The Men's Health Revolution: Testosterone, Peptides & Shockwave Therapy Explained

Episode 16 | Fertility and Other F Words

In this episode of Fertility and Other F Words, Dr. Amy Pearlman and Dr. Larry Lipshultz sit down with Alex Tatem, MD to discuss one of the most talked-about topics in men’s health right now: testosterone, peptides, and regenerative therapies for erectile dysfunction.

Dr. Tatem is a board-certified, fellowship-trained urologist specializing in men’s health, sexual medicine, and male fertility. He earned his medical degree at the Medical College of Georgia, completed his urology residency at Indiana University School of Medicine, and went on to complete fellowship training in Male Sexual and Reproductive Medicine at Baylor College of Medicine, where Dr. Lipshultz had the opportunity to work alongside him.

He now practices in Indianapolis, helping lead a high-volume men’s health program focused on erectile dysfunction, Peyronie’s disease, male infertility, and complex prosthetic surgery. Beyond the clinic and operating room, Dr. Tatem is also a standout educator on social media, known for breaking down nuanced men’s health topics into clear, practical, and highly engaging content for both patients and clinicians.

In this episode, we cover:

• Innovations in men’s health: steroids, peptides, and shockwave therapy for erectile dysfunction
• Testosterone therapy: expert insights on dosing, formulations (oral vs injectable), and patient selection
• Amino acids, peptides, and biologics: what they are, how they work, and where they fit in clinical practice
• The rise of peptides: regulatory changes, including reclassification during a prior U.S. presidential administration, and why demand is exploding
• Big Pharma vs compounding pharmacies: the growing tension shaping access to peptides and hormone therapies
• Performance-enhancing drugs and “bro science”: what clinicians can learn while prioritizing safety and evidence-based care
• Shockwave therapy for ED: mechanisms of action, clinical evidence, and real-world outcomes

Key Takeaways:

• Testosterone therapy must be individualized—symptoms, lifestyle, and patient goals matter more than a single lab value when treating low testosterone 
• All androgenic therapies (including testosterone and anabolic steroids) suppress fertility—family planning should always be part of the conversation 
• Shockwave therapy for erectile dysfunction (ED) is safe and biologically plausible, with the strongest evidence supporting low-intensity shockwave therapy (LiSWT)—not all devices are equal, and many “radial wave” machines lack evidence for ED 
• Best candidates for shockwave therapy are men early in their ED journey, when vascular changes are just beginning and outcomes are more favorable 
• Peptides, amino acids, and biologics are rapidly growing in popularity, driven by patient demand, accessibility, and gaps in traditional treatment options
• Peptide regulation and reclassification have shifted the landscape, fueling a surge in patients sourcing therapies from gray and black market online vendors rather than regulated compounding pharmacies
• Not all compounding pharmacies are created equal—quality, sterility, and third-party testing vary widely and directly impact patient safety
• The ongoing tension between Big Pharma and compounding pharmacies is reshaping access to hormones, peptides, and regenerative therapies
• A harm-reduction approach is essential when managing men using testosterone or performance-enhancing compounds—prioritizing education, monitoring, and long-term health outcomes

To watch content by Dr. Alex Tatem subscribe to his YouTube channel, @DrAlexTatem

Notice: 

The Fertility and Other F Words webcast and YouTube channel are intended for general informational purposes only. They do not constitute the practice of medicine nor do they provide medical advice or create a doctor–patient relationship. Use of the information provided through this webcast, YouTube channel, or any linked materials is at the listener’s/viewer’s own risk. The content is not a substitute for professional medical advice, diagnosis, or treatment. 

Listeners/viewers should never disregard or delay seeking medical advice for any health condition and are strongly encouraged to consult their own qualified health care professional with any questions or concerns.

All content from the Fertility and Other F Words webcast is the property of PODCAST WITH DRS. AMY AND LARRY LLC.

Listeners and viewers may not use, distribute, re-distribute, reproduce, alter, or edit any portion of this content without the express written permission of the webcast owners.

The views and opinions expressed in this webcast are those of Drs. Amy Pearlman and Larry Lipshultz and do not reflect the official positions or responsibilities of Prime Institute, Baylor College of Medicine, or any affiliated institutions.

Transcript

SPEAKER_01 0:01

I am your doctor. I am not your dealer. And if you start to like see where you're redlining your system, you have to ask yourself, is this going to be worth it to me? Okay. Is the increased risk of atherosclerosis, plaque buildup, uncontrolled hypertension, potentially a hurting kidney function, et cetera, et cetera, cardiomegaly, is that worth what I'm trying to pursue? And that's a personal choice that patients have to make.

SPEAKER_03 0:27

When you were my fellow, we were writing peptides. We got a relationship with a very large uh, which became large, compounding pharmacy, that was very innovative, that started selling peptides. And as they would bring them on, we would find out what they did and we would use them. And they were amazing. I mean, we had GHRP 2 and 6 when you were with us, and they were amazing compounds for skinny guys who needed to put on weight.

SPEAKER_01 0:56

One of the biggest like levers for me personally as a chronic skinny guy, right, is I could not force myself to eat enough. So in addition, whenever I was diagnosed with low testosterone and I started testosterone therapy, that was that during a period of time where MK677, also known as ibutamorin, which is not a peptide, it is a small molecule, okay, but it binds to the ghrelin receptor and it activates IgF-1 release, but also stimulates hunger. I was able to incorporate that as well as prescribed to me from you know a 503A compounding pharmacy at the time. And that was huge because all of a sudden I had enough appetite that I could actually eat enough protein to achieve what I needed to and actually recover from my workout. The truth is that again, we spoke earlier about you know using terms like, you know, evil when describing large organizations. I don't think that's accurate or helpful, but you have to understand that these are large corporate monsters that care only about profit.

SPEAKER_03 1:51

This segment was ostensibly called innovations in men's health. We want to get your input on what you're doing now with shockwave therapy, uh especially for erectile dysfunction.

SPEAKER_01 2:03

What this technology does is it actually causes what we would describe as microtrauma or just little uh kind of shaking up the cells is what I've described it, that actually stimulates two different angiogenic pathways. One is called VEGEF, the other one is called enos, which actually promotes cellular recruitment and cellular repair so that patients will develop new blood vessel formation and increase blood flow to the penis, which results in better sexual function. I just expressed very strong opinions on like shockwave therapy, okay, and versus radio wave therapy. And the reason why I have that strong opinion is because we have definitive data showing that radio wave therapy does not work. Exactly, which is why I think that people that continue to offer it and charge thousands of dollars for it, I think are ethically compromised.

SPEAKER_06 2:50

Welcome to Fertility and Other F-Words, the webcast that tackles fertility, sexual health, and everything in between. No topic too taboo and no question off limits. I'm Dr. Amy Pearlman, board-certified urologist with expertise in sexual, hormonal, and genito-urinary health, and co-founder of Prime Institute in Miami, Florida.

SPEAKER_03 3:08

And I'm Dr. Larry Lipschultz. I'm professor of urology at Baylor College of Medicine. I'm a board-certified urologist, and I am chief of the division of male reproductive medicine and surgery.

SPEAKER_06 3:20

All right, Larry, tell me something good. What have you recently seen in clinic?

SPEAKER_03 3:23

Well, I don't know if it's good, but it's interesting and it's topical. Anyway, so I'm going to talk to you a little bit about a young man I saw uh presenting with no sperm in the ejaculate, azospermia. He's 21, he's young, he's been married for two years, they've had unprotected intercourse, and they really, really want a baby. Interestingly enough, when this young man was born, he had uh severe hypospatius, meaning the tip of the penis where the urine exits was located at the bottom of the penis. Um very severe hypospatis. So he had to undergo uh several procedures uh to get this straightened out, but there were no complications. He presents at this time uh looking fairly normal in terms of his body habitus uh and the penis. Uh the meatus, the hole in the penis, is in the correct position. The testicles are four cc's. Now that is tiny, that's like lima bean size. So very, very small. He does have a normal vase on both sides.

SPEAKER_06 4:31

And no one detected this beforehand.

SPEAKER_03 4:33

Uh what?

SPEAKER_06 4:34

Like no one, I mean, he's 21 years old right now. No one determined his testicles were this small when he was a teenager.

SPEAKER_03 4:41

No. Well, interestingly enough, his testosterone is 321. It's not terrible. So he had enough testosterone to masculinize. His voice is deep. Uh, so why would he go to a doctor? He's urinating fine. Yeah. And that was his only urologic complaint. So it's not unusual not to have a testicular exam uh by the time you're 21 by anybody, right? And he would have normal sexual function. So he wasn't complaining about that. It was the lack of a pregnancy with his wife that initiated him going to the doctor. So, of interest is while his testosterone was 321 low certainly for a 21-year-old. So if he had come to me complaining of, you know, low libido, inability to put on muscle mass, brain fog, et cetera, I would have treated him with something for his low testosterone. But that's not what's bothering him. It's the lack of a pregnancy. His FSH, which is the most sensitive indicator of what's going on with sperm production, is 40, with the top normal being 12. So that's very LH. That's very high. His LH, which is the hormone that stimulates lighting cell function, testosterone synthesis in the testicle, was likewise elevated at 22. Interestingly enough, the marker of testosterone production in the testicle, which is 17 hydroxy pregninolone, was very high at 567. We still don't understand that yet.

SPEAKER_06 6:09

And normal is less than uh normal is about 100, 100.

SPEAKER_03 6:14

And also um uh his inhibin B, which is the marker of a Sertoli cell function, is less than four, meaning they can't find any. But his malarian, antimalarian hormone, which is another way of looking at Sertoli cell health, is normal at 3.4.

SPEAKER_06 6:33

So how do you make sense of this?

SPEAKER_03 6:35

Well, I mean it's very difficult because the it what it's telling us is that the Sertoli cells are not terribly uh dysfunctional, but something is preventing them from actually nourishing the germ cells. And it could be the lack of interaction of germ cells with the Sertoli cells that actually increases urine. So anyway, the thought processes here, which is why I brought this up, is that there's l data, increasing data that these very high FSHs are defining an FSH that's not 100% bioactive. So we want to give him bioactive FSH, which we can buy. I mean, not the urinary, but the uh genetically engineered. But we can't do that when his FSH is so high. So we're going to lower his FSH.

SPEAKER_06 7:23

Why? Because it would compete with it?

SPEAKER_03 7:25

Because all the receptors would be, you know, at least marginally occupied by this stuff that's not being 100% bioactive. So what we're going to do is to lower his FSH by putting him in, putting him on low levels of testosterone stimulation using either a topical cream or the oral version, uh, Kaisotrax. And when it gets below 10, we will introduce the new FSH, the healthier FSH that we know is good. Yeah. Now, is this going to work? What's our percentage? We don't know.

SPEAKER_06 7:59

Yeah. This is the first time you're doing it.

SPEAKER_03 8:00

Yes. But it's innovative, it makes sense, but we're not going to hurt him in any way.

SPEAKER_05 8:05

Yeah.

SPEAKER_03 8:06

And the j the the young man has no other hope at this point.

SPEAKER_05 8:10

Yeah.

SPEAKER_03 8:10

We did we did do a um uh large bore needle aspiration of the testis. Actually, we did a tiny little biopsy on this fellow, and there were no sperm. So he we we can't find sperm in the testicle. It might be someplace else, don't forget, you know, we're not under the microscope, but he's got very small testicles. So hopefully we can increase testicular size by enriching Sertoli cell size as it becomes healthier. And we will see. Yeah. It's it's a long shot, but you know, if you don't do innovative things with unexplained azospermia, then you're never gonna find uh out what's really going on.

SPEAKER_06 8:47

Yeah. So this is really interesting for a couple of reasons. And I will say one is you're using what we would consider to be one of the problems with putting someone on testosterone therapy, which is shutting down their pituitary signaling function. But you are gonna do that purposefully.

SPEAKER_05 9:02

Right.

SPEAKER_06 9:02

That's very interesting. Now, going to the uh the formulations of testosterone that you're considering, you said topicals and you said oral testosterone in the form of chizotrex. One of the benefits of something like Kaisotrex is it doesn't reduce pituitary signaling as much as some of the other formulations. So I guess my question for you is are you doing that on purpose not to knock his FSH down to zero like some of the other formulations would and to just knock it down enough?

