Do you have questions about men’s health? Many times medicine focuses on women’s health and we know how men hate to go to the doctor! Dr. Ruscio has men covered with this episode as he interviews Dr. Geo Espinosa, Naturopathic Urologist, on all topics men’s health.
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Dr. R’s Fast Facts
- Morning erections indicate sleep quality.
- Things that can negatively impact testosterone:
- Statins can decrease testosterone
- Excessive stress/cortisol castrates
- Body fat causes high estrogen, estrogen can shut down testosterone
- Low testosterone in men can cause increased risk of:
- Heart disease, cognitive decline, osteoporosis and falls
- There are natural and prescription options for optimizing male hormone levels:
- Herbs, adrenal support, HCG and estrogen blockers
- The first step is diet, lifestyle and gut health
- Women take notice, there are some things you may notice in your partner that are important:
- Prostate health & prostate cancer:
- Testosterone does not appear to cause prostate cancer, it may actually be estrogen
Dr. Geo Espinosa bio…..5:03
Causes of low testosterone…..9:15
Health implications of low testosterone…..27:10
Testosterone replacement therapy and prostate cancer…..29:17
Available treatments for low testosterone…..35:24
Hormone replacement therapy…..45:26
(1:00:01) Thrive Don’t Only Survive
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Men’s Health with Urologist Dr. Geo Espinosa ND
Welcome to Dr. Ruscio Radio, discussing the cutting edge in health, nutrition, and functional medicine. To make sure you’re up to date on this and other important topics, visit DrRuscio.com and sign up to receive weekly updates. That’s D-R-R-U-S-C-I-O.com.
The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor.
Now, let’s head to the show!
Dr. Michael Ruscio: Hey, everyone. This is Dr. Ruscio with your fast facts. A great episode today with Dr. Geo Espinosa all about men’s health. Dr. Espinosa is a urologist, and so we went deep into items of male health, but for the women listening, he discussed some very important things for women to be on the lookout for in their partner because you may be able to pick up on some of the signs and symptoms of a problem that a man may not follow up on because we can be pretty darn stubborn, so your hunch, your observations, and maybe your gentle kick in the butt to prompt some movement by your counterpart may be very helpful. Here are some of the fast facts that what was a really great call.
Morning erections indicate sleep quality, and this is likely because testosterone is produced at night and you need to be sleeping soundly in order to produce testosterone. Good sleep, good testosterone, and then erection.
Things that can negatively impact testosterone—this is not an exhaustive list:
- Statin medications or cholesterol-lowering medications can decrease testosterone.
- Excessive stress or cortisol, as Dr. Espinosa very aptly puts it, can castrate men. That’s figuratively, not literally.
- Fat causes high estrogen, and estrogen can then shut down testosterone. Now, I should clarify this is body fat, not dietary fat.
Low testosterone in men can cause an increased risk of heart disease, cognitive decline, osteoporosis, and falls.
There are natural and prescription options for optimizing male hormone levels. There are certain herbs, which Dr. Espinosa expands upon. There are also herbal adrenal supports. There is a prescription known as HCG, and there are some estrogen blockers which actually will help to increase testosterone, as we’ll also discuss.
However, per Dr. Espinosa—and I am, of course, very much in agreement with this—the first step toward optimizing male hormone levels is going to be diet, lifestyle, and—you guessed it—gut health.
Women take notice: There are some things you may notice in your partner that are important, like we discussed a moment ago. One of the specifics might be frequent urination at nighttime.
And finally and very interestingly, we talked about prostate health and prostate cancer. Dr. Espinosa is just finishing a book on prostate cancer, and amongst the other things we discussed, testosterone does not appear to cause prostate cancer, and it may actually be estrogen.
With that, we will jump in. OK, thanks, guys.
DrMR: Hey, everyone. Welcome to Dr. Ruscio Radio. This is Dr. Ruscio, and I am here with Dr. Geo Espinosa, one of the best-looking urologists in New York City. He kind of has a Vin Diesel-esque kind of look to him.
Dr. Geo Espinosa: I never thought of it that way, but now that you mention it, I can see that!
DrMR: Well, if Vin Diesel was a doctor, I think that would be you.
DrGE: For better or for worse. I’m not quite sure that he’s that good looking, but I’ll go with it!
DrMR: Well, at least he looks tough, right? No one’s going to push you around.
DrGE: That’s right.
DrMR: There’s so much to say about you and your background. Just really quickly to kind of get the audience up to speed, we met… gosh… it must have been sevenish years ago at a… was it a bioidentical hormone replacement conference, I think?
DrGE: It must have been a conference with… Wasn’t it the California Naturopathic Association, maybe?
DrMR: Yes, that’s what it was.
DrGE: I spoke about prostate and prostate issues, and we met and we’ve been pretty good friends since.
DrMR: Yeah, a fellow East Coaster, so we had a lot to connect on.
DrGE: That’s right!
DrMR: I’m really happy to have you here to talk about everything kind of male-health related. As a urologist, you’re the guy I kind of come to or the guy I refer to when we have a young man in the office and we’ve gone through some of our preliminary therapies and we’re still kind of scratching our head and saying, “Something here doesn’t look quite right.”
DrMR: You’re the guy I refer to for that.
Dr. Geo Espinosa Bio
DrMR: Can you tell us a little bit about your background, your training, and what you’re doing right now before we kind of jump into the talk?
DrGE: Oh, sure. I am the director and a doctor at the Integrative and Functional Urology—not neurology, urology—Center at NYU here in New York. Essentially it’s a center where we do all urology and all men’s health. A urologist is the male gynecologist, so you can imagine that my practice consists of about 90 percent men and actually about 10 percent women just because women, too, have urological issues even though they don’t have a prostate or a penis.
If your audience has an idea of what functional medicine or naturopathic medicine is, then that’s pretty much the approach. And we also do a complementary approach or an integrative approach, where, look, sometimes some of my patients absolutely need a conventional therapy, whether it’s a surgical procedure or something else, so we work in tandem so that there are likely less side effects from the conventional therapies, and then we keep them well from our naturopathic and functional medicine approach.
