Erectile Dysfunction with Dr. Geo Espinosa: Rational Wellness Podcast 048
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Dr. Geo Espinosa speaks about Erectile Dysfunction with Dr. Ben Weitz.
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Podcast Highlights
1:05 Erectile Dysfunction is defined by the Mayo Clinic as the inability to get and keep an erection firm enough for sex.
3:10 Dr. Geo started the discussion by telling us that the penis is a barometer to a man’s health.
4:00 Dr. Espinosa said that the main causes of Erectile Dysfunction are anything that interfere with nerve flow to the penis, blood flow to the penis, or hormonal.
5:39 Dr. Geo shattered a myth when he explained that there is actually no decreased risk of erectile dysfunction or of incontinence for men who undergo robotic prostatectomy versus open surgery, despite all the outstanding marketing from DaVinci, the company that sells the robotic devices.
7:19 Radiation can also damage the nerves, Dr. Espinosa explained, depending upon what type of radiation you get.
8:50 Dr. Geo explained that even after surgery and radiation there is still a 50% chance of recurrence of prostate cancer and you can get secondary cancers, such as bladder cancer, from the radiation.
11:12 Dr. Espinosa said that there are no objective tests for decreased blood flow to the penis but he gets 80% of the information he needs from a good exam and asking key questions. He said there is the Sexual Health Inventory for Men (SHIM) http://www.urologysa.com.au/pdf/sexual-health-inventory-for-men-shim.pdf so you can place the patient on a protocol and then repeat the SHIM.
15:10 I mentioned that when it comes to neurological causes of Erectile Dysfunction, besides prostate surgery, you have to consider lumbar spine problems that can result in nerve injury. Dr. Geo said that he finds that chiropractic adjustments help to open things up and he recommends his patients get adjusted.
16:46 Next we reviewed the hormonal factors that influence Erectile Dysfunction. Dr. Geo explained that testosterone is a major factor both in sexual interest and in sexual function. He said that he does not like to put his patients on testosterone because their body stops making it and they become dependent upon it. He tries to get their own body to produce testosterone naturally by using nutritional supplements, like his Mr. Happy product/aka, XYVigor (the practitioner version). He’s o.k. with them using a small amount of a PDE5 inhibitor like 5 mg of Cialis or 25 mg of Viagra. Actually his Mr. Happy product contains 5 products, one of which is Horny Goat Weed which contains Icariin, which is actually a natural PDE5 inhibitor. It also contains L-Citruline, which leads to the production of arginine in the body, which stimulates nitric oxide inside the arteries, which increases blood flow. It also contains Rhodiola, an adaptogen.
23:30 If the total testosterone is normal but the free testosterone is low, you need to make sure you have enough protein in your diet and you need 500 mg BID of Nettle Root–not Nettle Leaf–to inhibit overproduction of Sex Hormone Binding Gobulin.
25:45 If men have too much estrogen, that can be a problem also. Dr. Geo likes to see estradial levels between 10 and 20 ng/mL which has been shown to be associated with lower heart disease, despite the fact that most labs say normal is below 40. If estrogen is too high, he will put patients on a liver detox using products like DIM and milk thistle and broccoli extract. You also need to reduce soy and other estrogenic foods.
28:45 I asked about low testosterone resulting from medication side effects? Many blood pressure medications like beta blockers are a problem. H2 blockers like Tagamet. Statins can reduce cholesterol too low, which reduces the production of sex hormones like testosterone.
30:16 Dr. Geo talked about a patient who was on a vegan diet with lots of soy products who had low testosterone and he got him to start eating grass fed beef and reduce all that soy. He also got him to weight train in a fasted state using heavy weights with lower reps, which stimulates testosterone production. He has him add a protein drink with creatine after the workout. He also uses Fenugreek, Maca 3 gms per day, and Ashwaganda. Tribulus is not that effective. He also works on improving their sleep if that is a problem since you make most of your testosterone during your sleep.
36:08 I broached the marijuana question and how it might affect testosterone? Dr. Espinosa said that marijuana lowers testosterone levels. Excess alcohol can also be an erection killers, though a small amount may be helpful.
39:00 Dr. Geo talked about Peyronie’s disease, which results from scar tissue and their penis becomes curved, which can result in erectile dysfunction.
43:09 Dr. Geo mentioned that low protein diets can play a role in ED by resulting in an arginine/amino acid deficiency. Zinc is a major male mineral and he likes to recommend between 30 and 60 mg but not higher, since too much zinc can create a copper deficiency. Also magnesium is perhaps the most important mineral. Also antioxidants like vitamin C, Alpha-lipoic acid, a mixed tocopherol vitamin E, and plant-based phytochemical antioxidants.
45:20 Next we talked about pyschological factors influencing Erectile Dysfunction and Dr. Geo explained that stress causes your body to release adrenaline, and adrenaline is the biggest erection killer. Sometimes your relationship is a big factor and the problem can just be that you no longer find your partner to be attractive. The other factor is porn. This is a huge factor in men under 40 and particularly millenials, who have incredibly easy access to porn on the internet.
