah, in, in. So in the body fat, we have an enzyme called aromatase, and testosterone typically converts over into estrogen through that conversion. Um, so we call it testosterone aromatizes to estrogen. So that's like a key phrase that, you know, our listeners can be aware of. So the more body fat a man has, that's gonna be a risk factor, the more alcohol he drinks. So I always tell my patients, cut the alcohol if you can, or take it to a minimum. I'm talking about, you know, according to average, healthy amount of drinks is one drink per week for a man. I think that's still too much in the realm of testosterone replacement therapy and preventing that high estrogen surge. So alcohol reducing body fat, so exercise, eating well, is going to be key in that man with the high testosterone, if he's sitting there on the couch, not working out, gaining weight, eating whatever he wants, drinking whatever he wants, he's going to be more at high risk to convert his estrogen over. And so those are the things we need to watch out for. Yeah.

Which means anybody who does all that could be having a lot more estrogen than you Want, right.

A lot more estrogen. Yeah. I mean, and there's studies that have been done on alcohol induced aggression and the same logic kind of follows. It's that estrogen spike that leads to their aggression. It's not. All of a sudden this guy is like drunk and his testosterone surging and now he's upset. No, it's not that. And then the personality type, men who are prone to kind of that more strict, you know, high dominance, what is it called? High dominance versus low impulse control, those guys are a little bit more at risk in terms of a psychological level. So in my screening, I always kind of look for that. Like, who is this man? Like, what's the history? I don't, I don't ask about, you know, a history of like domestic violence or abuse, but you can kind of tell, you can tell the guys that are in it just to be healthier. And then you can tell by the way he talks to you if he's going to be aggressive or not. And that's just things you just pick up over time, you know, dealing with men and trt. So.

Yeah, yeah, yeah. So some people may not want to do hormone replacement. Right. And there are men that really believe that they should be able to boost their own testosterone just on its own. How easy do you think that is? How, how achievable?

So, Gosh, in the 10 years I've been doing this, I have yet to see, except for those three or four that I mentioned earlier, I've yet to see a natural boost that can give me levels that exogenous testosterone does not even, you know, just straight testosterone sipionate mixed with a little hcg. I have yet to see levels rise to what I want them to be in terms of a seven hundred to a thousand naturally. But what we can try is, you know, a series of peptides like Kiss Peptin, that's been shown to effectively raise testosterone levels. So Kisspeptin is one way to go about it indirectly boosting growth hormone so you can build muscle mass. So the more muscle we have, especially in the quads, the leg. So the legs and the glutes, those are our largest muscle groups, some of the muscles of the back. As long as we grow those large muscle groups, the body will naturally request an increase in demand of production of testosterone. So indirectly, if we use like a CJC 1295 epamorlin, you know, stack a Tessamorelin on top of that, if we can elicit that, get the guy working out, get the guy building muscle, helping with that recovery we can indirectly boost testosterone that way. And then of course, you know, stress reduction, as we mentioned earlier, and just clean eating out, go outside. You know, there's other herbs. For example, ashwagandha, which is an adaptogen, meaning that it helps your body respond to stress triggers. Studies have shown that taking ashwagandha daily can help with reducing cortisol, which can then help to increase testosterone. Another herb, Tonga Ali, that's been studied not necessarily to increase testosterone, but to free your testosterone from sex hormone binding globulin. So we have total levels, but we also want to look at free levels. I forgot mention this. You know, free tea, anywhere from 5 to 25 is where we want to see it. I like to see it more in the middle. You know, 20 is a good range. Or if I want to take a guy to its his optimal, if I can get it somewhere between 20 to 25 on a free tea, I would love that. And that's, I've done my mission in life for this human being in terms of trt. But the Tonga Ali will not directly increase the testosterone. What it will do is free up your whatever you have in the total testosterone pool. So it'll separate your testosterone from sex hormone binding globulin. And now you have more circulating free testosterone. You need to have at least 26% Europtide in that Tonga Ali preparation for any of that to even work. Beta sitosterol also can be used to help free up some of that sex hormone binding globulin or free up some of the testosterone from sex hormone binding globulin. And then let's say you have a high sex hormone binding globulin. How do you bring that down? Nettle root. Root can do that. Not the leaf, just the root. About 500 milligrams twice a day for a few months can really be beneficial. So lots of ways in, in terms of using herbs, you know, herbal medicine, to also help, you know, improve the therapeutic efficacy of your testosterone treatment.

