The Science of Optimizing Your Testosterone | Abraham Morgentaler, MD

Dr. Gabrielle Lyon: 00:00

Does testosterone really cause prostate cancer? What's the relationship between testosterone and libido and how does the modern stress of life impact your hormones and sexual health? Hi, I'm Dr Gabrielle Lyon. These are just some of the questions we're tackling today with Dr Abe morgentaller, a world renowned urologist and pioneer in men's health. Together, we'll explore the biggest myths, misconceptions about testosterone, the surprising truths about sexual health, and what every person needs to know to protect their health and their relationship from how to spot early hormone imbalances to cutting edge advances in hormone therapy, this episode is packed with insights that could help you live longer. So are we looking at testosterone and hormones all wrong? Let's jump in, because these answers could completely change how you think about your health. I just wanted to jump on here with an exciting announcement. I am hosting the second ever forever strong Summit, April, 26 27th in Houston, Texas, 2025 there's going to be two days, the VIP day, on April 26 you will learn from former Navy SEALs, from former secret service, from individuals that you do not want to miss myself, my inner tribe will be there to support you to learn Everything from muscle health to science to nutrition, you don't have to be an expert. You don't even have to have a background. All you have to have is a will to win and stay strong. I will put a link in the show notes below. Please go to my website, Dr gabrielline.com, we sold out last year, and I would hate for you to miss this opportunity. So if you're waiting for a sign, if you're thinking, you need to change something up and you need community friends, we've got you covered. Dr Abe Morgentaler, welcome to the show. Oh, it's great to be here with you. Thank you. You are, really, I don't even want to say, the godfather of testosterone replacement therapy, but you are responsible for bringing testosterone replacement therapy to the modern world.

Dr. Abraham Morgentaler: 02:30

Thank you. You know, it's hard for me to accept something like that, but practically speaking, I think that that's right. And you know, I started doing this at a time when everybody thought testosterone was going to absolutely give people prostate cancer, like, pow right away, just a little whiff for a week or two, prostate cancer. That's the fear that we had, and I got interested in it. And I'd love to tell you how I got started. But my work has really been about using testosterone and showing that it didn't really cause prostate cancer. I didn't know that before I started, but that's what happened. And as the barrier to testosterone dropped because people weren't so worried about prostate cancer, then all sorts of things opened up. And here we are, 35 years later. You

Dr. Gabrielle Lyon: 03:22

know, it's really tremendous. And number one, you went to Harvard, graduated from Harvard College, then went to Harvard Medical School, and then you completed your residency at the Harvard program in urology. Just just tremendous. You are recognized as an international authority on men's health and a pioneer in testosterone replacement therapy, which you know we were all having dinner. You Your colleague, our colleague, Dr moquera, my husband, Shane kronstad, who is also a urologist, go figure. And there aren't that many giants left. There is not a ton of innovation happening from the individual level, right? But you were brave enough to do that at a time when testosterone therapy, and I want to talk about the history, was really deemed dangerous, right? And that people were 100% sure that testosterone replacement therapy was going to give people prostate cancer, and you challenged that notion. I would love to hear that backstory and how many tomatoes were thrown in your face, and how that you probably had three friends, and one of those included a sibling and maybe your

Dr. Abraham Morgentaler: 04:40

parents, oh, my god, so Well listen, thank you for that. And it's kind of amazing. Sometimes I sit here and think back, like on all the changes that have happened and how we went through things, and truthfully, it did require a certain amount of courage, because I knew I was doing something that. Was considered dangerous, but I always felt like what I was doing was in the patient's best in my patient's best interest, and with open communication and discussion of what the potential risks were. So the story originally begins, if I may, when I was 19 years old, and I was an undergraduate at Harvard, and I was supposed to be a hockey player, like, in my head, I was going to be like a professional hockey player. And it turned out I could play at a decent level. I played freshman at Harvard, which is a good school for to play freshman level. There's no way I was going to play varsity. And in my second year, I didn't know what I was doing, and I ran into a biology professor from whom I'd taken a class in Harvard Square, and I was completely lost. I was just a lost sophomore, not sure what I was doing. And he said, How you doing? I told him, actually, I'm not doing that. Well, I don't know if I should, you know, just stop college. You know, just drop out. And he said, Why don't you come work in my lab? You might like it. His name was David Cruz, and he changed my life and put me on a track from age 19 to Here I am, 50 years later. It's unbelievable. And so he had a reptile lab, and he was interested in sex hormones and the brain. And so the first project I worked on these little American chameleons. They're all over Florida. If you've been there, you see them everywhere, on the walls, on the sidewalks, inside your hotel room, sometimes terrifying and and you put a male in the cage with the female, and they had this bright colored flap of skin that comes out. It's called a dewlap. And the male sees the female, the do lab comes out, and their head bobs really quickly. It's almost like the male is going, yeah, yeah, yeah, yeah, yeah, like he's interested. The female does a little stately push up that says, okay, buddy, what you got? And then the male comes closer and repeats the behavior. And then they may so if you castrate the male, which means removing the testicles, which was the first procedure I ever did in a lizard, in anything, not knowing I was going to go to medical school, let alone become a urologist. But if you castrate the male, you put them in a cage with a female, they don't do anything. They have no interest. The female will sometimes do her push up and say, Hey, buddy, I'm over here, but their testosterone is gone. And then my project was we'd mapped out where in the brain, the itty bitty brain of these itty bitty lizards, what where testosterone was taken up, and what was likely to be the sexual centers. And my project that took three years to do was to put tiny implants of testosterone powder into those little sections of the brain. And when I was successful in doing it and putting it in the right place, these males that had no detectable testosterone, just testosterone in their brain, would see the female, the dewlap would come out. Head would bob up and down, yeah, yeah, yeah, and they would mate. It was the most amazing thing. And so my first publication on testosterone is in 1978 and and that was the start. And then when I became I went to medical school, I learned almost nothing about testosterone. It was important for puberty. That was about it. It was important for men to sort of be functional. But we didn't learn about testosterone deficiency or anything like that. And then I go into practice, and I start dealing with men with sexual problems, and some of these guys were desperate. How did you choose Urology? It Well, it wasn't obvious. I didn't know anything about Urology. I was in general surgery, and I loved operating. And I thought surgeons had, if you'll forgive the expression, the biggest balls in the hospital. And I said, I want to do that, but I didn't like being up at night, and a lot of the emergency operations were at night. Appendectomies, gallbladders were dealt with perforated ulcers. And so I looked for a field where they did good surgery, and they were nice, and they had very few nighttime emergencies. And the urologists that I encountered had told the best jokes in the OR, and they were some of them superb surgeons. I said, I'll do that, but I really didn't know much about it. And then it turned out to be perfect, because especially with my lizard experience and then human sexuality, that was a fit made in heaven. So these guys come to see me and they'd say, Doc, I'm desperate. This was 10 years before Viagra. This is 1988 and Don't you have something? My wife, my girlfriend, she's going to leave me like I'm desperate. I'll try anything. And I thought to myself, could testosterone work in men? Could men be like lizards? How far into practice were you just starting? Just starting. Just starting. I come out of residency in six years of residency, two years general surgery, four years of Urology. Never, once did we ever give testosterone. All we heard every week, like on weekly rounds, Grand Rounds, testosterone causes prostate cancer. You give testosterone, you have prostate cancer. And of course, we were treating, get this. We were treating men with advanced prostate cancer by removing men's testicles, not lizard testicles, men's testicles and and this is part of why there's a misunderstanding so much misunderstanding about testosterone and prostate cancer, which is, and I'll just tell you like some of this was obvious and impressive. There's a relationship, clearly. So back then, PSA was just beginning to be introduced, we didn't have a blood test to screen for prostate cancer, and so almost everyone diagnosed with prostate cancer back then was diagnosed when it was already metastatic, and they'd come into the emergency room with terrible pain, pain in their bones. Prostate cancer goes to the bones preferentially, and sometimes we would operate on them to remove their testicles, and the same night after surgery, their pain was gone. And so the story made sense that lowering testosterone help these guys, and if lowering testosterone is effective for guys with advanced prostate cancer, then raising it has to be dangerous. Like that story kind of made sense until, until it didn't. Until it didn't, did

Dr. Gabrielle Lyon: 11:38

anyone think to challenge that? Because one doesn't necessarily equal the other. You remove the testicles, you drop their testosterone, yeah, to what? Zero

Dr. Abraham Morgentaler: 11:48

Gabriella. It's an amazing story. I mean, it's really and it tells us not only about testosterone, prostate cancer, but how medicine works, and how medicine can often fail us, also, how you get these crazy bad ideas? I remember when I was like, 10 or 12 or something at the beach with my parents and and I had lunch, and then my dad says, and then my dad was a physician, he says, so you can't go swimming for two hours because you ate lunch. Yeah, because I ate lunch. I say, why? He says, Well, your digestive system needs the blood supply now that you've eaten. And it made no sense to me, but that was taught to doctors at the time, who then told everybody else, it's just nonsense, like, don't eat eggs, right? Yeah, the cholesterol thing turned out to be wrong. But for a generation, often these things are wrong. The testosterone story is wrong for 80 years. For 80 years now, it starts with 1941 a guy named Charles Huggins, together with his co author, Clarence Hodges, took based on experiments in dogs. They thought they there was no treatment for metastatic prostate cancer, so guys would come into the hospital regularly, through the emergency room in pain, like I mentioned. And is that how they would find prostate cancer? They found it, yeah. And so it shows up on X rays, plain X rays as denser than bone, which is unusual for cancer. So you could make the diagnosis almost exclusively on that. And they used the blood test. They started to use a blood test called acid phosphatase, which we don't use anymore, but that was big for Huggins. And what he did is he castrated these men, and he showed that this blood test, acid phosphatase came down when he castrated them. He also, he also claimed that raising testosterone made the cancers grow more quickly and and because of that work, 1941 people stopped using testosterone. It was first synthesized in 1935 became available soon afterwards, and there was this golden period of about four years where people wrote these amazing articles about the benefits of testosterone. Amazing articles. They were using it for men who and women who had angina, chest pain from exertion, right, where you don't have enough blood flow to the heart, with remarkable, detailed case histories. I think the largest series was 99 individuals. That's pretty big series for the 19 late, 1930s right? And very convincing and compelling. In 1941 comes this story about testosterone, more or less causes prostate cancer, makes it very dangerous, and everything stops like cold, so that by the 1980s when I was a resident, we never, ever, ever gave testosterone. For 40