Dr. Geo Espinosa is a Naturopathic doctor and men’s health expert and can be reached at http://drgeo.com/ His book on prostate cancer Thrive Don’t Survive: Dr. Geo’s Guide to Living Your Best Life Before & After Prostate Cancer is available on Barnes and Noble https://www.barnesandnoble.com/w/thrive-dont-only-survive-dr-geo-espinosa/1123391807 and Amazon. Dr. Geo’s new book, Integrative Sexual Health is now available on Barnes and Noble https://www.barnesandnoble.com/w/integrative-sexual-health-barbara-bartlik/1127405046?ean=9780190225889&st=PLA&sid=BNB_DRS_New+Core+Shopping+Books_00000000&2sid=Google_&sourceId=PLGoP164972&gclid=Cj0KCQjwy9LVBRDOARIsAGqoVns8kBd4mo4HQ09QF8oIP6DxDzQUE-6R-6o22z4erYsRl7yi3LVhLr4aApX5EALw_wcB
Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure as well as chiropractic work by calling the office 310-395-3111.
Podcast Transcripts
Dr. Weitz: This is Dr. Ben Weitz with the Rational Wellness Podcast, bringing you the cutting edge information on health and nutrition from the latest scientific research and by interviewing the top experts in the field. Please subscribe to the Rational Wellness Podcast on iTunes and YouTube, and sign up for my free ebook on my website by going to drweitz.com. Let’s get started on your road to better health.
Hey, Rational Wellness podcasters, thank you for joining me today and we’ve got a very interesting topic. We’re going to talk about men’s health, and in particular, we’re going to talk about erectile dysfunction, which is a very important topic. By the way, everybody who enjoys this podcast, please go to iTunes and give us a rating and review. That helps more people find out about our Rational Wellness Podcast.
So, Erectile Dysfunction is defined by the Mayo Clinic as the inability to get and keep an erection firm enough for sex. Erectile dysfunction affects quite a large number of men in the United States. The long-term results from the Massachusetts Male Aging Study reported in 2000, an overall incidence of erectile dysfunction of 26% among men in the United States, with the rate of erectile dysfunction increasing with increasing age. There’s approximately a 12-1/2% prevalence at age 40, a 29.8% at age 50, and 46.4% at age 60. Besides age, the prevalence rate will also increase due to lower education and increased rates of diabetes, heart disease, and hypertension. Psychological factors can also play a role. Erectile dysfunction is a side effect of many medications. Poor diet and lifestyle, fatigue, excess alcohol are some of the other factors that can play a role.
To help sort this out, we have Dr. Geo Espinosa who is the go-to guy in the Functional and Integrative Medicine world on men’s health. He’s the Director of the Integrative Urology Center at New York University Langone Medical Center. He’s a licensed naturopathic doctor. He’s a licensed acupuncturist, a certified nutrition specialist, and a registered herbalist. He’s the author of Thrive Don’t Survive: Dr. Geo’s Guide to Living Your Best Life Before & After Prostate Cancer, which is an excellent informative guide to dealing with prostate cancer. He’s one of the editors of a new book on integrative sexual health. Geo, thank you for joining me today.
Dr. Espinosa: Hey, thanks so much, Ben. It’s a pleasure.
Dr. Weitz: Okay, so how should we get started on this topic?
Dr. Espinosa: There’s many places to go. There’s many places to go, but it’s very important to understand first and foremost that the penis is a barometer to a man’s health. Every time I talk about this topic, I say the same thing because it’s really important for everyone to understand. A man who does not get an erection for three months, whether it’s because they don’t have a partner, or because they don’t have a morning erection, that’s a health problem. Other factors might be that need to be investigated. So, it’s not only for pleasure, which is a very important organ for pleasure, but it’s very important for just overall health.
Dr. Weitz: Right. What are some of the causes of erectile dysfunction? What are some of the most important ones?
Dr. Espinosa: The main causes are that it could be neurological. So, anything that interferes with three things: the nervous system, a problem with the nervous system, a problem with blood flow, or hormonal. Any of these three problems can interfere with either the nervous system transmitting signals to the penis or blood flow that can cause an erection. So of course, there’s things like multiple sclerosis, and sometimes surgery from prostate cancer can cause it, particularly if they sever the pudendal nerve that goes into the penis that can cause erectile dysfunction.
Dr. Weitz: What’s the actual numbers on that? I’ve heard like 50%.
Dr. Espinosa: Minimum. After a prostate cancer surgery, minimum 50%. It’s more toward 60% of men that actually get erectile dysfunction from these treatments.
Dr. Weitz: Okay. How much does getting the robotic surgery decrease that percentage?
Dr. Espinosa: How much is getting what? I’m sorry?
Dr. Weitz: Robotic surgery versus the open surgery? How much does the robotic surgery decrease the likelihood for there to be erectile dysfunction, because that’s one of the big selling points of it, right?
Dr. Espinosa: Well, it depends if you ask the robotic surgeon, because many of them would probably want you to think that it’s a very low rate. Actually, there’s very little change in both urinary incontinence and erectile dysfunction with men who undergo robotic surgery versus open surgery. So, there’s very little difference. There’s almost no difference.
Dr. Weitz: Wow.
Dr. Espinosa: You never want to make a decision of whether or not you will undergo robotic surgery versus open based on whether or not you can function afterwards. It doesn’t make much of a difference in that regard.
Dr. Weitz: Wow, so you’ve really popped a myth because I think there’s a very common perception that the robotic surgery is much safer.
Dr. Espinosa: Yeah. The company that creates the robotic machines and all the gadgets for the machine is called the Da Vinci Company, like Leonardo da Vinci. Their marketing has been outstanding. Their direct to consumer marketing has been outstanding, to the point that everyone asks for a robotic surgery these days, and they think they’ll get a better result, but that’s not necessarily true.
Dr. Weitz: Interesting. What kind of alternative is doing radiation, or radiation seed in terms of sparing the nerves?