Yeah, that's great.

Yeah.

What about other hormones? Because men, you know, yes, women is estrogen progesterone, but for men, I mean, these other hormones are important too, right? Do you, you, do you check men's progesterone as well?

Yeah, I do, I do check progesterone just to be thorough and complete. I'm just a little bit like that. I do check progesterone, especially if the man is having issues sleeping or if he's super anxious. He doesn't need a lot, just maybe two migs a Day. But that progesterone can also be very calming. It's GABA nergic, so it attaches to our GABA neurotransmitter, which is very calming to the brain. So I will check the progesterone. I also love to check a cortisol just to see where his cortisol is at. And then that's when I'll add some of the herbal components. You know, vitamin B6, B5 are also great to help with some of the, with cortisol as well. So we'll do some nutrient therapy as well. And then I'll also check for, like I said, insulin levels. Just making sure, you know, insulin is a hormone in and of its own. Right. So make sure that's normal. Their hemoglobin A1C is not above 5.7% and if it is, we need to adjust for that. So those are a prostate specific antigen, not necessarily a hormone, but a lab marker that I always want to make sure I address because there have been times where, you know, with testosterone replacement therapy, it can potentially lead to what's called benign prostatic hyperplasia or bph, where the prostate is enlarged. The good thing is now we have studies that have refuted the whole connection with, you know, testosterone replacement therapy and prostate cancer. It does not cause.

That's an important part to, to talk about because I still have, have, I've, you know, not too long ago, a patient was diagnosed with testicular cancer and the doctor told him to absolutely get off the testosterone. And he was, he said that was the hardest thing because everything plummeted and, and yeah, he had miserable, miserable months.

Yeah, that I, I feel bad for him. Yeah. To, to cold turkey. Any type of testosterone replacement therapy, it's tough, but, but in an active state of prostate cancer. Yes. I don't recommend, you know, taking any type of testosterone during, you know, a recent diagnosis or.

But it's been debunked.

It's been debunked as far as causing prostate cancer. But just, you know, for my mental wellbeing and peace of mind, I don't like to administer testosterone. You know, if I've just found out my patient has prostate cancer, I'll wait a little bit on that and then we'll resist zoom after he's spoken with his urologist and try to figure out. And then I'm on board with the urologist. If urologist is on board, I'm on board and we'll go ahead and, you know, start.

So you would taper off while probably Supplementing with other herbs and other lifestyle changes. Yeah, yeah.

But the pro. I was really happy to read in the studies that, you know, that has been debunked in terms of testosterone and prostate cancer. And Even, you know, 10, five years ago, I always thought. Wait a second. Second. You know, men have. There are incidences of prostate cancer in men who have never been on testosterone replacement therapy. So it was a little bit iffy from day one, but I'm glad that at this point, we can definitively say, nope, it does not cause prostate cancer. That was a major win.

Yeah, yeah, yeah. Wonderful. I think we covered a lot of ground. It's. As people can see, the body is a symphony, and hormone replacement is an art, and it's a complex matter. So. So being with somebody that's really experienced and really understand the whole scope of how these hormones work in the body and affect each other as well. So. Well, Dr. Sauer, what's the best way for people to actually get help from you?

Well, definitely can find us at Chara Health. We do. I will do all. I do all of those things here. We'll need some labs first, and then we can get started on whatever delivery form is appropriate for that patient. So we can just give our office a call.

Right. And you are. You're trusted not only among our patients, but also among our staff. Many of us have gotten help from you, and you're being so kind and so generous and done some miracles for some of them that were suffering.

I appreciate that.

Yeah. So, so great to have you and thank you for sharing your wonderful and vast knowledge in this subject. So I hope this is super helpful for people and really give you a good understanding of the complexity of male hormone. So there's a lot to consider. So hope you get the right help. If you've enjoyed this episode on hormone replacement, please check out our other videos on this channel and don't forget to subscribe.