Men’s Health with Dr. Matthew Cavaiola: Rational Wellness Podcast 138
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Dr. Cavaiola discusses Testosterone Replacement Therapy and Men’s Health with Dr. Ben Weitz.
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Podcast Highlights
3:47 To understand what a low testosterone level is, we need to look both at lab tests and at patient symptoms. The symptoms that a male patient with low testosterone may present with are fatigue, libido problems, difficulties putting on muscle mass or losing body fat, sleep disruptions, as well as a variety of others. Then serum total and free testosterone levels are run and we look first at total testosterone levels. But the lab reference ranges usually huge, with normal being from 150 or 250 to 1100. Because of this huge range, Dr. Cavaiola feels that many men are undertreated. If a patient has a total testosterone level of 250 or even 400 and they have many symptoms, then there can still be a justification for treating with bioidentical testosterone replacement therapy.
6:38 Free testosterone may be even more important than total testosterone, since it is the bioavailable proportion of testosterone that can be utilized by the body. The free testosterone is that portion of the testosterone that is not bound up by carrier proteins like Sex Hormone Binding Globulin (SHBG) and albumen or that has not been converted into other substances, like estrogen or dihydrotestosterone (DHT). Therefore, we need to measure both total and free testosterone and we also need to have adequate levels of free testosterone. But after we put a man on testosterone replacement therapy, it’s not as accurate to measure free testosterone any more, so it is more important at that point to mostly monitor levels of total testosterone. However, Dr. Cavaiola does still measure free testosterone along with total testosterone, as well as estrogen, DHT, and SHBG.
9:58 Dr. Cavaiola monitors estrogen levels in men because of the negative side effects that can result from higher levels of estrogen. He usually focuses mostly on total estrogen levels (combination of estrone (E1), estradiol (E2), and estriol (E3)) and he wants to see that level below 100 but above 30. In fact, a small amount of estrogen is important for bone protective effects, for libido, and even for erectile function. Dr. Cavaiola pointed out that estrone is partially a measure of exogenous estrogen exposure from pthalates in plastic and other environmental toxins that have an estrogenic effect. He does not focus as much on progesterone levels in men.
14:40 Let’s take the case of a young man, say 35 years old, who comes to see Dr. Cavaiola complaining of symptoms characteristic of low testosterone levels but does not want to take testosterone. After taking his history, examining him, and measuring all his hormones, Dr. Cavaiola will start with diet and lifestyle and usually wants to clean up the gut first. He will often run a complete stool analysis through Genova and food sensitivity testing through Great Plains Lab. Leaky gut and dysbiosis of the microbiome can have a negative impact on hormone levels. From a lifestyle perspective, men should not smoke, not drink to excess, and minimize exposure to environmental toxins. Smoking marijuana is not favorable for testosterone levels, so you should minimize this. Exercise is beneficial for raising testosterone levels, esp. strength training. Dr. Cavaiola also recommends such men follow an anti-inflammatory diet, which avoids dairy, gluten, sugar, corn, and soy.
23:05 Dr. Cavaiola has found that some of the commonly recommended nutritional supplements, like tribulus and maca, do not appreciably raise testosterone levels. However, he has found American ginseng to be helpful in raising testerone levels. Boron has good research that it can lower Sex Hormone Binding Globulin and unbind it from testosterone. SHBG levels tend to rise with age in men. Stinging nettle root may also be effective for lowering SHBG and also DHT levels.
26:35 Let’s take the case of a 35 year old with low testosterone who is willing to take a pharmaceutical approach but does not want to start taking testosterone replacement.
Dr. Cavaiola is a Naturopathic Doctor who also holds Master’s degrees in both Human Nutrition and Acupuncture. He specializes in men’s health and testosterone replacement therapy and his practice is Conscious Human Medicine in Santa Monica, which he shares with his partner, Dr. Hashemi. His website is ConsciousHumanMedicine.com.
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 and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.
Podcast Transcript
Dr. Weitz: Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field, to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates and to learn more, check out my website drweitz.com. Thanks for joining me and let’s jump into the podcast. Hello Rational Wellness podcasters, thank you so much for joining me again today. For those of you who are enjoying listening to our Rational Wellness Podcast, I would certainly appreciate it if you could go to Apple Podcast or whatever podcast app you’re using and give us a ratings and review. That way more people will find out about the Rational Wellness Podcast. Also, if you go to my YouTube page, you can find a video version and if you go to my website, drweitz.com, you can find detailed show notes and a complete transcript.
Our topic for today, is the use of bioidentical hormone replacement for men, with Dr. Cavaiola. As men age, their testosterone levels tend to decline, approximately 1 to 2% per year after age 30 or 35, depending upon the study. Though it’s not clear that is inevitable, since some older men do not experience this decline. We’re also seeing a society-wide decrease in both testosterone levels and sperm counts in the US. Much evidence points to the cause being endocrine disrupting substances in our environment, like bisphenol A, phthalates, PCB, pesticides, glyphosates, as playing a role in reducing these male hormones.