Most of my practice consists of prostate issues, prostate cancer, erectile dysfunction, erectile issues of all kinds, penile issues like Peyronie’s disease and things like that, male infertility and hypogonadism or what they call andropause.
DrGE: From a woman’s perspective, I presume you have a pretty large female following there, Michael.
DrMR: Yeah, I think we probably have more females than males, but I also know there’s a fair amount of males who follow these things, and so I thought this would be nice to kind of make it kind of the day for the men because we oftentimes hear all about the female hormone piece.
DrMR: And I know there are men out there who are probably like, “Well, I’m kind of worried about some of my male hormones. Where can I get a good expert in that realm?” I think there are some guys who are probably a bit underserved in terms of information in this space, and that’s, again, why I’m really happy to have you here to expand on this.
DrGE: And I can almost guarantee you that there will be a lot of women listening because women are the ones that take control of the health of the men in their lives.
DrMR: Right. Excellent point.
DrGE: Every time I give talks, oftentimes with a room full of women, they’re paying close attention because they want to take care of their husbands, fathers, sons, and grandfathers. They’re the ones when their husband is getting up five times a night to go urinate, they’re asking me, “What’s the deal with that? Why are they doing that? Why is that happening?” We have quite a lot for women, and we can give them some tidbits as to how to take good care of their men.
DrMR: That’s actually an excellent point. Women, don’t tune out. There may be a few things here that are important for you to hear about regarding your partner’s health because I think a lot of guys have a tendency not to do anything until they literally have a limb missing. They’re not going to go to the doctor until they get to that point!
DrGE: That is so true. That is the unfortunate truth, and there’s a certain psychology behind that that I am so in tune with. The main reason is because it takes one to know one, and I know my own behaviors and I study my own behaviors and that of my patients. That’s a story for a different day as to why we act the way we do, that I’d be interested in at some point.
DrMR: Interesting. Definitely. Well, I know you just wrote a book, and I want to come back to some of that a little bit later. The book is all on prostate cancer, and I think it’s great to have someone with your experience and your philosophy writing about that. I definitely want to come back to that, and I think a lot of the pieces of that will be kind of interwoven into our conversation, but I know that one of the things that comes up so quickly here ties into prostate cancer also, something that is kind of at the forefront of this discussion or this area for a lot of men, and that is testosterone.
Causes of Low Testosterone
DrMR: Low testosterone. You’re seeing the commercials now, that it’s just a number, low T, whatever it is, for some of the testosterone gels and what have you. Why don’t we start off with talking about testosterone. Can you take us through what some of the common symptoms are that testosterone might be an issue and what the health implications of low testosterone might be?
DrGE: Yeah, great question. Let’s get some things out of the way right from the beginning in terms of who is the majority of men that get diagnosed or what age groups get diagnosed with low testosterone or hypogonadism. Most people would think, of course, that’s an aging disease, just like prostate cancer is an aging disease, and prostate problems is an aging disease. Not true. Not true at all. In fact, I would say that maybe about 50 percent of the patients that I see with low testosterone are actually in their 40s, their early 40s. I have a 26-year-old—or he’s 25, actually—that came to the office last week with low testosterone.
DrGE: So either men are aging prematurely and at a very early age, or low testosterone is not an aging disease at all, one of the two. And I don’t know that it’s just related to being a New Yorker.
DrMR: Although I’m sure that doesn’t help. Right.
DrGE: It doesn’t help from a stress perspective. What happens when one is overly stressed, when the saber-toothed tiger is running after you continuously, 24 hours a day, you secrete an excess amount of cortisol from the adrenal glands that sit right on top of the kidneys. But the fact of the matter is, Michael, that cortisol castrates.
DrMR: Well said.
DrGE: I hate to say “good” or “bad” when it comes to hormones because there’s no good or bad. It’s an excess amount or inefficient amount of things that are secreted, just like cholesterol. Good cholesterol, bad cholesterol. There’s really no such thing as good cholesterol or bad cholesterol. Not to completely digress, but what we think of bad cholesterol is cholesterol that goes away from your liver. Well, you need cholesterol to go away from your liver because you need cholesterol to make certain things in your body.
DrGE: Like testosterone, right! Which brings up one idea—and I will jump around a little bit, but there’s a method to the madness, and I think your audience will appreciate it, all right?
DrGE: If you want to see a really unhappy male in your office, like really in bad shape—fatigued, pooped out, doesn’t have a nice jump in his step—that would be a man taking high dosages of a statin drug, which is causing his cholesterol level to go down too much. It’s not the lower you go, the better. I have these discussions with a lot of cardiologists, and really I want to bang my head against a wall because they do the cholesterol limbo. How low can you go?! Lower is better! And this is not true. Cholesterol is a very important component to create testosterone, and some older men that are taking statins, Lipitor or those kinds of drugs, at a very high dosage—or even at a low dosage sometimes—they develop low cholesterol levels, but then they have the inability to make testosterone from cholesterol. The bottom line is that very low cholesterol causes low testosterone as well.
Going back to cortisol, which is one of the main reasons certainly with New Yorkers because everybody is stressed out of their minds, and even these Wall Street guys, they have an excess production of cortisol that inhibits the production of testosterone.
The other thing with testosterone is that testosterone typically is made in the body at nighttime, during a man’s sleep cycle. Testosterone is secreted somewhere between 4 and 6 a.m. Well, the problem there, and it’s tightly connected with stress, guys that are having a hard time sleeping, whether it’s due to insomnia or high stress levels, that they start ruminating at night and they don’t sleep well. Or they’re going to the bathroom to urinate frequently. That will interrupt the proper phases of sleep that one needs to go through and then thus interrupt the production of testosterone.
DrGE: So poor sleep habits are a problem there as well. What else is a problem? What are the other causes? The other causes are men getting fat. The excess amount of fatty tissue that’s created produces an excess amount of estrogen because of the aromatase pathway. If you have high levels of estrogen, your testosterone goes down, and vice versa. If you have high amounts of testosterone, estrogen goes down. You cannot have it both ways.