Dr. Gabrielle Lyon: 14:43

years, men were castrated, not given testosterone because of a few innovators, I have a question for you. Yeah, that seems extreme. It's. So my question is, you know, just fast forwarding, thinking about, you know, I've been in practice since I've been a physician since 2006 Yeah, that would be very extreme for an individual. And no matter what their specialty is, to make a significant change, like castrate an individual, where there has to be some kind of reasoning where we know without a shadow of a doubt, perhaps, that what you're going to do is absolutely going to benefit the patient, because there's no reversing that,

Dr. Abraham Morgentaler: 15:32

right? So that's true, but what made it compelling the castration part, and they also used the estrogen treatment, also, which they didn't know, at lower testosterone. They thought it just antagonized how testosterone worked, meaning they gave estrogen or blocked it. No, they gave testosterone. They gave, I'm sorry, estrogen as a form of blocking the testosterone effect. They both worked. But what was compelling about it was just like I told you, that I saw in my own with my own eyes, just talking to the patients who came in when I was a resident, and we would remove their testicles and their pain would get better. This was the first treatment for these guys. Otherwise, they just got pain meds. There was nothing else. And Huggins rightly won the Nobel Prize awarded to him. 25 years later, he didn't just work on he was really the first, or one of the first ever show that any cancer could be sensitive to hormonal manipulation. And so other doctors would did what he did, and they saw with their own eyes that this worked. So that became the thing. And it wasn't just and where the things went awry is the idea not just that lowering testosterone to severely low levels was beneficial, but it got thrown in with this idea that testosterone must be dangerous and and that's where things are off. How

Dr. Gabrielle Lyon: 16:59

did you figure that out? Yeah. I mean, because you were the only one, I'm assuming that was willing to challenge that, or to think outside the box in a way that perhaps this wasn't right. Yeah.

Dr. Abraham Morgentaler: 17:12

So here's, here's how that happened. And just to lay the background a little bit, the reason nobody challenged it is because there was testosterone had just started. There was no we didn't think about it the way we think about it now, right? So there's a lot of physicians now who are very pro testosterone. Let's find these guys who are doing poorly in one way or another. Let's make them feel better and their health better, right? But that wasn't true back then, it was this new chemical that was available, and there was no doctor who had a huge number of patients in his practice that could say, Now hold on a second. I've treated 200 guys. This doesn't happen. They don't get prostate cancer. Those things didn't happen because it was a self perpetuating concept, like, if you really believe it, you're not going to use testosterone, why would you put your patient at risk? Totally so nobody did it, and the only reason I did it was because of my experience with lizards and the desperation of some of these men. So I lined up when I started. I wasn't trying to change the world, and I had no idea if testosterone would be good for him, no idea, but they were willing to try. And I told him, this could cause prostate cancer for you. They said, Doc, I'll sign anything. I don't care my I'm in trouble right now, and I'll do whatever it takes. And so we tried a few things, and right away, what these guys said to me is, yeah, not only was sex better, sex drive, erections were firmer, but they said things to me I had never expected to hear and I didn't really know what to do with it. They said, My wife likes me again. They said, I have four small children. I've never had so much patience with them before. One guy says, I wake up in the morning, I swing my legs over the side of the bed, and I'm optimistic about my day. I haven't felt that way in 1520, years. And I wondered maybe this is, you know, in medical school, you learn a lot about placebo effect. These guys were getting the male hormone,

Dr. Gabrielle Lyon: 19:22

30% should improve,

Dr. Abraham Morgentaler: 19:24

yes, and maybe this a placebo effect, the non sexual part. But what convinced me that it wasn't, was that, when I had to find out how to eat, treatment with testosterone. So I say nobody gave testosterone. There were exceptions, but they were rare, and they were treated by endocrinologists for these young men, generally, who didn't get through puberty, even though they were in their 20s, because of genetic issues like common syndrome, Klinefelter syndrome, or they had pituitary tumors, or maybe they had lost their testicles, both of their testicles, to trauma. Cancer. So there were in every city, there would be a handful of men with these rare conditions, and the endocrinologist learned how to treat those guys. But the idea that you could treat a regular guy without a pituitary tumor with two testicles wasn't known so but I went to the endocrinologist, the senior person. I said, How do you treat with testosterone at Harvard or somewhere else? Yeah, my hospital, Beth, Israel, Deaconess Medical Center. And she said, Oh, it's easy. You give 200 milligrams of testosterone cypionate every four weeks. So that's what I did. And the patients came back, and what I told you all the good stories they had to say were true. But every one of these first guys are lined up, said, But doctor, I got to tell you, for a week or two before my next injection, all my symptoms comes back. What's up with that? And I joke that it's like a bad version of a double blind experiment, because the patient didn't know, and I didn't know, I didn't know what was going on. So there's they feel so much better, and then they don't. Until I started checking blood tests on these men, and it turned out, by two weeks, everybody's blood blood level of testosterone had returned to their baseline low value. And so what I learned from that, from the first three patients was that, because there's no way the guys knew what their blood levels were. I didn't know, right? I said, guys can tell when their levels are good, and they can tell when their levels are low. It changes almost on a daily on a daily basis. They can tell that the moment that they drop. So I said, this is real. This is no placebo effect, and so that gave me and they didn't get prostate cancer. Were you worried? You must have been. Oh, I was terrified, terrified. I spent most of my career terrified.

Dr. Gabrielle Lyon: 21:53

I've been using element for years, and has really changed the game of electrolytes. It has sodium, magnesium and potassium, all minerals the body requires. Sometimes we don't need more caffeine for energy, but what we need are water and electrolytes. I use element daily, often in iced tea or just straight water between workouts or sip on it throughout the day to get more fluids. Pretty sure we could all drink more not that kind of drink. Element is a zero sugar electrolyte drink mix and sparkling electrolyte water made from a growing body of research. Each stick packs a meaningful dose of electrolytes, free of sugar, artificial colors and other weird ingredients. Element is formulated for anyone on a mission to restore health through hydration, and it is perfectly suited for athletes, those who are fasting. Maybe you're on a protein forward diet. If you are, we are friends, low carb, keto, whole food, you name it. Get your free element sample pack with any purchase. Go to drink. LM, N t.com/dr, Lion, and also try the new element, sparkling, a bold 16 ounce can of sparkling electro light water. Cherry lime is my favorite. That's drink. LM, N t.com/dr, Lion and

Dr. Abraham Morgentaler: 23:15

and the reason I say that is not with every patient, but

Dr. Gabrielle Lyon: 23:20

until it was proven otherwise.

Dr. Abraham Morgentaler: 23:23

So Well, I'll tell you. So I pushed the envelope in a lot of different ways. So the first hurdle was just, can you give testosterone without making it so these guys get prostate cancer? Where it went next was that there were men who had, like, pre cancers. We called them. Technical term is prostatic intraepithelial neoplasia pin, which we used to think meant, if somebody had a biopsy and they had pin, we said, oh, there's got to be a cancer hiding in there somewhere. And we would re biopsy them, like within weeks. And I gave testosterone to these guys with these pre cancers. Nothing happened to publish that data, and then gave it to men after they'd been probably cured of their of their cancer by surgery. We never there's about a 15% recurrence rate after surgery, so you never know. And then eventually, near the end of my career, even gave it to men who had metastatic cancer or their cancers had come back, and at every point I was still, I was still worried that maybe something's gonna bad's gonna happen to him. And it never happened, never once. So this metastatic cancer thing is amazing. So today, the controversy is so I think everybody is clear out in the medical community, pretty much that giving testosterone does not increase the rate of cancer compared to a placebo. Biggest study that we've had is called traverse. Came out about a year and a half ago. In 2023 numbers of cancers in the pro in the testosterone group, were 12. Number in placebo was 11. This over 5000 men three years of follow up, roughly, it's the same. It's the same. And so that part is kind of clear, giving testosterone to men who have prostate cancer. That's still controversial, but I've treated many hundreds and hundreds of men like that, never seen anything bad happen. Do

Dr. Gabrielle Lyon: 25:33

you think that, and this is a global statement, and partially I'm setting it up because I think I know your answer. Do you think that there is any in any chronic disease state, or it for any reason that someone who has low testosterone, from a safety perspective, should not be given testosterone.

Dr. Abraham Morgentaler: 25:58

I don't know. I can't think of any condition where that's problem. You know, where it comes up is, there's still some debate about Veno thrombotic events, DVTs, pulmonary emboli, things like that. I think the data are clear. I've been involved in a couple of studies around this, and the traverse trial two showed nothing with that. But I'll tell you where how people think and have what they do. There was a guy, there's a doctor who was published on testosterone and this venous thrombosis risk. It's published a lot on it, and he believes testosterone increases that risk. So there's a epidemiology type guy who invited me to participate in research that he was doing looking at this problem, and he invited that other doctor who thinks that it's a problem to be an author on the paper. The study comes out, or the data comes out, and we're all just discussing it. It's written up, and it doesn't show any increased risk, none. And this guy's a very his name shocked by our young is a very accomplished sort of public health researcher and and the fellow who thinks that it's a problem looks at the data and says, Well, you didn't look at this and that, I think if you do, we're going to find more of these events. So Jacques goes back and he re looks at the data the way this guy wanted him to, and nothing. At which point there's an interesting conversation with the other author, and says, Listen, you know, if you don't want to be an author on this, I'll understand it, but these are the data we have. And to that fellow's credit, he said, well, listen, you did the you did the analysis. And if that's what it is, I'm happy to be a part of it, which is really the way medicine and science should work. So a credit to him. But where his original work came from is he took people who already were at risk for having DVTs and PES like you can have clotting problems, right?

Dr. Gabrielle Lyon: 28:03

Meaning? Did they have genetic disorders that make them hyper coagulable, or cancer or something else? Exactly.

Dr. Abraham Morgentaler: 28:11

So some have the slide and five factor that predisposes to it. And so some people say, Well, maybe you shouldn't give testosterone to those people. But this is not, this is not clear thinking. So people who are at risk for something are at risk for something. If you then add in something like testosterone, which has not been shown to anything, yes, they can get clots again, but it's not because of testosterone. It's because they're at risk for it, right? You might as well say

Dr. Gabrielle Lyon: 28:39

you just take a margin. Let's see if that's exactly, exactly

Dr. Abraham Morgentaler: 28:43

right, yeah. So no. So the answer is, listen, the big ticket items that we've worried about, prostate cancer, cardiovascular risk, those are now clean. As far as I'm concerned, like, there's just no data to show that there's a problem.

