Health Longevity Secrets
A podcast to transform your health and longevity with evidence-based lifestyle modifications and other tools to prevent and even reverse the most disruptive diseases. We feature topics including longevity, fasting, ketosis, biohacking, Alzheimer’s disease, heart disease, stroke, cancer, consciousness, and much more so that you can find out the latest proven methods to optimize your life. It’s a mix of interviews, special co-hosts, and solo shows that you’re not going to want to miss. Hit subscribe and get ready to change your life. HLS is hosted by Robert Lufkin MD, a physician/medical school professor and New York Times Bestselling author focusing on the applied science of health and longevity through lifestyle and other tools in order to cultivate consciousness, and live life to the fullest .
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Health Longevity Secrets
Oral Testosterone For Better Health with Dr Andrew Sun
Curious about the real power of testosterone beyond the realm of bodybuilding? Join us as we sit down with Dr Andrew Sun, a fellowship-trained andrology specialist, who unpacks the diverse roles this crucial hormone plays in men's health. Discover the surprising factors, like poor sleep and metabolic syndrome, that can lower testosterone levels even in younger men. Andrew guides us through the significance of testosterone replacement therapy, not as a vanity metric but as a doorway to enhancing overall health and longevity.
This episode is sponsored by Gatlan who makes the new oral testosterone called Kyzatrex that we will be discussing available in their program. I am an advisor to Gatlan but I only advise companies that I believe in and would use for myself and my family.
Ready to navigate the complex world of testosterone therapy? We explore the pros and cons of various treatment methods, with a focus on injection challenges such as hormone fluctuations, potential side effects, and fertility concerns. Andrew shares his expert insights on long-term treatment commitments and strategic side effect management, like regular blood donations to tackle increased red blood cell production. We also discuss the importance of personalization in therapy, ensuring dose and frequency adjustments are tailored for optimal patient outcomes.
Innovation takes center stage as we explore Kyzatrex, a promising oral testosterone therapy that aligns with natural circadian rhythms. Andrew reveals how this treatment minimizes traditional side effects seen with other testosterone delivery methods. Whether you're considering therapy or just curious about the latest advancements, this episode offers a comprehensive look at how testosterone innovation is reshaping men's health for the better.
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Hey, Andrew, welcome to the show.
Speaker 2:Hey, how are you, Rob? Good to be here. Thank you.
Speaker 1:I'm so excited about talking about oral testosterone and your experience in the overall space as an expert in this, but before we dive in there, could you take a moment and just tell us a little bit about your background and how you came to be involved in such an interesting area?
Speaker 2:Yeah, sure. So my name is Andrew Sun. I'm a urologist, specifically a fellowship-trained andrology specialist, which means like the study of men's health essentially Grew up in Maryland, I went to college in Maryland, I did my med school at Harvard and then residency at the Cleveland Clinic. After that or I should say during residency I kind of fell in love with this sort of men's health space. That or I should say during residency I kind of fell in love with this sort of men's health space. I just liked treating the patients. It was actually at the VA, which was just a great experience for me.
Speaker 2:And so I decided to do a fellowship in male infertility, sexual medicine and andrology, did that at UCLA, learned a lot of testosterone and male sexual health stuff, and then moved to Texas where I currently direct the Men's Health Center for a large urology group. We have 32 doctors and like 16 PAs, so fairly big practice. I 100% specialize in men's health and that means low T, erectile dysfunction. You know a lot of the kind of things that fall into that category and which means I prescribe a lot of testosterone, and you know just being in the nature of that whenever there's like a new testosterone product that came out. I've just been very curious to try it. So when we finally had available oral testosterone that you could realistically put in a patient's hand, which came about with Kysotrex, I started trying it very quickly and learned a lot of very interesting things about the differences between this version of testosterone and other existing forms, and it's been quite an interesting journey since then and learned a lot and love to share some of that.
Speaker 1:Yeah, yeah, I'd forgotten. You were at UCLA. What years were you there?
Speaker 2:Yeah, 2019 to 2020.
Speaker 1:Oh, okay, yeah, I was there. I switched in about 2012. I switched over to USC but before I was at UCLA, so I'm sure we know a lot of the same people and I'm based in LA and have close contact with both places there. But yeah, so testosterone replacement, why should people care about that? Why is it important? And especially as people get older, I guess our longevity population also.
Speaker 2:For sure.
Speaker 2:You know, I think I think for too long testosterone has had this sort of characterization that it's only about like bodybuilding and steroids in that sense, and like sports and athletics and muscle performance gains, and I think that that is true.
Speaker 2:But testosterone is also a just, critically important metabolic hormone for men and women.
