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Jeremiah Velasquez: Started testosterone placement therapy was around 600 total testosterone. It has been one of the most impactful and profound things that I have ever done for myself in my life. I'm not going to say that I'm here today because of it, but I am going to say that it has set such a profound change on my ability to communicate, my ability to push myself, my ability to put myself in uncomfortable situations, that I highly doubt that without it, I would be as far as I could. Most people spend their whole lives outsourcing the three things that matter most: their health, their money, their relationships. Not here. The optimized NP is where a double board certified NP and serial entrepreneur breaks down what actually works, cuts through the noise, and gives you the kind of clarity they never wanted you to have. Rebel? Maybe. But you believe every episode. Sharper than you came in. Medicine, fitness, business optimized. Let's go. Welcome back to another episode of the Optimized NP. I'm the Optimized NP, double board certified NP, and I've treated over 500 men with testosterone replacement therapy. And a question that I think needs to be answered is: how significant is the number that we see on lab work in conjunction with my eligibility for treatment? So today we're going to talk about a couple of things. We're going to talk about the labs. And once again, these are all my personal opinion on lab work, the correlation to treating men and their overall outcomes. We're going to be talking about erythrocytosis or elevation of red blood cells, PSA, and its relevance to prostate cancer. And we're going to be talking about fertility. So before we begin, it's important that we talk about the numbers. So you want some testosterone placement therapy. You feel crappy. You want to feel better, you get some blood work, you get it back. Number looks fine. It's not bolded, red. It's normal. So now what? Does that just mean you're not eligible for treatment? Does it mean you're overexaggerating? Does it mean the testosterone isn't the answer to your problem? Well, this is my view on it. Testosterone replacement therapy, an older term. When we think about that. We're replacing your testosterone to a normal range to make you feel normal. It's very medical, it's very sterile. But the real question is: what about optimization? Testosterone optimization therapy. What does it even mean? We talk about optimization all the time, but what does that word actually mean? And the reality is, it means a lot of different things. To a lot of different people. Optimization isn't just a definition. It's something that I really believe is the indicator of how well someone does on testosterone. Because testosterone is a very, very powerful tool. But that's it. It's not a map, guys. It's not going to tell you where to go or how to get there. You already need to know what I am looking to achieve? When I'm sitting across the table from another man or seeing them on telehealth, one of the most important and profound questions I ask them is if you could fast forward three months, what does that version of you look like compared to now? And that tells me what are the things we're trying to do. I want to improve my muscle mass. I want to have higher limbido. I want to improve intimacy with my partner. I want to be a better husband. So on and so forth. These are better metrics than I want to sleep better at night, I want more injury during the day. I mean, we all get tired, guys. Who doesn't have nights of poor sleep? Who isn't tired in the middle of the day at times? It's really not a great indicator because we can all, even on TRT, have those symptoms. But I want to know more specifically, what are your goals and what are you already doing to get there? If your goal is to have increased muscle mass. Are you going to the gym? And if not, why? And if not, when will you? I want to lose body weight. I want to lose body fat. Are you tracking your calories? If not, why? If not, when? It's important that you're already putting in steps to achieve your goals without testosterone before you add it in. Because if you're not changing anything, if you're miserable in your life. You're not gonna change anything. You're injecting testosterone. It's a waste, guys. Sure, you might get a little bit of benefit here and there, but the reality is, waste. I've seen it way too many times where someone will come into the office and say, I was told they have low testosterone. My buddy's on testosterone. He's doing really well. I want to try it. I don't know what to expect. Let's just see what happens. Never works well. That's going to be the guy that says, testosterone didn't work for me. Testosterone was a waste of time, waste of money, waste of effort. And it was, but it wasn't because the testosterone failed you, you failed the testosterone. So realize, use it like a tool. Now, going back to the labs, it doesn't tell us nearly as much as we want to know. When we look at that testosterone level, we really have to correlate it to how you feel. Now this is the common scenario. You come in, testosterone's it's there, maybe on the lower end. Towards the middle, you feel horrible, you want to optimize. Fantastic. Let's do it. I've also seen this end of the spectrum. Someone comes in, testosterone's reading low. They feel fantastic. They feel fine. It's really one of those situations of, I don't know how much you're going to benefit from testosterone replacement therapy. Now, really important, guys, remember we're shifting our mindset from medical to optimization. So You will never die from low testosterone. That'll never be on your death certificate. Okay. You will never die of low testosterone. It's never happened, never will. Sure, there are some complications of low testosterone, mostly because of the low estradyl states, but you will not die from it. It's a want. So take it out of your head as I need testosterone. If anyone says you
