Endocrine Essentials: Males and Testosterone
featuring Doreen Saltiel, MD, JD, FACC, FAARM, ABAARM
Audio Only:
Episode 8
Published June 7, 2022
In this week's episode, we're joined by Doreen Saltiel, MD, an expert on men’s health and testosterone. Listen to hear Mark Newman and Dr. Saltiel discuss men's health and review the research on testosterone therapy. You'll hear her insights on the benefits of testosterone therapy for male patients, plus what to look for on the DUTCH Test to identify potential risk factors.
About our speaker
Doreen Saltiel, MD, JD, has practiced medicine for more than 40 years. She is a board-certified practitioner with a cardiology fellowship and has practiced interventional cardiology for more than 25 years. Dr. Saltiel completed advanced fellowship training in Metabolic and Nutritional Medicine from MMI as well as their advanced certification in Endocrinology and Cardiovascular Health. She currently practices functional medicine with an emphasis on hormone health and preventative cardiology, and has co-authored multiple peer-reviewed papers. Along with the founder of Precision Analytical, Mark Newman, she recently presented hormone testing research to the North American Menopause Society at their 2021 Annual Meeting.
Please Note: The contents of this video are for educational and informational purposes only. The information is not to be interpreted as, or mistaken for, clinical advice. Please consult a medical professional or healthcare provider for medical advice, diagnoses, or treatment.
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Full Transcript
00:00:00:03 - 00:00:17:13
Noah Reed
Welcome back to the DUTCH podcast, where integrative medicine providers can expand their understanding of functional endocrinology and testing. And everyone, no matter who you are, can learn more about their body’s most complex communication system. I'm Noah Reed, vice president of sales and marketing for the DUTCH Test.
00:00:17:18 - 00:00:33:02
Noah Reed
And coming up on this week's episode, it's endocrine essentials, the male testosterone addition. This week, Dr. Saltiel will share her expert insights on male testosterone. How much is too much and when is the best time to start testosterone therapy?
00:00:33:07 - 00:00:47:15
Noah Reed
Her extensive review of research gives her a great point of view for this discussion, so stay tuned to hear her insights on the benefits of testosterone therapy for male patients and what to look for on the DUTCH tests to identify potential risk factors.
00:00:48:02 - 00:01:12:15
Noah Reed
Dr. Doreen Saltiel has practiced medicine for more than 40 years. She is a board-certified practitioner with a cardiology fellowship and has practiced interventional cardiology for more than 25 years. Dr. Saltiel completed advanced fellowship training in metabolic and nutritional med medicine from MMI, as well as their advanced certification in endocrinology and cardiovascular health.
00:01:13:01 - 00:01:31:05
Noah Reed
She currently practices functional medicine with an emphasis on hormone health and preventative cardiology and has coauthored multiple peer reviewed papers. She and Mark Newman recently presented hormone testing research to the North American Menopause Society at their 2021 annual meeting.
00:01:31:18 - 00:01:33:05
Noah Reed
And now onto the show.
00:01:33:23 - 00:01:45:05
Mark Newman
Thanks, Noah. And I'm super thankful to have Dr. Doreen Saltiel, my friend and our testosterone expert here to chat with us about testosterone in men. Thanks for joining us.
00:01:45:20 - 00:01:48:08
Doreen Saltiel
Thanks, Mark. I really appreciate you all having me.
00:01:49:01 - 00:02:04:01
Mark Newman
So, we had a nice conversation about androgens and their role in women. So, we talked about where they're made and all of that. Let's start there with testosterone and men, especially since it contrasts with how and where they're made in women.
00:02:05:08 - 00:02:10:22
Mark Newman
Where do men get their testosterone and what is its primary role in our male patients?
00:02:12:01 - 00:02:37:20
Doreen Saltiel
As you alluded to, as opposed to women where testosterone is made in three different places, almost 100% of testosterone in the male is made in the testicles. Very little is made anywhere else. And it's really important that males have optimum testosterone levels to improve sexual function.
00:02:38:08 - 00:03:02:21
Doreen Saltiel
Lean body mass. But all body composition. And there's data on cardiovascular disease and in maintaining. An erection and there's no data on cognitive improvement as to benefiting men with optimum testosterone levels.
00:03:03:22 - 00:03:18:02
Mark Newman
So, there are plenty of benefits of having a normal versus a low testosterone. What's the most typical for you? Male patient. 100 male patients come to see you that have low testosterone. What are the top things that they're going to be complaining about?
00:03:21:15 - 00:03:38:09
Doreen Saltiel
I have a foggy brain. I'm losing my muscle mass. I'm not as sharp as I used to be. My libido is decreased. My inability to maintain an erection as long as I used to, a lack of a morning erection.
00:03:38:20 - 00:03:49:11
Doreen Saltiel
And so, the first thing I ask them is, when was the last time you felt. Like you were 20 years old. And I start from there.
00:03:50:15 - 00:04:11:00
Mark Newman
Okay. We're really into comprehensive testing, right? We like to look at testosterone and estrogen and cortisol and other things. So, start with the cortisol picture. Which of those things that you just listed can also be seen in someone who's got stress, cortisol, dysfunction, access dysfunction?
00:04:11:05 - 00:04:16:10
Mark Newman
Which of those things could be not a low testosterone issue, but maybe an issue with cortisol?