Speaker 2:In men it controls a lot of different things.
Speaker 2:I mean obviously muscle growth, and that is one of them, but sexual drive, performance, but even beyond that, you know, bone health, mental sort of, just function of the brain, uh, cardiac health, lots of different things are subject to the control of testosterone, and so I think a big piece of it is reframing just the general discussion about testosterone from being one about, you know, bodybuilding to one about vital metabolic health. The causes of low T are all the same, causes of general, like metabolic syndrome, you know, obesity and not exercising, and and you know, and then it it also precipitates diabetes and cholesterol problems, and so it's all intertwined and that's why I think we should care because, as our population unfortunately is quite unhealthy, you know, a lot of people have low testosterone and intervening on that can not only make them feel a lot better but can also just make a profound impact in their general health, not just for older people you know with from the bone density perspective, but anybody of any age, and I just think it's such a critical, critical thing to understand for everybody.
Speaker 1:Yeah, that's such a great point. A lot of people, when they hear about, oh, I'm taking testosterone, it's like, well, wait, you're bodybuilding, you're in the gym and that's not what we're talking about. We're talking about restoring low levels of testosterone to normal, not supernormal levels necessarily for extreme, which can be unhealthy bodybuilding levels and correct me if I'm wrong with aging, with normal aging, a large percentage of men, their testosterone is one of many, many hormones and chemicals in the body that decreases with age. Is that?
Speaker 2:correct, correct. There's approximately a one to three percent decline in testosterone per year as you get older. We used to think that that was like the main reason why you had low T as you were older, but then the reality is that I have 20-year-olds with testosterone of 200, and for reference, let's say, 500 is normal, and I have 80-year-olds with testosterone of 600. So it's clearly not just the numerical age. I think what we believe now is that that does have a piece of it, but it's also the accumulation of comorbid medical conditions. So testosterone which is made generally medical conditions so you know, testosterone which is made generally speaking every night while you sleep, is going to be very affected by poor quality sleep, is going to be affected by being overweight, it's going to be affected by metabolic syndrome, and so you know there's a lot of different pieces that come into play with it.
Speaker 1:Yeah, and so not not everybody is the age necessarily has a problem with low T, as you, as you say, but for but for many people it is and it's worth checking out and for those people the testosterone replacement supplementation back to normal levels would be almost like a longevity drug, in a sense of restoring metabolic health, restoring testosterone function and improving lifespan improving life lifespan, hopefully. So what are the current options before we get to oral testosterone? What was the landscape before or before this new version of oral testosterone came into, came into play?
Speaker 2:Yeah, so you know, in the beginning, when they were trying to research the testosterone, what they essentially did was they took I think they were sheep testicles, pureed them and injected them into guys. This was like in the either the early 1900s or even the late 1800s, and they felt better and younger and there are sort of reports about this being like a vitality enhancing thing. In around 1935 they first synthesized testosterone and, like with with most things, the first thing that you try to make out of it is a pill. The only way to do that was at that time was to conjugate it to this methyl thing. So essentially you had methyl testosterone, or what we used to think of as oral testosterone. Unfortunately, that stuff is really bad for your liver and so for a long time we sort of equated this oral testosterone thing to being bad for your liver and so we don't have that. It's not on the market. What we had instead was injections, which I think were first made in like the seventies once a week or once every two weeks or twice a week or whatever regimen, but injections were kind of the mainstay. And then we had topicals uh, basically something you put on your skin. It could be a gel, a cream, a patch Um, those have been around for a while as well.
Speaker 2:They tend to be a little bit sticky. They tend to not absorb that well, or at least we could say the variability of absorption is really high between individuals, and there's also this risk of transferring it to somebody else. I remember this episode of House about this where, like it was like dad was putting on the gel and then, like the daughter was going through puberty like way too early, and they figured out it was because there was transference of topical testosterone, oral testosterone on decanoate, which is what the newer formulations are, although the first FDA approved version in the US was in 2019. It's actually been around in Europe and Asia since, like the late 70s. The problem was is that the formulation was very, very fast release, so you had to take it five times a day, which nobody's going to do Right. So, um, that really wasn't much of an option, but it did give us some degree of safety data that this version of oral testosterone, unlike the original version from the thirties, is not dangerous for your liver, and so that's really changed the landscape for us.
Speaker 1:So this new, new oral testosterone and the one, the one brand that I'm familiar with is Kysotrex, although I guess there's several versions, but the this particular oral testosterone. Why would anyone do oral testosterone instead of? Because it's a daily a couple times a day? Right, it's a pill a couple times a day. So I'm an older guy, I want to fix my testosterone. Why wouldn't I just do a shot once a week I mean, it's still a shot, but it's once a week and then forget it versus twice a day? What are the advantages of oral testosterone or what are the disadvantages of the other approaches and how do they compare?