SPEAKER_03 9:28

Right. So we feel we can titrate it better.

SPEAKER_06 9:30

Yeah.

SPEAKER_03 9:31

But I I really think he's gonna go with a topical cream.

SPEAKER_06 9:34

Uh-huh.

SPEAKER_03 9:34

Because we do want it to come down faster.

SPEAKER_06 9:36

Yeah, yeah. So very interesting.

SPEAKER_03 9:37

Yeah. So tune in and I'll let you know what happens down the road as we progress in his management.

SPEAKER_06 9:42

Yeah. Well, let me ask you this too, because you've been on the cutting edge of male infertility your entire career. So, how often does something, a scenario like this come up where you say, okay, I have no other options. Let me think of something I can do to help this person.

SPEAKER_03 9:57

Well, it really doesn't come up that often because we're just starting. In the past two years, we started looking at internal markers of testicular health with inhibit, AMH, 17 hydroxyproject. We weren't doing that before. Now, much of the of the thinking behind this goes to Taylor Cohn, one of our new faculty.

SPEAKER_06 10:16

Shout out, Taylor Cohn, raise the roof.

SPEAKER_03 10:18

Shout out, raise the roof. Because he was on here in our previous episode talking about his creative research. So he is kind of focusing on these new markers of function.

SPEAKER_06 10:27

Yeah. Well, that's great. I love hearing about the innovative work that you're doing at that point.

SPEAKER_03 10:30

And we needed in male fertility because there is nothing.

SPEAKER_06 10:33

Yeah. And you had mentioned before that there was not a single FDA-approved medication for male infertility.

SPEAKER_03 10:38

Not one.

SPEAKER_06 10:38

Yeah, that's crazy. So let me bring you into my clinic. So I saw a 56-year-old guy, and he had come in with a two-year history of erectile dysfunction that interestingly started after he stopped a cholesterol-lowering medication that he was on. So he stopped it for a few months and then developed erectile dysfunction. And this guy is otherwise extremely healthy. He's a fellow physician. And he wanted to do shockwave therapy. He was actually referred for shockwave therapy. So after the very first session of shockwave therapy, he said, My erections are amazing. Like they're back to what my great baseline erectile function is. You think it's in here? So, but my question is, okay, this isn't, I mean, he developed ED after he stopped his cholesterol-lowering medication, right? So my question is, okay, did he build up some plaque in his artery that needed a little shockwave therapy to get rid of it? And then he noticed better erections. I mean, I yes, there is a placebo effect, and there certainly is a placebo effect when it comes to shockwave therapy. But this guy's he's a doctor and he's saying, I had great erections last night.

SPEAKER_03 11:40

As much as I like shockwave therapy in its place, uh what's it going to do in one session?

SPEAKER_06 11:47

Well, that's and that's the interesting thing, right?

SPEAKER_03 11:49

Because interesting and unexplainable.

SPEAKER_06 11:51

Correct, right? Because typically it can take at least six weeks to notice benefit with shockwave. But that's probably with the mechanism that we describe in terms of angiogenesis because creation of new blood vessels takes weeks, if not months together.

SPEAKER_03 12:03

Right, but it's it's been shown, apparently in animal models, you can do that, but I've not heard of this knocking off stuff from the Right.

SPEAKER_06 12:09

So that's the question. Does it make existing blood vessels healthier?

SPEAKER_03 12:13

No, I don't think maybe, but over time.

SPEAKER_06 12:15

Right.

SPEAKER_03 12:15

Not in a single second.

SPEAKER_06 12:16

So I thought this was super interesting. I was shocked that he noticed benefits so quickly. He also was coming in with urinary symptoms, like a weakening urinary stream. I suspected it was related to pelvic floor dysfunction. And as part of the shockwave treatment, we do put the probe in the perineum behind the scrotum. And so I was also essentially treating his pelvic floor, and both of them improved with the first session. So I don't know how to explain it. I'm grateful he got better.

SPEAKER_03 12:37

Yeah, I mean, you can't argue with success. Right, right. You're now a hero. Heroine. You're now a heroine, but uh, I don't know. It's a little bit too fast.

SPEAKER_06 12:46

Yeah.

SPEAKER_03 12:47

Too much too soon.

SPEAKER_06 12:48

Yeah. So it was kind of interesting. But on the topic of regenerative therapy, because everyone's talking about regen therapy, and in the ED space, we oftentimes think about three therapies in particular when it comes to regenerative therapies. We talk about shockwave, which I just discussed with my patients. We discuss PRP or platelet-rich plasma and stem cell therapy. Right. So you have an article that you pulled, Breaking Bedside News, on one of those regen therapies.

SPEAKER_03 13:08

Yeah, there are two articles that I found that I thought were interesting. One is advances in stem cell ther stem cell therapy for erectile dysfunction, and the other was male fertility restoration with stem cell-based therapies. I must say the the the article dealing with uh infertility is very rudimentary. I mean, the it's this is not ready for prime time. Uh I think we're closer on the ED side with stem cells. Yeah.

SPEAKER_06 13:37

How often does someone come into your clinic and ask for stem cell therapy?

SPEAKER_03 13:41

Very rarely.

SPEAKER_06 13:42

Uh-huh.

SPEAKER_03 13:43

I mean, it's not out there in the media and people aren't talking about it for this particular purpose. And everybody's rushing to get their joints injected. Yeah. But in terms of the penile injection therapy of stem cells, I've not heard of people doing it clinically, have you?

SPEAKER_06 13:58

Um, not from any of our colleagues, but I know people uh or I know of other clinics that are offering stem cells. But that goes to show, and it's interesting, I mean, they discuss this in this paper, is there are lots of different stem cells that we're talking about. And sometimes clinics or providers will refer to cells as stem cells that aren't necessarily stem cells.

SPEAKER_03 14:15

Right.

SPEAKER_06 14:16

Yeah. So I was actually yeah, go ahead.

SPEAKER_03 14:18

And we know also there's now subpopulations of stem cells, yeah, some of which are recently reported to be better than others.

SPEAKER_06 14:26

Yeah. So I think we're still in the infancy. I don't think as urologists, we should just poo poo-poo this innovative therapy. I think we need to stay curious. I was actually surprised reading this article that there are trials. I mean, there are human trials looking at stem cells when it comes to ED. Right. So I can't, I shouldn't be continuing to tell my patients we have no human trials because we do, right? But I think um the data is still out there. And I think we can't just say stem cells as one type of therapy because there are so many different types. It has to be more nuanced.

SPEAKER_03 14:53

Exactly. Yeah. And then what about what are you telling your patients about PRP?

SPEAKER_06 14:57

Yeah. So what I tell patients about PRP is I don't use it for erectile dysfunction. Um, the study at a university in Miami that was published a couple of years ago compared PRP to placebo and did not show any benefit compared to placebo. That's what I tell my patients. Um, I and because we have so many other therapies that are going to be more cost effective, then usually I can find something else within that algorithm that's gonna help them. And if they're interested in a regenerative therapy approach, I can offer them shockwave therapy. Exactly, which we know does have something. Yeah, there's research to support the use of that. So it's not like it's, you know, um PRP is our only option when it comes to regenerative therapies.

SPEAKER_03 15:31

How about you remember that we went through that phase when people were offering P shots?

SPEAKER_06 15:36

Yeah. And what were those were Well, I mean, I've done them before, like in my training. I was one of the people that offered, you know, the P shots. What was it? We didn't call it P shots, it was PRP. So you would just draw their blood, you spin it down into centrifuge, and then you you know inject part of that back into the person. What I will say is it's safe, you know. Um, people didn't develop like a compartment syndrome because we had activated it. And so it can after after a few minutes, it will develop into a gel. And so a concern might be that the person could develop a compartment syndrome in their penis. We didn't see that. Um, but I would say the patients that were coming in asking for repeat treatments, it was like they just they thought they got benefit, so they came in and we did the injection, you know. But um, I when I look at that University of Miami study, the question then becomes too well, does PRP not work? Or is it the PRP kit that they use or the setup of how often they injected the PRP? Right. The devil is in the detail.

SPEAKER_03 16:26

Or how they inject it.

SPEAKER_06 16:27

Exactly. So I did they use a tourniquet, did they not use a tourniquet? So I don't I wouldn't say to someone that PRP doesn't work. I will say, with the studies that have come out, including the University of Miami study, the PRP kits that they use, the protocol that they employed did not show a benefit compared to placebo.

SPEAKER_03 16:43

Yeah, that's a good point, you know?

SPEAKER_06 16:45

Because maybe they need more injections.

SPEAKER_03 16:46

Right.

SPEAKER_06 16:47

Oftentimes in the PRP realm, I I've actually attended several webinars on PRP just to learn more about it. And they're saying that we are oftentimes underdosing what we're injecting. And I think that's part of the problem. The kits are important. Just with stem cells, not all PRP kits are created equal.

SPEAKER_03 17:02

Yeah, so like like you say, the devil's in the details, and we need to uh get more studies done to understand.

SPEAKER_06 17:08

And it's very complicated. Every additional webinar I attend on PRP, it actually increases the questions that I have rather than answers them. Yeah. It is very complicated. Yeah. All right. Well, why don't we introduce our guests for today?

SPEAKER_03 17:23

Of course.

SPEAKER_06 17:24

Welcome to today's episode. I am thrilled to introduce our remarkable guest today, Dr. Alex Tatum.

SPEAKER_03 17:30

Dr. Tatum is a board-certified fellowship-trained urologist specializing in men's health, sexual medicine, and male fertility. He earned his medical degree from the Medical College of Georgia, completed his urology residency at Indiana University, and then went on to fellowship training in male sexual and reproductive medicine at Baylor College of Medicine with me.

SPEAKER_06 17:54

He currently practices in Indianapolis, where he helps lead a high-volume men's health program with a focus on erectile dysfunction, Cironis disease, male infertility, and prosthetic urology. In addition to his clinical and surgical expertise, Dr. Tatum is an engaging educator on social media, known for translating complex men's health topics into accessible, high-impact content for both patients and providers. We've previously had Dr. Tatum on our podcast. We couldn't get enough, and so he invited him back on for today's episode.

SPEAKER_03 18:23

So, Alex, thank you so much for coming back and visiting with us here in Houston. Uh the first time was amazing, and I know you're gonna even do better this time now that you're very comfortable in this environment, and but you're always comfortable.

SPEAKER_01 18:37

So you know, the my my wardrobe consists of jeans and t-shirts. I'm a pretty comfortable guy. So I especially like your t-shirt.

SPEAKER_06 18:43

Yeah, I love this shirt that you're wearing. Where did you get it? My gosh.

SPEAKER_03 18:46

So you have to so I I I drove Alex over here and we stopped to get something for him at a convenience store.

SPEAKER_01 18:54

And uh the thing is, is that I was wearing, like, again, I'm a very simple man, and so I was wearing like the same like t-shirt that I had worn last time. And you know, you guys are just so good looking. I'm like, God, I can't wear the exact same t-shirt, so I'm you know, gas station t-shirt. So, you know, let's roll. It's really nice. Yeah, so I'm all I'm all about it, but I very much appreciate you guys bringing me back.

SPEAKER_03 19:14

Uh just as a form of an intro, Alex was a fellow with me in 2018-19, and we have remained close friends since and have shared many uh happy uh times and uh patience and science.

SPEAKER_01 19:29

Blackmail worthy stories, all the good stuff.

SPEAKER_06 19:31

Let me ask you this. So I know the Alex now. What was Alex like back in fellowship?

SPEAKER_03 19:35

Alex was basically the same. He wasn't as big. He was actually skinny. Yeah. You were skinny back then. We'll talk about that. But the same personality.

SPEAKER_06 19:46

I mean which is what? Like curious, outgoing, friendly, a question asker, problem solver.

SPEAKER_03 19:53

Yeah, solved, you know, all those things.

SPEAKER_01 19:56

Funny, funny, case study. Uh a case study of ADHD, you know, a little bit of Tism in there, you know. Um, but yeah, like whenever I was a so when I started fellowship, you know, I had obviously I'd just gone through residency, and residency was this is like just absolute slug fest where you would spend hours and hours and hours and hours in the hospital working where you're not sleeping, you're not eating, you know, you don't have any time to invest in yourself. So when I came here, I was like skin and bones. I was like 168, 170 pounds at six four.