00:04:16:23 - 00:04:42:23
Doreen Saltiel
All of them. Every single one of them. Because testosterone and cortisol balance each other. When cortisol needs go up or the body senses the stress hormone, cortisol goes up. Testosterone because it immunomodulators imbalances, cortisol will go down. So, whenever you're assessing a gentleman who you think may have low testosterone, part of that workup, in addition to a
00:04:42:23 - 00:05:05:21
Doreen Saltiel
series of laboratory testing, is to assess their cortisol. It's very, very important. And then also estradiol, because as estradiol goes up, as men get abdominal obesity and diol goes up, what happens at that woman goes down because the aromatase enzyme becomes upregulated, and more testosterone gets converted.
00:05:07:08 - 00:05:31:04
Mark Newman
So, topics that are central for us that overlap with testosterone is going to be cortisol and estrogen. So, what I'm hearing is I need to be concurrently looking at those things because, you know, cortisol as an example can could be the driving cause in someone in symptoms that maybe are mistakenly thought to be testosterone or are going
00:05:31:04 - 00:05:43:19
Mark Newman
to exacerbate those symptoms. If you have a testosterone deficiency and you deal with the deficiency of testosterone, but you don't address the cortisol issue, harder to succeed then in those patients, if you're not thinking about both of those things at once.
00:05:44:03 - 00:05:59:22
Doreen Saltiel
Absolutely. You can't over supplement a bad lifestyle. You can take all you can. You can give people as much testosterone or supplements as you want to. They're not going to get better until you address their age access.
00:06:00:14 - 00:06:17:02
Mark Newman
So, there's a long conversation that we could have about testosterone deficiency and what can we do about it? Testosterone replacement therapy. Before we go, there are the men who make too much testosterone indigenously. If that's even a thing like a is that a thing?
00:06:17:02 - 00:06:23:03
Mark Newman
And B, what do those men tend to complain about if they have an excess of testosterone?
00:06:25:05 - 00:06:26:04
Doreen Saltiel
That's unusual.
00:06:26:17 - 00:06:26:22
Mark Newman
Okay.
00:06:27:10 - 00:06:42:11
Doreen Saltiel
I've not seen adult males make too much testosterone because how do you define too much? Because that range is so why? Some labs say up to 1100 is okay.
00:06:42:11 - 00:06:42:17
Mark Newman
In.
00:06:42:17 - 00:06:45:16
Doreen Saltiel
Blood without supplementation.
00:06:46:03 - 00:06:46:10
Mark Newman
Right.
00:06:47:08 - 00:06:56:01
Doreen Saltiel
It's very hard for a guy to have a total testosterone level in the blood of 1500, 2000. It doesn't happen.
00:06:56:05 - 00:07:08:23
Mark Newman
Right. Okay. So, that's going to be rare. Okay. Because I know for us, we've tested hundreds of thousands of people. And if you ask me that question, there's one guy that I would point to, and I never had any personal interactions with him.
00:07:08:23 - 00:07:26:18
Mark Newman
I just know he saw the labs and the range ends at like 115 and he was in the one throes. And he actually had this long, really weird story about, you know, erections when he didn't want them and those sorts of things, which I thought, oh, that's a rare story, but nice to know that it exists.
00:07:27:18 - 00:07:43:22
Mark Newman
So that's going to be a rare one, not the type of patient that's going to walk into our provider's offices very often. So, let's start with the gentleman who has low testosterone. He's pretty young, but dealing with those issues, let's just say for the sake of argument, estrogens, fine.
00:07:43:22 - 00:08:01:15
Mark Newman
And cortisol is actually doing well before you get into the conversation of testosterone replacement therapy. I have heard a lot of conversations from people about this supplement, that supplement as it relates to testosterone. I haven't heard a lot of success stories, also haven't dug into the literature.
00:08:01:16 - 00:08:09:16
Mark Newman
What about that? What about guys that are going to try to take some supplements to address either low testosterone or low testosterone symptoms?
00:08:11:05 - 00:08:40:23
Doreen Saltiel
Well, the first thing is in a young male, and I'll say less than 50. Testosterone should never be your first choice. Never. You should address lifestyle, nutrient deficiencies. And we're going to assume all of that. Okay. And they either have low testosterone, meaning around 300 will say they may have they may have, you know, heavy metal toxins
00:08:40:23 - 00:09:05:15
Doreen Saltiel
. They may have other toxicities that will impact testosterone. And so, we're going to assume all those are okay. And so now you say, what do you do with this guy? Well, there are a couple of options. A lot of people like to try nutraceuticals first, in my experience, and in that that I have surveyed over the years
00:09:06:08 - 00:09:29:09
Doreen Saltiel
, they really don't work that well. What works well is if they're overweight, losing weight, if they're not sleeping well, you know, not is sleeping better if they drink alcohol, stopping alcohol and eating a higher protein diet that works as well as most of the supplements out there.
00:09:29:10 - 00:09:46:20
Doreen Saltiel
And they don't get the benefits that you would get in somebody with low testosterone, which is mainly preservation of bone mineral density. And cardiovascular health. So, one of the things that I do in young guys is I offer them peptides.
