I am delighted to have Dr. Tracy Gapin joining me today! Dr. Gapin is a board-certified urologist, world-renowned men’s health expert, best-selling author, and professional speaker.
Almost every day during his twenty years as a urologist, Dr. Gapin saw men grappling with issues of brain fog, difficulty in focusing, problems with physical performance, and remaining engaged and present as fathers. That inspired him to help men become the best husbands, fathers, and leaders they can be. Now, Dr. Gapin considers himself a recovering urologist because earlier this year, he formally exited traditional Western medicine to focus on men’s health.
In this episode, Dr. Gapin discusses his background and talks about what sparked his interest in integrative approaches to urologic problems and men’s health issues, the contributing factors to low testosterone, and why there is a growing low testosterone pandemic with men. We also discuss hormone replacement therapy that goes beyond just testosterone, the role of peptides, SARMs (Selected Androgen Receptor Modulators), biohacking, libido, erectile dysfunction, and more. You won’t want to miss this conversation, so be sure to tune in!
“There is this men’s health pandemic that for some reason gets no attention.”
Dr. Tracy Gapin
IN THIS EPISODE YOU WILL LEARN:
- How Dr. Gapin developed a passionate interest in male hormones.
- The story of Dr. Gapin’s vasectomy.
- Contributing factors to the escalating issues with low levels of testosterone.
- The factors that could hamper a detoxification process.
- How insulin resistance can drive testosterone levels down.
- Why it is vital to approach your health systematically.
- The optimal range for testosterone.
- Non-prescription treatments to improve testosterone levels versus prescription treatments.
- Lifestyle and nutritional factors that could negatively impact testosterone levels.
- Optimizing growth hormone levels.
- Some possible causes of erectile dysfunction.
- Are there benefits to using red light therapy for low testosterone?
- Common reasons for using peptide therapy.
- Dr. Gapin shares his thoughts about SARMs.
Connect with Dr. Tracy Gapin
On his website
Get your free copy of Dr. Gapin’s book, Male 2.0, here
Connect with Cynthia Thurlow
- Follow on Twitter, Instagram & LinkedIn
- Check out Cynthia’s website
- Check Out Dry Farm Wines: www.dryfarmwines.com/cynthiathurlow
About Everyday Wellness Podcast
Welcome to the Everyday Wellness podcast with Cynthia Thurlow! Cynthia is a mom of 2 boys, wife, nurse practitioner, and intermittent fasting and nutrition expert. She has over 20 years experience in emergency medicine and cardiology, but pivoted to focus on food as medicine. She loves to share science-backed practical information to improve your overall well being and is grateful to be interviewing leaders in the health and wellness field. Her goal with Everyday Wellness is to help her listeners make simple changes to their everyday lives that will result in improved overall wellness and long term health.
Presenter: This is Everyday Wellness, a podcast dedicated to helping you achieve your health, and wellness goals, and provide practical strategies that you can use in your real life. And now, here’s your host, Nurse Practitioner Cynthia Thurlow.
Cynthia: Today, we are joined by Dr. Tracy Gapin. He’s a board-certified urologist, world renowned men’s health expert, bestselling author, and professional speaker. We dove into his background, what got him interested and focused on integrative approaches to urologic and men’s health issues. We talked a great deal about contributions to low testosterone and how he feels strongly. This is a growing pandemic, not only within the United States, but elsewhere. We chatted about hormone replacement therapy, specifically things beyond just testosterone, the role of peptides as well as SARMs, which are selective androgen receptor modulators, biohacking, libido, erectile dysfunction, and more.
Tracy, I’m so thrilled to finally have convinced you to come on the podcast, largely, because there’s been such tremendous interest in having a male hormone specialist because women that listen to the podcast want to know how to support their loved ones, their significant others, their family members. So, thank you for carving time out of your busy schedule to connect. I know this will be a really great conversation and I would love for you to share with the listeners a little bit about your background. Obviously, in the intro they learned a little bit about you. But what got you so interested in male hormones? Obviously, you did a residency with a specialty in urology. But what got you thinking that hormones are really driving a lot of the issues and concerns you were seeing with your patients?
Tracy: Thank you so much, Cynthia. First of all, thank you for having me. I’m honored to be on here with you. So, it’s my pleasure to be with you today. So, in terms of male hormones, I am very passionate about this topic because there’s a big overarching theme beyond just testosterone. I have been a urologist. I now consider myself a recovering urologist since I have formally-
Tracy: -exited traditional Western medicine earlier this year to focus on men’s health. But in my 20 plus years in urology, I saw men every single day who come in the office struggling with issues like brain fog, difficulty focusing at home, difficulty focusing at work, issues with performance, either in the gym, performance in the bedroom, which I’m sure we’ll talk about, and even their ability to be a present and engaged father. For me, that’s where my passion lies is really helping men be the best man they could be so that they can be present and engaged husbands, fathers, and leaders. So, when we look at hormones, there’s this men’s health pandemic that for some reason gets no attention and it’s a crisis. Testosterone levels are plummeting by as much as 30% over the past few decades. And that has tons of consequences which we could talk about. So, for me this has become a huge passion of mine.
Cynthia: Well, I’m so glad that you are talking about it. I think in many ways, men struggle in some ways to discuss these kinds of topics and to have those open, honest conversations because I think for women, we’re kind of conditioned that from maybe teenage, early adulthood that we are having conversations with our nurse, midwife, or OB-GYN about female hormonal issues. And yet, I feel like men in many ways, maybe until they’re at a point where they’re struggling with fertility issues, male factor, or they’re dealing with, you know, they need sterilization. I think for a lot of men they don’t really think about it until they start having a problem per se. I think about how many of my cardiology patients were on medications for hypertrophy prostates or they were on hormonal therapies for addressing prostate cancer, and that’s probably when they really were thinking or connecting with a urologist.