Speaker 2:Yeah. So let's talk about three general categories injections, topicals, and then now the oral. There are others, there are long acting injections, there are pellets, but we'll just use that as a category for now. By definition, all versions of testosterone replacement therapy TRT are replacement right. They're not supplementation, they're not augmentation, they're not boosting, they're replacement. When you replace the body's testosterone, the body senses that degree of replacement and says, hey, we got so much testosterone floating around, why bother making any anymore? And so your body's internal production shuts down. That means you basically become reliant on that external replacement therapy.
Speaker 2:The example of this that makes the most sense is an injection. So when you take an injection, it generally lingers in your body for about 10 to 12 days. There's sort of like an excretion curve where it's sort of high in the beginning and then it slowly goes down. Some of the advantages are well, it definitely works and this is probably still the most common way of doing testosterone therapy. But it does come with a lot of drawbacks. One is because you're giving it this big change over the course of like seven to 10 days, patients can sense a difference in how they feel between one day after the injection versus eight days after the injection. So there can be what we call a peak to trough, you know, delta or a change between that.
Speaker 2:There are some side effects that come along with doing testosterone in this fashion, by elevating testosterone levels to such an extent because in order to make it last for 10 days, you basically have to give a big enough dose that at the beginning it's pretty dang high and then at the end it's not too low, but because you're getting those numbers, like you were saying, almost super therapeutic or super physiological. There are some side effects that come with that. One, probably most common, is that your body makes more red blood cells, and by increasing the red blood cell production it can essentially thicken your blood, and when you thicken the blood you theoretically have a higher risk of things like clots or strokes. You know that's never actually been definitively proven, but that is something that we worry about. The other thing is that when you have so much extra testosterone on board, the body in some way doesn't know what to do with it, and so it starts to change it into other things in a way to get in an effort to get rid of it. Some of those other things are estrogen, and so your body will take.
Speaker 2:Men can't make estrogen except from testosterone and so it takes that extra testosterone and makes it into estrogen and sometimes you have to give a medication to block that. It can change it to dihydrotestosterone or DHT. Dht does a lot of things, but one thing it does do is it makes you lose your hair and so you can get some hair loss, kind of, from this high level of testosterone it can cause acne. You know a few different things like that and, like I said, it's completely suppressive to the internal system.
Speaker 2:Just to go on a little longer thing about that, there's a normal circadian rhythm to testosterone production in a normal body. It gets made overnight, it's high in the morning, it goes down throughout the day and it gets made again overnight. Therefore, giving somebody an injection of testosterone to make their T high for 10 days in a row, there's nothing normal or physiologically normal about that, right, and so because you've basically spammed the system with so much testosterone, the body shuts down the testosterone production, you get zero sperm production, so you don't make sperm, your testicles can shrink and you're basically kind of taking it forever. I can stop there, but we can talk about it.
Speaker 1:A couple of questions. So the suppression of the natural testosterone made in the testes, that's a scary thought. I mean, does that lead to infertility, or is it just that the testosterone production goes down? And are you then required to take it for life? If you knock your testes offline, is that right, right?
Speaker 2:I mean in the concept of it. Yes, so it definitely leads to infertility. About 98% of men on testosterone injections will be completely azoospermic, meaning making zero sperm after one year. In terms of the shutdown, it also causes the testicles to shrink. Now there are some other injections that you can take to combat that called HCG, but that's a lot of injections and if you did this for six months, you know, and then you stopped, you'd probably be okay, like it would recover, it would turn back on.
Speaker 2:But if you did this for 20 years, you're now 20 years older. Your testicles have basically the factory's been off for 20 years. If you stop the testosterone, you cannot expect the testosterone to be any better than it was 20 years ago and in fact it's definitely going to be worse. And you've been used to a higher level of testosterone from being on exogenous replacement for a while. And so, yes, and to some extent, when I tell people about testosterone injections, you know you're sort of committing to doing it permanently or for life. I mean, again, you could stop it in six months and be okay, but the longer you're on it, the less likely you're going to do well off of it ever.
Speaker 1:Yeah, yeah, I mean that's, that's a significant, a significant commitment for someone to make and and giving up giving up fertility, like that, and then and then you mentioned the, the, the increased red blood cells, the polycythemia. What do people do about that? Is that I've heard blood transfusions? Is that I'm not donating blood? Rather, is that transfusions? Is that I'm not donating blood?
