ExcelMale's podcast

Welcome to the podcast page for ExcelMale.com, the leading and best-moderated men’s health forum focused on increasing health, testosterone replacement, exercise, nutrition, potency, and productivity in men. #menshealth

Top Things Your Doctor May Not Tell You About Testosterone 04/20/2023

How to Increase Testosterone Naturally: What You Need to Know 04/12/2023

High Hematocrit Caused by Testosterone: How to Lower it. 04/07/2023

Cost of Blood Tests With or Without Insurance 04/07/2023

Best Vitamins and Supplements by Nelson Vergel 09/15/2022

Your Compounded TRT and HRT Access is Under Attack by the FDA: Interview with Scott Brunner from APC 09/15/2022

Estradiol in Men: Roles, Myths and Facts 09/01/2022

Estradiol in Men: Roles, Myths and Facts Nelson Vergel, author of the book Testosterone: A Man's Guide (Available on Amazon.com) and founder of the men's forum www.ExcelMale.com speaks about the role of estradiol in men and the consequences of over-treating estradiol with anastrozole and other aromatase inhibitors. Testosterone is the precursor hormone for estradiol. Estradiol is a hormone more abundant in women than men that is produced by the aromatization of testosterone in liver, fat and other cells. Nature created it for a reason. It has been shown to be responsible for healthy bone density but its role in men's sex drive, body composition and other variables is source of great debate. Many anti-aging or men's health clinics prescribe anastrozole, a blocker of estradiol production, to men who start testosterone replacement (TRT). Higher estradiol blood levels not only can cause breast tissue growth (gynecomastia) but also water retention (edema). Some people speculate that high estradiol can also lead to erectile dysfunction but no scientific papers have been published on this subject. Since higher testosterone blood levels can originate higher estradiol levels, the belief is that using anastrozole will prevent breast tissue growth and erectile dysfunction by lowering any potential increase in estradiol. However, we have no data on how high is too high when it comes to this hormone in men. Some even speculate that low testosterone-to-estradiol ratios may be more closely correlated to gynecomastia and erectile problems than estradiol alone. The truth about these speculations is starting to emerge but we still do not have enough data to say what the upper value of the optimal range of estradiol really is. We have a lot of evidence about the lower side of the optimal range since it has been found that estradiol blood levels below 10-20 pg/ml can increase bone loss in men. A recently published study also nicely demonstrated that low estradiol can be associated with higher fat mass and lower sexual function in men. So, be very careful when a clinic wants to put you on this drug without first justifying its use. Another concerning fact is that many clinics may be using the wrong estradiol test that may be over-estimating the levels of this hormone in men. An ultrasensitive estradiol test more accurately measures estradiol in men instead of the regular test that costs less. Fortunately, most men on TRT do not develop gynecomastia even without using anastrozole (gynecomastia is common in bodybuilders who may use high doses of testosterone, however). Those that have gynecomastia at TRT doses (100-200 mg of injectable testosterone or 5-10 grams of testosterone gel per day) may be genetically predisposed to having more aromatase activity or have liver dysfunction. Treating all men who start TRT with anastrozole from the start may be counterproductive since this may lower estradiol to very low levels. Some physicians monitor estradiol blood levels after 6-8 weeks of having a man start TRT alone using the ultrasensitive estradiol test to determine if anastrozole use is warranted. Doses range from 0.25 mg per week to some clinics using excessive doses of 1 mg three times per week. After 4-6 weeks on anastrozole, its dose can be adjusted to ensure than estradiol is not under 20 pg/ml. Fortunately, many men on TRT do not need anastrozole at all. /episode/index/show/excelmale/id/24245247