Dr. Gabrielle Lyon: 28:59

I think it's a, this is a really important conversation, because I have, you know, I have one dear friend that I can think of right now that he would really benefit from testosterone replacement. Very active individual. He's on the lower end. And we should talk about what low is and the numbers. And if you're 310 in the US versus 310, somewhere else, is it still low? But he is concerned about two things. He's, number one, concerned about safety, and number two, he's concerned what other people would think that he is using it because they're worried about safety. Oh, yeah, and that just makes me think about the beginning of the conversation when you went back to examine the data from is it Hutchinson, Huggins? Huggins, well, Hutchinson's, or else? Huggins, Huggins. You went back and you looked at the original data that everyone had. Spent 40 years building upon. Yeah, can you share what that is? Because I know at the time we were talking last night at dinner, at the time, we didn't have the internet, so you actually had to go to the basement of Harvard to get this study. And I am just curious, as is the listener, what? What did it show? Yeah,

Dr. Abraham Morgentaler: 30:17

it's an amazing story. So, so I started publishing data showing that this old relationship we thought existed between testosterone prostate cancer wasn't true and and even published in the New England Journal of Medicine,

Dr. Gabrielle Lyon: 30:34

not without recourse, though it wasn't easy to get that published. No, no,

Dr. Abraham Morgentaler: 30:39

no, but we published New England Journal of Medicine, together with my former fellow, or nanny, Rodin, that the this in 2004 that we just could not find a single piece of evidence that supported this idea that testosterone was dangerous for prostate cancer. We couldn't find it. We didn't say it didn't exist. We say we can't find it. Yeah, and the editors doing in journal, they didn't want to publish that. That was the crazy idea. Everybody was taught this around the world in medical school. Medical School, it's a it was a foundational concept in oncology that testosterone makes prostate cancer grow. It's bad. You can't use it. And they sent it out over the course of a year, to three sets of reviewers. First urologists, they couldn't find anything wrong with it. Then three endocrinologists, they couldn't find anything. Finally, to three oncologists. And listen, when we did it, I was relatively young, I thought maybe we missed it. I mean, I believed it until that until, actually, I pulled all those papers. I believed that high testosterone must still be a problem in some way, even though I couldn't define it. But that's what I've been taught and and then nobody could find any fault in what we'd written. So it was published 2004 took a year. And so I'm kind of on the lecture circuit within matter, within medicine and urology, and I'm talking about how we couldn't find the evidence, blah, blah, blah. And there's a great prostate cancer specialist Paul named Paul Lang, and he was on the same faculty this thing, I think it was at veil. And we're talking afterwards, and he says, Listen, Abe, this is really interesting stuff you got me, you better be careful, because it could be different in metastatic cancer. Huggins said, so. So I'd heard, of course, of Huggins. Huggins is probably the most important, biggest character in all of Urology. Prostate cancer is our biggest topic. He's the prostate cancer guy, Nobel Prize winner, the only urologist to ever win the Nobel Prize. So everybody knows Huggins, but we didn't have access at that time to articles online the way we do today. You can pull up Huggins article now in 20 seconds, I'll give you a couple of keywords to him. You'll have him, but not then where articles, especially old literature, existed was in bound volumes of published journals and in a department of urology or any department surgery, gastroenterology, whatever people would have their their bound volumes behind their desk, but it's stuff that they had collected, and maybe it went back there and practiced 15 years. They had 15 years worth of bound journals. I was very proud when I started by getting my own journals bound and but nobody had articles that went back 40 years. To do that, you had to go to this crazy building that housed old stuff. It's called the library. People don't never been people, yeah, and down in the basement of the Harvard and so I went, because this guy, Paul Lang, said to me, hudkins said, so excuse me. And

Dr. Gabrielle Lyon: 33:57

everybody believed it, and everybody practiced based on it, yeah, 40

Dr. Abraham Morgentaler: 34:01

years. Well, we we knew about it, but I'd never read his article. I knew what people said about his article. I knew what my former teachers taught me about his article. So at some point I said I got to see what he wrote. I was nervous about it,

Dr. Gabrielle Lyon: 34:17

and armpits were sweating. Is a whole thing. Well, to be honest, I

Dr. Abraham Morgentaler: 34:21

had a good thing going around this testosterone, probably my patients were happy, and I didn't want to mess it up. And I, in the end, I said, I got to do it. So I go down to the basement of the library. There are all these old, dusty volumes. Yeah, you take it out, you have to blow the dust off the top. And there it is, 1941 cancer research. And there's the article by Huggins and Hodges, and I read through it. And I had two small children at the time, and I'm thinking I read through it in the last sentence, the last sentence of the article says, testosterone injections activate prostate cancer. And I was sick to my stomach. I was I was awful. My hands. Were sweaty, and I had visions of the Harvard police coming and arresting me then and there, and it being a big Boston Globe front page store that my kids would see, you know, the Harvard doctor like arrested for, you know, ethical malpractice by giving testosterone. And so I forced myself to reread the article and just wrote down a few basic questions, how many men Did he treat for how long? And it turned out that the number of men he had treated, most of this was about the guys he'd castrated. The number of men he treated was only three. And of only three of the three he had treated, he only actually gave any information about two of them. One of those men had already been castrated, which today we know is a special case. So this whole idea that testosterone causes, this general concept makes prostate cancer grow, or, as Huggins said, activated is was based on one guy who received testosterone for only 18 days and and his curve is uninterpretable. Goes up and down, up and down, before and after testosterone. It was amazing. We

Dr. Gabrielle Lyon: 36:20

have to pause there. Why we have to pause is the gravity of what you're saying. People have to understand, yeah, they were castrating men based on a belief from this individual, who, again, is probably a phenomenal scientist. There were two viable patients in the study, maybe one viable because one was cast only one, one viable patient. Yeah, based on a way you guys were looking at this acid as phosphatase, acid phosphatase, which now isn't even used, treated for 18 days with testosterone and changed the lives of millions. Yeah, millions, yeah, of brothers, of fathers, of husbands, yeah. What can we learn from that? Yeah,

Dr. Abraham Morgentaler: 37:19

I'm so glad that you're underscoring this point, because, you know, I've done research since then, for 50 years, since I was not since yesterday, and and, and all different kinds, right, like randomized trials, pharmacokinetics studies, animal studies, basic science studies. My greatest discovery was actually figuring out, finding out that Huggins based this whole thing on one patient, and he was wrong about there was a misinterpretation of that information and and that's the basis why people around the world have learned for 80 years, have been told that testosterone activates prostate cancer, and later it switched. Huggins never said this, but people started to believe that testosterone actually caused prostate cancer, which it doesn't do either. There's no evidence for that, none, zero, nor does it make the cancer any worse, unless, here's the thing, unless you're already castrated, which only happens if you've already been treated for advanced prostate cancer, and that's where people have messed up. Do

Dr. Gabrielle Lyon: 38:34

you think that this is a bigger conversation about blind spots and critical thinking? Yeah,

Dr. Abraham Morgentaler: 38:38

it absolutely is, you know, so the field is moved. I'm proud to have been involved in some of that. But, man, it's hard. I've been railing at this point for so long, you know? I've been debating on stage at the National urology meetings, prostate cancer stuff for so long,

Dr. Gabrielle Lyon: 39:04

and that's probably not a comfortable place to be. Well

Dr. Abraham Morgentaler: 39:07

this, I have to tell you, there's a part of me that enjoys that I do, and because, especially because all the arguments are on my side, like it's an amazing thing, and to try and get people to open their minds, but these ideas die hard. I would say that the myth about testosterone and prostate cancer is the most persistent myth in medicine. It's been pervasive. And just the other day, I had somebody that I know who's in his mid 70s. He's got an uncertain spot by MRI of this prostate. So we went to see this prostate cancer specialist. Says, Listen, we're going to biopsy it. I don't know that we're going to treat it necessarily, you know, given your age, and it may just be, you know, a low risk thing, but if we find anything at all, you're going to have to stop your testosterone, which he's been taking for about 10 years. Dollars with great success. Now this is an academic center in a major city. There's no reason. It makes no sense that academic people are still saying this garbage to people. It's based on nothing.

Dr. Gabrielle Lyon: 40:13

Why? Why is that still happening? It's the same thing where someone says, don't eat eggs because they are raise your question, raise your cholesterol.

Dr. Abraham Morgentaler: 40:22

Yeah, which they don't. But that's one other topic. So you know who you know who said it best is, um, so old ideas die hard. And there's this guy, Max Planck, who won the Nobel Prize for Physics somewhere in the 40s or 50s, and and he wrote about new ideas. And, yeah, I'll try it. I'll try and do the quote credit, because I think it's great. He says, new scientific concepts do not triumph, because the opponents to it have been convinced, and now they see all of a sudden, see the light. It's because they die. It's because they die, and the new generation that's familiar with it grows up with it. And the short version of that is that science precedes One funeral at a time.

Dr. Gabrielle Lyon: 41:12

And you're not the first scientific expert that has said that, right? So

Dr. Abraham Morgentaler: 41:17

it's just amazing people hold on, and what happens is people don't like new information. They don't like new concepts that differ from what they've been taught. I've had people, you know, early days, I people walk out of my lectures. I gave grand rounds at important places like UCLA and and elsewhere, and there was an older chief, and the chief always has the last word after the guest speaks and and I remember at UCLA, Gene deckernian, who was a famous and very important, brilliant man. So some of the stuff I'm talking to you about today is was not nearly as it didn't have as many supporters as it did then. And he said, Well, this is all very well and good, but you know, I remember back in the day, we had experiences that were completely different with that, so I'm not going to take it too seriously right now. Thank

Dr. Gabrielle Lyon: 42:11

you to one skin for sponsoring this episode. I bring sponsors of products that I personally love and use. I first became obsessed with one skin because of one of my girlfriends, her skin completely transformed, especially under her eyes, which I definitely have issues with, and I wanted to know what she was doing. And it was one skin. I've always had issues with texture on my own face, and I've tried a million and a half different products. I landed on one skin. It's really helped me, personally transform my skin. I've been using their face broad spectrum sunscreen, their eye cream, their topical body supplement. I actually need more of that. It has a unique, clinically studied peptide that helps with DNA repair. You can get 15% off your one skin with the code oneskin.com and the code is Dr lion. That's 15% off one skin with the code, Dr lion. And

Dr. Abraham Morgentaler: 43:08

that was it. He had the final word. The students are there, the residents are there, the other faculty are there. And and it's just hard. Some of the old ideas have to just the people who hold them don't want to change their their minds. There's a lot of evidence that people confronted with evidence that contradicts what their beliefs are, actually double down and they make and they hold their beliefs even more strongly.