Speaker 2:rather, is that? Is that common or is that more extreme cases? No, it's very common. Probably 40% of men on injections have red blood cell counts higher, sustained elevations that need blood, frequent blood donations, and you know it may.
Speaker 2:If you do it once or twice a year, I mean, look, that's good for society, like we'll take the blood and you know we always need more blood in the medical field. But there is definitely a point of doing it too much. And so you know you have to rebuild that blood. But you don't rebuild the iron quite as quickly as you rebuild the red blood cells when you are donating super frequently and on testosterone. And so you have some guys that are like on a high dose injection and they're donating I don't know, every month.
Speaker 2:If you look at those guys on a red blood cell count alone, it looks okay because they're donating so much. If you check their iron levels they're usually very low because they essentially have not rebuilt the iron fast enough. So I don't really like my guys to have to donate more than say four, maybe at most six times a year, you know, every two months. If it's more than that, then we really need to consider changing the dose or the frequency or different version of testosterone so that we don't have that problem as much anymore. And certainly that problem is most pronounced with injections because of that big level that you're sort of getting in the beginning of the injection cycle.
Speaker 1:Yeah and so the. So the the injection thing cycle yeah and so the. So the the injection thing. Uh, a friend was using the analogy. He said it's sort of like a coffee. You know, I, I want a cup of coffee every morning to get my caffeine and I take it once a day. But to do that if it was an injection, I did it once a week. It'd be like drinking 10 cups of coffee on Sunday and then, you know, for three days I'd have a lot of caffeine on board.
Speaker 1:The three days? I wouldn't. It seems like a very, very unphysiologic way of delivering that to the system. Now turn the page to these new oral formulations, which are not to be confused with the older methylated ones, which sort of has a bad reputation. This is new oral, it's a new kind of thing. How is that different than these other approaches as far as the side effects, and do you have experience with that or what can we?
Speaker 2:say so far? Yeah, definitely. In the last two years I've probably treated many, many hundreds, maybe over a thousand patients with oral testosterone. Now, and it's so different, almost to the point where I conceptualize it differently, and I'll explain what I mean. Classically we had two divisions of testosterone therapy. We had testosterone boosters. There's a medication called clomiphene which can tell your body to make more testosterone, hcg, which tells your testicles to make more of your own testosterone. Those things increase internal testosterone production, but they don't work that well. And then we had testosterone replacement, which is the stuff we've been talking about now.
Speaker 2:I actually think about it as three categories. There's boosting, there's long-term testosterone replacement and then there's short-acting testosterone and I guess I would officially still have to call it replacement, but I call it like augmentation, you know. And the difference is is that if you give somebody testosterone from the outside but you limit the timeframe to a shorter amount of time and you don't suppress their internal testosterone production, you sort of get the best of both worlds, where you get the benefits of testosterone replacement but without some of the downsides of shutting things down. And because the orals have about a 10 hour sort of you know, hang around time in your bloodstream, they're able to do this. Now, the official way to take the orals is twice a day, and many of my patients do that, and many of my patients take it once a day, but essentially, when you think about it, you're taking a testosterone replacement option that only is there when you need it and not there when you don't need it, like, for example, overnight, and so a few different things about the orals. One, the new generation of orals, is completely different from the old generation of orals.
Speaker 2:Testosterone undecanoate, which is what it's called, is not even actually absorbed through your bloodstream into the liver, so it doesn't even go through the liver at all. It directly gets absorbed through your intestinal system into the lymphatics and goes directly to work, and so, because you skip the liver, you don't get any of that liver problem like we had with the 1935 generation of testosterone. What it does mean, though, is you do have to have intestines that are absorbing stuff, and so you have to take it with food. You have to remember that when you're taking oral testosterone, it must be taken with food. Then it basically enters the system, and it peaks at about three, four, five hours, last six, seven, eight, and then it's mostly gone by about 10, 11, 12 hours, and so, if you think about how that works, you can deliver testosterone to the person only at the time in which they need it, but not have their body be under the effect of constant external testosterone, which allows the body to continue to make some of its own.
Speaker 2:So there are some hormones that we check when we look at testosterone levels called FSH and LH, which are the brain's internal testosterone production system, and when you're on injections they go to zero. But when you're on Kisotrex they don't go to zero, they go down, but just not to zero, which means those guys do not get testicular shrinkage. It means they're not completely shut down. It means if they were to stop it, they would bounce back much faster because they're still kind of making their own testosterone, and it may mean that they still actually preserve their fertility as well. Now, the data for that is still yet to come, but I've definitely seen some patients in which they definitely still preserve their fertility despite being on testosterone replacement therapy, which is really exciting.