Sexual Health Myths & Taboos: Dr Rachel Rubin Tells it Like It Is 08/31/2022

How to Use hCG and Testosterone Injections at the Same Time 03/08/2021

How to Use hCG and Testosterone Injections at the Same Time Today I'm going to be explaining the use of HCG together with testosterone injections (Video Transcript) Why Do Some Men on TRT Need hCG? Men with a result need testosterone replacement therapy (TRT), either by getting a prescription from a doctor for a gel, like AndroGel, Testim, Axiron, Fortesta, or getting a prescription for testosterone injections, like Cypionate, Enanthate, or Aveed (testosterone undecanoate). There are many benefits of using testosterone to replenish or to increase your testosterone back to normal levels for your age. However, there are disadvantages. One of the disadvantage of using testosterone is shutting down your own body's production of testosterone. Your testicles basically stop producing testosterone. There are cells in the testicles called Leydig cells that go dormant when you start using testosterone gels or injections. This testicular cell shut down can cause , meaning your testicles can shrink with time. Testicular atrophy can fortunately be reversed with the use of hCG together with testosterone injections, gels, pellets and other TRT options. TRT can also cause your fertility and sperm count to go down. This decrease in sperm count and quality may impair your ability to get your wife or girlfriend pregnant. After long term TRT, some men may start feeling that TRT is not working as well when it comes to boosting their sex drive. Other men may feel that their penis is not as sensitive when performing sex. So, that's where Human Chorionic Gonadotropin (hCG) comes into play. hCG is a peptide obtained by prescription that it's legal and FDA approved in the United States for enhancement of fertility in men and women, and for increasing testosterone in men with hypogonadism (testosterone deficiency). hCG has had a lot of bad publicity due to its use in the “hCG diet”, which is not supported by clinical data and the FDA. hCG has also been proven by studies to also improve testicular size when experiencing testicular atrophy due to TRT. And last but not least, and penis sensitivity. How to Use hCG with Testosterone Injections at the Same Time Most protocols used by different TRT clinics out there use two or three injections a week of hCG either under the skin or in the muscle. Along with hCG, they prescribe testosterone injections either once a week or twice a week. That protocol requires, when you add injections up, five injections a week. I don't know who likes to inject that much! Personally, I do not want to inject so many times per week as I'm really trying to simplify my life and to avoid what we call “needle fatigue”. We're all busy and yes, we want to have the best sex drive, the best mental capacity, the best mood, but not with that kind of commitment to multiple injections. Therefore, I designed a protocol that will simplify my and everybody's life by using hCG together with testosterone injections only twice per week, with both products combined in the same syringe. I use a very tiny syringe- 27-gauge 1/2 inch. These type of insulin syringes come in a bag that you can get online without a prescription. How to Inject hCG plus TRT You also need alcohol swabs to clean the vials and also your skin. And you obviously need to get a prescription of testosterone, either Cypionate, Enanthate or Undecanoate. This vial contains 200 milligrams per milliliter (or cc) for a total of 10 mL. Depending on the dose, so that you may need only 100 milligrams a week of testosterone, or only 200 milligrams. In severe cases of lack of TRT efficacy, the TRT dose can go as high as 250 per week. You can divide that dose in two injections. In my case, I use 100 milligrams of testosterone per week, divided by two, that's 50 milligrams twice a week. hCG comes in a vial of 11,000 units IUs (or other types of units depending on the compounding pharmacy). hCG comes in a powder and the pharmacies send bacteriostatic water with it that you have to mix it once it gets delivered to your place. The best way to do so is injecting 5.5 mL of bacteriostatic water it into the hCG powder vial of 11,000 IUs, which means basically every cc or mL will contain 2,000 IUs. So, for 50 milligrams of testosterone Cypionate that comes in vials that contain 200 milligrams per mL, I need 0.25 mL for every injection, twice a week. The same thing goes for hCG. I need only 0.25 mL to inject 500 IUs per injection. Some men seem to derive benefits from hCG with 250 IUs twice a week. There is debate about what is . How Do You Know What hCG plus TRT dose is Right for You? You'll know it within two or three weeks if your testicles are not feeling fuller and you're not feeling more sex drive. For increased sperm count, it takes a while (8 weeks) to find out if it's working or not. Take the top off each vial (testosterone and hCG). Use an alcohol swab to clean each vial top. Then you can inject on my shoulders or glutes at 90 degrees, or subcutaneously under the skin in the abdomen. I combine the two products in the same syringe. It's only 0.25 cc of each, so it's a total of 0.5 cc. Testosterone is an oil-based product, and HCG is water-based. So, they never really combine in the syringe. I'm just trying to save time and frequency of injections. Two injections of the combined hCG plus TRT per week. So just pull the top off. I'm going to just draw a little air just so that I can push it into the testosterone vial. Just push it in, and then turn it around, and just very slowly because it's a 27 gauge very thin syringe, so just be patient. Testosterone cypionate is an oil-based product. So, it basically flows very slowly. But it's not that big of a deal. It's only 0.25 cc, so the wait is only less than a minute. The same procedure for pulling hCG out of its vial. Just tilt the vial over. Let a little bit more air out there, and then check the air, and pull the hCG out. hCG is water-base, so it flows really fast. So pretty much, there are two products in the same syringe. Just tap it a little to get air bubbles out. And then that's it. Basically, you're loading the syringe with two products, 0.5 cc total. Then inject that volume at 90 degrees in your shoulders. It doesn't hurt. It's really a tiny syringe, half an inch long. Like this. I didn't even feel it. And then push it in. As simple as that! I hope this helps. It's not easy to inject so much and so frequently. Everybody's busy. So hopefully this will help a lot of guys to adhere to and comply with the hCG plus testosterone therapy. /episode/index/show/excelmale/id/18243260

