Welcome to the Huberman Lab Podcast,

where we discuss science

and science-based tools for everyday life.

I’m Andrew Huberman,

and I’m a professor of neurobiology and ophthalmology

at Stanford School of Medicine.

Today, my guest is Dr. Kyle Gillette.

Dr. Kyle Gillette is a dual board certified physician

in family medicine and obesity medicine,

and an expert in hormone optimization.

He is an MD, that is a medical doctor,

and he treats patients with a variety of backgrounds,

ages, and goals.

Today, we discuss male hormone optimization.

We discuss behavioral tools, nutrition-based tools,

supplement-based tools, prescription drug-based tools,

and their interactions in determining overall levels

of testosterone, free testosterone, dihydrotestosterone,

estrogen growth hormone, thyroid hormone,

and many other hormones that impact mood,

libido, wellbeing, strength, cognition,

and various psychological factors.

We’ve covered hormone optimization in both men and women

in previous episodes of the Huberman Lab Podcast,

but today’s discussion is different.

Dr. Kyle Gillette offers very specific recommendations

for people with different goals and of different ages,

and we get deep into the weeds of, for instance,

how does one know whether or not their testosterone

is optimized or not?

How often to test for specific hormones,

such as testosterone and other hormones,

and really how to gauge how good one should feel.

This is something that’s often overlooked in discussions

about hormone optimization or health optimization

of any kind for that matter.

For instance, people will talk about reduced libido

and discuss whether or not testosterone levels are to blame,

but how does one calibrate their libido in the first place?

That is, how does one know whether or not their libido

is normal, too low, or too high?

We also discuss, for instance,

whether or not hormone optimization should be pursued

continually throughout the year, for instance,

whether or not you should cycle on and off supplements

and or prescription drugs

geared towards hormone optimization,

and we discuss the behavioral foundations

of optimal hormone function.

These are things that every male should be doing

and various things they should actively avoid

if their goal is to have healthy hormones

and to quote unquote optimize their levels of every hormone

from growth hormone to testosterone at any stage of life.

And while today’s discussion

is about male hormone optimization,

I want to emphasize that we discuss all the various ages

for male hormone optimization.

So for those of you that are parents,

for those of you that are young,

those of you that are middle-aged or old or teenagers,

we explore adolescent, puberty, teen, and late teens,

early adulthood, adulthood, and into the late geriatric ages.

So regardless of your age

and whether or not you are male or female,

today’s episode ought to be of interest to you.

I should also point out

that we will soon also be hosting an expert guest

on female hormone optimization.

One thing that I’m certain people of all ages

and biological sex will enjoy about today’s conversation

is that we also get into descriptions

of how psychology and life events impact hormones

and how hormones impact our psychology

and the way that we show up to various life events.

So today is really a broad overview

that goes all the way down to fine details

about male hormone optimization.

And I’m certain that by the end of today’s episode,

you’ll have an immense amount of new information

about how this endocrine,

that is hormone system in your body, works

and how it interacts with your brain and other tissues

and many, many actionable tools that you can pursue

regardless of stage of life.

Before we begin, I’d like to emphasize

that this podcast is separate

from my teaching and research roles at Stanford.

It is, however, part of my desire and effort

to bring zero cost to consumer information

about science and science-related tools

to the general public,

In keeping with that theme,

I’d like to thank the sponsors of today’s podcast.

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And now for my discussion with Dr. Kyle Gillette.

Dr. Gillette, great to have you back.

Great to be back, thank you.

I’d like to begin with a question

about one of the most mysterious

and important phases of life, which is puberty.

I’ve long wondered whether or not

how quickly somebody goes into puberty, so at what age,

and how long puberty takes,

so how brief or protracted that puberty is

for them to acquire

the so-called secondary sexual characteristics,

things like hair growth on the face for males,

changes in bone and muscle density and growth, et cetera.

When I was in middle school and high school,

I noticed that some people transitioned

into all that very fast,

and some people took a long time

to acquire those characteristics.

Can we learn anything about ourselves, our hormones,

and maybe even how long we’re going to live

based on the time in which we enter puberty

and how long it takes us to progress through puberty?

I guess that also raises the question,

does puberty ever truly end?

There are many takeaways from puberty.

Some of the actionable items from it is,

yes, it can and does affect your adult height

and also stature and also body composition.

So puberty is a time,

and if we’re talking specifically about males,

think of it as a time where if you have obesity as a child,

you could potentially use that time

to change your lifestyle and habits and reset things,

and it is a bit easier.

It’s almost like a free injection of testosterone

and metabolism and drive and effort into your life.

There’s a wide variation in how quickly puberty goes through.

So there’s stages called tanner stages,

which we don’t necessarily need to get into,

but if you enter puberty very early,

then it can decrease your adult height or stature.

So for a given male that enters puberty at 13

versus a male that enters puberty at 15,

can we say that the guy that entered puberty at 13

is going to be shorter than the guy

that entered puberty at 15,

or it’s not quite that straightforward?

If they are identical twins

and the individual who entered puberty at age 13

also finished puberty,

went all the way through the tanner stages,

and if you do a bone scan,

which I believe is usually done on the left wrist,

and it says, yes, your growth plates are mostly closed,

you’re not gonna grow more

than a couple inches of height after that.

Okay.

Just a related question.

When I was growing up, it was thought,

or at least people would say,

that resistance training in particular,

lifting heavy weights could stunt one’s growth.

Is that true or false?

It is false when you’re talking

about just lifting heavy weights.

Dirty bulking certainly has the potential

to stunt one’s growth for two main mechanisms.

Could you define dirty bulking?

So dirty bulking is eating an excess of calories,

not just to acquire lean metabolically active body mass

or get stronger, but purposely acquiring body fat.

So purposely acquiring muscle and fat by overeating

and lifting weights can stunt one’s growth.

Do I have that correct?

Correct.

So it does two things.

If you’re doing it as a very young child,

that fat can become leptin-resistant

and it can produce more leptin,

and that leptin can activate the hypothalamus,

which activates the pituitary,

which releases gonadotropins,

which basically just increase testosterone

and estrogen earlier than it otherwise would have.

It’s the same mechanism behind

why childhood obesity causes early puberty.

Interesting.

I do remember a paper published in Science Magazine.

I believe it was focused mainly on females,

but showing that when enough body fat accumulates,

the hormone leptin is secreted

and that triggers the onset of puberty.

Given the increase in childhood obesity

that we’re observing now,

are we seeing an earlier onset of puberty

in males and females?

Yes, in both males and females.

Not to get too technical,

but there’s a G-protein coupled receptor

on the hypothalamus and leptin directly binds it.

So it does appear directly causatory

and not just correlation.

Okay, so, and if I understand correctly,

what you’re saying is for a young guy,

let’s say 13, 14,

who wants to really bulk up

and deliberately, excuse me, overeats

and is doing their squats and deadlifts and bench presses

and really trying to get big,

they will get big,

but only in the lateral dimension.

They’re effectively limiting their total height

and it can shut down the long bone growth of their limbs.

Is that correct?

Correct.

The growth of the long bones

is mostly related to the estradiol alpha receptor.

So basically one of the receptors for estrogen,

which can be secondary to early puberty

and also is related to body fat

because you have that conversion

of testosterone to estrogen.

So can we assume that if a young male

wants to get into resistance training,

that body weight exercises are probably okay

and maybe even some weight training, kettlebells, et cetera,

but that they should avoid doing so-called dirty bulking,

trying to deliberately gain weight up until what age?

Until puberty is over?

I would say an individual should limit

the amount of body,

abnormal body fat accumulation

or dirty bulking indefinitely

throughout their entire life.

So again, if I understand correctly,

that recommendation to avoid deliberate weight gain

or rapid weight gain is not just to allow an individual

to reach their maximum height,

but also to avoid laying down a lot of body fat cells.

Correct?

Correct.

The balance between that is

when you are going through puberty,

you are able to add a lot of lean body mass,

not just muscle mass,

but bone mass and other mass as well.

I started lifting weights when I was 16

and I confess I trained pretty heavy at times.

I don’t know whether or not

I would have been taller than I am now,

but when I started that training,

I had already reached what was at least close

to my predicted height.

I can’t say that I deliberately waited until I’d grown.

It just so happened that I stumbled into the weight room

and found that I liked it at age 16,

at which point I was already the height that I am now.

So in any case,

what I’m hearing is that laying down

a lot of excess body fat is not a good idea.

What if somebody grows up chubby or fat for whatever reason,

reasons related to the eating patterns in their family,

maybe even some genetic reasons,

is it safe and or wise for a young person?

So let’s say somebody who’s around the age of puberty

or even younger or in their late teens

to be dieting and actively trying to lose body fat.

Is that safe?

Under the supervision of a physician,

it is certainly safe to change your body composition.

In pediatric obesity medicine,

you’re often talking about a recomposition

or a re-normalization of the growth curve

compared to peers.

Great, thank you.

So as you may have sensed,

we started chronologically with puberty,

and I know that there’s another puberty

that even precedes the puberty that we’re all familiar with.

Maybe if you want to just briefly mention that,

because I was talking with you about this before we started,

the puberty that I’m most familiar with,

and I think most people are most familiar with,

the acquisition of deepening of the voice,

growth of muscle and bone, body hair,

acquisition of libido and things like that,

that’s actually the second puberty that we all go through.

Maybe just mention for us and educate us

on the first puberty.

I think most people will be hearing this

for the very first time.

The first puberty of everyone’s life

is the first three months of their life.

You may notice that your baby has more acne

the first three months,

and that they also have, in general,

just more changes related to androgens and estrogens,

perhaps oilier skin, even more genital growth

during the first three months.

And this is mostly due to DHEA, which is an adrenal hormone.

The second puberty or the puberty that most people know of

actually starts that same way as well.

It’s called adrenarche,

and it’s when the adrenals kick in,

I guess, for the second time.

Is there a standard age or age range

in which the testicles descend in males?

Usually before birth.

It is not uncommon to have one

or even two undescended testes,

but there is a risk of testicular cancer,

especially if they’re not fixed early,

and also heat damage to the testes.

Well, thank you for that coverage of the two puberties.

So early in life.

I imagine some of our listeners

are probably still in one or the other puberty.

The ones that are in the first puberty,

obviously aren’t aware that they’re listening

to this podcast,

but maybe it’ll be embedded in their subconscious.

But some listeners probably are still in puberty.

But I think everyone can remember back to their puberty

and roughly when they first entered puberty

and how quickly they aggregated

the secondary sex characteristics.

I’d like to turn now to a general question

about what all males ought to do

in order to optimize their hormones.

So if you could just list off the things

that all males should do on a daily basis, weekly basis,

I mean, should guys in their teens and twenties

be getting their blood work done?

Should they be taking supplements?

We already talked about weight training.

What should they be doing?

What should they avoid doing

if the goal is to have a long arc

of healthy hormone optimization throughout the lifespan?

There’s many things that you should do.

An analogy that I often make is

when there’s a brand new car

that comes off the assembly line,

you do a full scope of diagnostic workup,

hook it up to the computer.

And I think we should do the same thing with humans as well.

During puberty, obviously you’re a functioning human,

but I would say there’s still development.

And I think that the human always develops.

I don’t think development ever ends,

but you wanna monitor that progress

across a person’s lifespan.

Oh, sorry.

So for blood work,

what would be the earliest,

let me put it this way.

If blood work didn’t cost anything

and everyone could get it,

when would you want to see everybody

get their blood work done for the first time?

Obviously individuals under the age of 18

should talk with their parents about this.

And as long as that the parents and the child kind of agree

and the parents are on board with this as well,

you can start getting blood work.

Often a child will come in with complaints

of either precocious puberty or delayed puberty.

And this individual might be nine

or this individual might be 15.

For a healthy child,

when they’re going through kind of their later tanner stages,

which is four and five,

so they’ve developed several

secondary sexual characteristics,

they might have hair growth

or starting to notice more beard growth.

That’s a good time to do it.

If you’re concerned with stature or height,

or if you’re not tracking along

where most members of your family have,

not just their height and stature,

but also the timing of their puberty,

then that’s time to get labs.

Right, so if I could travel back in time,

I would have gotten my blood work done

for hormones and lipids and everything else at 18.

I unfortunately didn’t know where and how to get that.

And I didn’t have any pressing clinical issues.

And so I think the first time that I got my blood work done,

I was in my late 20s, maybe even my early 30s.

And I’m still dying to know what my blood work was

when, for instance, I was 17 and I felt a certain way.

And I confess that in many dimensions,

I actually feel better now, I’ll be 47 soon,

at 47 than I did in my teens and 20s.

And I think it was more on the psychological side.

I think that, but in terms of just understanding

why we felt great or why we felt or feel terrible

or not so great, I think blood work

is extremely informative.

What do you think are the key things

to look for in blood work?

I mean, testosterone is always the topic that comes up

in the context of male hormone optimization,

but certainly there are a lot of other hormones

that are important as well.

And with testosterone, you want to get either testosterone

and SHBG or a free testosterone.

Could you define SHBG for our listeners, please?

It is sex hormone binding globulin.

It is the protein that binds up all androgens

and estrogen in the body.

So the stronger the androgen, the stronger it binds.

During puberty, strong androgens, especially DHT,

which is the strongest bioidentical androgen,

has a huge role, a prominent role

in secondary sexual characteristics.

And if your SHBG is very high,

then your DHT can run higher because it’s not metabolized,

but there’s not quite as much free DHT.

So you want to balance between a high enough free DHT

and a high enough total DHT.

And obviously these blood tests are going to have

to be read and interpreted by a qualified physician.

Most people aren’t going to be in a position

to evaluate them properly,

or at least not with the full depth that they could

if they had an MD like yourself looking at them.

Okay, so everyone should get blood work

as early as possible,

depending on their budget and availability.