A study in the Archives of Internal Medicine in 2007, found that lower levels of anabolic hormones, which includes testosterone, DHEA IGF-1, in men over age 65, is associated with increased mortality over a six year period. [Relationship between low levels of anabolic hormones and 6-year mortality in older men.] However, it’s controversial these days whether having higher IGF-1 levels is better or worse for longevity. There are some studies recently, that have shown that having lower IGF-1 levels, is associated with improved longevity. [ROLE of IGF-1 System in the Modulation of Longevity: Controversies and New Insights From a Centenarians’ Perspective] Men with low testosterone levels may have a number of significant symptoms, that are associated with a lower quality of life. Including decreased sexual desire, erectile dysfunction, reduced strength, reduced muscle mass, reduced bone density, insomnia, and cognitive dysfunction among others. The question we would like to answer today is, should such a man be prescribed androgen hormones like testosterone and DHEA? And what are the possible negative and positive consequences of taking male hormones like testosterone, besides the ones your body naturally produces.
Our special guest is Dr. Cavaiola, who is a Naturopathic Doctor. He also holds a master’s degree in both human nutrition and acupuncture. He specializes in men’s health and testosterone replacement therapy and his practice is Conscious Human Medicine in Santa Monica, which he shares with his partner, Dr. Hashemi. Dr. Cavaiola, thank you so much for joining me today.
Dr. Cavaiola: And thank you for having me, very much appreciated.
Dr. Weitz: Excellent.
Dr. Cavaiola: Great introduction.
Dr. Weitz: I appreciate that. So let’s start by defining, what do we mean by low testosterone levels?
Dr. Cavaiola: So those testosterone levels, there’s basically a clinical definition and more of a symptomatic definition. So when a male patient comes in and sees us in our clinic, essentially, we evaluate the patient. First of all, understanding what’s happening with the patient overall, symptomatically, right? And again, you mentioned some of the symptoms that oftentimes are associated with low testosterone. The picture that they might present with is, I have fatigue, I have difficulties with libido, difficulties putting on muscle mass or fat deposition or weight gain, those types of things. Sleep disruption, a whole variety of other things. So when they come and see us, it’s important to first of all, understand the root cause. As Naturopathic Doctors, it’s important for us to get to the root cause of people’s problems. So that is important for us, so okay, let’s understand the symptom picture and at that point in time, you may recommend some lab work. And so once we run lab work, the labs can come back and the lab values, the reference values range for total testosterone, from 250 to 1,100. So that’s a huge, huge range, so a lot-
Dr. Weitz: So these are serum levels, you typically do serum-
Dr. Cavaiola: Correct, yes. So there are different measures of testosterone, there’s different applications, there’s different lab methodologies that you can use to evaluate testosterone. Serum probably is the gold standard and one of the best, and kind of the most easily used for insurance purposes as well. So we typically use serum levels and when a total testosterone level comes back between 250 and 1,100 it’s a huge range. So part of the problem that we’re running into, is that a lot of times men, depending on where they fall along that scale, they’re being undertreated. And a lot of times because as long as you’re above 250, if you’re 251, you’re considered normal, right?
Dr. Weitz: Sure, and some of the labs say the bottom range is 150 or it changes sometimes for age ranges.
Dr. Cavaiola: Yes, exactly, so really, we need to be looking at the entire picture and that really is the key. So if a patient comes in, their levels are 400 and they feel like, they just feel awful, then there is a potential clinical reason for using testosterone for that patient. So we both look at the lab values, which again, the lower end of the scale is 250. So clinical definition of hypogonadism or low testosterone is anything below 250. Although we need to be looking at the clinical picture, plus the labs for the majority of our patients.
Dr. Weitz: Okay, so what about free testosterone levels? Are lab measures accurate? I know there’s some controversy about that.
Dr. Cavaiola: Yeah, I mean, I think free testosterone levels are accurate and that free testosterone, if people listening out there don’t understand the differences between total and free testosterone. Basically what you have is a total pool of testosterone that’s being released from your testes essentially, and also to a lesser degree, your adrenal glands, which we’ll talk about, I’m sure, in a little while. But your free testosterone basically is the proportions of your testosterone that is not either bound up to carrier proteins, one of the major ones is called sex hormone binding globulin, HSBG, albumen or being converted into other things. Things like estrogen, things like DHT, those are the primary things that testosterone oftentimes is converted to interest blood stream. So the free testosterone is basically the bioavailable proportion of testosterone that can be utilized by the body. It’s very, very important, so although you may have a normal total testosterone, whatever considered normal is, you can have a lower proportional level of free testosterone. And that’s problematic because that really is what’s doing the magic in the body. So we want to have adequate levels of free testosterone, so we need to measuring both total and free.
So what there is, there is controversy about free testosterone because if we do put a man on testosterone replacement therapy, which we’re going to talk a lot about today, free testosterone increases, at that point in time, it’s not as accurate to measure. Basically, at that point in time, we want to be just looking at the total testosterone because essentially, we’re increasing exogenous levels, endogenous levels of testosterone by injecting testosterone. So it’s the free testosterone levels are going to go up.
Dr. Weitz: Okay, so you’re saying, looking at free testosterone levels is not as helpful, why is that again? I don’t quite understand, so-
Dr. Cavaiola: So free testosterone is important when you first running it-
Dr. Weitz: Oh, after you start adding testosterone.