00:09:47:08 - 00:10:08:10
Doreen Saltiel
There are two peptides. One is called Kip peptide, which is actually like Clomid. It stimulates the body mate. So, it's, it's similar to what the body makes, and kids think it'll get into trouble releasing hormone and then you get a release of FH in LH, which would increase sperm and should increase testosterone.
00:10:09:13 - 00:10:25:09
Doreen Saltiel
But of course, the work is done in that setting, right? The other is called controlling. What that does is I can see you out of the body. Also makes the man rolling. So, you can offer two peptide options to guys.
00:10:26:00 - 00:10:46:07
Doreen Saltiel
HPV vaccine you like one which is good at rolling guys like better because it does raise estrogen and you will see if the testicles respond and that's really what you want to see. So, the guy has a really high age, then he can respond, right?
00:10:47:10 - 00:11:02:04
Doreen Saltiel
Because it has to be a particular issue and you are dealing with a signaling issue. If you give an admiral, an architect or if you like plumbing or HDD, but those are the things that I would use in a young guy.
00:11:03:03 - 00:11:08:09
Doreen Saltiel
I never give a young guy testosterone when he's under 50.
00:11:08:09 - 00:11:34:17
Mark Newman
So not not pulling out the testosterone card definitely is a first pass for young men. We've gone through a little bit of an acronym exchange here. So, let's explain the basics of testosterone physiology just so as we as we hit up these different topics, people understand, so what is my brain making that signals my test, my testicles
00:11:34:17 - 00:11:36:06
Mark Newman
to make testosterone, that is.
00:11:37:18 - 00:11:49:17
Doreen Saltiel
Gonadotropin releasing hormone from the hypothalamus signals the anterior pituitary to make follicle stimulating hormone and luteinizing hormone.
00:11:49:18 - 00:11:51:21
Mark Newman
Okay. FC Agent LH Got it going.
00:11:52:08 - 00:12:19:11
Doreen Saltiel
Luteinizing hormone triggers the testicle to make testosterone. Everything triggers the testicle to make sperm is important for spermatogenesis. And so that's why guys need estradiol, not only for maintenance of bone mineral density and these other things, but it needs that empathy trigger to make sperm.
00:12:19:13 - 00:12:33:20
Mark Newman
Which is the reason why you're so slow to take a 30-year-old and give them testosterone because you're going to shut that whole mechanism down and now, you're not making sperm and now you've got some long term impact and infertility and that sort of thing in my in my head in the right direction with that.
00:12:33:22 - 00:12:52:17
Doreen Saltiel
Yes. And even though I have heard people say, oh, you just stop the testosterone, and these guys get better, well, some do. Maybe a lot to. But some don't. And you don't want to tell one to those who don't.
00:12:53:14 - 00:12:54:16
Doreen Saltiel
You can't have babies.
00:12:55:10 - 00:12:55:17
Mark Newman
Right.
00:12:56:18 - 00:13:12:18
Doreen Saltiel
If you are going to give a young guy testosterone because of whatever reason, you should tell them to freeze their sperm. You go to a sperm bank and freeze your sperm.
00:13:14:00 - 00:13:14:14
Mark Newman
Right. And you're.
00:13:14:14 - 00:13:16:15
Doreen Saltiel
Someone who can give a guy testosterone.
00:13:16:15 - 00:13:17:00
Mark Newman
Right?
00:13:18:11 - 00:13:36:09
Doreen Saltiel
He's not going to make any more sperm. And then if you stop it, you shut off his intrinsic mechanism. So, not only is he going to have no libido, he may not have any testosterone, which is going to help drive that libido and the rest of his sexual function.
00:13:37:19 - 00:13:42:11
Doreen Saltiel
But he also may not generate enough to FC to make sure.
00:13:43:01 - 00:14:03:17
Mark Newman
Right. So, no, not a biochemistry type mechanism thing that you want to casually enter into interfering with. So, particularly for for young men, not something to to do without like heavy consideration of the consequences. Yes. You have mentioned a few times.
00:14:06:00 - 00:14:24:21
Mark Newman
Serum testing for testosterone. Without mentioning what we do, and that's for good reason. Why is it that your primary method of inquiry for a man in terms of is this enough? As is is it not enough? Is a blood test a serum test as opposed to a urine test?
00:14:26:01 - 00:14:39:03
Doreen Saltiel
Well, sometimes based to detoxification doesn't happen appropriately or face to group. Urine addiction doesn't happen appropriately.
00:14:39:03 - 00:14:53:06
Mark Newman
Meaning the. What we find in urine as a measure of testosterone is uniquely, occasionally and rarely but problematic in terms of the number being as reliable as what you get in blood.
00:14:54:04 - 00:15:16:07
Doreen Saltiel
Correct. Now I do both together. And part of that is you should never, ever, ever give a male. Any form of therapy that's going to increase their testosterone and may increase their risk for dial. Without knowing your risk for human capitalism.
00:15:18:10 - 00:15:39:06
Doreen Saltiel
And if the the mail doesn't have this union keep the two conjugations snipped, then it kind of what I've seen is it kind of mirrors what you see in regarding free testosterone. Now what is it that you see?
00:15:40:01 - 00:15:57:04
Doreen Saltiel
I say the other is typically either an immuno ashamed or you can use smashed. The ranges are different so you're looking at really where they live within the reference. Are they in the middle of either reference? Right. It's not going to be a 1 to 1 sermon.
