Recently I interviewed Mira Dessy, and we talked about ingredients that can trigger thyroid autoimmunity. If you would prefer to listen to the interview you can access it by Clicking Here [1].
Dr. Eric Osansky:
I am super excited to chat with today’s guest on men’s health. We are going to be talking about men’s hormones, tying that into thyroid health. I have Dr. Tracy Gapin, who is a Board-certified urologist; a world-renowned men’s health and performance expert; and the founder of the Gapin Institute for High Performance Health.
Dr. Tracy is a thought leader, a professional speaker, and the author of the best-selling books Male 2.0 and Codes of Longevity. He has over 20 years of experience focusing on men’s health, human performance, and longevity. He has been featured in Entrepreneur Magazine, Dave Asprey’s Biohacking Conference, and NBC. Recognizing our healthcare system as broken, Dr. Gapin created the proprietary G1 program designed to help entrepreneurs optimize their mind and body to function at the highest level. Thank you so much for joining us, Dr. Gapin.
Dr. Tracy Gapin:
Thanks so much, Eric. Glad to be here with you today.
Dr. Eric:
This will be fun. Before we get into men’s health and hormones, can you talk about what led you to taking more of a functional medicine approach? For years, you had a general urology practice, correct?
Dr. Tracy:
Exactly. I like to say I am a recovering urologist. I spent 23 years in traditional allopathic medicine as a very busy clinical urologist, doing robotic surgery every day, treating prostate cancer, kidney stones, you name it.
About halfway through my career in urology, through my own health issues, I came to realize that we were really failing men. I found that we were great at treating disease, symptoms, problems, but really bad when it comes to helping men with the common issues that they complain about. “I want to have more energy and focus. I want to lose weight. I want to have better sex. What do I have to do to live longer?” I found in traditional medicine, as a “men’s health expert,” as the urologist I was, we didn’t have the answers for them.
Selfishly, to overcome my own health issues, I went down rabbit holes. I started studying and getting certifications and going through courses and programs and research. I fell in love with precision medicine and epigenetics and functional medicine and wearable technology and peptides and all this world-renowned generative medicine and longevity. I put all these concepts together and created what is now the G1 program. I was able to transform my own health. When I shared this same approach with my patients, they had the same great results.
Many years ago, I made the decision that it was time to step forward and commit myself to doing this. I made the very massive decision to jump off a cliff a few years ago, and I stepped away from traditional medicine. I launched the Gapin Institute for High Performance Health, where I can now spend all of my time working with high performing individuals to help them with those challenges that I mentioned: I want to have more energy and focus. I want to lose weight. I want to have better sex. I just want to live longer. It’s fun. I love what I do now.
Dr. Eric:
Wonderful. I know you’re in Florida. Is it Sarasota?
Dr. Tracy:
That’s right.
Dr. Eric:
Awesome. Let’s dive into the hormones. What are some of the main reasons why so many men have low male hormones, especially with an emphasis on testosterone?
Dr. Tracy:
Great question. We can look at things like our crummy diet, the standard American diet, with the high trans fats and pro-inflammatory Omega-6 fats and the high processed, refined carbs and sugars. We can look at the stress in our daily life and chronically elevated cortisol that we know are crushing our gut and putting us in a catabolic state. We can look at the poor sleep we’re experiencing. We can look at the lack of exercise and sedentary lifestyles. We can look at all of these factors that definitely come into play.
Without question, in my opinion, the single biggest factor when it comes to low testosterone is endocrine disruption. The toxins in our environment that are crushing our health. We can look at toxins in our food, in our water, in our personal care products, that are around us each and every day. Studies have clearly shown they are crushing endocrine function. They crush thyroid hormone function obviously and testosterone especially.
Dr. Eric:
Any specific ones? There are obvious ones like drinking out of plastic water bottles and other sources of plastic with xenoestrogens.
Dr. Tracy:
Exactly. BPA and phthalates are used to make plastic water bottles, food containers. They are used to line metal cans. They are ubiquitous. They are almost everywhere.
We can also look at things on our food, like our crops are sprayed with pesticides, herbicides like Atrazine. Atrazine is the second most commonly used herbicide behind glyphosate. Clearly shown to crush testosterone function in men.
We can look at a lot of the chemicals in our personal care products, like laundry detergent especially. We are washing our clothes in these laundry detergents that we are bathing in our skin on a daily basis. These chemicals have been shown to crush hormone function. It’s about recognizing where these toxins are and making the little decisions every day to avoid them.
Dr. Eric:
Of course, that’s a big reason to try to eat organic. Try to use natural cleaners, cosmetics.