Dr. Cavaiola: Right, so essentially what’s happening is, if you’re injecting or using some other type of application of testosterone, you’re taking in hormones into the body, right? So it’s asking the body to raise both your total testosterone and your free testosterone levels. So you’re not getting an accurate representation of really what’s happening inside the body. So really at that point in time, the free testosterone is relatively negligible in terms of measuring, we do it anyway, just to kind of see what’s happening overall, with the entire picture, but not as important at that point in time, rather than the collecting of the baseline numbers.
Dr. Weitz: Right, unless of course, you don’t see an increase in free testosterone because a lot of it’s getting bound up.
Dr. Cavaiola: Absolutely, yes, bound up or being converted to other things. So yes, in that case, like I said, we do want to see the entire picture holistically and as people who don’t just prescribe testosterone and get them in and get them out of our practice. We really want to understand what’s happening overall with the hormone picture. It’s really, really important for us to understand what’s happening with estrogen? What’s happening with DHT? What’s happening with SHBG? And then what’s happening with the patient overall?
Dr. Weitz: And do you also look at estrogen and progesterone?
Dr. Cavaiola: Yeah, absolutely, estrogen more so than progesterone. There’s some docs out there that really love to run progesterone levels, haven’t found-
Dr. Weitz: Yeah, I’ve even heard some docs prescribe progesterone for men in certain circumstances.
Dr. Cavaiola: A few of them do, yeah and really from a clinical standpoint, we’re always more concerned about estrogen because of the negative side effects that it can have. There are less side effects associated with progesterone in men and maybe necessarily not as many men need progesterone compared to women.
Dr. Weitz: Right, so when you look at estrogen and you basically focused on the estradiol or do you into total estrogen?
Dr. Cavaiola: We look at total estrogen in our practice and really, it’s really important. Some people just look at estradiol or estradiol alone. And what we’re seeing actually is, estrone (E1), is a relatively potent form of estrogen. For your listeners out there, there’s basically three types of estrogen. You have estrone (E1), estradiol (E2), and estriol, which is E3. And essentially, estriol is negligible, it pretty much doesn’t exist, it’s in very, very small amounts. Estrone and estradiol in the body, they both have similar effects in men and women. Obviously women have more estrogen than men and vice versa. So essentially, what we want to be seeing is not very high levels estrogen total. And you had mentioned earlier the fact that we are taking in more and more exogenous, meaning outside of our body, estrogen nowadays, right?
Dr. Weitz: Right.
Dr. Cavaiola: We’re being bombarded by it all throughout our environment, it really is scary. And so estrone sometimes is a measure of, not estradiol, of our exogenous estrogen exposure. So for instance how much plastic water bottles we’re drinking out of. So plastic of course contains phthalates, that we’re taking into our body, we’re ingesting orally and then basically, get trapped into our body, so-
Dr. Weitz: And by the way, it’s almost impossible to avoid plastic, you can avoid plastic water bottles and then you have some fish and find out it’s got microparticles of plastic in it.
Dr. Cavaiola: Absolutely, everything, we’re turning into a plastic society, unfortunately and there’s no, about one person on this earth at that point in time, who doesn’t have plastic in their body.
Dr. Weitz: Absolutely, and you pick up a cash register receipt, it’s coated with bisphenol A, which is one of the hardeners for plastic and yeah. Do you look at DHEA levels?
Dr. Cavaiola: We do, so as part of our routine baseline analysis for our patients, we’re looking at total and free testosterone, both types of estrogen, DHT, DHEA, cortisol, SHBG. Those are the primary things we’re going to be looking at for our patients. So yes, we look at both DHT, dihydrotestosterone, which is a by-product of testosterone and DHEA. Now DHEA is interesting, it’s an adrenal hormone, by cortisol and DHEA is interesting because I mentioned earlier in the podcast that basically, you have two major sources of testosterone from the body. It’s from your testes and also a little less from your adrenal glands. And you are going to get a little bit of production from adrenals in the form of DHEA converting into some of the other androgens kind of systemically.
Dr. Weitz: Right, on the estrogen levels, isn’t it important that the estrogen stay at a certain level? Like if the estrogen gets too low, that’s not ideal and then-
Dr. Cavaiola: Absolutely.
Dr. Weitz: What level are you worried about? What’s the range you like to see the estrogen at?
Dr. Cavaiola: Very good, it’s a great question. And what we like to see is, the total estrogen, that’s the combination of both estrone (E1) and estradiol (E2), being less than 100. That’s our kind of cut off point, our more a danger zone if you will, I suppose. But like you mentioned, if estrogen goes too low, we can also have effects. So men need estrogen, men need a little bit of estrogen for bone protective effects, actually for libido a little bit. We need some estrogen for natural libido and for our erectile function. So estrogen shouldn’t be lowered and bottomed out, in fact, I’ve seen clinically, when we do that, men run into problems down the line. So we want the estrogen between roughly I would say probably 30 total and 100, that’s kind of our cut off points.
Dr. Weitz: Okay, that sounds good. So, let’s start with how you would handle a younger man, maybe a 30-year-old, maybe 40-year-old, who comes into your office and has symptoms of lowered testosterone. Let’s say you evaluate him and maybe in one case they have low total and free testosterone and what would tend to be your approach in handling this patient?