00:15:57:05 - 00:16:16:21
Doreen Saltiel
You're never 1 to 1. Is it going to be at the higher end of the reference range? So, I'll give you a lot of information regarding what your and regions are doing and if they do have a huge snip, you could look at and reduce metabolism as well as estrogen metabolism.
00:16:17:05 - 00:16:36:04
Doreen Saltiel
And you can look at other markers in urine like Andros. Tyrone is a testosterone metabolite, which typically if somebody has really, really low testosterone, you are going to see interest from being okay or within the normal reference range.
00:16:36:04 - 00:16:58:07
Doreen Saltiel
The same thing with extra dial. If a guy's testosterone when you look at it is really, really low. And their estradiol is normal, that testosterone is really low. Look for you guys now because 100% of the dialog comes from testosterone in a man.
00:17:00:03 - 00:17:20:18
Mark Newman
So, you're describing some of the complexity of urine testing with testosterone. When you look at a man who is potentially deficient in testosterone, what are you using for the diagnostic tool to confirm that that is the case before you consider treatment?
00:17:20:19 - 00:17:26:15
Mark Newman
What is that? What is the protocol for a doctor to say? This man is hyper gonadal testosterone deficient. What are you doing?
00:17:27:08 - 00:17:43:22
Doreen Saltiel
In the fasting state on two separate occasions? I do a morning fasting. Total testosterone and free testosterone. I get a serum. Hormone binding globulin. I get a prolactin. And of course, I get thyroid function test. And why do I need a prolactin?
00:17:43:22 - 00:18:06:06
Doreen Saltiel
Because prolactin will suppress the release of LH. And so secondarily, it can decrease testosterone. So, you want to make sure they don't have a prolactin and ensure a hormone binding globulin you want to see. So, you can tell how much of testosterone is banned.
00:18:07:12 - 00:18:15:17
Doreen Saltiel
So, somebody could have a normal testosterone level, but 80% of it is banned. So, they will have testosterone deficiency symptoms.
00:18:16:01 - 00:18:18:06
Mark Newman
Because their free testosterone is low, is.
00:18:18:06 - 00:18:18:13
Doreen Saltiel
Low.
00:18:18:14 - 00:18:38:10
Mark Newman
And that's typically what would then be reflected in the DUTCH test with a low testosterone. So, and as a as a as we've discussed, you know, the primary tool in a man for defining hypogonadism low testosterone, maybe someone in need of therapy, is that serum measurement and a confirmation serum measurement?
00:18:38:14 - 00:18:56:09
Mark Newman
And you've described to me, you know, the DUTCH test as a great complementary tool in men's health in terms of peering into that. Those questions about testosterone are the things that are related. Why do you consider the DUTCH test a great complementary test for men when you're looking at testosterone issues?
00:18:57:00 - 00:19:25:18
Doreen Saltiel
Number one, cortisol. I want to look at cortisol. Cortisol metabolize the cortisol to cortisone ratio. I want to get a complete picture of their age access. I also want to look at things like pyro glutamate, which is a brutal find precursor and really because glutathione is the most potent intracellular antioxidant, melatonin is the most potent extracellular, but
00:19:25:18 - 00:19:33:02
Doreen Saltiel
also, a potent intracellular antioxidant. You want to see how well they are able to detoxify.
00:19:33:17 - 00:19:45:15
Mark Newman
So, you've just mentioned two of the organic on the organic acid panel, things that complement that picture being the glutathione deficiency marker. While we're also looking at the B6 and the B12 marker, melatonin.
00:19:45:16 - 00:19:50:16
Doreen Saltiel
Oxidative stress, all of those. Okay. I want to look at their estrogen metabolism.
00:19:51:01 - 00:19:51:09
Mark Newman
Okay.
00:19:51:17 - 00:20:15:09
Doreen Saltiel
As we all know, estrogen has a very complicated relationship with prostate cancer. And really, it's the intracellular free diet, all the upregulation of aromatase that causes prostate cancer and it's the er alpha receptor that's upregulated as opposed to the er beta receptor.
00:20:15:15 - 00:20:30:00
Doreen Saltiel
You really want to know how they're metabolizing estrogen just like you do in a woman in a woman for breast cancer. And then I want to look at their androgen metab. I want to see what the army and regions are doing.
00:20:30:01 - 00:20:48:02
Doreen Saltiel
Do they favor the five-alpha, which is more rigid, or do they favor the Five-beta, which is less intricate because a guy can have, you know, the testosterone can be in that 300 ish range in serum. Not really sure, but their DHT looks really good.
00:20:50:13 - 00:21:04:23
Doreen Saltiel
Their symptoms are kind of wishy washy. They're not fit. I have a low libido, which is the number one symptom. Well, sometimes I do. Sometimes I don't. Right. And so, they don't want to address their cortisol. You know, you want to make them lose weight.
00:21:05:07 - 00:21:25:01
Doreen Saltiel
You want to put them on a high protein diet. You know, you don't want to go just, okay, here's testosterone or even here's a peptide you want to work on those other things to allow their own body to equilibrate and adapt so their testosterone comes up on its own.
