What are the medications available to treat low testosterone? | Peter Attia & Mohit Khera

maybe we'll talk about all the different ways that we can replace testosterone so the three ways that we have historically done it in our practice I guess technically four um one is and we don't do this anymore um we used to use clomiphene so we would give Clomid it had the advantage of several things one it's uh it's a pill very convenient you'll take it three times a week uh two it preserved uh function meaning you you preserve both testicular volume and spermatic function so you preserved fertility um and actually it was quite efficacious I found it to be because you could titrate the dose and get to almost whatever you mean the drawback is if the man didn't have testicular Reserve uh he wasn't going to get much of a bump sure so so you know there were some guys who had kind of peripheral hypogonadism as opposed to Central this was a great treatment for Central but you were at the limit of what the testes could do there are reasons we ended up stopping it that I won't necessarily get into but we basically haven't used that in a very long time we then would use as the alternative to that HCG HCG is just a mimetic for LH glutenant hormone which you talked about of course is the direct stimulant of the ladig cell which makes testosterone lots of disadvantages it's pretty expensive it's an injectable it's a very delicate injectable so it has to be refrigerated if you drop the bottle the protein misfolds and it's it's crap so lots of problems associated with it but again seems to preserve testicular volume which young men care about maybe older men do too as well not clear if it's as good as Clomid at preserving fertility I would love to hear your opinion on that um but again it feels less problematic to men in the sense that it's less permanent sure of course we then use the Mainstay is injectable testosterone cypionate or its derivatives and again we'll talked about all the pros and cons of that and then lastly pellets so testosterone pellets don't do that anymore now that we've switched to being more of a remote practice so I don't see patients in person to and to put the pellets in them sure um and also for men pellets are a much bigger deal than for women the pellets are so much bigger sure for women when you're putting little estrogen and testosterone pellets in it they're it's a sure it's a walk in the park they don't even notice you've done it for men they notice it sure great topic so this is really important so you talked about two so let's talk about endogenous ways to race this awesome first and you can use Clomid you can use HCG some people use an astrozol I don't recommend that but we'll talk about that so Clomid first it's a serum negative feedback to the estrogen receptor the problem with Clomid is the following we get a discrepancy effect and this is what happens you get a very nice bump in the testosterone level that's true but roughly 40 of patients say I have no desire for sex I have no erections I don't feel at any desire because the waist this Clomid works it blocks estrogen receptor centrally men needed estrogen it is critical you need Estes for libido and sexual function so they have these beautiful 800 900 levels you take that same patient put them on exogenous testosterone at 800 he says it's working so the way Clomid works is that it blocks and so that mechanism is not conducive for many men yes it's easy there's a national backorder so now we're starting to use a little bit more enclomid is n Clomid legal in the U.S uh it is compounded remember Repro and try to get it through in 2015 that the FDA never made it through but it was it's you know it's a trans isomer of Clomid and so of a zoo Clomid so and essentially it is available compounded and you can get it but it's hard to get Clomid now even because there's a national backorder and and is this just due to all these tea shops opening up on every corner that are well they're different so they're more into giving the T and the injection and you come in and get the injection for a fee okay but this still is on the endogenous side if Columbus bad I mean but why is there such a run on this stuff because what happened was HCG wasn't for many years compounded and recently the FDA has said that ACG cannot be compounded so everyone dropped the HCG went to Clomid and now there's a mad rush to get the climate you can still get HCG commercially yeah let's do the roofs so what happened was that everyone started going to Clomid and so now we're back ordered on Clomid and you can still get HCG but it's pricey and did the FDA say no more compounding HCG because it's too complicated and they couldn't do quality assurance I think it was a patent infringement I think it was more to the fact that I think Merck still had uh rights to the patent on HCG and it was too similar because the compounder can make something but it has to be different that's my understanding so I I I for some reason our compounded you know so I think certain com I think it's going to start coming back but there was a national shortage on HCG and that's why people started going to Clomid but Clomid it's it's not the 60 will say my T goes up you got to give it every other day or you can get a tachyflaxis so seven percent can get tachyphilaxis if you give it daily some patients for I say they say I can't remember every other day I say fine take it every day and the seven percent chance you may become resistant to the seven seven percent yeah okay so that's