What should everybody do in terms

of monitoring those markers?

So assuming that there’s no major intervention,

how often do you recommend

that people get their blood work done?

Let’s say, let’s take an individual who just turned 18.

They just got their first set of blood work.

They’ll probably find something in it

that they may want to optimize

using shared decision-making with their physician.

Usually a good follow-up is about six months.

Okay, so twice a year getting blood work done

and having a physician evaluate it.

That sounds reasonable to me.

And for those that didn’t initiate this at 18,

such as myself, I guess the best time to start then

would be as soon as possible.

In terms of the other things that all males should do,

meaning all males of all ages, puberty and beyond,

should do, what are some of those things?

So on a daily basis,

maybe you could just take us through the arc of a day

and push out some of the protocols that you use

or the things that you’d like to see your male patients use

in order to try and optimize their hormone status.

I’ll briefly touch on some of the lifestyle pillars to start.

Diet and exercise are the first two.

In puberty, sleep is particularly important, of course.

But with diet and exercise,

throughout a lifespan,

you want to not exclude things that are helping you.

For example, during puberty, if you’re consuming dairy

and then all of a sudden you cut out all dairy,

dairy can help increase IGF-1 and free IGF-1.

And just again, for our audience,

maybe you just mentioned what having enough IGF-1

can do for us that’s beneficial is?

It helps you grow.

It helps with genital development,

secondary sexual characteristics, and long bone growth,

skin growth, hair growth, a host of things.

So getting an array of nutrients that include dairy,

what other sorts of nutrients

are important during development?

You want to have adequate vitamin D.

Vitamin D helps with testosterone production.

It helps, again, with bone mineralization and stature.

After an age of about 25, and there’s not a strict cutoff,

but up to about an age of 25,

optimizing your growth hormone and IGF-1

helps with bone density and bone growth.

So from the dietary standpoint,

you want to have enough free estrogen,

not too much when you’re growing,

but you want to help basically stockpile bone

to prevent a risk of osteoporosis or thin bones fractures

when you’re older.

Well, as someone who broke his left foot five times

while in high school, I can say that whatever

young people can do to optimize their bone density

would be great.

That problem seems to have resolved itself over time,

but I don’t know, back then I was,

I did a short run as a vegetarian,

but I’ve always been an omnivore.

I realized that some of this relates to ethics

and food allergies and things of that sort.

But would you say that on balance,

that most people would benefit from eating a combination

of quality proteins from animal sources

and non-animal sources, fruits, vegetables, and starches?

I mean, what do you think, for instance,

about people following a pure carnivore

or a very pure vegan diet in their 20s and 30s?

In their late 20s, it might be a reasonable option.

In early 20s and certainly teens,

it is a horrible idea because it is likely

to significantly decrease your free androgens.

So you will have less testosterone acting on receptors

through the body.

Are there any other micronutrients or macronutrients

that people in their 20s and 30s should emphasize?

We haven’t really touched on fatty acids or fiber too much.

Fiber is going to be paramount in kind of like setting

your set point of your gut microbiome the rest of your life.

There is prebiotic fiber, which you could think of

as fish food for your good gut microbiome.

Your gut microbiome is kind of like an aquarium

or a fish tank.

No, I’m just thinking about goldfish swimming around

and the goldfish eating people.

Don’t eat goldfish, people.

Thank you.

Live or dead.

Yeah, but any fiber or food that you’re putting in your gut,

it’s either going to skew your gut microbiome

towards something that is more beneficial

or more detrimental.

And would you say that the prebiotic fiber

and getting essential fatty acids,

that would be important to do throughout the lifespan

or just for people in their 20s and 30s?

Throughout the lifespan, particularly important

in the teenage, 20s, 30s,

because it helps with brain development.

You’re certainly more of an expert than me

when it comes to brain development,

but it does continue to develop really throughout

the lifespan, but certainly through the 20s and 30s as well.

About taking a multivitamin while you’re growing up,

so many people do that.

Is it necessary?

Is it useful?

And if it’s not necessary, is it safe to do anyway?

It’s generally safe to do anyway.

I do not think everybody needs a multivitamin.

The more exclusionary your diet is,

for example, if you have celiac disease

or if you’re planning on fertility soon,

then perhaps it’s more reasonable to take a multivitamin.

In a previous discussion of ours,

I asked you about caloric restriction and testosterone.

And if I recall correctly,

the idea was that if somebody is overweight,

they have excess fat, adipose tissue,

then getting rid of some of that adipose tissue

through caloric restriction and exercise,

provided it’s done not too fast in a healthy way,

is going to be beneficial for testosterone in the long run.

But that for individuals who are not carrying

an excess of body fat, caloric restriction

is actually going to lower testosterone.

First of all, do I have that correct?

And second, are there any addendums to that

that you’d like to give us now?

That’s correct.

If you look at an individual in a caloric deficit,

several changes will happen.

One is that they’ll have less building blocks for hormones.

Another is that they will be in a catabolic state more often

so that balance of anabolism and catabolism

will be different.

They’ll likely have less signaling

from growth hormone and IGF-1,

and they’ll also have the high SHBG

that we defined earlier as the binding protein,

so there are free androgens and free estrogens will go down.

Got it.

Okay, so we touched on sleep being critical,

I would say, throughout the lifespan.

Try and get enough quality sleep,

at least 80% of the nights of your life,

and the other 20% are just what happens

when there’s noise outside or you’re stressed,

you have an exam or you’re having a great time

for whatever reason.

There are a lot of good reasons

to lose some sleep now and again as well.

But so we have sleep, we’ve got nutrition,

and we touched on that.

We’ll get back into supplementation.

Now, what are some of the other pillars

of creating the proper environment for hormone optimization?

Stress is probably the next one.

During both puberty, but also the 20s and 30s,

individuals are figuring out

how they want to cope with stress

and also figuring out what they want to choose

to put their effort into.

So if someone is overstressed,

then it can put all the other lifestyle pillars

and then they stop dieting well,

they stop exercising, and everything else can go askew.

There is also some degree of social component to this,

so perhaps I need to add a seventh pillar of social.

During your 20s and 30s,

you may be forming a family as well.

Perhaps you have children,

and the health of the family unit

is going to be vitally important.

Not necessarily directly for hormone optimization,

but it’s gonna throw everything else off if it’s off.

And for people that are not starting their own families

in their 20s and 30s,

can that social connection be extended to friendships

and work relationships as well?

Absolutely.

In fact, if someone’s not starting a family,

it is just as concerning, but for other reasons.

Each individual is gonna have

their close group of family and friends.

And if someone does not have one of those connections,

that’s when things can potentially get bad,

not just for them individually, but also society.

So when you say stress,

you mean learn to manage your stress.

What does that look like?

I mean, if a patient has high blood pressure,

even if they don’t, you just sense that they’re stressed.

They have a lot of pressured speech,

or they’re not feeling well,

or communicating that they’re not doing well.

What are some of the things that you recommend

in order to try and ameliorate that stress?

There’s different mindfulness or relaxation techniques.

Going outside can often help with this as well.

Dietary changes and exercise can help with this too.

Some people like prayer or meditation.

And a lot of people like counseling or therapy,

or even just talking openly

with a family member or a friend.

What would be some of the other pillars

for hormone optimization?

Here, I feel like we’re not just talking about people

in their 20s and 30s, but again,

we’re wrapping our arms around basically puberty onward.

I mean, gosh, looking back,

I started meditating pretty early.

I started weight training and running early.

I gave some thought to my diet in high school,

but really it was in college that I started thinking more

about what I was ingesting and why,

and trying to do better there.

But people are coming to the table

at different stages of life

and trying to optimize for hormones.

So what would be some of the additional things

that everybody should do?

Everyone should get outside

and find a movement past time to last a lifetime.

You’re gonna get sunlight,

you’re gonna get some degree of heat and cold exposure,

and you’re also just gonna move more.

Being in an artificial environment

where there’s artificial lights,

artificial air conditioning

is going to have many effects on your body.

So that’s vital.

Another one is finding what your purpose is in life.

So I call this spirit,

but it’s really just the self-actualization component

of Maslow’s hierarchy of needs,

which is basically your physical needs, your mental needs,

and then your purpose in life, what you really like to do.

Picking some goal or target.

And I always say that you don’t have to stick

to the same goal over time.

Certainly I haven’t,

although I got started early in the science game

and I’m still in it.

The idea is not to pick the end goal,

it’s to pick a goal.

And then once you reach that goal to assess

and then pick another goal and so on.

I think sometimes when people hear about picking a purpose,

they’re like, oh my goodness, I have to define,

sort of like naming oneself,

that you actually can change your goals

and purpose over time.

This is terrific.

Would you suggest that people actively use

or avoid supplementation

prior to doing all these other things?

I’m somebody that likes to throw the kitchen sink at things,

but I also like to do things pretty systematically.

So I always say behaviors first,

then nutrition, then supplementation,

and then maybe, and if and only if there’s a real need,

and of course working with a doctor, prescription drugs.

But there are probably people in their 20s or 30s,

maybe even in their 50s that aren’t feeling great

and they want to do something

in order to be able to train more

or to feel more confident to seek out social connection.

They try and go about the whole business

from the other side as well.

What are your thoughts on that?

I see supplements and medications as very similar.

One’s prescribed and one’s not.

In general, medications have more side effects

or potentially stronger therapeutic with more efficacy,

but they’re just tools to reach an end goal.

So depending on the goal,

if there’s an individual that’s an athlete,

then certainly they should consider supplementation.

Or if someone desires optimal

or a very high level of cognitive performance,

they should also consider supplementation.

At the same time, food is medicine

and a lot of the benefits you can get in supplements,

you can get in food as well.

I guess it depends on how much time and energy

you’re willing to spend, and also finances.

You know, I know that when I was in college,

I could afford just a few supplements

and they were basically whey protein and some fish oil.

I was fortunate that I was pointing

in the direction of those things and some creatine.

I couldn’t afford much else.

Over time, of course, I could afford more,

but it really does often depend on finances.

Before we get into some specific recommendations

to optimize testosterone, estrogen, thyroid,

growth hormone, et cetera,

I wanna ask you a question I’ve been wondering about

for a long time.

You know, so often in the discussion

about male hormone optimization, people will say,

well, you know, if your libido is suffering,

you know, you might wanna be concerned about testosterone

or even estrogen, right?

Because we know that estrogen can impact libido as well.

Sometimes having estrogen too low

is detrimental for libido.

Or people will say, you’re not recovering from workouts

or you’re feeling kind of depressed.

The problem is it’s all subjective.

So how does one know whether or not

their recovery from workouts, their energy,

their confidence, their libido is within a healthy range?

I mean, obviously for people in a relationship,

they can know whether or not their libido matches

the sort of cadence of the relationship in their partner.

But how should people think about this?

And maybe even start to talk about it,

because one of the big differences I think

between males and females is that

because females have a monthly cycle,

they are familiar with the changes that occur

in their hormones over time.

Because every 28 days,

those hormones are changing dramatically

in ways that impact their physiology and psychology.

But for males, I feel like there’s sort of a dearth

of language to get into the more subtle aspects of this.

It also has to do with privacy issues

and people feeling like they don’t wanna overshare too much,

not knowing what’s appropriate to share.

But when you talk to a patient who’s in their 30s

or maybe even their 70s or 60s, doesn’t matter,

a male patient, what are you listening for?

And I know you’re not a psychiatrist,

but what are your ears tuned to

in order to try and figure out

whether or not this person could really use some help

with hormone optimization or whether or not something else,

or maybe they’re just doing great and they don’t realize it

because they’re placing demands on themselves

that are excessive?

You wanna use a lot of open-ended questions.

This process is called motivational interviewing.

And your goal is to listen to the patient

and not plant an idea in their mind that they can follow.

Because everybody is going to have a different goal.

Some people are better at reading their biofeedback

or telling how they feel on a daily basis.

There is screening questionnaires designed,

for example, an ADAM questionnaire

to look at men’s health and hormone-related health.

It’s called an ADAM questionnaire?

ADAM questionnaire.

A-D-A-M?

Correct.

Is it available online

that people could administer it to themselves?

Although we don’t want people making clinical diagnoses

of themselves or anyone else.

Is it that sort of exam?

It is.

Interesting.

I don’t believe it is a clinically validated tool

like an ASCVD,

which is like a risk of heart attack and stroke tool

or many other tools.

There’s one for depression.

There’s one for anxiety.

They’re called PHQ-9 and GAD-7, respectively.

But anyway, there’s often an in the ADAM questionnaire

and what you hear from the patient,

if you are a very careful listener, is often different.

Can you give me an example of some of the questions

on this ADAM questionnaire

or the sorts of motivational interviewing that you might do?

So say I’m your patient, we sit down,

what sorts of questions would you ask

to probe these kinds of dimensions of hormones?

Questions about libido,

questions about athletic performance,

questions about motivation.

And often the patient will answer one thing,

but what you hear from them subjectively is far different.

Interesting.

Can you give me an example of a question?

I’m happy to be the guinea pig here.

A classic one is a guy comes in

and a lot of times they say,

oh no, the wife made me go to the doctor.

I go, once a year, that’s it.

I don’t want anything.

I don’t want any medications.

Their screening questionnaires might be zeros

across the board.

So nothing, no issues.

They’re apparently in perfect health.

They talk to you for a while.

They get some rapport.

They like you.

And then right as you’re finishing up the visit

and about to go out the room,

they mentioned that their libido isn’t quite there

and they’re having a little bit of ED as well.

And perhaps they’re even having

some chest pressure tightness.

I see.

So right as you’re leaving the room,

a patient will tell you

that they’re having some sexual side effects

or not side effects,

they’re having some sexual challenges.

And then they’ll mention chest pressure.

Is the chest pressure a sort of general decoy

for it’s gotta be my heart

or is it related to the other things they’re reporting?