00:21:26:07 - 00:21:50:07
Mark Newman
Okay. So, you're addressing them like a brilliant functional medicine provider, hoping that you can equilibrate that, and they find their way back to something that looks a lot more like what they were like at 20. But you fail in a particular case because the testosterone is too low or whatever, and you're into the world of testosterone replacement
00:21:50:07 - 00:22:11:13
Mark Newman
therapy. So, first off, tell me, as the person who is at the top of my list of people who know the literature and have spent time and time and time digging into the literature as a doctor, but also leaning on your experience as as a lawyer and being able to just research what are the top, let's say
00:22:11:13 - 00:22:17:11
Mark Newman
, five things that a man is at risk of having low testosterone and not doing anything about it.
00:22:21:21 - 00:22:24:13
Doreen Saltiel
Number one, cardiovascular disease.
00:22:24:17 - 00:22:24:20
Mark Newman
Okay.
00:22:26:07 - 00:22:30:00
Doreen Saltiel
Number two. Osteopenia and osteoporosis.
00:22:30:08 - 00:22:31:04
Mark Newman
So, heart and bone.
00:22:32:13 - 00:22:47:04
Doreen Saltiel
And so, then we're going to get to the what I'll call softer, but probably more important symptoms for the guy who's sitting across the table or next to me, because I typically sit next to people across the desk, which is lean body mass.
00:22:48:08 - 00:22:52:06
Doreen Saltiel
Brain fog. And sexual function.
00:22:53:05 - 00:22:53:09
Mark Newman
Okay.
00:22:53:12 - 00:23:22:06
Doreen Saltiel
Those are the big one. Now we know that testosterone is really important, as is estradiol for cognition. However, the literature has not shown that women. When you replace testosterone, you're going to improve cognitive performance. So, you know, Sunil is similar to, you know, if you just say man, woman, the cognition data is really mixed
00:23:22:06 - 00:23:38:15
Doreen Saltiel
and soft. But the other data is here fairly, fairly strong now. Now, I would say to me if I were you, but what about those four studies that said that testosterone increases heart attacks? And I would say to you, those four studies are flawed.
00:23:39:09 - 00:23:58:01
Doreen Saltiel
One of them included 10% women. One of them used a pit on oral testosterone in guys with liver cirrhosis and oral testosterone in men with liver cirrhosis and doses that led to testosterone levels of 21,000.
00:23:58:21 - 00:23:59:07
Mark Newman
Oh, wow.
00:23:59:23 - 00:24:18:01
Doreen Saltiel
Yeah. And one of the other ones measured different things. Didn't really measure the effects of testosterone. And actually, experts all over the world have said and we pulled these studies, but they haven't been pulled in. The FDA mandated a black box warning.
00:24:18:09 - 00:24:35:17
Doreen Saltiel
And now there is a large study going on of the reverse trial, which my good friend Mody here is a principal investigator, and I set him up. What does this study look like? And of course, because he can't reveal the data, he said the data looks the.
00:24:36:15 - 00:25:02:23
Doreen Saltiel
So so far so good. So, my hope is when these publications come out in the next few years is what we'll see is testosterone does not increase cardiovascular risk and in fact, decreases cardiovascular risk. And before these four studies, it was highest of literature saying it decreases all-cause mortality, decreases cardiovascular mortality, decreases mild strokes, all of
00:25:02:23 - 00:25:12:05
Doreen Saltiel
those kinds of things. So, testosterone therapy is good for men, just like estradiol therapy is good for women.
00:25:12:14 - 00:25:25:00
Mark Newman
So, I think that's really helpful that a you're telling us what the whole of the literature says or what you conclude from surveying it, but also to acknowledge that there are some studies that show that it's these are complex relationships.
00:25:25:20 - 00:25:39:18
Mark Newman
But on the whole, testosterone replacement therapy for aging men who have low testosterone have positive effects on their well-being and and longevity. So, that's that's great for us to know.
00:25:40:11 - 00:26:01:14
Doreen Saltiel
Yes. So, then I also I will say the caveat to that is you don't want them to have super physiological. Because if you drive a man's testosterone up too high, what happens? Testosterone goes to ash, right? You can potentially you increase inflammation.
00:26:01:20 - 00:26:05:12
Doreen Saltiel
You can potentially increase the risk of prostate cancer.
00:26:06:07 - 00:26:18:19
Mark Newman
Okay. Supra, physiological levels of testosterone not putting your testosterone back to where it used to be but putting it even higher yet puts you at some risk for prostate cancer. So, let's let's dove into that just a little bit.
00:26:18:19 - 00:26:28:08
Mark Newman
Can you explain? Because this gets pretty confusing, I think, for people is what is the relationship between testosterone and prostate cancer?
00:26:29:16 - 00:26:49:19
Doreen Saltiel
Testosterone does not cause prostate cancer. There is a sanctuary to point at around 250 grams per deciliter where the property is saturated. So, if you go below that level, say a guy has a testosterone level of one nine and you give him testosterone.
00:26:49:22 - 00:26:52:16
Doreen Saltiel
Each PSA is going to go up, but it's going to plateau.
00:26:54:10 - 00:26:54:18
Mark Newman
Okay.
00:26:55:07 - 00:27:10:16
Doreen Saltiel
If you give a guy who's 300, it may go up and teach, but it's not going to go up. Where unless they have a prostate cancer that is slow growing, that nobody did a rectal exam or wasn't able to be filled.