SPEAKER_03 20:26

You talk about an ozempic face. Yeah, there is definitely a post-residency book.

SPEAKER_01 20:31

100%. There is.

SPEAKER_05 20:32

Yeah.

SPEAKER_01 20:32

Yeah. And so uh, and then you know, I I thought fellowship was wonderful because we actually had like time to eat, and like I was able to like work out in the mornings because like we started clinic at a certain time. And so like I just was able to like stick with that as we went through uh fellowship and then on into practice. And then, you know, a big thing that really helped me out is you know, I was diagnosed with low testosterone, and so I was able to incorporate that into my life as well and you know incorporate testosterone therapy. Yeah, I'd incorporate testosterone therapy into my life, and then that has just been a huge improvement as far as like my overall health goes, you know, and I've been you know kind of you know just trying to be the best version of myself.

SPEAKER_03 21:07

It's interesting you mentioned because I'm thinking back. So when you when you came to Houston, your wife was pregnant?

SPEAKER_01 21:13

No, she remembered she o she we were trying to get pregnant. So when did you start the testosterone? And not until after our daughter was born and we were done having kids. And so I uh can that's why I held off. And so I had had my testosterone checked while we were still trying to get pregnant, and it was low, but like at the time, you know, there were really again, you shouldn't take testosterone if you're trying to have kids. There are some subtle nuances to that of ways to work around that, right? But at the time, I was like, well, I don't want to mess with that, let's just get done having our kids, and then that'll be something I can focus on. And you know, I've been very fortunate at the time it worked out well. Yeah, it certainly did.

SPEAKER_06 21:46

Well, I love how you're coming from a personal experience here. So if you don't mind, and you don't have to share if you do mind, but what were some of the symptoms that you were experiencing as a man in his 30s?

SPEAKER_01 21:56

Well, you know, again, I will say that you know, if we look At when most men don't experience low testosterone until later in their life. And you know, I need to be honest and practice what I preach. You know, our bodies are usually pretty good at doing what we tell them to do. And so if you eat right, sleep, and exercise, you know, the vast majority of men are going to be able to preserve, you know, more than sufficient endogenous natural testosterone production for the better part of their lives on average. But the thing was, is like that was not my life. I was in a very grueling residency program that did not prioritize health, wellness, or trying to take care of residents as whole individuals. You were just cogs in a larger machine. And so I had had five years of that continuously, just kind of, you know, knocking me down. And I, you know, again, personally, this is anecdotal, but I think that is what contributed to my symptoms, which were just sheer exhaustion, inability to recover from workouts, like mental fog, inability to like really dial in and focus, and you know, also, I mean, like lack of sex drive. Like I just, I mean, man, I just wanted to fall over the moment I, you know, came back in the house. And so those were all things that, you know, kind of came together as a doctor who was training to treat low testosterone. I was like, oh crap, I probably need to get this checked out. And then, you know, lo and behold, here we are.

SPEAKER_03 23:09

So I want to ask both of you, this is an important thing. So if if I see a lot of young guys, and I'm talking about late 20s, 30s, and their testosterone are in the 200s. I mean, it just amazes me. Now, the caveat is I don't time my testosterone draws because we're so busy. So a lot of these men are in the afternoon. Now, if you look at AUA guidelines, sure, which I have some issues with, they say they have to be under 300 in the morning before 11.

SPEAKER_01 23:40

Yeah.

SPEAKER_03 23:41

So if you see somebody, and I'm gonna ask you each individual, you can't copy the other person.

SPEAKER_05 23:46

Okay.

SPEAKER_03 23:47

But if you see somebody in the afternoon, sure, classic symptoms of low T, young guy, let's say less than 40, and he comes in with a T of 250, are you gonna bring him back in the morning before you treat him?

SPEAKER_01 24:00

I would say that it depends if I see that man and he is still trying to get pregnant. He is not eager to No, we're taking the pregnancy question out.

SPEAKER_06 24:10

He wants to be on testosterone.

SPEAKER_01 24:11

Yeah. Oh, if this is a man that wants to be on testosterone, has all those symptoms, and he's got a low T even on the afternoon. I will absolutely treat him.

SPEAKER_06 24:18

I'm not looking for a reason not to help someone.

SPEAKER_01 24:20

Yes. I'm looking for what are reasons that I would put a pause on this in the in the interest of like their overall picture.

SPEAKER_03 24:27

But I hope we realize you two are not the majority. Yeah. Well, I think the people in this space are very still focused in that morning draw of testosterone. And I it makes no sense to me. And I don't even know where it came from. Because if it feels low, it came from the endocrinology work.

SPEAKER_06 24:44

But if it feels low in the afternoon, why is that any different from being low in the morning? I mean, everyone hates the afternoon slump.

SPEAKER_01 24:50

Well, I I will I will play devil's advocate for a moment. I have had a number of young men still in college who have come to see me for evaluation of low testosterone. And particularly I've seen this in athletes where they're over-training. So these are natural guys, they're not enhanced, and they're training six, seven times a week. They feel like crap, and then they have a low afternoon testosterone. And I have seen it beneficial in those men where I'll tell them, hey, take a break from training for about three to four days. All right, make sure that your sleep is good, make sure that your diet is good, and then let's get an accurate morning testosterone. And in those patients, I've seen them have really good testosterone levels there. And I'm like, hey, listen, your low testosterone, that initial screening, is probably the result of you pushing your body too hard and not giving your chance to yourself a chance to recover. Let's work on these lifestyle things and maybe we can.

SPEAKER_03 25:36

Okay, but as the devil's a devil advocate, yeah, it's still low in the afternoon.

SPEAKER_01 25:41

It is, but I will say that I have there are many patients that are eugonatal and don't have symptoms who will have a low testosterone in the afternoon, and we see that in our fertility patients.

SPEAKER_03 25:50

Yeah, but see that but yeah, but now you're getting into people who have testicular disease. Yeah, that's different. I I agree. So you can't use them, but I also think that the the important thing is their symptomatology. Now, the caveat there is it's not very discreet in terms of and focused. There are generalized symptoms, fatigue, you know, uh loss of libido, mental functions, not totally related to testosterone, but I have not seen I've seen very few, if any, people when you treat them who don't come back better.

SPEAKER_01 26:21

Yeah, I I will say that at least for me, it's very much individualized on the patient because ultimately we're trying to leave the patient better than when we found them. Okay. And so if I have a young man who, let's say he is one of these, you know, uh outside examples where he's training way too hard, uh, he's not giving himself time to recover, he's not investing in his sleep and diet and that sort of thing. And yeah, he's got a low testosterone in the afternoon, but he's got normal in the morning and he wants to have kids in the future. If I start that man on injectable sipionate, I may be doing him a disservice and he'll be worse off because of all of the downstream effects of that. Okay. Whereas if I have a man who necessarily, let's say, you know, doesn't, you know, have those future goals and isn't in that situation, well, then maybe testosterone would be the right choice. And if you want to get even more down in the weeds, I had a recent patient who fit that uh profile of he looked like he was training way too much, he wasn't resting, he was a college athlete. I went ahead and I got a morning testosterone on him. It was still low, it was really bad. And then I had to have a conversation with him and his parents. I was like, he needs testosterone. He has an intrinsic deficiency that is not reconciling with lifestyle modification. And for him, we came up with a regimen using oral testosterone, chizotrex, along with enclomophene and with you know a little bit of arimidex on there, so that we could try and preserve ganatotropins, make sure those testicles are still being stimulated, maintain spermatogenesis. I got a semi analysis beforehand to make sure you get spermatogenesis from the rip. And then uh we are gonna preserve testicular size. And so there are ways that you can treat even those edge cases with testosterone and maintain try to avoid the worst side effects.

SPEAKER_03 27:52

But once again, I yeah, I the oral is fine. Yes, it's not gonna give you the same levels you get with an injectable. Yes. And I think there is something definitely positive about the spike you get with an injection. There's something about that spike that either activates more androgen receptors, does something. But I think it's very important for athletes. They uh they actually, I think, get a benefit out of the spike.

SPEAKER_01 28:16

Oh, 100%. And that's why it's a it's a different conversation. And so, you know, I it's why I like having oral as an option because it's like uh a flathead, you know, screwdriver versus a Phillips head. You have to pick the right tool for the right application. But like I've got, you know, a very significant cohort of power lifters and strength athletes, you know, uh strong men in my practice, you know, my guys who again are in a different place in life. They are using compounds on their own before they came to seek care from me. And for them, it's a totally different conversation. Again, you're focusing on the patient and trying to provide a personalized solution for that.

SPEAKER_03 28:48

So I think orals are great for older guys who have symptoms of low testosterone unrelated to anything to do with athletics.

SPEAKER_06 28:58

It's interesting because I have some athletes that come in. One is a marathon runner and he loves oral testosterone. Well, you're gonna find you can't like you can't predict it. That's what I'm on a mission is how do I predict the guy that comes in, which formulation of all the testosterone formulations is he is he gonna do best with?

SPEAKER_03 29:13

Well, I think you have to individualize. Right.

SPEAKER_06 29:15

And you just it's a little bit of experiment.

SPEAKER_03 29:16

Plus, some trial and error. Some men are have needle phobia. Yeah, they will not give them self-injections.

SPEAKER_01 29:21

And there are guys out there that maybe from an objective standpoint would do better with, let's say, injectable sypionate and maybe throwing some HCG on top of there for like their unique situation, then maybe a better medical answer, but like they're just not, they don't want to be a pincushion. And they're they're not like me. They're not used to sticking themselves full of strange things coming from China, okay? And so, like, for those guys, well, hey, you know what the best medicine is? One you're actually gonna freaking take. So let's do that.

SPEAKER_06 29:45

Well, let's get back on this topic really quick the young male athlete or the endurance athlete, right? We talk about the female triad, and it's very obvious for women because women stop menstruating, right? Yeah, what are we screening for in the young endurance athlete who's a man? We're not checking their semen analysis. No, I mean, this is a problem.

SPEAKER_03 30:00

But the I don't understand. The question is, what are we screening for?

SPEAKER_06 30:03

We're not screening for them. I mean, I worry about their bone density over the life, and I worry about their fertility, I worry about their testosterone level.

SPEAKER_01 30:09

So, this is somebody we don't know their children.

SPEAKER_06 30:10

It's like 20 years old who has fatigue, the exact patient he described.

SPEAKER_01 30:14

So, what Amy is describing is the real phenomenon of how extreme uh endurance athletes will often develop uh ganatal dysfunction. And so, in you know, female endurance athletes, you'll know because they'll have amenorrhea, they won't have their periods anymore. But I've had probably five different guys referred to me this year who are all ultramarathoners, like running a hundred mile, 150 mile races, and they feel like trash. And you go and you check their testosterone levels and they're just through the floor because they are just beating their bodies to death, putting so much mileage on it. Exactly. And so, you know, it's a it's a challenging conversation to have with, especially those athletes, because you bring up testosterone. Well, because it's a performance-enhancing drug. And so if they're in a tested federation, then that's a problem. And so then that's a conversation of okay, what do we need to do to adjust your training so that way you can still hit the milestones you need to, but you're still functional as a human being. Because often what they'll experience is they also hit a plateau in their physical performance as they experience they're they're so tired. And that's why I think something that's often lost in a lot of uh in the fitness you know community, um, not so much in endurance, but definitely in strength, definitely in bodybuilding, is you'll have uh non-enhanced young guys buying PDFs and training guides from dudes that are on gear, and they try to translate that to what they are able to do and recover from and do two different conversations. If you look at the volume and intensity that you can tolerate when you're enhanced versus when you're natural, these are two totally different conversations.