Dr. Tracy:
Absolutely. A big one is our water supply. A lot of people aren’t aware of this. Men in this country are on birth control. I say that jokingly, but our water supply is tainted with synthetic estradiol, which is from women’s birth control. The synthetic estrogen does not get filtered very well by our water treatment plants. What happens is we are drinking synthetic estrogen. What it’s doing is it acts like glue to an androgen receptor. It binds to the receptor and doesn’t let go. It switches on and never turns off. That disruptive estrogenic effect is what is crushing testosterone production and function.
Dr. Eric:
I imagine it’s both the water that we drink and bathe in, or is it mainly just oral consumption?
Dr. Tracy:
Certainly, when you’re bathing, it comes into play as well. It’s a short contact time when you’re taking a shower, and you don’t tend to absorb it nearly as much through your skin. It’s much more a factor in the water you’re drinking.
You mentioned plastic water bottles. Any time you are drinking water, it’s going to be in your body longer. I carry a stainless-steel water bottle everywhere I go. I use a water filter at home for my water and ice. I think that’s one of the biggest sources of estrogenic stimulation in our body.
Dr. Eric:
We have chemicals from food, cosmetics, cleaners, and water. How about the impact of stress? How big is that when it comes to the low hormones?
Dr. Tracy:
It’s a big deal. I’m glad you brought it up. A lot of people don’t talk much about stress. Most of the high performing individuals I work with, they’re entrepreneurs. They’re uber-wealthy, super rich, young men who have already retired and are now busy building new businesses. They are professionals, lawyers, accountants, other doctors, and athletes. What a lot of men don’t recognize is the chronic stress in their life that is having a major effect. A lot of guys don’t realize this, but we can test for this. There are ways we can quantify this with cortisol testing.
Chronic stress, and we’re talking specifically about psychological stress here. Other stressors come into play here, like dietary, nutritional, sugar, food sensitivities, issues with dysbiosis in the gut, all these other things I look at as “stress” to our human operating system.
Psychological stress, men tend to discount it. “It’s not affecting me much at all.” We can quantify it, and we do a lot of cortisol testing with our clients. We can see chronically elevated cortisol.
You ask the question of what it does. It has a major impact. What cortisol does, and I know you’ve talked about this in the past, is the thyroid system gets affected. It affects TSH production and comes into play when we look at T4 conversion into T3. It certainly affects thyroid production and function.
With testosterone, what it’s doing is it’s going back to the brain and turning off the natural releasing hormone, luteinizing hormone (LH), and testosterone production. Cortisol in and of itself can be very significant and have a great impact on testosterone production and ultimately function.
Dr. Eric:
With all of your patients, do you do adrenal testing and focus on stress management techniques?
Dr. Tracy:
Absolutely. We’ll talk about the big picture in a moment. It’s super important to look at adrenals, things like DHEA, which is coming from the adrenals; cortisol; and all the other key hormones that are coming into play. It’s like a symphony. Men don’t recognize we have over 50 hormones in our body. Testosterone gets all the attention, and it’s where we started the conversation here. It’s important to recognize there are a lot of hormones that come together and all influence each other to some extent. We start with testosterone but have to look at all the other hormones as well and understand how they all interplay.
Dr. Eric:
How about insulin? Insulin resistance is a big factor, too. That also affects not just testosterone but other hormones.
Dr. Tracy:
It becomes a vicious cycle. You mentioned cortisol. I will give you an example of how this is all connected together. I’ll work with men, and they’ll stay up until 1am working on a project, or maybe they’re just binge-watching Netflix. I don’t know. But they’re staying up late. Then they will fall asleep and wake up 2-3 hours later. They can’t fall back asleep again because their mind is racing. Classic elevated cortisol picture.
What that’s doing is promoting inflammation by raising cortisol. That elevates blood sugar. That puts stress on the pancreas, trying to release insulin to control this blood sugar elevation. Over time, it can’t control it. Over time, the pancreas gets overburdened and stressed, and that is ultimately how rising fasting insulin and post-granulin levels rise.
It gets to the point where your body can’t handle it anymore. You’re storing it as fat. What does all that do? It crushes testosterone production and function as well. That excess visceral fat you’re producing from the cortisol, inflammation, and insulin resistance is taking that testosterone and turning it into estradiol as well. Now, you’re tanking your good, healthy, optimal testosterone to estrogen ratio. You have that estrogen to testosterone ratio.
That is a quick summary about how it all plays upon itself. Low testosterone, high estrogen in women will promote further chronic inflammation and insulin resistance, and it becomes a vicious cycle.
That’s metabolic syndrome. It’s about correcting that entire ugly process that happens. It’s ubiquitous in guys. Once they hit 40, 45, 50, it happens in almost every guy unless they’re aware of it and make the real decision to do something about it.