Dr. Gabrielle Lyon: 43:35

It's it's just so fascinating, and I think especially, you know, we all have bias, right, right? I believe that there's a certain way to stimulate muscle, and I believe that muscle is so important and how we're going to feed it, and nutritional aspects of it, and it is a struggle to remain open minded about other input, but I'm well aware that there's multiple ways to get something done. If you show me well done, randomized control trials, great evidence, then I have to be willing to change my mind, right? You know, it brings me to testosterone, testosterone replacement. And there's a few things, there's incredible stigma. Now still,

Dr. Abraham Morgentaler: 44:26

would you agree that which stigma just

Dr. Gabrielle Lyon: 44:29

take out testosterone and prostate cancer, take out testosterone and cardiovascular disease? If one were to just look at testosterone replacement in a man or a woman, people still feel like it's edgy, it's controversial, it's an anabolic which it is, yeah. Why do you think that that is? And then, of course, I want to get into if someone has low testosterone, how can, how do these numbers make sense? And. Yeah. And how are they different here versus other places? Yeah.

Dr. Abraham Morgentaler: 45:03

So part of the challenge is, is that testosterone is still considered by many to be fringe medicine, right? And and the reason for that, in my opinion, is that it's not taught in the medical schools still. So people, you know, we have remarkable amounts of information, wonderful scientific data about testosterone. What's amazing about it is that it's a natural chemical in the body, and it's also true in all these different animals. All the vertebrates have testosterone. Sub have testosterone or something very close to it, including fish. And so we have natural models to even look at testosterone. The wealth of the wealth of research into testosterone is phenomenal, right? And yet, people and we have studies in the top medical journals in the world, right? New England Journal has really liked all the RCTs about testosterone. Jama has published it. Who have stuff in Lancet. All the top journals have have data on this. And sort of the the regular physician who wants to keep up with the literature, you know, they trust those journals, but it hasn't impacted what they do, and part of the reason and so what we have is we have a medical condition, testosterone deficiency. Used to be called hypogonadism, where people have too little of it, men or women, we tend men get most of the the most of the publicity around this, and it's better studied in men, but it's true for both. And do you know that testosterone deficiency is either predicts the development of or is associated with many of the most important medical conditions we deal with in healthcare? So obesity, diabetes, the metabolic syndrome, cardiovascular disease, mortality, dementia, osteoporosis, these things are all associated with the deficient amount of testosterone in the body and beyond that these men, let's focus on men for a moment, these men have symptoms that often make them I say that testosterone deficiency is a reduced state of the human condition. There are data. I told you. There was a golden period of testosterone research, from the late 1930s to about 1940 1940 this guy, Dr Joseph Aub. Aub writes an article in New England Journal of Medicine that says, this is one of the most potent medications that we have in our in our armamentarium. And they describe men who were basically they called them broken men. Back then, broken men, that was the term. There were these men who just they lacked confidence, they were quiet, they were introverted, and they got testosterone, and they became better. Now I suspect that we didn't have blood tests back back then, not till the 1970s I suspect that many of these men who underwent these trials had extremely low levels. In the lower your level, the more of a benefit you're going to see, right? And the more the low level is going to impact who you are and how you carry yourself. But men, this, this makes a huge difference in how people live their lives. And so the fact that it's not yet accepted by what, you know, I'm a mainstream doctor, but I'm going to call this not accepted by mainstream medicine, is our number one problem, and what gets compounded then is that because there's a tremendous need. People now know that testosterone deficiency exists. They know somebody. They heard of somebody who got treated. They say, maybe I can get some too, if the regular primary care doctors aren't treating it, they go elsewhere. And so some of the docs that are doing this are docs that the sort of, I'm an academic guy, you know, it's like science based, but the academic docs see that those groups of physicians, and they say, I don't want to get involved with that. I don't think that well, of those practices. It's,

Dr. Gabrielle Lyon: 49:22

do you think it came from sport? Do you think it because maybe, potentially, it got demonized from sport and anabolic use, part of

Dr. Abraham Morgentaler: 49:31

testosterone problems has a bad rap. Yeah, has a bad rap.

Dr. Gabrielle Lyon: 49:34

Because what, what drug? We'll call it a drug or synth or naturally occurring hormone that one could give could affect bone, brain, heart,

49:47

blood vessels, blood vessels. I treat everything,

Dr. Gabrielle Lyon: 49:50

nearly every organ system. Yet it is not routine. You don't go into the hospital, and it's not as if 50% of the high. Hippo gonadal or testosterone deficiency in men, it's being treated, right?

Dr. Abraham Morgentaler: 50:06

No, we're treating a we're treating a tiny fraction of the men who have it. And it's funny, because in some ways, testosterone is the men who really need it don't get treated, not enough of them, and a lot of the men who don't need testosterone are getting it right through whatever gyms or now there's a trend to give it to people who aren't even deficient. You know, I have some talk about that, yeah, kind of feelings about that. I

Dr. Gabrielle Lyon: 50:31

would love to chat with you about that. Let's define testosterone deficiency good in terms of numbers and when one could consider treatment? Yeah,

Dr. Abraham Morgentaler: 50:43

good. So I think there's broad agreement, and I certainly agree with it, that that people should be treated. If they have low levels of testosterone, they have either symptoms or what we call signs. Symptoms are things that people experience, like my sex drive is down, signs or something you can measure like their hematocrit, their red blood cell count is reduced, or their bone density is down, something you can measure. So traditionally, all the guidelines say you should have both. The challenge is, what's a low level of testosterone? So and critics of testosterone therapy say the experts can't even agree on what a low level is, and that's true, and that's true, and it's part of the part of it is that some of the decisions about what a low level is has been arbitrary. So you know, the the if you the FDA uses a number below 300 nanograms per deciliter, and if you look at any of their writing, they have no citations for that. There's no reference. This is where they got that number from. So the the the urban myth that's, I think, is true, is based on talking to people, is that when there was a first new testosterone product brought to the FDA in the late 919, 98 I think it was a patch, the FDA said, Well, you have a drug that's supposed to normalize testosterone. Please tell us what a low level is

Dr. Gabrielle Lyon: 52:07

air. I mean, that's really fair. And so

Dr. Abraham Morgentaler: 52:09

they had a very senior expert, and he said, well, people disagree on the number, but some people think it should be 400 some say 350 some say 250 and free testosterone was not discussed. Nobody's talked about we have, we have to talk about free testosterone, but nobody's that has been part of the conversation for forever. But, and so this guy said, apparently to the FC, I think 300 is a fair number,

Dr. Gabrielle Lyon: 52:34

but now I'm defined on age. So Matt, my producer, could have 300 and my dad, Nate, could have 300 and let's say it's 310 for both of them, right? Could we treat them?

Dr. Abraham Morgentaler: 52:45

Well, of course, you can, if they have symptoms. In my opinion, the idea that there's a, first of all, the idea that there's a single number that separates everybody is just, it's, it's, it's anti scientific, right? Like, we're not like we don't work like that. Our bodies are not we're not clones of each other, right? You do research in animals like rats, they're all the same genetic strain. They're all basically identical twins. That's not true for humans, and we all have different set points for a lot of different things, people can tolerate cold, heat, pain, like we're all different with all these things. And true also for when people become symptomatic, in terms of having low levels of testosterone. But it's worse than that. It's worse than that because what a low number is is defined by specialty and by geography. So the endocrine

Dr. Gabrielle Lyon: 53:38

and geography you have to say that, because you got to pause on that, yeah.

Dr. Abraham Morgentaler: 53:43

So get this. So in the United States, the endocrinologist their guidelines say, yep, be below 264 urologists say 300 FDA says 300 guess what happens in Europe? In Europe, they use 350 I ran a expert panel on testosterone some years ago, which we published, and we had a couple of European guys, and there's one guy from Europe who says, if they have symptoms and they're under 400 I'll treat them.

Dr. Gabrielle Lyon: 54:12

But that's not the guideline. No, it's

Dr. Abraham Morgentaler: 54:14

not guidelines. So geography, so if you have a guy like 310 in the United States, you go to a primary care doctor, he says, it's normal. I'm not going to treat you. If you go to Europe, they say, Oh yeah, you're low. We'll treat you well. That doesn't make any sense, because if you go see an endocrinologist, they say you could have a testosterone at 275 the endocrinologist said, kind of the guidelines, you're normal. I shouldn't treat you. But the same endocrinologists that write that have also performed many of the most important studies we have where they use values under 300 or in some cases they had one. They said we wanted unequivocally low levels, 275, but that's not even what their numbers are now. Now it's even lower.

Dr. Gabrielle Lyon: 54:59

Yeah. So what is and also, age doesn't matter, right? It doesn't right.

55:06

Well, according to guidelines, according to the guidelines, and

Dr. Gabrielle Lyon: 55:08

as physicians, we are taught to treat according to guidelines, yeah. What does that mean for the well being of the patient?

Dr. Abraham Morgentaler: 55:18

Yeah? So you know. So I'll give you my take on guidelines. Guidelines is an important has been an important step forward in the last it's really only in the century, you know, the last 20 years or so. And it's really they provide guidance, but they're not the rule of law, right? And in the end, it's a group of individuals, you could have 10 people sitting in a guideline panel, and they all might practice differently, 10 different ways, but they have to come up with basically a consensus document. So they might say, Okay, let's say 300 is the number. So they put that out, and maybe they have other requirements too. How many times do you check does that be mornings? Happy afternoon? And at the end, after putting that out, they all go home to their practices, and they can still practice differently than the guidelines 10 different ways. But people think, oh, it's guidelines. There's a clear way, right way to do things and wrong thing, and you can't deviate. No, not at all. I think guidelines are helpful for the novice. In my opinion, that gives you a general sense of what's probably safe to do and in almost all circumstances conservative. But I think once a physician or a healthcare provider gains a certain amount of clinical experience, clinical experience can, in my opinion, often outweighs what the guidelines say.

Dr. Gabrielle Lyon: 56:39

Is there a saturation point? So what I mean by that is, would there be any benefit from going if someone was taking 200 milligrams of testosterone, right up to 400 and we're not saying that, we recommend that, but would it affect all tissues equally. And how do we think about is more better if we know testosterone is great, is just in terms of a safety profile, if at all?