SPEAKER_03 31:34

But I think something that's not appreciated is the impact of weight. And there's lots in the literature, well done studies showing that men who weigh more need more testosterone when they become deficient. I have a great example of this. I have one too. Wonderful. Uh I'm gonna go first. Please do. So I have I mentioned this before. I have a 21, 22-year-old college football player, right, with Kleinfelder's disease. And for the audience who doesn't know, this is a genetic abnormality, and they classically have very low testosterone, right? So I diagnosed him, very low testosterone. Maybe he was in high school at the time. We started him on testosterone. I think I started him at a half, didn't get it. I went to a CC, he was fine. Yeah. Perfect, right? Yeah, and his levels never got that high, and they never got to a thousand because he was so big. He was 350. Yes, 6'6, 350 pounds. Yep. When he gets to college, goes to play football in college, I got an exemption because he had a genetic abnormality. So he was taking his testosterone. I would see him regularly and test him. He was always in the normal range, uh, high, but in the normal range. Um and then they had another person join the the board of what is it, N double, what is it? N C A. N C A. Yeah. And they they wrote to me, we want him down, we want him cut back to a half a C C a week. Stupid. Why?

SPEAKER_01 33:00

What physiological physiologic reason for that?

SPEAKER_03 33:03

They never saw him. Of course not. They never they don't know what he looks like.

SPEAKER_01 33:06

And I bet they don't prescribe testosterone for a living, or at least they're terrible at it if they can't.

SPEAKER_03 33:09

And I and I, you know, and his parents were very upset because he didn't feel good. Uh they were afraid that he would break something. And I wrote the letter, they would not budge. Yeah. And I said and I said to the family, I said, I'm I'm not, I don't want to be, you know, overly critical, but I bet the new person on the board is an endocrinologist. Sure enough, it turned out it was an endocrinologist. Not just they and because they were treating the number. Yeah. They didn't like the number.

SPEAKER_06 33:36

So how do you incorporate someone's weight when you're deciding on someone's dose?

SPEAKER_03 33:39

Yeah, so I mean it's a gestalt now because there's no real form, you know, I go back to the case.

SPEAKER_06 33:43

But I mean I've never seen an uh an algorithm. There isn't. Or an equation for that.

SPEAKER_01 33:47

You know what's funny is that if you look in like the bodybuilding space, like there have been a number of conversion factors that have been uh thrown out there. And uh, you know, I funny enough, some of them are actually pretty accurate, which is why I love learning from my patients because the truth is is that you know, the enhanced athletic community has been treating themselves as lab rats and n of one experiments for you know years and years and years. Now, is an N of One on its own powerful? No. But I mean, when you talk about the collective knowledge of thousands of guys over generations, like there is knowledge there for us to glean. And so I continue to learn from my patients in that regard. But I will give another example, you know. So I have a patient of mine, and he's fine with me sharing his name, you know, Steve Gentili, um, Instagram handle PTFitness500. If you want to look at him, I mean the guy's a monster. He's uh elite level powerlifter, guy benched six wheels at his uh peak. You know, what does that mean? Six plates on either side, over 600 pounds. Okay. I mean, the guy is one of the strongest humans to walk the earth if we're talking about percentage points. And the thing is, is that now, so and again, he has previously used, you know, uh all kinds of different anabolics in the past. That is not what he is doing now. He's just on regular TRT for me. But you're talking about someone who is walking around right now at 262 in the morning, okay, at about 11 to 12% body fat with 22-inch arms. He is he's a Viking. And so if you look at his TRT dose, he's on about 240 milligrams a week, which most people be like, are you kidding me? That's a mini-cycle. But if you actually look at his serum testosterone levels, whenever we check him, they're like in the 600s. Like, and the truth is is that he is just has this giant repository of antigen receptors in his muscle that are just sucking up all the testosterone. And so trying to give him the same dose that you would give me or that you would give somebody else who's, you know, let's say a buck fifty soaking wet, it makes no sense. Like hold on.

SPEAKER_06 35:37

So it's weight-based or muscle-based?

SPEAKER_01 35:40

Both. So it's a combination. Combination. Obviously, lean muscle, lean tissue is going to have, you know, more ARs that need to be saturated. And so, like, we we've all had morbidly obese patients in our practice that only need a tiny dose of testosterone. What's going to say, right?

SPEAKER_06 35:53

Is because I have men that are overweight that actually do very well with a very low dose. And I think this argues that we need to be tracking body composition.

SPEAKER_03 36:01

Yeah. And the only have an in-body in the office, which is while not perfect because serves its purpose. Yeah.

SPEAKER_01 36:08

Bioelectric impedance, it may not be the gold standard wherever we're trying to assess, you know, body composition for professional purposes, or but on the other hand, it's the easiest to administer to patients whenever they're coming into the office. And it gives you something at least relative you can pull off of. And you combine that with what they're seeing on the scale, with what they're seeing in their clothes. And yeah, it's another data point. And so I think that's really helpful if you're trying to run a high-level testosterone practice.

SPEAKER_06 36:32

So, Alex, let me ask you this because you alluded to kind of the bro science, right? And you are a fellowship-trained, you know, urologist. And so you see a lot of these people in the clinic, and then you also learn from the people that you work out with in the gym. So, what are some of those other lessons that you that we can learn from people that you work out with and train with?

SPEAKER_01 36:50

Well, I think, you know, the the biggest lesson for me is to number one, be open-minded. Because the thing is, is that guys who are coming in often in in my practice, at least in this select subset of men, they've been exposed to androgens before. They've used androgens before, and they know what that makes them feel. And then you also, so you can't necessarily deny someone's truth of, oh, I felt better on 300 or 400 of testosterone than I do on 150. Okay. And so you have to listen to them when it comes to that. But at the same time, like I also like to add in, well, here's some of the data that I can bring. This is what your cholesterol profile looks like when you're on 150 and what your serum testosterone levels are and your free testosterone looks like. This is what happens whenever you're running a cycle. Okay. So let's talk about what those differences are and what that risk profile looks like. And, you know, if that, if you are, again, I am your doctor, I am not your dealer. Okay. If you decide to go out and you decide to take certain androgens and certain compounds, then you know, that's on you. Okay. But I'm going to try to keep an eye on you. And if you start to see where you're redlining your system, you have to ask yourself, is this going to be worth it to me? Okay. Is the increased risk of atherosclerosis, plaque buildup, uncontrolled hypertension, potentially a hurting kidney function, et cetera, et cetera, cardiomegaly, is that worth what I'm trying to pursue? And that's a personal choice that patients have to make. And so as a prescriber, I very much fall into the uh the belief that take the Hippocratic Oath, do no harm. Okay. Again, I'm your doctor, I'm not your dealer, but we have an entire subspecialty of addiction medicine that has really normalized the idea of harm reduction, okay? And trying to keep patients safe and trying to educate them. And what we found is that that is more effective from a public health standpoint by saying, like, oh, you can't do that. And oh, like, you know, you did like one D ball cycle, you know, like last year. Get out of my office.

SPEAKER_06 38:37

You're not their dealer or their daddy.

SPEAKER_01 38:39

No, absolutely not. Like the thing is that, like, and the men that are seeking me in particular, listen, they don't need me to get gear. Okay. All right. Like, there's there's a guy out back who can do that for them. All right. Like, they're coming in to see me because they care about their health, because they're starting to think about these things.

SPEAKER_06 38:54

They want it under supervision.

SPEAKER_01 38:56

And they want to, they want to be around for a long time. And this is what I tell them. Like, I like, listen, I want you to hit all of your plat or to bust through your plateaus. I want you to lift hard, you know, be stronger than you were, you know, last year, but I want you to be around for a long time. Okay. So is there a way that I can help you thread and find that happy medium? And I've had so many men who have come in to my clinic who have, you know, again, been using incredible, you know, doses of medication. And guess what? Now we've worked to a place. They're actually just on normal TRT now and they're murdering.

SPEAKER_03 39:25

Okay, so a couple of things here. Yeah. Number one, and we talked about that as when the people come to see you, yeah. Men from the gym, yeah, you know, enhanced athletes, as we're calling them. Yeah. You know, what they're taking for the most part is not what we're giving them. Uh-huh. And we have no quality control on what they're taking. Their testosterone products may be half the potency of our legitimate testosterone products.

SPEAKER_06 39:46

But you have to ask about the volume because the concentrations are often different.

SPEAKER_01 39:49

Exactly. And the concentrations are like half made up, right? Because, like, listen, like I tell them, I'm like, you know, listen, if you buy a couple grams of Coke down in Miami, someone's going to have stepped on that, right? So they can get more out of their product. The same crap happens with like your bathtub primo, okay, where like people are going to underdose. You're not really going to get 200 milligrams. You know, you can go ahead and send that off to Janishek or any of the other, you know, online, you know, uh COA, you know, providers, and you can actually see where a lot of these compounds have been underdosed and what's on the vial. So what a patient thinks they're taking versus what they actually are maybe two wildly different things.

unknown 40:20

Yeah.

SPEAKER_03 40:20

And the other thing I think it's interesting, and we don't have answers for it, is a lot of the supplements, steroid derived that these enhanced athletes are taking from the gym actually work. And they actually work different than testosterone that we can write. And I have no idea why. We do not understand the science of these compounds. I mean, like you say, you can learn from your patients. I mean, I would love to do some studies on some of these compounds.

SPEAKER_06 40:49

With fewer fertility implications. So they work for no.

SPEAKER_03 40:52

No, no, no. I'm no no. They're all bad. All bad, all bad for fertility.

SPEAKER_06 40:56

Okay, so I think that's important, though, but a plug to mention a plug. Yeah.

SPEAKER_03 41:00

Last year we published a paper showing we can protect these people, number one. Number two, we can bring them back. Yeah.

SPEAKER_01 41:06

With HCG and FSH incombinate.

SPEAKER_06 41:08

From men on testosterone.

SPEAKER_03 41:09

Yeah, or yes, or men who want to take testosterone.

SPEAKER_01 41:12

And that also includes men that are on other androgenic compounds as well.

SPEAKER_03 41:14

Yes, it's all the same. But I don't you agree that there's something different, prema premobolin and uh masteron that we don't equal by giving them testosterone and sypionate.

SPEAKER_01 41:26

No, and it's funny because like you would think in your mind, like, okay, so we've got a receptor and we've got a ligand. Okay. So I can change a ligand and it will bind to that receptor. So ligand in this case being the androgen, whether testosterone, prima, masteron, whatever you're using. So you'd think like, oh, like if it's binding for longer or tighter, it's just like it's you should the end result shouldn't be that different. All right. But they are, they're wildly different. So I will tell you, as a patient, okay, uh, who is on testosterone, I have been prescribed like Nandrolone, you know, uh decanoate. And, you know, that is available through reputable, you know, competition. And we can catch these. Yeah, exactly. And the thing is, is that when I am on a dose of that, like all of a sudden, like my shoulder pain that I've had for years because I had terrible bench technique and flared my shoulder one time, okay, like that gets a lot better. Okay. If you look at the nitrogen retention that I get in my muscles and the pumps that I get and what it does to me as far as my performance and my lifts, like there is a demonstrable difference that is not equitable to just giving more testosterone. Right. And so, like, there is a whole world of nuance there that has really been, you know, lost by general mainstream medicine and has been thoroughly investigated.

SPEAKER_03 42:33

It has been not investigated because, you know, people don't want to work with a non-FDA approved now, I think a Nandron may be FDA approved. So I'm not sure.

SPEAKER_01 42:41

Yeah, Nandrolone was FDA approved back in the 1970s uh for uh anemia. And so, which is one of the reasons why we have to be careful about polycythemia, right? Elevated hematocrit, you know, on it.

SPEAKER_06 42:52

Um, and you know, just explain that really quick with testosterone.

SPEAKER_01 42:55

Yeah, so whenever you're taking an exogenous androgen, okay, whether it's testosterone, nandrolone, or any of the other derivatives, that actually upregulates erythropoietin synthesis, erythropoietin being the messenger created by the kidneys to stimulate your bone marrow to make more red blood cells, okay? And so more red blood cells means that the blood increases in viscosity or thickness. I joked with some patients that your blood looks like maple syrup, okay, whenever it gets too thick. And so that is actually incredibly helpful if you're a patient who has thin blood or low red blood cell count. Again, for my patient Steve, before he got his uh kidney transplant, he was chronically anemic. Nandrolone was an amazing adjunct in him because it actually managed to raise his red blood cell production, which really helps when you're going in for a frickin' kidney transplant and you're gonna be doing a vascular anastomosis. Okay. And so um, there are again, there are nuances and subtleties with these compounds that have yet to be fully elucidated. Uh, because we're still in a world where, despite what AUA guidelines, you know, have have said, people there are some people out there that still think that testosterone causes prostate cancer. There are people out there that still think that uh thoughtfully administered TRT. Increases the risk for, you know, cardiac disease, which we have not seen that happen with TRT related doses within a certain threshold. So there's a lot of misinformation there just on the basic level. So the more exotic stuff has been totally untapped.