Dr. Eric:
It’s definitely widespread, and it is this vicious cycle. What I see is diet plays a big role, but usually depending on the severity, many times, just cleaning up your diet, it’s certainly often not sufficient alone to reverse this process.
Dr. Tracy:
Exactly. This is why I really believe strongly- My philosophy is based on a systems model, understanding that we have all of these systems that come into play, and you can’t focus on any one of the hormones. We have over 50 we have to look at. You also have to look at your nutrition and your gut health, and get your microbiome cleaned up. You have to look at stress and how that’s affecting cortisol. There are various types of stress. You have to look at detoxification pathways. Are you optimally clearing those toxins from your body? You have to look at sleep. So many of these high performing individuals that we work with have crummy sleep, whether it’s intentional or not. Correcting sleep is a big part of breaking that cycle.
Dr. Eric:
How about some of the common signs and symptoms of an androgen deficiency?
Dr. Tracy:
A lot of guys will notice decreased energy, fatigue. They may want to take a nap later in the afternoon. There’s something wrong if you’re taking a nap in the afternoon. You should not need a nap. That is typically a sign of endocrine problems.
These guys will have cognitive alterations, where they can’t think as quickly or clearly when they could before. They can’t make decisions. Mental acuity is off. They call it brain fog.
Sex drive will be one of the most common symptoms that men notice initially. Decreased libido. Impairment in sexual function can come into play.
Guys will sometimes have difficulty sleeping. Testosterone will cause issues with sleep, which obviously will promote low testosterone as well. That is a cyclical issue.
Guys will start to put on belly fat. They have fat around their belly they can’t shake. So many guys will say, “I run on the treadmill every day. I’m eating perfectly clean. I can’t seem to lose weight.” When I hear that, it makes me think of hormone issues. It typically centers around testosterone as one of the first parts of that.
Dr. Eric:
You mentioned earlier about thyroid. Can you talk about the impact of thyroid hormone on testosterone?
Dr. Tracy:
It’s interesting. So many people think that thyroid issues are solely a female problem, but they’re not. We see a lot of guys who have most commonly clinical hypothyroidism that is undiagnosed that they don’t realize is a problem. I’ve seen hundreds of men over the last 20 years now who come to see me and are on testosterone already but feel like crap. They have low energy, they can’t lose weight, they’re sluggish, and they end up having great testosterone levels but crummy T3 levels. A lot of these guys have issues with metabolism, energy, weight loss, poor sleep. A lot of it is associated, as you know, with microbiome issues, too.
There is this common finding that almost every man that has low testosterone will have some element of at least subclinical hypothyroidism as well. We know that elevated TSH will suppress LH production from the brain. High TSH will suppress the natural releasing hormone effect on the pituitary. Therefore, low LH leads to low testosterone. There is a clear connection there.
There are also common variables, where just like chronic inflammation and insulin resistance, microbiome issues, stress, can also affect thyroid. Those same underlying etiologies are affecting testosterone production as well. Very common to see guys with both testosterone and thyroid issues.
Dr. Eric:
One thing that caught my ear is you said T3. When we talk about testing, when it comes to testosterone, you focus more on free testosterone than total testosterone, not that total testosterone isn’t good to test, too. Same thing with the thyroid. The T3 is the free thyroid. Many doctors just look at TSH and T4 and neglect that T3.
Dr. Tracy:
Eric, it kills me. We have a couple of endocrinologists here in town that I’ve gone to war with. The fact that I’ve had patients who will come in, and they’re being told that their Synthroid is working great. Their TSH looks great. They have never had their free T3 checked. They check their free T3, and it’s 2.8. You fix that, and it is amazing how that can drastically impact their life and change their brain function, their energy. They’re alive again. This is a great example of how so often, it’s not testosterone; it’s some of the other hormones that definitely come into play as well.
Dr. Eric:
I agree. A number of people listening to this have hyperthyroidism. Typically, you get elevated sex hormone binding globulin (SHBG) here. With that pattern, you would expect to see lower free testosterone levels, correct?
Dr. Tracy:
Yes. High SHBG will bind to testosterone, so you’re right. Free T will be lower. In those cases, it’s tough to artificially lower SHBG. There are not a lot of great maneuvers that will do that. You need to go higher on testosterone therapy to get free testosterone to where it needs to be.
Dr. Eric:
Let’s talk about testing. When someone comes in, what do you do as far as blood testing, adrenal testing, whatever you want to talk about? Lead the way.
Dr. Tracy:
I’m obsessed with advanced diagnostics. That’s the beginning when clients work with us. We do a lot of blood tests, saliva testing, stool testing, urine testing.