DrMR: This is because they both reflexively inhibit the brain signalling to produce more of the hormone, right?
DrGE: That’s absolutely correct. It’s what’s called a negative feedback system that the body has because we are not supposed to secrete an excess amount of anything. The intelligence of the body is such that if you increase one of one thing, then it sends a signal back to your brain to say, “Hey, stop producing either that one thing or the other thing,” in this case being testosterone or estrogen is overproduced.
DrGE: Having a big belly, beer bellies and things like that, that also induces low testosterone levels.
DrGE: I think those are the main causes. We could go on and on, but those are the main causes that I see here in my office frequently.
DrMR: A question that I’d like to ask to get your perspective on as someone who’s looking at this closely, you hear a lot about xenoestrogens and phytates, these things found in plastic or in the environment. My approach here—and I’d love to hear if yours is the same or different or what have you—is, yes, these things certainly be detrimental, so we want to practice some practical and basic adherence principles, but I’m not convinced and I haven’t seen anything compelling showing that becoming really crazy in how much you avoid… like never ever drinking out of a plastic water bottle. Sure, make the lifestyle intervention to try to drink out of plastic as little as possible, but I don’t think if we have one exposure to a plastic water bottle once a week it’s going to necessarily cause a huge difference in someone’s testosterone levels.
And then wrapped in with that there are lab tests that are available and some maybe detox things you can do to try to pull some of these chemicals out. I haven’t seen a lot that I could really get behind there, but again, I don’t specialize in this, so what is your take there?
DrGE: When we have a patient and we’re doing our type of medicine, Michael, we can only go so far. We can only say so many things. We may have an hour to an hour and a half with each patient, so we have to say, OK, what’s the biggest priority here in terms of what it is they need to do, because they may have to do a lot.
DrGE: To be honest with you, them not drinking from plastic bottles is not the first thing that I suggest. I might say that in a follow-up visit. Why? For two reasons. Number one is because the poison is in the dose, like Paracelsus said thousands of years ago. Them drinking from plastic bottles, if they do it frequently, it might be an issue, so you could test for all kinds of estrogenic levels in the body through different urine tests and even blood tests. That could be tested. Of course, only if there’s really high estrogen levels, where there’s an imbalance with testosterone, will I even go there. This is part of individualizing the treatment and the protocols, of course.
Before we went online, Michael, we were talking about the importance of us practicing, not only writing great books and so forth with no experience, but having a practice, so that we really have a basis to have a discussion and to write about certain things that we feel comfortable with based on our clinical experience.
One of the reasons why I like specializing in men’s health is because you have to know the psychology of the type of patient that you’re seeing, not just the physiology. We’re mind-body. We do it all. It’s a very holistic approach. We really need to know the psychology, so I don’t want to just turn people off. They’ll say, “Oh, this is too damn hard. I’m not going to do anything.”
DrGE: So, again, I do have some of them steer away from plastic bottles. We know it’s a problem. We know that all these estrogenic compounds from the plastics, they leach into the substance that you’re either eating or drinking. I tell them general things. I will them, for example, don’t let these plastic bottles get heated. Don’t leave them in the back of your car on a hot summer day, don’t expose them to heat, and the harder the bottle, the better. There’s less leaching with harder plastics than with softer plastics. They have certain numbers. You look at the bottom of each plastic bottle, and there’s a number there from 1 to about 9 or so, and the numbers that are OK are—I may butcher this—4, 5, 6, and 7, or something like that.
DrGE: Those are better. That information is widely online in terms of what are the right numbers. But the bottom line is that, yes, there is a problem. The question is, is that what you need to do if you have low testosterone?
DrMR: Gotcha. I asked that question just to help contextualize things for people because one of the things I see many patients struggle with is they go on the Internet and they read about many different things, and they’re not sure what is the most important and what is maybe what we would consider the last or one of the last things that you want to do. It sounds to me like there are more important core issues that you’ve mentioned and, I’m sure, that we’ll expand upon that are really more important to be addressed first for most cases, right?
DrGE: For most cases, yes. Again, male infertility, for example. We know that chemicals, you have to detoxify. Once again, not to completely digress, but I had a conversation when I was on a radio show yesterday on male infertility, and about 50 percent of men are responsible for an infertile situation. It was thought that it was mostly a women’s problem, that women were 99 percent responsible for infertility. No. Fifty percent of men are responsible for infertility. In an infertile man where you can clearly see abnormalities in their sperm, they definitely would have to do no plastics and be more careful.
DrMR: OK, that makes sense.
DrMR: All right, so we’ve talked about some of the causes. I think we’ve pretty much pinned down most of those.
Now, I know there are a few different indicators that men hear about in terms of symptoms for potentially declining levels of testosterone. Obviously sex drive would be one, sexual performance would be one, getting erections, maintaining erections. What about getting morning erections? I’ve heard different things on this. I’ve heard some people say if you don’t get a strong erection every morning something’s seriously wrong. I’ve heard other people say it’s not that strongly tied. Do you have any thoughts on that?
DrGE: Yes, I do. The penis is an amazing barometer to a man’s health. Some men are just not sexually active, so you have to have the masturbation conversation. “When you masturbate, do you get an erection? How about in the mornings? Do you get an erection?” The answer is that while it is not necessary for a man to get an erection every single morning to determine whether or not they’re making enough testosterone, it is a major part of a man’s life to indicate that they are making… Interestingly enough, Michael, the way I look at it is that morning erections can be indicative of the quality of sleep in a man.
DrGE: Why is that? Because you need to be in phase 4, phase 5, REM sleep almost, to make the testosterone, yes, and the increase in testosterone in the morning is what’s causing the erection to occur in the morning. So if they man wakes up with an erection, it doesn’t have to happen every morning to indicate whether they’re having good enough sleep, but if they wake up with an erection every now and then. It doesn’t matter what age either. These are men in their 20s… Well, in their 20s, men wake up with erections almost every morning. But even in their 40s, 50s, and 60s, they still wake up with erections, or in the middle of the night because a man has an erection about three to five times during their sleep cycle.