00:27:12:06 - 00:27:32:11
Doreen Saltiel
Again, we're talking about males who don't have prostate cancer. I'm not saying testosterone doesn't increase the possibility of prostate cancer growth because that's a much more complicated issue, because they give high levels of testosterone and then they take it away.
00:27:32:18 - 00:27:48:05
Doreen Saltiel
You know, there are regimens in men who have prostate cancer, but it's, you know, prostate cancer. Testosterone doesn't cause prostate cancer. If if the gentleman's PSA goes up, don't stop the testosterone. Just send him to urologist on testosterone.
Prostate cancer, testosterone, and the DUTCH Test
00:27:49:22 - 00:28:16:20
Doreen Saltiel
So, what happens is if you get too much testosterone, then you get all these conversion rate dials, which can be a culprit for prostate cancer within prostate cell. And really what we're extrapolating is we're saying that if your serum levels are high, the assumption is that's going to attach to the receptor.
00:28:18:07 - 00:28:46:15
Doreen Saltiel
The estrogen receptor on the prostate and doing damage inside, but also from intracellular testosterone. You can make its own dial in that call the science of infer chronology where it makes its own hormones within the cell. And it will do it will have a balanced aromatase activity because of inflammation and whatever else is going on.
00:28:46:19 - 00:29:02:03
Mark Newman
Okay. So, to stop the short of that, I think what I'm hearing you say is that testosterone within normal limits and normal ranges that you find in normal, healthy men, there isn't a relationship or a linear relationship between where that testosterone is and prostate cancer.
00:29:02:16 - 00:29:05:09
Mark Newman
Correct. And there was a risk of getting prostate cancer.
00:29:06:05 - 00:29:22:08
Doreen Saltiel
Correct. It does not increase the risk for prostate cancer. Does not increase prostate cancer. And when you get to super physiologic levels, it's not that testosterone, it's it's conversion to green dial. And that's what you must monitor for dial in men.
00:29:23:12 - 00:29:44:02
Doreen Saltiel
In spot. It's between 20 and 40 picograms per million after using LCA method. Ms. acting. Insurance because of accuracy and you want to keep them in there. 38 It's a pretty tight margin, 25 to 35. Okay. Men are pretty happy there.
00:29:44:18 - 00:29:58:20
Mark Newman
So, we don't want too much estrogen if they're taking testosterone. So, you you mentioned the things that you tend to get if you don't address low testosterone. One of those things have been proven to improve with the use of testosterone therapy.
00:29:58:20 - 00:30:17:11
Mark Newman
So, you talked about heart, you talked about bone, you talked about you talked about the fact that that memory isn't our cognition isn't what about those other things of heart bone sexual function? Are those proven to improve in the average man who corrects a testosterone deficiency with testosterone replacement?
00:30:18:00 - 00:30:27:20
Doreen Saltiel
Yes. The dam is robust. That it absolutely does. There's not even a question in my mind.
00:30:29:15 - 00:30:43:18
Mark Newman
Okay. Well, that's good to know. It's good to have confidence in that. And I and also will will let people know that Doreen's actually working on a summary of what the what the data says from all the peer reviewed literature that's out there.
00:30:43:22 - 00:31:02:19
Mark Newman
And so you can look for that in the next few months of of a really nice summary of some of that data so that you can address that topic with confidence because it is a complex topic if you don't have the time and the expertize to go meticulously through the research, which nobody does that better than Doreen
00:31:02:19 - 00:31:21:22
Mark Newman
Salter. So, thank you for that labor of love for us and for the industry. One more topic on testosterone replacement, and that is pros and cons of the type of testosterone replacement therapy that people use. We've got creams, we've got injections.
00:31:21:22 - 00:31:34:08
Mark Newman
We've got pellets. Give me your top couple, maybe two of that you would use in a man who's 55 and testosterone deficient and that sort of stereotypical story top couple. And why?
00:31:37:00 - 00:31:56:13
Doreen Saltiel
If his dial is normal. Also, injections are a good way to go. Subcu injections and you want to start low and go slow. And typically, I started 25 milligrams twice a week. And I see how they do in old man.
00:31:56:13 - 00:32:23:09
Doreen Saltiel
I can't use any and think he causes less swelling in younger guy. You can get away with simply because they seem to not have as much water retention and lower extremity surgery. I typically start with skills that's my go to and if the guy wants an FDA approved gel, I'll use AndroGel and I typically start at 50
00:32:23:09 - 00:32:42:12
Doreen Saltiel
milligrams a day because that's what the data has shown. Then you get all those benefits. You get some benefits in 25, but not that much across the board. 50 milligrams will give you that benefit, and it typically takes men to a testosterone level of greater than 500.
00:32:42:19 - 00:33:00:00
Doreen Saltiel
You may have to go up a little, but that's a good place to start. And if the gentleman wants a cream. I typically start with that same 50 milligrams in what's called an apprentice base in a typical versus base.
00:33:01:00 - 00:33:16:06
Doreen Saltiel
Creams don't absorb as well as gels do, but the increased base improved that to some degree. Does it improve it 100% to where it's equal to a gel? Depends on the guy. And so that's why I started the same dose.