Blood testing, we’re looking at all the major hormones. Testosterone, free T. We are looking at estradiol and DHEA sulfate, which is a common problem in these guys as well. It’s a fairly misunderstood hormone, but it’s very important when it comes to men’s health. It does help men with a lot of the same things that testosterone is responsible for: energy, mood, metabolism, etc.
A lot of guys are deficient in DHEA. I’ll find also that if men are on testosterone therapy, their DHEA sulfate levels will typically be much lower than they need to be as well. It does suppress DHEA production very commonly.
In women, it tends to stimulate DHEA levels for whatever reason. I don’t think we clearly understand why. In men, DHEA levels are suppressed when on testosterone therapy.
We look at free T3, free T4, thyroid, TSH. We are looking at thyroid antibodies.
We are looking at markers for growth hormone. IGF1 is not perfect, but it’s an easy serum test to assess growth hormone function. Understanding its limitations.
Looking at insulin, fasting insulin, homeostatic assessment of insulin resistance, fasting blood sugar. Looking at micronutrient levels, advanced lipid markers, which can be closely correlated with insulin resistance for sure.
For salivary testing, we look at cortisol in men, recognizing that they all tend to have some element of adrenal dysfunction, whether they are hypercortisolism or whether they have already crashed and need support. Somewhere in between is pretty common.
We do a lot of microbiome testing, looking for dysbiosis, looking at gut integrity and permeability, looking at markers of food sensitivities that are pretty common in men.
We do some urine testing, specifically organic acids testing. A lot of these guys have candida, mold, etc.
Looking at markers of energy production, mitochondrial function, as well. A lot of lab testing.
I really believe that it all starts with getting hormones optimized.
Dr. Eric:
I really like organic acids testing. When it comes to the gut microbiome, do you do a GI Map or GI Effects?
Dr. Tracy:
We’re doing a GI Map right now. We seem to be getting great results with that.
Dr. Eric:
For adrenals, I do a lot of saliva testing, too. I do some dried urine testing. Do you also do Dutch testing as well?
Dr. Tracy:
We do Dutch testing. You bring up a good point. I love Dutch testing when we’re looking at estrogen metabolism. The 2 4 and 16 hydroxy estrone, the metabolism of testosterone into estrogen. We’re looking at methylation, DHT. That third page is the money shot. You look at oxidative stress on the last page, the neurotransmitter markers.
The cortisol, I don’t use much at all. It’s interesting when you talk to the folks in Dutch. They concur with the research I’ve found. Urinary cortisol testing is not validated like salivary testing is. I really believe that saliva testing is where it’s at. Serum would be great, but you can’t do that nearly as easily. Salivary in my opinion is where it’s at for testing cortisol.
Dr. Eric:
Would you have them do a Dutch complete and a saliva test? Would you have them do the hormone portion of the Dutch and then the saliva test?
Dr. Tracy:
I can do Dutch+. It comes with the salivary test with it. I will look at the metabolized cortisol part of the urine, but I don’t personally put much stock in those numbers.
Dr. Eric:
Okay. That’s good to know. With the testosterone in Dutch, I’m sure you’ve noticed this, that a lot of times, it’s low. Even in the report, it says it’s common to have false low results. They recommend testing it through the blood if it’s low. Do you also find a lot of low readings?
Dr. Tracy:
We do. I’ll use serum for testosterone typically rather than dried urine.
Dr. Eric:
With the blood, do you test for DHT or androstenedione? Is it free testosterone and total testosterone?
Dr. Tracy:
I tested DHT in the past. The issue is, what are you going to do about it? I don’t test it on every man. Some guys have hair loss issues; DHT is the culprit there. Stimulation of DHT receptors is what would cause me to be concerned there. I don’t check those on every guy.
I don’t think I have intentionally checked androstenedione. Maybe I should, but I haven’t serum-wise. I know you see that in the Dutch and some of the organic acids tests. A test has it. I have never tested it. Do you test that?
Dr. Eric:
I don’t. I was asking you because you’re the expert. I want to make sure that I shouldn’t be testing that.
Dr. Tracy:
I have never seen a value for it. When I have checked DHT, I don’t know what to do with it. Let’s say you check DHT, and it’s high. What are you going to do there? If the guy has no symptoms or major androgenic side effects, I won’t do anything about it. If he is having problems, like male pattern baldness, excessive acne, and we decide to block that, what are we going to do? It’s a 5-alpha reductase inhibitor like Finasteride. I know from the research out there with post-Finasteride syndrome, that it can be pretty devastating when you crush a guy’s sexual function permanently, irreversibly with that drug. I honestly try to avoid it if I can.
Coming back to the beginning, that’s why I didn’t order it. What am I going to do if it’s high? Probably nothing. I only order a test if I am prepared to do something about the results.
Dr. Eric:
That’s a great response. Why do a test if you’re not going to take specific actions based on the test results? It’s wasting the patient’s money.