It can be related.

In fact, erectile dysfunction

is known as the canary in the coal mine.

So coal miners would take the canary down

and the canary would die before the coal miners would have,

I believe, carbon monoxide poisoning.

And often one of the causes of ED is plaque buildup,

which can happen in the coronaries as well.

But sometimes they notice the symptom

in the genitals before they do in the coronaries.

So for such a patient,

let’s say that patient was a young person

where plaque buildup in the arteries and veins

is not all that likely

if they’re let’s say in their 20s or 30s,

what would be your next step of the interview at that point?

And what would you consider?

Would you immediately order labs for that person

to try and rule out any kind of

actual hormone level deficiency?

I certainly would order labs.

There are some individuals that are very similar

and they come in and they have the same symptoms.

And one individual might have a very, very high testosterone

and one individual might be severely hypogonadal.

So there’s a big difference between the subjective

and what the labs look like.

So I certainly order labs.

You also ask them about if it’s situational or not.

You ask them if they have ED,

if they’re asking about their habits,

you even ask about porn and masturbation

and all these issues.

And of course it’s between the doctor and the patient.

And depending on what they tell you,

you can often determine if there is a situational component.

Some people call it psychogenic ED,

but I don’t love the term psychogenic ED

because it kind of puts some blame on the patient’s mind.

But a lot of the time that is the case.

There’s even a test, and this is very rarely ordered,

but it’s called a nocturnal penile tumescence.

Yeah, because is it true that there are

periodic erections during sleep, correct?

Yes. Yeah.

So you basically put a cuff to see

if you’re having a normal sized erection during sleep.

And I believe about 90% of the time they do that test,

they are indeed having erections.

Which would point to this psychogenic origin

of whatever challenges they’re having

in terms of sexual interactions.

You mentioned porn and masturbation.

This topic has come up a bunch of times on this podcast

and on other podcasts I’ve gone on

because of the relationship between dopamine,

sexual motivation, and sexual behavior.

And I’ve been of the pretty strong stance that

while I’m not judging porn or masturbation,

it can create a brain wiring situation

where males in particular essentially teach their brain

to be aroused by watching other people have sex

as opposed to being the first person actor

in sexual interactions.

So in that sense, you know,

that’s more about the brain wiring

and neuroplasticity and dopamine,

but what are your thoughts on porn and masturbation

as they relate to hormones?

I mean, this is a big debate on the internet.

In fact, one of the most common debates

is whether or not masturbation increases

or decreases testosterone in males.

Certainly it will decrease motivation

to go find sexual partners.

We know this.

And there are more and more data on this all the time.

In terms of the effects of pornography and masturbation,

and here I suppose we need to be somewhat specific

and operationally define what we’re talking about.

We’re talking about porn and masturbation

to the point of ejaculation.

Because my understanding is that the ejaculation

and orgasm associated with it

causes an increase in prolactin,

which blunts libido for some period of time.

The duration of that will vary from person to person

and circumstance to circumstance.

But basically all of this points to the fact

that porn and masturbation can really limit libido

in the real world.

And to me, pornography and the screen

is not the real world.

Screens exist in the real world.

The real world doesn’t exist in the screen.

That’s an accurate statement.

And prolactin does have a significant acute increase

after ejaculation.

It does to some degree after orgasm as well,

but prolactin acts on the pituitary

to inhibit the release of the hormones LH and FSH,

of which LH can increase testosterone.

So this may be one of the cases

where the dose makes the poison.

And if it is a very frequent habit,

certainly daily or more than once a day

would be very detrimental from a hormonal component,

not even taking into account the neural wiring.

Listen, I think it’s terrific

that you’ve actually defined frequency

because this is the problem.

On the internet or even in the doctor’s office,

you’ll see descriptions about pornography being dangerous

for certain things or detrimental to hormones.

People say frequent, but what’s frequent?

So you were saying daily or multiple times per day

would be potentially detrimental

to the hormone profile of a male of essentially any age.

And that’s just for masturbation.

With pornography, with porn use as well,

it would likely be worse.

Why is that?

Just the sort of dopaminergic drive of the stimulus,

just a really intense visual stimulus?

Dopamine sensitivity.

I think that using the analogy of a dopamine wave pool,

it would deepen the pool,

but not increase your supply of dopamine.

Maybe you could describe the dopamine wave pool

because I think it’s such a powerful way

of thinking about dopamine and what dopamine does.

In fact, I’ve always credited you when I’ve done it,

but I’ve generally stolen your analogy

of the dopamine wave pool because it’s so astute.

The dopamine wave pool describes the natural variation

of ups and downs in your dopamine or your motivation.

And in the wave pool, depending on how high the peak is,

you often have a deeper trough.

So you do not want too high of a peak.

In addition, if your peak is very, very high,

for example, when you’re using many substances

like cocaine or like amphetamines,

your dopamine can go so high,

you lose almost all the water from the wave pool.

And then when you crash from that,

not only is the trough low,

you have less dopamine in the pool to begin with.

The dopamine receptor is extremely sensitive

as is the GABA receptor, which is an inhibitory receptor.

Whereas dopamine is technically a stimulant

more related to adrenaline or noradrenaline.

The depth of the pool can change very quick.

So you wanna have that happy medium

where you’re fairly near the top,

but you’re not so near the top

that the depth of the pool is gonna go down.

So if I interpret that in the context of this discussion

about libido, sex, porn, and masturbation,

if somebody has a very intense sexual experience,

here we’re not necessarily talking about an intense orgasm,

we’re talking about just a lot of intense visual.

So a lot of intense imagery or auditory input or both,

that is going to lead to a situation

where dopamine is going to be depleted afterwards.

A guest on this podcast before,

my colleague at Stanford, Dr. Anna Lembke,

who’s an expert in addiction,

talked a bit about this as sort of a seesawing.

Here we’re talking about a wave

and a crashing out of the water from the wave pool there.

It was a seesawing from pleasure and pain.

There’s gonna be a longer and deeper period

of lack of pleasure following that.

And I think a lot of people think, oh, well, that’s great.

They want the intense experience.

But if that intense experience is coming

from pornography and masturbation,

or I suppose coming from high adrenaline activities

like life-risking parkour

hanging off the side of a building,

it inevitably is going to lead to depressive episodes,

low libido episodes that follow.

Is that right?

Correct.

In a similar physiologic way

to withdrawal from stimulants like amphetamines.

Now, is sex with a partner different?

Because there are many people

who are chasing more and more intense experiences

with a partner as opposed to

through pornography and masturbation.

Again, here we’re talking about all ages.

And I should always say,

anytime we’re talking about sex with a partner,

we’re talking, the four conditions

that I always lay out on the Human Lab podcast

are that we’re talking about consensual,

age-appropriate, context-appropriate,

species-appropriate interactions.

Yeah.

And this is also a case where the dose makes the poison.

So if there’s, you know,

obviously meeting all those criteria,

if they have one preference

that for both of them is a positive experience,

then that is likely okay.

You’re not going to be able to maintain dopamine

over a certain threshold for a long period of time.

So there very well may be a crash

from that experience as well.

And the crash may be different

in one partner than the other.

Interesting.

Oh, I’ll draw an analogy to food.

It’d be like, you know,

you don’t have to serve the banquet meal

seven nights of the week, maybe just two.

Is that right?

And there are other delicious foods out there.

Can we use that analogy?

That is very reasonable.

Okay, not trying to be PG-13,

just trying to parsimony,

Occam’s razor,

the ability to describe a lot of things in a few words.

I’d like to return to the key things that people should do,

or I should say the key things

that men should do to optimize their hormones.

So we talked about getting some movement,

getting some sunlight,

getting quality social connection one way or the other,

avoid excessively frequent masturbation

and viewing pornography.

And for some people,

zero might be the optimal number.

And I keep coming back to this-

For most people.

For most people, interesting.

I feel so fortunate to have grown up

prior to the availability of internet pornography.

I’ve never been a big consumer of pornography.

It just not been my thing,

but I hear so often from males of all ages

about their addiction to it, their affliction by it.

It’s really a serious issue.

And that’s one of the reasons why I’m grateful

that you’re willing to talk about this

in your clinical experience with these patients.

I’d like to take a quick break

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In terms of exercise, you know, here’s, again,

it’s a double-edged sword.

On the one hand, it’s great to get exercise,

but I’m familiar with, you know, if I train an hour a day,

you know, 10 minutes of warmup

and 50 minutes to an hour of weight training

or 50 minutes to an hour of cardio, I feel great,

especially if once a week I take a complete day off.

That’s sort of my general schedule.

I’m also familiar with when I go out

for runs that are excessively long, two-hour runs,

or I spend 90 minutes in the gym too frequently,

I start to feel like garbage.

Everything suffers.

My sleep starts to suffer.

It doesn’t matter how much I eat.

I don’t seem to recover.

I don’t feel well.

So I realize that recovery ability varies

between individuals, but what do you think

is a healthy, sustainable exercise regimen

that anyone can follow

that will also support their hormone status?

For really vigorous exercise,

around three to four times a week

is very sustainable over a long period of time.

On top of that, you could add in three or four more instances

of less vigorous exercise.

Okay, so for less vigorous,

what do you mean that, you know, zone two cardio

where you can hold a conversation,

but beyond which you can’t?

And for more vigorous, you’re thinking weight training

or high-intensity interval-type training?

Is that right?

Correct.

You can also weight train and have some benefit

even at a low to moderate intensity.

If you think about weight training where you have,

and it’s not necessarily related to the incidence of DOMS,

which is delayed onset muscle soreness,

but if you weight train lazy or easy from time to time,

obviously you wanna weight train very heavy

from time to time as well

because of more lean body mass growth.

But if you weight train lighter,

you’re going to be able to do it more often.

And it can still help with the hypertrophy of collagen,

for example, in tendons and ligaments.

So here again, I’d like to perhaps drill into this notion

of intensity and lightweights,

because for me, some of the most brutal workouts

I’ve ever done were in what I would consider

a high repetition range, 15 to 50.

Actually, I went up to Oregon

to watch the International Track and Field Championships.

We went by Cameron Haynes’ place, the Cameron Haynes,

and he and his trainer put us through a workout

that was 25 to 50 repetitions per set,

and it was done in circuit and it was brutal.

So it was light.

I mean, those weights were nothing.

In some cases it was body weight,

but the number of repetitions was brutal.

So when you say limiting intensity,

are you talking about limiting the number of sets to failure?

Are you talking about really being

kind of a lazy bear in the gym?

I like to do that every once in a long, long rest,

that sort of thing.

What are your thoughts on that

as it relates to hormone optimization?

So I’ll just mention, and then I’ll let you answer.

I feel best overall when I’m training

for 10 minute warmups and about 45 or 50 minutes

of weight training where I’m pretty lazy between sets,

two to three minute rest,

training somewhere in the six to 10 rep range,

going to failure every once in a while,

but mostly getting that sort of last rep

before what I would think is failure.

No four straps, that kind of thing.

And then jogging on the other days, nice and easy.

When I do that,

I feel fantastic in all other dimensions of life.

When I train more intensely than that,

even with lightweight, so faster cadence and lower rest,

I feel like garbage.

I get a headache, I’m kind of ornery, everything suffers.

So what are your thoughts on kind of defining

a optimal exercise strategy for hormones?

I’ve never measured my hormones

in those two different contexts,

but I have to imagine that it’s cortisol related.

When they study the effect of exercise,

specifically vigorous exercise,

one area that’s been studied is vigorous exercise episodes

lasting longer than an hour.

And they usually track it by a rating of perceived exertion,

which isn’t perfect and it’s not extremely actionable,

but it’s helpful for clinical science.

But the takeaway from that is basically do not,

it is not hormonally helpful to train,

especially regularly train vigorously

for longer than an hour.

Great, so I’m happy to hear that

because it sounds like for most people

that hours of work is really the threshold.

I think this is important for people to hear,

especially males,

because I think with all of the incredible examples

out there of people like Cam, like David Goggins,

people who are training for very long periods of time,

and leaving aside all issues of what people are doing

in order to optimize the recovery,

I think an hour a day of exercise is just a great program

that most anyone can follow.

And beyond an hour, you start running into challenges.

And the occasional 90 minute or two hour workout

is no big deal.

But if you start doing that more than once every two months,

I think you’re headed for trouble.

Have you seen that in people’s blood work

and in their hormones?

Do you ever see people that are just badly over-trained

because they’re just training too hard and too often?

Yes, when the blood work is particularly bad,

they’re often in a large caloric deficit as well.

There’s a synergistic effect between a caloric deficit.

Even if you’re maintaining adequate protein intake,

you might not be maintaining adequate iron intake

or adequate vitamin D.

And you’re also just literally in a caloric deficit,

perhaps low carbs as well, very low free testosterone.

And they’re simultaneously doing a lot of vigorous exercise.

Interesting.

I often hear, and I’m starting to wonder whether or not

some of the quicker to results nutrition tactics,

things like dropping all carbohydrates,

or the quicker to results exercise habits,

starting to do six day a week, really intense workouts,

whether or not in the short run they work

because they cause the cosmetic changes

that people are seeking,

but that they really undermine the overall goal,

which is at least to me to have your hormones

maybe not optimized to the 100%,

but to always be aiming for 100%

and be close to it at every stage of life.

Consistency is key here.

If you are not consistent,

then the law of diminishing returns certainly applies.

So 80 or 90% of the benefit over many, many months

is far better than 100%, but only half the time.

Yeah, one thing that I’ve found to be tremendously useful

is to finish the workout while I still have energy,

to not take myself to exhaustion.

And then I’m able to kind of talk about

the dopamine wave pool.

I’m able to sort of ride that into the rest of the day,

feeling great.

I sort of save or bank some of the vigor from the training

to bring it into my work.