Now, for the benefit of the listeners, I really would love for you to share your story about your own vasectomy, which-
Cynthia: -I have to honestly say, I’ve known you for two years and just this summer I heard the story. The first thing I said to you was you have to share the story when I interview for the podcast. So, obviously, we’re going to touch on all the issues that you’ve already talked about.
Cynthia: But I would love at the very beginning to give you an idea of how much of a badass you are. I want you to share your experience giving yourself a vasectomy.
Tracy: Thank you. Yeah. So, first of all, you’re absolutely right that men and women are so different when it comes to health, when it comes to being proactive about your health and taking charge and owning it, and I love being on podcasts like yours that have more of a predominant female focus, because it’s the women who tend to be the ones who drive health decisions, and who get their men to finally seek help, and so, I’m glad for the opportunity here today to be able to really emphasize that women need to push their men to go get check, check your testosterone level, check your other hormones, get your prostate exam, and check PSA, all basic preventive healthcare.
But yes, a lot of men will come see for a vasectomy, and everyone has a superpower. I like to say everyone has their zone of genius-
Tracy: -and I like to say that everyone should stay in their zone of genius, whether it’s my employees, whoever it may be, I really like to find your zone of genius and keep you in that zone. For me, it’s doing vasectomies. So, I do no scalpel vasectomy, I can do it in probably under 10 minutes or so. Fairly painless, quick and easy in the office, and get the job done. So, after my wife and I had our second child, it was time for me to get my own vasectomy, and I knew that that was my superpower, and some of my partners without being disparaging, that’s not their superpower. They have other superpowers.
I realized that when it was time for me to get it done, there was no one I wanted to do mine more than me. So, my wife and friends told me you can’t do it, no way, don’t even think about it, and stubborn me, I’m here to prove everyone wrong, and so, one Friday afternoon, I had my nurse set up a tray table in the exam room, she sat down the hall, the nursing station, and I said, “Hey, if you hear a loud thump, when if I hit the ground or if you hear me scream, come get me otherwise, leave me alone.” So, I sat on the edge of this exam table on this Friday after work, and about 10 minutes later, it was done, and it was not that hard. [laughs]
Cynthia: Well, I’m so impressed, and it really speaks to the fact that when you’re a trained surgeon and you’re a trained professional, that you can take the emotion out of it and just take care of business if you will, but I think that’s one of my favorite stories you’ve ever shared about me. But let’s pivot a little bit and talk about this epidemic with men, you know, what is contributing to escalating issues related to low testosterone. I myself started making a long list last night, and I’m sure that you will touch on all of these, but this really is a huge issue. So, whether you’re a male or a female listening to the podcast right now, low testosterone has profound downstream detrimental effects for both sexes, not just men. So, let’s unpack that a little bit. What do you think is the largest contributor right now to lowered or suboptimal levels of testosterone?
Tracy: Yeah, great question, Cynthia. This is something that’s not really discussed very often. People talk about the Western diets, the cause of it, or poor exercise, or whatever it may be. But the biggest underlying factor for low testosterone, which is a true men’s health crisis is endocrine disruptors. So, for the listeners, let me explain what this is. These are toxins, chemicals, toxicants in our environment that alter normal hormone, either production function or action at the receptor level, they can mimic hormones, they can block hormones, or they can alter intracellular hormone function. So, there are a number of chemicals, toxins in our environment, which we know have a direct effect on testosterone.
On the food we eat, our crops are sprayed with an herbicide called atrazine, which is the most secondly commonly used herbicide behind glyphosate in the country. Several huge studies have shown that atrazine crushes testosterone, and our food are laden with it, and if we check urine samples, there are studies that look at urine samples of humans, and we have over 20 toxin metabolites in our urine, and these toxins come in from the food that we eat such as atrazine. They come in from our personal care products such as deodorant, and shampoo, and laundry detergent, and sunscreen, and they come from plastics in our food and water. So, plastic water bottles for example had BPA and phthalates, plastic food containers, K cups.
These plastics are leaching into our food and water, they’re getting into our bodies and our water supply systems are not being filtered properly. So, these chemicals are staying in us, and they get into our fat cells, and they don’t clear. Estradiol is obviously a female birth control. But I like to joke that most men are on birth control because estradiol does not get filtered by our municipal treatment centers. Our water has estradiol at a detectable level. So, we’re drinking this water and is getting into our bodies and not clearing. So, all these chemicals, long story short are crushing testosterone levels, and it has a cumulative effect, and it has a transgenerational effect as well.
We know that exposures from our grandparents affected our parents affecting us and are going to continue to affect our children and grandchildren and so on. So, it’s a massive problem that doesn’t get any attention. I spend a lot of time with the guys I work with on how to number one, eliminate exposures as much as we can. Number two, improve our detoxification system, so that we can help our body clear those.
Cynthia: I think it’s so critically important because I can’t think of anyone in the male medical space that’s talking so openly. I have had the privilege of bringing on Robyn O’Brien, who’s shining a light on what’s going on in the food industry, as well as Lara Adler, who is a toxin specialist. But I can’t recall any male voices really talking about this. So, thank you for the work that you’re doing on so many levels, and it seems really overwhelming when someone hears this information for the first time. And I oftentimes will encourage men and women to just change one thing, you know, one thing that you’re doing that’s so different.
I have teenage boys. They think I’m a gigantic dork, and I’m the one that’s switching out deodorant, and I’ve been doing this for a long time. But we’re in a new house, and we’ve come to find that in our new city, the water here is very mineral laden. So, it impacts water that you brush your teeth with, probably not for you, but for any woman listening, you spend a lot of money on hair color, and highlights, and things like that, and you realize that things start to change with the differences in water. So, we have a whole house filtration system, and that’s something that seems very intangible.