Dr. Espinosa: So radiation also, that can damage the nerves of the penis. It depends upon what kind of radiation. There’s different kinds. There’s external beam radiation that radiates the whole pelvic area. There’s more focal radiation, something called CyberKnife now that’s proton beam radiation. That’s more focal. That can save the nerves a whole lot more than external beam radiation. Sometimes men need both. Sometimes, they get a radical prostatectomy. Let’s say the physician saves the nerves of the penis–that can happen, but sometimes they need radiation afterwards and it makes it almost 100% impossible to get an erection after that.
Dr. Weitz: Yeah. One of my patients had … He was told originally that it was confined to the prostate, to the gland, and when they went in, they found out that it broken through the capsule. Then, they subjected him to 60 sessions of radiation. Unfortunately, there wasn’t any sign of the cancer, so I questioned what they were radiating–just the area around it.
Dr. Espinosa: They’re radiating blindly sometimes thinking that there is or will be cancer cell somewhere around the pelvic area, but they won’t know exactly where. So, they radiate blindly throughout the whole pelvic bed.
Dr. Weitz: How effective do you think that is for decreasing recurrence?
Dr. Espinosa: Well, the reality is that the recurrence of prostate cancer after all that can occur up to 50% of the times. So, you go through all that and up to 50% of the times, you can have a recurrence of your prostate cancer, not to mention that after radiation, you can have secondary cancers like bladder cancer, and that’s in the data. So, it’s a fine line between what you think will keep you living longer, and the quality of life that you can live while you stay living longer.
Dr. Weitz: Right. Okay. In terms of the vascular supply, the blood flow to the penis. Really in this case, we’re talking about this is another barometer of your overall cardiometabolic health. So if you’re going to have blockages to the arteries, to your heart, and your coronary arteries, you’re talking about the same type of situation that’s going to decrease blood flow to the penis, right?
Dr. Espinosa: Absolutely, absolutely. You want to make sure that the vessels are not atherosclerotic. So, the penile vessels are very small. They’re much smaller than other vessels particularly to the heart. So, things that can happen to the penile vessels can certainly work its way up and eventually happen to the heart vessels. So, you want to make sure that the vessels are nice and supple, like all your vessels, not just the vessels from your penis, so that they expand, and dilate, and constrict. Dilation of the vessels of your penis is what gives a man an erection. Then, the venous level closes in so that the blood stays in there and so a man gets an orgasm, then blood flows back into the system. That having clean blood vessels is the name of the game, along with a clean nervous system as well.
Dr. Weitz: So what are some of the tests that you would do with a man who had erectile dysfunction and you wanted to see if vascular issues were a problem?
Dr. Espinosa: You know Ben, there are no objective tests for that really.
Dr. Weitz: Okay.
Dr. Espinosa: One of the better … As a practitioner, I think you’ll appreciate this. I still get 80% of what I need from a good physical exam and asking key questions. That cannot be overlooked to try to find a fancy test. So then, we have all these tests on purpose. So along those lines, there’s the sex inventory questionnaire called the SHIM, S-H-I-M, which you can download. Anyone can download, and that still one of the best questionnaires is sexual history inventory questionnaire that it could quantify the issue, and you can put them on a protocol and then give them another SHIM score questionnaire three months after or six months after, and you can see the difference if they’re improving or not.
There’s no objective test at this point where we can measure nerves are going … There’s actually an old test that you may not be aware of or you may, where if you insert the … You can do it yourself or do it to a patient. Insert the tip of your finger in the tip of the anus of the patient or yourself, and then if you squeeze the tip of your penis, you can feel the tip of the anus tighten at the tip of your finger as you press on the tip of your penis. That’s an indicator of… if that makes any sense.
Dr. Weitz: I couldn’t hear the last part. It’s an indicator of what, of neurological?
Dr. Espinosa: Yeah, neurological health of the pelvic area of the penis.
Dr. Weitz: Okay. I just got to turn the music off. Somehow, it popped on in my office. Okay, good.
Dr. Espinosa: Okay.
Dr. Weitz: Yeah. I never heard of that one, but that’s kind of interesting. Yeah, I like to run those advanced lipid profiles and take a look at all those factors, and then try to change their nutrition to balance those things out.
Dr. Espinosa: Yeah. You want to rule out metabolic syndrome.
Dr. Weitz: Right. So, diabetes obviously, blood sugar problems, hemoglobin A1c, inflammation, which is going to increase the likelihood, right?
Dr. Espinosa: Yes. Absolutely, absolutely.
Dr. Weitz: What’s your favorite way to measure inflammation? Do you use hsCRP to measure inflammation?
Dr. Espinosa: I do.
Dr. Weitz: Yeah. Okay.
Dr. Espinosa: I do hsCRP. That’s my main form of measuring inflammation. I use hemoglobin A1c, fasting glucose, and I use the NMR LipoProfile as well that has an insulin resistance marker there that I find valuable.
Dr. Weitz: Right. I like to look at also the omega-6 to omega-3 ratio as inflammation marker and then try to modulate that.
Dr. Espinosa: Excellent. What labs do you use for that?
Dr. Weitz: We’ve been using the CardioMetabolic test through SpectraCell. It’s a really nice test and they’re offering it at a really reasonable price. For a patient with insurance, it’s 50 bucks. It includes all the particle size, homocysteine, CRP, omega-3. It’s a neat test. I’d look into that. So, when it comes to neurological problems, besides prostate surgery, I know, as a chiropractor, that problems with lumbar disk or nerve injury that can affect the nerves from the lumbar spine can affect the ability for erection. Isn’t that correct?