Speaker 1:Wow, this is really. This is fascinating. Just a kind of a practical thing If you're taking the weekly injections, you check the levels sometime during the week. If you're taking the weekly injections, you check the levels sometime during the week. If you're taking this short-acting oral testosterone, you want to check your levels for therapeutic levels. You do it a certain number of hours after you take the pill, or something like that.
Speaker 2:Four, four hours-ish, three to five hours after taking. It is probably the ideal time, and you know that's a very good point, because when you're doing injections, if you check the levels one day after the injection versus 10 days after the injection, you're going to get a very different level. So you have to know how many days it's been since the injection. With the pills the same thing is true, but it just it happens on a day-to-day basis. So it's very important to time the labs correctly and to make sure that the patient took the medication that day. You know what time did time? Did they take it? Did they take it with food? Maybe a fair percentage of the time?
Speaker 2:I'll put a patient on Kisotrex and he'll come back a month later and I'll ask him how he feels. Then he's like oh my God, doctor, I feel amazing. Energy's great. Sex drive is great. You know I'm getting better lifting in the gym. You know my testosterone level must be like a thousand. And I'm like well, it's like 300. They're like 300. What's going on there? I'm like well, this lab was at 9am. What time did you take your pills? He's like yeah, 8am, you know, with breakfast. I'm like well, it's only been an hour, so you're not in that window of really seeing the effect, and that happens very often, and so whenever I see a number on the Kysotrex patient that doesn't correlate with their symptoms, my first thought is timing. Did you take it that day? How many hours has it been? It is definitely something that you have to be a little nuanced about.
Speaker 1:And the other thing I guess the advantage with the cream or with the injection is you can vary the dose and everything. How important is varying the dose of these new oral testosterone, the Kisotrexas? Are there various levels and you just take a larger pill or something like that?
Speaker 2:Yeah, pretty much, so you know there are three doses.
Speaker 2:It comes in 100, 150 and 200 per pill and all the doses are supposed to be two pills twice a day. Now, that's what it's supposed to be. I'll tell you that I have patients that do any kind of combination under the sun, you know, once a day one pill in the morning, two in the afternoon. You know whatever they want to do and that's fine. But you know, fortunately the safety profile, which we haven't gotten to yet, is really really, really good. So I've allowed them to do that.
Speaker 2:If you look at the clinical trial for Kisotrex and you look at where everybody started, so everybody started at 200 milligrams twice a day like total, and then you look at where they ended up, 50% of them ended up at 300 milligrams twice a day, 25% of them ended up at 400 milligrams twice a day and only 25% of them ended up still at the 200 milligrams twice a day dose. So I took that information and I just started going with the middle dose, opening at that. You know, starting with that for everybody, 300 twice a day and what I found was that patients did well, they felt better, their numbers looked good and they asked for more, because every testosterone patient will usually ask for more if they're feeling good. Uh, and it's very hard to decrease a dose, and so eventually I titrated a lot of those guys up to the 400 twice a day and their safety numbers were still good. I still didn't see much red blood cell count increasing. It's maybe 3% versus 40% with the injections.
Speaker 2:And so because of that massive difference and now I just start everybody at 400 milligrams twice a day I start them at the highest dose. And that might seem a little like wow, because you wouldn't do that with injections, but the difference is is that the safety is just so much greater that it's much better for the patients to just immediately get that feeling of if it's going to help or not. You know, I don't really want to spend a lot of time having to change this and change that. Like, let's just start with something that we know it works as long as it's safe which it is and then if it works, great, we're already done. We don't have to do a lot of titrating, we're there right. And also, on the opposite end, if I can already prove that at the highest dose that there's no safety issues, I kind of give my patients the freedom to choose a dose for themselves less than that if they so choose. And a lot of them will do a little variation or whatnot, take it here and take it there, unlike with injections, where it's just you take this dose at this time every week and it's very, very sort of stodgy, and that it's not a lot of room for error.
Speaker 2:With Kisotrex, especially if you can prove the safety at the highest dose, you can kind of give the patients the freedom to take testosterone when they feel like they need it. And that gets me to just a very interesting philosophical point, which is a lot of us in this testosterone, longevity, men's health space, hear the term bioidentical testosterone. It gets thrown around a lot. There's a lot of different definitions of it, you know, depending on whether it's what it's made from or if the molecules are identical or whatnot. But I have never personally heard like a necessarily pure, solid definition of that.