Dr. Tracy:
There you go. I’ll do DHT every now and then. It’s not on my standard lab panel.
Dr. Eric:
Let’s talk about increasing testosterone. I’m sure you get a number of people, and I’m going to ask you here right now: What can someone do to increase it naturally? Can they increase it to a healthy level naturally? Maybe it depends on how low it is.
Dr. Tracy:
Wonderful question. Yes, for the listeners, there are ways you can naturally boost testosterone levels without question. One of the biggest ways is heavy strength training. We are talking about moving heavy weights, specifically leg muscles like quad and hamstring and core and back, these big muscles in your body, doing heavy lifting. You can definitely raise testosterone.
Perfecting your sleep can definitely improve testosterone for the reasons we talked about in relation to cortisol.
Lowering stress also has a big impact, for the same reasons.
Getting sufficient micronutrients, things like zinc, magnesium, B vitamins. Good healthy nutrition. Getting enough fats in your diet. It’s a misconception that if you have a low fat diet, it will crush your testosterone. It won’t have a major effect, but you want key macronutrient ratios.
Sunlight can help. Believe it or not, sunlight has been shown to help testosterone levels, especially on the scrotum. I know it sounds crazy, but going out nude first thing in the morning for half an hour with direct sunlight exposure to the scrotum has been shown to help. Those are the natural ways that you can raise testosterone.
Let’s talk about how much. The key question that you ended there with is how much can it raise it? is it enough? We’ll talk about lab numbers in a moment. I think this would be a good tie-in. In general, what I find most of the time is you cannot get your levels up to where they need to be with natural approaches, unless you’re just a little low. If you’re a little on the low side, which I almost never see in my practice. Never say never. “You’re almost there. Let’s do some natural stuff to boost it.” No. Guys need to be 20-30 with free T3. Most guys are at 4, 6, 7, 9. Nowhere close to where they need to be. Yes, natural can help them to some extent, but not enough to get them to where they need to be optimally.
I will recommend those things anyway in addition to giving them testosterone.
Dr. Eric:
Makes sense. You don’t want to just give testosterone. You want to try to address adrenal imbalances if they have them or endocrine disrupting chemicals. Makes sense. I know you focus more on the free testosterone, but is there an optimal range for total testosterone that you like to see?
Dr. Tracy:
Depends on the SHBG. Assuming that our target is 20-30, I have had guys where total testosterone of 800 meant a free T of 21. I have had other guys with a total T of 1,400, and their free is still 12. Purely based on the SHBG levels. Total testosterone can be a guide for men, where you know where their SHBGs are. In general, the free T is the critical number there.
Dr. Eric:
Thanks for that example. You really do need to do free testosterone.
Dr. Tracy:
Yeah, across the board.
Dr. Eric:
How about estrogen? Is looking at estrogen in men important? Do you do blood testing like estradiol or total estrogens?
Dr. Tracy:
We do. This gets into some fun controversial conversations. Estrogen is not the enemy. A lot of men think estrogen is the enemy, and we have to lower it and get it down as low as we can. That’s not accurate. Estrogen is incredibly beneficial. It’s helpful for men when it comes to sexual function and energy. We know that estrogen has massive benefit when it comes to cardiovascular health. This is why postmenopausal women are given estrogen, not only for symptoms and quality of life, but we know it has some protective benefits.
For men, estrogen is not the enemy. What’s important is the balance between estrogen and testosterone. A lot of men come in with insulin resistance, and they’re obese and have super low T and very high estrogen. We want to get estrogen down, not by blocking it, but by reducing visceral fat and improving testosterone levels. That will help with that ratio.
When working with men, I do assess estradiol in all of them. When it’s elevated, my main question is: Is there a problem? Are there any side effects? Is there a reason to lower it? The main side effects that men would get from elevated estrogen would be breast tenderness, breast enlargement. They’re moody, they’re crying over puppy movies, they’re excessively tearful and emotional. We had a guy this morning who had some rage issues, where he was angry and short-fused. That is typically not what you see from high estrogen. You’re more emotional and effusive and crying.
When you do have those symptoms, then it’s worthwhile to look at bringing estradiol levels specifically down. If there is no symptoms involved, then nothing says we have to bring it down to any certain range.
The key question there is: If a guy does not have symptoms, what is the threshold for when you should lower it? When should you get concerned? Some doctors will tell you if you get above 60, if you get above 80. This one doctor I know will say he gets concerned when estradiol gets above 1,000. He says that jokingly because he doesn’t measure it, he doesn’t test it, he doesn’t care. He has no concern. He doesn’t block estrogen ever because he doesn’t think it’s a problem unless a guy is having symptoms.