SPEAKER_03 44:14

Right. So let me just get back to something because I think it's a good segue. Okay. And that is you said you took Deca and Nandrolone Decanoate because you were having joint pain. Yes. Now we have BPC, TB500. Yep. Uh two different peptides that are usually prescribed synergistically. Correct. So should we segue to peptides?

SPEAKER_06 44:33

Yeah, I think that's great. Because you do the most amazing content I've seen online when it comes to these agents in a way where I was literally at the gym this morning laughing out loud, watching his episode on BPC 157 TB500.

SPEAKER_03 44:46

Yeah. Yeah. I uh so first of all, if we're going to talk about peptides, which we need to because it is the future. Yeah. Could you explain?

SPEAKER_06 44:53

Well it's a present. The present and the future.

SPEAKER_03 44:56

Present and more common in the future. Yeah. Could you please explain what peptides are, how they're derived, and then we could start talking about different ones that we could ask you about.

SPEAKER_01 45:06

Totally. So let's start off by saying that when we say the term peptide, you might as well be saying the term pill. It is not a therapeutic class. So, like we talk about androgens, that's a therapeutic class. They're all derived and they kind of do similar things working through similar receptors. Um, we can talk about like uh statins. Different statins are a therapeutic class. Uh when we say peptide, that is a structural class, just what makes up the molecule. And uh, we start off with what I call the bricks, okay, which are the building blocks. And those are going to be your amino acids, right? There are 20 amino acids, they are present throughout our body. This is what a it's an organic molecule that you've got your amine, you've got your carboxyl, you know, attached to that, and then you've got your side chain, and that's what creates the 20 different amino acids. 11 of them we can make on our own from different things, you know, that we have in our diet. Nine are what's called essential, which means you have to consume them because we can't make them on our own. All right. And so those are the bricks. All right. Now, when you start piecing these together, all right, anywhere from two amino acids up to maybe around 50, that is what is generally considered to be a peptide. Okay. And this is an organic chemical messenger that can actually activate certain receptors within the body with a high degree of specificity, which is very, very different than let's say a small molecule like a statin or like a Viagracialis, these things that are small molecules that can have wide systemic effects, because this is larger than a small molecule and it's very, very targeting. All right. And then whenever you start to get above 50-ish, okay, then you the classification can change again. And then we're talking about proteins, okay? Or biologics. Well, biologics is a regulatory definition. Okay. And so above 50. Actually, above 40. Above 40 is technically considered a biologic now. They changed it. Yeah. So what happened is that above 40 is considered a biologic right now in America. And so that means, but which also incorporates some peptides. So for example, one of the original peptides that was used therapeutically is insulin. Insulin is 51 amino acids, all right. But they changed the definition of a biologic, and then all of a sudden, insulin, even though it's a peptide, is not classified as a biologic, but because it's uh biologic now, compounding pharmacies cannot make it, okay, which is one of the reasons why insulin, although it's come down in price now, okay, uh your 503B compounding pharmacies, outsourcing facilities, can't make insulin to provide that to hospitals and clinics because of regulatory capture, not because it's a hard molecule to make. And so if you're thinking about this, think about amino acids as the bricks. Think about your peptides as a wall, and think about your proteins as a finished house. And what has happened is we have seen an absolute explosion in the peptide space because we've identified these very pointed, targeted messengers that might affect profound downstream effects. So that's where we are. That's what a peptide technically is, but it's a very challenging space right now because of a lot of interest, but a lot of headwind when it comes from a regulatory perspective.

SPEAKER_03 48:00

Well, one other thing is peptides are protein hormones. Yes. They are not steroid hormones. That is correct. So protein hormones act on the cell membrane, whereas the androgen-derived testosterone drives have to get into the cell to the nucleus. They're freely permeable.

SPEAKER_01 48:18

Yeah, the the steroids will bind to a surface-expressed andrion receptor, but then that has to translocate into the nucleus to all to alter mRNA expression. Right. And so you're right, you have to get to the nucleus whenever you're talking about steroids. And also, steroids are gonna be uh more accessible past like the blood brain barrier, blood drivers. But they're fat soluble. Exactly. And so that's the uh a big that's a chemical difference in the case. Okay, so back to the body.

SPEAKER_06 48:41

But really quick though, talk about the fertility implications comparing steroids with these protein peptides.

SPEAKER_03 48:47

Well, I mean apples and oranges. Yeah. Yeah, the steroid implication is that testosterone derived products can turn off the hormones from the pituitary, FSH and LH, that are important, mandatory for normal sperm production. Yeah. The peptides don't have that down that that affects.

SPEAKER_06 49:06

Which I think is really important because a lot of the people that are given peptide space might want to have are interested in current or future fertility. So of course these people are going to be interested.

SPEAKER_03 49:14

But but a caveat, and that is peptides don't do what steroids do. Oh, not even close. And that's so I mean you have to. They're very synergistic, they they don't activate androgen receptors.

SPEAKER_01 49:26

So also a a big so this we can get into this, but so uh a lot of people are exposed to content on social media where you will see someone doing a before and after, and as part of their after, they'll show a very significant increase in lean tissue mass, you know, a lot bigger muscles. But the truth is that none of the peptides that exist are really good at lean tissue accrual. Now, you might argue that something like IgF1 LR3 that you know may help you know in that regard, but not anywhere to the degree that a shot of testosterone would. And so whenever you're seeing these before and afters online, you know, buyer buyer beware, it's usually accompanied with a discount code and a referral thing where you know you're trying to buy your research-only peptides through someone who has a clear incentive to sell you something. And again, no shade. I've you know have met people across this industry on all avenues of it, but you know, peptides are inherently different molecules with inherently unique end organ effects that are and that are totally different from individual peptides.

SPEAKER_06 50:24

Yeah. Yeah. And you had mentioned in a previous conversation that the people you would consider peptides in, you're seeing them for low testosterone first, right?

SPEAKER_03 50:32

Well, I'm seeing them for symptoms of low testosterone, and often they do have low testosterone.

SPEAKER_06 50:37

So you're typically adding peptides in combination with a testosterone regimen.

SPEAKER_01 50:41

Yeah, and that's yes, I am. But that's a that's a reflection of our practice, right? Because we primarily treat, you know, men, okay, and men who are interested in coming to see us, they're usually presenting with symptoms of low testosterone. They happen to have low testosterone, and then they are trying to achieve other goals and that peptides can be beneficial towards. But I also think that there's an entire giant like piece of the population that don't have a problem with testosterone. I'm talking about, you know, female patients, okay, that don't have a testosterone deficiency, male patients that don't have a testosterone deficiency, but would still really benefit from peptide therapy.

SPEAKER_03 51:13

While you're talking about peptides, you have to mention the GLP.

SPEAKER_01 51:16

Yes. And so the question is is like, where did we get to uh peptides being what they are today? And the thing is that this goes back to peptides have been around forever. Insulin's been around forever. Yeah. Oxytocin's been around forever. All right. These are not new as a structural class. Right. But what happened is that with the introduction of semaglutide, we all of a sudden saw how radically powerful peptides could be. Then we had semaglutide, we have trisepatide, and all of a sudden there was a lot of interest in this space of peptides. We also then had an increase in interest from these compounds that were starting to be promoted for wound healing, like BPC TB500. If we're talking about collagen turnover and uh improvements in aesthetics, we saw GHK, the GHK Q, you know, come out, you know, uh, for that. Talk about Q for copper. Exactly. Yes. Uh new video dropping soon on our channel. And then, you know, we have like nootropics like uh, you know, Celank and uh other options, right? That can, again, have widely very, very impressive end-organ effects. But those were available not through a regular CVS or Walgreens, they're available specifically through compounders because these are uh substances that have not been formally evaluated by the FDA. Some of them have. Some of them have, they've been through part of that process, but none of the ones that we're talking about, as far as like popular peptides right now, have been all the way from the beginning to the end and come to market. All right. Um, uh, maybe tesamoralin, but that's a different one. Okay. Uh if I'm talking about BPC, TB, GHKT. The ones that are commonly used now. Exactly, right? And so um the what happened is that those compounds, you know, were still able to be made by 503A compounding pharmacies. So section 503A of the Food, Drug, and Cosmetics Act allows compounding pharmacies to make medications for patients and allows the production of some that have not gone all the way through FDA approval, which included the peptides.

SPEAKER_03 53:10

But so differentiate between 503A pharmacies and 503B pharmacy.

SPEAKER_01 53:15

503A is your regular pharmacy that's uh a compound pharmacy, compounding pharmacy on the corner of the street, okay, that creates scripts for individual patients, which is I'm a doctor, I am writing a script for Amy, I am sending it to that compounding pharmacy, they're making a custom formulation for Amy that they sell to her, okay? A 503B, also known as an outsourcing facility, they can sell medications in bulk to both clinics and to hospitals, all right? But they have a very select number of medications that they can make. They are highly regulated. And whereas 503As are traditionally inspected and regulated by mostly by the state, okay, the FDA themselves on a federal level has the ability to inspect 503Bs. Okay. So what could happen is that we had these compounds, they were available uh from 503A compounding pharmacies. And then one of the last gifts of the prior administration, one of the dumbest moves, if they ever, if they didn't want to promote peptides, is they moved them from what's called category one, which is permittable to be compounded, to category two. And whenever that transition happened in 2023, all of a sudden we have what we talked about, the Streisand effect, where we, if people can't have something, then they want more of it. And, you know, they poured gasoline on the black and gray market, where all of a sudden everyone on TikTok was talking about peptides. TikTok was growing at the time. They wanted to encourage anything that got more views. And so they incentivized their algorithm to this. And then all of a sudden we had this, you know, really like large, mature kind of Wild West industry of research only, uh, research use only compounds for uh purchase via different websites, via crypto.

SPEAKER_06 54:48

Some like even had PayPal and they're basically online storefronts, not compounding pharmacies.

SPEAKER_01 54:53

Correct. These are online storefronts. Many of them are not making it themselves, they're buying them in bulk from you know Chinese suppliers, rebranding it, sending it. And again, because these are not regulated to the same degree that compounders, or they're not regulated at all, okay, but they're not regulated like compounders are, okay. There can be wide variability in dosing.

SPEAKER_03 55:10

And that's but I have to clear something up, and that is when you were my fellow, yes, we were writing peptides. Absolutely. So it's not something that happened in 2023. No, no, we were prescribing it before.

SPEAKER_06 55:21

The classification changed.

SPEAKER_03 55:22

The classification changed. The interest was there.

SPEAKER_06 55:24

Yeah, the interest was Well, you've been prescribing peptides for how many years?

SPEAKER_03 55:27

I don't know. I can't count that lot high. But no, it's not that high. I mean, it's just a long time. Yeah. Because we we got a relationship with a very large uh which became large compounding pharmacy that was very innovative, that that started selling peptides. And as they would bring them on, we would find out what they did and we would use them. And they were amazing. I mean, we had GHRP two and six when you were with us, and they were amazing compounds for skinny guys who needed to put on weight, which is like a full-time job, right?

SPEAKER_01 55:59

It is, it is. And I I so that's something I didn't mention. So one of the biggest like levers for me personally as a chronic skinny guy, right, is I could not force myself to eat enough. So, in addition, whenever I was diagnosed with low testosterone and I started in testosterone therapy, that was that during a period of time where MK677, also known as ibutamorin, which is not a peptide, it is a small molecule, okay, but it binds to the ghrelin receptor and it activates IgF-1 release, but also stimulates hunger. I was able to incorporate that as well as prescribed to me from you know a 503A compounding pharmacy at the time. And that was huge because all of a sudden I had enough appetite that I could actually eat enough protein to achieve what I needed to and actually recover from my workouts and accrue lean.