Dr. Abraham Morgentaler: 57:11

Right, so let me use that question to get back to solving the mystery of testosterone and prostate cancer. Like, how is it that lowering it is helpful, but raising it doesn't seem to be dangerous, right? And the answer is the term that you used, which is saturation, that I came up with in about 2007 and then, together with my dear colleague, Abdul Trish, we really put the the finishing touches on it. And what saturation means is that if you started out either prostate cancer cells or prostate cells or animals or humans with essentially zero testosterone, you give them more testosterone. Prostate tissue does need androgens, testosterone like substances, in order to grow. True, it's a requirement for them. But it turns out that the maximum ability to grow maxes out at a relatively low concentration of testosterone, which looks like it's around 250 nanograms per deciliter. So we there's studies, and I'm a part of one. Mokira that you mentioned, published another one where if you have men who have levels below 250 and they get testosterone, the PSA, which is a marker of prostate activity, goes up. If they start with a testosterone above 250 and you give them more testosterone, nothing happens so that saturation. Imagine a sponge with water. You can put it on a scale, has a certain weight. You add a little water, it absorbs it. The weight goes up. You add more and more water, at some point it's saturated. It can only hold so much water. Adding any more water doesn't do anything, right? So it's maxed out. And different prostate it looks like the saturation point is around 250 different tissues are different. So you know, men, men who are castrated or undergo treatment, so medical equivalent of castration, get hot flashes, just like women in menopause, it turns out, and we call that vasomotor instability, like the blood vessels and whatever is sensing it centrally in the brain goes crazy, right? And but it turns out that if you let a guy's testosterone get back to about 100 which is extremely low number, it's gone. No more vasomotor instability. So whatever that is, that saturation point is probably around 100 prostates around 250 but a lot of guys at 250 still have symptoms from testosterone deficiency, like low libido, and some of that probably gets satisfied at numbers around 500 maybe 600 depending on who the guy is. That's saturation for that symptom in the brain. So that's what

Dr. Gabrielle Lyon: 59:54

it's a brain some of this is Brain symptoms. Yeah, listen

Dr. Abraham Morgentaler: 59:58

my lizard stuff. Testosterone is a brain hormone. Yes, it also works on muscle and fat and all these other organs, but it's a brain hormone, absolutely. So, um, so one thing that's interesting is that is fine. So the question comes up, if somebody who doesn't have low testosterone, takes testosterone. What's going to happen to them? Great question. Yeah. So this sorry, let me take you

Dr. Gabrielle Lyon: 1:00:28

wonderful. No, no,

Dr. Abraham Morgentaler: 1:00:29

you're Forgive me. Forgive me, please. Yeah. But this is part of because we

Dr. Gabrielle Lyon: 1:00:36

have all kinds of people that listen to the show, and let's say a woman is listening for her husband and she's concerned that her husband is on testosterone or that he doesn't need it, right? We have to be able to rethink about these conversations, and because the ultimate outcome that we want is health and longevity, right? And muscle, yeah,

:: 00:56

which is all part of the same, exactly,

Dr. Gabrielle Lyon: 1:00:57

exactly. So what if someone isn't low, and if we were to define but let's say they are on the lower end, 350 sure if you increase someone's testosterone. I mean, you had mentioned that they there might be brain effect at four or 500 is there a number? Well, what happens if someone is not low? And or how would you define not low? And if you give them testosterone, what would happen? So

Dr. Abraham Morgentaler: 1:01:25

what I mean by not low? In some ways, the easiest way to define this is certainly well within the normal range, and that individual has no symptoms, right? They just say, I think I might be better in some way with testosterone. So if you have a guy with let's look at sex drive, for example, a guy who's upper end of normal we often define as around 1000 Okay, so he had a guy who's 900 compared to another guy who's 700 which they're both well within the normal range, they're going to have, on average, the same amount of libido as a matter of fact, you can take the same Guy, let's say you could manipulate his hormones at 700 to 900 nothing changes for him, not erection, nothing because his testosterone is normal, the one area that does not seem to max out his muscle, his muscle. And that's why the body builders, the athletes who are taking anabolic steroids that are all versions of testosterone, like compounds versions of testosterone. Why they can have muscles on top of muscles on top of muscles, right? So anybody that's on normal amounts of testosterone therapy, just trying to get them, maybe to the upper into the normal range, or the upper end, or even if they might slip a little bit above it here and there. It's not a problem. I've I've treated 1000s and 1000s of men. There's nobody who walked into my office looking like just regular muscular who walked out like super built.

Dr. Gabrielle Lyon: 1:03:00

This episode is brought to you by timeline. Remember, we set standards, not goals, and one of the core standards that we should all set is having healthy muscle, and that starts with robust mitochondria. There are various ways to get healthy muscle that includes a amazing resistance training program. It includes dietary protein. And if I were to pick one supplement for muscle health and mitochondria, that would be mitopure. It's a precise dose of a postbiotic urolithin, a and it works by promoting essential cellular cleanup. And this process clears out old, dysfunctional mitochondria. I would make a mother in law joke, but I'm not going to and timeline has done an incredible job at leading the way, from a science perspective, to bring you the only clinically backed urolithin A on the market. And I will tell you what I've been using your lithium a for years. My husband uses it. My friends use it. And here's why, we have better energy. We recover faster. I feel like I have more endurance, and it really helps me meet my physical standards, and I know that it will help you, too. And by the way, there is more and more research coming out on your listen a so go to timeline.com/dr lion, and you will get 10% off your order. That's timeline.com/dr. Lion, 10% off your order. I think that this is an extraordinary product, and I think that wherever you are on your training muscle journey, that it's going to benefit you.

Dr. Abraham Morgentaler: 1:04:36

You need to get levels that are 10 to 50 times higher in terms of testosterone equivalents to start doing this. So

Dr. Gabrielle Lyon: 1:04:44

what would that look like? Would that be a total testosterone of 5000

Dr. Abraham Morgentaler: 1:04:48

so here's the thing, most of these people don't actually use testosterone or maybe part of their regimen, so they stack, they use multiple agents that do this, and some of these agents have never been really tested in human. They've been used in cattle and horses, for example, like wind strong, and they seem to be more potent for the muscle effects, rather than sort of the libido effects and things like that. But in terms of testosterone equivalency, in terms of muscle potency, some of them are more potent. And the reason that testosterone works differently in muscle, is muscle has an extra receptor for testosterone. So for almost everything testosterone does in the body, there's one receptor, which is a chemical that binds it. It's called the androgen receptor. In muscle, there is a second receptor that's bound to the cell membrane. It's called the G protein coupled receptor, and it's hard to see. It's I'm not sure that there's an upper limit to how much you can get with testosterone. With testosterone through that second mechanism,

Dr. Gabrielle Lyon: 1:05:56

that's fascinating, and I'm sure that there is a muscular potential for an individual, and maybe one could only get so big, or maybe if they use anabolics, then it would overcome that muscular potential. It would be really fascinating. Yeah, in terms of free testosterone, that's what is that? I won't put words in your mouth. Is that what you care about more? Yeah, I'm

Dr. Abraham Morgentaler: 1:06:19

so glad you asked. So you know, the the everyday scenario that I hear about is that somebody goes to the doctor and they have symptoms of low testosterone, and their testosterone comes back in what is called Low normal range, right? So let's say it's 310, or 320, or 350, and the doctor says, well, you're normal. Almost all of those men will have low levels of free testosterone. And in the short bullet is the free testosterone is the more most reliable indicator of a man's testosterone status. So I don't get, I hope I don't get too sort of nerdy with this, but, but your your viewers can handle it, I'm sure. Yeah, so listen, so when you measure total testosterone, what they do is they take a certain amount of your blood and they measure how much testosterone in total is there per little unit of blood. So it's measured in nanograms per deciliter, a 10th of a liter, and, but testosterone circulates in three forms. More than half is bound to this carrier molecule called SHBG, sex hormone binding globulin. And what's important about that binding is it's so tight that testosterone can't come off it. So if the testosterone attached to shpg is just floating past the cell, that's saying, Hey, give me some testosterone. I'm hungry for testosterone. Testosterone can't get in there. That portion is not biologically available. Most of the rest is attached to these other proteins in the blood, like album, but it's weakly bound, so it goes on and comes off, goes on and comes off. And so when that cell is saying, hey, I need some there's enough of it coming off of that that it can get in there, and one or 2% is free, which means that the not that the test doesn't cost you anything, but, but that it's it's Unbound, unbound. And what gets through that cell membrane is the free testosterone only. So testosterone is lipophilic. It likes lipids. The cell all cell membranes are lipid bilayers. It's like, like, likes like, and it can just go right through it. It doesn't need any carrier proteins. It doesn't need sodium channels, calcium channels, just gets into the cell that needs it. And so the free only makes up one or 2% of the total. So as we get older, our SHBG rises and it tends to bind more of our testosterone, and so most of that isn't available to the cells, so the total can look normal, but actually the free may be low. How

Dr. Gabrielle Lyon: 1:09:12

would you know? This makes me think about women who go on birth control and increase SHBG, right? Irreversibly, yeah. How would and perhaps it's different for men and women, how would they increase free testosterone, right?

Dr. Abraham Morgentaler: 1:09:27

So SHBG is. The beauty of free testosterone is it's unrelated to whatever SHBG is doing. So SHBG is binding up a lot of the testosterone that gets measured in that blood test, but the free testosterone is just hanging out, doing its thing. So it is, whatever it is, it's either low or it's normal, or potentially it could be high if you're on treatment. So it's unrelated, but what it means is that women who have been on birth control pills, and women in general, tend to have higher shbgs than men. Do you. So it means that their total testosterone is even less reliable in women than it is in men. And so in order to properly interpret what a man's status is, you either need to get a free testosterone test, or we always measure SHBG and you can actually, they're these online calculators. You just put in the SHBG value, the testosterone value, and it'll spit out a number for you for the free testosterone. And

Dr. Gabrielle Lyon: 1:10:26

when I, I asked about how to increase the free testosterone, yeah, would that be one? Would have to increase the dose. So if, for some reason, someone is on 150 milligrams a week of testosterone, right, and the free testosterone is still in the lower range, you would have to increase to 200 or even potentially beyond,

Dr. Abraham Morgentaler: 1:10:47

yeah. I mean, so, so what happens is that the total testosterone number when SHBG is generous or high is unreliable. It's going to look like it's fine when the person is really deficient, right? And but if you give testosterone, the free will go up, and the total also goes up. And so when I have somebody where there's a discrepancy, so most of the time, when there is a man who has a lot of symptoms who say, Oh man, his blood tests are for sure, going to show levels, low levels of testosterone, and his total comes back within the normal range. It's almost always explained by having low levels of of free testosterone, which usually goes along with generous levels of SHBG. The treatment is the same. The treatment is the same, and the goal of treatment is not to get the total testosterone into the normal range. The goal is to improve the symptoms that the man is having and hopefully resolve them, and they will resolve if it's hormone related and but because these guys with elevated or generous SHBG levels already may have good total levels, I always tell the patient, and I put it in the record, because other doctors will see these notes that the total testosterone is likely to be very high with treatment, because we're treating a free testosterone

Dr. Gabrielle Lyon: 1:12:09

because oftentimes providers in the patients will become concerned, yeah, that their free testosterone is outside or their total testosterone is outside of normal range, but their free testosterone is barely there where, you know, barely over the minimum. Yeah,