But then again, I’m not an athlete.

I get paid to think and to speak,

not to lift weights or to run.

Another component of that is the balance

between your sympathetic,

which is your fight or flight nervous system,

and your parasympathetic,

which is your rest or digest nervous system.

There is an anecdote which is likely true

that many elite bodybuilders are very parasympathetic

besides while they’re lifting weights.

You mean they’re lazy and they like to eat a lot.

Yeah.

The lazy bear in the gym kind of phenomenon.

Absolutely.

But that being said,

after a very, very vigorous workout,

for example, one where you’re trained to failure,

which bodybuilders and power lifters do all the time,

you feel the tiredness or you feel the strain

from that heavy sympathetic activity

when you are lifting a heavy weight.

And it can potentially affect

how you feel the rest of the day.

So many people who have a job that is highly cognitive

do not like to have an extremely vigorous workout

in the morning,

which is when a lot of people are able to exercise.

When I exercise early in the morning,

that is before 9 a.m.,

I have more energy all day long.

If I do it mid-morning,

I have experienced more of an afternoon crash.

There’s probably some circadian biology in there.

I’ve also noticed,

and I’ve actually seen in my blood work,

that if I don’t get out for a 45-minute jog

at least once a week,

all of my blood profiles suffer in the direction

that I don’t want them to go.

In particular, testosterone and estrogen

move in directions that are not conducive to my goals.

I’d like to talk about some of the approaches

that people can use in order to optimize hormones.

And these days, for better or for worse,

I think for worse,

younger guys are asking about

and using testosterone replacement therapy, so-called TRT.

And I just want to frame this up by saying

there is no strict cutoff for what is TRT.

There are plenty of people whose blood levels

of testosterone and estrogen

are within the normal reference range

and decide to start doing these things.

Of course, they can limit fertility.

There are a bunch of issues,

even at non-quote-unquote steroidal

performance-enhancing dosages.

I’d love to frame this up by first defining our terms,

because one of the challenges on the internet

is people talk about TRT,

then they’ll talk about performance-enhancing drugs,

they’ll talk about steroids.

They’re all steroids, right?

I mean, testosterone and estrogen are both steroid hormones.

But what one considered replacement therapy

versus what one considers performance-enhancing

is going to depend, right?

So here’s my question.

Why in the world, why in the world

would any male in his teens or 20s

or even 30s whose blood levels of testosterone and estrogen

are at the appropriate levels,

meaning within the normal reference range,

why would they take exogenous testosterone

given all the negative effects on fertility,

some of the challenges that it can present

if the dosages aren’t quite right, et cetera?

Why would they do that,

certainly if they are not being paid

for a particular endeavor,

like they’re not making money.

If they are playing a sport,

chances are they’re not allowed to do that anyway.

It’s on the banned substances list.

So to me, it just seems like a crazy idea.

But then again, I’m of a generation

that really hasn’t thought about doing that stuff

until people were in their 40s and 50s or even never.

So is there ever a case for somebody in their 20s or 30s

to take testosterone if their blood levels

are within the 300 to 900 nanograms

per deciliter reference range?

Not many cases.

The reason for any performance-enhancing drug,

whether or not it is a steroid, synthetic,

bioidentical or otherwise, it varies a lot.

Some individuals do it only for cosmetic reasons,

even if it can have deleterious effects

on the cosmetic appearance, for example,

of your skin in the long run.

But everyone has their different reason

as far as when does the benefit outweigh the detriment.

Not very often if you’re in your 20s

and certainly almost hardly never.

There’s always rare cases like Kalman syndrome

and whatnot, but almost never if you’re very young.

Okay, so for people in their 20s, 30s and beyond,

40s, et cetera, whose testosterone and estrogen levels

are at the appropriate ratios

and within the normal reference range

and they feel pretty good, right?

We talked about the Adams Exam

or this sort of like feel pretty good

as sort of code for libido, energy recovery, et cetera,

are feeling at least workable for their lifestyle.

For those people, what can they do besides get great sleep,

train but not too hard or too often, et cetera, et cetera?

What are some of the things in the realm of supplementation

that can help them optimize their testosterone and estrogen

without suppressing their own endogenous production

of testosterone and estrogen?

Let’s mention creatine as the first one.

Creatine is interesting

because it has multiple different effects.

It helps with amino acid synthesis.

It also helps with oxidative stress.

It can also serve as the backup fuel tank

for your mitochondria.

So kind of holding backup ATP

and it does slightly increase total testosterone

and it also increases the conversion of testosterone

to dihydrotestosterone.

So potentially it’s especially useful in men

in even their teenage years and their 20s.

You mentioned the conversion of testosterone

to dihydrotestosterone and there is mythology out there

that creatine can increase hair loss.

I’m guessing because there’s at least one study

showing that creatine can increase DHT,

dihydrotestosterone and DHT is one of the primary hormones

that can promote male pattern baldness.

So the question therefore is,

does creatine supplementation

increase the rate of hair loss?

Theoretically it can, but in each individual,

preventing hair loss is a very poor reason to take creatine

because it’s not going to take you

to a supraphysiologic level.

It’s not going to increase your androgens

to an unnormal level of binding.

So I feel like if that was a reason

to not take creatine for hair loss, then that’s-

Sorry, you mean hair loss is not a reason

to avoid taking creatine?

Correct, hair loss is not a reason to avoid taking creatine.

Think of it as just bringing you

to what you are naturally inclined to have.

If your conversion of testosterone to DHT is already high,

then often creatine does not affect this.

It just kind of resets your balance

between testosterone being aromatized to estrogen

or being 5-alpha reduced DHT.

So it’s not going to speed up hair loss

more than just naturally being a male does.

So in some individuals, it will have no effect.

In some individuals, for whatever reason,

they have almost no 5-alpha reductase activity.

It will return them to natural or normal.

I see, well, I take five grams a day

of creatine monohydrate.

I do it for the tissue voluminizing effects,

for exercise benefits, but also for the cognitive effects.

I don’t know if it’s increasing my hair loss.

I mean, I’ve got a little bit

of sort of a widow’s peak type hair loss.

That’s where it is for me.

I suppose beard growth is associated with DHT too.

Is that right?

What I learned, but then again,

I haven’t been into this literature in a long time,

is that because of differences in receptors

that DHT causes hair growth on the face

and hair loss on the head.

Is that right?

Yes, and the amount and the sensitivity

and density of those receptors is genetically determined.

And is it true that if your mother’s father was bald,

that you will be bald in the same pattern?

And if that he wasn’t, you won’t?

That is a decent correlation.

Part of the proposed mechanism of this,

well, there’s several genes

and you can actually test your genes for hair loss.

You do get a decent amount of them from your mother.

The unique thing you get from your mother

that she may have gotten from her father,

that she got one of the copies from her father

is your X chromosome.

And the androgen receptor gene is on your X chromosome.

So all men got their androgen receptor gene

from their mother.

It’s on their X chromosome, not on the Y chromosome.

Correct.

Interesting.

Even though all of the sort of,

quote unquote, male promoting genes are on the Y chromosome,

like mullerian inhibiting, et cetera.

Interesting.

Okay, so five grams a day of creatine

for most people should be fine.

Beneficial for tissue voluminizing.

So strength, bringing water into the muscles

and for the cognitive effects

and the clinical support for creatine,

I think is quite strong at the five gram per day dosage.

What other sorts of supplements can people benefit from?

We already talked about the omegas

and making sure that people are getting enough

prebiotic fiber to support the gut microbiome and vitamin D.

So what other supplement-based tools can people consider?

Another one we can loop in with creatine is betaine.

Some people are non-responders to creatine.

So you can increase that to 10 grams

or you can use its cousin betaine

to help with amino acid synthesis and shunting of energy.

Along with that, I would put L-carnitine,

which is actually the smallest peptide hormone.

It’s just two amino acids that are put together.

So it’s a-

It’s a hormone.

Interesting.

I’m not challenging it.

Peptides.

Yeah, I would call it a peptide more than a hormone.

So I would not call L-carnitine a hormone,

but I would call dopamine a hormone.

Yeah, a neuro hormone.

It’s so hard to define things as transmitters

or hormones at some level.

I agree.

So L-carnitine, actually I should backtrack.

Betaine, do you recall what dosage

people typically would take

if they’re a creatine non-responder?

One to three grams per day.

Yeah, several versions of creatine have betaine mixed in

because it helps with the processing

of methionine and homocysteine.

So if somebody is already taking creatine

and likes it and responds to it,

I would raise my hand, such as myself.

Would adding betaine help

or is it redundant with creatine?

Only if their homocysteine is persistently elevated.

And homocysteine is kind of like an inflammatory marker

that can build up if you’re not converting

enough of it downstream.

How would I know?

Just a blood test.

Okay.

Or if you knew your MTHFR polymorphism,

which is basically how you add methyl groups

to many things in the body.

Great, any side effects of betaine

that people should be aware of?

Not that I know of.

Okay, people can look it up

and examine.com is a great site for that.

They’ll surely list it.

They just revamped their site, by the way,

and it was awesome before and it’s platinum now.

So L-carnitine, what are the ways to take L-carnitine?

I know that there’s an oral form,

so capsules and there’s injectables.

Injectables, I think you need a prescription,

is that right?

Correct, you need a prescription for the injectables

or you should really get a prescription for the injectables.

When you inject it, of course,

at the supervision of your doctor,

it’s usually done intramuscularly.

It’s an aqueous solution,

so it does not have like an oil or a carrier oil in it

like testosterone esters do.

However, if you inject it too superficially,

it’s not gonna make or break anything.

Often it just burns if you inject it subcutaneously

and it does not disseminate throughout the body as well.

L-carnitine potentially has localized effects

if you inject it.

If you ingest it orally,

then it has a very low bioavailability, maybe only 10%.

Well, I think most people are going to be able

to get L-carnitine only in its capsule form.

So what are the dosages of L-carnitine

that one needs to ingest then if they wanna get a benefit

because if only 10% is being absorbed,

it’s probably a lot of L-carnitine.

How much should people take per day?

Usually I recommend for oral L-carnitine

between 1,000 milligrams and up to four or 5,000 milligrams.

So one to four, maybe even five grams.

Correct, up to five grams a day.

If you’re on that much,

especially if you have a dysregulated gut microbiome,

you should be concerned with TMAO,

which is a potential carcinogen

that both carnitine and choline can convert into.

And your gut microbiota determine how much that happens.

Is it true that I can offset any negative effects

of alpha-GPC choline, that is N-L-carnitine,

that I take by ingesting garlic?

Is that right?

There’s a compound in garlic called allicin.

I believe it’s A-L-L-I-C-I-N.

It’s also part of the scientific name,

the genus of types of garlic.

And this can help decrease the conversion to TMAO.

Berberine actually slightly decreases

the conversion to TMAO as well,

probably through alteration of the gut microbiome.

And then just optimizing your gut microbiome

can decrease conversion.

So not everyone needs allicin,

but it’s something that you should certainly consider

if you were on a high dose.

I’m going to continue to take the 600 milligrams of garlic

every time I take my L-carnitine,

but I’m going to skip the berberine

because berberine gives me brutal headaches

and it makes me crave carbohydrates

because it drops my blood sugar.

It has many other effects, including the dawn phenomenon,

where it drops your blood sugar when you’re sleeping

and you can’t even realize it.

I am not a fan of berberine,

and I’m sorry for those of you that are.

I’m not trying to offend anyone,

although frankly, if you’re being offended

by my stance on berberine,

then maybe we should have another discussion.

In any case, injectable L-carnitine,

if one can get that through a doctor,

how much is absorbed and how much should one take?

Almost all of it’s absorbed.

In general, you’re taking between 500 milligrams up to,

you can take a pretty high dose, up to 2,000 milligrams.

Okay, and what we did not talk about

is what L-carnitine does.

So why should someone go through all of this?

Is it to optimize testosterone?

Is it working on the receptor side?

What’s L-carnitine doing?

It’s a shuttle.

So I think it’s named carnitine palmitoyl coenzyme A.

Basically, it just takes nutrients

from outside your mitochondria and puts them in.

It also has a unique effect.

Well, not too unique because Tadalafil

actually has this effect as well,

is that it increases the density of the androgen receptor

in the cytoplasm of your cells.

So even if your androgen receptor sensitivity doesn’t change

and even if your testosterone does not change,

you will have more testosterone

binding to that increased number of receptors.

Does one need to cycle L-carnitine, creatine, betaine?

No reason to cycle any of those.

Okay, what other supplements can one use

to try and improve hormone profiles?

And here I realize we’re using a very broad brush

because when we say improve hormone profiles,

what are we really talking about?

And for me, at least, I think about the subjective stuff.

Do people feel like they are going to have more energy

as a consequence of doing these things?

Are they going to have the more optimized libido?

Are they going to have more optimized

recovery from exercise?

Because it’s not clear to me that taking one’s testosterone

from 600 to 800 is always going to be a good thing,

especially if estrogen is increasing in parallel.

That could cause issues.

It could certainly make things better.

It could certainly make things worse, right?

So with that backdrop,

what are some of the other things people can take?

And then we’ll go back to this issue

of what really is optimization.

Let’s briefly mention vitamin D, which is also a hormone.

It’s actually a sterol hormone.

And if you have deficient vitamin D and you replace it,

then you will optimize your testosterone.

Let’s also mention boron.

So if you have a very high SHBG,

boron can acutely help lower it,

usually in a dose of five to 12 milligrams per day.

It’s not really a sustained effect,

but boron is depleted in soils.

In many countries, I believe it’s very high in soils,

in Greece and Turkey.

So eating dates or raisins that are from those areas

potentially have more boron.

Boron also might be one of the reasons

why the reference range for testosterone

is much higher in those countries than other countries.