SPEAKER_03 56:39

Yeah, I just wanted to bring that up because it this these peptides are not new. No. These peptides have just become extremely popular, and I think because of what you call the Streisand effect, because people couldn't get them, so they wanted them.

SPEAKER_01 56:50

Yeah. And you know, the the challenge is this. Okay, so you've got these very compelling compounds, all right, that can provide an incredible benefit for patients. But I believe it was in uh uh 2013, and I'd have to fact check the exact date. But essentially a Supreme Court case came up with a company called Myriad Genetics, which they were the company that identified the BRCA1, so BRCA, BROCA 1, and BROCA 2 mutations that led to breast cancer and ovarian cancer. We've since learned they also lead to prostate cancer in men. And they discovered this and they're like, okay, great, we're gonna patent this. And that was challenged. And in a nine to zero decision, the Supreme Court and said, you came down and said you can't patent something that is made by God, something that has endogenous and is natural, that belongs to nature, not to a pharmaceutical company. So, okay, great, now everyone could do work based off the BROCA, you know, uh genes, incredible win for cancer. But now there is zero incentive for pharmaceutical companies to investigate and pour money into these peptides because they don't have a clear way to monetize them.

SPEAKER_06 57:50

Because they're naturally occurring.

SPEAKER_03 57:52

Uh and correct me in my thinking, but you know, one of the our leading topical testosterone products, test them, was made from yams. Yes. Now that's a naturally occurring vegetable.

SPEAKER_01 58:05

Yes, but you can't go out, so the yam just provides the basic four uh ring structure, um, which fun fact is made mostly of C13 as opposed to C14, which is why you can actually look at mass spec and see if someone's natural testosterone is heavier or lighter if you're trying to separate injected testosterone versus natural, which is great if you're wada. Wada sucks. They're really I'm kidding. They're I they I just think they're just like kind of like narcs, whatever. Um, but uh the thing is is that they then modify that, okay, go through a process to create the testosterone molecule. And because they go through that synthetic process, all of a sudden that could be you know patented these days, but it's not even.

SPEAKER_03 58:39

Aren't they also synthesizing and purifying the peptides?

SPEAKER_01 58:43

Well, again, it could you potentially, okay, have a legal team come together and try to put together a patent for something like that. Yes, and that's been done. So, for example, BPC 157 has a Croatian patent on it that lasts, I think, for another three to four years. The Sikoric team who discovered BPC 157 ended up patenting it. But the challenge is it's not whether or not you can patent, but will that stand up in court? Because then if somebody else comes along and challenges it and then they look back at American like law precedent and they pull up the myriad genetics case, you could be SOL as a company.

SPEAKER_03 59:15

And that's the reason why big pharma does not make peptides. Yeah. Because they can't patent it. And that's the reason why big pharma is anti-peptides. It's not because they worry about the health of American men or women, it's because they can't make money off of it. So they don't want it out there competing with something that they may have.

SPEAKER_01 59:32

Exactly.

SPEAKER_06 59:33

And also talk about the GLP ones, though, in that space too, and how they're able to patent something like that.

SPEAKER_01 59:37

Well, that's because the thing is that you've got a uh a novel peptide that binds on a receptor, but semagluide isn't natural. We don't all have a certain amount of semaglutide circling around in our system, okay? We don't have a certain amount of trisepatide or retitrutide. And so these have different, like those examples have fatty acid chains that are added onto them that will prolong their half-life, which is how you could get away with just a single subcutaneous injection weekly. Okay. They've been, these are very modified compounds, even though they're binding to a natural endogenous receptor.

SPEAKER_06 1:00:07

Which is important for the oral therapies that are coming out now, because these other clinics are now offering, you know, oral medications for the GLP1s, but not actually in a way that will keep it around in the body.

SPEAKER_03 1:00:16

Well, never been that the oral GLPs have been around a long time.

SPEAKER_01 1:00:20

So ribelsis first came out in 2018, okay, which was novonordis product for oral semaglutide. And they developed this compound called SNAC, uh, I can't say it's a long word, all right, which basically protects the uh semaglutide from being absorbed in the or for being destroyed in the gut and broken down because our gut is designed to break down protein, but it creates a pH buffer around the semaglutide so that it can be absorbed. And it's the bioavailability is terrible. I think it's like one to two percent, but semagluti is just crazy potent. And so even with the snack, you're only getting one to two percent, you know, bioavailability. That's okay, that's all you need to get the end organ effect. But then the challenge is is like, okay, if we're talking about if someone is trying to make a compounded semaglutide, a compounded trzeptide, do they happen to have a different mitigation uh scheme for allowing oral uh absorption so it doesn't get destroyed by the gut? Now, as of today, I am unaware of any compounding pharmacy that has that, at least it hasn't been communicated to me. And then so then you have the legal case of well, you know, can if the point of compounding is for personalized medication, okay, that uh is overcoming a barrier. Let's say you have a patient that is sensitive to commercial snack, okay, that's in an oral ribelsis or an oral wagove. Oh, let me go to a compounded pharmacy that has a different oral mechanism for going around that. There could be a legal case there, but I haven't seen that demonstrated yet. And that is a valid point from pharma look uh towards certain compounders looking at it saying, hey, you're not technically fulfilling your obligation because that's different.

SPEAKER_03 1:01:49

For clarity, yeah, the legal actions of big pharma against compounding pharmacies for the GLPs total lawfare was was not because they were compounding, they were arguing that it was what they were producing, because they started producing it when the big pharma couldn't produce it. There was a huge shortage.

SPEAKER_01 1:02:09

So when Ozimpic started uh taking off, and then when um Zetbound and then uh sorry, when Monjaro and then Zetbound came out, essentially there was, you know, a huge demand in the marketplace, and Lily couldn't make enough to save their life. Nova Nordis couldn't make enough to save their life. And so those drugs were put on a shortage list, which allowed compounders writ large to make GLP ones as a safety mechanism in order to meet market demand. And so compounders like stepped up, they spent an incredible amount of money on their own infrastructure in order to make those compounds and sell them. And they did it to a tune of about $7 billion in total sales across all of all the compounders, okay, all right. But compare that to the worth of just frickin' Eli Lilly, which during a recent surge had a valuation of over $1 trillion. And so what happened is, okay, this compounders step up, they're able to actually get patients the medication they need. All right. The pharma companies are losing their mind and they're livid that they are losing money because they can't get their drug off the shortage list. They finally do get the drug off the shortage list, and then they see compounders as an existential threat. And they start a multi-front war through lobbying, through lawfare, through buying, like recently buying a Chinese API supplier to try and shut off international access to the APIs that compounders use to turn this off, trying to essentially regulate compounders out of business, even though compounders were the ones that bailed the American public out when pharma couldn't meet the demand of their own products. And so I'm a big believer in playing by the rules. And if you look at the rules that are on the books for 503As and 503Bs, the truth is that they can compound personalized forms of medication that are not available in the cookie cutter forms that you get from a from Lily or for nobody selling them with B12 or B12 or also just in the in a vial. So, like there are some patients, for example, that you know get started on a dose, even a small one, and they are have a significant GI upset. I have friends who work as emergency room doctors, and like half the belly pain consults they're seeing these days are just people that are having a hard time adjusting to their GLP ones because these are in pre-metered pens that are administered in bolus doses once a week. And there are a lot of patients who actually would benefit from incremental dosing and small sub Q doses every single day and slowly ramping that up in a linear fashion as opposed to the stepwise fashion that is mandated by those pens. And so we have that option when it comes to compounders. Compounders also add in other medication like B12 or niacinamide that has, you know, additional clinical benefits. But Lily does not care, Nova Nordis does not care. We have seen a concerted effort from this FDA to essentially act like the mob enforcer for these pharma companies.

SPEAKER_03 1:04:47

But, but, but despite the fact that there's these lawsuits going on from Big Pharma against compounding pharmacies, they're still making it.

SPEAKER_01 1:04:55

They are. And if you look at all of the lawsuits that have been filed from Big Pharma towards compounders, it's not towards the fact they're making GLP ones, because that is technically allowed given those caveats in the law. They're trying to get them on every little nitpick advertising thing, uh every other small regulatory issue, but again, just trying to pick and at the weakness that they can. But they're doing it because they're making GLP1s.

SPEAKER_03 1:05:16

And they're not suing everybody. They're suing the big ones. They're going for the big fish, right? Right. Because they know they, you know, they are their biggest threat.

SPEAKER_01 1:05:22

It's it's like freaking prison, man. You just go and you pick a fight with the biggest guy in the yard, take him out, and then hopefully scare everybody else.

SPEAKER_03 1:05:28

But I but I what I don't understand is the greed. Because look at the amount of money they're making anyway, despite the compounding pharmacies and the fact that it's so ubiquitous in the marketplace.

SPEAKER_01 1:05:40

No one the truth is is that uh again, we spoke earlier about you know using terms like, you know, evil when describing large organizations. I don't think that's accurate or helpful, but you have to understand that these are large corporate monsters that care only about profit. They do not care. I don't care.

SPEAKER_03 1:05:56

Well, they have their boards. They have their boards. They have to report to the board. Shareholders.

SPEAKER_01 1:06:01

And they do not care despite what they say. Okay. For example, John Kuckelman is one of the lead legal counsel for Novo Nordisc. And he has said on the record that they want to categorically categorically eliminate compounders. Okay. This is someone gone on the record saying that they want to eliminate an entire industry that provides vital medications to patients. And do you think it's because like that's better for patients? No, it's because he gets bonus and incentivized to take other people out so that Novo Nordis, you know, share price goes up. Well, what is their product? Uh uh Novo Nordis is semaglutide, okay? Which, you know, by the way, is now going generic in a number of countries at a price that is less than one-tenth of the lowest price that semaglutide has ever been available. And so, you know, like again, I I respect like the work that is required to bring a drug from the lab up until the point that it reaches the market. But the truth is, a lot of that freaking research starts at the freaking NIH, which is paid for with our tax dollars, the tax dollars of our patients. Then that gets licensed to Big Pharma, they're able to then take it, pursue it further, create this final product, they charge insane prices for it to suck as much profit out of the system. Okay. And again, there's other problems in medicine. Insurance companies are a huge issue. But the thing is that if we compare how Lily, I think they they multiplied their market cap, their uh value of their company several, several times, okay, due to gesturze. They have not had a blockbuster drug like this since Cialis. Okay. And then you compare that to just seven billion dollars across like multiple compounders and entire nationwide during the GLP one shortage. Dude, that is like a drop in the bucket when it comes to the size of these companies.

SPEAKER_03 1:07:34

And so no one talks about the dollars. One talk, they just talk about the concept. Yes, you know, that they're going after the compounders because they're not, you know, legitimate or they're not.

SPEAKER_01 1:07:44

Show me the show me the any significant case of uh mass poisoning from Empower's GLP1 medications or any of our other you know friends and colleagues in the compounding space. It doesn't exist, okay? These are regulated facilities that are currently regulated, currently inspected, that operate at a very high level of purity and quality because they're inspected. If they don't, they go out of freaking business.

SPEAKER_06 1:08:08

It's also important to um understand how they're different from the online storefronts that we previously spoke about. Exactly.

SPEAKER_03 1:08:15

I mean there's compounding pharmacies and there's compounding pharmacies.

SPEAKER_01 1:08:18

The ones that Well and Gray Market, which is what Amy was referring to, gray and black market, which is a different animal entirely.

SPEAKER_03 1:08:24

But but but I'm telling you the compounding pharmacy that they're going after, and you mentioned empower. Yeah. I would I would just love to be able to show a video of that compounding pharmacy is mind-blowing what it looks like. It's it's it it's basically big pharma in Houston, Texas. Yes.

SPEAKER_06 1:08:44

But clarify your comment though. What do you mean? Because I don't know that you're purposely trying to say that empower is like big pharma.

SPEAKER_03 1:08:50

No, I'm saying in terms of the quality of their drug production and their facilities and their being like pristine and top of the line. And the pill making apparatus. I mean, and the owner has also, because he's an engineer.

SPEAKER_06 1:09:03

Right. It's not someone in the back office.