But I think for anyone that’s listening, recognizing these changes or things were exposed to these toxins, whether it’s personal care products, food, or environment, it is constant onslaught throughout the day. If your house is fairly clean, and then you go to a restaurant, or you’re traveling, or you’re in a hotel, and all of a sudden, the variables are all impacted, and I definitely think that there are individuals who are far more susceptible than others, and some of that can just be you know, snips or epigenetics or just the way that we are, our bodies are designed.
Now you touched on a concept that may be less tangible for people that are listening. So, let’s talk about, when we talk about detoxification, and I know that I tell people, how you breathe, and how you poop and pee, and how your liver detoxes. But let’s unpack that, so that, it’s less intangible, because I think people just assume that it all works effortlessly, and yet you and I know that there are a lot of things that can contribute to making the detoxification process in our bodies hampered or it’s burden, and so, it doesn’t work quite as efficiently.
Tracy: Yeah, absolutely. And this is something that interestingly is just not talked about very much, especially, in the men’s health community. It tends to be all about testosterone, it is all about sex, and all about building muscle, and it’s so much more than that we can dive deep into detox, but this bigger picture. Why do we care about this man? It’s because this affects your ability to burn fat, this affects your ability to actually think clearly at work, and focus, and be able to handle that presentation, or that deadline, or whatever work you may be doing. It affects your ability to train, to exercise, working out, and it affects your ability to just be present and be in a healthy happy mood, state of mind to interact with your friends, and your family or your kids, or whatever it may be. So, this is not just about sex, this is not just about muscle, this is about like an entire man’s life.
Diving deep now to detox like yes, it’s important to realize that our body to handle these toxins, number one, we can eliminate exposures and that could be from being very careful about the personal care products we use, about the avoiding plastic water bottles, avoiding K cups, avoiding all these things. But then, how do we optimize our detoxification pathway? When we look at detox, we look at liver function, specifically, things like glutathione support, we look at things like superoxide dismutase, which is a fancy term for an enzyme in our liver that handles toxins and free radicals, and this comes down to the antioxidant system in our body. So, how can we optimize our antioxidant system? I will emphasize that this is very personalized. When I work with guys, one thing I do is using genetics to individualize what support might you need.
There are some basic things we can look at, things like the foods that we eat, in terms of proper gut health, in terms of things like sauna and other tools that we can use to help clear toxins. But at a big level, it comes back to from a genetics perspective, what does your body individually need? So, that’s going to really be tailored to each individual.
Cynthia: I think that’s so important that there’s not on one side, because we share this Western medicine kind of mindset that is evolved. We’re trained and this is how we treat hypertension, this is how we treat an enlarged prostate, this is how we treat this, whereas I think in integrative approaches and what you embrace, and obviously, what I embrace as well is looking at each patient as their own individual. Now, one thing that I know I think fervently and obviously the toxin exposure absolutely is driving down testosterone. But another thing that I think quite a bit about is just the degree of metabolic inflexibility, obesity here in the United States.
The most recent statistic I read was that 88% of the population is overweight or obese. So, obviously, that degree of insulin resistance just from a hormonal perspective can be profoundly detrimental. It’s interesting on Twitter, that’s where I tend to see quite a bit of chatter between men going on in terms of communication and so, there’s definitely this desire for people to better understand how being insulin resistant can drive down testosterone as well. Can we talk a little bit about them?
Tracy: Oh, absolutely. Yes. This is a massive topic here. I’m so glad you brought up metabolic health. When we talk about this, we talk about how does our body handle glucose and how is that related to inflammation, to lipids, and to ultimately hormones? There’s this vicious ugly cycle and it actually starts to a certain degree on levels of stress. So, by stress, I’m talking about crappy foods that you eat, I’m talking about poor sleep, I’m talking about not taking time to relax and ground yourself and practice mindfulness techniques. So, what do all these things have in common? All these things have in common that they raise cortisol. Cortisol is a stress hormone. Cortisol is that fight or flight hormone that when you’re getting attacked by a bear, it helps you respond. We don’t need high levels of cortisol on a daily basis. But we have become so stressed in our daily life through again, either overtraining, or eating shitty food, or not sleeping, or not taking time to relax, whatever it maybe, or even micronutrient deficiencies, it goes on and on all the different stressors that we have.
Stress raises cortisol. Cortisol causes you to store fat. Fat has an enzyme called aromatase. Aromatase will convert testosterone into estrogen, okay? This relates to your body’s ability through insulin, your body’s ability to handle glucose. So, what happens is, you get– your fat cells are unable to handle the elevated chronic blood sugar. Now, how do you get elevated blood sugar from cortisol? So, eventually, your pancreas can’t handle it. It’s trying to spit out more insulin to handle the elevated blood sugar from the high cortisol.
Eventually, you can’t handle it anymore and it becomes a vicious cycle. So, systemic inflammation, insulin resistance, low testosterone, obesity, and increased risk of cardiovascular disease are all tightly interwoven. This is why I love that you and I are on the same page about this, about a systems approach to health is the only way this is going to work. Just giving guys testosterone is not the answer. So, focusing on stress, focusing on proper nutrition, focusing on sleep, which is overlooked, focusing on eating the right foods, all these are going to contribute to ultimately improving insulin sensitivity and metabolic health.
Cynthia: I love that you really emphasize the lifestyle as medicine piece, because that’s critically important. I think for a lot of women, and certainly women that listen to this podcast, they maybe in perimenopause, they maybe in menopause, they’re curious, do I need hormones, do I not need hormone replacement therapy, and talking to them about the fact that you may ultimately require hormonal supplementation or hormonal medication. But if we don’t do all the other work, the sleep, the lifestyle piece, etc., it is going to make it so much harder.