And just to remind people,

the SHBG, sex hormone binding globulin,

is attaching to the testosterone molecule

and limiting the amount of so-called free testosterone

that’s available to have its impact on cells.

When Dr. Peter Attia was on this podcast,

in fact, sitting in that very chair,

he said that the ideal level of free testosterone in males

should be about 2% of one’s total testosterone.

Would you agree with that number or disagree?

I’m sure Peter would be fine if you said either.

2% is a good rule of thumb.

Usually the reference range is between about one and 4%.

Some people do have genetic polymorphisms in SHBG,

a specific gene mutation where they have very low SHBGs.

Also men that have varicose veins in their testes,

also known as varicoceles, tend to have very high SHBGs.

So that percentage would likely be less than 2%.

So just because your percentage of free T to total T

is a little bit above or below 2%, that’s okay.

We just need to figure out the reason why it is.

How would somebody know if they have varicose veins

in their testicles,

especially if their testicles

are still attached to their body?

Sometimes it’s hard to tell.

There is several grades.

If you have a grade three or grade four varicocele,

it has what’s called a bag of worms appearance.

So think about if you’ve just resistance trained

or it’s a really hot day

or you’re wearing very tight fitting clothing,

then if you feel it and it almost feels

like there’s worms in the scrotum.

The other way is to do-

It’s a scary visual.

Yeah, bag of worms.

Well, just that, yeah, anyway,

I think parasites when I hear that,

but that’s not what you’re referring to.

You’re talking about just the texture.

The best way for most people to check

is to valsalva for a long period of time.

When you valsalva, venous return will decrease.

Can you explain valsalva for people?

It’s bearing down, like you’re lifting a weight

or having a bowel movement where you swallow.

And a lot of times you can almost see buildup

of blood in your like jugular veins as well.

So you have decreased blood return to the heart

and increased blood in the veins themselves.

Okay, so vitamin D3,

I’m guessing you’re talking about vitamin D3 specifically

when you say vitamin D

and then boron five to 12 milligrams per day, right?

And then what are some of the other things

to optimize testosterone that are in supplement form?

We can talk about things

that affect the steroidogenesis cascade.

So we could touch on tonkat-ali.

I know we’ve talked about that a little bit before.

Yeah, but I’m guessing a number of people

probably haven’t heard that conversation.

Also known as long jack

and that upregulates several different enzymes

in the steroidogenesis cascade.

And by that, what you mean if,

and this is another good thing to Google,

I think anybody interested in hormone optimization

should understand where sterol hormones come from.

They come usually from cholesterol

and they can be shunted off to vitamin D very easily.

They can be shunted off to testosterone or estrogens

or progestogens quite easily as well.

But tonkat helps with the conversion of multiple key steps

where you synthesize testosterone.

Another, think of it as like a coenzyme or a cofactor,

an up regulator of these steps is insulin and IGF-1.

So a good rule of thumb is if you are not expecting

as much growth hormone, insulin and IGF-1,

for example, lower carb diets, caloric deficits,

you’re trying to cut body fat or body weight,

then tonkat is going to be theoretically especially powerful.

What sorts of dosages of tonkat

do you recommend to your patients?

Anywhere from 300 to 1200 milligrams a day.

With tonkat, you need to be careful with the standardization

because, and if you’re thinking about

a general tonkat supplement,

which is by far the most well-studied,

then you’re looking at the uricomonone content,

which is a plant compound that is likely

the main active pharmacologic effect.

So that’s the compound that’s having the effect on the body.

And if you standardize the uricomonone very, very high,

then theoretically you’re having more effect

at a lower dose.

I take 400 milligrams of tongkat ali per day.

I take it early in the day

because it has a bit of a stimulant effect.

And if I take it after 2 p.m.,

it starts to inhibit my sleep.

I’ve been taking it for years

and I rather like the effects.

It seems subtle, but consistent.

I’ve never cycled it.

Do you recommend cycling it?

I don’t see any reason to cycle it.

There is a reason to cycle some supplements,

but no reason to cycle tongkat.

My blood work tells me that it causes an increase

in free testosterone for me,

and also a slight increase in luteinizing hormone for me.

What are some of the other effects on various hormones

that you’ve observed in the blood work of your patients

taking tongkat ali?

Tongkat can also slightly increase DHEA.

And if you have a very high SHBG,

again, that’s the protein that binds up your androgens

and estrogens, an extremely important protein.

The higher your SHBG, the more it helps decrease it.

So they’ve studied tongkat in populations

with very normal SHBGs and it does nothing for SHBG.

Interesting.

Does that mean it does nothing for somebody overall?

So if somebody has SHBG that’s in the normal range,

will taking tongkat benefit them in any other way?

Yes.

It’ll increase their total and free testosterone.

Got it.

Okay, is it known to have effects on anything else

like thyroid hormone, growth hormone,

or is it purely in these steroid synthesis pathways?

Or steroid, I should say, synthesis and receptor

and modulation pathways.

There’s no direct effect on those pathways.

However, anytime you alter your free androgen

or free estrogen,

particularly one without altering the other,

it will alter the binding protein

that binds thyroid hormones.

So any change you make,

whether it’s natural optimization or hormone replacement,

you’re going to slightly skew your thyroid hormone profile.

One common actionable example of this

that I see often clinically is someone starts,

let’s say, estrogen replacement or testosterone replacement.

Maybe they’re taking AI with their testosterone replacement.

Aromatase inhibitor.

Correct, an aromatase inhibitor,

which blocks the conversion to estrogen.

If they’re taking testosterone

and they have very little estrogen,

then you’re going to decrease the binding protein,

also known as thyroxine binding globulin,

which binds active thyroid hormones.

So if you start TRT

and you either have low aromatase activity

or no aromatase activity, no conversion to estrogen,

then your free thyroid hormones will go up,

even just acutely.

Usually feedback inhibition,

which is how the body talks to itself and says,

we need to make more of this or less of this.

But acutely, there’s not always enough time.

You’re going to have very high thyroid hormones

and you can have tachycardia, which is a fast heart rate,

or you can feel kind of like overly fight or flight

due to increased thyroid hormone activity in the end tissue.

Interesting.

Okay, so Tongali,

that’s a broad range, 300 to 1,200 milligrams per day.

And I realized that the source matters there.

What are some of the other hormones

that you prescribe to your patients

who do not want to go on testosterone replacement therapy

or take exogenous DHEA or anything like that?

We can talk about Fidosia next.

Fidosia is interesting because it’s a genus of plants.

Fidosia agrestis is one of them.

There’s many others that are very interesting.

That species is likely the most well-studied

and it will increase LH.

So I would not consider it an LH mimetic,

so it doesn’t really mimic it,

but it increases the release of luteinizing hormone

from the pituitary.

That’s a hormone that binds to the leydig cell,

to the LH receptor, kind of like HCG does.

And it will increase the release of testosterone.

I see.

So I think for people that aren’t familiar with HCG,

so human chorionic gonadotropin

is basically synthetic luteinizing hormone.

And luteinizing hormone is the hormone

released from the pituitary

that is going to travel down to the testes

to stimulate the production of sperm and testosterone,

but mainly testosterone.

Is that correct?

Mostly correct.

Technically, synthetic LH is also known as little-r LH

or recombinant LH.

And HCG can be synthetic,

but often it is just refined

from the urine of pregnant ladies

since the placenta makes it.

That’s why it’s called chorionic gonadotropin.

So where are they getting all this pregnant women’s urine?

I mean, is there a location?

I mean, not that I want to go there.

Donation, yeah.

Really, so there are women that are sending-

First trimester pregnant ladies, it’s very high.

Donating their urine and then they’re purifying it

and then men are injecting it.

Yes.

Wow.

And that’s actually the same for menopausal ladies.

So first trimester pregnant ladies,

that’s how you can make, you know, non-synthetic HCG.

And then for minotropins, which are also known,

there’s a couple of different names for it, like minopure.

You have menopausal ladies that have very high LH and FSH,

and then you refine the FSH and LH.

Okay, so moving away from the sources and from urine,

phytogia agrestis,

what dosages do you have patients take?

I’ve heard of some potential toxicity

to the testicular cells.

There is one study, and this is a rat study,

but you can equate the dose of toxicity in rats and humans.

They did not give these rats any antioxidants,

but it increases a couple different,

like pro-inflammatory markers.

One is GGT, or gamma-glutamyl transferase,

comes from both the testes and the liver,

and one is alkaline phosphatase, also known as ALKFOS,

again, coming from both areas.

There are several different ways

that you can attenuate this increase,

and you can also just check to see if you have increased.

In the rat dose that equates with humans that had no effect,

so the safe dose, was an average of 300 milligrams a day.

So that would be 300 milligrams a day in humans

is the dosage that did not have toxicity, correct?

Correct, and often, even if there is toxicity in rats,

there is not toxicity in humans,

so it’s not directly equitable.

But to be safe, another regimen that I have people take

is 600 milligrams every other day,

or 600 milligrams three times a week,

often Monday, Wednesday, Friday.

This is very interesting and relevant

because I’ve been taking Fidogia for some period of time.

All my markers and tests indicate that there’s no toxicity,

but I’ve been taking 600 milligrams per day,

but I’ve been cycling it for about eight to 12 weeks on,

and then a few weeks off.

Based on what you’re saying,

I’m thinking maybe three times per week

or every other day might be better, is that right?

If you weren’t gonna get any labs,

that is certainly the regimen that you want.

If you’re gonna check your GGT and ALKFOS,

or even take other things to prevent those from increasing,

then you can certainly be more aggressive

with your Fidogia dosing.

You can increase it quite a bit,

and it has a dose-dependent response

in both the activities associated with high testosterone

and also just LH and testosterone.

So the more aggressive regimen

would be 600 milligrams daily for a month,

and then take one to two weeks off.

Great, I think that’s more or less what I’ve been doing.

Okay, terrific.

In terms of other hormones,

what are some of the supplements

that can support growth hormone,

a hormone that’s associated with tissue repair,

and in some cases, metabolism and fat loss?

What are some of the tools,

nutritional and or supplement-based,

one can do to tap on the growth hormone pathway?

And let’s lump IGF-1 in there too,

since they’re essentially working along the same dimensions.

A quick synopsis, growth hormone is a peptide hormone,

and it is released by the pituitary.

There’s growth hormone-releasing hormone

and ghrelin that stimulate the release.

So there’s also peptides

that are very analogous to these two things.

You have that pulsatile secretion of growth hormone

in a very fast half-life of just minutes,

and then it increases IGF-1.

There is both peripheral IGF-1 and central IGF-1 and IGF-2,

but no need to get into the specifics.

There is a happy medium

to where your growth hormone is at a adequate level,

and your IGF-1 is an adequate level.

Usually, those two are congruent.

So in most cases, we just check an IGF-1,

and occasionally, the binding peptides for IGF-1,

kind of like SHBG that we talked about earlier,

but you’re estimating a free IGF-1.

It’s kind of confusing because almost all hormones

have binding proteins to help regulate them,

but often, you wanna look at free testosterone,

free estradiol, free IGF-1, or at least estimate it,

free cortisol even, and free thyroid hormone.

But when you’re talking about growth hormone and IGF-1,

usually, you don’t need to do anything to optimize it.

If you are diabetic,

then depending on the type of diabetes,

your IGF-1 and growth hormone can be too high.

Specifically in type 1 diabetes,

your growth hormone is extremely high,

but your IGF-1 is low.

So if you’re in a dysregulated state or have pathology,

I would just talk to your doctor

about IGF-1 or growth hormone.

Taking amino acids before you go to bed

could potentially help with growth hormone release

just because most growth hormone is released while you sleep.

I’ve heard that fasting can increase growth hormone,

and I know there are certain patterns of weight training

that can increase growth hormone.

Some of those regimens in the weight room

that increase growth hormone have been covered

by Dr. Duncan French, who is a guest on this podcast.

So maybe we’ll refer people to that episode

for the specific protocols, these high-volume training.

During those training exercises,

it usually does it transiently for a period of a few hours.

And a lot of this IGF-1 is released by the muscle itself.

So it’s not necessarily released by the liver.

IGF-1 that is released directly

due to growth hormone signaling,

usually the growth hormone comes from the pituitary

and binds to the liver,

where it usually has a half-life of about a week,

where the paracrine or autocrine,

think of it as like the peripherally acting

or acting in the muscles itself, which is also helpful,

is released and is not as concerning

because it’s not related to insulin resistance,

but it is related to the training itself.

So fasting and growth hormone,

is it true that fasting can increase growth hormone?

And maybe as a little related tangent,

I’ve heard that limiting food intake for the two hours

before going to sleep can increase

the pulse of growth hormone

that one experiences during sleep.

Of course, everyone gets a pulse of growth hormone

during sleep, but especially carbohydrate-laden meals

can blunt that peak that occurs

during sleep quite substantially.

So two questions, does avoiding food intake

in the two hours prior to sleep

help increase growth hormone release?

Maybe it’s being overly neurotic.

Maybe people need to avoid food

in the four hours before sleep.

But regardless, what is the relationship

between fasting and growth hormone release?

I find this really interesting.

Fasting certainly potently increases growth hormone release.

However, the end binding to the receptor is less sensitive.

So although fasting does increase growth hormone,

the genes that are downstream to it,

both the growth hormone genes

and IGF-1 related gene transcription activity

will not be significantly higher.

However, if you are optimizing the growth hormone

that is released as pulsatile secretion,

it is helpful to avoid eating for two hours.

So the general rule of thumb is avoid eating

about two hours before bed.

I think that’s clinically significant and helpful,

but fasting otherwise specifically

for growth hormone optimization

in someone who already has normal growth hormone signaling

is not helpful.

That’s extremely useful to hear

because one of the major reasons why people fast

is to get that growth hormone increase.

But if they’re adjusting things on the backend

that negate that, well then no such luck.