Dr. Cavaiola: So first of all, I will just back up and I think it’s important to mention to your audience that we are seeing younger and younger men coming into our office with low testosterone. It is no longer an old man’s problem. We really are seeing men in their 20s, 30s and 40s, who have low testosterone. So although our testosterone relatively peaks in our 20s and starts to decline after, like you mentioned around the age of 35, we are seeing men who have low testosterone at a younger and younger age. Again, primarily due to environmental factors. However, when a patient comes in during their 30s or 40s, how we approach the patient is, first of all understanding again, the hormones in totality. Let’s understand all of the hormones, what’s going on from a holistic perspective? And then saying to a patient, “These are the options, we can start you on testosterone replacement therapy, we can start you on something that might be helpful in raising your testosterone levels outside of testosterone, or some combination thereof.” And then I’ll also explain to the patient that if they are interested in fertility, testosterone has the capabilities of lowering your fertility levels. So we can talk more about that in a little while, but basically, if you take exogenous testosterone, essentially it shuts down your own production of sperm and testosterone, so-
Dr. Weitz: So let’s take the case of a guy, 35-year-old guy and he says, “Look, I don’t want to take any testosterone. I don’t want to take any pharmaceuticals.” What’s your diet and lifestyle approach?
Dr. Cavaiola: So diet and lifestyle is crucial. Obviously we want to be cleaning up the gut, a lot of times as Functional Medicine practitioners, we start with the gut, we start with diet. It is so, so vitally important to look at the gut as the root cause of so many problems that we have.
Dr. Weitz: How do you analyze the gut and how do you clean up the gut?
Dr. Cavaiola: Great question, so a lot of the times, we look at a stool analysis, look for particles and look for things that might lead us to believe that there’s what we consider intestinal permeability. We also do food sensitivity testing in our office as well, which can give you clues as to what’s happening internally.
Dr. Weitz: What type of stool test and food sensitivity testing do you tend to use?
Dr. Cavaiola: So are you asking for brands, or are you asking for-
Dr. Weitz: Sure, yeah, you can talk about brands or-
Dr. Cavaiola: So typically, I don’t know it’s allowed in this podcast or not.
Dr. Weitz: Yeah, there’s no CEUs.
Dr. Cavaiola: Right, right, so a lot of times we’ll run a Genova stool analysis, comprehensive stool analysis, CSA. And then we really like Great Plains food sensitivity test. And so what’s important is getting these clues as to what’s happening. If the gut is permeable, what we are seeing nowadays and also looking at the microbiome to some degree, we’re seeing more and more correlations between microbiome health and also hormone levels in the body and if you can clean up the gut by repairing the holes that had been punctured into the gut, I suppose you could say, tightening things up, so proteins are not leaking into the blood stream. And also, improving the microbiome, improving the health of the microbiome, that can actually help hormones levels long term. And then from a diet standpoint and a lifestyle standpoint. First of all, lifestyle, it’s important that men do not, they don’t drink to excess, they do not smoke, they minimize their environmental exposures because that really is a key nowadays, more so than a lot of other things and-
Dr. Weitz: What about smoking marijuana?
Dr. Cavaiola: So smoking marijuana is controversial, there’s some people who say it does lower testosterone and some people who say it doesn’t. I’m in the camp of, if we can do whatever we can to maximize our hormone levels and kind of what the research says, then we should be doing that. I would say, if you do that, don’t do it to excess. How much are you doing to begin with? I think that’s part of the battle. If you’re drinking every single day, you’re going to have lower testosterone levels, most of the time, right? If you’re smoking every single day, a pack a day or a half a pack a day, it does cause lowered testosterone levels. So those are things we can be doing from a lifestyle standpoint, an actually-
Dr. Weitz: Yeah, I tend to think that the marijuana, I’ve seen enough evidence that it certainly, there’s a fair chance that it may lower testosterone levels.
Dr. Cavaiola: Yes and there’s actually a new study out and kind of there were studies before this too, but actually it linked it to testicular cancer as well in men. So that’s not favorable for marijuana unfortunately. But yeah, and then the other thing, exercise is another thing that’s very, very important to help to raise testosterone levels. There’s a lot of I guess you could say, controversy in terms of understanding what the best types of exercise are for men to raise testosterone levels. And we don’t really know what the gold standard is at this point in time. As long as guys are getting out there and moving their bodies and doing strength training. Strength training has been shown to raise testosterone levels, it doesn’t matter-
Dr. Weitz: Wait, hasn’t heavy resistance training been shown to be the most beneficial?
Dr. Cavaiola: Yeah, I mean strength training, heavy strength training has been shown to be beneficial, as has mixed training as well. So resistance, as well some kind of cardiovascular aerobic training. And one thing that I really love recommending for patients is HIIT training, high intensity interval training, which has actually been shown to be very helpful. Not only to raise testosterone levels, but also to essentially help with a lot of cardiovascular, metabolic parameters too. And from a diet standpoint, we always start, obviously we only have a certain amount of time for our podcast, we could go on and on and on about diet and nutrition. But I think starting with an anti-inflammatory diet would be the best way to go for the majority of people.
Dr. Weitz: Which basically, is what?