Dr. Espinosa: It is correct. Absolutely, it is correct. Certainly as a non-chiropractor, I do find value in those lumbar adjustments that you guys do, just kind of opening things up for my male patients. So, I get them to get adjusted as well.
Dr. Weitz: Yeah. We get patients who find that when they’re having an issue with their lower lumbar region, sometimes they’ll get pain into the testicles or pain into the groin. We know that it can have an effect, and diabetic neuropathy, that can be a factor as well, right?
Dr. Espinosa: Absolutely, absolutely. Anything that contribute to any type of the metabolic type of syndrome presentation, high lipids, high blood glucose, big waist size, all those things are contributing factors and you have that hormonal aspect that’s very important as well.
Dr. Weitz: Right.
Dr. Espinosa: We can segue into that if you want or we can pause if you want.
Dr. Weitz: Yeah, sure. Let’s do that. So what are the hormonal factors that you like to look at the most?
Dr. Espinosa: So, we looked at how well … Testosterone is a major, major hormone not only for sexual interest, but sexual function. Interestingly and infrequently, I find men that say that they can function with lower testosterone levels in the three and 400s, that’s not too common. Oftentimes, these guys say that they don’t wake up with an erection. So, waking up with an erection or at least you recognizing that you have one is actually a very important thing. It doesn’t have to happen every day, but every now and then, you should be able to say, “Hey, I woke up with an erection.” The morning woody is a healthy thing.
Dr. Weitz: How much does free testosterone versus total testosterone matter? How much importance are given to each of those measures?
Dr. Espinosa: That’s a great point. I had a patient today with a total testosterone of 486 and a free testosterone of 7.2, which was very low free testosterone and total is actually low, but within normal. Normal range is a wide range, but it’s very low free. It was very important, and if you don’t have free testosterone, it won’t work. When it’s bound to sex hormone-binding globulin, that testosterone is not free to do what it’s supposed to do. So, it’s very important.
Dr. Weitz: So, how would you treat a patient like that?
Dr. Espinosa: I tell you what I don’t do and it’s not that I’m against it. It’s that, I try to have the patient make the amount of free testosterone that they need as naturally as possible. So, I don’t do exogenous testosterone. Again, it’s not that I’m against it necessarily. I think for some patients it’s the right thing, but they become so dependent on it that their body just shuts down from making it, and it’s very difficult to get them off it once they’re on it.
So, what I do is … There’s two things that I do. Number one is if they have erectile dysfunction, and it’s associated with poor hormone or low free testosterone, they want to function as soon as possible sexually. So, that functioning sexually is more important than health to them. It’s just the way it is. So, I don’t mind that they use a low amount of PDE5 inhibitor, whether it’s Cialis five mg, very low dose, or 25 mg of Viagra. Again, very low, that’s the lowest dose that they have.
I get them some extra nutrients that I use. I use a supplement called … Well, actually it’s my formula, so I don’t want to sell on your podcast, but it does have L-citrulline…
Dr. Weitz: No, feel free to mention it. It’s your Mr. Happy formula?
Dr. Espinosa: It’s Mr. Happy and there’s XYVGGR is very good. So, I get them to do two of those with those formulas, these Mr. Happy formula. They have to take two twice a day on an empty stomach and that’s a very important factor. Then, they may not need a PDE5 inhibitor.
Dr. Weitz: What does that product have in it?
Dr. Espinosa: Yeah. So it’s five ingredients at a very high dosage. It has L-citrulline, which L-citrulline makes more arginine in the body than just taking arginine by itself.
Dr. Weitz: Right.
Dr. Espinosa: It has epimedium. Epimedium has a chemical in it called Icariin I-C-A-R-R-I-N. Icariin is actually a PDE5 inhibitor just like Viagra, Cialis, and Levitra. So there’s these chemicals-
Dr. Weitz: Arginine helps with-
Dr. Espinosa: … in epimedium.
Dr. Weitz: Arginine helps with nitric oxide production, right?
Dr. Espinosa: Correct. So, eventually what you want is your blood vessels to open up. Arginine helps with that. So, your arginine helps stimulate the inside of the arteries to produce nitric oxide, and then your vessels open up. How you get more arginine in your body? You could eat arginine or drink supplements but you have a lot of arginase in your system that breaks it down very quickly. So, you have to take … I mean, studies have shown that arginine works at about five grams a day, but you have to break that up to [inaudible 00:21:42] as shown to actually make more arginine in the body than just taking arginine. So, it was always my preference when I’m trying to raise arginine levels. There was one randomized trial that showed that it helped with sexual erections specifically with the citrulline.
Dr. Weitz: Okay.
Dr. Espinosa: Epimedium or horny goat weed, is the other herb. It’s a layman’s term. It’s called horny goat weed. It actually has icariin, which is like a PDE5 inhibitor, very good. The other is you want adaptogens in the system. Adaptogenic herbs, this is a group of category of herbs that kind of like the name implies, it helps your body adapt. So, adaptogenic herbs are very important. The one in Mr. Happy is rhodiola and it’s one of my favorites, but then you have ashwagandha and you have Siberian Ginseng. Those are good too.
I have to say those are not in the formula and the reason why they are not is because I like the studies in rhodiola, not so much in relation to sexual health, but in relation to extra energy that you would get after a long day’s work, per se. So, that one of the problems that men have is that they work all day, and then they’re pooped out at the end of the night. We try to avoid that. Rhodiola is the best type of herb adaptogen for that.
Dr. Weitz: If you have a man who has total testosterone levels but the free testosterone is low, that means too much is being bound up by like sex hormone-binding globulin. Are there specific nutrients that can help with that issue?