Speaker 2:What I want to almost propose is that you could argue that bioidentical testosterone has less to do with the molecule and more to do with matching the augmentation of testosterone to someone's natural circadian rhythm, because that's really bioidentical right to someone's natural circadian rhythm, because that's really bioidentical right. And so with Kisotrex, because you can take it when the patient needs it. So let's say I take it at breakfast, I get a boost of testosterone in the morning, when my normal circadian rhythm would be high. Then I take it again at lunch, because I get a boost in the late afternoon, which is when most people will primarily complain of their symptoms of fatigue and being tired. But then it's gone by 10 o'clock at night, which means overnight. I don't have external testosterone, allowing my body to still make its own testosterone. Then I have essentially augmented my testosterone in a way that matches normal human circadian biology, and to me that's better in terms of bioidentical than anything else, and so I think that's been really interesting and that's how I dose most of my patients. Breakfast and lunch.
Speaker 1:And on the safety profile before we leave that you mentioned the polycythemia injections versus this oral would be 3%. I mean, sorry, 40% polycythemia versus 3% with the new oral ones. In infertility you used a figure of almost 98% for people on the injections. Do we have numbers for what it is on these oral ones yet? Infertility or what that looks like?
Speaker 2:Not yet. What we do have is some data from the Kysotrex clinical trials, where they looked at the FSH and LH, which are the pituitary brain hormones, at the beginning and, I think, 180 days later, showing that it probably cut in half by about 50%. But, you know, was still present. But they didn't do semen analyses in that study, of course. So that study is currently ongoing. Dr Mohikara at Baylor is running a study on that.
Speaker 2:Currently I have a few anecdotal patients, but I can't tell you that I have, like you know, on that. Currently I have a few anecdotal patients, but I can't tell you that I have, like you know, data for that yet. But definitely there are some patients that will still suppress down. Different people have different sensitivities to it. Some people there's a dose dependency to it. So the more you take there's probably a little bit more suppression. One trick that I've come up with is actually combining N-clomiphene or clomiphene and kisotrex to support the body's internal production while still getting a boost externally, and that has definitely kind of helped keep some systems kind of functional in terms of those guys that might suppress more. So data is pending, but definitely very encouraging to see.
Speaker 1:And I assume the other side effects you mentioned with the estrogen production, hair loss, the acne, I assume those are lower. Any numbers on that yet?
Speaker 2:Yeah, Also not on paper, but anecdotally chisotriax is different than an injection because you're taking it twice a day, you're getting many peaks, but those peaks do not go quite crazily as high and they don't last as long, right, because they're there for a few hours, right?
Speaker 2:Not that the body is actually talking, but in my mind the body has like this own little brain and it's saying like wow, there's so much testosterone, we got to get rid of it, so change it to other things, whereas with Kisotrex it's like getting enough, that's there, but then it goes away before it has this need or or activation to start converting it.
Speaker 2:So I don't see anywhere close to the amount of estrogen conversion, which means I don't have to prescribe these guys a second pill. I don't see the hair loss from DHT conversion, which means I don't have to prescribe them a third pill. I don't see the red blood cell count thing, which means they don't have to go donate blood. I don't see the ball shrinkage, the testicular shrinkage, so I don't have to prescribe them a medication for that. And it simplifies the entire complicated regimen down to just one simple pill twice a day, which has allowed for many of my partners, who don't usually manage testosterone to prescribe this when they had a hesitancy to do injections because it was just more stuff that could go wrong and different things like that. Um, it's definitely been a huge, a huge win on that front.
Speaker 1:Um, yeah, I mean it sounds. It sounds uh, almost you know. It sounds like it's so positive on in so many ways. I'm curious what kind of resistance do you get from this? Or is is everyone, everyone taking it, everyone happy? I mean it seems like why would anyone do the creams or the injections with all these things that could go wrong.
Speaker 2:Yes, almost all good, but nothing's perfect right. And so there are a few kind of situations. To mention One, you know you have to sort of assess each individual patient as their own individual and what they want out of it. Ultimately, my philosophy of testosterone, like you stated at the very beginning, is normalization, you know, getting back from people that are low to feeling good again, and I would say I would call that optimization, but I would not call it super maximalization, right. And so there are guys who what they really want is the super maximalization piece of it. They want 2000 testosterone, they want to put on huge amounts of muscle, they want some of that stuff for those patients, ultimately speaking, probably injections is going to be better than Kaisertrex to really get those crazy numbers. Now, some people are super absorbers and Kaisertrex can still work for them, but you know those guys might be interested in something a little bit bigger in terms of like the, the hit that they get with um, with injectable therapy.