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need this, question it. want. You want it and that's okay. It's okay to want testosterone. Me personally. It was such a hard, hard time to even get a level checked through my primary care provider. Not dog in primary care. I've done it for most of my career. I understand how difficult it is. I'm young, I'm 34 years old, or I was at the time. What do I need to check my testosterone for? I'm in fairly good shape. I go to the gym every morning. Okay. Fair. Once again we're taking out The need and go to a want. My testosterone, when I started testosterone placement therapy, was around 600 total testosterone. It has been one of the most impactful and profound things that I have ever done for myself in my life. I'm not going to say that I'm here today because of it, but I am going to say that it has set such a profound change on my ability to communicate, my ability to. Push myself, my ability to put myself in uncomfortable situations, that I highly doubt that without it, I would be as far as I am. We'll never know, but that's my personal speculation. So, what labs do we even want? And do they serve clinical application? Well, at this point, you might be thinking, we don't even need labs because it's all symptom based. That's arguable. Some providers will say that that's the case. Might be, I still like to at least get a total testosterone. Let's look at it. Let's talk about it. It's a good teaching point. LHFSH. These are helpful because it helps us differentiate primary from secondary hypogonadism or low testosterone. This is also a good indicator of whether something like HCG or enclomaphy is going to be beneficial for you. It gives us an idea of testicular function and whether those medications will even give you enough of an oomph to be effective. It gives us an idea of: hey, what is our signaling hormone? Do we have an upstream issue? Is it a downstream issue? Is this all just completely normal? It gives us some information. Free testosterone. Everyone talks about free testosterone because total testosterone looks at everything in your body. It looks at all the testosterone, even the testosterone, you can't use. Now, what I mean by this is testosterone cannot move freely through the body. It has to be carried by proteins. And those proteins are sex hormone binding globulin and LBN. Now, when it's being carried, they cannot bind to androgen receptors. You cannot use it. So A free testosterone looks at all the unbound testosterone, the testosterone you fill. Sometimes you'll see someone with a normal or even high total testosterone and a low free testosterone. And at that point you can say, well, you got plenty of raw materials, but you're not using it effectively. And so in that case, you could justify this is a good candidate. It's okay. It's a good measurement. It's a good education piece. I don't necessarily think it gives us much value. SHBG. Do you want to check it? Do you want to see how much of that testosterone is being bound up? A lot of
people will say yes. Some will say no. I'm kind of on the fence. I don't necessarily treat SHBG. So if your SHBG is high, I'm not going to purposely try to lower it to free up more testosterone because we're going to suppress it with exogenous testosterone anyway. Oftentimes, give the guy more testosterone. So I think the total testosterone. Is plenty because we're very symptom driven, result driven. It's always good to have some baseline lab work. In certain situations, I think the other labs are important. If someone wants them, it's a good educational piece. I don't think it should be a requirement across the board. Now, what about some of the risks? Increased red blood cell count, prostate cancer, fertility problems. Sure. Well, red blood cells, this is important. CBC, I think, is paramount. I think a C B C should be a required blood work for anyone getting on testosterone. And an important educational piece is the influence that testosterone has on a CDC. So, first of all, we look at a white blood cell count and we use this as a surrogate for your immune system. Now, contrary to popular belief, testosterone does have some influence on a white blood cell count to a degree. It does affect Specific stem cells, and it can cause them to go down specific pathways called myeloid pathway, where it becomes white blood cells and red blood cells. And in about 30% of my patients, at six weeks after TRT initiation or a dose adjustment, I've seen a slight increase in white blood cell count because testosterone is going to improve your immune system. We can see a small increase, but this is important. It