Dr. Cavaiola: So an anti-inflammatory diet would primarily be things-
Dr. Weitz: There’s many diets that people prescribe as anti-inflammatory.
Dr. Cavaiola: Yeah, absolutely, so if somebody out there is listening, who has never started on any kind of dietary program before, what we oftentimes recommend is avoiding the four or five big guns. That’s what we call them. So something like dairy, gluten, sugar, absolutely, notice how close I got to the camera. Sugar and corn and depending on who you are-
Dr. Weitz: Soy, yeah.
Dr. Cavaiola: Yes, absolutely, so soy has been show to essentially kind of mimic estrogen in the body and to also unfavorably lower testosterone levels. So that would be a good starting point.
Dr. Weitz: We’ve been having a great discussion, but I’d like to take a minute to tell you about the sponsor for this episode. I’m thrilled that we are being sponsored for this episode of the Rational Wellness Podcast by Integrative Therapeutics, which is one of the few lines of professional products that I use in my office. Integrative Therapeutics is a top tier manufacturer of clinician designed, cutting edge nutritional products, with therapeutic dosages of scientifically proven ingredients, to help patients prevent chronic diseases and feel better naturally.
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Dr. Weitz: Besides doing those things, you’ve cleaned up the gut, you’ve got their diet doing better, they’re doing exercise, are there any specific supplements that you have found to be beneficial?
Dr. Cavaiola: Yeah, I mean, there’s a ton out, there’s a gaggle of products out there, that claim to raise-
Dr. Weitz: Which ones work?
Dr. Cavaiola: So things like tribulus, that has gotten a lot of press. Tribulus, Maca, some of these things. And having covered this a bunch of times in presentations and research, they don’t have any real benefit in men on raising testosterone levels. It may help from a libido standpoint, from a symptomatic standpoint, but they don’t really cause any major bumps in testosterone levels. Now, one herb that I very much like, is ginseng. I talk about it all the time, I used to teach at Bastyr University in California and my students would just get sick and tired of me talking about ginseng because of great it is for raising testosterone levels.
But it also really is an all healing kind of thing, that’s what the prefix ANX means to begin with, all healing. It has really, really great effect on the human body. I would like American ginseng from the perspective of raising testosterone levels. Korean ginseng and Siberian ginseng can also be helpful as well, but American ginseng is really, really great for raising testosterone levels.
Dr. Weitz: Yeah, I personality have found Maca to be beneficial, especially if they get sufficient levels. I think just taking a couple of capsules is not enough, but if they can get a substantial amount, like several tablespoons. And then what if they have reasonable of decent total testosterone, but low free testosterone? Let’s say it’s related to high sex hormone binding globulin.
Dr. Cavaiola: Yeah, so interesting question, there are some things out there that we’re recommending now, to be able to… What we’re trying to do is we’re trying to encapsulate the testosterone from the SHBG. SHBG as opposed to something like albumen, which is another carrier protein in the blood. SHBG, once it binds onto testosterone, it does so very, very strongly. It doesn’t want to let it go. So as men get older, believe it or not, their SHBG level goes up and that really is a problem because it binds on more to free testosterone.
So that’s a problem, so what we want to do is, we want to encapsulate that, we want to get that SHBG off of the testosterone. And so, to do that, one mineral that’s been shown to be able to do that is boron. Boron has some pretty good research on helping to basically kick off the free testosterone from SHBG. And some other minerals, magnesium, zinc and then of course, a good diet and exercise have also been shown to do the same thing.
Dr. Weitz: Dr. Geo Espinosa, who’s an expert on men’s health, I had a personal communication with him, he recommended stinging nettle root and I’ve been trying that on some patients and we seem to see some effectiveness.
Dr. Cavaiola: Great, great, also a great product and it also can actually help to possibly lower DHT levels in men too, so that’s-
Dr. Weitz: Oh, okay, good, good, good. So now take the same 35-year-old, who’s willing to try some pharmaceuticals, but maybe doesn’t want to get on testosterone because he’s thinking about having a family.
Dr. Cavaiola: Ah, got you, yeah, so very important factor. First and foremost, I will say that if a man, even in their 30s starts on testosterone replacement therapy and wants to have a family at some point in time, testosterone replacement or the effects of testosterone replacement on fertility are reversible. So it is not permanent, it does take three to six months, roughly speaking, to basically get the body to start doing its own thing again, from a sperm production. However, it is reversible. Now, there are some things you can do to come back at, let’s say if the guy is on testosterone, what we’ve also been shown to be helpful is something called HCG, human chorionic gonadotropin, it’s a mouthful.
HCG, it’s actually a hormone that’s typically found in highest amounts in pregnant women. Both men and women have some, to a certain degree. What’s interesting about HCG is it basically is an LH agonist, meaning that, LH is a hormone produced by your pituitary gland and LH is the signal to your testes to produce testosterone. So the sub units of HCG look like LH to a certain degree and it actually causes your body to produce a little bit of its own.
And in doing so, helping to raise sperm levels. So HCG can be used in combination with testosterone to help to improve fertility. That being said, if the guy says, “No, I don’t want to do either one of those things.” You can take HCG solo to raise testosterone and help with sperm production, or there are some pharmaceuticals out there, something like Clomid, which has been shown to be helpful. A lot of docs are becoming privy to Clomid, to be able to raise testosterone levels and sperm counts, so interesting.