Michael, you have kids, don’t you?
DrMR: I don’t. Nope.
DrGE: You don’t have kids?
DrMR: I do not. I am still a bachelor out here in California.
DrGE: No way! Well, can we talk about that and not men’s health?! Can we talk about your bachelorhood over there in California?
DrMR: I think the personality piece is more than most women can get past. I need to find a woman that probably can’t hear, and then I think I’d probably have a shot.
DrGE: I think you’re going to get a lot of calls now after this podcast!
What I wanted to say is I have three kids, and hopefully maybe you’ll experience this at some point if you ever have kids. At any given moment, and my kids are 12, 11, and 3, less so with the older two, but at any given moment, they have some sort of a nightmare or they’re sleepwalking into our bed, and they sleep next to us. That’s a common scenario. And there are times when they wake up and you’re kind of surprised and shocked that you have a very strong erection. [phone ringing] Excuse me one second here. Sorry about that.
DrMR: No worries.
DrGE: This is live recording, man. I think that was one of my kids calling, actually.
DrMR: Speak of the devil!
DrGE: Exactly! So then it’s a little bit embarrassing with your child. These things occur to every man who has kids. So there you can tell that, yeah, even if you don’t wake up with one, you discover that in the middle of the night you have one.
The bottom line is this, that to me, waking up with an erection not every day, particularly as you get older, but two to three times a week can be an indicator of the quality of sleep that you had the night before.
DrMR: Gotcha. That makes a lot of sense. One other question to piggyback on this: I’ve also heard and made some observations myself that if you have to pee, that can sometimes stimulate an erection because when you’re erect you have valves in the penis that prevent urination. Is there anything to that, or is that just hearsay?
DrGE: No, that’s pretty much true, and the other thing that’s important along those lines is that a lot of men complain about having a difficult time peeing in the morning, and they always say, “Well, my stream is so slow in the morning, and I think I have a prostate problem.” That doesn’t necessarily mean they have a prostate problem. That means that they maybe they have a semi-erection. I won’t make any assumptions because we have a lot of women listeners probably. When men get an erection, they can’t pee with an erection. Even if it’s a semi-erection, sometimes they can pee, but it’s a little bit more painful or a little bit slower stream. That’s one of the reasons why men have a slower stream in the morning, because they just had an erection or maybe have a semi-erection. It is oftentimes—not all the time, but oftentimes—not related to some sort of prostate disorder.
DrMR: Gotcha. And I believe the reason for that is because the urine has compounds in it that will kill the sperm. So there is evolutionary intelligence behind that, right?
DrGE: Behind men not being able to pee because they have a semi-erection?
DrMR: Well, because when you ejaculate or if you’re in that realm, because urine can damage and kill sperm, you kind of want to be in mode or the other, but not really both.
DrGE: Yes, that’s an evolutionary phenomenon. There’s that valve that you spoke about earlier that either closes or opens depending if you want to ejaculate or urinate. They don’t open at the same time for both. Yes, that is the purpose.
Health Implications of Low Testosterone
DrMR: So, Geo, what are some of the health implications? Let’s say someone truly does have lower or low testosterone. What are some of the health implications? Of course, it’s not fun to experience some of the more notable sexual side effects, but are there other health implications, like neurological? I’ve heard there are increased incidence of falls or just accidents of any type or cause or potentially a cardiovascular implication for this, so what are some of the risks of low testosterone?
DrGE: Well, let me tell you one thing off the bat that I think is incredibly and crucially important, and that is that testosterone does not cause prostate cancer.
DrMR: I was hoping you were going to bridge on that.
DrGE: No, there are no bridges. Right off the bat.
DrMR: Let’s go into it!
DrGE: Let’s get that right out of the way! Because that’s probably the most common question I get asked, maybe because I do a lot of prostate cancer, but testosterone does not cause prostate cancer. To the contrary, what the research clearly shows is that men with low testosterone levels have higher rates of prostate cancer. So not only does it not cause it, but it may raise the risk of prostate cancer. That’s to say that the medical establishment has had it all wrong since the 1940s.
DrMR: Is this because—this is what I’ve heard, but again, I’m not involved in this clinically, I’m not actively researching this—when testosterone goes low, that can allow estrogen to go high, and that high estrogen and estrogen in and of itself can be more of a proliferative type of hormone and that can have a proliferative effect on the prostate cells?
DrGE: That seems to be the case. There are certainly a lot of estrogen receptors on the prostate, so that’s what seems to be the case. It seems to be that one should be less concerned about testosterone and more concerned about excessive amount of estrogen production or an imbalance between estrogen and testosterone.
Testosterone Replacement Therapy and Prostate Cancer
DrMR: So this then begs the question of, do you do testosterone replacement therapy in someone with precancerous or cancerous prostate issues? I know this is kind of a very controversial issue, but what’s your take here?
DrGE: Here’s my take. Look, let’s not beat around the bush here, and I think your audience knows this. There’s a certain level of a doctor protecting themselves from any type of judicial issue or lawsuit, right?
DrGE: What do I mean by that? Let’s be straight and honest. What I mean by that is that if somebody had low-grade prostate cancer and I give them testosterone and their cancer gets worse, I am still likely liable even though there is no connection.
DrGE: I think your audience needs to know that. One thing is to do the right thing—or least what we think based on research and evidence that is the right thing. The other aspect is a doctor just protecting their ass-ets.
DrMR: Right. It’s a sticky situation because you want to help a patient, but you also don’t want to incriminate yourself, and unfortunately we live in a fairly litigious society where protecting yourself is a concern.
DrGE: It is. It absolutely is. I can knock on wood right now. I’ve never had any type of legal situation, and you know what? I really don’t want one, but it’s part of the reality of medicine in this day and age.
So let me answer your question a little bit more. Have I had patients who have had low-grade prostate cancer, they’ve had their prostate cancer treated, three years later their PSA is undetectable, but they’re also hypogonadal with low testosterone, and we give them a little bit of testosterone because they’re having symptoms? The answer is yes, and we follow them thoroughly. There’s no magic number after one is diagnosed with prostate cancer as to when you start that type of treatment. We like the three-year rule just to play it a little bit safer.