Dr. Espinosa: Yeah. There are two things. A low protein diet, it’s a contributing factor to high SHBG. So, a low protein diet. So, vegans sometimes have high sex-binding globulin hormones, and I use nettle root. I don’t use it in a formula because I use high dosage of nettle root up to 500 mg twice a day of nettle root, not a leaf.
Dr. Weitz: Nettle root?
Dr. Espinosa: These things are all very … yeah.
Dr. Weitz: Is that the same thing as stinging nettles?
Dr. Espinosa: It’s the same thing as nettles but sometimes you see nettles, and it’s nettle leaf.
Dr. Weitz: Okay.
Dr. Espinosa: We don’t want nettle leaf for this particular purpose. We need the root.
Dr. Weitz: Okay.
Dr. Espinosa: Nettle root, it’s what’s important to inhibit over production of sex hormone-binding globulins.
Dr. Weitz: So, do you use capsules or tincture?
Dr. Espinosa: I use capsules for the most part and I use about 500 mg. It’s high dosages and only nettle root, not in a mixed formula. I kept emphasizing that because then, if you use a formula, and I’m okay with formulas but not for this particular purpose, then the dosage will be too low, and the dosage needs to be high for this particular purpose.
Dr. Weitz: You have a favorite manufacturer for that product?
Dr. Espinosa: Yeah, I like MediHerb. First of all, for herbal products, I like MediHerb.
Dr. Weitz: Okay.
Dr. Espinosa: I’m a big fan of MediHerb. So that’s the main one and I like … I also use Gaia sometimes.
Dr. Weitz: Okay.
Dr. Espinosa: G-A-I-A.
Dr. Weitz: Yes.
Dr. Espinosa: Yeah.
Dr. Weitz: Okay cool. What if they have excess estrogen?
Dr. Espinosa: Great question, yeah. There’s not such a thing as bad chemicals or bad hormones in men. I think we get very caught up with bad this, the problem with cholesterol.
Dr. Weitz: Sure.
Dr. Espinosa: Let me say this before I answer your question because my mind is going somewhere else briefly as I mentioned cholesterol. I saw a patient, I posted on Facebook with a 101 total cholesterol level and very low testosterone, 101 without being on a statin. I’ve never seen that before.
Dr. Weitz: Wow.
Dr. Espinosa: I’ve never seen 101 cholesterol in a man that’s not on a statin.
Dr. Weitz: Right, very unusual.
Dr. Espinosa: It is unusual, and so this guy’s not making any of his hormones. His hormones are low. So, as a result, that’s throwing things off. My point with that is that there is … We used to think and of course forever cholesterol is bad, cholesterol is bad, cortisol is bad, estrogen is bad in men. We don’t want any estrogen in men, that’s not true. Estrogen is a very important hormone in men and studies have shown that men that have levels of estrogen, estradiol between 10 and 20 nanograms per milliliter actually have lower heart disease. So, I like men to have between 10 and 20, not higher than 20.
Dr. Weitz: Right.
Dr. Espinosa: Or certainly not lower.
Dr. Weitz: I know a lot in the lab say it’s normal until 40, but I agree with you. I think 20 is probably a better cutoff.
Dr. Espinosa: Yeah. You know what we do? We optimize our ranges, is what we do as functional medicine doctors, and that’s the number … and this is based on research. This is not my opinion.
Dr. Weitz: No, I know you’re always based on research.
Dr. Espinosa: Yeah. So, that’s what I like my men to be. So, yeah. We look at estrogen levels, and so if it’s over, sometimes it’s over a 20, or 30, or 40.
Dr. Weitz: Right, what do you do in those case?
Dr. Espinosa: What we do is liver detox. Liver detox, get them away from … My vegans are sometimes very high in estrogen because they start … They’re probably eating too much soy products. So, I get them to lower down their soya intake, and I do liver type of detoxification. I use a lot of DIM and broccoli type of extracts, milk thistle, get him on a good detox and just get their bodies normalized typically if you reduce estrogenic foods and just clean your liver.
Dr. Weitz: Yeah, good. Cool. So, we know that low testosterone or erectile dysfunction is actually a side effect of a lot of medications. What medications do you find are the most common culprits in this regard?
Dr. Espinosa: So many of blood pressure medications are a problem like beta blockers. So, beta blockers contribute to erectile dysfunction. Some H2 blockers for acid reflux like Tagamet interferes with the production of testosterone.
Dr. Weitz: Those are among the most commonly prescribed medications?
Dr. Espinosa: You better believe it, yeah. You better believe it. Statins, sometimes they lower cholesterol way too low, and so the patient is not making enough cholesterol to make their steroid hormones, their reproductive hormones. So, statins can be an issue.
Dr. Weitz: By the way, you mentioned the patient with low cholesterol. What do you do with a patient with low cholesterol? Do you actually have them … What do you do to try to increase their cholesterol? I heard of a product from sheep’s skin or something, some cholesterol product that one doctor said she used.
Dr. Espinosa: Yeah. I’m not familiar with that. I’m familiar with … So, I’ll tell you what I do in general, and then I’ll tell you what I’ll do with this patient because there are two different things.
Dr. Weitz: Okay.
Dr. Espinosa: This patient is 51 and he has concerns about prostate cancer, so he’s doing a lot of things from an anti-prostate cancer perspective. A lot of that is being vegan and eating soy products.
Dr. Weitz: Oh, I see.