00:33:16:11 - 00:33:41:10
Doreen Saltiel
And in a month, I checked. Some guys will use Peloton guys to either tell me they'll forget. They don't want to give them Self-Shot they want me to do it once and that's it. And Peloton the trickiest because people tend to want to high and this is where you get these super physiologic doses and here's the rule
00:33:41:10 - 00:34:04:08
Doreen Saltiel
of thumb for every 75 milligrams, you want to increase a guy serum testosterone, give him a 75 mg pill that that has been shown in the test compound world. But if you use compounded pellets, which is what I tend to do because they're made of cholesterol and you have less reactions from them, then I just kind of
00:34:04:08 - 00:34:22:15
Doreen Saltiel
calculate it out and I give to about 800. And so, the average guy, if you get want to get by just to eight or 900 is about 600 or 750 milligrams. Now, here, you're a guy who may have to give more to just because of their body mass index.
00:34:22:17 - 00:34:35:11
Doreen Saltiel
Right. But a good starting place is in a lean guy, 600 milligrams in a bigger guy, 750 and you work your way up. It's always easier to give him more. Then to take it away.
00:34:37:04 - 00:34:58:16
Mark Newman
Okay. Well, that's helpful. Let me let me give you my sort of opinion on the most typical way to use testing. And then I want you to give your honest commentary. If you're a young man looking at a guy with just issues related, then I'm going to want total and free testosterone in serum.
00:34:58:16 - 00:35:18:13
Mark Newman
That's where I'm hanging my hat. On his testosterone status always in the morning. And then a DUTCH test to see if the testosterone agrees there that the DUTCH test is going to be a 24-hour representation. But as we've discussed, testosterone correlates to serum less reliably than the other hormones that we measure.
00:35:18:13 - 00:35:31:01
Mark Newman
So, I'm looking at that. But still, serum is my primary. And then I'm looking at the testosterone metabolism. I'm looking at my estrogen and the metabolism, looking at cortisol, looking at all of these things to assess just what his story is.
00:35:31:01 - 00:35:51:09
Mark Newman
Right. And then and then on we go from there in a man who is on testosterone replacement therapy, and this is where I particularly like your feedback. You want to keep a man's testosterone above a certain point. So, I like the idea of using serum testosterone testing when you're at the bottom, meaning if I'm on injections or
00:35:51:09 - 00:36:09:05
Mark Newman
pellets before the next dose to see how low I'm getting, knowing that I'm getting a bit higher before that, and then using the urine testing between doses. Right. Because I want to know what the testosterone is, but particularly when I want to look at that estrogen story, I kind of want to look at your average estrogen story
00:36:09:05 - 00:36:22:12
Mark Newman
. I know if I look at you, you know, right after dosing, you're getting the biggest testosterone you're going to get, probably the biggest estrogen level. And then that's going to drop off right before the next dose is obviously going to be the lowest point.
00:36:22:12 - 00:36:36:09
Mark Newman
So, I like the idea of looking at serum before the next dose to see where that guy's at. And then midway between dosing using the urine as a complementary product to check in on his cortisol, look at the metabolism of testosterone.
00:36:36:09 - 00:36:49:15
Mark Newman
How much estrogen am I making? How am I metabolizing it? And all the other things that that that fill in pieces of the story in the male patient. So, how do you do it, your feedback on that sort of approach to testing?
00:36:50:03 - 00:37:15:14
Doreen Saltiel
I do it exactly that way because it's really important for me to see estrogens and estrogen metabolism sort of in that middle. Pellet. For example, pellet only lasts about 90 days. That's the pharmacokinetics. And when you give a guy pellets or injections, you're going to suppress his intrinsic LH So that, you know, you're really not looking to
00:37:15:14 - 00:37:33:19
Doreen Saltiel
see it's going to be suppressed, you know, the levels are going to be on the lower side, but what you're trying to do is see, number one, you need to aim for injection, you need to give injections more frequently because giving a higher dose is you're going to get a higher peak.
00:37:33:19 - 00:37:52:18
Doreen Saltiel
It's still going to go away in the same time frame. The half-life doesn't change the same thing with pellets, the half-life doesn't change. So, what they say in creams is an everyday kind of a thing. And so, you know, with creams, I think you it's less important exactly when you test because they're putting up every
00:37:52:18 - 00:38:02:14
Doreen Saltiel
day. Right. But I think with pellets and injections, it's much more important to check because of those peaks. And then it comes down.
00:38:03:04 - 00:38:18:16
Mark Newman
When the estrogen levels are reliable and urine and give us a good window into that. And if you're checking the estrogen just at the nature of the testosterone, so at the lowest point, then it's spending much of that time at a higher level.
00:38:18:16 - 00:38:37:05
Mark Newman
So, I like to look at the urine at a different time, but with let's just take pellets as an example because that's your long stretch there, right? So, if you give a pellet every three months and you're testing in serum before the next dose, do you test another time within that to see where the testosterone is
00:38:37:05 - 00:38:42:22
Mark Newman
at a higher value or using serum multiple times in a three-month period for a for a pellet?
00:38:43:16 - 00:38:50:09
Doreen Saltiel
The first time I do a peak and I just do to see where they wind up. And that's at about six weeks, 46 weeks.
00:38:50:14 - 00:39:00:09
Mark Newman
Okay, so six weeks serum and then on an ongoing basis, you would test them at the bottom before the next dose and then urine in that halfway space, halfway between doses.
00:39:00:17 - 00:39:22:05
Doreen Saltiel
Began to stable on pellets. I don't necessarily do serum every single time before the next pellet unless they're complaining of something. I'll do it at least. Two or three times a year, every three months, and they're as stable as can be.