Dr. Abraham Morgentaler: 1:12:27

I have a very prominent patient who has a lot of doctors, and he's just like that. His total testosterone is fine. His doctors didn't think he needed anything. His free testosterone was low and his total testosterone was mid range normal. I don't remember the exact number. It's many years ago since we've started treating me, let's say was 500 Yeah. And most people say, Oh, that's robust, right? And but he had all the symptoms. He had low free testosterone, so we treated him, and all his symptoms got better. It's interesting. This is a man who was on top. Who should you and I would think that everything he's done he should be on top of the world, but he wasn't. He's a guy like everybody, and when testosterone is low, he wasn't who I thought he should he would be. He was really struggling, yeah, and you know, life is hard, like it just is right. We have challenges every day, whether you have small children, elderly parents, difficult relationships work like life is hard and what would I see testosterone doing for a lot of people, even if they're not like out and out miserable, is they lose what I call the critical 5% there's a certain way that you, for example, are successful, because you've got drive and passion and skill, but if you lost a little 5% of you, you could get through your day, you could do podcasts, you could write, but it would be a chore for you, and you would lose some of what it is that makes you you, and that's what I would see with a lot of these men. They'll lose their sense of humor, right? They lose their sense of play. They lose their reserves. People think testosterone makes people irritable and aggressive. It does not. Testosterone does not, does not, but irritability happens when people don't have emotional reserves, and they lose those reserves when their gas tank is approaching empty. So, yeah, so I'm sorry for that little song, so I think it's, I think it's really important, but yeah, in the end, what I'm really saying is, you know, here we're talking about numbers, and they're important, and they're going to help people out there who are listening, and hopefully health care providers too. But in the end, we're. We're talking about our people. We're talking about people, and I've had discussions with prominent endocrinologists and other academics, but why don't you take this testosterone business more seriously? We've got great research. And they say things like, I remember this one conversation this very you know, academically important person said, Well, I think we'll take it more seriously once we have studies that show, you know, important differences in outcomes. And what she's talking about are, you know, mortality rates or complication rates of this, that or the other. But what gets lost in all of that is the individual person, the individual person. And one of the most gratifying things for me, and part of why I fought on with the testosterone story, especially early days, is that I I was, I was making a huge difference in the lives of these individual people. I didn't have an agenda to show testosterone was good. I was working hard just to be okay at what I was supposed to be okay at. I was learning surgical skills, trying to become an expert in all these things. But I had these patients, and it turned out that these guys who had low levels of testosterone, some of them just low free testosterone. If I treated them, they'd come back, and they had the most marvelous stories about how their lives were improved and when I was especially early days. What was amazing? I felt like I was seeing because nobody, none of my colleagues, were treating with testosterone. It's not just that they weren't treating they thought I was doing dangerous medicine,

Dr. Gabrielle Lyon: 1:16:40

and they, I'm sure they shunned you, yeah, I caught

Dr. Abraham Morgentaler: 1:16:43

a lot of a lot of flack. I had some tough, some tough situations, but, but what kept me going was I was seeing something that wasn't being described in the literature or that I had been taught. I was seeing something that was like, these guys saw all the best known urologists or endocrinologists, like in Boston where I was, and they'd cut and without success, and they'd see me. I said, Well, your testosterone is low. Let's see what happens. I mean, I didn't have any guarantees, and they'd come back and they said, Oh my god, like my life is better. I tell you one story. This guy came to see me as a surgeon. He didn't care about, I don't know whether sex wasn't an issue for him in his in his life, or he just didn't care about he says the problem is, is that he's up all night operating, and the next day he has full clinic see, the full day of seeing patients. And he says, you know, for the first 15 years of my career, that's not a problem. He says, Now I find that I'm falling asleep the next day after being up all night, and I'm just wondering if it could be testosterone. His testosterone was low, and I treated him, and he came back and follow up, and I said, How's it going? And he said, Well, I don't fall asleep anymore the next day. So he was like, happy. I said, that sounds great. He says, but it's more than that. He says, Since I started with you, he says, I've reorganized my entire division. I've written three papers, I've made two educational videotapes, like this guy had gone to town. That's who he was before he had stopped doing that. What got him is he couldn't stay awake, right? Like, that's what brought him to the office. But in fact, this guy was a superstar. He was a dynamo, and he'd lost part of his dynamism, and that's what testosterone can do for people who are deficient. Do

Dr. Gabrielle Lyon: 1:18:36

you think that that is the same, and I know you don't treat women, but do you think that that's also the same for women? Absolutely. Have you seen obviously, I know the answer to this question, but I'm asking you, have you seen the transition as of various types of testosterone delivery systems? Oh, yeah, from oral to gel to sub q injection. Do you think that there is one that is better. But before you answer that, I am curious so much to talk about. I know, I know. But testosterone in women, yeah, do you think that it will have the same impact?

Dr. Abraham Morgentaler: 1:19:14

You know, I'm chuckling. So listen, testosterone is the most interesting chemical. It reminds

Dr. Gabrielle Lyon: 1:19:19

me of, what is that Don Perry honor, or this the most interesting madam? Or, no,

Dr. Abraham Morgentaler: 1:19:25

no, I do. I know that. Yeah, but yeah, and it's not that guy. Or, I think it's

Dr. Gabrielle Lyon: 1:19:31

do SEC is right. So if doseki was a molecule,

Dr. Abraham Morgentaler: 1:19:33

it would be testosterone. Testosterone, yes, no, it's true. It's fat, the amount of stuff that's involved, it's everywhere. We had a talk. We have a annual meeting. It's called the, excuse me, the androgen society. We had an ophthalmologist come and talk about effective testosterone on the eye. Turns out that the number one cause of office visits to eye doctors is dry eyes. Guess what? Testosterone does? Yes, it makes lubrication for the eye or helps to enhance it. So people who have dry eyes often have deficient tear production. Wow, testosterone is involved with that. Would they

Dr. Gabrielle Lyon: 1:20:10

this is just a side note. Do you think that there's ever a place for intra eye drops that are hormones

Dr. Abraham Morgentaler: 1:20:17

they have? So According this guy, they use some ointment that has testosterone in it. They use that for the eye.

Dr. Gabrielle Lyon: 1:20:22

Sign me up, right? Like you're gonna be super sharp,

Dr. Abraham Morgentaler: 1:20:25

right? Yeah. And it happens more in women who have less testosterone than men. I'm not saying that testosterone is the entirety of that story, but it's a contributing factor. Yeah. So testosterone are women. So I don't you know, I started years ago a Men's Health Center, and so I saw, actually, the

Dr. Gabrielle Lyon: 1:20:41

first, you started the first Men's Health Clinic. Yeah,

Dr. Abraham Morgentaler: 1:20:46

thank you for thank you for saying that the the you know, it's funny. So I was so proud when it we opened it up 1999 and Men's Health was hardly a concept back then. And I was full time faculty at the hospital Beth Israel Deaconess Medical Center, where the Harvard teaching hospitals and I go to the President, and I say, and we have all these hospitals in Boston. They're all these high powered places. They all compete with each other. And and I went to the President, I said, Listen, every hospital in Boston has a women's health center. Nobody has a Men's Health Center. I say, I think I practice what could be termed men's health. I do male infertility, male sexual stuff, testosterone, some prostate. I think the hospital should open up a Men's Health Center. I'd like to run it. And we had a couple of conversations. And at the end of the he says, oh my god, this is great. Let's do this. And I said, super. And I said, How long will it take? And he said, four years. And I said, What? He said, listen, we're a big institution. We're a bureaucracy. We can get this done, but it'll take a lot of years. And so I left my sort of lab research stuff, and I went out on my own, and I thought it was a great idea, and it worked out well for me. For

Dr. Gabrielle Lyon: 1:22:00

me, pregnancy was very difficult. I had hyperemesis gravidum, which meant I threw up through my entire pregnancy. If you or someone you know is thinking about conceiving, or even post the ages of conceiving, essentially, if you know any women, then I strongly recommend needed products, and here's how I found them. I was looking for a new prenatal for myself and my patients to make sure that nutrient needs were covered. 95% of the women in the prenatal stages, meaning before they get pregnant, have nutrient deficiencies. Most prenatal vitamins just have the bare minimum based on outdated research and guidance. And frankly, we deserve to thrive through any stage of our lives. Needed is based on practitioner validation, clinical research. And of course, there are 1000s of women and practitioners that have used needed supplements, and that is why I believe in these products, they have been formulated by experts in women's health, and are backed by clinical insight from their collective practitioners. Their products offer the forms of nutrients that your body can actually use. Dosat, you guessed it, optimal versus bare minimum lows. They have third party testing, which is very important, testing every batch to ensure the safest product needed, prenatal multi is available in capsules and an easy to take vanilla powder that's perfect for nausea or, let's just say you have pill fatigue needed, offers premium supplements for every stage, whether it's egg quality Support for women trying to conceive or lactation, four breastfeeding moms stress and sleep. Support you name it. This supports these products. Supports all women. You can get yours by heading over to this is needed.com and use the code Dr Lyon for 20% off your first order. This is needed.com/dr lion, to get 20% off your first order. And what

Dr. Abraham Morgentaler: 1:24:08

that was 1999 it was called Men's Health, boss, and it still exists, but I'm not part of it anymore, and but what's funny is that Men's Health, these men's health centers have now gotten a little bit of a wonky reputation, and so I used to be so proud of it. Now I don't always mention it, but the idea was to have a place that really focused on various aspects of Men's Health, and to do it in a respectful and way with expertise. And I still think it's a great idea. Do

Dr. Gabrielle Lyon: 1:24:40

you think that they have somewhat of a stigma because individuals experience it as kind of a turn and burn? It's just everyone's getting the same treatment.