Dr. Weitz: Yeah, I know Dr. Howard Elkin, he was discussing this with me and he often will recommend for that type of patient a combination of Clomid and HCG.
Dr. Cavaiola: Yeah, good.
Dr. Weitz: When they use HCG, how long do they use it for before they see an effect?
Dr. Cavaiola: So it’s not going to be as immediate necessarily as testosterone. It’s going to take a little while longer, but at the same time, and it’s not going to be to the same degree that testosterone works. You’re going to get a small bump in your testosterone levels as opposed to taking exogenous testosterone. It just doesn’t work as well, but you can usually notice an effect probably in about a month, a month to a month and a half I would say.
Dr. Weitz: Okay, since we talked about these endocrine disrupting substances, do you ever try to get rid of those with some sort of a detox?
Dr. Cavaiola: Yeah, absolutely, so detox is crucial. Especially if we find that your estrone levels are high. We’re like, “Well, there probably is some kind of exogenous estrogen coming into the body, right? So how do we get this out of the body? That’s crucial, and I’m sure you practice and work with your patients a lot in terms of detoxing. And a lot of people think of detox as this weird, magical fufu kind of thing. And it’s not just about drinking juice on a daily basis, it’s really about purging the body of harmful chemicals. And especially if there’s, you basically have four main ways of getting rid of stuff from your body, whatever that is.
Sweating through your skin, poop, through your intestines, getting it purged from your liver, and also through your breath, and through your urine, five major ways. So you have to get it out of your body. So first of all, you need to mobilize and then you need to get rid of it as well. So if you have, let’s say you have a bunch phthalates stored in your fat tissue. First, you need to purge it from that fat tissue, you need unglomp it from your adipose, so one of the main ways to do that is heat. And we use Far-infrared sauna in our practice, to be able to do that.
So it heats at a deep level, Far-infrared sauna and purges those phthalates out, to be able to be excreted through your feces or your urine. So you need to make sure those, what we would emunctories are open, so that you can get rid of them, right? So you need to be pooping properly. You need to be urinating, you need to be drinking water, which a lot of people just do not drink enough of. I would say 80% of our patients come in and they don’t drink enough water. So water and making sure that you’re eliminating properly are really crucial for getting rid of that stuff once you’ve unlocked it.
Dr. Weitz: Okay, do you ever consider the factor of sleep in terms of testosterone levels?
Dr. Cavaiola: Absolutely, so sleep is crucial for so many things in your body. And one of the major things is helping to recharge. Recharge the battery once you’re sleeping, that’s what sleep is all about. And what we oftentimes see is patients who are chronically sleep deprived or who work night shifts and people who just are stressed out to the max. Why that’s important is that basically, it’s a stress on your body. Any kind of stress like that prevents you from basically recharging when you’re sleeping and secondarily, it kills your adrenal glands. And the adrenals are, like we mentioned earlier, a portion of the testosterone that you’re going to release on a daily basis. So we need to make sure that your adrenal glands, and you’re sleeping properly, absolutely. So eight hours sleep a night or whatever it is that you use as your litmus test for the amount of sleep that you need, is really crucial to be able to heal.
Dr. Weitz: Okay, so now you have a man, who has hypogonadism, i.e. low testosterone and he’s interested in taking the recommendation to get on testosterone. What’s your preferred type of testosterone you like to utilize?
Dr. Cavaiola: Great question, so first and foremost, we use something called bioidentical hormone replacement therapy. So bioidentical, meaning it’s like the hormones that are found in your body, so what’s great about bioidentical hormones as opposed to synthetic hormones, is that your body takes them in and recognizes them as cell. So it doesn’t really have to do anything with it, doesn’t have to synthesize it or be overly processed by your liver, takes it in and can utilize it right away. It’s like, “Oh, thank you so much for these extra hormones, they’re very much appreciated.” And so there’s different applications that you can use of testosterone, we’re going to typically prescribe something called testosterone cypionate, C-Y-P-I-O-N-A-T-E. Cypionate, that’s derived primarily from soy and yam, mostly yam, not as much soy, which is a problem for some people. And so what we do is-
Dr. Weitz: And this is something that you take by injection.
Dr. Cavaiola: Yes, so there’s different applications, there’s injections, there’s creams, and then there’s pellets. So we found that creams are helpful to a certain degree, it is in daily application, so getting people to be compliant on it is always a problem and making sure that people are doing enough of it, is also a problem. And making sure there’s no transference where there’s kids in the family, or transferring to a partner is not going to be a problem. So they work relatively well, but again, you need to be doing enough of it to make sure that you get a benefit.
Dr. Weitz: And where do you tell them to apply it?
Dr. Cavaiola: So typically, you can apply it twice a day or mostly at night time.
Dr. Weitz: And to which part of the body?
Dr. Cavaiola: So you’re going to apply it to non hairy skin. It’s just best easily absorbed when it’s on non hairy skin. And there are some doctors out there, that say to apply it to the gonads, to the testes, please don’t do that. It’s just you’re applying testosterone to an area that’s very androgen sensitive to begin with and we’ve seen a lot of people end up with prostate problems or further atrophy in their testes because of it, so don’t do that. And so the other thing is, we can also do pellets as well, pellets are a small little amount of testosterone and plant it under the buttox of the skin.