I do think there is some rationale for having some threshold to lower it down to a reasonable level. It’s arbitrary. Interestingly, there is no clear science that shows estrogen in men is harmful. This was for me quite shocking when I heard this. I looked, and you cannot find anything that says estrogen is specifically harmful in men. It’s really more the ratio of your hormones all together.
Dr. Eric:
When it comes to helping improve estrogen metabolism in men, is it a similar approach to women, as far as helping to support detoxification, including methylation, and the gut microbiome?
Dr. Tracy:
100%. We are looking for the same 2 hydroxy estrone pathway on the Dutch. We want to make sure they are having healthy estrogen metabolism for sure.
Dr. Eric:
DHEA, since it’s a precursor to testosterone, can you increase testosterone by taking DHEA?
Dr. Tracy:
Typically, no. Can you get some marginal elevation? Yes. Not anything substantial. You can’t use DHEA as a way to support testosterone production unfortunately.
Dr. Eric:
We will get to bioidentical testosterone. With DHEA, if it is low, do you typically give DHEA?
Dr. Tracy:
I do, understanding that when DHEA sulfate is low, it’s from one of a couple reasons. It could be low substrate, low DHEA, in which case giving DHEA should help that.
It could be chronic inflammation. Inflammation can affect the sulfation process, so DHEA does not get converted to the biologically active form of DHEA sulfate. If you have bio salt issues or gut issues, that can also affect the sulfation process as well.
Yes, I give DHEA. You put guys on 25mg once or twice a day of DHEA, and I will typically see massive changes in their DHEA sulfate levels. If I don’t, that’s when I will start looking deeper into the gut or other reasons why it is not coming up.
Dr. Eric:
Let’s move onto testosterone. Most people who you work with, their testosterone is so low that a natural approach won’t get it up by itself. You will do things to improve adrenals and reduce toxic burden, but it sounds like really, the best thing to do in addition to that is to give testosterone.
Dr. Tracy:
Absolutely. I feel very strongly of the benefits of testosterone therapy. Without question, it provides incredible improvements in quality of life, whether it’s energy, cognitive function, sex drive, ability to burn fat and build muscle, general sense of wellbeing and vitality and feeling like a man again.
It has amazing benefits when it comes to cardiovascular risk. We know that men with low testosterone have a markedly increased risk of cardiovascular disease and about a 30% increased risk of a major adverse cardiac event. Dozens of studies have shown the same thing. About 30% reduction in a major adverse cardiac event when you optimize testosterone.
We know men with low testosterone very counterintuitively have an increased risk of clinically significant prostate cancer. Flies in the face of everything I was taught conventionally in urology for 20 years. Men with low T have a higher risk of prostate cancer. In my opinion, there is negligible risk but tremendous benefit to giving testosterone therapy.
Dr. Eric:
What form do you give it? Is it injection, orally, or topically?
Dr. Tracy:
There are a couple different options. You can do injectable. An injectable comes subcute or intramuscular (IM). You can do topical. Or you can do pellets. I generally tend to recommend them in that order as well.
Dr. Eric:
I don’t know the average age of the person who sees you. If someone is in their 50s, 60s, 70s, this is just me talking, but there may be a greater indication to take testosterone. You do have to factor in the age. It does decline as we get older.
If someone comes in in their 30s, and they have really low testosterone. As you mentioned, a natural approach is unlikely to increase it. Even someone who is on the younger side, would you still recommend testosterone?
Dr. Tracy:
This is where it gets a little tricky. A natural approach will be a little more effective in those men, but not enough to get the free of 6 to a free of 20.
In young men, you have to recognize there is still some fertility issues to consider. If a guy is 30 years old, and you give him testosterone, you are going to be shutting off fertility, sperm production through negative feedback. Testosterone is going to tell the hypothalamus and the pituitary gland, “We’re good here. We have enough hormone. We’re fine.” It will shut off production of both LH, which is what stimulates testosterone production, and FSH from the pituitary. FSH is what tells the testicles to make sperm.
When you’re giving a 30-year-old man testosterone, you are turning off sperm production, which may not be what they’re looking for. A young guy, you need to have a conversation about fertility. Are you and your partner looking to have more children at some point in the future? If so, there are other ways that we can stimulate testosterone levels to get where we need them without giving testosterone directly. That would be things like ACG, Clomid, other medications that can help boost testosterone. There is even a peptide that is somewhat beneficial as well.
Dr. Eric:
That was my next question, the peptides, if those could help boost testosterone.
Dr. Tracy:
Yes, I have used Kisspeptin a number of times. I have been fairly disappointed each time. It’s not quite as robust an outcome as you get with ACG and Clomid.
Dr. Eric:
Yeah. Do you use other peptides in your practice?