I get questions asked as to whether we should treat prostate cancer with testosterone. That’s a very common question, and that’s not a completely idiotic way to go about it. Actually there is research by Abraham Morgentaler, actually, who wrote a great book that I recommend for your readers called Testosterone for Life. That book, while it’s somewhat outdated, it’s still pretty relevant, actually. There are aspects that have evolved, which is treating advanced prostate cancer with testosterone. Now, that is sacrilegious right there.
DrGE: Talk about revolutionary. That is analogous to Fidel Castro taking over Cuba in 1958.
DrMR: Right! Maybe to contextualize this a little bit for those listening that aren’t up to speed on this, one of the standard therapies—and again, please correct me if I’m wrong, Geo—for prostate cancer is actually testosterone blockers. They try to really lower testosterone as much as they can.
DrGE: Particularly in advanced prostate cancer. With low-grade prostate cancer, typically the treatments are nothing, active surveillance in which case I put patients on an aggressive naturopathic protocol, or the treatments are surgery, which is the most common treatment, where the prostate is removed through a prostatectomy, or radiation. Or in more advanced stages, then it’s hormone therapy. So once again, I just said that for advanced stages, there are some doctors doing research using testosterone while others are doing the standard 80-year-old treatment of testosterone depletion or androgen deprivation therapy.
DrMR: I think, of course, one of the main criticisms of that is the severe quality-of-life implications that it has. It really kind of demasculinizes men, and from everything that I’ve read and heard, it’s a really hard therapy to do because you just really lose drive. You lose your sex drive and everything else.
DrGE: And you’re increasing your risk of cardiovascular disease, of metabolic syndrome, of osteoporosis, which is why you said when you posed the question, does low testosterone cause an increase in breaking bones from, I don’t know, going to the bathroom? Actually as men age, one of the high causes of death among men that are aging is nighttime urination when they go to the bathroom, break a leg, and they hit their head against something and then they pass. It goes back to low testosterone.
DrMR: Right. I think you’ve kind of indirectly answered a lot of those questions, which are when we give testosterone-blocking therapy or androgen deprivation therapy, when we get testosterone really low, that increases cardiovascular disease, risk for falls, osteoporosis. Is there anything else there that people should be aware of? What problems can emanate from low testosterone?
DrGE: Cognitive decline and Alzheimer’s disease.
DrGE: I rarely recommend hormone deprivation therapy, but in some cases it is required for many reasons, but not in those that have a strong family history of Alzheimer’s disease.
DrMR: So you recommend against the androgen deprivation therapy if someone has a strong history of Alzheimer’s?
DrGE: Correct. I do. It increases their risk significantly.
Available Treatments for Low Testosterone
DrMR: So what do you do now? I guess this is really what we’re building up to. If someone thinks that they’re in this camp, what are some of the available treatment options to try to turn this around? I know a lot of men that I work with who have concerns about this, they see me because they’re wondering if their gut health might be contributing to inflammation or to chronic stress, and by improving the health of their gut, they might be able to increase their hormone levels. In many cases we see that, but it’s certainly not a cure-all, so what else do people have for treatment options for increasing or rebalancing their testosterone or hormones?
DrGE: To your point, let’s be clear that, of course, and I’m sure your audience probably knows this adnauseum, but the gut is the center part of every person’s health. You have a good healthy gut, you make better hormones, you make the hormones you want to make, you make the neurotransmitters you want to make, etc., etc., etc. Let’s get that out of the way.
And by the way, I don’t know if there’s a study that has compared men to women, but typically what I’ve seen in some of the women that I’ve seen, there are fewer gut issues with men than there are typically with women I’ve seen. I don’t know if it’s a chromosomal thing or some sort of hormonal thing. There are some men with gut issues, and these guys typically present, Michael, with chronic pelvic pain. The guys who are having gut issues also typically have chronic pelvic pain. How’s that for another digression?
DrMR: Interesting. Yeah, definitely interesting.
DrGE: Like excessive pain in their testicles, excessive pain in their penis. I’m talking about an extraordinary amount of pain, and it’s oftentimes associated with all sorts of gut imbalances and so forth.
DrMR: Is this a type of referred pain, do you think?
DrGE: It’s referred pain. If a man presents with prostatitis, which is another diagnosis of exclusion, oftentimes they have gut issues that would include constipation. The colon is right posterior to the prostate, so it’s right in back of the prostate. I mean, right there, so if there’s any level of constipation, that’s going to push up against the prostate. The prostate is going to become inflamed, and there’s some sort of referred pain through the pudendal nerve that’s going to cause pain and tingling sensations and burning and all kinds of things in the testicles or the head of the penis or the shaft of the penis.
DrMR: Gotcha. And just for the audience, referred pain just essentially means you have pain or inflammation in one spot and that can kind of radiate and cause pain or the sensation of pain in an adjacent or nearby area even though there might not be anything wrong with that other spot.
DrGE: That’s right. So going back to the original question!
DrGE: I’m notorious for this, Michael. I’m sorry. Everybody who hears me and anyone that knows me, they know that I can go all over the place. And hopefully, if I’m lucky, I’ll bring it back.
DrMR: It’s all good, my man. It’s all interesting stuff.
DrGE: All right, so what do we do for low testosterone? What are some of the approaches? To me, it’s the gut first. Then it’s what’s going on with your life. Once again, I’m a father and I’m always thinking fatherly things. I tell my patients, “Look, go to timeout and think of what you’re doing wrong.”
DrMR: I like that.
DrGE: “You’re causing your testosterone levels to be low. Go to timeout!”
“Are you not sleeping right? Are you overly stressing? Do you hate your job?”—That’s common. “Are you eating too many refined carbohydrates?” That can lead to a compromised gut and can lead to metabolic syndrome or excessive fat formation, excessive fat in the body, etc., etc., that’s causing low testosterone levels. So what’s happening?
Some guys are so low in testosterone, so fatigued, so low energy, so not enjoying life because they have low-to-no libido, that they need something exogenous.