Unfortunately, we’ve conditioned our patients to ask for a medication before we ask them to do the hard work and we’ve done that. I say to everyone that we’ve unfortunately, whether it’s, you know, the influence of the pharmaceutical industry on how we practice, but that is something that has to evolve and change, because that model isn’t working. So, I love that you kind of bring that up, the lifestyle piece. It’s so, so important and you live what you preach, which I think for anyone that is north of 40 years old, you can differentiate, you can really see like some people are just surviving at this point, other people are thriving.
Oftentimes, they’re thriving because they recognize how critically important the super sexy topics of eating proper nutrition, and getting high quality sleep, and really monitoring your mindset, and managing and mitigating your stress is certainly super important. Now, you would probably not be surprised to know that a lot of the questions that I received were about hormone replacement therapy. So, we just kind of unpacked all the things that can drive down testosterone, but there’s so many other hormones at play, and so, I think that it would be helpful to start from a position of saying, let’s at least initially talk about testosterone. What should people be asking for? Like if you are a loved one, like I know even with my husband a couple of years ago, I had asked his primary care provider, these are some labs I love for you to run. How do we test or what is your favorite way to test for testosterone? Do you prefer to use blood, do you integrate the use of the DUTCH test in your patient population, do you find that helpful?
Tracy: Yeah, great question. I actually short answer, I do both. So, longer answer, guys come in every day and all they care is about testosterone. I love that we’re going to dive deep into testosterone. Just a brief asterisk next to it to say that testosterone alone is not the answer, and you have to go beyond testosterone and focusing on a much bigger systems-based approach or else you’re not going to get the results that you’re looking for. But to answer your question, I do both blood and DUTCH -based testing, and I like them both for different reasons. I love the DUTCH testing, which is the urine-based hormone testing. We do several spots throughout the day on these little urine paper strips, you can mail them in and I love it because you get a complex view of, first of all, cortisol metabolism. You get a complex view at estrogen metabolism, which actually is to a certain degree still important in men as well, even though, men are so focused on the testosterone. It helps show us DHT production as well, which all of that’s really important, and the testosterone level also from the urine hormone testing perspective is valuable. But the blood testing and I know this goes against some functional medicine docs out there, I look at blood testing, specifically, the free testosterone as one and really the most valuable test for me when I work with men.
When we look at blood testing, most doctors out there, all will do is check total testosterone. Total testosterone is a joke for a number of reasons. Number one, total testosterone doesn’t matter. It doesn’t matter at all because most of that total testosterone is not even available for use. It’s like having an army and having a bunch of soldiers with no guns. It does nothing for you unless it’s free or bioavailable. So, the free testosterone is specifically testosterone that is not bound to other proteins in the blood, meaning, it’s freely available to get into the cell. That’s really important to actually get into the cell into the nucleus and cause the epigenetic effects that testosterone has to achieve the outcome you’re looking for. So, proteins like SHBG, which is sex hormone binding globulin is a protein in the blood that will bind up testosterone and make it relatively unavailable. Now guys will always say, “Well, can we just lower SHBG to have more free?” Well, the problem with that is now you’re starting to mess with nature, number one.
Number two, SHBG is what gets testosterone through the blood brain barrier into the brain, for the testosterone hit your brain centers, and so, you do need SHBG as well. You don’t want necessarily artificially trying to lower that. But it is important to realize that the free testosterone is the only testosterone that’s available for use. The second aspect of testosterone, why I think it’s a joke is, this range or this reference range that we’re given, if you look at a lab slip, it’ll say something like, a range of 190 to 800 for example is a joke. So, what that range is, is nothing more than the average of the population. So, they take every lab result out there, and they graph it, and if you can imagine a bell curve, that’s what you get. So, that’s the reference range that these lads are using.
Now, remember, we started this conversation with the fact that we’re experiencing a testosterone pandemic, and levels have plummeted 30% in the last couple of decades. So, therefore that bell curve, if you could imagine has shifted downstream 30% over the last 20 years. So, that can’t be normal and it’s not optimal, it’s just the reference range. I can’t tell you how many men will come in to see me because their doctor, even their urologist, who are supposed to be the men’s health expert said, “Hey, Joe, your testosterone is 301, your total testosterone is 301. You’re normal, you’re fine, you need something else.” It’s a joke. It’s unfortunate that this reference range is so misleading. So, in reality we care about optimal ranges and if I had to give you some numbers out there, I would say that an optimal number for total testosterone, they might be around a 1000, maybe even 1200, which is people’s “Oh, that’s way too high.” It’s not way too high. It’s above that reference range.
But again, what we care way more about than that is the free testosterone. The free again, the same– reference range again, we don’t care about it, we care about what’s optimal. Typically, it depends on the scale you’re using on your labs. But typically, I look at around 200 or the other scale we’re looking at about 25 depending on whether it’s nanograms per deciliter or picograms per milliliter. But if it’s a two-digit number you’re aiming for around 25 or so is ideal, if it’s the three-digit number, you’re aiming for around 200, even 250 might be okay, which is way higher than that ridiculous reference range.
Cynthia: I think it really does men a disservice because if that they’re being told, “Oh, it’s not a testosterone problem. But most men, it is a testosterone problem. What I found interesting when I was looking at statistics, we know that you get a 1% annual decline in free testosterone after the age of 30. So, it is a normal physiologic thing that much like women go through menopause, men can go through andropause, and if you’ve never heard of that before, it is a real thing unless you do things to help support your body. That in and of itself is not what we’re talking about. We’re talking about the net impact of profound changes hormonally to what’s happening to men.
Again, as I mentioned earlier, I think a lot of men feel very uncomfortable having these conversations or they’re just being given testosterone without really looking at all the other contributors to why this can happen. I imagine how many healthcare providers are saying to their male patients, “It could be the shampoo you are using which you wash your hair with, and then it coats your entire body when you rinse your head, or the deodorant that you’re using in an area that’s very exposed to let your lymphatic axillary area, just all the things that can contribute.”