Speaker 2:One thing that's interesting about Kaisotrex that I haven't mentioned is the effect on free testosterone versus total, every clinical guideline and every person. When they talk about testosterone as a number like 300, 400, 1,000, 700, they're talking about total testosterone. We talk about total testosterone not because total testosterone is what's biologically active, but because that's what we can measure reliably in the lab, and so the clinical guidelines are all written to total testosterone. What actually matters to the body is the free testosterone. But because the measurement of free testosterone is more challenging and more variable, we just haven't used that. There's a substance in the body called sex hormone binding globulin, or SHBG. Sex hormone binding globulin binds testosterone at some percentage, such that most of that total is bound up and only a small percentage of it is free. If you just look at total testosterone, sometimes you may not see quite as high of a number with Kisotrex as you would with, say, an injection. But Kisotrex has a very unique property in that it lowers the shbg production of the body, and so for whatever given number of total testosterone you get on kisotrex, you actually get a percentage wise greater increase in free testosterone. And so we believe that, since the side effects seem to be correlated with excess total testosterone, but kisotrex liberates more free testosterone. That's why people can feel better, even though their total T number may not be, you know, 1500. Sometimes it is, but you know, maybe it's like 800, 900, but their free T's go go, free T's go up a lot.
Speaker 2:That being said, um, different people have different variabilities in how their guts absorb, right, gut permeability, different things like that. There's probably variation. There's definitely variation between people and how they absorb like an intramuscular shot, but the variability between people in their gut absorption is greater. And so you'll have some patients that just don't absorb the stuff that well, even despite taking like a nice fatty meal with it and getting the lymphatics going. And so you know there's going to be some patients where you try it and maybe they have to move to something else.
Speaker 2:But I almost write no gels or topicals anymore because I can't think of a reason that you would use a topical when you could use an oral. Most people's default assumption when they think oh, I have a problem, can I take a pill for that? Right, it's not. Can I inject a big 25 gauge, one and a half inch needle into my gut? For that it's? Is there a pill? And now that there is a pill, it's hard to imagine why you would start with anything else at first. And for those selection of patients for whom it doesn't work out, you have other options. But I never switched to gels.
Speaker 2:There's going to be some patients that may do better on injections, but that's pretty much it Now. There's always going to be some side effects. The side effects in general are lower, but you're going to have one side effect with chylotrex that you don't have with injections, which is a tummy ache, right? I mean any pill can have that GI upset. It's not common, but it definitely can be a thing, and you wouldn't get that with an injection, but you can get that with an oral pill. Is that a major thing? Does anybody really complain about that that much? Not usually, but it's there.
Speaker 1:We're almost out of time. I want to be respectful of your time. Several people have written in our audience and wanted to ask the question, since you're an expert in this area. In the prostate cancer patients who need to have prostate cancer patients who need to have testosterone supplementation after their treatment for various reasons, is there experience with Kysotrex? Any reason not to use oral testosterone instead of injections for those patients?
Speaker 2:No, I mean testosterone is testosterone, right. So the risks are all the same, the benefits are all the same, and just to. I mean, I could talk for an hour on the prostate cancer and testosterone piece, but to sum it up, testosterone doesn't cause prostate cancer. The prostate, we believe, saturates at a level of testosterone somewhere around 250 to 300, such that further increases of testosterone do not cause it to, like, grow or anything. What used to be absolutely banned, which was giving a prostate cancer survivor testosterone, is now quite common and those patients do really well.
Speaker 2:You do have to keep track of the PSA, but I'll say that in this aspect you could argue that chisodrex is still superior because it's short acting. If you're at all concerned about a prostate cancer patients, cancer coming back, then you would ideally want a testosterone that you could turn on and off, you know, on the fly, as opposed to something that would like linger and linger and you couldn't get rid of it, and so I very much like to use kaisertrex in those prostate cancer patients. Uh, if I'm going to use a version of testosterone, because I have the flexibility to kind of increase or decrease the dose or turn it on and off in a 10-hour time frame know, and that allows me a measure of safety that I think doesn't exist with some other versions of testosterone.
Speaker 1:And I guess a follow-up question to that then, uh, as contraindications for Kysotrex, as far as uh patients at uh, male patients, you follow their PSA. Is that what you do? And uh, basically, um, as long as that's not elevated, they're fine.
Speaker 2:Yeah, most of the, the, the, the there's, there's all the sort of warnings for every version of testosterone and they're all kind of the same. But the way that you know when, when people come and ask me about this, I tell them to do a thought experiment. And the thought experiment is is, if you came in with the same history, say you had prostate cancer and we checked your testosterone and it was 500, what would we tell you? We tell you all right, great, sounds good, you know, have a nice day. We wouldn't castrate you just to get it down lower, just for fun, unless you have, like, advanced metastatic disease. That's very different, right.