Not that I have anything against fasting.

I do a pseudo intermittent fasting

mostly because I prefer to eat it

fairly regular times of day.

Okay, so it doesn’t sound like there’s a lot

that people can take in supplement form

to improve growth hormone.

What about thyroid hormone?

What are some of the things that people can take or do

in order to make sure that their thyroid hormone levels

are appropriate?

You wanna have a balance of iodine

and you wanna have a good source of iodine.

So there’s some camps that say

you should use a huge high dose of iodine

and there’s protocols for it.

And there’s some that say you should use

just barely enough iodine.

I believe it’s like 200 micrograms per day,

but you wanna balance.

One of the things that I see that many people

do not talk about when it comes to iodine and thyroid

is there is compounds known as goitrogens

or goitrogens.

And these goitrogens are neither good nor evil,

but they’re actually kind of a nice check and balance.

You need more iodine if you consume more goitrogens.

And some examples of these are some of my favorite foods,

cruciferous vegetables, boron is also a goitrogen.

So higher goitrogens, higher iodine.

So ingesting iodine containing salt is useful, yes or no?

Iodized salt does prevent goiter,

but it is not necessarily the ideal form of iodine.

Good forms of iodine often come from the ocean.

If you look at a chart of hypothyroidism,

there is a tendency to have more hypothyroidism

the more inland you go.

So trying to eat some cruciferous vegetables each day

would be the best way to improve thyroid hormone.

Along with plenty of iodine.

You don’t want too much iodine signaling.

Many people are familiar with radioactive iodine tablets,

and that’s basically an extremely high amount of iodine

to block out the, like the radioactive iodine

that comes from after, you know,

like a nuclear meltdown or whatnot.

So we’ve got creatine, pyridine, L-carnitine

with allicin, garlic to offset the TMAO,

vitamin D3, boron, tonga, ale, fedogia, some fasting.

Love to talk to you about peptides.

So I can imagine a hierarchy.

Hierarchy starts with behaviors and nutrition.

Behaviors, of course, includes training and limiting stress

and all the things we talked about before,

sunshine, et cetera, and optimized nutrition.

Then we talked about supplements,

all the things we just listed off

to optimize testosterone.

And we can get into this, but estrogen as well,

which is important for libido and brain function

and tissue function and joints feeling good, et cetera.

But then we get into the realm where one might

or could consider exogenous hormones,

taking a small dose of testosterone

or taking a small dose of GH even,

if that were appropriate

and certainly only working with a doctor.

But in between, there’s a step of so-called peptides.

And of course, there are many peptides.

We’ve already talked about some of them,

but when people talk about taking peptides,

the ones that I hear most often about

is a category that increases GH and IGF-1.

And those, to my knowledge,

go by the things like sermorelin,

ipermorelin, tesomorelin,

sort of a kit of things that are taken separately

or in combination to increase GH and IGF-1.

But then other people, for instance,

are taking peptides like BPC-157

to try and improve tissue healing and recovery.

There’s a lot of interest in peptides.

Please, if you would, tell us about what you know

about the safety of peptides in terms of their sourcing

and the utility of peptides.

Is this something that people should consider

before thinking about hormone replacement?

Should people be wary of these things?

I am very wary of particular sources that are sold online

that are not clean.

They contain contaminants and that could be dangerous.

I really would love your thoughts on peptides.

So I’m just gonna sit back and let you riff on peptides.

But if you could touch on some of the ones

that I mentioned, I’d be most grateful.

A peptide is just a chain of amino acids

between two and a couple hundred in length.

So I think of peptides as several different categories.

And the GHRPs that you mentioned, I would consider those,

and that stands for growth hormone-releasing peptide.

You have two main types.

The ghrelin agonist or they hit the ghrelin receptor

and it helps release growth hormone because of that.

And then also the GHRH-like peptides.

So they’re very similar to growth hormone-releasing hormone.

Often they just change a couple amino acids

and it acts like that.

Tesamoralin is one of them.

Cermoralin is another one.

And CJC is another common one.

I believe those are all in the class of GHRH-like peptides.

Whereas ipomerelin or ibutamorin,

which is also known as MK-677,

those two are in the class of ghrelin agonist.

So they’re more like they hit the receptor

that ghrelin does,

whereas the other ones hit the GHRH receptor.

I think of ghrelin as making me hungry.

Hungry and angry.

Why would I wanna take something

that would increase ghrelin signaling?

Some people are trying to gain weight.

It also does increase your growth hormone.

So if your growth hormone is very low, you can consider it.

Ibutamorin is a long-acting,

so it has a long half-life, also known as MK-677.

It was studied mostly in growth hormone deficiency.

And do these people get angry also?

They can.

Many people report a side effect of anxiety

or significant hunger.

Most people take it in the evening

so they don’t notice that hunger as much.

It can also greatly increase your blood glucose.

So if you’re insulin resistant or pre-diabetic,

it’s especially concerning.

This is one of those rare moments

where I hear something and I think,

okay, even though there’s this kit of compounds

that can increase GH and IGF-1,

based on everything you’re telling me,

maybe just taking GH is the better option for those people

because growth hormone, at least it’s,

synthetic growth hormone is mimicking an endogenous hormone.

I mean, certainly not taking anything might be the ideal,

but for those that wanna increase growth hormone

and they wanna use pharmacology to do that,

it sounds like these peptides are pretty precarious.

Yeah, it kinda depends on the situation.

If there’s an individual that struggles with hunger

and not eating enough, for example,

someone who has a very small stomach

or they just have a very low hunger drive,

sometimes you want more of that orexigenic signaling.

The hypothalamus, you have anorexigenic signaling,

which is kinda like anorexia and orexigenic signaling,

which is, I call it the hangry center of the hypothalamus

or the hangry center.

And if there’s an imbalance between those two,

then perhaps it’d be helpful,

potentially theoretically helpful in anorexics,

of which the incidence of anorexia in men

is increasing significantly.

As you’re telling me this,

I’m remembering being 14 or 15 years old

and I would go into the kitchen sometimes

and I was so hungry,

I would just obliterate all the food.

And I do remember being,

I’ve always been a pretty high energy guy,

but having an immense amount of energy.

I can’t recall if it was a hangry feeling or not,

but I’m guessing that was growth hormone.

I grew one foot in a single academic year.

So I imagine that was at least in part

due to growth hormone.

In any case, sermorelin is the peptide

that I hear the most often about.

I admittedly tried a run of it.

I was researching a book

and decided to take it before sleep on an empty stomach.

It gave me a tremendous depth of sleep,

but that sleep was really truncated,

which is just nerd speak for saying deep, but short sleep.

I would wake up after very intense dreams.

I can’t say that it helped me recover

from exercise that much.

I didn’t notice any additional fat loss or anything.

Sort of abandoned it, except for occasional use.

Again, this was prescribed by a doctor.

You know, I was trying to get the sense

that these peptides and their effects

are somewhat vague and distributed and highly individual.

Is that a fair way to describe them?

Part of the problem with the effect of peptides

is many people take them in levels

that are far above the physiologic range.

Even individuals who are checking their IGF-1

while they take these different GHRPs,

most of them do not check the binding peptides.

For example, IGF binding peptide one, two,

or three, and their free IGF-1 level

might be significantly different.

So the common doses that people will take these off-label

for as a supplement are often much greater

than the therapeutic or physiologic range.

Which for me just underscores the fact

that it’s pretty precarious.

I mean, I’m not coming in here as the referee

of what anyone should or shouldn’t do.

Just trying to gather and distribute information.

But I’ve heard, for instance,

that some companies where people can acquire these things

without prescription, those companies are not good

at cleaning out the lipopolysaccharide, the LPS,

which can cause an inflammatory response.

In other words, these are dirty compounds.

And that just sounds risky.

It just sounds, frankly,

it just sounds really dangerous to me.

LPS is a common additive in many companies

that are not pharmacies, but they’re selling things

that people often use as human consumption.

One interesting note about lipopolysaccharide

is your gut microbiome actually makes a lot of it as well,

especially Prevotella, which is a specific species

that can have to do with your baseline body temperature.

So your baseline body temperature might also change

depending on if you’re on a peptide that has LPS in it.

Yikes, yikes, and yikes.

But I tend to be pretty conservative

when it comes to taking anything exogenous.

But I do rely on many of the supplements

that we talked about earlier,

and I do try and optimize the behavioral things

and nutritional things for a long time.

Okay, so then leaving peptides behind,

we are now, I suppose, in the territory of exogenous hormone.

So let’s say that somebody decides

they’re not concerned with fertility,

or they’re going to bank sperm, or they already have kids,

or they’re going to defer on this issue

of wanting to have kids.

My understanding is that nowadays,

a lot of people are using testosterone.

Let’s not even call it replacement therapy,

because some of these people have 600, 700,

or even 800 nanogram per deciliter reads.

So they’re not replacing anything that is diminished.

They’re just trying to augment what’s already there,

increase what’s already there.

My understanding is that taking a low dose more frequently

is going to be more beneficial

than the kind of old school way of giving 100

or even 200 milligrams in a single injection

once every two weeks.

Is that right?

And what do you do with your patients?

So let me give you a hypothetical.

Somebody comes into your office,

they do their blood work,

and they have blood levels of,

let’s say 600 nanograms per deciliter testosterone.

Their estrogen is also in normal range.

Everything else checks out,

but they’re complaining of slightly diminished libido,

slightly poor recovery from workouts,

maybe reduced motivation and drive,

although no major depression.

And you come to the conclusion that testosterone therapy,

not replacement, but testosterone therapy

might be a good option to explore.

What’s a typical dosage range

and frequency of administration range

that you might consider exploring?

And some of this depends on the SHBG

and free testosterone as well.

So if that same individual had a very high SHBG,

which again is the binding protein

that binds up the testosterone

and all androgens and estrogens,

if it is extremely high

and they have a free testosterone of two,

then they might need a different dose

because they need enough testosterone

in order to have a normal eugenital free testosterone.

But a general normal dosing range,

especially for someone starting,

is around 100 to 120 milligrams

divided over the course of a week,

usually either every other day or three times a week,

occasionally twice a week.

Many people with SHBG a bit higher

can get away pretty easily with twice a week.

This is assuming that the ester is cipionate or enanthate.

So 260 milligram injections

of testosterone cipionate per week.

Yeah, very common dosing.

To hit that 120 milligrams per week

as kind of the typical average, correct?

And I would consider this

like a physiologic eugenital dose.

For many people, even 200 milligrams a week

is far above the reference range.

All of this is said with the caveat

that testosterone is normally released

in a pulsatile manner.

So it’s high in the morning, low in the evening.

Whereas if you’re on testosterone therapy,

then you’re going to have a steady state.

So your testosterone level is gonna be

pretty much the same even in the evening.

And in your experience, when patients do that,

I’m guessing they report the normal constellation

of positive effects, you know, improved mood,

improved energy, improved sleep, recovery, et cetera.

What are some of the hazards or things

that can crop up in blood work or just subjectively

that can be warning signs that even a dosage

of 120 milligrams divided into these two

or three dosages per week is too high?

Every organ system in the body.

So this is when you really have to be

at least well-versed in every organ system,

not just the genital system.

You need to have dermatology prowess.

Acne is a very common change.

Lots of different skin pathologies

or even bruising can be related to hormone replacement.

Hair loss is very common to see as well.

Mental status changes, it could occasionally

it even induces a manic or a bipolar episode

because testosterone is also dopaminergic.

And then cardiovascularly, not just in the heart,

but also concerns for like microvascular ischemic disease,

ferritin buildup because the estrogen also increases

and then fertility concerns as well.

And lipid concerns too.

So you really have to be a hematologist, dermatologist,

cardiologist, a lipidologist, the whole nine yards.

So another reason or set of reasons rather

to if one is considering using testosterone therapy

to really do this in close communication

with a really good physician,

because that’s a lot to monitor.

Knowing whether or not you have acne or not is one thing,

but knowing whether or not your LDL is going up,

your ApoB is going up, that’s a whole other biz

and that needs to be done through blood work

is what I’m hearing.

Correct.

And if your physician that is managing

or prescribing your testosterone therapy

or your HRT is not well-versed in these systems,

you would want him or her to be part

of an interdisciplinary team where they have other experts

that can monitor those systems.

I skipped over a sort of still intermediate set of things,

prescription drugs, but maybe talking about testosterone

first was a bit of a mistake on my part

because I’m aware that there are,

actually I think there are companies,

but certainly groups out there that say,

no wait, don’t go straight from nothing to supplements

to testosterone.

Once you’re doing behaviors

and optimizing nutrition supplements,

let’s forget peptides,

but instead of going straight to testosterone therapy,

one idea that many people are pursuing

is to take the prescription drugs

that trigger luteinizing hormones.

So taking HCG, human chorionic gonadotropin,

which my understanding is will increase testosterone,

but also estrogen,

or they’ll take things like clomiphene.

In fact, I think there are a bunch of companies

out there now that are, I’m saying,

don’t take testosterone, it shuts down spermatogenesis,

shuts down testosterone production,

clomiphene is the way to go.

Maybe you could educate us about the HCG monotherapy,

I think it’s called, where you’re just mono one,

just taking HCG and clomiphene as a,

and or clomiphene as a tool to ratchet up hormones.

So quick points on HCG, human chorionic gonadotropin,

made during especially the first trimester of pregnancy,

it has effects other than binding to the LH receptor.

It also binds to the TSH receptor in the thyroid.

So thyroid stimulating hormone.

Yes.

In fact, if you look at a molecule of HCG

and thyroid stimulating hormone,

they are extremely similar.

However, you need a relatively high dose of HCG

to bind to the TSH receptor.

This is the normal mechanism in pregnancy

that accounts for the increased need of thyroid hormone,

usually about 30 to 40%.