So, I guess, it begs to question. So if someone has done all of the things, they’ve improved their sleep, they’ve cleaned up their diet, they’ve cleaned up their personal care products and what they’re exposed to in their food. When you look at prescribing testosterone therapy what are the currently FDA approved options that are out there for men? Because currently there are none for women. But for men, what is available conventionally, and then let’s take a twist on it and talk about some of the unique ways that you look at this issue?
Tracy: Yeah, great question. I want to briefly back up and just highlight what you just emphasize that. It’s a really important point, which you said is that, testosterone levels decline by about 1% a year after the age of 40. So, we definitely see this andropause situation that you’re describing. But what’s more important than that is the fact that there were three studies, a US, Sweden, and Finland study, all three studies show the exact same thing. And that is over the last 20 years, we’re seeing a dramatic precipitous decline by again over 20% free testosterone by over 40% age for age. So, what that means is a 50-year-old guy today has a testosterone level that’s 20% to 30% lower than a 50-year-old guy, 20 years ago. We’re seeing both. We’re seeing year by year, but we’re also seeing over time, age matched populations are having a dramatic decline.
But to answer your question, what do we do? We have low testosterone, how do we handle it? Obviously, there’s a lot of lifestyle work that we can do. We can focus on sleep. Studies have shown that one night of sleep deprivation can lower your testosterone by 50%m five-zero percent. Amazing. Stress, again, chronic stress raises cortisol, cortisol crushes testosterone, it causes promotion of fat, which creates like conversion of testosterone to estrogen, which makes testosterone come down even further. We know that crappy food can cause low testosterone, diet high in refined processed packaged foods, vegetable oils, canola, sunflower, safflower oil, we know that eating too low fat of a diet, a diet that has not enough fat in it is actually harmful as well, because testosterone is created ultimately from cholesterol.
The steroid pathway starts with cholesterol, and it goes to pregnenolone, and then ultimately you form testosterone. So, nutrition can have a huge effect. We talked about detox, we can look at micronutrients. You know, zinc, and magnesium, and B vitamins are certainly important for testosterone production. There are all these things that we can do. Even strength training, I forgot to mention fitness. So, strength training can have a dramatic effect on testosterone. I see a lot of guys who do too much endurance training, which can actually be harmful for testosterone. That takes a lot and we’re talking about running marathons, but suffice it to say that the right type of exercise is important as well. There’s a lot of work around lifestyle that I focus on primarily as a way to improve testosterone levels, whether it’s some supplementation, whether it’s altering fitness, altering lifestyle, sleep, stress, nutrition.
A lot of that, however, is based on genetics. Every guy I work with, we like to start with your genetic blueprint to understand what should you be eating and not eating? What kind of micronutrients might you have risk for deficiencies? How can we improve your detox? What genes might you have related to sleep that might be altering your sleep quality? So, I look at genetics and I look at data. So, I’ll look at wearable tech to actually track your stress levels, and track your sleep, and track your intake, and track your activity. There you go. Yeah, Oura here, Garmin here. I’m not trying to sell them, but tracking your data is critically important. We have all this stuff packed around the concept of non-prescription medication like treatments that we can employ to improve testosterone level. Now, put all that aside for a second.
When I see a guy who comes in and his testosterone level is 200, and his free testosterone is six, that guy’s in trouble. That low testosterone, again, increases the risk of obesity, 30% increased risk of cardiovascular disease, and early mortality. We’re not just talking about sex, we’re talking about a man’s life here. So, it’s critically important that we get that testosterone level where it needs to be. That lifestyle work is critically important. It’s going to help raise that testosterone to some degree. But I get this question a lot. So, if I’m at 200, can I get to 1000 or 1200? Can I get from a free of six to a free 25 with those lifestyle maneuvers? And the honest transparent answer is hell, no. There’s no way. Now, if you’re free is 20, and you want to get it to 25 or if your total is 800, you want to get to a thousand, yes, those things can have a massive impact. But most guys that are dealing with testosterone levels in the toilet, they’re not going to get where they need without prescription medication for therapy. So, that’s where we look at testosterone therapy to help that.
Now, when it comes to giving testosterone, one thing to be aware of is that, there’s the FDA has a black box warning label about testosterone because two shitty studies out there suggested there was an increased risk of cardiovascular disease, although, we have over hundred that show 30% decreased risk, these two poorly designed biased studies, which had been ripped apart by every medical community on the planet almost showed otherwise. So, the point of that is to know that, if you are wanting testosterone and your level is in that ridiculous reference range, it would be off label. So, that’s really important to be aware that, that testosterone therapy for a man who is not hypogonadal is off label, which is ridiculous. Because again, that reference range is not optimal range. It is just the normal population. So, every guy I work with, who comes in with low testosterone, and by low, I’ve may mean his total is 600 and his free is 12. That’s still low in the middle of that bell curve. That’s still low. I just want to clarify that testosterone therapy for that man is off label.
Cynthia: That’s so sad.
Tracy: He needs it.
Cynthia: That’s so sad.
Tracy: That’s important and he needs it. Yeah. I know that was a long-winded answer to your question.
Cynthia: No, but I think that you really emphasize just like I do with my own clients and patients how critically important it is to do all the lifestyle medicine stuff first, and then, really save the hormone piece for when it’s absolutely needed. Clearly, there are people that do need it. I’ve got a lot of questions about other types of hormones for men. So, human growth hormone, we know that this is very helpful for increasing muscle mass, and lowering body fat, and it can boost bone density, and one of the ways you know, the intermittent fasting crowd likes to talk about how just fasting in and of itself can help contribute to boost an HGH and with a population of people that are generally eating all day long and not giving themselves much digestive rest, that can be hugely helpful. Are you integrating this work with some of your patients if appropriate for them?