It’s a minor surgical procedure and essentially, we’ve seen that unfortunately, it should last between three to six, depending on how much they put in. And we see a lot of times what ends up is that men get a lot of huge dose at the beginning and not as much at the end. So they feel great at the beginning, or they actually have too much onboard at the beginning and they kind of have some negative side effects and then not as much in the beginning, they feel like crap.
Dr. Weitz: So you had [inaudible 00:35:27] testosterone cream, what particularly product do you like to use, AndroGel, do you use compounded products?
Dr. Cavaiola: That’s a great question, so some of the pharmaceutical derived testosterone products out there, first and foremost are messy, they’re expensive and they oftentimes don’t work because they don’t have very much in them. So you need to use gobs and gobs of it to get clinical benefit. As opposed to something like a compounded version of testosterone that we get from a compounding pharmacy, where we can specify how much testosterone we want per milliliter or per gram. So that we can make sure the patients are getting enough, that really is crucial.
Dr. Weitz: Okay, so what about AndroGel?
Dr. Cavaiola: So AndroGel, I’ve had patients who have been on it and they come in and they say, “This doesn’t seem to be working.” And when you run the lab test, it verifies that. Their testosterone levels are not, they’re not really seeing a large increase in their testosterone level, nor are they getting any better. And that really is the worst thing, it’s a double whammy. So what we oftentimes recommend is bioidentical form of testosterone, that we can better control and the patients get more of a clinical benefit.
Dr. Weitz: So what percentage of your patients are on topical versus pellets versus injections?
Dr. Cavaiola: So patients who come see us, the majority of them, 90%, 95% are on injections, about 5% are on creams.
Dr. Weitz: How often do they inject?
Dr. Cavaiola: Injections typically vary depending on who the person is. If they have very, very low levels of testosterone, sometimes they’re injecting weekly, most of the time they’re injecting weekly. And if they are somebody who utilizes it very quickly, you can only really understand this if you start a patient on testosterone, they don’t really notice a benefit or they’re bottoming out towards the end of their injection cycle. Meaning six days or seven days. We sometimes do injections twice a week, which does help a lot of patients. So it’s typically twice a week to weekly.
Dr. Weitz: Does taking testosterone increase or decrease cardiovascular disease? I saw one paper that showed increased coronary artery plaque that resulted from taking testosterone from one year. This was a JAMA article.
Dr. Cavaiola: Yeah, that JAMA article and unfortunately, the JAMA article was, I think you’re speaking of the article in the for frail older men. And so this was the study that came out and there was a subsequent study that came out as well, that kind of had a similar finding. And what we’re seeing is, that was in frail, older men, who were people in the VA system, VA healthcare system. And you are partially correct, the research says that there’s a slight uptick in the risk of having a coronary artery event, if during the first part of testosterone replacement therapy in older, frail men, I will just say that.
Now, there’s been subsequent studies that have come out, that have completely debunked this and basically said, “Uh, uh, not true. Basically, yes, there is a small uptick in your risk at the start, but overall, testosterone has a positive benefit for cardiovascular health. And it’s a positive benefit for metabolic health and its positive benefit for so many other things, including like you mentioned earlier in the introduction, for lowering all cause mortality. That is the key, and improving quality of life as you age.” So the study, if you really break it down, and look at the percentages, actually, what they showed was, the men who were in the testosterone replacement group, was a smaller group than it was the non.
And actually, the proportions were actually lower than for the people who had cardiovascular events. It was actually lower in the testosterone replacement group. So you need to know how to crunch the data, you need to look at the data and really analyze some of these studies a little bit closer, so you can understand what’s happening and we don’t want this to get a bad rep and it did, unfortunately. For three to five years testosterone was all over the place, there was lawyers, who were having a field day with this. There’s commercials on TV of, “Did you have coronary artery disease, have you been on testosterone replacement?” So it really scares people and we need to kind of put the positive spin on things to say, “This was in one population group only.”
Dr. Weitz: There’s actually an interesting relationship between testosterone and cholesterol, isn’t there?
Dr. Cavaiola: Absolutely, so there’s been so studies that have come out, looking at this. The fact that testosterone improves cholesterol markers, just by doing that and that alone, not even dietary modification, testosterone lowers LBL, it raises HDL levels and it can lower total cholesterol as well, so-
Dr. Weitz: And actually, if you lower your cholesterol levels too low, cholesterol is actually the backbone molecule that your body uses to make testosterone.
Dr. Cavaiola: Absolutely, so all these would come see us, who have been chronically, they’re put on statin medications and they’ve been on them for five, 10, 15, 20 years even. Oftentimes we see these guys with low T and low thyroid function and low everything production because cholesterol, like you mentioned, is the backbone, it’s making virtually every hormone in the body. So it’s really, really important.
Dr. Weitz: Yeah, now we know that testosterone increases red blood cell production, so hematocrit levels go up. So how do you handle this?
Dr. Cavaiola: Great question, and so really, I would say this doesn’t happen to every single patient and-
Dr. Weitz: How often does it happen?