fine I want people to get a pill box when we used to use it yeah it was just Monday Wednesday Friday and don't have to think about it right if you forget take it every day and like end club would we give it every day and what doses do you use uh 50 for Clomid every other day or end Club at 25 a day right or if they forget on 50 every other day we use 25 chroma daily okay fine it's not a great but it does help we use it for fertility so patients were coming to me for fertility to help them achieve a pregnancy reuse it you can use HCG HCG is expensive and it is pricey uh typically it depends on what dose you want to use um but it's 1500 three times a week up to two thousand three times a week it can be effective it's nice for patients who have pituitary pathology because I bypass the maturity go straight to the testicle and they can start making testosterone and then in patients who have an elevated LH and FSH initially klinefelters yes you can't really use HCG or clone because the weight because they're already maxed they're already maxed out so you've got to use an astrosol or because I'm trying to increase the TD ratio increase the T and typically I'm using this medication to improve spermatogenesis so that I can then do a biopsy or a testy to receive spermine and how I've never seen a man with client I've never seen a man with Klein filters if when a man presents with Klein filters what are his typical T DHT and E levels they're so the E's are typically High the t's are pretty typically 40 30. they're not super high but they are and it depends on how far along you see them along with FSH and LH are typically already elevated pretty high so if the FSH and LH are already elevated I can't use Clomid or HCG right so that's the prevalence of Klein filters uh one in 500 so it's quite common yes just tell people what kleinfelter is it's a genetic abnormality where you have an extra X chromosome xxy so phenotypically you're a man phenotypically you're a man but there are issues infertility you can have gynecomastia uh they're typically long stature in nature um normal you can live in a normal sexual function uh they have no issues with Ed but the t is low so that may affect the Ed so but we treat these men with medications to raise the tea right and so we see that and why can't you just give them testosterone uh we can but it what if they want to have a child right so so that's the only thing so what we may do is I see a lot of these patients when they're 14 or 15 when they're first diagnosed so we have the power they usually I mean I know the diagnosis is genetic but what brings them to presentation a lot of times what you'll see is that there's no facial hair development so they're delay in development right no shaving and so what you'll notice and so the if there's a suspicion long stature uh small testicles on exam the pediatrician may say let me just take a karyotype and just see what's happening and then you see two X chromosomes then you know yep you know so so it's one in 500 that means there's a lot of people listening to this podcast that have kleinfelters presumably they know it but they may not and if they know it they might be wondering is testosterone an option and what you're saying is not necessarily first line unless you can block estrogen as well right and of course it depends on the fertility status right and some of these patients will start testosterone and then when they're ready to have children we will do a procedure called a microtessy at that time and what we'll do is we'll stop the testosterone and so my reversal dose is HCG 3000 units three times a week and then we'll either give them go no F or Clomid with it so there's three ways to look at it there's patients who've taken testosterone and they're abusers and they've come in now and they want to have children that's the type number one of patients that patient stops the testosterone HCG 3000 units three times a week plus uh recombinant FSH or going off 75 units three times a week and that actually does help reverse anywhere from three to seven months you can see recovery of spermatogenesis and these that's great okay and tell me that guy shows up having been on testosterone for how long to be in the years and and many times they may have gotten the testosterone from a gym or something and they didn't want getting monitored and they're at Super physiologic levels so this is how long have you been on it and how high was your dose dictates how far along you know so so you tell patients that and we use physiologic doses so a typical dose for us is 50 milligrams of cypionate twice a week that's what we do yeah okay so so we would say that physiologic dose you don't want to be on this for more than two years and we are really hyper Vigilant and say I wouldn't be on this for more than a year unless you're willing to be on it yeah what do you say so typically it depends on you're talking about younger patients though yeah so someone who's like in his 40s right so in his 40s I still try to the second so the category two is a young man who just wants to use HCG alone and that's not three thousand three times a week that's 1500 three times a week as a dose and then there's the last one and this is a study that we did at Baylor where there's a patient who wants to take tea and we give them HCG with it to protect the access and that's 500 three times so 500 1500 3000 there's three different patients the preservation of you know and this also is about 500 of HCG three times a week it's not due doing anything