SPEAKER_03 1:09:07

These are industrial operations, they're wild. He has he has a sp gigantic room that just sends different humidified air to all these different places in this gigantic structure. Yeah. I mean, it's massive and it's beautiful and it's squeaky clean. Yeah. And it I can't imagine there being anything better someplace else. Yeah. Uh so any comment on the inferiority of a compounding pharmacy, you need to look at the best of the best before you make a global statement. But we want to get your input on what you're doing now with shockwave therapy, uh, especially for erectile dysfunction. Yeah. And to explain to those watching or listening what it is and why we're using it and how it's working.

SPEAKER_06 1:09:48

Because you had just mentioned that not all compounding pharmacies are created equal.

SPEAKER_03 1:09:52

That's perfect.

SPEAKER_06 1:09:52

And I think that's exactly what we need to delve into when it comes to shockwave therapy.

SPEAKER_03 1:09:56

Yes, and the machines that are available.

SPEAKER_01 1:09:58

Yeah. So very briefly, you know, for the sake of our audience, you know, a large portion of my practice is dedicated to penile implant placement, which is what happens when your erectile dysfunction has gotten so bad that even the pills aren't working and you need a serious intervention from a highly skilled surgeon to get a great outcome. And again, we've got that down. It's a 15-minute outpatient procedure. Like it is slick and patients get great outcomes. But as someone who is very, very interested in not just treating sickness and treating disease, but in health optimization and helping men to achieve like their best possible natural function as long as humanly possible, you know, when you look at that in the ED space, everything that we've had in D and in the ED space prior to shockwave are all band-aids. We're not fixing the underlying pathology of inadequate blood flow to the corporacabinosa, to the penis, and we're not reversing the clock in any meaningful way. But with shockwave therapy, which is the use of these supersonic sound waves and a converging pattern into tissue where you get penetration and you can deliver energy inside the body with an applicator that is just touching the skin.

SPEAKER_06 1:11:00

So it doesn't actually shock the penis. It does not shock the penis. No, no, no, no. It's painless.

SPEAKER_01 1:11:03

Yes. Do not put your penis inside an electrical socket. That is a bad idea. Um, but the what this technology does is it actually causes what we would describe as microtrauma or just a little uh kind of shaking up the cells is what I've described it, that actually stimulates two different angiogenic pathways. One is called VEGEF, the other one is called enos, which actually promotes cellular recruitment and cellular repair so that patients will develop new blood vessel formation and increase blood flow to the penis, which results in better sexual function. Because that's usually the underlying problem. Correct. Yeah, I tell patients all the time that, you know, 90, you know, some odd percent of erectile dysfunction is a plumbing problem, inadequate blood flow where you need it most. And so what we have with shockwave is a novel way of addressing this. And it's extremely effective, but only when you're using it the correct machine, the correct energy, okay, and in the correct patient. And I think that's where things get lost because when you start to use the term shockwave writ large, you could inadvertently include uh the machines we're talking about, which are low-intensity shockwave therapy machines, okay, versus radio wave devices, which is just as basically just your mom's Hitachi Magic Wand, you know, on steroids. Okay. Um, and so if you look at a Hitachi wand. No, I support that. 110%.

SPEAKER_03 1:12:22

She's going on air saying it.

SPEAKER_01 1:12:23

It's it's a great device, okay? But the challenge is that if you are looking at these two machines, they can look similar in the clinic. They both plug into the wall off of a regular outlet. They have applicators that attach to the skin. And you're like, okay, this they kind of look the same, but they are wildly different. If you're looking at the speed of a shockwave that's coming out of a low-intensity shockwave device, what we use, okay, it is supersonic. This is fast as all get out, and it penetrates. But there's electrohyohydraulic and then there's uh piezoelectric, and so different ways of generating that shockwave, okay? And those are just different approaches, but ultimately we'll achieve the same low-intensity shockwave result. You've got things that are electrohydraulic, like the original ED1000 from MetaSpec, which is one of the OG shockwave devices. And then you've got the piezoelectric, which is what I have in the device that I use, which is the Stortz Dualith SD1. Which I have a we all have this, right? Exactly. Now there's another one, like the Direx Mornova, another one. I don't know if that's available in the US. And then there is like this off-brand version of this MetaSpec ED1000 that they're trying to sell as like a cosmetic device here, but it's the same thing as the ED1000. But the FDA will eventually catch on to that and tell them to stop selling it because they're selling a class uh three medical device as a class one, which is a no-no. Okay. So, anyways, and then you've got radio wave devices, which is again just a superficial vibrator that does not have any tissue penetration. Um, and as a result, you are incapable of achieving that sort of tissue disruption or microtrauma within the erectile bodies of the penis. But the challenge is that the majority of the people that are offering radio wave are more interested in separating patients from their wallets than they are in actually providing, you know, uh meaningful care.

SPEAKER_03 1:13:59

Isn't radio wave the one used most commonly for joints by uh people have tried to use it for joints, people have tried to use it for wound healing.

SPEAKER_01 1:14:07

There are a bunch of different applications.

SPEAKER_03 1:14:08

But they are using it in uh in aspects of medicine, but not for this. Yeah, not for this. It just is But you're not saying that there's something.

SPEAKER_06 1:14:15

Well, the research doesn't support the use of radio waves for rectangle function. For doctor medicine.

SPEAKER_03 1:14:19

Yes. But it does have places in medicine.

SPEAKER_01 1:14:22

Exactly. You know, but the thing is that you know, salt is great on my eggs, but uh, you know, if I throw it, you know, in my coffee, that's gonna suck, right? Like application matters. And so um you just come up with that. Yeah.

SPEAKER_06 1:14:33

I love that.

SPEAKER_01 1:14:34

Yeah, I mean, well, listen, I have small children that like it really they think the sugar and they think the the salt looks the same and they will mix and match those. It is it is a terrible science project. So the thing is that application matters, and we know that uh radio wave definitively does not work because there was a randomized placebo-controlled trial that came out comparing placebo compared to radio wave, and placebo did better. And that was published back in the Journal of Sexual Medicine, I believe, in 2023. And there have been one or two others. And so we know for a fact that radio wave is garbage, and I have very strong opinions on people that continue to offer that for erectile dysfunction, okay? But we do know that low intensity shockwave actually does cause, does improve things, but we have to be honest with ourselves. If we look at the three month, six month, and then two-year improvements off of low intensity shockwave therapy, you get a IIEF five or a shim score improvement of about four. Okay, which is that an improvement? Yes. Is it less than what you go via grancialis? Also, yes. Okay. Is it the bare minimum to meet what we define as a meaningful clinically significant difference? Also, yes. And so where I have found having offered shockwave now in my clinic for god, six, seven years, I have found it to be most useful for men that are early in their journey, most useful for men that don't have multiple other risk factors.

SPEAKER_06 1:15:50

Describe what you mean early in their journey.

SPEAKER_01 1:15:51

So just now starting to experience issues with their sexual function. Maybe they just started oral medication or haven't even started oral medication. Like our C Alice. Are they oral medication responders or non-responders? If a man responds to an oral medication, they are much, much more likely to respond to shockwave. Right. If they are an oral medication non-responder and they do shockwave, they can still do it, but they only have a one in three chance of becoming an oral medication responder. And so the thing is we know there's some threshold that men will cross when it comes to their erectile dysfunction, where a regenerative therapy like shockwave fails to yield any benefit. And the challenge that we have in our practice is because I'm the penile implant expert. I'm the guy who people see after they've already failed everything. Men tend to come to me very late in their journey, as opposed to when shockwave would be the most beneficial, which is off the rip, which is why we're here talking about it, trying to get the word out saying that this is something that men should either pursue as soon as they start to develop symbols of DD, or I would argue they should pursue as a preventative intervention as early as 35, 40. We're learning that.

SPEAKER_06 1:16:50

Maybe part of this longevity space without making that a bad word.

SPEAKER_01 1:16:54

Like the cardiologist came out with new guidelines saying that statins may convey benefit in men as young as 30, given their risk factors. And why should we wait until the first heart attack before we give a man a statin? You know, I'll tell you that I have a, you know, gosh, like if you look at my family cardiac history, it looks like the freaking killing fields of Cambodia, man, like the Khmer Rouge, like, you know, a plaque disease. It's terrible. Okay. So you love his illusions here. No one's gonna get that. No one's gonna get that. I got it. You will, you will. I don't know if anyone in our audience will. I like geopolitics and history. But the thing is, is that um so for me, I'm on a statin already. I don't have any evidence of any plaque or calcium on uh a CAC. Okay. Uh my, you know, uh I've had a cardiac echo which shows mild cardiac hypertrophy related to prior issues I had with poorly controlled blood pressure. Um, that is now totally fixed. Shout out to you know, renal artery denervation. Uh, it doesn't work for everyone, worked amazingly for me. I was a patient in that trial. Um, but you know, again, preventative medicine works. We know that that's gonna be personalized. Preventative medicine is the wave of the future. It's medicine 3.0, and we should apply that to not just our hormones, not just to our lipids, not just to our sugar control, but also to our sexual function. And that's where I think shockwave fits perfectly.

SPEAKER_06 1:18:03

And it's incredibly safe. Oh my god. The number one thing that we kind of ask ourselves is how can this intervention hurt someone? And it's not gonna help everyone. No. But if you can't hurt anyone with shockwave therapy, then it opens up this interest in a lot more people where they're like, I don't want to regret ever having done this, but people aren't gonna regret have done shockwave. As long as they're counseled on what they can expect.

SPEAKER_03 1:18:23

But listen, if you ask 90% of my men, yeah, are you having some problems with erections? Yes. And they all go on daily sales, you know, or on demand. Yeah. So is this the population you would offer shockwave to? Yes. Because if so, I will have a line all the way down for a mile. Well, I I would say this.

SPEAKER_06 1:18:44

Oh, well, I don't I don't end up doing shockwave in those guys, but they probably are the ideal population.

SPEAKER_03 1:18:48

So you're not doing it at this point.

SPEAKER_06 1:18:49

Well, I do it, but I counsel them on all their other options. And the most, you know, cost-effective approach is gonna be to take a daily Cialis. And I let them know that.

SPEAKER_01 1:18:58

I try to tell patients this is not an either or. Okay. You the thing is is that you can like listen, if it were me, okay, and guess what? I am a patient. I am already on daily Cialis from a preventative standpoint. Have you had shockwave? I have not had shockwave yet, but I will tell you this. You know what? If I practice what I preach, I probably should, you know. And the good news is that, you know, um But you have all these women in your clinic. I mean I've got one male nurse who, you know, I could potentially get to hook me up, okay. Or I do it myself. I can do it myself, you know. I can't do the penile girth enhancement myself, all right, because I've only got one other person who does that, and she's a female, and that would just be uh there would be a lot of meetings and emails over that. But I could administer shockwave myself. I'm pretty confident about that. And I'll tell you, you know, I had a uh a member of our team who's not with us anymore. God bless him, um, who uh oh no, he just moved on to a different home. No, no, he's one of our nurses. No, no, he was one of our nurses, he's fan freakantastic, and I miss him, but he just went to he took a gig that was he drove over 45 minutes every day to get to our clinic and he found a job that was five minutes away. And so, but you know, he uh you know used shockwave on himself without telling me. Uh but afterwards it was like, oh my gosh, this was such an improvement for both, you know, me and my spouse. And so it's like, well, people that I know, you know, have you know seen a real difference from this, which backs up the clinical data. Yeah.

SPEAKER_03 1:20:12

Is there clinical data that doing shockwave younger is more efficacious than older, or is it totally related to the degree of erectile dysfunction?

SPEAKER_01 1:20:20

I don't I am unaware of where anyone has done a multivariate analysis to specifically look at age. We do know that diabetes and severity of ED, so you need to have a shim score ideally 12 and above if you're going to be an ideal responder to that. But we know from a pragmatic standpoint that the younger patients are, even if they have ED, they will typically have higher shim scores. So there it is totally reasonable to, you know, come to the conclusion that the earlier we use shockwave, the younger a patient is, the better the outcome.

SPEAKER_06 1:20:47

And I would say in my clinical, you know, patient population, my patients benefit from it. But I would never just offer shockwave in any of my patients. We're talking about nutrition and exercise and sleep and stress, and I'm likely putting them on Cialis, and we're talking about vacuum pump therapy, right? So at the end of the day, it's impossible, just like with the peptides, right? And testosterone. When are we just putting a patient on one single intervention? So it's hard to tease it out. But that's exactly what I tell patients. I don't oversell the technology, but in the right patient at the right time, I agree it can be very beneficial to be able to do that.