Dr. Espinosa: Which I never put him on that diet for prostate cancer prevention. So he loves meat, and so one of the things we’re going to do is … He’s a blood type O, and I think O’s can handle, they do better with eating a grass-fed beef and animal products. So, I’m going to get him to eat animal products again. I’m going to get him off all that soy. I’m going to get him to focus on big muscles and train big muscles, less repetitions not high reps, more weight, and that’s another way of increasing testosterone. I’m going to get him to do weight resistant exercise on a fasting state. So, that’s interesting because that also helps increase testosterone. So, no pre-workout anything to drink.
Dr. Weitz: Oh, really? Ha, that’s interesting.
Dr. Espinosa: Yeah. Then a protein drink with creatine because I think that’s what he wants after his workout.
Dr. Weitz: Really? Don’t you want to take creatine before because-
Dr. Espinosa: Yeah. So, for the purpose of testosterone, I’m a big fan of lifting, weight resistant on a fasting state only water, only water. Creatine can give you that extra push and that extra … Drink creatine to help you get that extra lift.
Dr. Weitz: Yeah, right.
Dr. Espinosa: It has a pretty decent lifetime, and I’ll get him to take it hours before or the night before. I know creatine can help for certain people. For example, if you have normal testosterone, creatine as a pre-workout is fine, but for guys that I’m trying to raise their T levels and their free T, I get them to just do on an empty stomach with no macronutrients in their system at all.
Dr. Weitz: Interesting.
Dr. Espinosa: Yeah. So, with regards to supplementation, I use herbs. I use fenugreek. That’s been studied quite extensively. Testofen is what’s used. I use maca, and again when it comes to maca, I use only maca three grams a day, so I don’t mix it with anything else. I use XYVGGR or something like Mr. Happy. So, what I’ve noticed in my patients that use … XYVGGR is the practitioner line for Mr. Happy by the way.
Dr. Weitz: Okay.
Dr. Espinosa: So, the formula is the same thing, so I may use the names interchangeably as we talk.
Dr. Weitz: I see, I see. Why do you take the maca by itself? Is it different if you mix it with other products or foods?
Dr. Espinosa: I take it by itself because you need three grams for it to have any efficacy. You can only fit so much into a capsule.
Dr. Weitz: Okay.
Dr. Espinosa: That’s the only reason.
Dr. Weitz: Right.
Dr. Espinosa: Yeah. The other adaptogen that has actually been shown in studies to help increase testosterone is ashwagandha. So between ashwagandha, fenugreek, and maca, that’s my main three herbal combination. It’s not tribulus.
Dr. Weitz: Okay.
Dr. Espinosa: It’s not tribulus because I know a lot of people are taking tribulus, and I just don’t know the evidence for it. I don’t see it, and I don’t see it clinically.
Dr. Weitz: Okay. Interesting.
Dr. Espinosa: Then I get them to … I figure out their sleep patterns and then if that’s a problem, we work on that.
Dr. Weitz: Okay, what if-
Dr. Espinosa: As you know, you may … Sorry to interrupt Ben. As you know, we make most of our testosterone during our sleep cycle, anywhere between 4:00 to 5:00 in the morning.
Dr. Weitz: So, is it crucial when we test testosterone that we test it pretty early in the morning?
Dr. Espinosa: It is. Particularly on younger men, younger than 50. Older men, older than 50, studies actually show that it doesn’t matter because their testosterone is pretty leveled off throughout the day. So, I don’t know.
Dr. Weitz: I thought that older men category started at 70.
Dr. Espinosa: Well, I want to think that too by the way. As you see, my face is graying by the day. When they talk about older men and younger men, I take that a little bit with a grain of salt because a 60-year-old man is not a 60-year-old man. You could be a 60-year-old man who’s like 70 biologically, or who’s 40 biologically. So, I’m very careful with that. I’m just a messenger here.
Dr. Weitz: What do you think about marijuana and testosterone levels? Especially since marijuana is-
Dr. Espinosa: I’m sorry, marijuana.
Dr. Weitz: Yeah. It’s getting more popular, and even CBD oil, and it seems to be a very hot topic right now.
Dr. Espinosa: Right. So, marijuana lowers testosterone levels, and so man, want to be careful. Is there a toxicity to the dose? I don’t know. I don’t know if you smoke two joints versus one if there’s a difference. Same with alcohol. Alcohol in excess, it can be an erection killer. A little bit of alcohol can take the edge off and can help you get into the mood. So, there’s a fine line. I don’t know if there’s a fine line with marijuana. I think men, I want to be very careful, but I do know that it lowers testosterone level. So, men want to be very careful with the usage of marijuana.
I know it’s now the in thing and there’s a big industry now. I think Snoop Dogg is a partner in one of these marijuana companies and everything is big business, but I think men want to be careful if they want to keep their testosterone levels high.
Dr. Weitz: What about adrenal fatigue? I know DHEA, which is produced by the adrenals is a precursor to testosterone.
Dr. Espinosa: Yeah. So, that’s very good. So, DHEA has shown to help with erections as well in men who are deficient in DHEA, and men who have no deficiencies in DHEA, I would not give DHEA for that particular purpose anyway. If there is a deficiency in DHEAS, then you would want to give DHEA and that may help as well with erections.
Dr. Weitz: You know just-
Dr. Espinosa: Yeah?
Dr. Weitz: I was having some discussion about sexual issues with women, and women are using a bunch of topicals including topical DHEA cream now. Are there topical creams like that? Does that have any effect for men? I’m just curious.
Dr. Espinosa: Not that I know of and not from an erection perspective.
Dr. Weitz: Right.