Tracy: Absolutely. So, intermittent fasting, I love it. I’m a huge supporter. I love you and all the great work that you’re doing. And I do emphasize for every man that they need to be intermittent fasting. A lot of guys when they’re just starting on how to do, just do one day a week, just try it, start it, and I escalate that, and I really do emphasize the critical importance of intermittent fasting. It is great for growth hormone. So, to answer your question about growth hormone, growth hormone is a double-edged sword. It is incredibly important for longevity, it’s important for maintaining healthy bone density, muscle mass, it is important for cognitive function, support for metabolism, and used to be considered the fountain of youth. Rightfully so, because there’s a lot of tremendous benefits to healthy growth hormone levels.
Growth hormone levels plummet as we age just like we’re seeing with testosterone, but growth hormone after the age of 40 really starts to dramatically decline. And so how can we optimize or improve growth hormone? So, you can give growth hormone– exogenous injections of growth hormone every day, but what that does is that alters your normal production of growth hormone and that suppresses you know, there’s a diurnal twice a day you have peaks of growth hormone, especially, right after you go to bed around just before midnight is the peak of growth hormone. Your body was created to respond to that growth hormone pattern if you will, appropriately. So, what happens when you give a blast the growth hormone as an injection, you alter that pattern and you alter it really permanently. So, while there are benefits of healthy growth hormone levels giving exogenous growth hormone can be detrimental when you’re trying to create benefit. So, that leads to the question, “Well, what can I do?” That brings us to the topic, I love so dearly and that is peptides.
There are a number of great peptides, but specifically a few that are what we call growth hormone secretagogues. What that word means is, that helps your body increase natural secretion of growth hormone without me giving you growth hormone exogenously. So, what these peptides will do is they’ll stimulate the hypothalamus, which is a part of your brain that releases growth hormone releasing hormone, whose job is to number one, go around the body and have some effects just like growth hormone, so in and of itself its valuable.
Number two, it goes to the pituitary and says, “Hey, make more growth hormone in the normal healthy diurnal pattern that it is supposed to.” So, these peptides will work through that fashion through the hypothalamus to increase GHRH, which is almost as important as growth hormone itself as well. If I were to give you growth hormone, it turns off that pattern in the brain, and you’re turning off growth hormone releasing hormone, which is so incredibly important. So, that’s why I love using peptides to stimulate increased growth hormone production naturally.
Cynthia: I love that and we’re going to definitely touch on more peptide therapy, because I’m learning through you and I find it absolutely fascinating, and I know that listeners will want to connect with you to be able to learn more. So, I also think about, I got a lot of questions about progesterone therapy, especially for men that have benign prostatic hypertrophy, which for anyone’s listening, this can be a normal variation. Obviously, you’re the expert in this area, but this can be a normal function of aging that the prostate gets enlarged, and men have disruption in urine flow, and they may urinate more frequently, they may feel like they don’t empty their bladders, it’s kind of like the scourge of men like women are dealing with urinary issues throughout their lifetime generally speaking, and then it’s like a middle aged, it’s almost like you get a stop gap. So, when you were in your more traditional urologic practice, were you using any progesterone therapy? Because I actually did some digging after I got multiple people asking me questions about it. Were you seeing a lot of that utilized to help augment symptoms?
Tracy: Short answer, no. Longer answer, there’s been a bunch of discussion around progesterone use in men. I’m a follower of hormone expert. His name is Neal Rouzier. He teaches other doctors how to manage hormones. I was at AMMG, the Age Management Medical Group annual meeting a couple of years ago, pre-COVID. One of the doctors got up, “Neal, why don’t you use progesterone?” His response was wonderful and it sticks with me, and that was, “Show me the study that actually works. Show me the study, it actually does something for men.” That’s the problem is that, there’s really a paucity of data on the real benefit of progesterone. There’s a lot of anecdotal stuff out there, but I looked at the research myself, and I didn’t find anything that was compelling enough to warrant me using it. So, I honestly, Cynthia, my wife uses progesterone for her use, but I don’t prescribe it for men.
But you’re right, I see men, my urology practice, it was everyday bread and butter. Guys with urinary issues relate to prostate enlargement, and it is a massive problem as guys age. So, there are some natural things we can do. But it comes down to prostate growth, which we believe is hormonally driven. So, as men age and they start to have this increase in body fat, the body fat is converting testosterone to estrogen, and we believe that is actually the estrogen that has a bigger effect on prostate growth than the testosterone. So, when guys ask, “Well, why am I suddenly having urinary trouble?” Well, it’s from longstanding hormonal stimulation of the prostate, which causes glandular growth of the transition zone or the central part of the prostate, which causes urinary issues.
Cynthia: That makes a lot of sense. I think in the context, the question is being asked because of the degree of estrogen dominance that they were hearing about in men. I get progesterone, it’ll balance it out, and in the context of middle-aged women, yes, that can be helpful, but to your point, and what I think listeners really need to use is the takeaway, there’s not enough research. So, there’s other ways around that. The one thing I do want to emphasize. When we talk about estrogen effects in a male body, obviously, very different than a female, but when I think about someone who has a lot of aromatization, testosterone to estrogen, I think about man boobs, we call them moobs, which is gynecomastia is the kind of technical vernacular. I think about a lot of– much like women, if they have a lot of circulating estrogen, they have a lot of abdominal obesity, and obviously the net impact on the prostate would be driving a lot of those urinary symptoms, which I’m sure are incredibly annoying, I don’t know from personal experience, but I would assume are incredibly annoying.
It would be without saying, if we don’t at least touch on erectile dysfunction. A lot of questions came in about that as well. Back in my baby nurse practitioner days and it was the first grand rounds, I sat in as a new nurse practitioner, and there was a vascular surgeon, and this at the time in the early 2000-time range was really the first time I heard it, and it really harkens back now as I think about how important this is. He used to say, when you see erectile dysfunction in a patient, the first thing you need to think about is insulin resistance. At the time that just blew everyone’s minds. We were like, “What are you talking about?” Retrospectively, I’m thinking how absolutely brilliant that was that, if there’s so much erectile dysfunction issues, people having issues with either sustaining or maintaining an erection, it’s more than just hydraulics.