So that’s why if someone has hypothyroidism,

you need to increase their dose of thyroid

because the HCG is not gonna be doing it for you.

The clomid or clomiphene, there’s two main,

I believe it’s diastereoisomers,

and one of them is N-clomiphene,

one of them is ZOO-clomiphene.

And these two work slightly differently.

N-clomiphene, I believe, has a faster half-life

and it is potentially slightly better tolerated.

However, they were studying it,

clomid is a very commonly prescribed drug,

and obviously there is plenty of N-clomiphene in clomid.

However, the drug, which was Andrazol, A-N-D-R-O-X-A-L,

did not go all the way through the FDA approval process,

despite clomid being FDA approved.

Okay, so there’s clomid, which contains clomiphene,

but there are also,

because we’re talking about male hormone optimization

this episode, there are males out there

who want to increase their testosterone

and other hormones, maybe growth hormone, et cetera,

who opt to not take exogenous testosterone,

so no cream, no pellet, no pill, no injectable, cipionate,

but decide to take clomiphene a couple of times a week.

My understanding, I’ve never done this,

I would say if I had,

my understanding is that taking clomiphene,

maybe two 50 milligram tablets a week

is what I hear people are doing,

will increase what, luteinizing hormone,

the various estrogen receptor subunits.

Could you explain how clomiphene would benefit anyone?

And is this a good strategy?

I’m hearing that it’s being done quite a lot now.

It will increase testosterone in a dose-dependent manner,

but it has many other pharmacodynamic effects,

which is the effect of the drug on the body,

other than its effect on the hypothalamus

and the pituitary.

So in the hypothalamus and the pituitary,

it does what’s called negative feedback inhibition,

or it blocks the oxygen of estrogen,

so it crowds out estrogen from the estrogen receptor

on the hypothalamus and the pituitary.

And what’s the subjective effect that that would cause?

So my understanding and experience of estrogen

is that if I ever took,

and I did take a very low dose

of an aromatase inhibitor once, and I felt terrible.

Actually, reduced libido, joints felt achy.

That’s when I discovered that, wow,

estrogen is actually really important

for your brain function, for joint function, and for libido.

And suppressing estrogen, for me,

just turned out to be the wrong idea.

But my levels indicate that it’s within reference range.

Okay, so why would I want to take something

that would increase the activity of an estrogen receptor?

I just can’t find the rationale for that.

The main rationale behind taking a CIRM

is as a very temporary measure

that is not going to suppress pituitary

or hypothalamic function

if your testosterone is just so drastically low

that it is unlikely to recover anyway.

So most of the time, it is not clinically useful,

and CIRM should not be prescribed very often,

certainly not as long-term testosterone replacement

or testosterone optimization in most individuals.

There’s always exceptions to everything,

but there’s five different estrogen

and estrogen-related receptors.

There’s two main estrogen receptors in Clomid,

and every CIRM has a very unique profile

because they selectively inhibit some receptors

in some tissues, but not other receptors in other tissues.

For example, Clomid can inhibit receptors

that are in the eye,

and it can cause visual changes, blurry vision,

especially at higher doses.

And it also acts in every other tissue of the body.

So side effects from Clomid

and other selective estrogen receptor modifiers

are very common.

Hmm, so I’m, at least by my mind,

I’m going to pool them with peptides

and say it sounds precarious

and probably not ideal for most people.

Going back to testosterone therapy,

then again, notice, folks,

I’ve deleted the replacement part

because I think so many people

are using testosterone therapy

without the sort of reference range need

to replace anything,

but rather are building on what they already have

for purposes of increasing vitality, et cetera.

Going back to that,

my understanding is that taking HCG

several times per week

can help maintain spermatogenesis and fertility

even while people are on testosterone,

but, and you and I were talking about this earlier,

that there’s tremendous variation.

Some people will take a small amount of testosterone

and just crush their sperm count.

They just won’t make any viable sperm.

Other people can maintain viable sperm production

while on testosterone,

especially if they’re taking HCG.

Is that right?

Correct.

And there’s many reasons for this.

Some of this has to do with heat damage to the testes.

So potentially cold therapy could be helpful for that.

Ice baths, cold showers,

and certainly avoiding sauna and hot tub.

Yeah.

Stopping the daily hot tub

can restore fertility in many people.

I know a number of people

that are trying to conceive children

that go into the sauna

and they’ll just put a cold pack in their shorts

or between their legs,

depending on whether or not they’re wearing shorts

or not when they go in,

or they’ll alternate ice and heat

in a way that maintains coolness

of the milieu in which the sperm live.

In other words, they’re cooling their scrotum deliberately

in order to avoid killing the sperm.

Actually, I saw an interesting paper

that said that for every two degree increase

in temperature of the scrotum,

there’s a 20% decrease in spermatogenesis

and viability of sperm.

And that actually, if you look at the difference

between people who stand a lot, sit a lot, and drive a lot,

what you see is a progressive decrease in sperm count.

Because when people are sitting,

there’s an increase in temperature.

And then when they’re sitting on the hot seat of the car,

or using the heated seats, actually it kills sperm.

I think there are good data on that.

Yeah, excellent data.

And anecdotally, you see it as well.

I’ve had several patients come in

for fertility consultations.

And all we do is, no medications, no supplements.

We change their several lifestyle things.

Very tight-fitting clothing is another one.

And soon they have fertility, and they’re no longer,

they have sperm, whereas before they did not.

Interesting.

I’d like to talk about some of the do’s and don’ts.

But we have talked about a lot of do’s,

things that one can do to optimize hormones.

Maybe we could just do sort of more rapid-fire Q&A

on some of the don’ts, and maybe throw in some science

where you feel it’s appropriate.

Cannabis, marijuana, THC, yes or no,

it diminishes testosterone levels?

Smoked cannabis, I would say diminishes testosterone,

increases prolactin, that’s a no.

Other cannabinoids, not particularly harmful.

So CBD?

CBD, not particularly harmful.

Smoked CBD, I’m not sure.

What about edible cannabis and THC?

As far as I know, edible cannabis and THC

does not significantly increase prolactin

to a point where it would be disruptive of hormones.

Can marijuana, THC, cannabis, whatever you wanna call it,

increase gynecomastia, the growth of male breast tissue?

Yes, it certainly can.

And there’s a pretty good association

between smoked THC and gynecomastia.

What about nicotine and testosterone

and estrogen and other hormones, smoked nicotine?

Nicotine is particularly concerning,

not only for testosterone, but also for estrogen.

Part of it is, if you’re talking about nicotine from tobacco,

there’s many other carcinogens in it,

especially if it’s smoked.

But nicotine, even if it is chewed in a dose-dependent

manner, so if you can use an extremely small amount

of nicotine, then it’s not as concerning in the long run,

but it’s a vasoconstrictor,

and one of the main concerns with it

would be cardiovascular disease

or even microvascular ischemic disease

that can lead to neurodegenerative disease,

so like a type of dementia that can be partly due

to nicotine.

If you use nicotine for a very long period of time,

especially at a higher dose, it’s a dose-dependent effect

on your hormone profile.

Is that also true for nicorette and nicotine,

other nicotine gums?

At high doses, if you can use an extremely low dose

of a nicotine gum, then theoretically,

that would be maintainable.

It’s not gonna overload the nicotinic receptor.

You have acetylcholine and the cholinergic system

as one of your main nervous systems, of course,

and you have muscarinic receptors and nicotine receptors,

and there’s just better ways to optimize

your nicotinic receptor activity.

For example, acetylcholine precursors like alpha-GPC,

phosphatidylserine, phosphatidylcholine.

Acetylcholinesterase inhibitors, especially natural ones,

potentially have a part as well, and then other alkaloids.

So nicotine is an alkaloid from the tobacco plant.

There’s other plants like cytosine

and that genus of plants,

and that alkaloid is also a nicotine receptor agonist.

Is it true that cycling for too long,

literally bicycling, sitting on a bike seat too long,

can damage the prostate?

Yes, it can be very concerning,

especially if you’re seated while cycling,

especially if you’re putting a lot of pressure

on the perineum.

Your core is kind of like a box

where your diaphragm sort of makes the top,

and your abs and serratus make the front and the sides.

Your back muscles make the back,

and then your pelvic floor makes the bottom of the box,

which is arguably the most important part of your core,

and that pressure can weaken

and even lead to incontinence and impotence.

So we were talking earlier today in the gym

about how heavy leg work, hack squats, deadlifts,

those kinds of things a lot of guys are doing

to increase their testosterone,

done correctly can actually augment

and build up the strength of the pelvic floor.

Done incorrectly can actually weaken the pelvic floor

and lead to all sorts of issues,

including sexual effects, negative sexual effects.

So how does one go about learning

whether or not their movements are being done properly

to support pelvic floor or to destruct pelvic floor?

The pelvic floor is a constellation of muscles

just like any other kind of like system in the body.

And form is important.

If you’re doing the Valsalva maneuver,

which again is that kind of like bearing down

or deep breath where you feel all of your abs are tight,

you can also notice that your pelvic floor is tight as well.

If you have a history of an inguinal hernia,

which is a hole kind of like connecting the abdominal cavity

down through the pelvic floor,

or even the scrotum in some cases,

and that can be a sign that there is weakness in that area

and you might have to concentrate on it most

or even have a physiotherapist or a physical therapist

specifically target the pelvic floor.

Many exercises in which you Valsalva

or use your glutes or legs,

you can learn to squeeze them

and have that mind muscle connection

in order to help build up the pelvic floor.

And there’s other things,

many people are familiar with Kegels.

That is just one of the many different exercises

that can help your pelvic floor.

My understanding is that

while strengthening the pelvic floor is good,

excessive contraction of the pelvic floor

can actually limit blood flow to the pelvic area,

the penis and so forth.

So this is, again, it’s a double-edged sword, right?

I mean, you don’t want guys out there

to just start doing endless number of Kegels every day

because they’re actually gonna constrict blood flow

to that area, right?

There’s a, and in fact,

the erection response is parasympathetic.

It’s a relaxed induced response, right?

So, you know, for the reason I chuckle is that, you know,

cause we’re talking about things,

we don’t have visuals or charts

and certainly it’s hard to know

whether or not a given exercise like Kegels

are gonna be good or not good.

If it’s excessive, what, you know,

how many sets and reps does it take

before it goes from good to bad?

Is there a kind of general rule of thumb

for people to think about this?

I mean, clearly blood flow to that area is key, right?

For sexual performance.

And yet when one trains the legs or even walks,

you’re getting blood flow.

So my understanding is this,

that a combination of weight training

to stimulate the positive hormonal and muscular

and connective tissue growth is key,

provides not overtraining,

but so is casual exercise,

like walking and stretching and the sorts of things

that will then return blood flow to that area.

Is that an overly basic way to think about it

or will that suffice?

I think that’s a good way to think about it.

I think the main point with Kegels

is they’re just a one of many different things.

So if you’re having some pelvic floor pathology certainly,

or even just concerned about your pelvic floor,

don’t just, you know, take the advice,

do Kegels and you’ll be okay.

That is not near enough.

It’s just one of the many aspects.

Okay, so going back to the rapid Q&A,

and then we’ll come back to this issue of blood flow

because there’s some interesting science

and protocols there.

Question I have is,

alcohol, does it increase aromatase,

the enzyme that converts testosterone into estrogen or not?

And is there a dose dependence there?

It significantly does.

There is a dose dependence.

In general, I would not recommend more than

three to four, you know, standard drinks.

One huge glass of wine is probably five standard drinks,

but I’d say every two weeks.

Yeah, that’s consistent with what I discovered

researching alcohol in an episode we did on alcohol,

that no alcohol is definitely better

for all aspects of health than any alcohol.

And anyone that says that,

well, red wine contains these various things,

well, it doesn’t contain enough of those positive things

to have a positive effect.

But that if people do opt to drink alcohol,

that two drinks per week,

and meaning 20 grams of alcohol,

so that’s probably two 12 ounce beers

or two, you know, four ounce glasses of wine

is going to be the upper limit

beyond which you’re gonna start seeing

all sorts of negative effects.

The other thing to keep in mind with alcohol

is it has a lot of calories,

seven kilocalories per gram,

almost as much as fat, which is nine.

And then it’s also very GABAergic.

So it can activate inhibitory neurotransmission.

And that can also affect how many,

how much LH and FSH is released.

So that can also decrease testosterone

almost kind of similar to how opiates

can decrease testosterone.

I feel very lucky that I don’t enjoy alcohol,

never really did, can kind of take it or leave it.

Certainly don’t like sedatives like Valium

or anything like that,

which as you just mentioned can suppress testosterone.

You said the word fat.

So I’m gonna pick up on that and say,

in order to optimize hormone production,

is it important to have some saturated fat in one’s diet?

And what happens on very low fat diets

to testosterone, estrogen, and other steroid hormones?

Fat’s interesting because there’s so many

different beneficial fats, omega-3s.

Almost every American gets plenty of omega-6s

in any developed country really.

When it comes to saturated fat,

there is more of a correlation with hormone optimization.

If you’re eating things with saturated fat,

those are things with more fat-soluble vitamins

and things that are very nutrient-dense otherwise,

but it is not vital.

In general, you want to eliminate any trans fat

unless it’s trans fat from the ruminants.

There’s always an exception to everything, right?

So there is healthy trans omega-3 fats,

which are formed in the stomach

of like grass-fed and finished ruminants.

But ingesting mostly olive oils,

maybe nut butters in limited amounts

because they’re very calorie-dense,

but unless people are trying to increase their calories,

in which case they’re a great source of calories.

Small amounts of butter or ghee, probably okay,

but not excessive amounts, is that the idea?

Yes.

Fat is perfectly fine.

Cholesterol has an interesting,

so cholesterol and in general phospholipids

make the bilayer that’s around the cell,

but cholesterol is also a hormone in and of itself

because it binds to the estrogen-related receptor alpha.