Dr. Espinosa: That I know of anyway.
Dr. Weitz: Okay. So, I’ve heard of a few patients who had scar tissue in their penis from riding a bike or other trauma. Can you talk about that as having an effect on erectile problems?
Dr. Espinosa: Well, I don’t know if these particular patients you’re referring to if they’ve had Peyronie’s disease. So, that with scar tissue, their penis bends a little bit and becomes like a curve, it curves. If there is Peyronie’s, there can be erectile dysfunction. There’s like three levels of Peyronie’s. If they have like level one, they may just see a slight curvature upward or sideways, and that’s not … If you have a level one, it doesn’t interfere with intercourse at all.
If they have a level two or three, they may have erectile dysfunction from that. A little bit harder to treat, the natural approach is very, very extensive. It’s very difficult. I have not been that successful, I have to say with Peyronie’s disease just with natural methods alone anyway. So, that’s very difficult to treat. So, any other type of trauma not so much from bike riding. I mean, it depends. If they have prostatitis and maybe prostatitis or an inflammation of the prostate, and that can contribute to erectile dysfunction because now, the nerves that are going to the penis are irritated and inflamed as well.
Dr. Weitz: Well, I’ve also had some of those bike riders tell me about just numbness in that whole area too. I suspect that, that could potentially be a-
Dr. Espinosa: Yeah. That’s neurological for sure, yeah.
Dr. Weitz: Yeah. There are some physical treatments for erectile dysfunction. I was listening to one of Mike Mutzel’s podcast and he had this Dr. Kathryn Retzler on, who’s a naturopathic doctor. She mentioned, number one, giving PRP injections into the penis, and she also talked about-
Dr. Espinosa: Yeah.
Dr. Weitz: … a GAINSWave sound therapy. What have you … Do you know anything about those?
Dr. Espinosa: Yes. I don’t do them, and not because I’m not interested is because I can only do so much. I know that PRP is used for Peyronie’s disease.
Dr. Weitz: Okay.
Dr. Espinosa: On that curvature of the penis-
Dr. Weitz: Yeah.
Dr. Espinosa: … with some level of success. So, that with sound wave therapy, I’ve heard anecdotally good things. Ben Greenfield, who actually we met at Mindshare-
Dr. Weitz: That’s right.
Dr. Espinosa: Actually was that Mindshare?
Dr. Weitz: Yeah, I met him as well.
Dr. Espinosa: He is like a guinea pig with all kinds of things, and he’s reported to do that with his penis without having to. He didn’t have a problem. He just wanted to do it, and he’s openly talked about it. He talks positively about it that his organ is bigger at least to him.
Dr. Weitz: Right.
Dr. Espinosa: That it works. There’s a stronger orgasm when he has intercourse, and then indeed it helps with longer erections. So, there’s a lot of anecdotal information. There’s a big to do, to do the PRP and the sound wave. Quite frankly, I think it’s a little bit … I like to see some objective evidence before I send a patient to do that. I would send a patient to do PRP for Peyronie’s just because there’s not much out there to begin with. So, for that purpose, I would … but yeah. I’m still waiting for a little bit more data or something for me to hang onto, so I can say with low level of concern for patient to move forward with that.
Dr. Weitz: Are there any nutritional deficiencies that you think can cause erectile dysfunction or play a role in that issue?
Dr. Espinosa: Yes. So, guys that are with low protein diets because they probably not … They don’t have enough arginine in their system. That’s a concern. So, it’s some sort of amino acid deficiency like arginine, and once again zinc. Zinc, it’s a major male mineral, other than magnesium, which magnesium obviously it’s involved in many biological pathways and is probably the number one mineral. Other than that for a man, zinc is a man’s best friend.
Dr. Weitz: Okay.
Dr. Espinosa: Anti-oxidants because there’s a lot of … much of erectile dysfunction and male infertility can be due to oxidative stress. So, you need to find combination of antioxidants and you know the deal. Alpha-lipoic acid, vitamin C, mixed tocopherols, vitamin E, all those are all very good and plants. A plant-based phytochemical antioxidants as well.
Dr. Weitz: Is there an upper limit to zinc supplementation that you don’t like to not go above?
Dr. Espinosa: Great question, I hang around 30 to 60.
Dr. Weitz: Okay.
Dr. Espinosa: Which is fine anywhere once. I try not to go at … I’d never go above 60 or anywhere near a 100 with any mineral. Too much of a good thing may not be such a good thing. Zinc is one of them, and of course zinc and copper they work together. So, once you start giving more than 30 to 60 milligrams of zinc, you may want to give one or two milligrams of copper so that you don’t have a copper deficiency. So I don’t go higher than 60 milligrams.
Dr. Weitz: Okay. And one last issue I’d like to touch on because I don’t think it would be complete to talk about this topic without mentioning some of the psychological issues like depression, stress, relationship problems, and even watching porn, which seems to be a problem.
Dr. Espinosa: Yeah. So, adrenaline is the biggest erection killer in the world.
Dr. Weitz: Stress.
Dr. Espinosa: So, there is no strong chemical, any type of stress, or anxiety, or guilt, or anything like that can … It will cause the production of adrenaline, norepinephrine, epinephrine, and there’s no chemical that I can inject in your body that’s stronger as an erection killer than these adrenaline chemicals. Okay, so that’s one big takeaway.
Dr. Weitz: Cool.