should always come back down to baseline. So we should always come back down to baseline, meaning not elevated where it was at before TRT initiation. We call that a transient increase. And it's it's expected. I don't see it very often. It can happen. Now, red blood cells. Red blood cells are very important because they carry oxygen throughout the body. Think of them as an athletic performance. There's a reason professional athletes do blood doping. There's a reason they want more red blood cells, more oxygen. carrying capacity. Cool. Now the question is, how does testosterone do this? Because we know it will. Well there's two essential mechanisms. One, it releases what's called EPO or erythropoletin the kidneys. This essentially causes increased red blood cells from the bone marrow. But two, it reduces what's called hepsidin. Hepcidin is a peptide. It's an iron regulating peptide. So when we have lower amounts, we're going to get More bioavailable iron, which causes new red blood cell production. We call this omithropoesis. So we've just talked about the two mechanisms, how testosterone increases red blood cells. Now the bigger question is when do we sound the alarm? When do we say, Hey, we need to stop testosterone? We need to decrease your dose. We need to do a therapeutic phobotomy. Really? The first two? I say never. And as far as therapeutic phlebotomy, it depends. So let's talk about that for a second. The cutoff. The cutoff varies. It's anywhere from 54 to 56%, typically 56%. And the biggest reason is we don't know long-term safety of hematocrits above 56%. There are some very big studies that evaluate this. And unless you've got a genetic condition or some type of bone marrow cancer, it's not necessarily dangerous. But When we actually think about too many, essentially too many red blood cells going through your vessels, think of it like a highway, right? When a highway traffic is running smoothly, there's enough cars to where you can get off on your exit and people can merge and they're not bumping into each other. And then think of a traffic jam. You have too many cars in that same amount of space, that's essentially your hematocrit. How many red blood cells are in the same amount of space? And if we have too many, well, you can't really get off on your exit. That could be a you know, equivalent to oxygen disassociating to the tissue. So it can cause issues. Don't get me wrong. But the question is, how do we intervene on this? So prevention. I'm a huge advocate for preventing it in the first place, because testosterone alone should not cause your hematocrit to get above 56%. It just shouldn't. There's gotta be, most oftentimes, a secondary component. Most commonly, Hydration. Dehydration is the most profound. I've seen guys come in, not on TRT, with hematocrits significantly elevated, from dehydration, especially people that work outside. It's summer, very common. Most of us really suck at drinking water. Sleep apnea. This is huge. You know, being a guy, being a man, we've already got a risk factor, our gender alone. Now, sleep apnea is a Characterized by periods of apnea or not breathing during the night, your body says, We're not getting enough oxygen. So it creates more red blood cells to better utilize the oxygen you are getting by increasing oxygen carrying capacity. And so we see this erythrocytosis or increased red blood cells from periods of not breathing, apnea. Testosterone, it's going to improve your sleep. It can also worsen sleep apnea. Let's get real for a second. Yeah, aging happens, but feeling exhausted, struggling with sleep, losing your edge in the bedroom, and watching your confidence tank, that's not just getting older. That's a hormonal imbalance. And you don't have to live with it. They'll tell you hormones are dangerous, but hand you a prescription with a mile-long list of effects. Enough is enough, guys. At Still City HRT and Weight Loss, we cut through the noise. We offer safe, bioidentical hormone therapy customized to you and backed by real lab monitoring and personalized care because your health isn't one size fits all. If you're done with the BS and ready to feel like yourself again, strong, focused, and confident, call or text us at 719-669-4223. Let's build a plan that actually works for you. Still city HRT and weight loss. Be the hero of your own
story. So guys on testosterone replacement therapy, they've never had a sleep study, maybe never been screened, they're sleeping better, could worsen their sleep apnea. We could see that be a cause. Also, on the other end of the spectrum, maybe they're going to the gym. They should be. They're exercising, they're losing body weight, they're improving their sleep apnea, they reverse it. That's the best case. But dehydration, sleep apnea, elevation is always a huge, huge thing. I'm licensed in several states, but most of my patients are from Colorado. Colorado is very high in elevation. I've got people that live 11,000 feet. That plays a role, guys. It absolutely plays a role. And that's something we have to think about. There are certain medications that will cause this too. We have to think of this holistically. But typically, if I see someone with hematocrit above 56%, we don't freak out. We don't stop the medication. We don't lower the dose. We repeat two weeks, eliminating specific variables. I have a very unique hydration protocol that I implement with my men works great. Using myself as an example, my hematocrit's been as high as 63%. 