So I consider that like in the estrogen receptor category

and that can help with metabolism,

but also potentially have concerns

for cancer and tumor risk.

I wanna go back to the prostate

and talk to you about something

that’s kind of a newer emerging trend.

I know that you’ve talked to a little bit about this

in previous podcasts, that a number of men,

or I should say a number of physicians

are prescribing low dose Tadalafil,

also known as Cialis, to their male patients.

So in doses ranges of like 2.5 milligrams

to five milligrams per day,

but not for erectile dysfunction,

but rather for improving prostate health.

And presumably they get sort of a boost

in terms of blood flow to the genitalia as well.

But again, not specifically a deal with erectile dysfunction

but to deal with prostate health

and blood flow to the prostate.

Is that something that you sometimes often prescribe

to your patients and of what age?

Tadalafil is a very underrated medication.

The age would kind of depend on the indication.

So Tadalafil is also a blood pressure medication.

It can very slightly decrease blood pressure,

especially at higher doses.

At higher doses, a high dose would be 20 milligrams,

not 2.5 milligrams.

But consistently it can somewhat affect

with the cones in the eye

that have to do with red and green sight.

Although if you remove it, that effect is reversed.

So basically if you don’t need really, really good

red green discrimination, you can take higher doses.

But in general, I recommend no higher

than 10 milligrams a day,

usually just two or five milligrams.

One other benefit or other use of Tadalafil

is that it increases the density of the androgen receptor,

similarly to L-carnitine.

So that’s an interesting benefit.

Another benefit is that if you give it to people

with nocturia, which is urinating at night in general,

it will cut the episodes in half.

So it could go from two to one,

which can make a big difference for your sleep,

which will secondarily make a big difference

for your growth hormone and testosterone optimization.

Interesting, so you said 2.5 to five milligrams per day

is kind of typical for these prostate enhancing effects.

Yes.

And you mentioned the potential side effects

on adjusting visual perception.

As a vision scientist, that rings in my mind.

But in terms of red green color discrimination,

I’m guessing, unless you’re gonna be a subject

in one of the experiments in my lab,

or you wanna be a fighter pilot,

chances are you can probably get away

with a little less red green color discrimination.

Correct, it’s not considered clinically significant

unless someone is a commercial pilot.

Great.

So if someone’s getting their like pilot exam,

that’s one of the things we look for.

Okay, so commercial pilots aside,

you might wanna ask your doctor about low dose Tadalafil

for sake of enhancing prostate health.

Certainly monitoring PSA,

prostate-specific antigen is important.

I can give an anecdote there.

When I tried Cermoralin,

one of the surprising side effects that was not welcome

was a dramatic spike in my prostate-specific antigen.

No one could explain to me why that would happen.

But when I stopped taking Cermoralin,

it went back to normal.

So it’s one reason I avoid Cermoralin,

at least frequent use of Cermoralin.

PSA should be kept what below levels of,

you know, somewhere between one and four

is considered healthy, is that right?

It depends on the age.

If there’s a 20 year old, likely between zero and one.

If there’s a 40 year old, likely between one and three.

And then if there’s an 80 year old,

it would not be abnormal to have a PSA of five

and have that be well within the reference range.

Another thing we should mention about PSAs,

if you do take a 5-alpha reductase inhibitor,

like finasteride or dutasteride,

often these will cut your PSA in half.

So if you, for example, if you have a PSA of six

and you start finasteride or dutasteride,

and then you recheck it in six months, and it’s 6.5,

that is a huge concern because that’s actually doubled.

I’m glad you brought this up

because I almost overlooked the fact

that I get a lot of questions about drugs

to offset hair loss.

Most of those drugs are going to operate

through the DHT system, the dihydrotestosterone system,

for the reasons we talked about before,

DHT receptors being on the scalp

and causing beard growth on the face.

Is it the case that a number of people

taking things like Propecia and other things

to block the DHT or disrupt the DHT pathway

are going to experience diminished sex drive,

diminished kind of motivation and general vigor?

And if so, are there alternatives

like topical DHT antagonists that they might use

if they want to keep their hair

but not have those negative effects?

The way that I think about hair loss

is you have your fertilizers,

also known as a growth agonist,

and then you have your antiandrogens.

Whether they’re systemic or topical, there is both,

but that’s the general layman’s way to think about hair loss.

If you’re only putting fertilizer in your hair,

but you have androgenic alopecia or male pattern baldness,

then those hairs will still miniaturize,

and eventually you’ll still have loss.

Such a great word, miniaturize.

Yeah.

It’s enough to send anybody off to find a therapeutic.

And by the way, it’s difficult to tell

if miniaturization is happening

unless you have a magnifying glass.

You can use it for that.

I almost didn’t know, for a second there,

I didn’t know whether or not you were making a joke.

You’re talking about miniaturization of the hair follicle.

Correct.

So what can reverse that miniaturization?

That’s just a fun word to say.

I’m gonna just keep saying it.

Each individual has, again,

we mentioned the androgen receptor.

Males only have one androgen receptor gene.

It’s on their X chromosome.

So depending on how sensitive that androgen receptor is

and depending on the density of the receptors

in the hair follicle,

you can have a arbitrary threshold

and you don’t know what this threshold is

until you start to have miniaturization and loss of hair.

But over the threshold, the follicle will die

and eventually the stem cell will leave.

But under the threshold, you’re okay.

Every androgen binds to the same androgen receptor.

So there is nothing special about DHT.

DHT is just a stronger androgen.

So the higher your SHBG,

things that increase SHBG

are beneficial for hair loss prevention

because you have less binding of that receptor.

So if you think about hair loss,

specifically androgenic or male pattern baldness

in the terms of that androgen receptor

and everything in general binding to it,

not just DHT, but also testosterone, it’s helpful.

It’s just that DHT is a huge battering ram

whereas the other androgens

are just light presses on the door.

Got it.

So are some of the topical DHT receptor antagonists

going to be a better choice

for people that want to maintain their hair

or grow more hair if they wanna avoid side effects?

Likely so.

Some individuals benefit from systemic,

a systemic decrease in DHT for a couple of reasons.

One could be prostate

and then one could actually be hypertrophy

of the myocardium.

So DHT also disproportionately thickens the ventricle.

So for someone on TRT, that might be a benefit

that is prone to thickening of the ventricle at baseline.

However, many people that have just a bit of predisposition,

they can use things that are topical anti-androgens.

Ketoconazole is one of them.

Caffeine is actually another one.

Wait, drinking caffeine?

Topical caffeine.

Oh, I was gonna say, my hair tends to grow pretty fast

so it might be that, but I drink a lot of caffeine.

So topical caffeine, really rubbing coffee on their head

or taking caffeine tablets and how does it,

wait, you have to explain how this works.

How do people get caffeine into the hair follicle?

Topically, the caffeine enters the scalp

and crowds out, like somewhat crowds out the androgen.

It is a weak effect.

It’s likely just strong enough to be clinically significant.

Usually caffeine is put into formulations

with other things like ketoconazole

that are also weak anti-androgens.

Of note, spironolactone can be prescribed topically,

but it is absorbed systemically

because the size of the molecule.

So unless your doctor specifically prescribes that for you,

especially as a male, do not use topical spironolactone.

Topical finasteride is also a smaller molecule.

So it is also systemically absorbed,

but it is not extremely well systemically absorbed.

If you take topical finasteride,

then usually your systemic DHT will decrease by about 30%.

Topical dutasteride is likely a tiny bit

systemically absorbed, but it’s unique

because it’s half-life is much faster at a lower dose.

So topical dutasteride will not affect

your systemic DHT at all.

And I’ve seen this anecdotally on many people

on topical dutasteride therapy.

We’re gonna have to get you back on here

and do an episode all about DHT

and hair loss and hair growth.

Again, not a topic that I focus on a lot for myself,

but that I get a lot of questions about for men and women.

One thing that we could mention,

I got a ton of questions about turmeric

and curcuminoids after last episode.

Oh yeah, but I had reported my own anecdotal experience

that taking turmeric really crushed my DHT levels

and I did not feel good.

I mean, it crushed all sorts of positive feelings

of vitality.

The moment I stopped taking turmeric, felt great again.

Many people report this.

And the interesting thing about turmeric

is most of it’s beneficial action, not all of it.

Some people benefit from systemic turmeric

and some people that can tolerate it well,

it’s actually great for the prostate.

But most of the action, it does not need to be bioavailable.

It acts on the gut microbiome.

So you can take turmeric and if it is not absorbed,

some turmeric is put in special formulations

like micellar or liposomal or complexed,

but a lot of it is put with black pepper fruit extract,

which is also known as bio-purine,

which is actually also a 5-alpha reductase inhibitor

and it affects liver cytochromes.

And so many supplement companies

put this black pepper fruit extract,

bio-purine in almost everything.

So some people are on really high doses

and that could also be making most of the effect

of people who do not tolerate turmeric well.

Yeah, I avoid turmeric like the plague

based on that one previous experience

because it was clearly turmeric

that caused the negative effect coming off it,

everything reversed rapidly.

And the bio-purine, the black pepper extract,

I also avoid that like the plague

based on everything you just said.

I want my 5-alpha reductase, I want my DHT to be optimized

simply because my understanding is DHT

is the more powerful androgen

and it’s the one that, yes,

it causes a little bit of hair loss

and I’ve got a few patches here and there,

but I’m willing to live with that

based on all the other wonderful things

that DHT optimization does.

I’ll quickly mention a few other things.

One, salpalmetto is also a 5-alpha reductase inhibitor,

but only a couple of the isoenzymes.

There’s three main isoenzymes

and a lot of the problem is that you’re inhibiting

a couple of the isoenzymes, but not the other one.

Finasteride inhibits one and two.

Dutasteride actually inhibits all three.

And finasteride inhibits the isoenzyme

that is in genital skin,

but not in the skin throughout the rest of your body.

So a lot of the side effects of finasteride,

which is loss of sensation and loss of erectile function

have to do with the disconcordance

between the sensitivity of the genital skin and the skin.

Again, another reason to not disrupt 5-alpha reductase.

And we’ll definitely get you back on here

to talk about, I think we should just do a whole episode

about DHT, because so often when people are thinking

about optimizing hormones,

especially males trying to optimize their hormones,

they’re thinking testosterone, testosterone.

Maybe nowadays they think a little bit more

about free testosterone,

and maybe they think about estrogen

as also being important not to crush estrogen,

but DHT is, at least to my mind,

the linchpin of so many of the things

that subjectively people are really focused on,

libido, motivation, drive, et cetera.

I have one final question.

It’s just a brief one,

but many of us have heard that the BPAs

that are present in plastic bottles

and even in certain aluminum cans,

and phthalates, a difficult word to pronounce,

but a fun one nonetheless,

phthalates and work by Dr. Shana Swan

has shown that phthalate exposure to the fetus,

to pregnant mothers and the fetuses,

very likely is negatively impacting sperm counts,

testosterone levels, and even changing genitalia size

for the worse.

In males nowadays, I saw a beautiful lecture

that Dr. Shana Swan did on this when I was in Copenhagen,

and it’s very clear

that it’s negatively impacting the male fetus.

She was also on Joe Rogan’s podcast.

I hope to get her on this podcast.

However, what she couldn’t answer for me

was whether or not phthalates and BPAs

and these things present in plastics,

and some people even claim in tap water,

are bad for males after they’re born and after puberty.

What are your thoughts on,

or I should just ask you,

do you drink water out of plastic bottles?

Do you avoid drinking out of cans

that are not specifically non-BPA containing cans?

And do you actively avoid phthalates?

My understanding is that phthalates

are most enriched in pesticides,

and that’s why you’re seeing dramatic drops in sperm

and testosterone levels,

mainly in rural areas where they’re dust cropping.

Yeah, so I do avoid drinking out of cans that,

or plastics that may have BPA or bisphenol A in them.

Bisphenol A is known to bind to

what I would consider the fifth estrogen receptor,

estrogen-related receptor gamma.

So I would consider it a xenoestrogen.

So phytoestrogens are estrogens from plants,

and in general, they’re not concerning

or clinically significant,

and xenoestrogens are just other estrogens.

So I do avoid BPA, and I also test my water.

I use a water testing service,

and I test it both after it’s through my water filter

and the tap water that my two boys drink almost every day.

And it was very interesting.

I only found one microplastic

just a bit over the reference range.

So it wasn’t a terrible tap score,

but even in developed countries, these are widely variable.

As far as phthalates, again,

very difficult and interesting to pronounce,

but I remember learning about these

because there was, I believe, a lawsuit

that had to do with mac and cheese.

And this was probably five years ago,

and I was coming up with my list of,

each provider that does obstetrics has a list

what to avoid for the pregnant lady,

sketchy deli meats or high mercury fish

like swordfish and salmon,

and I actually added processed mac and cheese to that list.

Interesting.

Well, thank you for that.

I’m going to extract your statement

that you avoid drinking out of plastic bottles

when possible.

I’m guessing you’re not neurotically attached to that.

If you were dying of thirst,

you might crack a plastic bottle of water to survive.

But listen, Kyle, Dr. Gillette, thank you so much.

You gave us an enormous wealth of knowledge,

everything from behaviors to psychology,

to supplementation, to prescription drugs.

We will make sure to point out

where people can get ahold of you

on Instagram and on Twitter

and on other websites in our show note captions,

but really just on behalf of the audience

and just for myself, thank you so much.

You have an immense amount of knowledge

and you’re exquisitely good at sharing it with people

in an actionable way.

So thank you.

My pleasure.

Thank you for joining me today

for my discussion with Dr. Kyle Gillette

all about male hormone optimization.

And I just want to remind everybody

that we will soon have an episode

all about female hormone optimization.

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♪♪