to boost endogenous production protection it's just protection and the best study this is the best study came out a guy named koviella this is how we got the idea at Baylor koviella had a study in 2005 where he gave patients 200 milligrams of testosterone I am every week okay that's a big big dose every week and what he was measuring was intra-testicular testosterone levels at 200 I am every week the intertesticular went down 94 of patients were down to zero in three weeks so that's a good number to remember 94 decline in inter-testinal testosterone in just three weeks 94 decline then what he did was he gave these patients different doses of HCG 250 500 all the way a thousand and what he found was between 250 and definitely 500 there was no significant decline in intra-testicular testosterone very interesting so he's giving 500 every other show in 2013 amazing 2030 by partner Larry lipschultz uh said okay if that's true for intertesticular testosterone what is it doing for fertility yeah so let's do the same thing let's give these patients testosterone and 500 units of HCG every other day and what we saw was there was a decline but it wasn't a significant Decline and now that was the median so there are patients who can have I don't want people to think hey if I do this it's completely safe but it does help protect decreases hematogenesis but why is that the case given that HCG is acting on The Late egg cell you would think you would need recombinant FSH to get the protection of spermogenesis right because it has some FSH properties if you give a man for fertility just HCG you actually see improvements in spermatogenesis now there is some of the fact that some of the testosterone is being used by the sertoli cells for production is sperm production would you has someone done the study of giving clomiphene or mclomaphene with testosterone to maintain sperm production I have not seen that study but people do it off label yeah and it would seem to me that that would be even more efficacious people do it off label the only issue is that you got now two things working in opposite directions because you've got the estrogen problem yeah and also that you know that the when you're given the tea you're suppressing the LH and FSH and clomid's trying to raise the SLA right so but giving but giving recombinant FSH would be the better thing to do yes yeah how expensive is recombinant FSA extremely expensive so I would say it's really only used for fertility right that's it's on label uses infertility yeah up to 500 a month I think it's very expensive wow this is insanely expensive proposition once you start going and what does HCG cost it depends now because now you can't get a company no if you're getting pregnant about 300 to 4 300 a month insane yeah yeah these are you know these are you can understand why unfortunately men especially younger men who might not have the disposable income are basically just getting testosterone because it's very cheap uh and especially if they're you know getting it in an illicit fashion yeah uh so so you're you're keeping them out of the doctor's office where they can't be monitored and you're pushing them into the gym locker room where God only knows what they're getting there's one thing I forgot to mention on the fertility preservation side besides the Anastrozole clomiphene and HCG there is some data that just came out suggesting that the intranasal testosterone does not significantly suppress somatogenesis and this was interesting so it's done three times a day this was out of the group at a University of Miami three times a day in the text called natesto it's commercially available you go to Walgreens you can buy it I've never even heard of this I'm just about to ask you about the oral testosterone yeah so the Testo is a nasal testosterone that's implied it's 11 milligrams is applied in each nostril and you do it three times a day and essentially what happens is it has the fastest rapid on onset and then it declines and I always thought 11 milligrams tid said 33 milligrams daily right so in other words the bioavailability is much lower than an injection yes but the interesting thing is this I thought look if I looked at I looked at the pharmacokinetics I said how can this be effective like how it's in and out so quickly right and then you know doing some deeper work and talking to some endocrinologist said look Mo you don't have to have it around if it's bound to the receptor and it's doing its work it doesn't have to physiologically be there all the time in the serum and it's interesting these patients do feel better right they feel better and because of the rapid onset some of them do say they take it before sex they take it before a workout because it's very quick they say they feel better when they take it this is how has this not become the drug of choice but no significant suppression is fromatogenesis that was interesting now more studies need to be done but that was when was this approved uh the test show I think has been out for at least six or seven years it's been it's been for a while is it inhibit is it cost prohibitive uh it's it it you insurance does cover it uh it can also be compounded but um it's used by a lot of young men [Music]

Channel: Peter Attia MD

Views: 100,880

Keywords: peter attia, sexual health, erectile dysfunction, testosterone replacement therapy, low t, low testosterone, peter attia diet, peter attia podcast, peter attia longevity

Id: n-HMke2QSbs

Length: 15min 19sec (919 seconds)

Published: Sat Jul 01 2023