Facing HIV in the 80's and 90's: Interview with Nelson Vergel 05/26/2020

How to Increase Attraction in Your Relationship: Interview with Rebecca Watson 05/11/2020

Restarting Testosterone and Sperm Production After Stopping TRT or AAS 05/11/2020

Exercise Tips by Nelson Vergel 08/10/2019

Exercise Tips by Nelson Vergel The important thing to remember is that when done correctly, exercise can have the following proven benefits that go beyond just looking good: • Improved muscle function and strength. • Reduced trunk (belly) fat • Increased muscle mass • Decreased LDL (bad cholesterol). • Decreased triglycerides. Muscle hypertrophy (enlargement) induced by resistance training, may decrease triglycerides in those with high levels. • Improved mood and decreased stress. • Increase bone density in men and women. • Improved aerobic function and lung capacity. Getting Started There are some things to consider before you start an exercise program. Get your blood pressure, heart rate, weight, body dimensions, fasting cholesterol, triglycerides, and blood sugar measured. Your doctor should be able to advise you if you are capable of exercising without health risks. If you feel too tired and weak, start by walking every day to your best ability. Walking can increase your energy levels so you can start a more intensive exercise program as you feel better. Use a cheap pedometer to measure your daily steps; try to reach 10,000 steps a day since that amount has been associated with good cardiovascular health and fat loss. There are two types of exercise: resistance (weight) training and cardiovascular (aerobic) exercise. Resistance training uses weights to induce muscle growth. Cardiovascular exercise improves your body’s aerobic capacity (the way it uses oxygen). It also increases your metabolism so that you can burn fat, lower your bad , and lower your blood sugar. Do low-impact aerobic exercise for 20-40 minutes, three to four times a week. Exercises like walking fast, bike riding (stationary or the two-wheeler), stair-stepping, and using an elliptical trainer or treadmill are all effective. Switching between different exercises can help keep your interest going. Be careful about aerobic exercise if you are losing weight involuntarily if you are overly tired or recovering from illness. Recommendations Train with weights and machines three times a week for no more than one hour. Starting with machines is the safest way until you get familiar with the exercises. As you feel more confident and strong, bring in free weight exercise (hopefully with the help of a workout buddy). As you get stronger, increase your weights in every exercise. Exercise one body part per week, and do three exercises per body part. One light warm-up set and two heavier sets of eight to ten repetitions to momentary muscle failure (until you cannot do another rep) are enough for each exercise. If you do not have access to a gym, do push-ups on the floor and squats holding books or large bottles full of water at home. As long as you are “resisting” your own body weight, you are doing resistance exercise. Important Things to Remember • Learn how to do each exercise correctly. Concentrate on using strict form to get the most out of each exercise and to prevent injuries. • Make sure your muscles are warm before targeting them with more challenging weights. Warm them up with a light, high-repetition exercise set. • Don’t use your body to add momentum; cheating this way takes work away from the targeted muscles. Use a deliberate speed to increase the effectiveness of the movement. • Use a full range of motion on all exercises. Feel the muscle stretch at the bottom and go for a momentary peak contraction at the top. Don’t go too fast! • Warm-up before you work out and stretch afterward to prevent injury. Briefly stretch the major muscle groups before your training. This helps flexibility and muscle recovery. • Feel the muscles working by keeping your head in what you’re doing. Focus on your muscles contracting and relaxing. Concentrate on your body exercising, not on random thoughts or people around you. • If the weight is too light (more than 12 repetitions), try using a heavier one or do the movement more slowly and really feel the contraction. You should be barely able to finish the tenth rep if your weight is the right one. Of course, as you get stronger with time, increase your weights. • Keep rest periods to no more than about 20-30 seconds, or shorter, depending on how tired you are from your last set. This will also help to give your heart a mini-workout. Safety First Always remember -- safety first! If something you do in an exercise hurts, stop! Ask for help to figure out what you’re doing wrong. Maybe it’s improper form. If you hurt yourself, you will hinder your