Dr. Cavaiola: I would maybe 10% of the time. One out of every 10 patient you’re going to run into some kind of difficulties with this. And really, it-
Dr. Weitz: And what hematocrit level, is it hematocrit that you monitor for this?
Dr. Cavaiola: Yes, yeah, I don’t know the exact values right now, while we’re speaking. But what I would say, is making sure that it’s within the reference range, that’s really important, right? And of course, monitoring things over time, that’s why it’s really important for us to understand the patient to begin with, what are their hematocrit levels to begin with, baseline, and then measuring every three, six months, so we can understand what’s happening with the patient. We want to do our due diligence, we want to be ethical, we want to make sure the patient’s safety is protected at all times.
So when, and this does happen, there is a risk for hematocrit causing the blood to become sticky. When it becomes sticky, there’s a risk of cardiovascular events, that’s what we’re concerned about or throw in a clot, that’s basically what can happen, right? And so, what we do in these particular cases, is basically have the patient undergo a routine phlebotomy. Have them give blood and usually their hematocrit levels come down pretty quickly.
Dr. Weitz: Right, does taking testosterone increase or decrease the risk of prostate cancer?
Dr. Cavaiola: Well, it depends on who you are. If you have preexisting prostate cancer, testosterone replacement therapy is not necessarily the best idea for you, that preexisting. However, how many men out there know that they even have prostate cancer to begin with because it’s such a low grade, slow growing cancer, that oftentimes we just don’t even know until it’s clinically diagnosed or diagnosed by a biopsy. However, the research basically shows that testosterone actually has a prostate protective effect, than it does causing prostate cancer.
Dr. Weitz: So let’s say a man comes in to see you and as part of your screening, testing, you do PSA levels, what level PSA would you be concerned about whether or not you should put him on testosterone?
Dr. Cavaiola: So I don’t want to speak on behalf of every single patient who comes in because of course you always want to look at [crosstalk 00:43:48] patient, right? But I would say anything less than four, which is kind of the cut off point, would be kind of worrisome at that point in time.
Dr. Weitz: Right, let’s say you had a guy a three and a half.
Dr. Cavaiola: I wouldn’t be concerned probably, and again, given if there was no symptomatology and you did a prostate exam and everything was normal, there was nodules or masses found, we’d be less concerned.
Dr. Weitz: Okay, and so you have a man with prostate, chronic stage, would you ever consider administrating testosterone?
Dr. Cavaiola: I would highly consider it, yes. Would I necessarily do it all the time? No. I mean, I think there may be some other ways that we can raise testosterone levels, rather than doing testosterone replacement therapy.
Dr. Weitz: Would you ever do it?
Dr. Cavaiola: I think this is something to kind of consider on a case-by-case basis, with each particular patient, depending on the severity of the case. If it’s a stage on or in C2 kind of situation, you’re probably not going to be as concerned than it was if it’s metastasized to the bone, that’s just not a good sign.
Dr. Weitz: Right, when you administer testosterone, do you ever recommend certain supplements at the same time to make sure that the body processes the testosterone optimally?
Dr. Cavaiola: Yeah, I mean, in the way of preventing side effects or…
Dr. Weitz: Yeah.
Dr. Cavaiola: Okay, yeah, I mean, certainly there are some products out there that can be used. For instance, there’s a product called Chrysin, which is essentially derived from the plant passionflower and that has been shown to be helpful to lower estrogen levels. So sometimes we do Chrysin alongside of testosterone replacement to help to mitigate the effects of estrogen on the body.
Dr. Weitz: Okay, good, excellent. So I think that’s a wrap for today.
Dr. Cavaiola: Wonderful.
Dr. Weitz: Any final thoughts you have, and then give us your contact information, so patients out there can find out about you and your services.
Dr. Cavaiola: Thank you so much, yes, so I think what I would say to wrap it up is, if you are struggling with the symptoms of low testosterone or if you think you have it, do not be afraid to talk to somebody about it. I think so often it’s the case where we, as men, do not go see doctors because we’re afraid of what we’re going to find out. We’re going to think that we’re less of a man if we have low testosterone or we’re scared of doctors. Whatever the reason is, please go see somebody about it, go see somebody, who’s going to look at you and understand your case and really take the time to listen to you. That really is crucial and that’s what I would leave you with today. And so, don’t wait before it’s too long, before it’s too [crosstalk 00:46:44]. Okay, so if you are interested in kind of more of our services, you can visit our website at www.concsioushumanmedicine.com C-O-N-S-C-I-O-U-Shumanmedicine-
Dr. Weitz: How did you come up with that name?
Dr. Cavaiola: It’s really important to us, if you kind of look at, break it down in terms of the name, of course medicine stands by itself. But we are passionate about all of us becoming more aware of who we are as human beings and our health. Being conscious, being present and it’s important for us, as well, as practitioners to be conscious. We don’t want to just blindly see people, who come into our office and just give them supplements and send them on their way. It’s about a two-way street, it’s about having great relationships with our patients, being human.
Dr. Weitz: Excellent.
Dr. Cavaiola: Yeah.
Dr. Weitz: Thank you Dr. Cavaiola.
Dr. Cavaiola: Thank you so much for having me today, very much appreciate it.
Dr. Weitz: Excellent, I’ll talk to you soon.