Dr. Espinosa: Now, with that comes the relationship, the importance of how you get along. There are times when people are saying … Guys come into my office and say, “Well, I have erectile dysfunction.” I was like, “Oh, how do you know? What if I, I don’t know, what if I bring JLo into the office, will you have that …”. “Well, I don’t think so.” So, sometimes you can see there’s problems in their relationship. Do you still think that your woman, if it’s a woman, do you still think she’s hot and all these factors?
Now, these things are overlooked all the times but if we’re trying to address the underlying cause, then that needs to be addressed. So, how often do you wake up with an erection? Then, I do give them like some Cialis even if they’re not functioning to see if they get more spontaneous erections. If they do, that means it’s psychological. If they get an erection from anything, from a drug, or a supplement, that means that it’s psychological. So, I cannot overestimate the importance of just a good relationship, and we can have another podcast on what that would look like.
Dr. Weitz: Right.
Dr. Espinosa: The other aspect is porn. You mentioned some statistics initially that about 30% in men under 40 roughly have ED. I would argue that. What I see is a whole lot more than that in men under 40.
Dr. Weitz: Okay.
Dr. Espinosa: The reason for that is because the men under 40 particularly millennials have been … have had free access or paid access, easy access to porn since they were probably born. Well, that’s if they had access to it because they’ve been around iPads and so forth looking at porn, and they have this perception of what sexual intimacy is like. Then, once they start having intercourse and they start mating, then they think that, that’s what it looks like and they are having a lot of erectile dysfunction issues. When you and I, Ben, you look like a millennial but I know you’re not.
Dr. Weitz: No, I’ll be 60 this year.
Dr. Espinosa: Wow, you’re a milestone. Ben, that’s amazing actually. I think I’ll have to interview you sometimes to figure out what you’re doing.
Dr. Weitz: Sounds great.
Dr. Espinosa: Geez, that’s …
Dr. Weitz: Thank you.
Dr. Espinosa: If you or I, when we were growing up.
Dr. Weitz: When I finished my anti-aging book, you can interview me.
Dr. Espinosa: Absolutely, absolutely, would gladly do so.
Dr. Weitz: Okay.
Dr. Espinosa: When you or I wanted to get a porn flick, we had a VCR. We had to go to the store, go to the corner store, which was in this isolated section, nice and big, you see triple X. It’s a little bit embarrassing to go in there. So, we didn’t watch much porn relative to what’s available now growing up. So these young guys are more screwed up in bed than ever before.
Dr. Weitz: Right.
Dr. Espinosa: A lot of it has to do with excessive porn watching. It’s not my opinion. It is an absolute fact, and it’s been proven and confirmed in scientific studies. It’s bad. It’s a problem. Briefly, I’ll say this. Why is it a problem? Many reasons. They are watching positions and things that once they start mating with females, or whatever, or whoever, they may not do all those positions that are so wild and so forth. The other thing is that they all think they have a small penis, part of the reason why they think they have a small penis is because watching porn.
Dr. Weitz: Right.
Dr. Espinosa: Which is magnifying the size of the penis, and sometimes they’re holding it and inserting it at the same time, and they’re thinking that they could do that. Well, I can’t do that if I hold it. I can’t insert it. There’s not that much left. So, all these issue … I’m serious. I speak to these guys all the time, so they’re thinking that they could do all these things and they can’t. Almost at least five times a week, a guy comes into my office and say, “Oh, I think I have prostatitis. I think I have prostate. I’m urinating a lot, and I think I have a small penis. I think I have microphallus.”
Now, microphallus is a real diagnosis. That’s a real diagnosis. I’ve met one guy in my lifetime that has microphallus. In my lifetime, I’ve been practicing now for 13
years mostly men, once have I seen them. Microphallus is just the glans, only the head of the penis and that’s all they have.
Dr. Weitz: Okay.
Dr. Espinosa: So, most guys are not. They don’t have a small penis. Yes, some guys are bigger than others, but most guys don’t have microphallus. In any event, watching porn I think is one of the biggest no pun intended, contributing factors to erectile dysfunction amongst young men.
Dr. Weitz: Great, Dr. Geo Espinosa. This was a lot of great information. For those listening or watching this podcast how can they get hold of you?
Dr. Espinosa: Thank you so much. So, my website is drgeo.com, D-R-G-E-O.com, E for erections, not I. The book that just came out Integrative Sexual Health that I’m one of three editors.
Dr. Weitz: Okay.
Dr. Espinosa: We were talking about it before Ben. You almost don’t feel when you’re done with it that you have a good book out. I’ve written several books and at the end, I’m like, “God, I could have done more.” Then you read it, and then just like, “Oh, wow. Oh, wow, yeah.” It’s almost like you’re reading somebody else’s book. This particular book Integrative Sexual Health along with my coeditors Barbara Bartlik and Janet Mindes. It’s probably, not probably because I love to have many books behind me on sexuality.
It is the most comprehensive book on integrative and functional medicine for sexual health both for male and female. I actually learned tons from a female perspective because we got all kinds of expert authors to contribute, and quite frankly I know very little about female sexuality, which I think it’s important for men to know actually in order to … If you’re going to have intimacy with females. In any event, Integrative Sexual Health, it’s out now as part of the Weil Integrative Medicine Library of books.
Dr. Weitz: Good.
Dr. Espinosa: It’s a great, great, great resource. So, thank you for allowing me to mention it to your audience.
Dr. Weitz: Absolutely, and I’ll put a link to it on my web page, and add it to the YouTube page as well.
Dr. Espinosa: Thank you.
Dr. Weitz: Okay, talk to you soon.
Dr. Espinosa: Thank you very much.
Dr. Weitz: Thank you, thank you.