Dr. Abraham Morgentaler: 1:24:51

Do you think that that's where that comes from? Yeah. So these centers are often they advertise on radio, on sports radio, things like that. The. They've gotten a reputation for not necessarily practicing the best medicine and and, yeah, they a lot of churning is sort of what you hear. Now, there's a funny part to that I have to tell you, so I don't share those criticisms completely. And the reason is, is that within what I would call sort of more institutional medicine, right mainstream, you know, you're here in Houston with all these tremendous academic centers, if you go see an average doctor, Houston may be different, because of some there's some key individuals here who have popularized use of testosterone. But in most American cities, you go to a hospital based doctor or hospital affiliated with symptoms around testosterone, male or female, and you will not get treated you just want. You'll be shut down. So even at my own institution, the endocrinology folks, I'll never forget this. Can I tell story? Yeah, so all of that I see, so I would see a lot of second and third opinions, right? Like people have were shut out somewhere else. And this one guy comes in. He's in his mid 40s, 45 or so, and he's married, and his problem is he has no sex drive, and his wife is complaining and and he feels like it's wrong. He's not holding up his end of the bargain, if you will. And so his primary care got testosterone levels on him, and they were low, really, quite low. And so he got referred to the I need to be careful about how I how specific I get. He goes to see an endocrinologist at one of the teaching hospitals in Boston, and the guy says to him, looks at his labs and says, You absolutely have low testosterone, but I'm not going to treat you. He says, why not? He says, well, in ancient Egypt, there used to be eunuchs. Guys were castrated and they were regarded with great respect. They often had important positions in the in the Queen's coterie, and your testosterone is a lot better than any eunuch. And they did okay. You don't need it. And when the guy comes to see me, he tells me this story, and he says to me, very funny, I thought. He says, I don't give a rat's patootie about some ancient queen in Egypt. I care about the princess sleeping next to me in bed every night, right? So we treated him, and of course, he did very well. It's actually not rocket science. And I know some rocket scientists, do

Dr. Gabrielle Lyon: 1:27:39

you really? I know one, yes, absolutely. And an astronaut not.

Dr. Abraham Morgentaler: 1:27:43

It's not that complicated, right? You just need to know a couple of key facts and about how to treat and and we improve the lives of people. And the argument to not treat them is mystifying to me. And so getting back to these men's health centers, the reason I'm not so critical about them is, although I don't agree with that necessarily, everything they do, they often are giving three medicines instead of one that they need, and all and they grow in all this other stuff too, is at least those in patients are getting treated. I agree with you. I agree with you, at least they're getting treated. And I think most of the other stuff may not help them, but probably doesn't hurt them, so I can't give them like my wholehearted blessing. But geez, Louise, I mean, it's

Dr. Gabrielle Lyon: 1:28:32

better than nothing, and there's a need. Yeah, if primary care physicians were to be treating these testosterone deficiencies in both men and women, it would stop, then we wouldn't require more. I don't know outside the box method exactly delivering these medications

Dr. Abraham Morgentaler: 1:28:50

exactly right? What's missing is that what should be the normal response, right? It will be,

Dr. Gabrielle Lyon: 1:28:56

I think that it will be the next 10 years. If individuals are likely not treated with hormone replacement therapy, then it's just,

Dr. Abraham Morgentaler: 1:29:03

as they say, from your lips to God's ear, God, are you listening? I have a number

Dr. Gabrielle Lyon: 1:29:07

of issues I'd like to take up with you. I'll do that later. I think it's really important. And in terms of, you know, I also selfishly wonder about women's levels. I think that men are really well studied, yeah, and we have a sense of what I mean, and I don't know if there's a free testosterone that you think is optimal for a man. Is there, as all the men feel up there? Yeah.

Dr. Abraham Morgentaler: 1:29:31

So free testosterone come it gets complicated. They're different units that are used for measurement and different tests, but the most commonly used test is now called the calculated free testosterone. The lab reference ranges are useless. They none of them will say that any but you have to be incredibly low to be categorized as low, anything less than 100 picograms per mil is together with symptoms, in my opinion, bears treatment. That's what I used for 30 years. And

Dr. Gabrielle Lyon: 1:30:02

then women, I know, you don't treat women. Women are one would they be 110 that so

Dr. Abraham Morgentaler: 1:30:08

women have about 110 the amount of testosterone that men do. Free testosterone is more important in women as it is in men, maybe even more important because they have so much SHBG. And the data in women, there actually is many very good studies in women, and some of them go back also to the 40s. And the 50s,

Dr. Gabrielle Lyon: 1:30:27

seems like there's a robust amount of data during that there's a period where there seems to be

Dr. Abraham Morgentaler: 1:30:32

robust you know what happened in women is that their all their hair fell out,

Dr. Gabrielle Lyon: 1:30:38

no, because of testosterone, which can happen. Yeah, it's

Dr. Abraham Morgentaler: 1:30:41

rare. Rare. It's one of the risks in women, of course. But what happened is, there's no FDA approved testosterone product in women, and FDA has a funny relationship to medicine. FDA does not regulate the practice of medicine. They have nothing to do with what health care providers do or how they manage things, except for making pharmaceutical products available on the market. They govern the pharmaceutical industry, not the Pratt they and they will say straight out, we are not involved in the practice of medicine, somehow, along the way, some kind of institutional part of medical education got tied into the FDA in a way that I think is actually unhealthy. So for example, I do a lot, I organize and speak at a lot of continuing medical education events. It is part of the requirements. We call them CME, part of the requirement. Before that all speakers say whether or not they're going to be speaking about anything that is considered off label. Off label means use a medicine in a way that the FDA didn't say is Okay, so let's say a drug like, I don't know the new GLP ones, right? Great example. So they start off with whatever the first indication was. I don't know, weight loss, diabetes it is, yeah, but you know, it could be that. Turns out, there's incredible data that some of these medicines are good for other things, right, like kidney function and heart disease, right? But unless the drug company has applied for essentially permission from the FDA to state that is one of the benefits, then it's not, then the FDA won't give that as an indication. So every drug, every time you pick up a medicine, it's got a label inside, right inside the box, or whatever, and with a lot of fine print and all these scary things that can happen, and part of what it says is indications. That's what the FDA says the pharmaceutical company can promote that drug for.

Dr. Gabrielle Lyon: 1:32:56

But that doesn't change the ability to use it. It would just be used awfully. And

Dr. Abraham Morgentaler: 1:33:00

so physicians have discovered that all sorts of medicines have benefits and uses beyond what the label says. So at these conferences, and many of them are in guidelines. So for example, one of the treatments for in my field, erectile dysfunction is there's for people who don't respond to Viagra, Cialis, often. The next line is medicine that the man injects in his penis that gives him an erection more powerful than Viagra. And what does that medicine call it? So there's usually it's a combination. The most potent is a combination of three, and we call it tri mix. But tri mix has never been approved by the FDA, so it's off label. You can't pick it up at a prescription at a pharmacy like Walgreens or right compound. You go to a compounding one. But it's been around now for since the 1980s it's standard treatment. So if I was giving a lecture that involved a comment about that, I would have to say ahead of time to the organizers of a CME event, I'm going to be talk discussing something off label. But the off label part, for a lot of people say, well, that's kind of iffy. No, it's not. It's standard medicine, often, often, and so

Dr. Gabrielle Lyon: 1:34:15

that I have to pause you there. It's because this is so important, yeah, because basically what we're trying to do is break through the barrier to entry, and we cannot do that as physicians to our patients, or patients that are listening, or individuals that are listening, so they can advocate for themselves, that just because something is deemed off label doesn't necessarily mean that it is unsafe or that it's shoddy or that it shouldn't be used. Case in point, testosterone use in women. In women, exactly which one of the treatments for hype? I'll ask you this, what is the treatment in women? For hyposexual desire disorder,

Dr. Abraham Morgentaler: 1:35:03

right? Well, in some cases, if their testosterone is low, testosterone will be perfect testosterone, but it's not indicated fast. There are no products for it. So well, Addie, yeah, you just got approved. Yes, no, there's, there's a couple of products that are used for that, but there's no testosterone, pro Exactly, right? So listen, Addy is a non hormonal treatment. The medicine is called phlebaster, and the data are actually very strong. It is FDA approved for that right for a woman who is post menopausal and has basically her her gas tank for a couple of those sexual hormones, is at zero. Testosterone can help. Some women who are pre or perimenopausal may have low levels of testosterone. They can benefit from it too, and women's symptoms are often very similar to men. They have fatigue that isn't sort of normal, explained by activities, right? It's out of proportion. Fatigue. They don't feel right. Their energy, their zip is gone. Libido may be down, and testosterone works for them just like it works for men. We're not. You know, there are differences between men and women, but we have a lot that's so similar. Do

Dr. Gabrielle Lyon: 1:36:12

you think that if it were FDA approved for women, just your personal opinion, would it change things? Yeah,

Dr. Abraham Morgentaler: 1:36:17

it would, it would. It would make it much easier. Because here's the thing, you're together. So I mentioned that institutional medicine, or academic medicine, has this weird, I think, unhealthy. They they bow down to the FDA, as if the FDA is some arbiter of something. It's not, it's not well, it is, but only with regards to what their mission is, which is to make sure that the drugs approved in the United States are safe and effective. That's their mission. It's not to regulate how medicine works. And yet, there are too many people within the medical community say, Well, if the FDA doesn't list it as an indication, I shouldn't use it. Our studies are just as with or without an FDA approved indication. The studies are the studies and the studies show testosterone therapy in women can be highly efficacious and safe for women who have symptoms related to low testosterone. And

Dr. Gabrielle Lyon: 1:37:10

to to be clear, do you think again? I know you don't treat women. Do you think a free testosterone of 10 picograms per ml,

Dr. Abraham Morgentaler: 1:37:22

so that starts to be around the right place. So the sim this, the thing is, the person, the data around women and actual levels are less strong, yeah, you know. And what's funny is that they're, they're, well, there's a whole other topic. So I hesitate to take you too far afield. But, you know, the world of Endocrinology is based on blood tests of hormones, and it to treat people who are too low or too high, right? Whether it's thyroid or whatever it is, in order to decide what's normal, you have to have a control population and yeah, and and so forth, and so in men, this is really hard, but they've tried like, who's the control population, right? Is it 80 year old men? Is it 25 year old healthy guys? Is it the average, the average assortment of people you might see in a doctor's office, or is an idealized group of individuals with no medical conditions whatsoever, and people struggle with this. The reference range is for laboratory tests, for testosterone, for example, I mentioned earlier, they're useless. They're useless because they all differ their reference ranges and they're not based on clinical symptoms. So there's been an effort with testosterone to use young, healthy men with no obesity, no medical problems whatsoever, and to say this is our reference population. And then what's funny about that is it is a central tenet of Laboratory Medicine, that if you had, let's say, 100 individuals in your reference population, that the central 95% of them are categorized as normal. That's how labs work for any blood test you you want, with a few exceptions, like where there's targets, like cholesterol, PSA, otherwise, whatever it is, hemoglobin, hematocrit, liver tests, they have a reference population, and they say that the lowest 2.5% are low by definition, and the highest 2.5% are high. So if you had a condition where the prevalence is, let's say testosterone. Let's say low testosterone. Let's say you had a perfect reference population, whatever that is, it would be fine if the lowest 2.5% of the population had that condition, if the prevalence was 2.5% but what if the percentage is 5% or 10. Percent, but only the lowest 2.5% are getting categorized as abnormally low. It means that you're missing and mis categorizing in the 10% prevalence, which I think is a conservative number for adult men, you're mischaracterizing 75% of them as normal when they're actually low. Yikes. And so a lot of people don't understand what reference ranges are and how we use them. They're a guide, but they cannot be used as some rigid application of anything. So with with women, the data on levels and symptoms have been harder to find correlations with than in men. So I know I have a lot of my colleagues in the testosterone world do treat women with testosterone, and they won't base it generally on a level. They say, well, we just base it on symptoms. And that's not necessarily wrong, but into the world of in those I'm not an endocrinologist, but maybe I play one on TV, but I'm a frustrated one, or

Dr. Gabrielle Lyon: 1:41:06

maybe on your show, the sex doctors, yeah, he's a podcast. It's not a visual show. Guys like, Yes, I may be your lovely wife. Thank you.