DrGE: Other guys, we have the luxury of, well, we could do acupuncture. We have certain locations or certain points that seem to work well in increasing testosterone or at least helping men feel better.
I use certain herbs. I like the proper use of maca, for example. I like the proper use of epimedium. If they are low in DHEA, which is a precursor to testosterone, they get DHEA. Proper levels of vitamin D. We know that vitamin D helps with the production of testosterone, but only if they have proper blood levels, let’s say around 50 ng/mL, give or take a couple of points. There are quite a few herbs.
I love adaptogens. What are adaptogens? Adaptogens are this group of botanicals or herbs that kind of balance the body out from stress. They nourish the adrenal glands, a lot of them, and if there’s too much cortisol, they kind of bring it down a little bit—or if there’s too much of anything that’s stressful, stress chemicals. What are my favorite adaptogens? My favorite adaptogen is rhodiola, that I use frequently in a formula that I actually created. The other adaptogen that I like is ashwagandha. I also like Siberian ginseng. These are all things with which men typically do very well.
Once again, sometimes you need to go right for the big guns, and the big guns for me are not so big. For example, it’s not like testosterone injections, although sometimes that is the case, but sometimes what we use is things like Clomid or clomiphene or HCG, and what these drugs do is essentially try to help your body to make testosterone. It’s not exogenous testosterone where you’re just applying the testosterone to your body or injecting it. It helps your brain kind of produce its own testosterone.
DrMR: And what’s interesting—Geo, to help people understand these really quickly—HCG is just kind of like giving synthetic… or not really synthetic, but it’s giving another type of luteinizing hormone, which is the hormone that travels from the brain to the gonads to signal testosterone production.
And then the Clomid is an estrogen blocker, and we talked before about how if estrogen goes high, that will inhibit the brain from signalling for more testosterone because both estrogen and testosterone signal back to the brain to stop more estrogen and testosterone from being made. So if they give an estrogen blocker, and as that goes down, that may spawn more signalling from the brain to the gonads to produce testosterone.
Am I right in both of those assertions, Geo?
DrGE: Absolutely. I could not have said that better myself there, Michael.
DrMR: Wow. That’s a compliment because you’re pretty good with words. I’ll take that as a compliment!
DrGE: That was awesome, and that’s exactly what happens. Of course, some guys are coming to me and saying, “Look, I want the natural route. I don’t want any meds.” Look. I’m agnostic when it comes to being a clinician and a physician.
DrMR: I like that.
DrGE: I’m agnostic. I want to do what works, and I want to do what works from a perspective of natural first, things with very low to no side effects, and then move on from there. While I am a naturopathic doctor, I like certain meds and conventional approaches like clomiphene or HCG or even metformin, actually, for prostate cancer in the right patient population. You don’t want me to go there. I won’t go there yet.
DrMR: Actually I’d like to come back to prostate in a bit more detail in just a moment, but there’s one or two other things that I wanted to get your take on.
I guess, before we leave ways to boost testosterone, I think you’ve given a pretty good narrative, and I’ll just kind of try to reiterate this. We always start with diet and lifestyle, which would include stress, of course, and then a thorough gut evaluation would be a really good idea after diet and lifestyle, which I think my audience totally gets because I harp on that more than they probably even enjoy!
Then we have certain herbs that help with adrenal stress and herbs that can also just help with boosting or goosing the system to produce testosterone on its own. We have some drugs that don’t contain any testosterone but kind of help coax the body into making more testosterone, like the HCG and the Clomid.
And then we have actual testosterone therapy. With testosterone, I know there are a few options. There are creams, and there are also pellets, and there are also injections.
Hormone Replacement Therapy
DrMR: Now, without going too, too deep into this, there are a few things that I know from, again, a very cursory, very outsider sort of perspective, but in some of the training I’ve done on anti-aging medicine I’ve heard that creams have more of a tendency to cause high DHT, which may mean creams are really good for sex drive, but it may also mean that they more prone to cause hair loss, whereas pellets or injections don’t seem to have that same risk.
Do you have any thoughts or comments on that piece for people?
DrGE: Well, the first thing is that there’s absolutely nothing wrong with having hair loss and being bald. I’ll just start there.
DrGE: Your audience would know that… well, you did say I look like Vin Diesel, and he’s bald, so that’s what we do here.
DrMR: But you pull it off. You have a good head for being bald. My head is so oddly shaped, and I fear people would think I’m a leper if I had no hair.
DrGE: Well, you have a nice head of hair. Clearly you’re not producing a whole lot of DHT, which is nice to see!
So the answer to your question is yes. The answer to your question is that creams have a tendency to produce more DHT. But more importantly and more interestingly—and where one needs to be more careful actually—is that if you have testosterone cream, you need to be super careful with those that you hug.
DrGE: Because then you will have your wife or your child growing a beard. That’s not what you would want, that’s not what they want, so you have to be super careful with that. And that’s why I’m kind of against the creams, for those two reasons—high production of DHT and the fact that you can rub off some of that cream to a child or a woman.
DrMR: Gotcha. And if the dose to a woman was small enough, that can have a nice sex drive enhancing effect.
DrMR: So maybe, guys, just like a small hug once a week of you want to try that!
DrGE: Listen, listen, listen. Kiss her. Tongue her down—let’s just be real here—because your saliva actually has a lot of testosterone, and she gets excited when you give her some of your saliva from the testosterone that’s going right into her bloodstream.
DrMR: Hmm. There we go, guys.
DrGE: All right? Let’s go back to basics here!
DrMR: I like it. Kiss your wife, I guess, once a night for a week, and then reevaluate her sex drive.
DrGE: Exactly! But do it right… and that’s another podcast!
Thus Geo with three kids! It could have been four or five.