63. Repeat in two weeks, using hydration protocol, 53. Huge, huge difference, guys. Now, what about therapeutic lobotomy? Should we go donate blood? Well, it's very reactive, right? It's putting a band-aid on a hemorrhage essentially. We go, we donate 500 cc's of blood. Sure. We're going to lower the amount of blood. We're going to lower the hematocrit. Our body's going to say, Where the hell did that blood go? It's going to make more, right? And we're not just losing blood. We're losing iron, microcellular nutrients, growth factors. Now, I do think there's a use case for it. I'm making it sound pretty bad. But if someone has an elevated hematocrit and they're symptomatic, I'm getting headaches, my skin's flushed, blurred vision, right? Any of those symptoms. Then yeah, I think that therapeutic phlebotomy is more than justified to help alleviate the symptoms while we figure out what's causing it. Because we're just putting a band-aid on a hemorrhage, it will come back. This isn't going to fix the elevation in red blood cells. It's going to continue to increase until we address what's causing it. Now you do this too often. I've seen guys doing it every two weeks. You're going to put yourself in a bad metabolic condition, I promise you. You're going to have erythrocytosis and Iron deficiency. Okay, now remember we talked about iron. You take iron, you're increasing your red blood cell production. How do you replace the iron with erythrocytosis? Tricky, right? We've done it, but it's tricky. So the next thing: prostate cancer. This is something that most guys should be curious about. As long as you have a prostate, you have a risk of prostate cancer. And let me talk to you about this. So if this is the question I get asked all the time. Does testosterone cause prostate cancer? Absolutely, it does. Testosterone causes testosterone-dependent prostate cancer. Now realize there are non-testosterone-dependent prostate cancers, but as long as you have a drop of testosterone in your body and you have a prostate, you run the risk of prostate cancer. Unless your testosterone is zero, you will always have the risk of testosterone-dependent prostate cancer. Now the better question is at what point does our risk no longer increase? And does taking exogenous or testosterone from an outside source increase my risk? There have been studies that have been done, and from the studies we've done, they've developed what's called the prostate saturation model, which basically means think of the prostate as a sponge, and its pores, instead of holding water, hold DHT, dihydrotestosterone. Which is a downstream hormone of testosterone. Now, you can only saturate this prostate AKA sponge with so much DHT before it's fully saturated, meaning it can't hold even a drop more. And from the research they've done, take it for what you want, that number is about 250 total testosterone, which is low. That's going to read low on your art. So at a total testosterone of 250, theoretically, You are at your maximum prostate cancer risk. So the difference between a total testosterone of 250 and 250,000, being very extreme, is the same. Now that conversation changes if a man comes into my office and their testosterone is, let's say, 100. Now that conversation has to be we're closing the gap between 100 and 250. So there is a chance you are not at your full prostate cancer risk. We're going to put you there. That has to be the conversation. Always does. Not to scare someone, but to inform them. And once again, we don't really know as much about all this as we think we do. But when we're thinking about the prostate saturation model, it basically makes you say, Hey, my my total testosterone is 350. If I get on testosterone, am I increasing my prostate cancer risk? No. The other thing to think about too: men with low testosterone can also. get prostate cancer. And not just that, but there are actually studies that show that if you develop prostate cancer in a lower testosterone state, these are typically high grade lesions, which is worse, more negative outcomes. And that doesn't justify starting testosterone to lower the severity of your prostate cancer. All I'm saying is as long as you have a drop of testosterone, you have a risk of prostate cancer. Realize that. And as long as you have a prostate, you have a risk of prostate Cancer. Now, what about fertility? My overall recommendation is if a man is considering having a family, hold off on testosterone. Don't even risk it. Have your children, have your family. Testosterone will always be there. Having a family is typically time sensitive. So I prioritize that. Now, what happens? How does fertility get negatively affected? So when we talk about hormone production in a man, it all starts in the brain. In a place called the hypothalamus. It