Dr. Abraham Morgentaler: 1:41:16

Yeah. My wife is a clinical site. Marianne Brandon is a clinical psychologist and sex therapist. We met at a sex therapy conference where I was lecturing, and so we talk. We have a lot to talk about and and so are we talk about that in our show the sex doctors, it's fun, the

Dr. Gabrielle Lyon: 1:41:33

delivery mode for testosterone. So now we have kaisa tracks, and we just have various, you know, testosterone forms, I would love to hear your thoughts in terms of efficacy, what you prefer, what you've seen.

Dr. Abraham Morgentaler: 1:41:47

Yeah, so I've used, over the course of my career, every available form of testosterone for my patients, I always wanted to know what the story is with them, because everybody wants to hear what I have to say about it, and I want the experience. And I'm a firm believer that until you actually get some clinical experience with something, it's hard to know what's real and what isn't real in terms of all of these products work. If we can raise testosterone in men to adequate levels, they respond, and it doesn't matter where they got it, through a pill or an injection or a pellet or a cream. And the beauty of the orals is that most men are used to taking medicines by mouth, so the orals have been a great advance. That's just the last few years. We have three of them. Kaisa tracks is one, and the one that I have the most experience with, it's got the easiest dosage, dosages, by the way, have some weird numbers for the others, but they all work and but what's interesting about the orals is that they have the potential to have fewer side effects too. So what's interesting is, if I give somebody an injection once a week, or every two weeks, levels go up. They usually go above the normal range, and then they decline over days to a week or two. With the orals, you have to take them twice a day because the levels go up and stay up only for about six hours or so. Four to six hours they come down, and then you got to do it again. There's a part of that day where the levels are back to normal, but the guys respond as if their levels are good all day long. So that's very clever. The fact though that when we the fact that it comes back to normal for part of the day means, though, that the body isn't getting the experience of there being excessive amounts of testosterone. If I give an injection, one of the side effects of testosterone therapy, we say, is it reduces fertility for men while you're on it, because the body of the brain, hypothalamus and pituitary have a sensing mechanism, and normally they send chemical signals to the testicle to make testosterone and make sperm. If the sensing mechanism gets the feeling that there's too much testosterone, it stops sending those signals. And so the testicles basically go to sleep. They take a nap, they hibernate, and so sperm counts go down. And some men may notice that their testicles are getting softer, a little smaller. Most guys, if they're in married relationships or stable relationships, or they're over the age of 45 or 50, they don't care. The single guy who's out there dating might care some. And so there are ways that we can deal with that, but the orals don't seem to suppress the the those pituitary signals as much. And I think there's a study that's undergoing now, looking at sperm counts, and I think that that's probably going to be positive, in other words, that the guys will still have sperm, whereas with injections, usually we get guys down to zero, or very close to zero. I read

Dr. Gabrielle Lyon: 1:44:52

that the orals, there's maybe 20% are affected their fertility. It's affected maybe 20% as opposed to almost all the individuals taking you. I

Dr. Abraham Morgentaler: 1:45:05

don't think we have enough data yet to say definitively those studies if they've come out. I haven't seen them yet, but I know that they're underway, and I think that's pretty good. The other thing that we worry about is a risk of testosterone is what's called erythrocytosis. The red blood cell count goes up too high. So here's a fun fact.

Dr. Gabrielle Lyon: 1:45:24

You don't really worry about that. No, I'm just kidding. No. So here's

Dr. Abraham Morgentaler: 1:45:27

the thing. Is that men and women lots of controversy around that, yeah, but just in terms of our regular biology, most labs will say that the normal red blood cell count hematocrit is between, let's say, 38 and 50% different, slightly off, depending on the lab, but roughly that, it turns out that there's almost a clean cut between women and men, and that clean cut happens around 44 or 45 women tend to be 44 or less. Men tend to be 45 and higher, and that difference appears to be related to testosterone. So when I see men who are testosterone deficient, their hermeticates are often in what I would consider the female range, and some of them actually, if you count this low, we call that anemia. If somebody says you're anemic, it means your red blood cell count is too low, below 38 or whatever the number is for the lab. So there now have been two large randomized control trials where often, when people are anemic, nobody knows the answer. It's called unexplained anemia, right? You're not bleeding for money anywhere. You don't have a genetic abnormality, the doctors say we don't know, but it's not dangerous, so you're okay. And it turns out that testosterone is better than placebo in these trials at making people not anemic anymore, amazing, because testosterone increases the right blood cell count. I had a guy years ago, young guy who, just before he'd seen me for sexual symptoms that turned out to be related to low testosterone, he'd had a whole big gi workup because he was anemic. They did this whole workup. They looked with a telescope from above. They looked with a telescope from below. They did these other tests. Final diagnosis, we don't know, but you're okay. We don't know. And when I treated him with testosterone, his blood count became normal. And he said to me, if I had seen you before, the before them, would have I? Would I have needed those tests? And the answer is no, you wouldn't have, right? He would have had a normal hematocrit. So because testosterone can raise the hematocrit, some people may go up beyond what we want them to do. And so we say that's one of the risks. The truth is, we don't know anything hard, hard evidence that that's dangerous. The Endocrine Society has helped everybody in this way. They're normally a very conservative group, and they put a number at 54 which is actually gives a lot of room for people to go above the normal range of 50 and they say, shouldn't be above 54 it's an arbitrary number. But if somebody's at 53 or 52 I don't think you need to do anything.

Dr. Gabrielle Lyon: 1:48:17

I am glad to hear you say that, because I think that there's a lot of blood donations that happen, right? And then people actually don't feel so great or become anemic. There's just, you know, it's a, it's interesting, right? Especially when we're talking about, like, what you said, patients,

Dr. Abraham Morgentaler: 1:48:38

yeah, and, you know, there's a so in medicine, as I've discovered, there is a lack, often a lack of what I would call common sense. So it turns out the people who live at altitude have high hematocrits, right? If you go and you live in the mountains of Colorado, their normal range for these things can be up to 54 so guidelines say, Well, don't treat anybody whose hematocrit is too high. But these people live with hematocrit that's too high, and no one has ever shown that they're at any increased risk of anything because of them.

Dr. Gabrielle Lyon: 1:49:20

Yes, and it's a challenge because I I'm curious as to how those at altitude, if they get treated or not,

Dr. Abraham Morgentaler: 1:49:29

right? So the Colorado docs are cool about this. I know that. I know a couple they come to the meetings. One in particular says it's an everyday occurrence for me to see somebody not on testosterone with hematocrit of 54 so why can't I treat them with testosterone? They're already used to that hematocrit. And

Dr. Gabrielle Lyon: 1:49:50

then what about women? Is there a number for women for hematocrit above,

Dr. Abraham Morgentaler: 1:49:55

so the labs don't really make that distinction. That's why I say the normal range. Is usually between 38 and 50, and it applies to both men and women. But listen, I don't think that having a somewhat higher hematocrit does anything. The concept is theoretical. It's not based on anything. The theory is, if you have more red blood cells, your blood may be more viscous, more thick, and if it's more thick, maybe it's more sluggish getting through tiny vessels. I don't know that that's true. Testosterone, by the way, has actions on the endothelium, on the lining of the blood vessels, that may, in fact, make, may make them more pliable. Even if it were true that the blood is more viscous, it doesn't show up anywhere in studies. It's just not so that people with high hematocrits Because of testosterone, have been shown to have any problems at all.

Dr. Gabrielle Lyon: 1:50:46

I mean, there's a lot of myths. I think that we have covered a tremendous amount of myths, and the biggest myths that create a barrier to entry for people because of misinformation. Yeah, you also wrote a book, and I want you to mention the book, because I would love for the listener to get it. I expect to sign

Dr. Abraham Morgentaler: 1:51:06

copy. That's you. How did I not bring one for you? Exactly? Tell

Dr. Gabrielle Lyon: 1:51:11

me about your book. Yeah. Name where we can find it.

Dr. Abraham Morgentaler: 1:51:14

Yeah. So I've written, I've written four books, the one that's the most poor, the one that's the most popular and is called testosterone for life, and it's basically a primer for non medical people about how testosterone works. It doesn't, it's not dumbed down, but it's, I hope I've made it easily understandable, and I've had a lot of doctors tell me it's a paperback. You can get it off of Amazon. And a lot of doctors tell me that instead of discussing everything about testosterone with their patients, they just give them a copy of my book. I've had physicians who tell me that what they've learned about testosterone they got from my book. So it's intended to be it's full of patient stories, and it talks about levels and things like that and free testosterone like we talked about, the book I'm most proud of is actually was originally called why men fake it, and it was stories from my practice and what we learned about what I learned true education about men and sexuality and how men are very different than their stereotype. Its current title in paperback form is the truth about men and sex. It's got some amazing cases and stories and you know, the the bottom line that I would just share with you is that men have, I say testosterone has gotten a bad rap. I say men have gotten a bad rap, too. It's a difficult period the last, I would say, 20 years for men, somehow they've become a punching bag. And we think of men as if they're all 19 year olds on spring break, out of control. And that's not my experience of men having seen the behind closed doors in the doctor's office. By and large, with relationships, especially sexual relationships, there always are some bad apples, of course, but by and large, men are trying to be the best people they can in their relationships. And they may not always do it the right way. They may not do it. They may not express themselves or behave in a way that their partner would like them to or that suits them best, but they're trying, and that feature of men and their their interest in service, and I use the term in the book, and don't laugh at me, in effort at nobility, I think is something that has been under recognized and unappreciated.

Dr. Gabrielle Lyon: 1:54:00

I think that that's tremendous. I think that's tremendous statement and true. So Dr, Abe morgen teller, thank you so much for being generous with your time and your knowledge. I have just a world of respect for you, and I'm so grateful that you are here and that you're here to share with the world. So thank you.

:: 54:21

You're so kind. Thank you so much for having me. You.