DrMR: What about hair loss, Geo? Now that we’re kind of on the topic. That’s another thing that I’m sure a lot of guys are curious about, which is we have finasteride, the DHT-inhibiting drug, and there’s been some really bad press about the sexual side effects from the DHT-blocking, hair-preserving drugs. There are some natural options. There are potential sexual side effects with DHT-blocking drugs, and DHT is the fraction of testosterone that may lead to hair loss. There are natural compounds, like saw palmetto, that work on the same or similar pathway, but I’ve also heard criticisms that if the dose is too aggressive with those, you can also cause problems with sex drive because DHT, while it can cause hair loss, it also is a pretty powerful androgen and has quite a bit of stimulation on sex drive amongst other things, so how do you navigate that, and what are your thoughts in that regard?
DrGE: Well, it’s very simple. If you’re interested in growing hair but not interested in having sex with anyone, then you use Propecia or finasteride.
DrGE: I mean, if that’s the goal!
DrGE: I’ve seen it. I’ve seen Propecia have a very negative effect, I mean, really destroy men’s sexual life with the use of that drug, so it absolutely has an effect on lowering sex drive and even causing erectile dysfunction. Propecia is not something that I would do.
Excessive amounts of saw palmetto? Herbs work in a much milder, softer, longer way, so you have to use a lot of saw palmetto for it to have that effect. I use about 1000 mg of saw palmetto a day in some patients that need it, or not so much, 320 mg, which is what most people use, and I have not seen overproduction of DHT nor men losing their hair or their sexual drive from it. Maybe if you use 2000 mg. I don’t know. I never go that high. The bottom line is that saw palmetto will not cause that because it’s not as strong, from an alpha-reductase perspective.
DrGE: For your audience, testosterone is converted to DHT with this enzyme called 5-alpha-reductase, so these drugs—Propecia and finasteride—are alpha-reductase inhibitors. Saw palmetto is a very soft and mild alpha-reductase inhibitor, but it’s also an antiinflammatory herb.
So, yes, there is a problem with Propecia and finasteride and things of the like even though it’s a very low dose, and I would stay away.
When you google or when I look up what are men looking for in terms of health and what are the top ranked things, erectile dysfunction is one, and male pattern baldness is the other. And when they ask me, I kind of chuckle because, once again, I’m a proud bald guy. I’ve seen guys use Rogaine and all kinds of things. Quite frankly, I don’t think I have the answers for that at this moment in time, particularly from a natural perspective.
DrGE: Of course, it’s very important to just be holistic in the approach. Let’s take it back to basics. Take the crap out of the body, give the body good things, and let’s stay out of the way. Let’s see what happens!
DrGE: This is just good fundamental naturopathic medicine, and I think that’s what works. There are some amazing surgeons in New York City. Again, I’m a proud bald guy, but if I were aiming to take that route, there are one or two surgeons that do implants that make it look really, really natural. I don’t know how they do it. I don’t know if their technique is different, but there are others that don’t look that natural. Again, I’m agnostic. I care for what works.
DrMR: All right. Well, maybe using the saw palmetto as a transition point to the prostate, I’ve read some studies that… I believe it was saw palmetto can help reduce prostate volume, so maybe we can use that kind of as a transition into a very broad topic that I know you have a lot to say about. We’ve already talked about a few prostate issues, but how about some of these herbs that can help reduce prostate volume, and then just unload whatever you want to unload regarding anything else we haven’t touched on regarding prostate. Please, then talk about your book, too, on prostate cancer.
DrGE: Very quickly, there’s some confusion. We always lose the battle when we try to compare herbs to the drugs. That’s not a winnable battle most of the time. When you try to compare saw palmetto to finasteride or Avodart or dutasteride or Flomax or these other prostate drugs, that’s just not a good comparison.
With regards to reducing in size, there are two aspects to look at the whole scenario, but let me give a little context to your audience because maybe they don’t know why you would want to even reduce the size of a prostate. I taught a class when I first came out of school about 11 years ago. I was teaching anatomy and physiology to a group of undergrad students. We were talking about the urinary system. We were talking about how men with big prostates have urinary problems. It causes urinary frequency, urgency, nocturia, etc. And one young girl—she was about 18 years old—raised her hand and said, “Dr. Espinosa, I think I have a prostate problem.”
So from that point on…
DrMR: You start with the anatomy review?!
DrGE: I was like, OK, let’s take nothing for granted ever. Let’s just assume that most people just are not exposed to this kind of information. The reason why we’re having this prostate conversation in terms of reduction is because the prostate as men age becomes bigger. Typically it’s the size of a walnut, and within the prostate or through the middle of the prostate you have what’s called the urethra, and that’s the canal that brings out the semen and the urine. If that walnut increases in size, it starts closing in on the urethra, and it becomes very difficult for men to urinate.
So oftentimes, ladies, if you’re listening and if you have a husband or a significant other that’s getting up at night—two, three, four times a night—and he’s waking you up because you’re a light sleeper, that amount of times, one of the reasons is because they have some sort of prostate issue. It’s enlarged and that’s one of the symptoms. They have urinary frequency, they never feel like they’re emptying, they have urgency where they feel like they need to run to a bathroom, etc., etc.
Then Dr. Ruscio poses the question, can saw palmetto or some of these natural treatments reduce the size of the prostate? The answer is the following. What you and I are interested in doing is not only reducing the size of the prostate, but reducing the size of the prostate around the transitional zone. The transitional zone is the area that surrounds the urethra. One can reduce the outer size of the prostate but not so much the transitional zone, so that doesn’t matter much.
DrGE: And the opposite is true, too, where you can reduce the size of the transitional zone, but then the outside of the prostate still seems enlarged.
DrGE: So there is absolutely no evidence that anything natural other than vitamin D—I wrote a scientific review paper on prostate and vitamin D, and there’s some literature indicating that vitamin D can actually reduce the size of the prostate moderately. Whether or not saw palmetto does that or not, we don’t know because they’ve either not looked at that or there’s no way of really showing it. In order to really objectively look at the size of a prostate, you need to do either an ultrasound or an MRI of the prostate. That’s the only way.
DrGE: Now, do I guesstimate from my physical exam and my prostate exam the size of the prostate? I do, but that’s a guesstimate; it’s not that accurate. The main thing is that we want our patients to have fewer urinary symptoms, bottom line.