Dr. Tracy:
Yeah, I love peptides. I use a ton of them. Kisspeptin is the one that specifically we consider for boosting testosterone.
Dr. Eric:
Can you go over some of your favorite peptides for other purposes?
Dr. Tracy:
We use a lot of peptides for boosting growth hormone production. You mentioned the average age of guys in their 50s and 60s. We see guys typically between 40-60 or so. We see women as well. I have a nurse practitioner who focuses on women. Same approach. My passion and focus is certainly on men.
Those guys, once you hit 40, growth hormone production declines by about 1% a year or so. Growth hormone is an anaerobic hormone that is responsible for growth, for muscle, for burning fat. It’s responsible for energy, cognitive function. In some ways, maybe you consider the fountain of youth for longevity. There is a lot of debate around that that is questionable. A lot of benefits of having good healthy growth hormone levels.
Rather than giving growth hormone, which has some negative consequences, we would rather stimulate your body to produce more growth hormone on its own. That is where some of the peptides are great at telling the hypothalamus, the pituitary gland to make more growth hormone.
I love growth hormone peptides. We use a CJC Ipamorelin combination, which comes at it through two different mechanisms of action. Growth hormone releasing hormone (GHRH) is the hormone from the hypothalamus.
I want to make a brief point about this. GHRH comes from the hypothalamus and tells the pituitary to make growth hormone. It also has a lot of systemic benefits on its own that are important. When you give growth hormone through negative feedback, you are turning that off, which you don’t want.
CJC 1295 is a growth hormone releasing hormone peptide that works very similarly to have those same benefits that you’re looking for. That’s why that one is so beneficial. Tesamorelin is another GHRH peptide as well. Ipamorelin is a ghrelin receptor peptide that is paired with CJC because it will, through the ghrelin receptor, turn off somatostatin, which is what is slowing down growth hormone production. If you turn off the blocker, a double negative becomes a positive. By turning off somatostatin, you’re turning on growth hormone.
There are a bunch of growth hormone peptides out there. A CJC and Ipamorelin combination are the two we use most commonly, I would say.
BPC 157 is a great peptide. It comes from the stomach. It’s incredibly powerful for reducing inflammation, whether it’s in the gut or systemically or in joints. I love BPC.
Thymosin alpha is an amazing peptide that comes from the thymus gland. It shrivels up and involutes and goes away once you hit puberty. It’s really important for immune function, and it’s great for boosting T cell production and function.
Thymosin beta is another thymus gland peptide that is great for musculoskeletal repair. You can give that one subcutaneously in the belly, or you can give it subcutaneously near the site of injury for repair. That’s a cool peptide.
We love peptides that help with mitochondrial function, things like MOTS-c, a great peptide for mitochondrial biogenesis.
Peptides for sexual function, like PT 141 or Melanotan 2.
Epitalon is incredibly only two amino acids in length. It’s been shown in animal studies to extend longevity. Epitalon is a really cool one.
Semaglutide, by this point, everyone has heard of it, it seems. It’s a GLP-1 agonist. It’s technically a peptide as well. It’s used for weight loss specifically. It decreases appetite at brain level. It slows gastric emptying to make you full quicker. It works in the pancreas to increase insulin secretion to help reduce blood sugar levels. The three different mechanisms of action. It’s fantastic for weight loss.
Tirzepatide is another similar one that has another peptide combined with it, GLP-1 agonist. It’s probably a little more effective than semaglutide. Both of those have shown amazing benefits when you look at lipid numbers and cardiovascular disease as well. Intimal medial thickness data as well. Remarkable improvements with those peptides.
That’s just a sampling. We use a lot of them. Those are the top ones we use.
Dr. Eric:
Are they all injected? Are some of them oral?
Dr. Tracy:
A lot of them are injectable. I didn’t mention ones like Semax and Selank. Those are great nasal spray ones for anxiety and mood stuff. PT 141 is a nasal spray. BPC can be either oral or sublingual or injectable. Dihexa is a great topical peptide for cognitive function and memory. Different routes of administration. Probably 2/3 or 3/4 of them are injectable.
Dr. Eric:
Cool. Are they safe to take long-term? Are they supposed to be taken short-term? Any side effects that people should be aware of?
Dr. Tracy:
Great questions. The answer is there is not a lot of data on taking them long-term, like years and years. There is just no data out there. You won’t get randomized control trials like you will with Big Pharma. You look at the basic science, understand the mechanisms of action, and go with that. Everything we prescribe has research and studies behind it to demonstrate efficacy and safety. There are typically minimal side effects.
Everyone is different and unique with different physiology. I had a guy who had an allergic reaction to CJC, and he had a massive allergic reaction to Tesamorelin. We can’t use those with him. That’s one guy in hundreds of prescriptions I’ve given. There could be side effects, but most people typically tend to have none.