The joke in my cardiology practice was, at the time, again, when I was a baby nurse practitioner, that’s the heyday of Viagra, and they couldn’t keep the samples in the office. It was because the male, middle aged and above cardiologists were taking it home to use it-
Cynthia: -or having it available to handout to patients like water. So, let’s at least unpack a little bit about some of the things that can drive erectile dysfunction, libido issues. I know testosterone plays a huge role. The other little caveat that I want to tack into that is, is it a midlife crisis or is this andropause that exacerbates all these symptoms?
Tracy: Yeah. Oh, thanks. I love– and I want to go back to estrogen if we can also, because there’s so much to unpack around estrogen as well, because it’s all related. In men, for some reason, estrogen is demonized. We’re made to believe that estrogen is bad and because it causes man boobs, like everything, like you said, I think it’s important to point out whether it comes to erectile dysfunction or whether it comes to body fat, or wherever it may be. It’s the ratio of the two. So, when I see guys who come in, they’re obese, cardiovascular disease, have the man boobs, what we see in those situations is high estrogen in correlation with testosterone. Progesterone is not going to help that. What helps that is actually testosterone. So, shifting that balance is what we really care about. We want to get their testosterone up to balance out that estrogen.
Now, the question is asked a lot, “Well, should we lower estrogen?” And that’s dangerous, because estrogen is not the enemy. Estrogen is demonized, but we need estrogen. I see so many men who come in and their estrogen is zero, because they’ve been taking Arimidex because they heard that’s what you’re supposed to do, and they feel like shit, they’re irritable, they’re crying, and they had erectile dysfunction, and a lot of that is because you actually need estrogen. You need it for healthy cardiovascular system, you need it for vascular erectile function, you need it for actually burning fat and metabolism. So, there’s a nice healthy window of estrogen that we want, but we want testosterone higher than estrogen. So, I want to be sure we touched on that.
In terms of erectile dysfunction, you’re exactly right that ED is very closely tied to insulin resistance, and why is that? It comes down to nitric oxide. When you are insulin resistant, your vascular endothelium does not release that critically important molecule called nitric oxide. So, nitric oxide is the molecule that causes what? Vasodilation. It relaxes the blood vessel to improve blood flow. So, when you have insulin resistance, the primary negative effect that causes to affect sexual function is loss of normal secretion of nitric oxide. So, that’s why your cardiology attending was so emphatic about that. Especially, younger men in their 40s, I see all the time come in with issues with low testosterone and ED. The first thing you got to think about is cardiovascular health, because all that vascular system with insulin resistance, with chronic inflammation, and low hormones, they’re all intimately tied together.
Cynthia: Absolutely, and it became a running joke. There were never samples to give out to patients nice to say [crosstalk]
Cynthia: Very lovingly and my baby nurse practitioner voice looking at all these middle-aged docs, I would say, “Can’t we leave some for the patients?” Because they’re the ones that actually, genuinely, these are cardiovascular patients who genuinely need this. Now, before we tie back to peptide therapy, you’ve mentioned biohacking, which is one of my favorite topics to discuss. We’d already touched on a couple of high-quality sleep, intermittent fasting obviously are great bio-hacks, but I got quite a few questions about semen retention and scrotal [unintelligible [00:44:18]. I don’t know if you’ve heard about this, cold therapy, hot therapy, [crosstalk] scrotum, does it help, is it helpful? So, there’s a lot of misinformation. This is all the more reason I need to pull you on to Twitter because-
Cynthia: -there’s so much misinformation and you would be the proper person to be responding to these questions.
Tracy: Yeah, thanks. So, first of all, the concept of Photobiomodulation, PBM, or red-light therapy which is what is commonly called is amazing. There’s a lot of amazing benefits to red light therapy when it comes to detox, when it comes to you know rejuvenation, when it comes to increasing general health, hair, skin, nails, when it comes to inflammation, detox, amazing benefits. When it comes to red light on the scrotum, there’s a paucity of data is what I’ll say. There’re a few studies out there that look interesting, compelling, is there strong enough data that I would say, it’s going to have a massive effect on erectile function or massive effect on testosterone production, a massive effect on sexual function. I think the jury’s still out. I think that there’s the tendency to jump on the latest trend and call it a bio hack, because there’s one anecdotal study out there or one study that that seems to show some benefit. I don’t want to spend too much time on this.
But this brings up the problem that we have in this day and age with research. There are so many studies out there, which are trash. So many studies out there, which are published to show whatever the authors were wanting to show, and there’s so much bias. So many studies are done that don’t show the outcome that the authors wanted. So, it just doesn’t get published. So, it’s important to take with a grain of salt every single study out there that you read and you look at. If it is observational, if you have a group of 10 men, and I did this, and now, they show that, that’s not a study, that’s just anecdote. You need controls, you need randomization, you need to have a large enough group, you need to account for any co-variables, any other factors that may affect it. So without spending too much time on it, be careful what you read, be careful when you see a news article about this study showed this. Especially, when it comes to nutrition, most of it is nonsense BS and you got to take it for what it is.
Cynthia: I’m actually glad that you touched on that. I was trying to make my way into talking about there’s a paucity, there’s a lot of extrapolations, there’s a lot of smoke in mirrors on social media as well as just media these days. Frankly, it’s helpful for people say, “Hey, if it makes you feel good, and you enjoy doing infrared sauna, nude at your home, and you feel great, that’s awesome.” But you think that it’s then going to solve all of your other issues related to low T. We’re saying this is helpful for a variety of reasons, but that shouldn’t be the reason why you do it.