progress because you won’t want to work out. Learn proper form! Do not exercise if you feel you are coming down with a cold. Commit Yourself If you can afford it, join a gym. If you spend the money, you’ll be more likely to stay with it, and consistency is the key to success in any exercise program. Also, try to find someone who is enthusiastic to train with, or get a personal trainer (if you can afford one). It’s easier to stay motivated when you train with someone else who has a vital interest in your mutual success. It’s also safer to have someone to spot you when you lift heavyweight. Avoid Overtraining Working out for more than an hour can cause overtraining which can destroy your muscles and decrease your strength. Overtraining is probably the factor most ignored by exercise enthusiasts. Prolonged exercise (overtraining) may lead to suppression of testosterone levels, possibly lasting up to several days. In order to build muscle the body has to receive a stimulus, a reason, to grow bigger (hypertrophy). It’s really very simple: the body only does what it needs to do, what it is required to do. It isn’t going to suddenly expand its muscle mass because it anticipates needing more muscles. But if it is challenged to move weights around, it will respond by growing. Another way to look at it is, if you take any bodybuilder and put him in bed for weeks at a time, he’ll begin to rapidly lose muscle mass because the body will sense that it doesn’t need the extra muscle anymore. By lifting weights one delivers the needed stimulus to begin muscular hypertrophy. However, overdoing exercise stresses out the body and actually initiates the process of breaking down muscle mass as the body begins to burn its own muscles to use for fuel. This overtraining is why so many people don’t grow at a satisfying rate. Even worse, these same people often will think they aren’t training hard enough. They increase their exercise routines, thinking they just need more stimuli! And this is where the biggest error is made -- more is not necessarily better! It seems paradoxical that you could work out less and grow more, but this is very often the case. Any exercise beyond that which is the exact amount of stimulus necessary to induce optimal muscle growth is called overtraining. I know this sounds non-specific but the idea is that it will vary from person to person. You need to listen to your body. A Workout Log Is Recommended The best reason to keep track of your workouts is so that you can see graphically what you are accomplishing. You will be able to see whether you’re gaining strength at a reasonable rate. You can also analyze your pattern to see if you’re overtraining. You will find when you log your workouts, that if you are overtraining, you won’t be gaining in strength or muscle size. Document your workouts by keeping track of the weight you lift and the number of reps you lift for each exercise. Then when you go in to train again the next week, you’ll know what you are trying to improve upon. If you find out that you’re weaker than you were the time before, and everything else like nutrition, etc. is in line, you may be training too often. Food and Hydration Drink at least eight glasses of water a day to keep hydrated. Dehydration can rob you of energy for your workouts. Drink plenty of water while working out. Avoid sugary drinks, since they will cause fatigue after an initial burst of energy. Some people like to drink green tea or creatine supplements in water before a workout to help increase energy levels through a workout. A light carbohydrate meal (fruits, carbohydrate drinks, etc.) before a workout and a protein-rich one afterward is advisable. Keep yourself well hydrated with plenty of water throughout the workout. And get plenty of rest afterward. Do not work out right after eating a regular meal; wait at least two hours. If you need a snack, have some fruit and a slice of toast with peanut butter one hour or more before working out. Do not consume protein shakes before working out (leave them for after the workout). Digestion will slow down your workouts and bring your energy down. Within 30-60 minutes after the workout, feed your muscles with a balanced meal containing protein, good fats (olive oil, flaxseed oil), and complex carbohydrates, like fruits and whole grains. Supplements like glutamine, creatine, and whey protein may be a good thing to consider. A shake containing one heaping tablespoon of glutamine, two tablespoons of Omega 3 oils, one or two scoops of whey protein, some fruit, and milk (if you are lactose intolerant try almond or rice milk, though not soy, since it may increase estrogen in both men and women), provides a good balanced meal after a workout. More information on /episode/index/show/excelmale/id/10845755