Dr. Eric:
Even with herbs, most people will do fine with herbs, but you could be allergic to a certain herb.
Dr. Tracy:
You never know. In general, we don’t tend to find much in the way of side effects or complications.
Dr. Eric:
One last question with peptides: Do you personally take any on your own?
Dr. Tracy:
I love to experiment. I have probably tried them all at one point or another. For about three years, I struggled with tennis elbow in my left elbow. I went through all kinds of peptides for that. I have been through all the growth hormone ones. I have used a ton of them now.
I will emphasize for the listener that there are a lot of sources out there that are direct to consumers for peptides. I would caution anyone against going anywhere where the general public can run a credit card to buy a peptide. Any place like that that is direct to the consumer, there is no oversight or quality assurance compared to a compounding pharmacy, where there is much more regulation, much more of a close eye on quality control and assurance and certificates of authenticity.
There is a study that came out last year some time that found that after testing, one of these commercially peptide companies had nothing in it; it was like saline. You have to be careful about what you’re buying. If you’re injecting it in your body, I’d get that from a pharmacy.
Dr. Eric:
That’s really important.
Dr. Tracy:
I’ll also emphasize: I put out these YouTube videos on peptides. I get all these comments about, “Can I buy some peptides?” We’re not a pharmacy. We don’t sell them. We prescribe them for our clients who we serve. People get the wrong impression from a YouTube video I made talking about peptides. We are not a pharmacy ourselves.
Dr. Eric:
Tracy, you brought up one peptide that helps with sexual function. It made me think about how you probably deal with a lot of men who have erectile dysfunction. When it comes to that, it sounds like peptides could help. Also, increasing testosterone, I imagine it also could have a role. As far as ED, there is also a blood flow problem, too. Is it a multifactorial approach where you address different things?
Dr. Tracy:
When I talk about ED, I like to conceptualize it as four main buckets of causes of etiologies of ED. One is blood flow, as you mentioned. It’s arterial inflow, and it’s venous outflow. An erection is simply an engorgement of blood that gets trapped if you will. That arterial inflow is dependent on nitric oxide. That’s one of the other hormones we test. We can test it in my office. We know that things like insulin resistance crushes nitric oxide production. Chronic inflammation crushes nitric oxide production. We know that systemic issues like gut health and hormones and diet have a profound effect on blood flow. Blood flow is one. Arterial inflow comes in, and venous leak going out, that’s one.
The second cause would be hormones. As you mentioned, low testosterone can definitely be a cause. Sometimes it’s DHEA, insulin issues, or cortisol issues. Even growth hormone, thyroid, or other hormones can affect it. Testosterone is probably the biggest and most common culprit when looking at ED.
The third bucket would be nerve function. You need normal nervous function down there for an erection. Make sure there is no issue with neuropathy, especially if someone is diabetic. Looking at the history of pelvic trauma, pelvic surgery, prostate surgery, colon surgery, stuff like that. That is the least common of the categories.
The fourth is psychological. This is more common than you think. Issues with stress, with infidelity and marital strife. A big one is porn addiction. It’s such a rampant problem right now, where guys are having issues with porn addiction. They are not interested in their partner. All of these psychological issues come into play as well.
Four buckets: blood flow, hormones, nerves, and psychology.
Dr. Eric:
We covered a lot. Is there anything that I didn’t ask you that I should have asked you or anything else that you’d like to discuss before we wrap it up?
Dr. Tracy:
My philosophy has become a three-pronged approach. The first is advanced diagnostics. Know your numbers. We talked a lot about testing.
I believe in a very individualized approach, and that’s where functional testing comes in. We didn’t talk much about genetics, but genetics comes into play when it comes to understanding what’s right for our clients. What foods should they be eating or not? Detox pathways. Additional support? What exercise is right for you? It’s amazing how much genetics can really help us fine-tune things.
The third is precision lifestyle. This is where I have functional coaches who work with my clients because as powerful as the molecules may be that we prescribe, if you’re not doing the right things at home, then you’re not going to have nearly the success that you would otherwise.
Advanced diagnostics, individualized approach, and precision lifestyle is where it’s all at, putting all those pieces together.
Dr. Eric:
Wonderful. Thank you again, Tracy, for this conversation. Where can people find out more about you?
Dr. Tracy:
My website is GapinInstitute.com. If you text the word “Health” to 26786, we have a simple cheat sheet for 10 strategies to achieve high performance health today.
Dr. Eric:
Awesome. This was an awesome conversation. I learned a lot. I’m sure the listeners will learn a lot. Thank you so much.
Dr. Tracy:
Absolutely. A good time.