Speaker 2:And so if, if the guy who had prostate cancer or BPH or you know, enlarged prostate sorry, or something like that, who has a normal T, we would not artificially lower their T, then why should we be afraid of taking somebody who has low T and making them normal? I think that the key, especially given that there's pretty good long-term data showing that low T can cause an increased risk of heart disease, bone density loss, diabetes worsening, you know all sorts of stuff. And so if, at the end of the day, too much testosterone is probably not good, too little is definitely not good. We should all seek to be normal. Or you could argue you know a little bit better than average, right, something on higher end of normal. But I don't think we should be as scared of that, because if the guy came in off the street with a normal testosterone, we would just say have a nice day, right.
Speaker 1:Yeah, yeah. What do you shoot for again? What numbers?
Speaker 2:You know. So the middle third of all patients would be like 400 to 600. Low, officially, is less than 300, although it's not exactly a binary cutoff. So if a guy comes in and his T is 301, I mean he very well might have those symptoms. But um, you know, we probably shoot to treat to the high third, which would be 600 and 900. Um, you know you, nobody probably really needs more than a thousand testosterone, unless they're like bodybuilding. Um, but let's just say anything. 500 to 800, 900 should be more than fine on a total. But of course that doesn't even take into the nuance of the potential for free testosterone to be different based on their SHBG levels.
Speaker 1:Yeah, last thing what are you most excited about? Where's this space going to be in five years? What are you most excited about coming down the pipeline? Anything we need to know about? Yeah?
Speaker 2:no, that's a great question.
Speaker 2:You know, I think that the change in the field of testosterone therapy has really been revolutionized recently by the addition of shorter acting testosterone, and oral is kind of the main one.
Speaker 2:There is actually a nasal gel testosterone that is not very popular because it's three times a day and it's like the sticky goo that you have to put up your nose, that you have to put up your nose.
Speaker 2:But you know, I think that the big change is that we have ways of replacing testosterone now that more follow natural circadian biology that don't have anywhere close to the number of side effects. And my hope is that of the 25 million men in the US who suffer from low T right now, it's like 2.3 or something percent of them that are being treated, so we're treating 10% of the population that we could be helping. And with the epidemic of metabolic syndrome and chronic obesity and diabetes and all this kind of stuff, I think if we can shift that mindset on testosterone to being just a piece of just overall health and we could treat 23 other million men that are currently suffering with low T and have all sorts of downstream consequences from it on their heart, on their you know everything that would be really revolutionary. So my hope is that we're armed with this new version of T that's safer and healthier. If we can change the conversation and reach more men, that would be the biggest thing that I'm excited about.
Speaker 1:Anything I forgot to ask you or that you wanted to be asked Any other?
Speaker 2:questions. No, no, I think hopefully that was okay. I mean, we just kind of spitballing, but yeah, I've got one.
Speaker 1:Yeah, how can people reach you? And no, actually your practice in Dallas. You accept new patients from a telemedicine practice also. So even if people aren't in Dallas, if they're interested in testosterone or in men's health the type of things that we talked about today that you can help them with we'll put that in the show notes. Maybe you could share. You mentioned you didn't have a website, but if you want, do you know the website of your practice?
Speaker 2:Yeah, it's wwwupnturologypartnersofnorthtexascom. I have a website. I have a company that's currently building it and it's not online yet. It probably will be in a month or two.
Speaker 1:And it's just andrewsunmdcom, because I finally got around to paying somebody to do that for me. Well, now you can use the AI agents to do it right. Yeah, yeah, yeah.
Speaker 2:Revolutionary stuff, yeah no, but I just kind of say a piece which is, yeah, our. You know I practice in in Arlington, texas, which is in the Dallas Fort Worth Metroplex. Our group is called Urology Partners of North Texas and within that I run the Center for Men's Health. You can find our group website at wwwupnturologypartnersofnorthtexascom, and we certainly see patients in person and through telemedicine.
Speaker 1:Yeah. So even if you're not in Texas, I assume it's just US right, Just?
Speaker 2:US correct.
Speaker 1:Yeah, but anywhere in the US. So definitely, definitely check it out. Well, thanks so much, andrew. This has been a fascinating conversation. It's opened my mind up and hopefully helped people understand this rapidly changing space of testosterone and how men can improve their lives and really take advantage of this new technology. Thank you so much.
Speaker 2:Yeah, absolutely. Thanks so much for having me.