La Testosterona: Lo Que Todo Hombre Debe Saber 07/03/2019

Does Testosterone Cause Prostate Cancer and Heart Attacks? 07/03/2019

Does Testosterone Cause Prostate Cancer and Heart Attacks? Nelson Vergel from and interviews Dr. Mohit Khera, one of the world's top experts in urology and testosterone therapy with over 100 publications. He debunks myths about testosterone and prostate cancer, cardiovascular risks and DVT / blood clots. He discusses the use of hCG, clomiphene and other products. He also reviews data on natural ways to increase your own body's testosterone production. For more information visit: Transcript: Nelson Vergel: Hello everybody, Nelson Vergel here with excel male dot com and discounted labs dot com. I'm very honored today to introduce my urologist here in Houston. I'm very privileged to have doctor has published more than a hundred articles last time I Googled his name, and he's one of the experts in the field of men's health, urology, testosterone replacement, prostatic issues. I think you also treat, Doctor Khera, female sexual dysfunction, too. Very happy to have him, he's going to give today a lecture that I think everybody's going to find extremely interesting covering the controversies of testosterone therapy Dr. Khera: Thank you for the introduction. I appreciate it. As you mentioned, there have been significant controversies with the use of testosterone therapy over the past five years. Cardiovascular risk, DVT, prostate cancer, BPH, and today I'd like to discuss some of those controversies and give you some further insight into the diagnosis and treatment of hypogonadism. Dr. Khera: I always like to give you some of the statistics. I'm not sure if many of you know this, or are aware that in 2012 testosterone was one of the fastest growing medications in the United States. There wasn't a single medication that was selling faster than testosterone. The concern that while the testosterone sales were increasing, the testing in the United States during this time was also starting to decline. One interesting statistic was that roughly 27 percent of men who initiated testosterone did not have a blood test before taking the medication, and 21 percent of men who started testosterone didn't have a follow-up test. So clearly there was some abuse with testosterone and some concerns. Dr. Khera: When I talk about controversies today I'd like to give you three different perspectives. I want to give you the perspective of what the FDA label has to say, as well as what the guidelines have to say. We were very fortunate in 2018; two guidelines came out. The AUA, the American Urological Association, came out with their testosterone guidelines the same time the endocrine guidelines also came out with their testosterone guidelines, as well. So I'd like to share with you these three different perspectives as we go forward. Dr. Khera: The first is on the concept of venous thrombosis embolism or VTE, and so you should be aware that in the package insert of a testosterone products in 2005 in the adverse reactions section of the label, it was appended to note that one patient during the open-label extension trial did suffer from the DVT. Now in 2009, the label was changed again under the new medication guide that lists blood clots in the legs among the serious side effects. If you open the package insert for testosterone products, you will see, and this is just for Androgel, that they do put in the section warnings and precaution a concern for VTE. I'll read this. There have been postmarketing reports of VTE events including DVT, PE in patients using testosterone products, Androgel in this case. Evaluate patients who report symptoms of pain, edema, warmth, and erythema in the lower extremity for DVT and those who present with acute shortness of breath for PE. If a VTE is suspected, discontinue treatment with testosterone and initiate appropriate workup and management. Dr. Khera: So this is in the package insert, and you should be aware that patients will read this and they will ask you about this. We should be very careful because the guidelines slightly differ, and if you look at the American Urologic Association guidelines, it states that patients should be informed that there is no definitive evidence linking testosterone therapy to a higher instance of VTE. The entering guidelines don't have a guidelines statement on this, but they do have some comments that they've made. They do state that case-control and pharmacoepidemiological studies have not shown a consistent increase in the risk of VTE with testosterone treatment. However, there is two huge testosterone associated VTE events in randomized controlled trials to draw meaningful imprints. Dr. Khera: So you can see where there are three different perspectives here, and they all are slightly different in their beliefs in how testosterone affects VTE. Dr. Khera: The second controversy is cardiovascular risk. Many of you may be aware of this. There was a significant amount of concern at one point that testosterone may cause a heart attack. So I'll put this in the context of a story. It was very interesting, Molly Shores in 2006 published a very nice study looking at men at the VA and what she found was that those men with lower testosterone levels were much more likely to suffer from earlier death. They died earlier or sooner than men with normal testosterone levels. If