00:39:22:19 - 00:39:41:00
Doreen Saltiel
I'll usually do it either every other or something changes. I do do urine after when I initially dose after three months. And then I typically do it after the second one at six months and at least twice a year.
00:39:41:07 - 00:39:41:16
Mark Newman
Okay.
00:39:41:21 - 00:39:56:00
Doreen Saltiel
Because your metabolism can change. Right. So, everybody for me, regardless of modality, gets a dust test at least 2 to 3 times a year. Okay. We've.
00:39:57:08 - 00:40:16:13
Mark Newman
Okay. I want you to clear one thing up for us. So, I think this is really important that people don't get this wrong. If I have a woman who wants a little more testosterone and I give her DHEA, I look at my steroid pathway, I see DHEA, androstenedione, I get some testosterone and that works, right?
00:40:16:19 - 00:40:32:01
Mark Newman
I can I can see that convert. And that's not the topic of discussion for today. But if if I use the same logic in a man and say, hey, this is upstream of the guy, whether it's DHEA or Androstenedione, which is not as common to use.
00:40:32:05 - 00:40:45:14
Mark Newman
Why does that not work? Why can I not get a testosterone deficient man where he needs to be to get all the benefits of testosterone by just piling on DHEA until enough of it trickles down to testosterone to solve the problem?
00:40:46:07 - 00:41:07:21
Doreen Saltiel
You have to give him a boatload full. And they're just not you're not going to be able to raise his level or not, you know, because women have a ten or a 10 to 15 of a male dose.
00:41:08:00 - 00:41:13:02
Doreen Saltiel
Right. Remember, DHEA also can go to estrogen.
00:41:13:07 - 00:41:16:10
Mark Newman
Right. And without becoming testosterone.
00:41:16:16 - 00:41:17:05
Doreen Saltiel
That's correct.
00:41:17:07 - 00:41:17:14
Mark Newman
Right.
00:41:17:22 - 00:41:23:11
Doreen Saltiel
Correct. Even if some of it does go to testosterone in a woman, for example, it's no good estrogen.
00:41:23:20 - 00:41:24:03
Mark Newman
Right?
00:41:25:02 - 00:41:43:07
Doreen Saltiel
And that's a problem. And that's why I don't use pro hormones. To try and get it to the end organ, so to speak, because I don't know where it's going to go. Is it all going to go to thrown more in the mail?
00:41:43:08 - 00:41:43:18
Mark Newman
Right.
00:41:44:10 - 00:42:03:15
Doreen Saltiel
It's more. And even if you give him 150 milligrams, it's going to go to assure you you're not going to see enough of a bump in testosterone where the guy is just so happy. And instead he's going to be pissed off because his kidneys are now elevated and he's got man boobs crying all the time.
00:42:04:00 - 00:42:15:06
Mark Newman
Right. Yeah. That doesn't make you look very good as a doctor. So. So, you cannot rival testicular production of testosterone by giving precursors?
00:42:15:23 - 00:42:16:16
Doreen Saltiel
That's correct.
00:42:17:08 - 00:42:34:08
Mark Newman
But if you want a man, a young man whose testicles are functioning to make testosterone, there are some options you can explore. Clomid HCG, which act as the signaling pathway such as your brain would make to make your testicles make testosterone.
00:42:34:08 - 00:42:41:10
Mark Newman
That's an option in a young man to make testosterone, but you can't get it by giving precursors. Is that right?
00:42:41:23 - 00:42:50:03
Doreen Saltiel
That's absolutely true. Absolutely true. And if I had a 50-year-old guy who said to me, I may want to have more kids. Right. I would try that first.
00:42:50:13 - 00:42:50:23
Mark Newman
Gotcha.
00:42:51:17 - 00:43:00:13
Doreen Saltiel
I always have that discussion regardless of age. And then I tell them the likelihood of it being successful.
00:43:03:00 - 00:43:19:01
Mark Newman
Okay. Yeah, that makes sense. Okay. So, lots of good things packed in here. I think it's a complex topic. Um, and I think you unpacked it nicely for us. So, thank you for walking us through the testosterone story for our male patients.
00:43:19:18 - 00:43:32:11
Mark Newman
You're a wealth of knowledge, as always, and we love taking advantage of all the work you've done. So, you can summarize that for us so we don't have to work quite as hard, but so our providers can treat their male patients with success.
00:43:32:11 - 00:43:33:09
Mark Newman
So, thank you for your time.
00:43:34:06 - 00:43:35:16
Doreen Saltiel
Well, thank you for having me.
00:43:36:04 - 00:43:49:14
Noah Reed
Dr. Saltiel, it's been great having you on the show to discuss the male biology and testosterone. And a big thank you to all of our listeners who joined us this week. Stay tuned for next week's episode with another very special guest, Tom Williams.
00:43:49:19 - 00:44:04:19
Noah Reed
Mark Neumann will be back in the studio, and we'll hear some insightful perspectives on two controversial topics the pregnant woman's steel and adrenal fatigue. You won't want to miss this conversation. So, join us again for another great episode of hormone education.
00:44:05:07 - 00:44:08:17
Noah Reed
I'm Noah Reed and thanks for joining us today. Until next time.