SPEAKER_03 1:21:17

But it's a force multiplier. Yeah. But we're, you know, in in our in our uh facility, we wait until they are no longer responsive to the orals. Before they start, you might be missing out on an opportunity. So I think we, you know, I and in retrospect, I think we are.

SPEAKER_01 1:21:32

Yeah, I think uh again, I think this is an opportunity to be proactive as opposed to reactive. Yeah. And so, yeah, as we continue to try and like be more mindful of preventative, you know, approaches, I'm hoping that we will see, you know, a shockwave used more widely and sooner in patients. But the problem is that I still see reels on social media where, you know, physicians with I may I hope good intentions and they're just uneducated, are still offering things like radio wave or PRP. And again, there's multi some data out there on PRP, some of it positive, some of it negative. Okay. There's not enough data on PRP for me to confidently offer it as an alter uh regenerative therapy in my practice because the data isn't there yet. But when people go out there and they offer these therapies that are not backed up by data, then that kind of casts aspersions and uh, you know, kind of ruins it for the therapies we know that are efficacious.

SPEAKER_03 1:22:24

Yeah, so two questions. Yeah. Have you looked at whether or not the concurrent use of a PD5 inhibitor and shockwave offers anything better than not taking the PD5 inhibitor?

SPEAKER_01 1:22:36

So, and none none of the studies have looked at that, okay, because obviously they're trying, they don't want to do a multivariate analysis, they're trying to focus on just you know the shockwave, all right. But from a pragmatic standpoint, okay, I know that putting the patient on the daily Cialis isn't going to hurt them. It's not going to reduce their response to it. So the question is, why would I not give that? And the only reason I would not give it is if the patient had some incredibly rare contraindication.

SPEAKER_06 1:23:01

It's very rare. I think people think there are way more contraindications to Tadalafil use.

SPEAKER_03 1:23:05

Which second second question. Yeah. Would you have although the the data on PRP is plus minus, yeah, do you think theoretically it could offer an advantage if used with shockwave therapy?

SPEAKER_01 1:23:18

You know, I think that it could, but that needs to be a IRB-approved prospective study that does not cost patients money. And I have seen people who have used that theory as an excuse to charge patients thousands of dollars for things that have been unproven. And I think personally, when you're accepting that kind of cash, you are no longer a good faith, you know, uh investigator. You're an opportunist. Okay. And so clinical trials should not be paid for by patients. They should be paid for by the companies that have a vested interest in getting that positive outcome. Now, that may there is some nuance there. For example, we're talking about peptides. We may need government funding, NIH funding, in order to conduct the trials necessary to show efficacy. They will not pay for it. Well, I mean, I'm hoping that one day that there will be enough interest in public health that we could get taxpayer money to fund that sort of thing just to show enough that it's beneficial because I think that'd be a net positive for society.

SPEAKER_03 1:24:15

I think the problem, I think the problem with that is that the FDA, NIH, whatever would not be opposed to doing a study like that. But the problem with the peptides is not efficacy. The problem is safety. And to do a safety study, you need a huge number of patients. Correct. And no one's going to pay for it. Well, again.

SPEAKER_01 1:24:38

No, you're you're right.

SPEAKER_03 1:24:39

I mean, I so I again No, I could be wrong, but I mean that's been my overall feeling when it comes to drug trials.

SPEAKER_01 1:24:45

Yeah, nothing is impossible, okay? But I do think that there is potentially a needle that can be or can be threaded in the future to get uh as much more data than we have now. Right.

SPEAKER_06 1:24:57

I think it would be easy to enroll patients in those studies though.

SPEAKER_01 1:24:59

Oh yeah. Oh, totally. Hell, I'll show I'd sign up in a heartbeat. Yeah, my shoulder sucks. You know, give me all the juice. But then you could get to placebo. Oh, that's true. Yeah. Uh yeah, as long as I get promised to get the real stuff at some point, you know. Um, but you know, I do want to go ahead and I want to kind of throw up a devil's advocate argument, steal me and straw me on something, because again, I just expressed very strong opinions on like shockwave therapy, okay, and versus radio wave therapy. And the reason why I have that strong opinion is because we have definitive data showing that radio wave therapy does not work. Exactly. Which is why I think that people that continue to offer it and charge thousands of dollars for it, I think are ethically compromised. Okay. Now, someone could try to take that same argument and try to throw it at me for prescribing peptides to my patients. And I would respond to that by saying, I personally don't have any financial interest, you know, uh, at the time of this recording at all, in the uh in patients taking peptides or not. Okay. And the thing is, is that we but just because we don't have data that these things definitively work in certain like in certain human populations, absence of data is not data of absence. Radio wave, we have data showing no effect. Okay. So these are these are apples and oranges in my mind. Okay. And so I am very open to once, hopefully, as you know, Secretary Kennedy has intimated on you know podcast appearances that you know, supposedly the FDA is going to move 14 of the 19 peptides that are on category one back to category, or sorry, are on category two back to category one. I hope that happens, okay? All right, you know, faith in Washington is pretty tough. But if that happens, I will be the first in line to offer those to my patients once more, okay? But it'll be within an appropriate counseling of the data we have, the data we don't have, and you know, them understanding all the potential, you know, risk and implications of that. And again, which is why I make the social media content I do now, so that we can get that data out there, get that understanding so patients can educate themselves. Because once these compounds do become available again, it's going to be a rush. It's going to be a daily.

SPEAKER_03 1:27:00

Well, it's going to be the the internet is going to be offering them as a fire sale.

SPEAKER_01 1:27:05

It's true.

SPEAKER_03 1:27:05

And that's what we have to be wary of.

SPEAKER_01 1:27:08

And I don't think, you know, again, I d widespread peptide access, I think, is a good thing. But at the same time, like these people who are saying, Oh, I put on, you know, 30 pounds of muscle with TB and BPC, that's BS.

SPEAKER_03 1:27:18

That is, I don't think it's I don't think it's good. I don't think widespread access is good because it's, you know, it they're prescription drugs. Well, they're not saying they won't be prescription drugs.

SPEAKER_01 1:27:28

Well, sorry, when I say widespread access, I don't mean where you can go and buy them off the counter. I mean through a script from a physician who's educated on the topic from a reputable 503A, but I I use the term widespread access relatively because that is better access to a better product compared to gray market. Whereas, you know, I have had some gray market suppliers who have great product. There are other gray market suppliers out there that are you just don't know that have you know other contaminants, and that's just a fact that there's just no regulation. So there is high variability.

SPEAKER_03 1:27:57

One last thing about Shockwave. Okay, and that is. Is retreatment. So Paul Giddens, who was one of my fellows, who actually started me using Shockwave. Yep. Did you start before me? I did.

SPEAKER_01 1:28:09

I started, but it was because we both wanted to start at the same time, but you had more hoops to jump through at Baylor. Of course. And I just bought it.

SPEAKER_03 1:28:19

Oh, was it? Yeah. Oh, okay. But anyway, back to my question is Paul retreats people regularly. Yep. On a schedule. And he says they do better. We don't.

SPEAKER_01 1:28:29

What do you do? So I think Paul is correct in what he is doing. I think that uh the theory behind it lines up in Paul's favor. But I will say we do not regularly retreat patients or mandate it. We will give them guidance and say you would probably benefit from retreatment in a year or 18 months, but we don't schedule them for that. We let it, we leave it on the patient. And so uh probably making that more structured and recommending that would be better. But at the time when I developed our shockwave program, we and even to now, we don't have data saying that you should retreat or you should retreat within a certain period of time. And so at the time, shockwave was super controversial, and I was just trying to stick to the data that we had. But keep in mind, when we started offering Shockwave, the SMSNA still had a white paper and position statement against it. Okay. Which I thought was rich considering that many of the people that sit on the board already had machines in their clinic, some of which they got donated for free, and they're charging patients for. So I'm like, rules for the for uh me, but not for thee. Got it, cool.

SPEAKER_06 1:29:31

Anyway, what are your messages to like the young guy watching who's interested in shockwave and he's interested in peptides? What's his takeaway?

SPEAKER_01 1:29:39

So I think the takeaway is like this is one of the most exciting times that we have in health and wellness because we have more tools and more levers than we've ever had before. Okay. Um, and again, I love things like shockwave. Those are all things that you should pursue. I I think they're great. I think peptides are great, but ultimately, let's not forget the basics, okay? Peptides and shockwave are not gonna do anywhere near as much good for your sexual function or for your long-term health as effective diet, exercise, uh and sleep. Okay. If you can get those things in like freaking dialed, dude, you are gonna do awesome. So I think we need more education and encouragement along those lines. But then as you get those things dialed, okay, as you continue in your healthcare journey, incorporating different adjuncts like shockwave therapy, like peptide therapy can help you go that much further. You know, again, like we mentioned previously in our, you know, uh talk about you know growth enhancement, coming from a place of abundance rather than looking from a place of desperation, like that is where you're gonna get your best bang for the buck.

SPEAKER_03 1:30:37

I especially like the concept of early introduction of shockwaves. I mean, peptides are given for symptoms because we want to treat it and see the outcome. Sure. But this is almost prophylactic.

SPEAKER_01 1:30:48

Yeah. But I I will say, by the way, in the world of peptides, I think that we are going to see people who start taking, for example, GHKQ on a regular basis at a very young age to try and preserve collagen, you know, uh turnover, right? You know? And hair. And hair, right? Shit, I need all the help I can get, man. All right, you know, uh dutasceride after uh starting testosterone only does so much. Right. Yeah. Uh which I is a personal choice. I don't recommend everyone taking the five alpha reductase inhibitors that comes with certain risks. We'll talk about post-finasterite syndrome later. But, anyways, um but hey, I rolled the dice if it's okay for me.

SPEAKER_06 1:31:20

Alex, an incredible storyteller, an incredible educator. And where can people find you on social media?

SPEAKER_01 1:31:26

Just so uh Dr. Alex Tatum on uh YouTube, on Instagram, and on uh TikTok. Uh and uh yeah, not going anywhere. So thanks.

SPEAKER_06 1:31:36

So good to have you on Facebook.

SPEAKER_01 1:31:37

Yes, thank you again.

SPEAKER_03 1:31:38

It was fantastic. Thanks, guys.

SPEAKER_06 1:31:40

Larry, I really appreciate Alex's grounded viewpoint when it comes to these novel therapeutics. Oftentimes in medicine, we're either very pro, very con, and he's somewhere in the middle, which is I think where you and I sit as well.

SPEAKER_03 1:31:54

Yeah, but he's extremely enthusiastic. I mean, I think that comes across vividly.

SPEAKER_06 1:31:59

Yeah.

SPEAKER_03 1:31:59

Yeah.

SPEAKER_06 1:32:00

And what I like about the content he presented today, as well as his social media content, is he really delves into the literature on these topics that the men walking down the streets really want to talk about.

SPEAKER_03 1:32:09

Yeah, and and and a really good understanding of shockwave therapy and where it's positioned in the treatment of erectile dysfunction.

SPEAKER_06 1:32:17

Yeah, that's not all just marketing.

SPEAKER_03 1:32:19

No, and it's not just the cure all for everything, but it it has its place. And uh, I liked his discussion of some of the technical aspects.

SPEAKER_06 1:32:28

Yeah, absolutely. All right, so what's the F-word for today's episode?

SPEAKER_03 1:32:32

So I think given all the news information that we got, I think we have to call it forward thinking.

SPEAKER_06 1:32:37

Okay, I like it. Now, my favorite part of the show. Give me some foreplay for the next one.

SPEAKER_03 1:32:43

Oh god, that's so personal. Uh our our next speaker uh is going to be Michael Florida. Michael Florida is a Houston-based uh sports nutritionalist uh who is going to tell us how to take better care of our bodies.

SPEAKER_06 1:33:00

I love it. Thank you for joining us today on fertility and other F words.

SPEAKER_03 1:33:05

And don't forget to like, subscribe, and leave a comment.

SPEAKER_06 1:33:09

Until next time.