you look at the studies following the Molly Shore study, they were prospective studies, larger studies, all finding the same thing. Those men with lower testosterone levels tended to have increased mortality, and if you look at the right-hand column, the cause of death seemed to be cardiovascular death in many of these studies. Dr. Khera: Before 2010 there were also many studies suggesting that giving testosterone may decrease the risk factors for cardiovascular events. Risk factors meaning obesity, metabolic syndrome, diabetes, cholesterol, and they may have some beneficial effect in decreasing the risk factors of cardiovascular disease. Dr. Khera: We conducted our review and looked at every single article we could find from 1940 to 2014. We found over 200 articles addressing testosterone and cardiovascular disease. The majority of these studies being favorable against suggesting low testosterone is a risk factor of cardiovascular events, and we could only find four studies suggesting that testosterone may increase cardiovascular risk. Now, these are the four studies; I don't have the time to go into each one of these in detail. The majority of these studies are not randomized or placebo-controlled, and the Finkel study did not even have a control group. But suffice to say that these studies did bring up some concern that testosterone may have an increased risk for cardiovascular events. Dr. Khera: Based on these studies, the FDA did put in the package insert, and you should be aware, that to date epidemiologic studies in randomized controlled trials have been inconclusive in determining the risk of major adverse cardiovascular events and patients should be informed of this possible risk when deciding whether to use or to continue the use of Androgel one percent. So this is in the package insert. Dr. Khera: The EMA which is the equivalent of the FDA did look at this data and have not made any changes to their cardiovascular warnings of their products. The guidelines are a little different. I will tell you that in 2018 we also published another study looking at all the studies from the FDA warning in 2015 to the current date, and we found 23 studies also looking at testosterone and cardiovascular disease, and again we couldn't find any studies suggesting that testosterone increases the risk of cardiovascular events. We found studies suggesting that men who normalize their testosterone with testosterone therapy had a reduced risk of MI and death compared to those men whose testosterone failed to normalize. Dr. Khera: The AUA and endocrine guidelines do have statements on this, and the first statement by the AUA guidelines is very clear. Clinicians should inform testosterone deficient patients that low testosterone is a risk factor for cardiovascular disease. That's important. Low testosterone is a risk factor for cardiovascular disease. Now, they go on to say, "Before initiating testosterone treatment clinicians should counsel patients and this time it cannot be stated definitively whether testosterone therapy increases or decreases the risk of cardiovascular events." If a patient does have a cardiovascular event, the AUA guidelines suggest that we wait at least three to six months before starting therapy again. The endocrine guidelines are a little different. The editing guidelines recommend that we wait six months, not three to six months, but six months if a patient suffers from an MI we should wait at least six months. But the endocrine guidelines also agree there's no conclusive evidence to support that testosterone supplementation is associated with an increased cardiovascular risk in hypogonadal men. Dr. Khera: Those mechanisms, just so you know, is several, there are four theories, but the most common theory is the belief that the elevated red blood cell count, also known as erythrocytosis, could then lead to thrombosis, atherogenesis, and increased cardiovascular risk. That is the most common theory. We spent quite a bit of time studying this; this is a study that we published looking at patients. Remember that the injectables have the highest rate of erythrocytosis. In our study it was 66 percent, in other studies, it's about 40 percent. So if a patient starts developing an elevated red blood cell count, one of the quickest things you can do is get them off the injectable, put them on a gel. A gel typically has an erythrocytosis rate anywhere from two; I've seen as high as 13, 14 percent. It's a lower rate. Because there's less of a spike that occurs with the gels. The injectables cause a spike which increases erythrocytosis rate. Dr. Khera: Now that erythrocytosis typically doesn't occur until about three to six months, so there's no point in checking blood in two or three weeks. You have to give it some time. And the number you wanna remember is 54. The guidelines typically state that at 54 you want to either have the patient phlebotomize, which is donate blood, or you wanna decrease the dosage, but we don't want it to get above 54. Nelson Vergel: Doctor Khera, one question here. Nelson Vergel: Has anybody actually published data on hematocrit versus DVT risk? Dr. Khera: So two points. One, there has never been a testosterone trial, a testosterone trial showing that the elevation in the cardiovascular risk on the testosterone trial was the cause of a DVT. There's been anecdotal data on patients taking testosterone and