Two last topics that I definitely want to touch on. You had mentioned peptide therapy, and so, we briefly touched on this in relation to growth hormone. But what are some of the more common reasons you will utilize peptide therapy? It’s a huge topic. We could do a whole separate podcast just on peptide therapy, and hopefully, I’ll be able to convince you to come back to do so. But what are the more common reasons you will utilize peptide therapies with your patients that you find enormously beneficial?
Tracy: Sure. First of all, for the listeners, what is peptide therapy? What are peptides? Short answers are amazing. Number one, I always start my conversation of peptides with that, because that’s my best descriptor. Peptides are these magical molecules that already exist inside each and every one of us. They are enzymes or molecules that you’re born with and that have very precise, very specific functions. As you age, you start to lose optimal levels of these peptides. Peptides are nothing more than short chains of amino acids. So, a protein is a long chain of amino acids. A short chain of amino acid is simply a peptide. So, what’s beautiful about peptides is they’re signals that your body already recognizes. Examples of peptides, insulin is a peptide, growth hormone is a peptide that we’re born with, they’re natural, they’re enzymes.
The first thing to be aware of is that, they’re natural. In that sense, yes, they’re synthetically created, but they mimic exactly the amino acid sequence that our body is used to. So, once I make that clear to answer your question, we can use peptides in a very precise manner for things such as reducing inflammation, whether it’s systemic inflammation, whether it’s joint inflammation, whether it’s gut inflammation, peptides are amazing for reducing inflammation. Peptides are amazing for modulating immune function. I was just talking at the Mindshare Collaborative meeting yesterday, I was on a panel talking about censorship with Dave Asprey and Joe Mercola talking about how my own blog was censored by the FTC, because I spoke about the amazing immune function benefits of peptides. Like thymosin alpha and [unintelligible [00:49:13] and LL-37 among others, that are amazing for regulating our immune function especially, T cell immunity, which does not get enough attention.
Immune function, we can look at peptide for cognitive focus and for anxiety, or peptides for musculoskeletal repair, like if you have an elbow or wrist, or a hip, or an ankle injury, or knee injury, or you’ve had surgery recovering from those. There are peptides to help with improving mitochondrial function and there are peptides for sleep. There are peptides for weight loss, for hair loss, for skin, for erectile function, for libido. So, what I love about peptides is they have very precise specific functions, very minimal if any downsides or side effects. The pharmaceutical industry cannot tell you them because you cannot patent the peptides. They are awesome.
Cynthia: Yeah, we’ll have to have you come back and we’ll do a whole discussion about peptide therapy because I have nerded out learning so much about peptides through you, and I think for most listeners, it would really be kind of a welcome departure from more common topics that I bring up. The last multiplicity of questions that I got were specific to SARMs. So, for listeners, these are selective androgen receptor modulators. A lot of questions from clinicians that were asking, are you using them, what do you think of [unintelligible [00:50:33], curious what your thoughts are on them?
Tracy: Yeah, so, SARMs are powerful. They’re officially considered research molecules, research chemicals. So, SARMs are amazing if you’re looking to build muscle fast, if you’re looking to shred weight, and shred fat fast, you can use SARMs for a number of anabolic effects. I personally don’t prescribe SARMs. If guys are looking for specifics, I’ll talk about them and say pros and cons of them. But as a medical professional with a medical license that is probably important to keep, I don’t prescribe SARMs, but I will discuss details of them, and pros and cons of each of the different options out there and help guys choose which one might be right for them if you’re looking for them. But that’s where it ends for me.
Cynthia: No, I think that’s completely fine. It was interesting that when I went through questions across social media, it was evident that there were certain camps that questions came from, and there was definitely the– I would refer to affectionately is the biohacking, people that are trying to hack one thing or another with substances as opposed to lifestyle.
Tracy: Yeah. I give a good example of that. There’s a SARM that will create a massive effect on SHBG. So, it’ll dramatically lower your SHBG down to under 10. What does that do? That increases bioavailability of testosterone. So, well, that’s great. That’s wonderful. We don’t know what the unintended consequences are of that. This goes back to the fact that our bodies are complex. It’s a complex network, a complex system that we’re altering without knowing all the other cascading effects that we’re creating by trying to affect this one particular part of it. So, that’s why you got to be careful about. Biohacking can be wonderful to a lot of potential great benefits of it, but a lot of it is fringe worthy, and you just got to be careful what you’re doing.
Cynthia: Well, I’m so grateful for the work that you’re doing it. Bringing light to much needed topics relevant to men’s health. What are you working on now? I know that you are fast at work on a TED Talk.
Tracy: I am. Thank you. Yes, so, I’m working on my TED Talk applications at the moment with a wonderful consultant that you shared with me. So, I appreciate that. I am building out a high-level executive level VIP Men’s Health Center called the Gapin Institute for Men’s Health and Performance here in Florida, and I’ll be scaling that shortly as well, I hope. Then, I’m also building out a National Men’s Telehealth Business as well where we’ll be able to provide testosterone via telehealth, peptide therapy via telehealth, and even at-home lab testing through our site, and then a comprehensive Men’s Health Optimization Program as well all done remotely.
Cynthia: Fantastic. Well, I’m so excited to hear that, things are falling into place that beautifully for you. How can my listeners connect with you get more information if they’re interested in checking you out or perhaps for a loved one?
Tracy: Absolutely. Thank you so much. So, my website is drtracygapin.com. And if you go there, you can submit a question or reach out to me and my team if you would like to work with me. I also have an offer for your listeners. My book, which was called Male 2.0 was published last year, and your listeners can get a free copy of that just cover shipping. It’s drtracygapin.com/limitless.
Cynthia: Well, thank you so much. I know it’s a great book. I really enjoyed reading it and we’ll have to bring you back because I only touched on a small amount of questions that I received. So, we’ll have to have you back to dive a little bit deeper.
Tracy: Sounds great. Thanks so much for having me.
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