releases ganatotropin releasing hormone to the anterior pituitary gland, which releases glutenizing hormone and follicle stimulating hormone. LH FSH. LH goes down to the testes, interacts with latent cells, creates testosterone. FSH goes down to the testes, interacts with Sertoli cells, creates hormones for fertility, androgen binding protein, inhibit. And so what we have to realize. Is that it's all just a cascade. It's a circle because our body has a negative feedback loop. And so when we're getting this hormone production, it's going to come back to the brain and say, we're producing good amounts of hormones, which for men, it's typically anywhere between two and five milligrams of testosterone per day. It's going to slow that production. It keeps it regulated. If it gets too high, it reduces the amount of output. If it gets too low, increases the amount of output. But it's like a range, it's like a thermostat. It's always assessing its work to make sure we have a constant amount. And it's not a constant thing. I keep saying constant, but it's actually created spurts. So it's it's it's spurt and cyclic, is the way that it works. Now, when we intervened, we're doing exogenous testosterone. Your brain's smart, but it doesn't know, hey, he's injecting testosterone into his shoulder. Your brain thinks. I'm making too much testosterone. And so the only thing that I can do to regulate that is to stop production of those stimulatory hormones. Genadotropin-releasing hormone, glutenizing hormone, follicle stimulating hormone. And what will happen is we're not stimulating the testes. And so intratesticular testosterone decreases. Normally it's like 100 times higher than what's in your blood. We need a lot of testosterone for sperm health. Now, when we stop stimulating that, that's when we see testes shrink, completely normal, by anywhere from 30 to 50 percent. Now, that shrinkage is indicative of decreased intratesticular stimulation, decreased intratesticular testosterone. Now, we have less testosterone. Okay. We're not we're not making endogenous testosterone. So our fertility is going to decrease because of this. Remember, they need high levels of testosterone endogenously. Now, Not completely. It's not birth control. And this is very important to know because I've had several men who are on testosterone have children, okay, without any adjuncts, just TRT. And so realize that it's still possible, but I would not count on it. And so if your plan is to have a family, I would do it now. Now theoretically, if you stop this over some period of time, could be up to a year. Your testosterone is going to be naturally made again. And it should theoretically come back up to baseline. But one, it's never guaranteed. I would never just assume it's always going to come back because we just don't know. And I don't want to take that risk. Two, what was your baseline fertility? Have you had any sperm analysis before TRT? Were you fertile before starting TRT? Because if you weren't, TRT is not going to help the situation. But if you were, And then you can't have children, and you can't have children after it comes back, that could have been a result. Hard to say. But fertility is something that should always be discussed with any man. I don't think there is an H cutoff. I talked to all of my men about it, but if I have someone who's younger who's unsure, this is always a huge conversation, think about it. You can always get on testosterone replacement therapy. Having a family, like I said, is a very important part of most humans' lives. And it's Usually time sensitive. Side note on that, low testosterone, in and of itself, can decrease fertility because you're still having low amounts of intratesticular testosterone, just naturally. Let's sum all this up, guys. Labs, I do think they serve a purpose. Symptom first, results first. The labs do help to guide some treatment. I think that at a minimum, CBC, PSA, total testosterone, extradiol. I think that's a great jumping off point. Can you use others? Sure, we talked about it. At the end of the day, does it clinically change the way you're managed? Rocytosis, prostate cancer, fertility. These are all things that should always be discussed anytime you're going to get on testosterone and your individual risk factors of each and goals, how it can be affected by each should be discussed because it's very different from person to person. If I'm treating someone at sea level and then treating someone that lives at 11,000 feet, that discussion regarding brothocytosis is going to go a little different. If I'm treating someone who's young, they want a family, and I'm treating someone who's mid-50s, they've had all their kids, maybe they've had a disectomy, that conversation is going to be very different. So individualize that conversation for each person. And if you're a patient, you're someone who wants to get on TRT. Ask questions if you want a family. Let them know. That's very important because they will help you, they'll help guide you down the right pathways. Because testosterone is not the only way to increase your testosterone. So realize that. This information helped, guys. And if you guys have any questions, send them to the optimized np at stillcity-trt.com and we can do a QA session. This is what Optimize looks like in practice. If this episode moved the needle, share with someone still coasting on normal. That's how we build this. New episodes drop every other week. Subscribe so you don't miss a thing. Questions, feedback, or think you belong on this mic? Reach out at the optimized np at stillcity-trt.com. I'm Jeremiah Velazquez. This is the Optimized NP. Let's go!