getting a DVT. But there's not been a trial showing that the testosterone which caused an elevation of hematocrit that led to a DVT. Majority of the data that comes from an elevation in causing a DVT is from Polycythemia Vera data. This is a malignancy of bone marrow. There have been several studies showing that an elevation in hematocrit in this population may lead to an increase in DVT. Some studies were inconclusive; some studies did suggest that yes, in this population an elevation of hematocrit did lead to a DVT. But we should be clear that this population is very different from the general population, right, and so it's using a transference. You're just insinuating that this population and this data can be used in the general population. Dr. Khera: So again, I think you should be very careful. We need a trial. Nelson Vergel: Okay. Dr. Khera: One important point I do want to make is that if you look at the risk factors for low testosterone and you look at the risk factors for men who have cardiovascular disease, they're the same risk factors. It's obesity, hypertension, dyslipidemia, hyperglycemia, insulin resistance. These are the same risk factors. So it's not surprising that many hypogonadal men, whether they take testosterone or not, are at increased risk of having a cardiovascular event because they share the same risk factors for cardiovascular disease. Dr. Khera: But we should also be clear. Yes, Nelson. Nelson Vergel: No, no, go ahead. Dr. Khera: We should also be clear on the indications for testosterone therapy. Who is it indicated for? You should be aware that the FDA and their androgen class labeling guidelines in 1981 had a statement. "Androgens are indicated for replacement therapy in conditions associated with a deficiency or absence in [inaudible 00:13:32]. This is the indication." Then they go on to list primary hypogonadism and secondary hypogonadism. They do have the word idiopathic. So if a patient, now I don't believe that these conditions are meant to be exhaustive. Other conditions could cause primary or secondary hypogonadism. But if you have a patient that does not have a medical condition that is associated with hypogonadism, in other words, in my opinion, they're considered idiopathic. They have low t, signs, and symptoms, but they don't have a condition listed on this list. The FDA, you should be aware, had a chance and they made a statement in 2015 that cautions that testosterone products are approved only for men who have low testosterone levels caused by certain medical conditions. And the benefit and safety of these medications have not been established with the treatment of low testosterone levels due to aging even if a man's symptoms seem related to low testosterone. Dr. Khera: And so I think that's very important because if you look at the new FDA guidelines after 2015, this is very similar to the slide I showed you earlier when listing those conditions, the key difference is that the word idiopathic has been removed. That no longer exists. So the FDA is very clear that patients should have a medical condition listed on this slide here to be considered a hypogonadal. Again I don't think this list is exhaustive, but this is what we call indications for therapy. Dr. Khera: Now realize this was a very nice study by Doctor [inaudible 00:15:08]. Looking at roughly four thousand men who came to his clinic. He found that roughly 20 percent of men had hypogonadism. But the majority of hypogonadism is secondary hypogonadism. So roughly 85 percent. Of that 85 percent of men that have secondary hypogonadism, only 11 percent of them have a true medical condition or a specific condition. Eighty-nine percent of them is due to an unknown cause. And if you look carefully at that unknown cause, roughly 70 percent of those men who are unknown have one of three conditions. It's either diabetes, obesity, or metabolic syndrome. Many of us believe that those are conditions, particularly obesity, should be considered a true medical condition associated with low testosterone. But again, it doesn't fit the list that currently lists those conditions such as a pituitary tumor. Dr. Khera: Again, the majority of the patients don't have a medical condition listed on the list of conditions associated with hypogonadism. We believe that those men that don't have a medical condition but still have signs and symptoms of hypogonadism and low testosterone values also aren't benefiting from testosterone. In other words, men who have low testosterone due to a pituitary tumor, or men who have low testosterone just simply because their testosterone is low and they suffer from the condition should not be treated differently. They both will benefit from testosterone therapy. We call these patients adult onset hypogonadism. Remember a very important thing; men don't lose a significant amount of testosterone as they age, aging alone. They typically acquire medical conditions such as diabetes, obesity, metabolic syndrome that drop the testosterone below a threshold of 300. Aging alone, a majority of times, the majority should drop a man's testosterone level below 300. It is the acquisition of medical conditions as we get older that will drop the... /episode/index/show/excelmale/id/10389404

Estradiol in Men: Facts and Misconceptions 02/18/2019

Nelson Vergel's Exercise Tips 02/18/2019

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