DrGE: So the size of the prostate does not really matter as much unless it’s causing symptoms. It doesn’t increase the risk of prostate cancer. It doesn’t bother anybody unless you have urinary symptoms. There are some guys with humongous prostates that are three times the size of a walnut, or four times, but they have no symptoms and they’re fine.
So does saw palmetto—going back to the question!—does saw palmetto reduce the size of the prostate? No. Does it work? Does it help with symptoms? It depends on what study you look at, and it depends on how much you take, and it depends on how bad the patient is. If the patient is having severe urinary symptoms and it’s very clear that it’s from prostate enlargement, then saw palmetto won’t do it.
As an herbalist, the other thing is that you never use one herb. You use a multitude of herbs typically, herbs that work synergistically. Typically I use a formula that has a variety of things that includes saw palmetto at about 1000 mg a day. It includes nettle root, which is another herb, and actually it’s very important that one picks out the root because that has more of a prostate effect, more so than the leaves, the nettle leaves, which do not have a prostate beneficial effect. Nettle leaves are typically for allergies and things like that.
DrGE: I use a component of the saw palmetto called beta-sitosterol. I use quercetin, which is a natural antiinflammatory, very effective. I use things like curcumin, which is a natural antiinflammatory, because oftentimes what’s in the prostate is not just prostate growth, but it’s also inflammation. And of course, vitamin D.
DrMR: That sounds very reasonable. Now, regarding prostate health, maybe this is a good transition into talking about your book, which focuses on prostate cancer, what… what is the book about? That, maybe, is a hard question to answer in a short time.
DrGE: We would really never end!
DrMR: Right! But maybe give us a few highlights in terms of who this book might be able to help and maybe just a few tidbits that you think are really kind of salient to mention from that.
DrGE: Thank you for asking, Michael. This is a labor of love, as you know. You are in the process of writing your own book, and it’s really a labor of love, a very intense amount of work, and I’m so grateful that I have this opportunity. The name of the book is Thrive, Don’t Only Survive! It’s Dr. Geo’s Guide to Living Your Best Life Before and After Prostate Cancer. The idea here is to introduce a lifestyle prescription plan, a blueprint, for any man diagnosed with prostate cancer and for any loved one, family member, spouse, or partner that’s interested in knowing what to do. In every chapter, I have a little segment that kind of speaks to women and to life partners to kind of give them some guidance as to how they can best support their male partner.
The reality is that in my experience—and the reason why the book is called Thrive, Don’t Only Survive!—is because “survivor,” when that word is said after “cancer,” as in “cancer survivor,” that’s a term that really irks me. Of course, we all want to survive, and particularly if you’re diagnosed with cancer, the first thing is surviving. OK. But then people kind of continue just surviving, just kind of making it, just hanging in there barely.
DrGE: Always with the C-word in your head and kind of not living a fulfilled life. And in my experience with prostate cancer, this diagnosis is an opportunity to really live your best life, so thus the name. I think that people are confused with what they need to do. “What do I really need? I go to the Internet and it says, well, I need to be vegan. Then you go to the paleo folks, and they say I need to be paleo. And then you go to the fat people that like to eat fat, and they say, well, fat actually helps with prostate cancer. Or I need to eat more soy. Soy is the solution, so I’m going to drink a half a gallon of soy milk every day.” And so on, and so on, and so on.
DrGE: There’s a lot of confusion with regards to what to really do from a practical and sustainable standpoint with regards to prostate cancer. Thus the book, Thrive, Don’t Only Survive! I guess the best way to learn more about it, there’s a website in development right now called ThriveDontOnlySurvive.com, and maybe my blog if you allow me to mention the name.
DrMR: Oh, please, please.
DrGE: So the blog and website that is currently up and running is DrGeo.com. That’s Geo with an E, not an I.
DrMR: I know there’s a lot of great information over at your site. People can definitely dive in there, and like I said, you’re the guy I go to when I have urological issues that I need some advice on. Of course, this is your field.
DrMR: A question that I’m sure some people are asking themselves is, if I don’t have prostate cancer or I don’t have a family history and I’m not overly concerned with preventing prostate cancer, does this book contain guides for good prostate health? Or would you said it’s more specific to cancer prevention and survival specifically?
DrGE: I can easily change the cover of this book and make it more in relation to prostate health.
DrGE: I can easily change the cover of this book and say, well, this is how to live your best life before and after breast cancer, for example.
DrGE: The reason why I mention breast cancer specifically is because prostate cancer and breast cancer are like cousins. They’re very similar in the way they develop and progress. The types of approaches that are required from a lifestyle perspective are very similar, unlike other cancers, unlike colon cancer or even lung cancer or any other type, brain cancer. This is why it’s important for female partners and family members to read this and also look into applying it. You’re not going to grow a prostate from doing the protocols and the things in there.
DrGE: It actually can be very beneficial, so, yes, I think that anyone who’s really interested in really living a great life, particularly as they age… look, aging hit me hard. After I turned 40, I was like, oh, shoot. You really need to turn it up. And the people that are not doing well after 40, 45, and 50 are those that are still trying to do the same things they were doing at 30.
DrMR: Right. Well, great. I love the fact that it has broad applicability. There’s an old saying. I forget who said this, but it’s been said that, philosophically, the closer we get to truth, the more commonalities we find.
DrMR: I’d like to think that a book that’s good for any kind of health would have definitely some general and broad applicability. That is very nice to see. It’s been great having you here, Geo.
DrGE: It’s my pleasure.
DrMR: Guys, check out Dr. Espinosa. Do a side-by-side with him and Vin Diesel, and also check out some of his work and some of his writing.
DrGE: Fast and furious! That’s what it’s about here, fast and furious!
DrMR: Geo, thanks so much, and let’s try to get you back sometime in the near future, and maybe we can go into an expansion on one of those many tangents we went down and didn’t have a chance to go too deep on.
DrGE: Sounds good, Michael. Thanks for having me, and until next time, be well.
DrMR: All right, thanks.
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What do you think? I would like to hear your thoughts or experience with this.